Developing Topical Fluoride Hesitancy Measures for Causal Modeling and Intervention Research

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Topical fluorides help prevent tooth decay and are a routine part of dental visits for children and adolescents. However, concerns about the safety, necessity, and effectiveness of fluorides have resulted in fluoride hesitancy, leading some parents to refuse fluoride treatment for their children. Our data indicate that 13% of parents refuse topical fluoride during dental or medical visits, which is similar to vaccine refusal rates. Many more parents may accept fluoride but are hesitant. According to dentists, fluoride hesitancy and refusal are growing problems, but many dentists do not realize how universal approaches of providing fluoride to all children regardless of caries risk may have contributed to the problem. To convince hesitant and refusing parents to accept fluoride, dentists rely on paternalistic educational approaches that are largely ineffective at changing parents’ beliefs or behaviors. This is because education alone ignores the specific reason(s) why a parent is hesitant about fluoride. When efforts to change parent behaviors fail, some dentists dismiss these patients from their practices and most dentists avoid talking about fluoride to hesitant parents at subsequent visits to avoid conflict. Behavioral risk-based approaches could help dentists to address fluoride hesitancy and refusal in clinical practice. Validated measures will be needed to assess such approaches, but such measures currently do not exist. In this measure development study, we will address this critical gap. We will use the Health Belief Model and the Extended Parallel Process Model to understand fluoride hesitancy and refusal behaviors and to develop 2 measures for use in research and clinical settings. The Aims are to: (1) Construct a theoretical model of topical fluoride hesitancy/refusal; (2) Develop and validate 2 measures – a screening tool to identify fluoride hesitant/refusing parents and a diagnostic instrument to identify the reason(s) for topical fluoride hesitancy/refusal; and (3) Determine the stability of fluoride hesitancy/refusal behaviors. After the study is completed, the next step will be to design a behavioral clinical trial that incorporates a multi-pronged approach that addresses the specific reason(s) a parent is fluoride- hesitant/refusing and appropriate communication strategies used by health providers that incorporate a child’s caries risk. Our long-term goal is to improve oral health outcomes in high-risk children and adolescents who may otherwise not have an opportunity to benefit from fluorides, thereby addressing a growing threat to reducing dental caries rates and achieving health equity. The proposed study addresses Healthy People 2020’s Oral Health Objectives 1 and 8, and the Centers for Medicare and Medicaid Oral Health Initiative on Access to Quality Dental Care. By using dentistry as a laboratory, the proposed work is broadly applicable in understanding and addressing similar issues in public health like vaccine refusal and other phenomena involving communication of complex health information, interpretation of this information by parents, perceptions of health risks and benefits, and health care-related decision making.