ABSTRACT

Objective

The objective of this quasi-experimental study was to determine the impact of the Promotora Model (PM) as an educational strategy to increase oral health knowledge in parents/caregivers of children aged 2-5 years at high risk for dental caries.

Materials and Methods

Sixty-three caregivers who provided informed consent were included in the study. A structured 37-item survey was administered prior to conducting the Promotora educational intervention (PEI) that covered oral health topics and behaviors. Three (3) months after the PEI session, during their child's next dental visit, the same instrument was administered to 46 of the parents/caregivers that had completed the first instrument.

Results

Most caregivers were Hispanic (73.9%) and 50% reported completing high school. Before PEI, 56.5% of participants scored as having "good" general knowledge. Three months after PEI, 82.6% achieved that score (paired sample T-test, p< 0.00001).

Conclusion

Based on the results, it was concluded that the PM significantly increased caregivers' oral health knowledge.

Key Words:
Health educator; oral health; knowledge (source: MeSH, NLM)

RESUMEN

Objetivo

El propósito de este estudio cuasi-experimental fue determinar el impacto del Modelo Promotora (MP) como estrategia educacional para mejorar el conocimiento sobre salud oral de los padres y/o cuidadores de niños con edades comprendidas entre 2-5 años con alto riesgo de sufrir caries dental.

Métodos

Sesenta y tres padres y/o cuidadores quienes dieron el consentimiento fueron incluidos en el estudio. Se administró un cuestionario estructurado de 37 preguntas antes de la intervención educativa (IE) con el Modelo Promotora (IEP) el cual cubría tópicos sobre salud oral y conductas. Tres (3) meses después de la sesión de IEP, en la próxima visita dental del niño, el mismo cuestionario fue administrado a 46 padres y/o cuidadores que habían completado el primer cuestionario.

Resultados

La mayoría de los padres y/o cuidadores eran Hispanos (73,9%) y 50% reporto tener bachillerato completo. Antes del IEP, 56,5% de los participantes presentó un nivel general de conocimiento "Bueno." Tres meses después de la aplicación del IEP, 82,6% obtuvieron el mismo nivel de conocimiento (T-test, p<0.00001).

Conclusión

Se concluye que el MP mejora considerablemente el conocimiento sobre salud bucal de los padres y/o cuidadores.

Palabras Clave:
Educadores en salud; salud bucal; conocimiento (fuente: DeCS, BIREME)

Dental caries is the most prevalent chronic disease among children aged 2-5 years in the United States (23%) ¹1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief No. 191. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2015. Available from: http://bit.ly/2mpPZkJ.
http://bit.ly/2mpPZkJ... . Despite major efforts to improve oral health for the population as a whole, the prevalence of dental caries remains higher among children living in poverty than in more affluent children, and is also higher among Hispanics and non-Hispanic blacks than among non-Hispanic whites ¹1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief No. 191. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2015. Available from: http://bit.ly/2mpPZkJ.
http://bit.ly/2mpPZkJ... . Children from some racial/ethnic minority groups and large families, and whose care-givers have low levels of educational attainment, are at increased risk for suboptimal dental care ²2. Kelly SE, Binkley CJ, Neace WP, Gale BS. Barriers to care--seeking for children's oral health among low-income caregivers. Am J Public Health. 2005; 95(8):1345-51. Available from: http://bit.ly/2mvgt43.
http://bit.ly/2mvgt43... ^,33. McKinney VL. The relationship between early childhood caries and ca-regivers' oral health knowledge and behavior among Medicaid-eligible children in North Carolina [thesis]. Chapel Hill, NC: University of North Carolina; 2006. Available from: https://unc.live/2kOwIZC.
https://unc.live/2kOwIZC... . Hispanic populations frequently face significant barriers to oral health care due to language, poverty, level of education and acculturation ²2. Kelly SE, Binkley CJ, Neace WP, Gale BS. Barriers to care--seeking for children's oral health among low-income caregivers. Am J Public Health. 2005; 95(8):1345-51. Available from: http://bit.ly/2mvgt43.
http://bit.ly/2mvgt43...

3. McKinney VL. The relationship between early childhood caries and ca-regivers' oral health knowledge and behavior among Medicaid-eligible children in North Carolina [thesis]. Chapel Hill, NC: University of North Carolina; 2006. Available from: https://unc.live/2kOwIZC.
https://unc.live/2kOwIZC... ^-44. Vann WF, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: Impact on oral health outcomes in early childhood. J Dent Res. 2010;89(12):1395-400. Available from: http://bit.ly/2mvhxoz.
http://bit.ly/2mvhxoz... .

In fact, oral health literacy among caregivers is one of the most consistent predictors of oral health disparities in children ⁵5. Sanders LM, Federico S, Klass P, Abrams MA, Dreyer B. Literacy and child health: Systematic review. Arch Pediatr Adolesc Med. 2009;163(2):131-40. Available from: http://bit.ly/2mnyoda.
http://bit.ly/2mnyoda...

6. Watson MR, Horowitz AM, Garcia I, Canto MT. Caries conditions among 2-5 year- old immigrant Latino children related to parents' oral health knowledge, opinions and practices. Community Dent Oral Epidemiol. 1999; 27:8-15. Available from: http://bit.ly/2mtltWU.
http://bit.ly/2mtltWU...

7. Swan M, Barker JC, Hoeft KS. Rural Latino farmworker fathers' understanding of children's oral hygiene practices. Pediatr Dent. 2010; 32(5): 400-6. Available from: http://bit.ly/2mmYTPY.
http://bit.ly/2mmYTPY... ^-88. Hoeft K, Rios SM, Pantoja Guzman E, Barker JC. Using community participation to assess acceptability of "Contra Caries", A theory based, promotora-led oral health education program for rural Latino parents: a mixed methods study. BMC Oral Health. 2015; 15:103. Available from: http://bit.ly/2mPUJ33.
http://bit.ly/2mPUJ33... . In this context, healthcare providers need support staff that help improve caregivers' oral health knowledge, particularly among populations with low levels of education ⁹9. Gussy MG, Waters EB, Riggs EM, Lo SK, Kilpatrick NM. Parental knowledge, beliefs and behaviors for oral health of toddlers residing in rural Victoria. Aust Dent J. 2008; 53: 52-60. Available from: http://bit.ly/2mlznuh.
http://bit.ly/2mlznuh... ^,1010. Castilo-Carreno A, Espinoza-Venegas M, Luengo-Machuca L. Compromiso paterno y la relación con sus conductas promotoras de salud. Rev. Salud Publica 20(5):541-547, 2018. Available from: http://bit.ly/2muqq1D.
http://bit.ly/2muqq1D... . Consequently, educational interventions based on the cultural and linguistic characteristics of the population are important considerations for improving knowledge and skills ¹¹11. Garcia RI, Cadoret C, Henshaw M. Multicultural issues in oral health. Dent Clin North Am. 2008;52(2):319-32. Available from: http://bit.ly/2l-q3e4x.
http://bit.ly/2l-q3e4x... .

With the increasing size of the Hispanic/Latino population in the United States, there is a need to expand the availability of more comprehensive and culturally appropriate approaches for increasing oral health knowledge and skills ¹²12. United States Census Bureau. The Hispanic Population in the United States: 2014. [Website] Available from: http://bit.ly/2mSOZ8N.
http://bit.ly/2mSOZ8N... . Ideally, that education should include information on caries initiation, as well as training on effective oral hygiene techniques, including behaviors and caries prevention, which could help caregivers to improve their children's oral health ⁸8. Hoeft K, Rios SM, Pantoja Guzman E, Barker JC. Using community participation to assess acceptability of "Contra Caries", A theory based, promotora-led oral health education program for rural Latino parents: a mixed methods study. BMC Oral Health. 2015; 15:103. Available from: http://bit.ly/2mPUJ33.
http://bit.ly/2mPUJ33... .

Promotora de salud (Health Promoter) is the term used to refer to a female community health worker (CHW) working closely with Spanish-speaking population ¹³13. Promotores de Salud/ Community Health Workers. Health Equity. Centers for Disease Control and Prevention. Available from: http://bit.ly/2m-pV6RX.
http://bit.ly/2m-pV6RX... . The Promotora Model (PM) has been considered an educational approach to improve the health of Hispanic/Latino communities, increase appropriate use of health care services, and modify health behaviors ¹⁴14. Rural Health Information Hub. Promotora de la salud/lay health worker model [Website]. Available from: http://bit.ly/2moryUG.
http://bit.ly/2moryUG... ^,1515. Anders RL, Balcazar H, Paez L. Hispanic community-based participatory research using a promotores de salud model. Hispanic Health Care International. 2006; 4(2):71-78. Available from: http://bit.ly/2mlBdLH.
http://bit.ly/2mlBdLH... .

Through the incorporation of cultural values and customs, the use of pm has demonstrated a reduction of health disparities and improved health outcomes, especially chronic diseases ¹⁴14. Rural Health Information Hub. Promotora de la salud/lay health worker model [Website]. Available from: http://bit.ly/2moryUG.
http://bit.ly/2moryUG... ^,1515. Anders RL, Balcazar H, Paez L. Hispanic community-based participatory research using a promotores de salud model. Hispanic Health Care International. 2006; 4(2):71-78. Available from: http://bit.ly/2mlBdLH.
http://bit.ly/2mlBdLH...

16. Balcazar H, Alvarado M, Hollen ML, et al. Salud para su Corazón-NCLR: A comprehensive promotora outreach program to promote heart-healthy behaviors among Hispanics. Health Promotion Practice. 2006; 7(1):68-77. Available from: http://bit.ly/2mUpVhQ.
http://bit.ly/2mUpVhQ...

17. Walton A, Calvo Y, Flores M, Navarrete L, Ruiz L. Promotoras: Observations and implications for increasing cervical cancer prevention and screening in the Hispanic community. Journal of the South Carolina Medical Association. 2009; 105(7):306-308.^-1818. Capitman JA, González A, Ramírez M, Pacheco TL. The effectiveness of a promotora health education model for improving Latino health care access in California's Central Valley. Fresno, CA: Central Valley Health Policy Institute; 2009. Available from: http://bit.ly/2mossk2.
http://bit.ly/2mossk2... . This model has proven to be effective for fostering behavioral changes related to chronic disease prevention and management, and for improving oral health, especially in Latin America and the United States ¹⁸18. Capitman JA, González A, Ramírez M, Pacheco TL. The effectiveness of a promotora health education model for improving Latino health care access in California's Central Valley. Fresno, CA: Central Valley Health Policy Institute; 2009. Available from: http://bit.ly/2mossk2.
http://bit.ly/2mossk2...

19. Balcázar H, Alvarado M, Cantu F, Pedregon V, et al. A Promotora de Salud Model for Addressing Cardiovascular Disease Risk Factors in the US-Mexico Border Region. Available from: http://bit.ly/2kQj5sW.
http://bit.ly/2kQj5sW...

20. Hoeft K, Barker JC, Masterson EE. Urban Mexican-American mothers' beliefs about caries etiology in children. Community Dent Oral Epidemiol. 2010; 38(3): 244-55. Available from: http://bit.ly/2mpVIXA.
http://bit.ly/2mpVIXA...

21. Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the US-Mexico border. Health Education & Behavior. 2004; 31(4 suppl):18-28. Available from: http://bit.ly/2mvmXQr.
http://bit.ly/2mvmXQr... ^-2222. The Promotor Model. A Model for Building Healthy Communities. A Framing Paper March 29, 2011 Available from: http://bit.ly/2momT56.
http://bit.ly/2momT56... .

The PM was instituted ²³23. Davila ME, Tomar SL. PROMOTORA MODEL to improve oral health: An exploratory study among diverse low-income community. Revista Odontologica de Los Andes. 2017;.12 (2):24-32. Available from: http://bit.ly/2mQOE6w.
http://bit.ly/2mQOE6w... in the University of Florida (UF)/Naples Children and Education Foundation (NCEF) Pediatric Dental Center in order to increase the knowledge of parents/guardians, as well as their tools for improving their children's oral health. This pediatric dental care facility is staffed by UF College of Dentistry faculty members: 23 staff members and 10 residents in Pediatric Dentistry. Since opening in 2007, more than 4 200 children have received dental treatment under general anesthesia, intravenous sedation, or oral sedation. The large majority of the patients were Hispanic, many of whom spoke only Spanish, and about 90% of them were insured by Medicaid. The purpose of this study was to determine the impact of the PM as an educational strategy to increase oral health knowledge in caregivers of children aged 2-5 years at high risk for dental caries.

MATERIALS AND METHODS

The research protocol of this study was reviewed and approved by the University of Florida Institutional Review Board (IRB) as exempted research, protocol number: 2015-U-0888. The study was conducted at the UF/ NCEF Pediatric Dental Center in Naples, Florida. A quasi-experimental study design was used with parents/caregivers of children aged 5 years or younger and on the waitlist for dental care under general anesthesia or sedation. A convenience sample of parents/caregivers (n=63) who agreed to participate and provided their documented informed consent was considered for the study.

A structured questionnaire in English and Spanish, consisting of 37 questions, was developed. It was comprised of two parts: Part I included socio-demographic characteristics (e.g., age, level of education, country of origin and number of children), and Part II included 18 items regarding parents/caregivers' knowledge on oral hygiene techniques, fluoride use, diet, and caries etiology. The possible scores on the knowledge assessment ranged from 0 to 18. The participants' level of knowledge was classified as "Good" (14-18), "Fair" (9-13), or "Poor" (0-8).

The survey was administered to parents/caregivers in the education room in which the activities were conducted by the Promotora, immediately before the PEI and three months later, when children returned for their recall appointment. After the parents/caregivers finished answering the questionnaire, the Promotora conducted a 30-minute educational activity, in which she shared strategies following the risk assessment guidelines and protocols from the American Academy of Pediatric Dentistry ²⁴24. American Academy of Pediatric Dentistry. Guideline on Caries-risk assessment and management for infants, children, and adolescents. Reference Manual. 201; 37(6): Available from: http://bit.ly/2kTARf1.
http://bit.ly/2kTARf1... . The session included information on caries initiation, transmission, fluoride benefits, early childhood tooth decay, and oral hygiene techniques.

Then, the Promotora answered all questions raised by the parents/caregivers. After their dental recall appointment at 3 months, parents/caregivers were administered the post-intervention questionnaire. Only 46 parents/caregivers completed the two phases.

The data were analyzed by using IBM SPSS Statistics V21.0 software package. Descriptive statistics (frequencies, percentage distribution) were generated, and chi-square test was conducted to assess whether the distribution of categorical outcome variables differed based on the socio-demographic characteristics of the participants. A paired-sample t-test was used to compare pre-intervention and post-intervention scores, under the null hypothesis that the mean difference in those scores was zero.

RESULTS

There were 63 participants in this study at baseline. Three months after the PEI, 46 participants (73.0%) completed the follow-up questionnaire. All but one were mothers or female caregivers of pediatric dental patients. The large majority (73.9%) of study participants were Hispanic and 41.3% had less than a high school education (Table 1). The mean age of their children was 3.6 years.

The questionnaire asked caregivers whether they agreed or disagreed with specific statements on oral health knowle dge, and they had the option to answer that they did not know. Before the PEI, 56.5% had "Good" knowledge on oral health, and after the PEI, 82.6% had "Good" knowledge on oral health (Figure 1).

Higher levels of oral health knowledge were found among participants with at least high school education than among those with less than high school education, both at baseline and three months post-PEI (Table 2), but oral health knowledge increased for both educational groups. Shows the mean knowledge scores before and after the PEI. Knowledge increased significantly for all domains except knowledge on healthy diet (Table 3).

All parents/caregivers agreed with the statement that it is important to brush their child's teeth daily, even before the PEI (Table 4). Agreement with the statement that drinking fluoridated water is a safe and effective way to prevent cavities doubled between pre-intervention (45.7%) and post-intervention (91.3%). Regarding knowledge about bacterial transmission, 73.9% of participants were aware before PE intervention and 93.5% afterwards. Finally, in the pre-PEI survey, 67.4% of participants agreed with the statement: "By the age of 1, children should not be drinking from a baby bottle." Agreement increased to 76.1% after the educational intervention.

DISCUSSION

The study found that parents/caregivers had relatively low levels of knowledge on oral health when first surveyed, but knowledge increased considerably after a Promotora-led educational intervention. Findings are comparable to other studies that also found relatively low levels of oral health knowledge among mothers of low socioeconomic status ²⁵25. Akpabio A, Klausner CP, Inglehart MR. Mothers'/guardians' knowledge about promoting children's oral health. J Dent Hyg. 2008; 82(1):12 Available from: http://bit.ly/2kQ02in.
http://bit.ly/2kQ02in... . Consistent with that observation, the study found a negative association between parents/caregivers' education level and their oral health knowledge. These results suggest that the educational level of the parents is related to their oral health knowledge. Also, evidence indicates that a higher level of education of the parents/ caregivers, as well as race, age, number of children and literacy ⁴4. Vann WF, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: Impact on oral health outcomes in early childhood. J Dent Res. 2010;89(12):1395-400. Available from: http://bit.ly/2mvhxoz.
http://bit.ly/2mvhxoz... , may be associated with the oral health status of the child. Using the Promotora Model may help deliver effective information to parents/caregivers of young children ⁸8. Hoeft K, Rios SM, Pantoja Guzman E, Barker JC. Using community participation to assess acceptability of "Contra Caries", A theory based, promotora-led oral health education program for rural Latino parents: a mixed methods study. BMC Oral Health. 2015; 15:103. Available from: http://bit.ly/2mPUJ33.
http://bit.ly/2mPUJ33... ^,1515. Anders RL, Balcazar H, Paez L. Hispanic community-based participatory research using a promotores de salud model. Hispanic Health Care International. 2006; 4(2):71-78. Available from: http://bit.ly/2mlBdLH.
http://bit.ly/2mlBdLH...

16. Balcazar H, Alvarado M, Hollen ML, et al. Salud para su Corazón-NCLR: A comprehensive promotora outreach program to promote heart-healthy behaviors among Hispanics. Health Promotion Practice. 2006; 7(1):68-77. Available from: http://bit.ly/2mUpVhQ.
http://bit.ly/2mUpVhQ...

17. Walton A, Calvo Y, Flores M, Navarrete L, Ruiz L. Promotoras: Observations and implications for increasing cervical cancer prevention and screening in the Hispanic community. Journal of the South Carolina Medical Association. 2009; 105(7):306-308.

18. Capitman JA, González A, Ramírez M, Pacheco TL. The effectiveness of a promotora health education model for improving Latino health care access in California's Central Valley. Fresno, CA: Central Valley Health Policy Institute; 2009. Available from: http://bit.ly/2mossk2.
http://bit.ly/2mossk2... ^-1919. Balcázar H, Alvarado M, Cantu F, Pedregon V, et al. A Promotora de Salud Model for Addressing Cardiovascular Disease Risk Factors in the US-Mexico Border Region. Available from: http://bit.ly/2kQj5sW.
http://bit.ly/2kQj5sW... ^,2121. Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the US-Mexico border. Health Education & Behavior. 2004; 31(4 suppl):18-28. Available from: http://bit.ly/2mvmXQr.
http://bit.ly/2mvmXQr... . The adaptation of this model holds great promise in increasing oral health-related knowledge and skills of underserved communities, which could lead to improve children's oral health status.

Regarding knowledge of bacterial transmission of cariogenic bacteria, this study found a statistically significant increase after the PEI. These findings are consistent with other studies in which knowledge of bacterial transmission risk factors, such as blowing on the child's food or sharing food or utensils, are considered acceptable behaviors ⁵5. Sanders LM, Federico S, Klass P, Abrams MA, Dreyer B. Literacy and child health: Systematic review. Arch Pediatr Adolesc Med. 2009;163(2):131-40. Available from: http://bit.ly/2mnyoda.
http://bit.ly/2mnyoda... ^,66. Watson MR, Horowitz AM, Garcia I, Canto MT. Caries conditions among 2-5 year- old immigrant Latino children related to parents' oral health knowledge, opinions and practices. Community Dent Oral Epidemiol. 1999; 27:8-15. Available from: http://bit.ly/2mtltWU.
http://bit.ly/2mtltWU... ^,2727. Ashkanani F, Al-Sane M. Knowledge, attitudes and practices of care-givers in relation to oral health of preschool children. Med Princ Pract. 2013; 22:167-72. Available from: http://bit.ly/2mNy1IS.
http://bit.ly/2mNy1IS... ^,2828. Sakai VT, Oliveira TM, Silva TC, Moretti AB, Geller-Palti D, Biella VA, et al. Knowledge and attitude of parents or caretakers regarding transmissibility of caries disease. J Appl Oral Sci. 2008;16(2):150-4. Available from: http://bit.ly/2mNTKAr.
http://bit.ly/2mNTKAr... . Educating parents on bacterial transmission may help reduce dental caries among children younger than 5 years of age.

Additionally, no change was found in knowledge of pa-rents/caregivers regarding healthy diet before and after PEI. These results are disappointing because other studies found that parents' lack of knowledge on diet negatively affect their children's oral health ³3. McKinney VL. The relationship between early childhood caries and ca-regivers' oral health knowledge and behavior among Medicaid-eligible children in North Carolina [thesis]. Chapel Hill, NC: University of North Carolina; 2006. Available from: https://unc.live/2kOwIZC.
https://unc.live/2kOwIZC... .

The issue of parents not agreeing with professional guidelines that "children should be weaned from using baby bottles by age 1" has been reported previously ⁸8. Hoeft K, Rios SM, Pantoja Guzman E, Barker JC. Using community participation to assess acceptability of "Contra Caries", A theory based, promotora-led oral health education program for rural Latino parents: a mixed methods study. BMC Oral Health. 2015; 15:103. Available from: http://bit.ly/2mPUJ33.
http://bit.ly/2mPUJ33... ^,2626. Schroth RJ, Brothwell DJ, Moffatt ME. Caregiver knowledge and attitudes of preschool oral health and early childhood caries (ECC). Int J Circumpolar Health. 2007; 66(2):153-67. Available from: http://bit.ly/2mvnYbd.
http://bit.ly/2mvnYbd... ^,2929. Horton S, Barker JC. Rural Latino immigrant caregivers' conceptions of their children's oral disease. J Public Health Dent 2008; 68 (1):22-9. Available from: http://bit.ly/2kQuGrX.
http://bit.ly/2kQuGrX... . An increase in agreement with that statement after the PEI was found, but a relatively large proportion of parents still disagreed with this recommendation or remained unsure about it.

This study had some limitations that may have affected the results. Some baseline participants were not available to complete the post-intervention questionnaire due to migration and seasonal moves, which reduced the sample size. The study findings may have been biased due to the number of patients lost to follow-up. Levels of familiarity completing a questionnaire and varying levels of language ability may have influenced responses, although an investigator fluent in both English and Spanish was always available during the completion of the questionnaire.

In conclusion, the results of this study show statistically significant increases in parents/caregivers' knowledge of oral health practices, bacterial transmission, and fluoride use following their participation in a Promotora-led educational intervention, across levels of educational attainment. It can be highlighted that the PM instituted in the University of Florida (UF)/Naples Children and Education Foundation (NCEF) Pediatric Dental Center, using a bilingual Promotora with experience in public health, was an appropriate educational approach that can be used at clinical/or community sites in order to increase parents/guardians' knowledge regarding their children's oral health. This study demonstrated that the Promotora model, developed for educational purposes, has given the parents that visit the UF/NCEF Pediatric Dental Center the necessary tools to understand the importance of their children's oral health. Also, the PM can be implemented in any region with a high prevalence of dental caries.

However, parents/caregivers' level of education ²⁹29. Horton S, Barker JC. Rural Latino immigrant caregivers' conceptions of their children's oral disease. J Public Health Dent 2008; 68 (1):22-9. Available from: http://bit.ly/2kQuGrX.
http://bit.ly/2kQuGrX...

30. Ardérius A, Veiga N, Godinho M, Ribeiro C. The influence of parents' educational level in children's oral health behavior. Public Health Res. 2015;5(1):28-31. Available from: http://bit.ly/2mnFuOQ.
http://bit.ly/2mnFuOQ... ^-3131. Miller E, Lee JY, DeWait DA, Vann WF Jr. Impact of caregiver literacy on children's oral health outcomes. Pediatrics. 2010;126(1):107-14. Available from: http://bit.ly/2kQ18uv.
http://bit.ly/2kQ18uv... continued to show a significant correlation with oral health knowledge after the intervention. Further research is needed to determine behavioral and disease outcomes following the Promotora intervention ♣

Acknowledgement:

None stated by the authors.

REFERENCES

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