Process evaluation of the CountryKIDS intervention trial – explaining the unexpected

Objectives: To report the results of a process evaluation of the implementation of a community-based oral health promotion program (Country KIDS) for preschool children living in rural Victoria. Methods: The Country KIDS project aimed to promote the oral health of toddlers by intervening during their first year of life through local Maternal and Child Health services. The primary focus of the intervention was the promotion of the early use of fluoride toothpaste and risk-based referral to dental services by Maternal and Child Health Nurses (MCHN). Careful process evaluation of the implementation of the program was conducted to provide enhanced information to more clearly interpret the intervention outcomes. The process evaluation utilised a number of tools including MCHN participant diaries, program resource-use tracking, and focus group discussions with MCHN in natural work units. Results: Completion and return of MCHN participation diaries was poor. Quantitative data from returned diaries was incomplete severely limiting measures of self reported toothpaste distribution and referral. Program resource use tracking monitored by research staff showed greater resource use than expected. Qualitative analysis of focus group data revealed significant variation among MCHN groups in program implementation fidelity due primarily to strong collective value systems of the participating MCHN. Conclusion: Process evaluation revealed significant unexpected modifications to the intended intervention protocols. These results have allowed a better understanding of the modest outcomes of the Country KIDS trial and reinforce the importance of including process evaluation in intervention design. This study was partially funded by a NHMRC Oral Health Strategy Grant