Sampling for this study, was ceased once the researcher believed that saturation had been reached, that is, when the data became repetitive (Hennink, Hutter, ...
‘We can do it the hard way or the easy way’ oral hygiene practices in pre-school aged children.
Stacey Amanda Bracksley Honours in Public Health
A dissertation submitted in partial fulfilment of the requirements for the degree of honours (Public Health)
Discipline of Public Health Rural Health School
La Trobe University, Bendigo, Victoria 3550 Australia
December 2011
Statement of Authorship
Except where reference is made in the text, the dissertation contains no material published elsewhere or extracted in whole or in part from work by me for another degree or diploma.
No others persons work has been used without due acknowledgment in the main text of this dissertation.
This dissertation has not been submitted for the award of any other degree or diploma in any tertiary institution.
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Signed
Date
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Acknowledgments
During the course of this study, I have been fortunate to come in touch with a variety of people. This is an attempt to convey to the reader, my appreciation for these people who directly or indirectly affected the course of this study. Firstly I would like to express my appreciation to my supervisors Associate Professor Mark Gussy and Dr Bernadette Ward for the time and effort they have spent guiding my through the daunting research experience. Without their support, I would not have learnt as much as I have. In addition, I would like to thank Dr Jon Willis for getting me over the line. I would also like to thank those mothers who agreed to be interviewed, for, without your time and cooperation, this project would not have been possible. To my fellow postgraduate students, thank you for all your support, wise words over coffee and positive encouragement throughout this journey. A special thanks to Nicole Johnson for her supply of baked goods and constructive criticism, which has been invaluable. Mostly I would like to thank my family, especially my parents for instilling in me a drive and confidence to do whatever I set my mind to. Lastly, I would like to thank my partner Shaun without your support and your ability to make great coffee; I would not have been able to complete this study.
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List of abbreviations AIHW- Australian institute of health and welfare DHSV- Dental health services Victoria DMFT- Decayed, missing, filled permanent teeth dmft- Decayed, missing, filled deciduous teeth ECC- Early childhood caries MS- Mutans Streptococci
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Table of Contents List of abbreviations.....................................................................................................................................iii Table of Contents ....................................................................................................................................... iiiv Abstract ......................................................................................................................................................... 1 Chapter 1 Background .................................................................................................................................. 2 1.1 Dental caries ....................................................................................................................................... 2 1.2 Dental caries in children ..................................................................................................................... 2 1.3 Early childhood dental caries .............................................................................................................. 3 1.4 Cost of Early Childhood Caries ............................................................................................................ 4 1.5 Rural comparison ................................................................................................................................ 5 1.6 Factors that contribute ....................................................................................................................... 5 1.7 Community-level influences ............................................................................................................... 6 1.8 Family-level influences........................................................................................................................ 8 1.9 Child-level influences .......................................................................................................................... 8 1.10 Parents are important ....................................................................................................................... 9 Chapter 2 Literature review ........................................................................................................................ 11 2.1 Search Strategy ................................................................................................................................. 11 2.2 General critique of literature ............................................................................................................ 11 2.3 Socioeconomic status ....................................................................................................................... 12 2.3.1 SES and reporting of oral health status ..................................................................................... 12 2.3.2 SES and access to dental care .................................................................................................... 12 2.3.3 SES and oral health attitudes ..................................................................................................... 13 2.4 Parents education levels ................................................................................................................... 13 2.4.1 Education and children’s caries rates ........................................................................................ 13 2.4.2 Education and oral hygiene of children ..................................................................................... 14 2.4.3 Education and child’s dental attendance................................................................................... 14 2.4.4 The relationship between education levels and oral health ..................................................... 14 2.5 Parents habits and behaviours ......................................................................................................... 15 2.5.1 Parents oral health habits .......................................................................................................... 15 2.5.2 Parents diet ................................................................................................................................ 15 iv
2.5.3Parents dental attendance.......................................................................................................... 16 2.5.4 Reason for parents last dental visit............................................................................................ 16 2.5.5 Parents previous dental experience .......................................................................................... 16 2.6 Parental attitudes ............................................................................................................................. 16 2.6.1 Mothers attitudes ...................................................................................................................... 17 2.6.2 Confidence of mothers .............................................................................................................. 17 2.7 Oral health knowledge ...................................................................................................................... 18 2.8 Aims and objectives .......................................................................................................................... 18 Chapter 3 Methodology .............................................................................................................................. 19 3.1 Qualitative research .......................................................................................................................... 19 3.1.1 Qualitative description ............................................................................................................... 20 3.2 Sampling ............................................................................................................................................ 21 3.2.1 Inclusion/ exclusion criteria ....................................................................................................... 22 3.3 Recruitment ...................................................................................................................................... 23 3.4 Interview schedule ............................................................................................................................ 23 3.5 Data collection .................................................................................................................................. 23 3.6 Data Analysis ..................................................................................................................................... 24 3.6.1 Analytical frameworks ............................................................................................................... 25 3.7 Ethics approval .................................................................................................................................. 25 3.8 Rigour ................................................................................................................................................ 26 3.8.1 Thick description and verbatim quotes ..................................................................................... 26 3.8.2 Audit trails .................................................................................................................................. 27 3.8.3 Self-reflexivity ............................................................................................................................ 27 Chapter 4 Results ........................................................................................................................................ 28 4.1 Dental practices ................................................................................................................................ 30 4.1.1 Child’s dental routine ................................................................................................................. 30 4.1.2 Mothers’ dental practices .......................................................................................................... 31 4.1.3 Professional care ........................................................................................................................ 32 4.1.4 Dental information..................................................................................................................... 33 4.2 Perceptions of dental health............................................................................................................. 33 4.2.1 Healthy teeth ............................................................................................................................. 33 4.2.2 Importance of teeth ................................................................................................................... 33 v
4.2.3 Children’s dental problems ........................................................................................................ 34 4.2.4 Recognition of dental disease .................................................................................................... 34 4.3 Learning............................................................................................................................................. 35 4.3.1 Child’s learning ........................................................................................................................... 35 4.3.2 Behaviour modelling .................................................................................................................. 36 4.3.3 Mothers learning........................................................................................................................ 36 4.3.4 Mothers knowledge ................................................................................................................... 37 4.4 Parenting ........................................................................................................................................... 37 4.4.1 Parenting goals........................................................................................................................... 37 4.4.2 Parenting practices .................................................................................................................... 38 4.4.3 Parenting experience ................................................................................................................. 39 4.4.4 Parenting confidence ................................................................................................................. 39 4.4.5 Parenting priorities .................................................................................................................... 39 4.4.6 Parenting support ...................................................................................................................... 40 Chapter 5 Discussion ................................................................................................................................... 41 5.1 Proximal and distal factors................................................................................................................ 41 Figure 5.1 Proximal and distal model- a visual representation of the proximal and distal factors in this study. ............................................................................................................................................ 42 5.2 Health Belief Model .......................................................................................................................... 44 Figure 5.2 a visual representation of the Health Belief Model ........................................................... 45 Table 5.1 a breakdown of the proximal and distal factors and where they fit within the Health Belief Model .................................................................................................................................................. 46 5.2.1 Perceived susceptibility.............................................................................................................. 46 5.2.2 Perceived severity ...................................................................................................................... 48 5.2.3 Perceived benefits...................................................................................................................... 49 5.2.4 Perceived barriers ...................................................................................................................... 49 5.2.5 Cues to action ............................................................................................................................ 51 5.2.6 Self-efficacy ................................................................................................................................ 52 5.2.7 Summary of Health Belief Model ............................................................................................... 52 Chapter 6 Conclusions and recommendations ........................................................................................... 54 6.1 Recommendations ............................................................................................................................ 55 6.1.1 Future research .......................................................................................................................... 55 vi
6.1.2 Future practice ........................................................................................................................... 55 6.1.3 Participants recommendations .................................................................................................. 56 6.2 Conclusion ......................................................................................................................................... 56 6.3 Strengths of the study....................................................................................................................... 57 6.4 Limitations of the study .................................................................................................................... 57 References .................................................................................................................................................. 59 Appendices.................................................................................................................................................. 69 Appendix one- Flyer ................................................................................................................................ 70 Appendix two- Consent to be contacted ................................................................................................ 71 Appendix three- Interview schedule ....................................................................................................... 72 Appendix four- Ethics approval form ...................................................................................................... 73 Appendix five-Plain language statement ................................................................................................ 74 Appendix six- Consent form...................................................................................................................75 Appendix seven- Withdrawal form ......................................................................................................... 76
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Abstract Aim: The aim of this study was to explore the barriers and facilitators mothers’ experience when implementing oral hygiene practices in their pre-school aged children.
Method: This study utilised a qualitative approach and a descriptive study design. The sample included seven mothers with a pre-school aged child over the age of two and was selected using purposive and network sampling. Participants were required to partake in a 40 minute semi-structured audio recorded interview. Data obtained was coded and analysed using thematic analysis.
Findings: There were four main themes identified: dental practices; perceptions of dental health; learning and parenting. Participants discussed dental routines including past practices and changes to the routine. Dental practices refer to the mothers own dental practices, professional dental care routines, dental information and the sources of information. Participants discussed the health and importance of children’s deciduous teeth, and could list some dental problems children face, including appearance and pain as the signs of dental disease in children. Learning occurred with both the mother and their child and included learning about dental practices and the importance of these practices. The participants had an overall goal of their child having healthy teeth, with some of the participants having practices in place to achieve that goal. The experiences of being parents and their confidence in relation to dental practices were discussed. All the participants had differing priorities in relation to dental health. These findings can be interpreted using frameworks such as Health Belief Model and proximal and distal factors, and these interpretations can inform future dental practice and policies.
Conclusion: The mothers in this study discussed similar barriers for the implementation of oral hygiene practices in pre-school aged children. Furthermore, awareness needs to be raised about the seriousness of dental disease in young children with mothers. The data strongly support the need for further research into this topic as well as education programs for mothers with pre-school aged children.
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Chapter 1 Background 1.1 Dental caries There are numerous types of dental diseases; however, the main type affecting adults and children alike is dental caries. Dental caries is an infectious disease that affects the hard tissues of the oral cavity. Numerous aetiological factors must be present for the disease process to occur (Gussy, Waters, Walsh, & Kilpatrick, 2006). These factors include: fermentable carbohydrates from a person’s diet; cariogenic microorganisms in the persons mouth; and a susceptible tooth/host (Fejerskov & Kidd, 2008). The major cariogenic bacteria involved in dental caries is Mutans streptococci (MS)(Habibian, Beighton, Stevenson, Lawson, & Roberts, 2002). Bacteria in the plaque metabolise the substrate (sugars and starches mainly from a person’s diet) to produce acid. The acid lowers the pH in the mouth, this promotes mineral loss from the surface of the tooth, by acid diffusing into the tooth and breaking down mineral crystals (Featherstone, 2004).These minerals can be redeposited back into the tooth when pH has neutralised. This process generally occurs numerous times per day. If it is unbalanced or minerals are not being replaced this leads to weakening of the tooth and eventual break down (dental cavity) (Featherstone, 2004). Dental caries is a dynamic process that has different stages of progression, from the sub-clinical stage to white spot lesions to the breakdown of the tooth surface into a cavity (Featherstone, 2004). The very early stages of this disease process may not be visible to the human eye or cause symptoms (Fejerskov & Kidd, 2008).
1.2 Dental caries in children Dental caries has a significant impact on children’s wellbeing and overall health. It has been reported as one of the most prevalent chronic childhood diseases (Isong et al., 2010; Kelly, Binkley, Neace, & Gale, 2005; Southward et al., 2006), with it being five times more common than asthma (Filstrup et al., 2003). Dental caries can have a range of impacts on the child from dental pain, affecting growth and cognitive development due to lost school days (Fejerskov & Kidd, 2008). The exact prevalence of dental caries in Australian children in 2011 is unknown. However the prevalence data for the population of children aged 5-12 years from 2005 indicate that nearly half the children experience a carious lesion. Furthermore about 40% of children aged between 5-6 years had untreated caries present (Armfield, Roberts-Thomson, & Spencer, 2003). This was confirmed by a study undertaken in Western Australian which found that children age 6 years had the highest rate of dental caries (Kruger, Dyson, & Tennant, 2005). However, the prevalence may be higher as this data was
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obtained only from children that were enrolled in the state and territories school dental services, Victoria and New South Wales were excluded due to insufficient data.
1.3 Early childhood dental caries Dental caries in pre-school aged children is known as early childhood caries (ECC). Another form of this disease is classified as severe ECC and is dependent on the child’s age. ECC is defined as, at least one carious lesion in the deciduous dentition (Drury et al., 1999), whereas severe ECC is defined as a child under 36 months having a carious lesion on a smooth surface maxillary anterior tooth or a child of the ages 3, 4, 5 having a dmfs (decayed, missing, filled surface) score of 4, 5, 6 respectively (Drury, et al., 1999). ECC is a virulent form of dental caries (Milnes, 1996). The clinical presentation of the disease can range from one carious lesion to gross destruction of the teeth (Wyne, 1999). In the past ECC has been defined as terms such as nursing caries or bottle caries; however these terms implied that caries could only occur while the child was nursing and implied only the front teeth were being affected (Milnes, 1996; Wyne, 1999). In Australia little is known about the prevalence of ECC in the pre-school aged population (Neumann et al., 2011). This is due to a low proportion of this age group visiting a dentist (Slack-Smith, 2003) and the lack of monitoring systems for this age group. Although the study conducted by Slack- Smith (2003) is eight years old, it is the only accurate rate available due to this age group being hard to survey. This difficulty is due to no uniformed monitoring systems and the low rates of dental attendance for this 0-4 age group. For example, it was found only 12% of two year olds and 26% of three year olds in Australia have visited a dental professional respectively (Slack-Smith, 2003). Furthermore, it has been suggested that the rate of caries is higher in children from more disadvantaged social groups (Neumann, et al., 2011; Tran, Gussy, & Kilpatrick, 2010). Less is known about ECC compared to dental caries in other age groups. What is known is that ECC is a rapid and progressive disease and can have serious consequences for the child’s oral and overall health (Neumann, et al., 2011). ECC is known to be a more severe disease than caries in other age groups, with it being more destructive and virulent (Milnes, 1996). It is more destructive as this disease has a typical pattern of affecting the smooth surfaces of teeth; it is these surfaces that are easily cleaned and therefore usually less susceptible. ECC is believed to have a similar aetiology to the other type of caries however, it is still unclear what the predisposing factors are (Almeida, Roseman, Sheff, Huntington, &
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Hughes, 2000). This lack of understanding is in part to difficulties accessing this population, as mentioned earlier.
1.4 Cost of Early Childhood Caries The cost of ECC is extensive with communities, families and children all affected. The consequences of this disease for children are significant. These factors will be discussed in detail in this section. Due to the severity of the disease and the difficulty of treating it in very young children, it is likely to result in significant cost to the community, although exact figures are unknown. Restorative treatment often is provided in an operating room environment under general anaesthesia (Casamassimo, Thikkurissy, Edelstein, & Maiorini, 2009; Kanellis, Damiano, & Momany, 2000). The majority of children are not able to receive care in regular dental clinic settings, due to behavioural issues or not being able to cope with treatment (Quiñonez, Gibson, Jokovic, & Locker, 2009). The cost of general anaesthetics is much higher than other treatment options such as treatment carried out in the dental chair (Kanellis, et al., 2000). In Australia there is no monitoring system for the total cost of general anaesthetics for dental treatment. However, in the United States of America an estimated cost was between US$ 1700- US$ 2000 American dollars per general anaesthetic (Kanellis, et al., 2000). One Australian study explored the cost in Western Australia for treatment from infant to 18 years of age and found it to be a total of $111 million dollars just for the hospitalization costs for dental treatment under general anaesthetic (Tennant, Namjosh, Silva, & Codde, 2000). This does not include in chair treatment or the other costs faced by parents and the children themselves (Tennant, et al., 2000). There is also a burden both emotionally and economically to the parents/caregivers of children with ECC and the children themselves. Due to the nature of treatment for ECC, in the majority of cases being general anaesthetic, parents have the stress of the risk involved with this form of treatment. This procedure also has risks for the child’s overall health (Casamassimo, et al., 2009). There is emotional costs to the child who is in pain and has to go through an unknown and daunting process for treatment (Casamassimo, et al., 2009). In addition, the parents have the cost of paying for the treatment if it is not covered by public dental systems (Casamassimo, et al., 2009). Furthermore, additional costs can include the parent’s loss of income to attend dental appointments; cost of childcare and travel costs to attend appointments (Tran, et al., 2010). The consequences of ECC in children are significant; there are both short and long-term consequences. Short term consequences include pain, systemic infections and abscesses which can lead to hospital 4
admission to treat these consequences as well as the caries (Gussy, et al., 2006). Pain from toothaches can impact on a child’s growth due to altering eating and sleeping habits (Fejerskov & Kidd, 2008). In addition the long term effects include impacts on the child’s speech, space loss in the child’s mouth causing crowding of permanent dentition (Hoeft, Barker, & Masterson, 2010). Moreover, dental caries affects a child’s cognitive and growth development, as caries can interfere with nutrition and concentration at school (Gussy, et al., 2006). Finally, caries in the primary dentition has also been shown to be the best predictor of caries in the permanent dentition (Gussy, et al., 2006).
1.5 Rural comparison Children in rural areas have poorer oral health outcomes. A report conducted by AIHW in 2001, compared children from rural and remote areas to metropolitan areas, to ascertain if there was a difference in caries rates. This study found that in children aged 4-10 years (children with deciduous dentition) and 6 to 15 years (children with some permanent dentition) experience higher caries rates in rural areas. It is assumed that children less than 5 years old in rural areas would follow the same trend as rural children in other age groups and would suffer with higher rates of ECC. The exact figures of ECC are unknown. As mentioned earlier this is due to the lack of monitoring systems. However, the same factors such as lack of access, un-fluoridated water supplies that affect the other age groups would also affect this age group. What is known is that children aged 0-4 years in rural and regional areas had four times higher hospital admission rates for dental problems than their metropolitan counterparts (Victorian Government Department of Human Services, 2007).
1.6 Factors that contribute There are numerous environmental, parental and childhood factors which can contribute to children’s oral health. Oral health is a major component of general wellbeing and health, the mouth cannot be viewed as a separate entity (Patrick et al., 2006). Therefore, it may be assumed that factors that contribute to a young child’s overall health may also contribute to their oral health. A conceptual model developed by Fisher-Owen and colleagues (2007) puts forward a framework to view the influences on a child’s oral health. The conceptual model consists of environmental factors, parental factors and child
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factors (Fisher-Owens, et al., 2007).
1.7 Community-level influences A child’s environments and environmental factors can have an influence on their oral health. A discussion of these factors will include the physical environment, community oral health environment, dental care system characteristics and culture. A child’s physical environment can influence their oral health and these factors can include their water supply, population density and access to public transportation (Fisher-Owens, et al., 2007). The circumstances in which a person lives and can influence their general health (Watt, 2007). Water 6
fluoridation increases a child’s intake of fluoride, having a positive effect on a child’s dentition (Petersen & Lennon, 2004; Stecksén-Blicks, Sunnegårdh, & Borssén, 2000). In Australia the introduction of fluoride into the water supplies began in 1964 in Hobart. By 1977 every capital city in Australia except Brisbane had fluoridated water supplies (Armfield & Spencer, 2004). However, there are still many rural towns in Australia that do not have fluoridated water supplies. As a result children in rural areas may be exposed to non-fluoridated tap water or may be drinking non-fluoridated tank water (de Silva-Sanigorski et al., 2011). Population density is a measure of how available resources are to a community. If the population density is higher, this population will have better access to green groceries, healthy food options and dental services (Fisher-Owens, et al., 2007). For example, the availability of dental services decreases with increasing remoteness (Marshall & Spencer, 2006). Transportation is also a big factor in the ability to access resources (Fisher-Owens, et al., 2007). Positive community efforts such as oral health promotion campaigns and public policy improve children’s oral health. Oral health promotion in school or pre-school settings can have a positive influence on a child’s oral health (Moysés, Moysés, Watt, & Sheiham, 2003). In Victoria some preschools can participate in a program called Smiles 4 Miles (Dental Health Services Victoria, 2011a). This program targets: nutrition policies in the preschool; parent engagement activities; food and drink surveys of the children’s lunch boxes and curriculum activities that promote the healthy messages (Dental Health Services Victoria, 2011a). If a child is from a community that values good oral health then they are likely to have better oral health outcomes (Fisher-Owens, et al., 2007). The characteristics of the dental services that a child has access to influences their oral health. The options for dental care in Australia include public or private dentists. However, there is a maldistribution of dental professionals in Australia (Marshall & Spencer, 2006). Furthermore, the majority of private dentists ‘refuse’ to see pre-school children (Patrick, et al., 2006, p. 8 ). The other alternative is public dental clinics. In Victoria free dental checkups or reduced rates for checkups have been introduced for children aged 0-12 years at public dental clinics, to increase attendance rates (Dental Health Services Victoria, 2011b). Culture influences the beliefs and practices of people and can hinder or facilitate oral health practices and accessing health services. The literature surrounding this issue is varied due to different cultures holding different beliefs and practices (Butani, Weintraub, & Barker, 2008). Different cultures have varying rates of caries (Fisher-Owens, et al., 2007). This could be due to numerous reasons, firstly cultural beliefs and practices may influence diets of children (Fisher-Owens, et al., 2007). Also, in general 7
many cultures have some form of traditional medicine to treat dental problems (Butani, et al., 2008). Therefore, it may be perceived by people who have traditional medicine to treat diseases that dental visits are for problems and not preventative care (Butani, et al., 2008; Fisher-Owens, et al., 2007).
1.8 Family-level influences Children’s oral health can be influenced by family factors and characteristics. Family factors include: family composition; socioeconomic status; and the parent’s health behaviours and practices. The structure of families and how they function may influence children’s oral outcomes. First born children are less likely to have dental caries (Kawashita et al., 2009). While children from single parented or reconstituted families have an increased likelihood of caries lesions (Fisher-Owens, et al., 2007). The socioeconomic status of parents has both a direct and indirect influence on their child’s oral health. There is a correlation between the parents’ social class and the frequency of tooth brushing. Children with parents from a low social class report a lower frequency of tooth brushing (Gibson & Williams, 2000). Furthermore, an association between parent’s socioeconomic status and a higher consumption of confectionary is present in the literature (Gibson & Williams, 2000). Socioeconomic status has been shown to affect understanding of health (health literacy), which in turn affects health (Fisher-Owens, et al., 2007). Parents, but mainly mothers’ health behaviours can have both a negative or positive effect on their child’s oral health. Mothers are the principal source of MS for infants (Li et al., 2011). It is thought that these bacteria need the presence of teeth or non-shedding surfaces for stable colonisation; children are not born with this bacteria in their mouth they acquire it once a tooth has erupted (Li & Caufield, 1995). The transfer of this bacterium is through saliva (Harris, Nicoll, Adair, & Pine, 2004). Thus it is usually passed from mother to child through the sharing of eating utensils or the sucking of the pacifier (Gussy, et al., 2006; Kawashita, et al., 2009; Suresh, Ravishankar, Chaitra, Mohapatra, & Gupta, 2010). Transmission of cariogenic bacteria in the first year of life is associated with development of caries in early childhood (Boyce et al., 2010). It is believed that mothers who brush their teeth less may be less inclined to brush their child’s teeth (Kawashita, et al., 2009).
1.9 Child-level influences Finally, individual factors will be discussed that influence children’s oral health. These include physical attributes and health behaviours and practices 8
A child’s physical health can have an effect on the oral cavity. Low birth weight babies or children with poor nutrition in early life have an increased chance of developing teeth with hypoplasia (Peres et al., 2005). Hypoplasia is a condition which affects the enamel of developing teeth. These teeth are under developed and are therefore weaker and more readily colonised by MS. As a result of this the teeth are more susceptible to caries (Cameron & Widmer, 2008; Peres, et al., 2005). Another factor is the link between malnutrition in children and reduced secretion of saliva (Peres, et al., 2005). This is important as saliva acts as a buffering agent and is a protective factor against the development of caries (Fejerskov & Kidd, 2008). Many preventative actions have been put into place to lessen the burden of dental disease. Firstly fluoride has been regarded as the most effective measure in preventing caries (Hoeft, et al., 2010). Children who brush with fluoride toothpaste will have less dental caries (Marinho, Higgins, Sheiham, & Logan, 2003). Furthermore, diet can be a major risk factor, the high frequency of sugary foods and drinks increase a child’s likelihood of developing ECC (Hoeft, et al., 2010). Feeding practices also significantly increases the likelihood of a child developing ECC, such as taking a bottle to bed. Also the bottle contents such as juice, cordial and soft drink have a negative effect on a child’s oral health (Hallett & O'Rourke, 2003). Frequency of sugary foods has greater effect on the rate of caries than the amount (Gibson & Williams, 2000). Another factor that affects rates of ECC is brushing habits. If tooth brushing is commenced at an earlier age and is completed twice a day then the number of caries lesions is a lot lower (Gibson & Williams, 2000; Hallett & O'Rourke, 2003). Finally, children with poor oral hygiene were found to have higher rates of the cariogenic bacteria MS present in their oral cavity (Habibian, et al., 2002).
1.10 Parents are important Parents influence their child’s oral health and have also been shown to play a major role in other childhood health issues for example parents decide whether their child will receive vaccinations (Chen et al., 2011). Parents’ health literacy has been linked to child health care. A lower level of this has been associated with lower levels of health knowledge and healthy behaviours. Moreover parents’ health literacy can interfere with correct dosages of medications to their children (Shone, Conn, Sanders, & Halterman, 2009). In addition to this, asthma medication adherence in preschool age children is dependent on parents. Children do not have the knowledge to recognise the need for the medication; therefore, the responsibility lies with the parents (Rand, 2002).
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Parents play a major role in their children’s oral health. Parents rather than the children determine the social and behavioural environment that shapes the oral health practices (de Silva-Sanigorski et al., 2010). These conditions and habits such as dietary habits, dental attitudes and healthy behaviours that are established in pre-school years provide a foundation for oral health behaviours and use of dental services later on in life (Suresh, et al., 2010). Moreover, conditions and habits that are established are dependent on guardians and caregivers, especially mothers (de Silva-Sanigorski, et al., 2010; Suresh, et al., 2010). Accordingly, the literature review will explore parental factors that can influence a child’s oral health. Due to the complex nature of ECC and the disease process not fully understood. Many studies conducted with children do not differentiate between dental caries and ECC. Due to this both dental caries and ECC studies were included.
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Chapter 2 Literature review
In the last chapter it was established that parents play a significant role in children’s general and oral health. Therefore, this chapter provides an exploration of the literature surrounding parental influences on their children’s oral health. The literature varies; some studies include both parents, however, the majority of the literature focuses on mothers. It has been demonstrated that there is a stronger association between dental caries in mother and children rather than fathers and their children (Okada et al., 2002). Evidence to support this will be provided in this chapter. Parents are children’s primary caregivers even though over the last 2 decades there has been a shift in the ‘daily’ caregiver. In Australia in 2008 there were 1.5million children in some form of childcare (Australian Bureau of Statistics, 2010). Out of these children in care the highest percentage per age group is 3 years of age, with 50% being in some form of informal or formal day care. These informal types of day-cares can include grandparents or family members. However, for all age groups the average amount of hours spent in day-care was 17 hours a week (Australian Bureau of Statistics, 2010). Although, there has been an increase in children in care parents and mothers are still the main influence on children’s oral health behaviours and this chapter demonstrates this.
2.1 Search Strategy The time frame for the literature search was from 1995 to 2011. This period was selected due to decreasing trend in caries rates finishing in the late 1980’s. Therefore, other factors that influence caries would be researched in detail during the selected time frame. The following databases were searched for relevant literature; Proquest, Scopus, Medline. Using a selection of the following key terms; mother*, father*, caregiver*, guardian*, parent*, maternal, paternal, step-parent*, child*, early child*, pre-school child*, attitude*, practice*, belief*, intention*, knowledge, along with either dental or oral health or teeth. The articles obtained from the searches of these databases, were then used to find more relevant articles by using the articles reference lists.
2.2 General critique of literature Overall, the majority of the studies used in this review utilised quantitative research methods. Of the quantitative studies, the majority were cross-sectional design. This study design demonstrates only association relationships and not cause and effect. In addition, a majority of studies obtained the study sample from non-probability sampling. This form of sampling does not provide data that allows for 11
generalisablity. Furthermore, most studies were conducted overseas; therefore, further limiting the generalisations that can be made to the Australian context. Finally, the measurement of caries in all studies was the dmft (decayed, missing or filled teeth for deciduous dentition) or DMFT scores (decayed missing or filled teeth for permanent dentition). This in itself is an accurate measure; however, no studies differentiated between dental caries and ECC.
2.3 Socioeconomic status Different measures of socioeconomic status were used in the literature; however, the same conclusion was reached. These measures were: the level of household income; address of the school the child attends; level of formal education of the parents; what newspaper is read; number of cars the family owned; postal code of where the family lives; if the child receives free school lunches; social class and medical insurance coverage. Comparisons between the studies are difficult to make due to the many different classification of socioeconomic status. Thus, the comparisons made may not be entirely accurate. This being said the conclusions reached by all studies is that low socioeconomic status is associated with an increased risk of developing dental caries (Al-Mohammadi, Rugg-Gunn, & Butler, 1997; Bonanato et al., 2009; Peres, et al., 2005; Pine et al., 2004; Schou & Uitenbroek, 1995; Tagliaferro, Pereira, Meneghim, & Ambrosano, 2006). 2.3.1 SES and reporting of oral health status Parents’ socioeconomic status affects the way they perceive their child’s oral health. Parents with a lower socioeconomic status report their child’s oral health to be worse, whereas parents with a higher income report their children as having better oral health (Talekar, Rozier, Slade, & Ennett, 2005). Only one study found this association. However, the data used was secondary data from a national survey and confirmation by other studies has not occurred. 2.3.2 SES and access to dental care Dental attendance is less frequent in children that come from low socioeconomic families. Income levels are a factor in accessing dental care, with parents with a higher income accessing services more frequently (Kelly, et al., 2005). Southward and colleagues (2006) who found that children from low income families were less likely to receive comprehensive dental care and have higher rates of caries. However, a limitation to these findings is that, non-probability samples were utilised. Therefore, caution when generalising these to a wider population is needed. A suggestion to explain these findings was
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that financial constraints acts as a barrier to accessing dental care (Gao et al., 2010), with parents stating that they worry about the cost of treatment (Kelly, et al., 2005). 2.3.3 SES and oral health attitudes Numerous studies report associations between socioeconomic status and parental knowledge and attitudes towards oral health (Abiola Adeniyi, Eyitope Ogunbodede, Sonny Jeboda, & Morenike Folayan, 2009; Al-Mohammadi, et al., 1997; Gao, et al., 2010). Gao and colleagues (2010) found an association between high socioeconomic status and better knowledge/attitudes towards oral health and dental treatment. Similarly, Abiola Adeniyi and colleagues (2009) found mothers’ social classes can be associated with the child’s oral health status. A hypothesis for this may be parents with a higher socioeconomic status are aware of caries prevention and put preventative measures into practice (AlMohammadi, et al., 1997). These studies were cross-sectional; therefore, correlation and not causation has been demonstrated. While there are no Australian studies; comparisons may, therefore, not be valid due to different cultural backgrounds.
2.4 Parents education levels Parental education levels play a key role as a determinant of a child’s oral health status. This is specifically low education attainment correlates with poor child oral health (Watson, Horowitz, Garcia, & Canto, 1999). Parental education levels refer to the formal education level obtained rather than specifically oral health education and knowledge. The research falls into two categories. Firstly, studies based on parental education levels (Kelly, et al., 2005; Poutanen, Lahti, Tolvanen, & Hausen, 2006; Rajab, Petersen, Bakaeen, & Hamdan, 2002; Talekar, et al., 2005) and secondly, research which focused on the mothers’ level of education (Grindefjord, Dahlof, Nilsson, & Modeer, 1996; Mattila, Rautava, Sillanpaa, & Paunio, 2000; Suresh, et al., 2010; Tagliaferro, et al., 2006; Watson, et al., 1999). Despite differences in methodology these studies found that irrespective of child’s age, parental education was found to have the same outcome regarding the child’s oral health. 2.4.1 Education and children’s caries rates Parents’ formal education levels have been linked to their child’s rate of carious lesions; the lower the education of the parents, the higher the caries rates in their child. Peres and colleagues (2005) found that low education levels are linked to higher rates of caries in their children, whereas higher education of a parent is associated with better oral health outcomes (Skeie, Riordan, Klock, & Espelid, 2006). These findings were confirmed by the study prepared by Psoter and colleagues (2006) who found as the
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parents’ education increased, the risk of childhood caries decreased. The findings reported in the literature support the hypothesis that the higher the parents’ education, the lower the prevalence of dental caries in children (Kinirons & McCabe, 1995; Psoter, et al., 2006). Parents with a lower education rate their child’s oral health to be worse, where the opposite applies for parents with a higher education (Rajab, et al., 2002; Talekar, et al., 2005). 2.4.2 Education and oral hygiene of children The level of parents’ education influences the oral hygiene status of their children, the lower the education the worse the child’s oral hygiene. Abiola Adeniyi and colleagues (2009) found a correlation between mothers’ education levels and their children’s oral hygiene. This finding was further supported by Rajab and colleagues (2002) who reported tooth brushing was less frequent in families with a lower education. Furthermore, mothers’ education levels have an effect on their child’s dental attendance (Kinirons & McCabe, 1995). However, these studies were cross-sectional; therefore, a cause effect relationship cannot be determined. Also studies by Abiola Adeniyi and colleagues (2009) and Rajab and colleagues (2002) were conducted in countries with a lower average income than Australia, meaning the results may not be relevant to the Australian context. 2.4.3 Education and child’s dental attendance A child will attend the dentist more frequently if their parents are well educated, whereas the opposite is true for lower educated parents’ children. The three studies that reported these findings cannot state this is a cause and effect relationship, as two were cross-sectional studies (Petersen, Danila, & Samoila, 1995; Williams, Whittle, & Gatrell, 2002) and the third was a qualitative design (Kelly, et al., 2005). The studies conducted by Kelly and colleagues (2005) and Williams and colleagues (2002) were from countries that have similar economic climates to Australia. However, these countries have very different health care systems and the results may be due in part to health care structure in that country and less so to parents’ education levels. 2.4.4 The relationship between education levels and oral health There is no definitive reason as to why parents and/or mothers’ education influences their oral health however two hypotheses have been made. These are in regards to higher knowledge of health issues and higher understanding of preventative measures. Firstly, a hypothesis is that parents with a high education level can establish better oral health behaviours as these parents have better knowledge of health issues and how they can be prevented (Campus et al., 2009). Secondly, lower education indicates a lower understanding of preventative behaviours. This could be another reason why children from 14
lower educated families are at increased risk for dental caries (Tagliaferro, et al., 2006). However, Campus and colleagues (2009) and Tagliaferro and colleagues (2006) have not tested these hypotheses; these were secondary observations to the aim of the study.
2.5 Parents habits and behaviours Numerous parental behaviours and habits have been demonstrated to influence the oral health status of their children. Many studies were found that explored these behaviours and habits (Abiola Adeniyi, et al., 2009; Hilton, Stephen, Barker, & Weintraub, 2007; Leroy, Hoppenbrouwers, Jara, & Declerck, 2008; Mattila, et al., 2000; Saied-Moallemi, Virtanen, Ghofranipour, & Murtomaa, 2008; Sasahara, Kawamura, Kawabata, & Iwamoto, 1998; Schou & Uitenbroek, 1995; Shenkin, Broffitt, Levy, & Warren, 2004; Southward, et al., 2006; Watson, et al., 1999; Wigen, Skaret, & Wang, 2009; Williams, Kwan, & Parsons, 2000) and from these three major sub- themes emerged: parents own oral and general health habits; parents dental attendance and parents behaviours. 2.5.1 Parents oral health habits Parents own oral health care practices can have an effect on their children’s oral health status. Schou and colleagues (1995) found that if the parents had good oral hygiene and brushed their own teeth, their children would have lower rates of caries. However, this study did not explore the reason for this finding. Other studies have confirmed this finding (Abiola Adeniyi, et al., 2009; Saied-Moallemi, et al., 2008); however, the study populations were mothers. It was hypothesised that mothers with good oral hygiene practices may have a positive attitude towards oral care (Abiola Adeniyi, et al., 2009; SaiedMoallemi, et al., 2008). Furthermore, a study by Southward and colleagues (2006) found this same association however, it used the measure of mothers flossing. If their mothers did not floss, children would have higher carious rates (Southward, et al., 2006). Moreover, if a mother has two or more carious lesions, then it has been shown to increase the likelihood of the child having a carious lesion (Mattila, et al., 2000). This could be due to mothers having a biological role of the first microbial colonization in their child’s mouth (Mattila, et al., 2000). The study by Mattila and colleagues (2000) was a longitudinal, however, all others studies were cross-sectional. 2.5.2 Parents diet Parents’ diet has been shown to have an effect on their child’s rates of carious lesions. A study also found daily parental consumption of soft drink was associated with their child’s oral health (Southward, et al., 2006). It was also found was mothers’ working status play a role in caries development. It was
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shown children had more carious lesions if their mother worked. It was hypothesised that this could be due to grandparents babysitting the children whilst the parents are at work and spoiling them with frequent sugary snacks (Sasahara, et al., 1998). 2.5.3Parents dental attendance Children will attend the dentist more regularly if their parents’ have a dentist to attend themselves and attend for preventative reasons (Isong, et al., 2010; Schou & Uitenbroek, 1995). This was further supported by Wigen and colleagues (2009) who found that if parents do not prioritise their own dental needs, they will not take their child to the dentist. These same studies (Isong, et al., 2010; Schou & Uitenbroek, 1995) found that the parents own oral health seeking behaviours (whether parents seek the dentist for preventative reasons or due to pain) were associated with their child’s dental health status. However, the study conducted by Schou and colleagues had a low response rate. This response rate could affect the results as only the very motivated people participated. 2.5.4 Reason for parents last dental visit The reason for the mothers’ last visit to the dentists has also been shown to affect caries rates in their children. There was only one study that found this association and this study was found with mothers. Watson and colleagues (1999) found if pain was the last reason for attending the dentist, then their child was shown to have three or more carious teeth. A hypothesis given was mothers who were not regular attendees at the dentist would not be receiving preventative advice. Another possibility would be these mothers have high levels of streptococci in their mouth due to untreated dental caries which may be passed onto their children. However, the sample was obtained through convenience sampling and therefore the results cannot be generalised to a larger population. 2.5.5 Parents previous dental experience The parents’ previous dental experiences will influence whether they will take their child to dentist. Hilton and colleagues (2007) found that if the parent had a fear of the dentist, then they were reluctant to expose their children to possible trauma. However, the results of this study cannot be generalised to a wider population as the methods utilised were qualitative. Furthermore, these results have not been reciprocated in any other studies.
2.6 Parental attitudes Positive parental attitudes have been linked to a higher dental attendance rate for children. Parental attitudes towards oral health behaviours influence the child’s oral health behaviours (Adair et al., 2004). 16
These parental attitudes can affect the use of preventative dental care and professional services accessed for their children (Talekar, et al., 2005). Kelly and colleagues (2005) found children would access preventative dental appointments more frequently when their parents had positive attitudes or the belief in the importance of oral health for overall health, whereas parents who report oral health to be not as important as overall health children access preventative dental services less frequently (Kelly, et al., 2005). Research by Wigen and colleagues (2009) found parents have negative attitudes towards dental care or put oral health as a low priority if they do not have a dentist to attend. All these studies were conducted overseas, so may not relate to the Australian context. However, the study conducted by Adair and colleagues (2004) was conducted in 17 different countries and found the same results from all the different countries. This means that cultural differences may not influence these results. 2.6.1 Mothers attitudes Other studies have only taken into account mothers’ attitudes and oral health knowledge. Similarly, mothers’ overall attitudes and the attitudes towards their child’s oral health were linked with caries occurrence and oral hygiene status (Abiola Adeniyi, et al., 2009). Positive maternal attitudes were associated with an increase in the child’s tooth brushing, a decrease in carious lesions and good oral hygiene in their children (Abiola Adeniyi, et al., 2009; Saied-Moallemi, et al., 2008). Kinirons and colleagues (1995) found children were more likely to attend dental visits if their mothers had a positive attitude towards dental care and were more relaxed about dental treatment. All studies sample methods were non-probability, therefore generalisations cannot be made. Despite this, all studies were conducted overseas; meaning generalisations may not be accurate for the Australian environment. 2.6.2 Confidence of mothers If mothers feel they have the ability to look after their child’s teeth, then their child will have better oral health outcomes. Of these studies one found the most important factor that predicts a child’s oral health, is if the mother holds the belief that they are competent enough to look after their child’s teeth (Pine, et al., 2004). This was supported by a study undertaken by Gussy and colleagues (2008), which found that parents, who felt confident with brushing their child’s teeth, would brush them more regularly. The two studies that found this association were both cross-sectional, with one from Australia and the second study used 17 different countries for samples. Therefore, this association has relevance to the Australian population.
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2.7 Oral health knowledge Parents’ oral health knowledge has been shown to affect their child’s oral health knowledge. This is due to children obtaining oral health knowledge from their caregivers (Petersen, et al., 1995; Suresh, et al., 2010). Studies have found that some parents do not have or have partially correct oral health knowledge. One study conducted by Rajab and colleagues (Rajab, et al., 2002) found that parents had the belief that mixing hot and cold foods together was a cause of dental caries. However, this study was from a country with different cultural background. Therefore these beliefs may not be present in Australia. Another study found that few mothers knew the effects of sugary drinks on their child’s dentition and that only a third of these mother thought their children needed help when brushing (Petersen & Esheng, 1998). On the other hand, Petersen and colleagues (1995) found that parents do have oral health knowledge. However, this knowledge is not put into practice.
2.8 Aims and objectives As the literature has demonstrated, numerous factors can influence pre-school children’s oral health. It has been demonstrated that mothers are the main caregiver who is involved in their child’s habits and health practices. It has also been shown that some caregivers have oral health knowledge; however, this is not being put into practice. Knowledge therefore is not reflected in behaviours. Furthermore, very few studies have been conducted in the Australian context and fewer still in regional areas. Exploration of the factors why mothers are not putting oral health knowledge into practices is the aim. The aim of this study is to explore barriers and facilitators that mothers face when implementing good oral hygiene practices for pre-school aged children above the age of 2 years in regional Victoria. The objectives of the study are:
To utilise a qualitative methodology to gain an in-depth understanding of the barriers and facilitators mothers face when implementing oral hygiene practices in their pre-school aged children.
To make recommendations to improve dental professionals scope within the prevention of dental caries by utilising public health frameworks.
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Chapter 3 Methodology
In this chapter the chosen methodologies that were used in this research will be outlined. This includes the research approach, sample characteristics, data collection, data analysis and the reasons and rationale behind these choices.
3.1 Qualitative research Qualitative research aims to explore, interpret and gain a deeper understanding of a social phenomenon (Bower & Scambler, 2007). The researcher relies mainly on textual data as opposed to numerical data (Carter & Little, 2007). Open questions are asked about the experience in the natural setting in which they occur (Carter & Little, 2007; Pope & Mays, 2006). Qualitative research enables social issues to be viewed in a new way and it allows researchers to address questions regarding knowledge and practice which are difficult to answer using quantitative methods alone (Bower & Scambler, 2007). In addition, this methodology is useful when little is known about a research area. In the past, qualitative methodology has been viewed as the less scientific method and it has been underutilised in health research (Pope & Mays, 2006). In dental research, the majority of research is quantitative. This is due to qualitative research being viewed as lacking in rigour necessary for evidencebased dentistry (Newton, 2000). Evidence-based dentistry is an approach that requires the integration of evidence from scientific research to be put into oral care practice (Sakaguchi, 2010). However, qualitative research can provide knowledge around the social aspects of dentistry and is a complimentary approach to quantitative methods (Newton, 2000). If utilised correctly qualitative method can be used in evidence-based dentistry. Therefore, the adoption of qualitative methodologies in dentistry is not discounting quantitative methods. It just acknowledges that some questions require a different method (Newton, 2000). As the research aims to explore barriers and facilitators to implementing health behaviours in pre-school aged children, a qualitative approach has been chosen as an appropriate design. There is a dearth of research conducted in this area and utilising a qualitative methodology allowed for an in-depth understanding of the issue.
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3.1.1 Qualitative description Although there are many approaches taken in qualitative research, qualitative description was utilised. In this study, qualitative description is defined as a method of investigation that aims to describe a participant’s perception or experience of a social phenomenon, whilst closely adhering to the participant’s own language (Neergaard, Olesen, Andersen, & Sondergaard, 2009). This method is both distinguishable from other qualitative methods and foundational to others (Sandelowski, 2000). Methodological quality is judged on how appropriate the design is for the research and not the methodology itself (Hoepfl, 1997). Qualitative description is a method that gives a comprehensive description of a human experience without an in-depth interpretation of this experience (Sandelowski, 2000). The goal of this method is to stay close to the data, whilst still describing all the elements of the experience. The researchers ability to do this increased the rigour of this research project (Milne & Oberle, 2005). Although qualitative description is less theoretical than other qualitative methods, it tends to draw its beliefs from naturalistic inquiry (Sandelowski, 2000). The premise of naturalistic inquiry is that there are multiple constructed realities and these realities are what shape people’s views and beliefs (Green, 2002). The aim of naturalistic inquiry is to study people in their natural environment therefore, obtaining greater detail of the participant. The researcher is highly involved in the actual experiences of the participant (Creswell, 2003). Although naturalistic inquiry underpins qualitative description, aspects of constructivism formed a part of the methodology used in this research project. The theory of constructivism suggests that people learn or gain knowledge from experiences, interactions and ideas. Furthermore, this theory argues that everyone has a different view of what reality is. Constructivist researchers take a subjective approach to the examination of social phenomena (Appleton & King, 1997). Researchers must interact with the participants throughout the study in order to be able to access the multiple views of the different realities that may exist (Appleton & King, 1997). There is a lack of research around the issue; therefore, qualitative description as a method is appropriate. There is a need to gain an in-depth understanding of this issue, which in the past has been unknown to dental professionals.
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3.2 Sampling The aim of sampling in qualitative studies is to get ‘meaning rather than frequency’ (Liamputtong, 2010 pg. 19), and so compared to quantitative sampling, sample sizes are relatively small. The aim of a qualitative study is not to be able to generalize to a larger population, therefore it is reasonable to use non- probability sampling methods (Liamputtong, 2009). In qualitative research the method of sampling chosen is determined by the methodology utilised and the topic that is being explored (Higginbottom, 2004). In this study non-probability sampling was used. Purposive sampling was used as the first method of sampling. Purposive sampling is a form of sampling where the researcher exercises deliberate or subjective choice over who will be involved in the sample (Higginbottom, 2004; Walter, 2006).This is appropriate as this study was aimed at a certain target population, this being mothers that have a pre-school aged child older than two. Flyers (see appendix one) were used to advertise to mothers that meet the inclusion criteria and were placed in a variety of locations (for more details see recruitment). The second method of sampling was networking which makes use of the respondents used in the first method of sampling and these participants pass on information to other possible participants (Walter, 2010). Networking is a useful sampling method when the people that are being studied are well networked (Liamputtong & Ezzy, 2005). This was the case in this research; the participants were mothers that may have networks with other mothers from playgroups and childcare settings. This was achieved by asking the participants recruited from the purposive sample to pass on consent to be contacted forms to possible participants (refer to appendix two). Sampling for this study, was ceased once the researcher believed that saturation had been reached, that is, when the data became repetitive (Hennink, Hutter, & Bailey, 2011) and the researcher was satisfied with the depth of the data collected (Liamputtong & Ezzy, 2005). In this research, saturation occurred at the fifth interview but two more interviews were conducted to verify saturation. There are no guidelines as to why it should be conducted this way as ‘signals of saturation seem to be determined by investigator proclamation’ (Morse, 1995, p. 148). After the seventh interview the researcher was certain saturation had occurred.
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3.2.1 Inclusion/ exclusion criteria The study sample consisted of seven mothers from regional Victoria. Three participants were obtained through purposive sampling and four through network sampling. The number of children the participants had ranged from one to three. In order to participate in this study the participants had to have a pre-school age child, two years of age or older. The participant had to be over the age of 18 years and live in a rural or regional area. Participants over the age of 18 was set as an inclusion criterion due to consent issues. The age of the child (2 years to before commencing school) was placed in the inclusion criteria as this is an important time in a child’s life. Many oral health behaviours such as brushing are developed in this pre-school age stage (Blinkhorn, 1978). These behaviours that are learnt at this age ‘are deeply ingrained and resistant to change’ (Baric, Blinkhorn, & MacArthur, 1974, p. 222). In addition, mothers would still be their main caregiver and children are still heavily reliant on their mothers at the pre-school age. Moreover, at this age the children would have all, or some of their, deciduous dentition and some of these teeth would have been present for about 6 months to a year (Cameron & Widmer, 2008). The exclusion of those children attending school is due to the fact that once a child attends schools there are numerous other factors that the mother cannot control that may influence the dental caries disease process. To be eligible to participate in the study the mothers had to live in a regional town. This was set as an inclusion criterion as children in rural areas have poorer oral health outcomes. A report conducted by AIHW in 2001, compared children from rural and remote areas to metropolitan areas, to ascertain if there was a difference in caries rates. This study found that in children aged 4-10 years (children with deciduous dentition) and 6 to 15 years (children with some permanent dentition) experience higher caries rates in rural areas. The reasons for this are likely to be multi-factorial but may include difficulties with access for everyone and people living in rural areas face even more disadvantage (Marshall & Spencer, 2006). The reason fathers were excluded from the study is that it has been demonstrated that there is a stronger association between dental caries in mother and children (Okada, et al., 2002). Furthermore, mothers are the main caregiver who is involved in their child’s habits and health practices.
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3.3 Recruitment Initial recruitment was through flyers, refer to appendix one. Flyers were placed in various locations, for example: neighbourhood houses, private childcare centres and the university. Three participants responded to the flyers, one participant from the university flyer and two participants from two different private childcare centres. These three participants passed on consent to be contacted forms to other possible participants (refer to appendix two). The other four participants were recruited using this method.
3.4 Interview schedule An interview schedule was developed before interviews commenced, however, it was only used as a guide, as a reminder to cover off on certain issues and not a strict guide to follow (Clough & Nutbrown, 2002). The interview schedule consisted of four open ended questions; each question had a list of prompts (refer to appendix three). The interview schedule was developed from the themes that were indentified in the literature. After the first interview the interview schedule was reviewed and some of the questions were reworded to adapt to the emerging data.
3.5 Data collection The data for this research was collected through semi-structured in-depth interviews. In-depth interviewing is similar to having a conversation, but with an intended purpose (Minichiello, Aroni, Timewell, & Alexander, 1995). This approach gave the researcher access to private perceptions a person holds and allowed for an understanding of activities or events that the researcher could not directly observe (Minichiello, et al., 1995). Oral hygiene practices could not be directly observed by the researcher, therefore in-depth interviews were chosen to understand factors that hinder or facilitate these practices. The use of semi-structured interviews allowed for greater flexibility (Minichiello, et al., 1995), as the researcher was unsure about the possible themes that may have emerged from the data. Furthermore, this method of data collection was appropriate due to the ability to modify the interview schedule as new themes emerged. An important aspect of this data collection method was the structuring of questions. Open ended questions allowed respondents to speak about what they think or feel about a topic without preempting what the answer may be (Minichiello, et al., 1995). As there was very little research around this topic open-ended questions were used. Furthermore, the researcher did not want to anticipate possible data outcomes by using closed questions. 23
Data collection was terminated once saturation occurred. Data saturation occurs when no new themes are emerging from the interviews (Minichiello, et al., 1995). This occurred after the fifth interview was conducted but two more interviews were conducted to verify saturation. With participants’ consent, interviews were digitally recorded. The interviews lasted for approximately 40 minutes. Recording the interview allowed for the data to be captured in the participants’ own words, aiding in a detailed analysis. Recording the interviews allowed the researcher to focus on probing or clarifying certain points in the interview without the researcher needing to make notes (Liamputtong, 2009). It was arranged for the interviews to take place in mutually convenient locations including workplaces and private homes. Therefore, the majority of interviews took place at the participants’ workplaces and one interview was conducted at the participant’s home.
3.6 Data Analysis In qualitative and quantitative research, data analysis is the way of making sense of the data (Creswell, 2009; Liamputtong, 2009). There are several ways of achieving this, for this research thematic analysis was chosen. This was the chosen method as thematic analysis provides a way of making sense of the data, without going into an in-depth interpretation of the data. Thematic analysis is the process of ‘analysing data according to themes, relationships and/or differences in a data set’ (Gibson & Brown, 2009 pg. 127). Moreover, it is a process that reduces the data set into meaningful groupings (Grbich, 2007). All interviews were conducted and transcribed verbatim by the same researcher as this minimized any biases (Minichiello, et al., 1995). Transcription is the process of converting spoken into a written form (Liamputtong, 2009). Furthermore, transcribing allowed the researcher to improve their interviewing skills, by listening to the recording numerous time (Liamputtong, 2009). The researcher needs to become immersed in the data (Miles & Huberman, 1994). This occurred at the transcription stage as the researcher transcribed all the interviews (Walter, 2010). Once the researcher had transcribed and listened to the interviews several times, the next stage that occurred was open coding (Creswell, 2009). Open coding is when the initial identifying of topics occur, this is classed as coding (Ezzy, 2002). Coding is the creation of a category that describes common features of data (Gibson & Brown, 2009). A code is classified as ‘tags or labels for assigning units of meaning to the descriptive or
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inferential information compiled during a study’ (Miles & Huberman, 1994, p. 56). This coding is established by reading through the data and coding each sentence (Liamputtong, 2009). In this research coding was done by reading and re-reading the transcripts and by highlighting the main words or topics found in the data. These transcripts were exported into qualitative data analysis software Nvivo and the process of highlighting main words and topics was undertaken within the program. Nvivo does not perform the analysis; it is simply a tool to manage the data (Liamputtong & Ezzy, 2005). The second stage of analysis undertaken was thematic analysis. Thematic analysis was the process of identifying themes within the data. These themes were induced from the data and are not pre-determined (Ezzy, 2002). In this research, this was completed by looking at all the codes and grouping like codes together. A concept map was utilised to visualise the themes. This allowed for issues and themes to be identified that were not anticipated by the researcher because there is a dearth of research on this topic (Ezzy, 2002). The purpose of this research was to gain understanding that cannot be achieved by using predetermined codes. 3.6.1 Analytical frameworks Analytical frameworks provide a way of understanding phenomena in research (Anfara & Mertz, 2006). In this research, population approaches are needed to address early childhood dental health as the individual approach alone cannot address the underlining causes of dental problems. For this reason, two frameworks were utilised: Proximal and Distal model and the Health Belief Model. Proximal and distal model refers to determinants that contribute or bring change to a person’s health either by direct way or remote factors (Carr, Unwin, & Pless-Mulloli, 2007). The Health Belief Model is a framework used to explain why some people take action to avoid certain illnesses (Glanz, Rimer, & Viswanath, 2008). Despite providing valuable insight, these approaches to interpreting health are not widely used within dental research. This may be due to distal factors often being underestimated or dismissed as playing a role in oral health (Newton & Bower, 2005) or that the frameworks seem too simplistic, and lack a focus on other factors that need to be addressed such as ethnicity, culture, family socioeconomic status and environment (Amin & Harrison, 2007). However, these frameworks are useful as a way to view the findings of this study, as it is well understood that knowledge does not always transfer into health promoting behaviours.
3.7 Ethics approval Ethics approval was obtained from the La Trobe University Human Research Ethics Committee (refer to appendix four). Different types of research have varying ethical considerations (Grbich, 1999). The 25
participants’ ability to consent to participation in the study is very important (Grbich, 1999). Participants were given a plain language statement (refer to appendix five). All participants were over 18 years of age; therefore able to consent for themselves. The ability of the participant to read and understand the information and consent form was used as an indication of competence to consent and the researcher verbally checked this prior to the consent form being signed. Participants’ consent was documented (refer to appendix six) and participants had the ability to withdraw (refer to appendix seven). Confidentiality of the participants’ data is another consideration; a number of steps were employed. No documents included any identifying information of the participants; pseudonym was used for all places and names. An identifying number was assigned to each participant and all documentation for that participant only contained that number. Furthermore, documents regarding the study were kept in a locked filing cabinet, in a locked room in the Health Science building (room 3.07) and password protected computer files were. All data and consent forms will be kept for seven years and the previous measures were outlined on the information statement (refer to appendix five). However unlikely; there was a possibility of emotional distress for the mothers resulting from asking about their children’s oral health. If this occurred, a strategy to support the mother was developed. All interviews were conducted during office hours, and if any mothers became emotionally distressed the interview was stopped. There were two levels of dealing with emotional distress. First stage was to stop the interview and let the participant rest and resume the interview if the participant had consented. The second stage was to terminate the interview all together and provide support. The researcher would have stayed until the participant distress had decreased or other support had been accessed. To minimise researcher risk the interviewer rang the supervisor prior to and after completion of each interview.
3.8 Rigour Rigorous methodology and methods makes research more trustworthy and reliable (Walter, 2010). There were several strategies employed to enhance research rigor, these include thick description, use of verbatim quotes, audit trails and self-reflexivity. 3.8.1 Thick description and verbatim quotes The use of thick description of all aspects of the study, allows the readers to make decisions on how reliable and transferable the findings are (Liamputtong, 2009). Furthermore, when reporting on the results of the study the use of participants verbatim quotes, provides evidence to support the 26
researchers interpretation of the data (Liamputtong, 2009). Making the verbatim quotes available allows other people to assess whether the interpretations represent the data (Liamputtong & Ezzy, 2005). The use of verbatim quotes throughout the results chapter supports the interpretations made. 3.8.2 Audit trails Audit trails give the study methodological rigour by providing a detailed rationale for why theoretical, methodological and analytic decisions were made (Liamputtong, 2009) and by detailing how the research was conducted. A research and field notes diary was kept. This contained thoughts and reflections on the interviews. All the reasoning behind the choices made for the study were written in the research and fields note diary. 3.8.3 Self-reflexivity Due to the nature of this section, first person will be used. A consideration that needed to be taken in to account with this research was my experience and familiarity of this topic. I have a dental background and have worked for a couple of years in a public dental clinic. This experience has given me exposure to parents and especially mothers who attend the clinic with their children. This has provided me with an insight into the role mothers play in their child oral health. It has also provided me with a firsthand experience of the consequences and the frequency of dental caries. Going into this research I had preconceived ideas of what I may have found from the data, due to having already spoken to mothers in the dental setting about the reasons for their child not brushing their teeth. These experiences facilitated a self-reflexivity approach. This is a ‘conscious awareness by the researcher of their impact on the research and research process’ (Walter, 2010 pg. 409). Therefore, it gives the readers an honest and open narrative (Walter, 2010). It is necessary for me to reflect on how I may have influenced the data. Before I commenced data collection I wrote down all my preconceived ideas. By going through this process I was aware of these preconceived ideas and made a conscious decision not to bring these ideas into any of the interviews. Another method used to reflect on the role I was having on the research process was to have discussions with my supervisors. In these discussions we would converse about how the interviews were progressing and also discussed data analysis. The findings of this study are explored in the next chapter. These will be described through the main themes which were identified through the analysis process.
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Chapter 4 Results The key findings of the research are presented in this chapter. The following table presents demographic details of the participants along with information about the number of children, age of the children and whether the child/children have been to a dental professional. Participant
Number of
(pseudonyms)
children
Julie
2
Kim
Age of children
Been to a dental
Participants
professional
working status
3 ½ yo, 5 ¾ yo
Oldest child only
Full-time
1
3yo
Yes
Full-time
Sue
2
2yo, 5yo
Yes, both
Full-time
Narelle
3
3 ½ yo, 5 yo, 7yo
Older two have,
Part-time
youngest has not Ruth
1
3yo
Yes
Full-time
Elizabeth
2
2yo, 7 yo
No, both
Full-time
Amanda
1
2 yo
No
Part-time
During the process of thematic analysis, four major themes were identified. The themes consisted of: the dental practices; perceptions of dental health; learning; and parenting. A visual representation of these themes can be viewed on the next page. Participants’ quotes are displayed throughout this chapter to support the results and are presented in italics.
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4.1 Dental practices The first major theme that emerged from the data was dental practices. These included the child’s dental routine, the mother’s dental practices, professional dental care, and dental information. The practices included the past practices, changes to the past practices and the present practices. 4.1.1 Child’s dental routine All of the participants’ children had some form of dental routine in place. All children were brushing their teeth daily, with some children brushing twice daily. The participants spoke about developing a routine and how it was completed at certain times of the day. I think I have got much better at it over time, I’ve got much more of a routine getting them into the bathroom twice a day. (Narelle) So he has a bath of an evening and we brush his teeth. (Ruth) All the participants discussed the need to assist their child with brushing. Some of the participants helped on a daily basis, others a couple times a week and some participants were not helping at all. The participants that were not helping at all stated that this was due to the child getting older and needing to brush their own teeth to ‘gain independence’. The participants who were not helping with the brushing recognised that they probably should. Then we do it [brushing], but we have always been clear about the fact that an adult has to have a turn at some point in the brushing. (Narelle) There were a range of reasons why the dental routines started and for all participants these routines started at different ages and stages of a child’s life. Some participants started cleaning their child’s oral cavity before teeth had erupted. Other participants waited until some teeth had erupted, whilst others waited until all teeth were through. A range of triggers started these routines. There were prompts from maternal and child health nurses, from other family members, and from prior experience where the participants had older children. Other prompts for brushing included the child’s age, or the child’s understanding of brushing. It was only because aunty had a child the same age and she said ‘Look I brush their teeth’ and whatever. (Sue)
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So as soon as he really was old enough to know what brushing teeth was so I guess around two. (Ruth) The participants who started brushing their child’s teeth later did speak about brushing before they started the formal routines, but described it as ‘not brushing properly’. Some participants would let the child have a play with a toothbrush, whereas other participants spoke about brushing only being once a day. The reason for this was said to be due to the lack of children’s understanding. It’s just you know if you got the toothbrush in and you could wiggle it around a bit and try to get all surfaces you were on a winner. (Amanda) Half of the participants spoke about changes that had been made to the dental routine. One of the prompts for the change was the child visiting a dental professional. Another reason was learning about dental practices from other family members. I’ve been really diligent for the last probably six months *since going to the dentist+ and um just trying to get to get the food out from between her teeth. (Kim) So learning from her [Aunty] and yeah that we should be actually doing that for him brushing twice a day. (Sue) The majority of participants spoke about lack of time and not having enough time to fit everything in. Consequently two of the participants stated that the routines sometimes did not take place due to time issues. The main part of the day where time was an issue was in the morning; due to work commitments as outlined in the table page 35. The obstacle of the morning would be getting out of the house on time um and admittedly sometimes we leave the house without her having her teeth brushed. (Amanda) 4.1.2 Mothers’ dental practices In the majority of interviews, the participants discussed their own dental health and treatment experiences. None of the participants spoke about their previous dental experiences or their dental health in a negative way; instead they spoke about their own dental health as a reason for the dental routines to be in place. Over half of the participants spoke about how their own experiences made them value having healthy teeth.
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I have still got baby teeth in my head now, I know how vital, you don’t take care of them then by the time you’re my age they are not there anymore. (Elizabeth) Some of the participants then discussed their own dental health routines. The majority of these participants mentioned how they look after their own teeth by brushing twice a day with two participants brushing more than this. I’m a pedantic tooth brusher, like I don’t just brush my teeth twice a day on the weekends I brush my teeth three or four times a day. (Julie) 4.1.3 Professional care Some of the participants had taken their children to a dental professional. There was variation in the child’s age when they first attended a dental clinic. Some participants took their children once they reached a certain age while others took their child when they were old enough to understand. He has been to the dentist twice, when he turned two and when he turned three. (Ruth) The two reasons for the child’s dental attendance were dental problems, or for a general check up. The participants, who took their child for a general check up, reported wanting to know how everything was going. For the participants who took their child for a problem, this included dental injuries or cavities. I’m interested to hear how they are going *child’s teeth+ and you know and whether there is any changes and things. (Ruth) Going to dentist, Brittany did when she did her tooth [knocked her tooth] and she went [to the dentist] for a while after that. (Julie) Participants spoke about two reasons for not taking their child to a dental professional for a check-up: cost, and wanting the child to avoid the ‘terrifying experience’ of attending a dental professional. He was only three and to be honest I did feel like it was a great waste of money because it was nearly $50 and he was in the chair for about three minutes. (Narelle) Zack the whole time [at the dentist] I had to hold him and he was yeah crying the whole time yeah so I just try to avoid that. (Sue)
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4.1.4 Dental information Some of the participants discussed the difficulties in obtaining dental information and the lack of guidelines about how parents should care for their child’s teeth. One area the participants were all quite knowledgeable in was diet. All participants talked about the role of diet in dental diseases and which foods should be avoided. You know certainly when you see a dentist they will say be wary of these foods and what they can do and prevent. (Sue) The sources from which the participants received their dental information, included: dental professionals, maternal child and health nurses, family, friends, pamphlets, advertising around oral health month, the internet and information on the back of toothpaste packets.
4.2 Perceptions of dental health Participants discussed the health and importance of children’s deciduous teeth. The participants varied in responses to the questions. This theme has four sub-themes, which included the participants’ perceptions of healthy teeth, the importance of teeth, children’s dental problems and recognition of dental diseases. 4.2.1 Healthy teeth When participants were asked about healthy teeth and the benefits of their child having healthy teeth there was a range of diverse views. Three participants stated the link between the health of the child’s teeth and the effect on their overall health ‘If your teeth are healthy then your overall health is better’. Another benefit was the role that teeth play in eating. The two other advantages that were mentioned were appearance and subsequent social advantage ‘I think that they would be at a disadvantage if they had horrible looking teeth’ as well as the financial benefit. 4.2.2 Importance of teeth Participants acknowledged that deciduous teeth are important, even though they are eventually lost. Participants listed reasons such as they have a purpose to serve and the benefits of having healthy teeth for why deciduous teeth were important. Without being melodramatic it’s almost an epidemic problem now and the amount of young children that you see walking around either with teeth missing or discoloured teeth or those sort of issues there is a lot there is a lot of children with poor teeth. (Julie) 33
However, one of the participants viewed deciduous teeth as not as important. This participant admitted to thinking that they are only baby teeth so didn’t matter as much. Well look I did think that for a little while, you know they are just baby teeth so it doesn’t matter if we don’t brush them properly because they are just going to fall out anyway. (Kim) 4.2.3 Children’s dental problems Five of the participants had first-hand experiences with some dental problems where others had very limited knowledge of dental problems in children. The dental problems that the participants listed were cavities, dental injuries, crooked teeth, abscesses from cavities, problems with their jaw, and badly deformed teeth. Even though the participants provided an extensive list of problems, some seemed a bit unsure as to whether they were giving correct information. The participants also acknowledged the consequences of unhealthy teeth; these included pain and infections. I think if your cavity and you know that a cavity can still lead to abscess in the gums. (Amanda) The participants believed dental diseases are caused by diet and the cleanliness of the child’s teeth. However, all but one of the participants did discuss the role of genetics in developing dental problems. The participants who spoke about genetics did think there was an element of luck in the development of dental disease. I mean I suppose it could come down to the shape of the child’s tooth as in like I know if the I don’t know what the technical term for them, if the creases in your teeth are really deep and that’s genetic I suppose. (Amanda) Two participants had a fatalistic attitude towards dental problems; believing that dental problems in their children are inevitable. I guess that it is just part of life sometimes you can’t um yeah you are going to have problems regardless of how much you look after them but yeah I don’t know I guess I’ll face that when I come to it. (Ruth) 4.2.4 Recognition of dental disease All but one of the participants reported that their child had healthy teeth. When asked how they knew if they are healthy or not, the two signs the participants reported as being indicators for health and 34
disease were appearance and/or pain. Participants mentioned appearance frequently when discussing health of their child’s teeth. Indicators of healthy teeth were ‘nice’, straight, white, ‘they look good’, whereas unhealthy teeth were describe as discoloured, brown or black. The other indicator of disease was if the child had any pain. Ah the colour of them in a huge way, um (pause) any complaints that they might have if anything is sore in their mouth. (Ruth)
4.3 Learning One of the themes that emerged from the data was learning. This refers to both the child’s and the participants’ learning about dental practices and importance of good oral health. 4.3.1 Child’s learning The participants spoke about the need for their child to learn the importance of good oral hygiene and of having healthy teeth. All the participants were adamant about their child learning that dental routines are a part of life and needed to be completed on a daily basis. Half of the participants discussed the importance of the child learning about diet and what foods are unhealthy for their teeth. All participants agreed that this education needed to start from a young age. It is the whole about the education you know, as they continue to grow and learn about teeth and how important they are even if they are baby teeth and you know going to fall out, it’s still important I think to teach them really quite early on, um for them to know that that’s what they have to do. (Sue) All children learn differently and their willingness to learn, understand and undertake dental practices is different. All of the participants discussed their child’s willingness to learn and how this affects their oral health and dental routines. One of the main factors was the child’s independence. Refusal to open their mouth and the child’s mood were also identified. She is at the tricky age where I want to be independent; I want to do things on my own type attitude, so it is that attitude more than anything. (Elizabeth) He just wouldn’t open his mouth. (Narelle) Two of the participants spoke about the child wanting to brush their teeth without parental prompting, whereas the other participants spoke about the child liking having things in their mouth. 35
Jade is very much a in the mouth kid, even now, she is three and a half, um she chewed the mute button off our remote in the lounge room, she is very like everything is in the mouth still and I think she likes having that (toothbrush) in her mouth. (Julie) All participants reported on occasions their child would just refuse to brush or fight with the mother about brushing, with some children throwing a tantrum so they did not have to brush their teeth. This resistance often led to the participants not brushing the child’s teeth on that occasion. It’s just been him you know as kids crack they just decide they don’t want to do it. (Ruth) He just wouldn’t open his mouth, yep he would fight he would twist *when+ you hold *him+, you try and do whatever games, you know he would just would not cooperate. (Narelle) 4.3.2 Behaviour modelling The participants’ own habits influenced their children’s habits, with many of the participants mentioning that their child copies their behaviour. Some of the participants discussed how this behaviour replication encouraged the child to brush. I’m always in the bathroom cleaning my teeth and um Jade will come in and say ‘what are you doing? ‘ And I will say ‘I’m cleaning my teeth’ and she says ‘can I clean my teeth too?’ So we do it together. (Julie) 4.3.3 Mothers learning Mothers’ learning refers to both mothers finding out about their child’s dental needs, and the learning experiences which have influenced their child’s oral health. The majority of participants spoke about their own learning, highlighting two factors: how they ‘wing it initially’ with dental practices, and how they learnt from their own parents. Some of the participants spoke about not knowing exactly how to implement dental practices but learning from experience, which was described as ‘following your gut’ [instinct]. Another source of learning came from the participants’ own parents. One of the participants reported that she did not go to the dentist until she was a teenager and her children have not been to the dentist yet; she put that down to learning from her parents. First time parents trying to figure when to establish a dental routine what you are supposed to do, what sort of toothpaste to use, what sort of toothbrush, was very much trial and error. (Julie) But that comes from my mother as well who is very big into hygiene and oral hygiene so I think it is 36
learnt behaviour. (Elizabeth) 4.3.4 Mothers knowledge Half of the participants demonstrated low dental literacy. Some of the low dental literacy was around dental practices and the tools needed for these practices. On the other hand, some participants did have correct knowledge and this had a positive effect on oral hygiene practices in their children. I don’t know. I guess it has been instilled in me so it’s just automatically [brushing], I don’t even think about it I just think it is part of what you do every day and you need to brush them. (Ruth). Some of the participants mentioned that their knowledge of dental issues had changed. The main reason for this change in knowledge was after attending a dental professional for their child. After these visits all the participants reported an increased awareness and knowledge of dental problems and how to implement dental practices. One participant explained it as a real ‘eye opener’.
4.4 Parenting The participants discussed different aspects of parenting and how these aspects related to their child/children’s oral health. The areas that were spoke about included parenting goals, practices, experiences, confidence, priorities and support. 4.4.1 Parenting goals All of the participants spoke about the goals they had in place for their children, with the overarching goal being for their child to have healthy teeth. The smaller goals included learning the brushing routine and participating in this routine. They spoke about it being really important from a young age that their child learns the value of teeth and learns that dental routines are a part of life. Some of the participants wanted their children to have the same ideals and routines as themselves. I know how important it is for me it is a very important thing to look after your teeth and I want him to have the same ideals ah I don’t think it’s not like something you get taught when you have a kid. Ah yeah. Once they get teeth you need look after them. Ah. I just think it is just in me so it’s just an automatic thing for me um to make sure he looks after it um so yeah to get him into now is a better idea than introducing the concept of it when he is starting school cause then it is you know a few years too late. (Ruth) I think that those habits, good habits, and with anything good habits around dental care start
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when you are really young and so that one’s of the best things that you can give children a really great I guess attitude towards looking after their teeth. (Narelle) 4.4.2 Parenting practices Parenting practices refers to processes that the mother puts in place to achieve these goals for their child. These processes can refer to practices that will achieve or will not achieve these goals. These included the dental routine and attending dental professionals discussed earlier. Participants spoke about using creative and threatening approaches to dental practices. Some would change the toothpaste or let the child chose their own toothbrush or create stories. In the end it was a story, I just made up a story that I would tell and he just sort of, it was about a dinosaur that wouldn’t brush his teeth and what happen, and you know it was crazy stuff but he, that was sort of the key for him. (Narelle) Two of the participants discussed the use of threats to get their children to cooperate so the participants would be able to brush their teeth. Another mother had strategies in place so that the brushing routine occurred all the time. These participants tended to report that brushing occurred all the time, even if the child was tired or upset. They refer to it as ‘being cruel to be kind’ brushing, something that needs to be done that is for the child’s benefit. He doesn’t feel like doing it or whatever but it’s um you know it’s usual that I say to him well there is no more lollies or there is no more ice cream after tea you know there is no more treats (Ruth) One mother had a more extreme approach: I block her nose until she opens her mouth um and the laundry and she goes into the laundry for time out um so if she is not behaving that’s enough for her to toe the line. She understands instructions and you know you can repeatedly ask her to open and sometimes she won’t and sometimes she will um but yeah there are like strategies like I will say ‘the hard way or the easy way Jac’ and um sometimes she chooses the hard way straight down [on] her back and I get done that way [brushing]so I know it sounds brutal. (Amanda) There were times when the participant reported that the child was upset so they would not force dental routines on their child.
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There’s been once or twice where he has just really just screamed and you know you can’t do it then it just not, it’s instilling in him a fear then that it’s terrible *brushing]. (Ruth) 4.4.3 Parenting experience The participants spoke about the parenting experience, this active involvement in parenting that had increased their knowledge and skills to be able to implement good oral hygiene practices. The major experience reported was learning from having older children. All of the four participants that had more than one child explained that as their children got older and they had other children, oral hygiene routines became easier. I learnt from my oldest boy um cause he went through the same thing and it was only a couple of weeks really that we had to put up with and then he would get use to it, the fact that he could brush his front teeth ah and then we would get in there and do that back ones. (Sue) 4.4.4 Parenting confidence When talking about how confident the participants felt with looking after their children’s teeth, there were two schools of thought. Four of the participants reported how they were confident and that they just had to do it. These participants had the attitude that there is nothing to worry about and there is no point thinking that they were doing it wrong, just as long as they were doing something. The participants stated that they did not doubt themselves. I think I have been educated enough about good dental hygiene to know what is required and just sort of transfer to my own children. (Amanda) In comparison, the other participants described that they had less confidence. These participants were less sure about the routines and practices that they were performing. Even once these participants learnt more about routines and had increased confidence; the three participants reported that they still doubted themselves. But um yeah I do feel more confident, though I am still a little nervous about the youngest one... (Narelle) 4.4.5 Parenting priorities Participants discussed how high they prioritise dental health and care. Three of the participants said that it was very important. These participants stated that they would complete the dental routines even if it
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upset the child or they had limited time. One mother mentioned that dental care should be a high priority. I just get down as quickly as I could and there would be tears but you know as soon as I finished it would stop so it was just a means to an end just something that had to get done so yeah. (Amanda) In contrast, other participants also reported oral health to be important however, would not complete dental routines for different reasons. Some participants would not brush their child’s teeth in the morning due to time constraints or if the child was upset. One mother put off seeking dental advice, when there was a visible problem. These participants acknowledged that they should be taking their children for dental check-ups; however, this did not occur. Um, oh time pressure probably, yeah trying to get, to fit everything thing and be out the door by a particular time sometimes, you know you can’t go out without your shoes so sometimes it is the teeth brushing that probably falls off, um (pause) yeah I would say that’s the main one just fitting it all in. (Narelle) I know I should probably be taking them to the dentist from a young age, yeah but I don’t. (Sue) 4.4.6 Parenting support Parenting support was classed as support that was received from other family members. Some of the participants viewed family support as not helpful as they noted that they have family members caring for their child. These family members would try to buy the child’s love with treats. One mother reported that ‘her grandmother feeds her jelly beans for breakfast’. One mother noted that even when she asked the grandparents to stop feeding the children lollies, this did not occur. Other participants viewed support from families as a real help to implementing good oral hygiene practices. These participants received good advice from family members, which made the dental practices easier. So yeah just having the family support to know what we should actually be doing from when their teeth start appearing. (Sue) Within this chapter the role of participants in their children’s oral health was demonstrated to be influenced by many factors. These factors are dental practices, learning, perceptions of dental health and parenting. A discussion of these results in light of frameworks and theories is presented in the next chapter. 40
Chapter 5 Discussion This chapter is a discussion of the findings of this research in relation to relevant literature and frameworks. While the findings in this study describe factors that influence children’s oral health practices, in isolation they do not provide a complete understanding of the issue because knowledge does not always transfer into health promoting behaviours. By applying theoretical frameworks such as the Proximal-Distal Model or the Health Belief Model to the data, it is possible to gain insight into how these individual factors can act as barriers or facilitators to child and parental knowledge and understanding, which translated into health promoting oral health practices. As an example, despite widespread understanding of the factors which influence the development of dental caries, prevalence rates have not improved since the late 1980’s (Marthaler, 2004; Stecksén-Blicks, et al., 2000). This demonstrates that a different approach to what is already being done needs to be utilised for improvement to occur. These frameworks provide insights into reasons why mothers do not implement oral hygiene practices in their pre-school aged children.
5.1 Proximal and distal factors One way to view the results of this study is through exploring proximal and distal factors. Proximal factors act directly or very close to the cause of the disease; in this case hygiene practices and dietary habits (Petersen, 2005). These factors would be individual based factors and dental professionals would regularly provide advice on proximal factors to minimise the development or progression of dental disease. Advice would centre around factors that directly relate to dental practices such as brushing and the child’s diet. Proximal factors such as this can act as either a barrier or facilitator. On the other hand, distal factors are ‘further back in the causal chain and act via a number of intermediary causes’ (Petersen, 2005, p. 274). Distal factors, in relation to oral health refer to oral health services and socioenvironmental factors (Newton & Bower, 2005). For pre-school aged children the major environment factors are parents (especially mothers) and it can be the child’s own willingness to adapt to oral health routines. Distal factors are factors that a dental professional may not identify and if they are identified, they would not normally offer advice on. For example, a dental professional may notice the child modelling an unhealthy behaviour demonstrated by the parent; however, the dental professional may not offer advice to the parent about changing this. A visual representation of the proximal and distal factors that were found in this study can be viewed below. It is important to make a distinction between the proximal and distal factors, as it provides a way of viewing the barriers and facilitators for oral 41
hygiene practices. It also allows dental professionals to think about influential factors that are not directly related to the oral hygiene practices and enable the professionals to target health messages towards these more distal factors.
Figure 5.1 Proximal and distal model- a visual representation of the proximal and distal factors in this study. To date, no research has utilised the proximal and distal factors when discussing the oral health of preschool aged children. The participants in this study spoke about numerous factors that influenced the implementation of oral hygiene practices in their children, which were consistent with the proximal and distal model. The proximal factors comprised of the actual behaviours of the children that affect oral health. These proximal factors in this study included the child’s dental practices, professional dental care and the child’s diet. All these factors directly relate to the child’s oral health status and the dental
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practices of the children. Furthermore, these are factors that a dental professional would be able to observe during a dental visit and would be able to offer advice on (Threlfall, Milsom, Hunt, Tickle, & Blinkhorn, 2007). In contrast, distal factors consist of beliefs and experiences that affect and inform behaviours. This was demonstrated within this study through the mothers’ perceptions of dental health, the child’s learning and willingness to learn oral hygiene practices and parenting factors. These factors, although not entirely obvious have a major influence on whether the implementation of oral hygiene practices occurred with pre-school aged children. A child’s willingness (or lack of) can be a strong barrier to the implementation of the dental practices. This is interpreted as a distal factor because this uncooperative behaviour affects whether oral health practices are implemented. Other factors that are classed as distal factors are the mothers’ perception of dental health, dental information (or lack of information) and the mother’s prioritisation of dental health. These are interpreted as distal factors as they do not directly relate to the child’s oral health status; however, they affect the likelihood of the implementation of oral hygiene practices. These factors excluding dental information (or lack of) would not be discussed at a dental appointment and are not as apparent to dental professionals during the child’s visit to the dental clinic (Threlfall, et al., 2007). In the dental literature, the contributors to dental health are generally not discussed in terms of proximal and distal factors. These terms in the past have been used to view oral health disparities for the whole population (Patrick, et al., 2006), but contained intermediate and immediate factors as well as proximal and distal factors. The intermediate and immediate factors would fall under the broader term of distal factors utilised in this study. Whilst informative, this is not the only way the findings can be explored. The findings from this current study do not go to the macro environment level like the study by Patrick and colleagues (2006) who discussed factors like the natural environment or the characteristics of health services. This current study is the first of its kind to view the results through proximal and distal factors in pre-school aged children. Proximal and distal interpretations might be more useful than intermediate and immediate, as intermediate and immediate factors could also be classified as distal factors. The aim of utilising this framework is to increase the understanding for health professionals and bringing intermediate and immediate factors into this framework increases the complexity. Proximal and distal factors are a useful way to view the influences on children’s oral health, as many dental professionals do not consider distal determinants in clinical practice (Threlfall, et al., 2007). This 43
discounting of distal factors means that the barriers and facilitator influences, which may have a major role in this issue, are not taken into account. By viewing the influences on children’s oral health through this framework, it will allow dental professionals to tailor messages at both the proximal and distal determinants. It is important that dental professionals address the distal factors as well as the proximal factors, as this research has demonstrated that distal factors influence pre-school children’s oral health as much as proximal factors. Furthermore, the overall goal is to improve oral health of pre-school children (proximal factor), however, for this to occur the process is to concentrate on the environmental factors such as the mothers influence (distal factors).
5.2 Health Belief Model Within the previous section, it was demonstrated that proximal and distal factors offer a useful model for organising and interpreting factors identified by respondents, but the key problem then becomes how to understand these factors in terms of the impact on child and parental oral health behaviours. The Health Belief Model is one model that can assist with this transformation. This model is beneficial in a dental setting as it provides a useful framework for dental professionals to target interventions. Nutbeam and Harris (2004) state that the Health Belief Model ‘provides an essential reference point in the development of *health+ messages’ (pg. 13). Dental professionals can use this model as a guide to developing health messages. The four core interrelated components of this model are perceived susceptibility, perceived severity, perceived benefits and perceived barriers (Hollister & Anema, 2004). Other aspects of the model include cues to action and self-efficacy. These components of the Health Belief Model were evident across all the interviews with the mothers and helped to highlight the barriers and facilitators to oral health practices. A visual representation of the Health Belief Model is provided below (Ashford & Blinkhorn, 1999).
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Figure 5.2 a visual representation of the Health Belief Model It is useful when using the Health Proximal
Distal
Belief Model to consider that each component has both proximal and distal factors within it. The following table demonstrates how the findings from this study are consistent with the components of the Health Belief Model and then separates these findings into proximal or distal factors. Perceived susceptibility
Diet
Fatalistic attitude Belief in commonness of caries Poor recognition of disease
Perceived severity
Frequency of cleaning
Poor general health
Frequency of dental visits
Poor tooth appearance
Pain
Social consequences Maternal beliefs about deciduous/permanent teeth
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Perceived benefits
Ability to eat
Tooth appearance
Perceived barriers
Cost of dental treatment
Child behaviours like tantrums
Fear of Dental treatment
Parenting support
Child’s age
Parental dental literacy
Attending dental professionals
Support from other family
Cues to action
members. Behaviour modelling Self-efficacy
Mothers confidence for implementing oral hygiene practices
Table 5.1 a breakdown of the proximal and distal factors and where they fit within the Health Belief Model There are aspects of both the proximal and the distal to some of these factors, as well as differences in how they might be experienced by children and their parents (emic) compared to how they may be characterised by an observer (etic).
5.2.1 Perceived susceptibility Perceived susceptibility is whether the person thinks they are likely to get a disease or condition, and consequently be more likely to change or reduce the unhealthy behaviour (Glanz, et al., 2008). In the area of oral health, it refers to a mother believing her child to be at risk of dental caries. This can be either a barrier or facilitator to implementing oral hygiene practices in young children; depending on how ‘at risk’ a mother perceived her child to be. The mothers perceived susceptibility for their child having dental problems varied in the study. All the mothers believed their child was at some sort of risk, as all the mothers spoke about monitoring diet and watching what the children ate. Some mothers viewed their child as likely to develop dental diseases, and had a fatalistic attitude towards dental problems. Although they had practices in place they felt that dental problems were inevitable. This acted as a barrier; the mothers may be less pedantic over oral hygiene practices as they feel they have little control over whether their child develops dental caries. Some of the mothers held the belief that dental diseases were common. These results were also found in a study by Amin and Harrison (2007). However, the study by Amin and Harrison (2007) included parents with children that had caries lesions, whereas only one child in this current study had been diagnosed with dental caries. It may be that mothers think their child is at risk of dental disease but feel unable to change the outcome. This is a significant barrier to changing current oral hygiene practices.
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In this study, some of the mothers did not perceive their child to be at risk of developing oral health problems and this could act as a barrier to implementing oral hygiene practices in pre-school aged children. The majority of mothers in the study felt their child was not at risk of dental diseases as many of the children had only been to a dental professional for a problem (trauma or a visible problem). Other studies have reported that parents tend to seek professional advice for problems and not for preventative reasons (Chan, Tsai, & King, 2002; Talekar, et al., 2005). Some of the participants in this current study lacked the correct knowledge of the recognition of disease, therefore, very few of the mothers fully understood how susceptible their child was for developing dental caries. The Health Belief Model supports knowledge as a factor that can either positively or negatively affect the likelihood of behaviour change. In this case, the absence of knowledge acted as a barrier. Appearance and pain were the two measures of dental disease that mothers utilised to recognise disease. Amin and Harrison (2007) participants had similar ways of recognising disease. They reported that these measures were not reliable ways of recognising dental disease. One of the mothers in this current study held the belief that younger children could not develop dental diseases; this mother was the only mother to report dental caries in their child’s teeth. This is consistent with the findings reported by Talekar and colleagues (2005) and Amin and Harrison (2007) that parents reported young children as less likely to have dental problems. However, this belief is untrue as what we know is that around 40% of children in primary school have a carious lesion (Armfield, et al., 2003). These beliefs act as barrier as they influence the implementation of oral hygiene practices and therefore, the children’s oral health. The findings from this study and the previous research demonstrate that mothers may not perceive their child to be at risk, even if they are (Amin & Harrison, 2007; Chan, et al., 2002; Talekar, et al., 2005). This acts as a barrier as mothers may not present their children to a dental professional when problems exist. However, if mothers perceive their child to be a risk this may act as a facilitator to oral hygiene practices, as these practices may decrease their child’s risk. Perceived susceptibility is more complex than just whether they feel their child is at risk, it involves knowledge and other influencing factors that can effect beneficial behaviour change. Therefore, dental professionals need to provide information to mothers in different settings and by other avenues than just one to one advice. This will increase mothers’ knowledge about how common dental diseases are and how mothers play a vital role in preventing dental diseases in pre-school aged children.
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5.2.2 Perceived severity Perceived severity refers to how serious the person perceives a disease to be (Hollister & Anema, 2004). This component of the Health Belief Model is multidimensional as it includes the medical severity (symptoms) and the extent to which the disease will impact on social roles (Conner & Norman, 2005). In terms of oral health, it is how severe the mother believes the consequences of dental diseases will be for their children. If the mother perceives the severity to be high, it is likely to facilitate behaviour change. Likewise, a perception of low severity can act as a barrier. The majority of the mothers in this current study perceived dental caries to have serious consequences such as pain, with some mothers making the link between oral health and general health. These same mothers also expressed the value of deciduous teeth as being very high. These results built upon the findings of another study (SaiedMoallemi, et al., 2008) demonstrating that a high proportion of mothers acknowledge the potential consequences of dental disease as being serious. However, older children were the focus of this study and would have at least four of their permanent teeth. One of the mothers in this current study did hold the belief that deciduous teeth were not as important as permanent teeth. However, this mother still did not perceive the consequences to be too serious even once her child was diagnosed with dental caries. This lowered perceived severity acted as a barrier as this mothers’ implementation of oral hygiene practices did not improve as she believed the consequences of dental caries was not severe. Similar results were found in another study; however, this study was exploring parental change of behaviours after a child’s general anaesthetic dental treatment (Amin & Harrison, 2007). The study population was split into two groups: relapse (the child had a caries lesion 6 months after general anaesthetic) and no relapse (no caries lesions six months after treatment) (Amin & Harrison, 2007). The relapse group did not value deciduous teeth as much as the no relapse group. What has been demonstrated in this study and within the literature is that perceived severity of dental caries varies and can act as a barrier or facilitator. Perceived severity can be viewed in relation to the emphasis placed on preventative factors such as frequency of brushing and dental visits. In this study, all children were brushing daily with some brushing twice daily. This demonstrates some level of perceived severity as practices were in place to lessen the chances of dental disease. However, not all of the mothers took their children to a dental professional demonstrating lack of perceived severity. The findings from this study and other studies (Amin & Harrison, 2007; Saied-Moallemi, et al., 2008) demonstrate there are differing opinions towards the seriousness of dental disease in pre-school aged 48
children. Either mothers perceive it to be serious or that it is not as serious as the deciduous teeth exfoliate. Lack of perceived severity means that mothers may neglect oral health practices in their children and thus, these poor practices can carry onto adulthood. 5.2.3 Perceived benefits Within the Health Belief Model actions available to reduce the incidence of the disease is termed perceived benefits (Shumaker, Ockene, & Riekert, 2009). A person must believe that the benefits of changing the behaviour will outweigh the costs and barriers (Nutbeam & Harris, 2004). In terms of oral health this would occur when the person thinks healthy teeth will be a benefit to them, thus, facilitation of beneficial oral health practices may occur. When the mothers in this study discussed the benefits of having healthy teeth, the reasons given were very general like being able to eat and having aesthetically pleasing teeth. This may be due to dental health not being of great value to the mothers. This interpretation is consistent with the findings of other research which show that mothers do not view healthy teeth as beneficial; however, it is the opposite with mothers reporting worse quality of life when the child does have a dental problem (Pahel, Rozier, & Slade, 2007). However, the results of this study correspond with the literature, where there was minimal discussion on the benefits parents place on dental health. This may be one of the barriers to the implementation of oral health behaviours in young children, as mothers or parents do not understand the benefits to their child having healthy teeth. This study addresses the significant lack of literature in this area. By providing mothers with the information of benefits of a child having healthy teeth, this may increase their knowledge and consequently facilitate a change in their oral hygiene practices for their child. Dental professionals may need to address this issue by informing parents of the benefits of healthy teeth instead of just focussing on the negative aspects of a child having dental disease. 5.2.4 Perceived barriers Perceived barriers refers to negative aspects of a particular health action that may stop a person from undertaking a certain health behaviour (Glanz, et al., 2008). The negative aspects can include practical issues such as time, cost, waiting time, in addition to psychological considerations such as pain, embarrassment and impact on lifestyle (Conner & Norman, 2005). The majority of the results from this study fit into this component of the Health Belief Model indicating that there were a range of barriers that made oral hygiene practices difficult or impossible for their pre-school aged child. These included the cost and perceived ‘terrifying’ nature of professional care, the lack of dental information, parenting support and child’s learning. 49
Other studies have explored barriers to dental care; however, there is minimal literature around children’s learning as a barrier. This current study provided more explanation as to why children’s learning acts as a barrier. The majority of studies found that the cost of dental treatment was a major barrier (Amin & Harrison, 2007; Isong, et al., 2010; Kelly, et al., 2005), with one study finding treatment was deferred due to the cost (Isong, et al., 2010). Two of the mothers in the current study spoke about not wanting their child to have to experience a terrifying dental visit. Although other research does not focus on the ‘terrifying’ experience, Kelly and colleagues (Kelly, et al., 2005) found pain associated with dental treatment was a barrier to seeking care. The mothers in this current study spoke about the lack of available information regarding dental health. If mothers had the information it was because they sought this out themselves. This acted as a barrier as the information these mothers obtained may not be entirely accurate. Chan and colleagues (2002) found that the participants in their study also reported that lack of information acted as a barrier and over 80% of respondents stated they did not receive any information at post-natal appointments. Therefore, the addressing of these aspects is needed in order for pre-school children’s dental attendance to increase and this in hope will lessen these barriers that mothers face. Variations in family support could also act as a barrier. One of the mothers stated that maintaining her child’s diet was difficult due to other people caring for her child, as this made it hard to monitor the child’s diet. This is similar to the findings by Amin and Harrison (2007) who found that grandparents’ had a negative impact on the child’s oral health. However, the study by Amin and Harrison (2007) did not expand on why grandparents have this impact. In this current study, the negative impact grandparents had was in terms of the child’s diet: such as giving sugary treats as a way to buy the child’s love. This demonstrates the need of a public health intervention that includes all family members. This is due to family members acting as either a barrier or facilitator for oral health in pre-school aged children. The main barrier that mothers in this study discussed was the child’s learning and the child’s willingness to learn oral hygiene practices. These included: the child’s independence, the child’s lack of cooperation and the child’s resistance with tooth brushing. These factors acted as a barrier to implementing oral hygiene practices, as the child was resistant to the practices. This resistance lead to, in some instances, the practices not being implemented. However, there is a dearth of research around these factors and whether they influence oral hygiene practices. One study briefly reported that a barrier was parents’ struggles with home dental care (Amin & Harrison, 2007). However, this study did not expand any further on what made home dental care a struggle. Whereas this current study has provided some 50
factors that made home dental care a struggle, such as child’s behaviour and the resistance from the child. This study and previous research demonstrates that there are many barriers that mothers and parents must overcome to implement oral hygiene practices in pre-school aged children. Consequently, mothers may not perform oral hygiene practices due to these barriers. Therefore, dental professionals need to provide tailored health messages to suit each patient and their family’s needs, as a way of overcoming these barriers. 5.2.5 Cues to action Cues to action refers to prompts that can trigger action, for example, a media report or another person becoming ill (Glanz, et al., 2008). Cues can range from leaflets, reminder letters to speaking to health professionals or significant others (Conner & Norman, 2005). The mothers in this study discussed cues or prompts that made them either think about their child’s teeth or start to adapt oral hygiene habits. In this way, these factors could be seen as facilitators to the implementation of oral hygiene routines. Some mothers reported other family members as a source of dental information and this information was a facilitator to start or change oral hygiene routines. This finding supports the study by SaiedMoallemi and colleagues (2008) that found family and friends are important in changing and maintaining oral health behaviours in young children. Some of the mothers in the current study stated that family would provide information for the changing of habits, however, did not mention whether family members helped with the maintenance of oral health behaviours. This reinforces the earlier point regarding family as an important influencing component. Additionally, other cues that acted as facilitators in this current study and previous literature were behaviour modelling and attending dental professionals. Behaviour modelling acted as an additional cue for the child to brush. The mothers reported if the child saw them brushing it encouraged the child to want to brush. Minimal dental research has explored the role of behaviour modelling; however, studies have found that mothers’ self-care had a positive influence on their children’s oral health (SaiedMoallemi, et al., 2008; Schou & Uitenbroek, 1995), with one of these studies finding that these children had lower caries rates (Schou & Uitenbroek, 1995). Although these studies did not state that this was due to behaviour modelling, it may be one of the possible explanations for those findings. Attending dental professionals was another facilitator mothers mentioned. Amin and Harrison (2007) found that a child undergoing general anaesthetic for dental treatment acted as a cue to change or improve dental 51
practices. However, the downside of comparing the study by Amin and Harrison (2007) to the results of this current study is the general anaesthetics are a different experience to dental treatment preformed while the child is awake. 5.2.6 Self-efficacy Self-efficacy is the belief that the person can successfully implement the behaviour change (Glanz, et al., 2008). It refers to a person’s belief in his or her own competence. In this current study, there were two types of mothers: the mothers who had confidence when implementing oral hygiene practices and mothers who performed oral hygiene practices however, they doubted themselves. In this current study, mother’s confidence did not affect whether or not their child had dental caries. There is limited dental research published about self-efficacy and dental practices, however, there is literature that discusses parents’ confidence levels (Amin & Harrison, 2007; Gussy, et al., 2008; Pine, et al., 2004). Studies reported that the most significant variable for predicting whether children would be caries free was the parents’ attitude to their perceived ability to deliver the behaviour (Amin & Harrison, 2007; Pine, et al., 2004). An Australian study in rural Victoria also found that 68% of parents were confident with brushing their child’s teeth and were confident that they would know what to do should a problem occur (Gussy, et al., 2008). Self-efficacy is about empowering the parents to believe they can perform oral health practices. Therefore, by increasing the parents’ knowledge and skills with implementing oral hygiene practices this may increase the parents’ confidence towards implementing oral hygiene practices in their children. By increasing the parents’ confidence this may then act as a facilitator to oral hygiene practices. Hence, dental professionals need to work alongside other health professionals to increase parents’ knowledge and skills while the child is still young. 5.2.7 Summary of Health Belief Model Although this model can be related to oral health, very few studies have used it as a framework. The few studies that have used this model, have utilized it in different ways. In contrast, this research has focused on the barriers and facilitator mothers’ face when implementing oral hygiene practices in their pre-school aged child. The limited research available has focused on other areas such as: research summaries of caries literature, the development of a questionnaire in relation oral health behaviours, for development of education programs and to observe differences outcomes after general anaesthetic (Amin & Harrison, 2007; Buglar, White, & Robinson, 2010; Solhi, Zadeh, Seraj, & Zadeh, 2010). The Health Belief Model provides a framework to address less understood oral health behaviours. In this 52
case, there is prevalence data and research on mothers’ behaviour, however, what is lacking understanding is why the implementation of behaviours occurs or not. The Health Belief Model provides a framework that can lead to a broader understanding of how barriers and facilitators can significantly shape oral health practices. Furthermore, the model can guide an expansion of dental professionals understanding and incorporation of health promotion into their practice. The benefit of this expansion is that a dental professional would be to promote health of the oral cavity as well as treat dental diseases.
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Chapter 6 Conclusions and recommendations The conclusions reached through this research, along with recommendations are discussed in this chapter. The recommendations are made for further research, future practice and recommendations that the participants made. The study has enhanced understanding of mothers’ influences on oral hygiene practices in their preschool aged children. It has provided in-depth information regarding the barriers and facilitators that mothers face when implementing oral hygiene practices in their pre-school aged children. This current study has reinforced what is already known in regards to some of the barriers to implementing oral hygiene practices. However, this study has demonstrated some barriers that are not so prominent in previous research. These included parenting factors and the child’s learning. Parenting factors included the goals these mothers had for their child’s oral health and the practices that were or were not put into place to achieve these goals. It also consisted of the priority that mothers place on oral care for their child, along with the confidence they had with oral routines and lastly the support they received from other family members. The aspect of child’s learning that acted as a barrier to oral hygiene practices was the child’s willingness to learn and participate in dental practices, some children would not cooperate or are very independent. These findings are important as this study has demonstrated these factors to have a large impact on oral hygiene practices, however, are less understood. This research has highlighted the fact that these issues need to be addressed in order for oral health in pre-school aged child to improve. The facilitators for implementing oral hygiene practices were not as prominent for the mothers in this study and this is consistent with previous literature. The facilitators included behaviour modelling where the child would copy the mother, some of the parenting practices of making the brushing routine fun, prompts from family members and if the mother held dental health as a high priority. For improvement to be made in pre-school children’s oral health more emphasis needs to place on these facilitating factors. This study has demonstrated that the influence of family can either act as a barrier or facilitator to oral hygiene practices and therefore, highlights the need for education programs to include the families as well. This study has added to the body of knowledge in this area and has highlighted some areas where further research needs to be conducted. As this was a small study, there still needs to be more detailed research into barriers and facilitators into children’s oral health. The following section will discuss the recommendations. 54
6.1 Recommendations For the purpose of this study the recommendations have been broken down into three sections: recommendations for future research; recommendations for future practice and participants’ recommendations. 6.1.1 Future research In order to achieve a greater understanding of some of the issues raised in this study it is recommended that further research is conducted focusing on pre-school aged children’s oral health and the influences of the mother. It would be of benefit to conduct a larger quantitative study with a range of mothers (i.e. different socioeconomic status, a range of marital status, different age groups and mothers with different number of children) to further explore the barriers and facilitators mothers face when implementing oral hygiene practices in their young children. An issue that was found in this study, which is under researched, is the role of parenting as a distal determinant of good oral health practices in children. It is recommended that a study be conducted exploring different parenting styles and the affects the parenting styles have on the children’s oral health and oral hygiene practices. Another major aspect where there is a dearth of research is the child’s willingness to learn oral hygiene practices and the effects this has on oral hygiene. More research in this area may be beneficial, it would be helpful to utilise a longitudinal study design to follow these children and to report on differences through the different life stages. 6.1.2 Future practice The findings of this study have a number of important implications for future practice. The recommendations for future practice involve recommendations for dental professionals working in a clinical setting, as well health professionals who work with pre-school aged children outside of a clinical setting. Due to limited number of pre-school aged children attending for dental check-ups, a collaborative approach is needed with other health professionals involved. This demonstrates the need for a multidisciplinary approach to improve the oral health of pre-school aged children. The reason for the children attending a dental professional was mainly for a problem-based appointment, this demonstrates that children are not being taken at an early age. This has implications for dental practice as dental professionals are not able to provide preventative advice to these patients. Therefore, dental professionals need to provide information through other avenues such as
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kindergarten visits, working closely with other health professionals that have access to young children such as maternal and child health nurses and playgroup visits. This study has demonstrated that distal factors such as parenting have an influence on children’s oral health. This study shows that dental professionals need to offer advice on these parenting (distal) factors as well as the proximal factors. This study has utilised public health frameworks which can be used by dental professionals to develop oral health messages and health education programs in relation to parenting (distal) factors. These frameworks have been demonstrated to be useful in this area. There is, therefore, a definite need for future dental professionals to have greater training in public health frameworks and ideas. Whether, this occurs at the university level or by offering professional development days for already qualified dental professionals. This study has demonstrated that families have an influence on children’s oral health whether it is positive or negative. This demonstrates the need for health promotion programs to be addressed at not only the children, but also need to include the whole family. Unlike other chronic childhood diseases in young children there is less emphasis on the public health promotion strategies in relation to dental caries. Furthermore, awareness needs to be raised about the seriousness of dental disease in young children with mothers. This may be through an education program based at new mothers or social marketing strategies. Consequently, there is a role for a public health practitioner to assist in the efforts to increase awareness of dental disease in young children. 6.1.3 Participants recommendations A majority of mothers during the interviews recommended what they thought could be done to improve or help them with implementing oral hygiene practices in their pre-school aged children. The majority of participants mentioned the lack of dental information around. This was a major recommendation of the mothers, that there needs to more dental information that is reliable and easy to access. Some mothers went further by recommending that they need to get this information while there child is still a baby. This information should be provided by other health professionals and not just dental professionals.
6.2 Conclusion In conclusion, dental caries in pre-school aged children continues to be a health issue that is very common in today’s society. Although improvements have been made towards reducing caries rates in
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pre-school aged children, there is still a long way to go. Although the exact numbers of pre-school aged children with dental caries is unknown, what is known is that it significantly impacts on the child and their family. This study has demonstrated the wide range of barriers and facilitators influencing oral hygiene practices in pre-school aged children. Factors including: parenting, child and mothers’ learning, the mothers’ perception of dental disease and dental practices. This study has demonstrated the usefulness of utilising models such as Proximal and Distal model and the Health Belief Model to gain further understanding of the influencing factors. The results from this study have confirmed the need for further research and more training for all health professionals that deal with pre-school aged children to have an impact on caries prevalence.
6.3 Strengths of the study One of the strengths of the study is that there is a dearth of research on this topic and this research is addressing this issue. There is limited research around the barriers and facilitators that mothers face when implementing oral hygiene practices in their pre-school age children. Therefore, the method utilised in this study was a strength as it provided an in-depth understanding of lived experience where little is known (Creswell, 2003). As discussed in the methods chapter, one of the strengths of the study is the use of in-depth interviews. By using this method of data collection there was a considerable amount of in-depth information gathered during the data collection period. The use of the Health Belief Model provides a public health framework that is underutilised in dental issues and as such provides new insights into how behaviours influence dental practices. Due to the limited research conducted in Australia and even less in regional areas, the regional focus of this study is a strength. The literature has shown that children in rural areas suffer from poorer oral health outcomes than their metropolitan counterparts (Australian Institute of Health and Welfare, 2006). Whilst this is known, this is still an under research area and this study provides the unique perspective of mothers experiences in implementing oral hygiene practices within a rural context.
6.4 Limitations of the study Qualitative description was appropriate method as it allowed for a snap-shot of the participants. Given a longer period, the use of a longitudinal study to monitor the mothers and children over a longer time 57
frame may be a good approach. Another method would be the use of complementary data collection methods. For example, an observation of the dental routines and mothers to complete journals in regards to the oral hygiene practices. This would allow for triangulation of the data to occur. There have been some issues of the use of network sampling due to the homogeneous sample that is often a result of this method (Liamputtong & Ezzy, 2005). Regardless of this, network sampling was an appropriate method of sampling in this research. This collection method allowed data saturation to be achieved. Furthermore, this sampling allowed a specific population to be sought and it allowed for reducing of variability between participants, which was required for this study. However, the sample population consisted of little variation of participants. Furthermore, sample size can be considered a limitation of studies, due to the sample size was small, consisting of seven mothers. Although in qualitative research the size of the sample is depended on the quality of the data and depth of the data obtained to reach saturation and not the quantity (Tuckett, 2004). However, by utilising a larger sample size, this would allow to obtain participants from different populations.
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