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The purposes of this study were to identify parents' motivation, support, and barriers to twice daily tooth-brushing of infants and preschool-age children and to discover new approaches to encourage this important health behavior.
Qualitative interviews were conducted with 44 rural parents about tooth-brushing habits and experiences.
Forty of 44 parents reported that they had begun to brush their child's teeth; 24 (55%) reported brushing twice a day or more. Parents who brushed twice a day, vs less often, were more likely to describe specific skills to overcome barriers; they expressed high self-efficacy and held high self-standards for brushing. Parents who brushed their children's teeth less than twice daily were more likely to: hold false beliefs about the benefits of twice daily tooth-brushing; report little normative pressure or social support for the behavior; have lower self-standards; describe more external constraints; and offer fewer ideas to overcome barriers.
The findings support an integrative framework in which barriers and support for parents' twice daily brushing of their young children's teeth are multiple and vary among individuals. Knowledge of behavioral determinants specific to individual parents could strengthen anticipatory guidance and recommendations about at-home oral hygiene of young children.
Recent policy statements and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) emphasize the Academy's support of the concept of a dental home for infants, children, and adolescents. The American Academy of Pediatrics' (AAP) policy on the dental home, published in 2003,1 encourages parents and other caregivers to establish a source of professional dental care for their children by 12- months of age. This position was elaborated in 2008 in a joint statement by the AAPD and AAP that recommends establishing a dental home within 6 months of eruption of the first tooth and no later than 12-months-old.2 As this policy is implemented and reinforced by other health care professionals, it will change the patient mix seen by many dental providers and expand the content of care for infants and young children. Currently, relatively few children see a dentist prior 3-years-old. The National Survey of Children's Health, a telephone survey conducted on over 100,000 US parents of children from infancy to 17-years-old, found that only 24% of 2-year-olds received a preventive dental visit in the previous year. This was true of just 10% of 1-year-old children.3
Dentists can play an important role in the primary prevention of dental problems in young children through preventive treatments, risk assessment, and anticipatory guidance for parents regarding oral development, caries prevention, and overall oral health.4 Recommendations for at-home preventive measures, including brushing infants' and young children's teeth and using fluoride toothpaste, are key elements of anticipatory guidance to be provided to parents by the child's dental home.2 Perhaps surprisingly, relatively few parents meet professionals' recommendations to brush their children's teeth twice a day. A recent international study involving parents of over 2,800 children (4-years-old on average) documented wide variation in the frequency of parent-child tooth-brushing both between countries and between racial/ethnic groups. Within the US groups, twice daily tooth-brushing ranged from a high of 64% for African American children to a low of 50% for Caucasian children. Overall, the brushing behavior most strongly associated with being caries free at 4-years-old was onset of tooth-brushing prior to 2-years-old. This study made an important discovery: The single best predictor of children being caries-free was not a behavior at all, but a parents' belief that they could carry out regular tooth-brushing.5,6 Research by Blinkhorn et al. supports the point that effective tooth-brushing requires something more than simply knowing it is important. Their study, of 268 mothers, included questions about oral hygiene and direct observation of mothers brushing their preschool children's teeth. They reported that most mothers (71%) knew they should brush twice daily, but only half knew they should use a small amount of toothpaste and less than half (40%) showed adequate tooth-brushing skills.7 A study of 1,021 inner city African American mothers of 1- to 5-year-olds had similar findings.8 In this study, parents reported brushing their children's teeth approximately 9 times per week on average, which is below the recommended frequency of twice daily (14 times per week).
Additional research is needed to identify what parents know and need to protect their young children's dental health by brushing regularly. Information about why people do what they do—the determinants of behavior—is essential to design effective health promotion programs. Fishbein and colleagues9,10 have proposed an “integrative model” of health behavior that draws together several prominent theories of behavior performance and behavior change, including aspects of the theory of health belief, social cognitive theory, theory of reasoned action, and theory of planned behavior. The model posits intention as the primary determinant of behavior. Intention is described as a subjective probability that varies on a continuum from no or low likelihood to strong likelihood of performing a given behavior. Intention is a consequence of behavioral beliefs that give rise to proximate influences, including social norms and individuals' self-efficacy.
An individual's intention to perform a behavior can be impeded, however, by external constraints or an individual's lack of skills. The model predicts that a strong intention, the necessary skills, and lack of constraints are necessary and sufficient conditions for behavioral performance. Thus, individual differences in intention and associated beliefs, skills, and external constraints could explain why programs designed to increase tooth-brushing frequency are effective with some, but not all, parents of young children.11
The role of behavioral beliefs and related norms, self-standards, and self-efficacy has been largely untapped by studies of tooth-brushing behavior. These factors can vary among individuals by population subgroups or culture.12 Community characteristics also can define subgroups. Compared with their urban counterparts, poor rural parents are more likely to be younger and geographically isolated.13 Consequently, young rural parents might be less knowledgeable about where to turn for oral health advice or services. Additionally, in many rural communities there is a high value placed on self-reliance and strong social stigma associated with participating in public assistance programs.13
Thus, even if parents are aware of and have access to resources for their children, rural parents might avoid using them, preferring to “get by” on their own or with the help of family members. Utilization data show that rural vs nonrural children are less likely to use dental services overall and that rural parents are more likely to report the purpose of the last dental visit was due to something “bothering or hurting” their children.14 For all these reasons—isolation, parents' young age, limited formal education or knowledge of children's oral health needs, and a value of self-reliance—rural children especially might benefit from simple interventions to encourage an early and regular habit of parent-child tooth-brushing.
The goal of the present study was to identify motivation, barriers, and support for twice daily tooth-brushing by parents of infants and preschool-age children. The study was designed to answer 3 specific questions:
The results will be used to advance the prevention focus, emphasized in the Surgeon General's report, Oral Health in America, that “safe and effective disease prevention measures exist that everyone can adopt to improve oral health and disease prevention”15 by identifying information about parent-child tooth-brushing that can be used to tailor anticipatory guidance for parents and augment community-based oral health promotion efforts.
The setting was a rural county located in the southwestern region of Washington State. At the time of the study in 2006 and 2007, the population was approximately 15,000 people; most were Caucasian and spoke English as their primary language (95%). Nearly 1 in 5 (19%) children lived in families with household incomes below the federal poverty level. One quarter of adults who were at least 25-years-old lacked a high school diploma. Parents who participated in the research were clients of 1 of 3 early childhood education programs in the community that served low-income families with infants or preschoolers. The reason for the restriction was to elicit information that could be used in future parental education programs.
We used a community-based participatory research approach to include parents and community-based health professionals in each step of the study design and data collection. The chosen method was one-to-one qualitative interviews with parents of infants and preschoolers.
Parents were invited to participate in the research process as expert informants to “help researchers create information for parents of young children about how to take good care of their child's teeth.” Our goal was to elucidate a diverse set of points of view regarding the value and ease of brushing young children's teeth rather than to obtain a statistically representative community sample. We expected that 40 to 45 interviews would be needed before we could identify patterns in parents' responses, by which time additional interviews would provide no new information.
Study protocols and the interview guide were reviewed, revised, and approved by a steering committee coordinated by the study investigator. The committee consisted of 7 community residents, including 5 professionals in early childhood health or education and 2 low-income mothers with young children. Parent members were paid a stipend of $50 for 6 months service on the committee. The committee focused primarily on the appropriateness of the wording of each question, especially for parents with limited education and single parents who might be offended by questions that assumed a traditional family structure. The interviews were conducted by 3 paid community residents trained by the study investigators and who, prior to data collection, completed training in conducting research on human subjects. All procedures were approved by the Institutional Review Board of the University of Washington, Seattle, Wash. Informed written consent was obtained just prior to the actual interviews.
The final version of the interview guide included 9 open-ended questions about when, or if, parents had begun brushing their child's teeth, why they began, how often they were brushing currently, and barriers and sources of support for twice daily tooth-brushing. To measure a parent's intentions toward tooth-brushing, we asked “on a scale of 1 to 10 how confident are you that you will start, or continue, brushing your child's teeth twice a day?”
The interviews were audio recorded and transcribed by an individual unaffiliated with the study. The transcripts were compared to the audio-recordings to ensure accuracy and then coded by the study investigators. The coding used a mixed-method, qualitative approach.16 Techniques of grounded theory, specifically the iterative process of open coding and grouping similar codes, were used to extract all information about supports and barriers to brushing a child's teeth and identify core concepts. As those concepts emerged, we mapped them to the determinants of behavior described by the integrative model9: intention; behavioral beliefs (ie, norms, emotional reactions, self-standards, self-efficacy); skills; and external constraints. Our plan was to capture both positive and negative influences on the initiation of gum or tooth cleaning and on current tooth-brushing behavior.
Participants included 44 mothers and 1 father; interviews lasted less than 30 minutes in length. Fourteen of the 44 parents (32%) were younger than 21-years-old. Twenty-seven parents (61%) had a child younger than 3-years-old; the remainder included parents whose youngest child was up to 5-years-old. Twenty-eight of the 44 parents (64%) were first-time parents. Twenty-seven of the 44 children described in the study were boys.
Three parents did not report the age at which they began brushing their children's teeth. Of the 41 parents who did discuss this, 26 (63%) reported that they began brushing their child's teeth before their child's first birthday. Nine began brushing when their child was 1-year-old, and 2 began when their child was at least 2-years-old. Four parents (of 1- to 5-year-olds) had not yet begun brushing. Fewer than half (48%) of all 44 parents reported that anyone had ever shown them how to brush a young child's teeth. For most, this was a parenting skill they worked out on their own. Several recalled reluctance and fear that they lacked the skill needed to brush without hurting their baby's mouth.
When asked why they began brushing their children's teeth, parents' discussed 1 or more of 7 determinants anticipated by the integrative model. The 3 most common, in rank order, pertained to: (1) oral health beliefs (discussed by 10 parents); (2) social norms (7 parents); and (3) external factors (7 parents). Table 1 presents an example given by a parent for each of the 7 determinants. An unexpected finding was one illustration of the influence of social norms on the initiation of brushing –in this case, the young child noticed other family members brushing their teeth and wanted to join in.
When asked if twice daily brushing was a “very realistic recommendation for parents,” 40 of 44 parents said it was realistic, yet only 22 reported achieving this goal. Of the total sample, 4 had not yet begun tooth-brushing, 1 reported doing so on average less than once a day, 15 reported brushing once a day, and 24 of 44 (55%) reported brushing two or more times a day. Twice daily brushing was most often described in terms of a morning and bedtime or evening routine. Among parents who reported brushing less than twice a day, morning brushing was most often skipped due to early and inflexible work or school schedules. Some parents reported that it was easier to achieve twice-a-day brushing on the weekends.
A child's age was not related to brushing frequency (Table 2). Five of 6 parents (83%) with children 1-year-old and younger reported brushing twice a day. Brushing at least twice a day was reported by 5 of 12 parents (42%) with 1- to 2-year-olds, and by 14 of 26 parents (54%) with children who were at least 2-years-old. Brushing frequency was strongly associated with parents' self-report of their confidence to continue or begin this health behavior. For the group as a whole, the average confidence rating for brushing at least twice a day was 8.5 on a scale of 1 (low) to 10 (high); the range was from 3 to 10 points. The average confidence rating of parents who reported achieving this goal was 9.4 (mean=9.38±0.92 SD); the average of those who reported less frequent brushing was 7.5 (mean=7.50±1.99). A test of the difference between the means was statistically significant (t =3.89; P<.00l).
When describing a typical tooth-brushing session, 11 of the 40 (28%) parents who were brushing said they brushed their child's teeth for them, or went over the teeth to ensure thorough cleaning. The most common pattern, described by 22 of 40 parents (55%), was to be physically present and supervise the child's tooth-brushing behavior or brush their own teeth at the same time. One parent described tooth-brushing this way: “I just… take him to the bathroom. I give him the toothbrush, and he loves to brush his teeth for ever.” Seven parents (18%) reported that their child brushed on his or her own, without supervision. One explained this in terms of logistic difficulties: “It's all her. With 2 kids and even more adults in this house, it's kind of difficult to be the one standing next to her when she is brushing.” Another shared with pride, “She brushes her own teeth, and she's been doing that since she was two-and-a-half [years old].”
Our analysis identified 21 sources of influence on tooth-brushing frequency and how the task was carried out (ie, who did the actual brushing). Twelve category codes described facilitators of tooth-brushing, and 9 codes captured barriers. The concepts reflected in the codes were consistent with the 7 behavioral determinants described by the integrative model. In our data, examples of each determinant were offered by 1 or more parents as a source of support and by at least 1 parent as a type of barrier. In addition to identifying positive and negative influences on brushing, we sorted the data to learn if influences differed for those who reported brushing their child's teeth twice or more a day from those who reported brushing less frequently. The results, with examples drawn from the interviews, are summarized in Table 3 and discussed below.
In reporting sources of support for regular brushing, we restricted our analysis to information provided by the 40 parents who had begun brushing their children's teeth; 4 parents, not yet brushing, were excluded.
Most parents held the beliefs that home oral hygiene is effective and it is a parental duty to establish this behavior with children. Origins of parents' beliefs were apparent in their reflections on what they wanted and did not want for their children, often tied to their own adverse experiences with dental care or having poor teeth. One parent explained, “You need to brush their teeth; that's really something you need to do for your kids so they don't have bad teeth later in life.” Another parent discussed the importance of brushing in terms of its minimal cost and associated benefits: “Because I feel like brushing your teeth is really important and, like I said, it only takes two minutes a day vs a lot of pain in the future.”
Twenty-six of 40 parents reported having social support for regular tooth-brushing. The most common source of support was the extended family, however one parent enlisted a celebrity to bolster support: “I got him Spider-man toothpaste. We talk about Spider-man and how he would brush his teeth and [I] use his heroes to kinda play on to that. 'Spiderman would brush his teeth so he doesn't get cavities' and he [son] wants to be like him, so he'll like start brushing his teeth more, too.” Siblings also were enlisted as role models for younger brothers and sisters.
Emotional reactions to the consequences of not brushing were cited by 18 parents (45%) as a source of motivation for brushing. One parent offered: “A really scary picture of horrible decay might get me to be more regular about brushing.” Another parent explained how it felt when “…but I like forgot to brush, you know, like for a couple of days and you can see, you know, you can start seeing the build-up and it's just… it's not OK. It's gross.”
Overall, 33 parents described self-standards as a source of influence. One parent said, “Yeah, I try to push for 3 [times per day], but he's 5…so probably about 2 to 3 [times per day].” Some parents recalled past childhood experiences, for instance, “I grew up in a family that didn't brush their teeth, and I am trying to do better than my parents.” High self-standards as a behavioral determinant were described by all 24 parents who reported brushing at least twice a day and by 9 of 16 (56%) parents who had started brushing but were doing so less than twice a day.
Seven parents (18%) said establishing tooth-brushing as a structured part of the day or just figuring it out on their own made the experience more manageable. Not surprisingly, parents who reported brushing at least twice a day were more likely to describe it as routine. For them, their children came to understand that brushing was just one of several tasks of the morning and evening. One parent explained, “I mean it's something that you just have to do. It's just, you know, part of the routine, and it's like if your kid doesn't like vegetables, you have to give vegetables.”
Fourteen parents (35%) described a variety of skills they used to encourage their children's cooperation. The most common was to make it “fun” for the child. One parent followed her dentist's lead: “With my son, I have to play with him. And when we went to the dentist the first time … they were telling him to open his alligator mouth to make it a game for him, so he was! It was fun for him and it helped him, so I have to say things like that. My older daughter does it on her own. But my son, I have to sort of supervise him and make it a game for him.” Another parent incorporated songs into the tooth-brushing routine, “Umm … just making it fun, singing songs. My daughter, she sings ‘Happy Birthday’ or ABCs.” Three volunteered that being flexible about location was helpful; they described brushing in the bath, while the child watched a video, or in car if necessary. A few parents suggested the benefits of visual reminders, such as checklists or charts hung in plain sight, and one offered the idea of using stickers as an incentive to encourage the child to brush.
When asked what makes brushing easier, 15 parents (38%) said it was easier if the child was cooperative or in control. One mother explained it this way: “I let her do it, really ‘cause as long as she is doing it herself she thinks it is a good idea, but if I was to like sit there and make her do it, that's when she gets all fussy.” Several noted that child-oriented supplies such as cartoon-character toothbrushes and flavored toothpastes were an effective enticement. One parent said: “We just got a vibrating one [toothbrush] and he's going like, “Ahh!” And whenever he sees it, “Whirr….whirr … whirr” he says. And … and then if we take it from him he gets really mad so…. He like actually really likes that kind of stuff.”
All parents (n=44) were included in the analysis of barriers to tooth-brushing.
Seven parents (16%) shared beliefs about tooth-brushing when discussing obstacles to brushing. Some were false beliefs. For example, one parent remarked, “ People say that if you like brush more than you're supposed to it picks off the enamel or something.” Beliefs as barriers were described by 5 parents (25%) who brushed less than twice a day and 2 parents (8%) who reported brushing twice a day or more.
Sixteen parents (36%) said the lack of a social norm or other support for twice daily brushing made it more difficult to achieve. One mother summed it up this way: “It's just coming down to basically her and I.”
Emotional reactions were apparent in the descriptions of parent-child tooth-brushing given by 5 parents. They talked about not wanting to upset their child, and in turn, themselves. One said, “It's kind of distressing… him being so resistant.” Another parent described how her child's emotional reaction prevented or curtailed brushing. She said, “Yeah, 'cause I wouldn't want him to get that upset and be scared to brush his teeth later on. Honestly.”
Eleven parents (25%) held relatively low self-standards for brushing; most (9 of 11) were brushing less than twice a day and some felt that brushing once a day was sufficient. For example, one parent reported, “If I get them once before bed, I think it's better than forgetting.” Another labeled herself as “just lazy” regarding tooth-brushing.
Three parents offered no ideas about how to reduce self-reported barriers to brushing. One mother described it this way: “If she doesn't want her teeth brushed, it will be a big struggle … that's like probably the biggest issue, ‘cause you can't really like fight with a kid that's 3. If they're not going to open their mouth, what are you going to do?”
Only one parent mentioned skills as a barrier; she said she had not made twice-a-day tooth-brushing a habit for her child.
Thirty-nine of 44 parents described external factors that made twice-a-day brushing difficult. The most common were struggles with a fussy or moody child and lack of time in a rushed schedule. Brushing in the morning seemed to be particularly difficult to accomplish, as one parent described: “Well, in the morning, when I brush my teeth, he doesn't wake up in time so it wouldn't be possible…he barely gets up, so if I could possibly brush his teeth in the morning I would.”
When the coded data were sorted to compare responses of parents who reported that their children's teeth were brushed twice a day vs less often, the following patterns emerged. Parents who brushed their children's teeth twice a day or more were more likely to describe utilizing specific skills (eg, make it fun) or personal reminders to overcome barriers. Also, more parents in the twice-a-day group expressed high self-efficacy for this task and high self-standards for establishing it as a routine. Parents who brushed their children's teeth less than twice daily were more likely to hold negative or false beliefs about the benefits of twice daily tooth-brushing, report little normative pressure or social support for the behavior, have lower self-standards, describe more external constraints, and offer fewer ideas to overcome barriers.
This study's purpose was to describe the tooth-brushing experiences of rural infants and preschool children to identify sources of support and barriers to twice daily brushing reported by their parents. We chose a rural community as the study site because little is known about the home oral health practices of rural caregivers. Tooth-brushing was chosen as the behavior of interest because of persuasive evidence that early brushing with fluoridated toothpaste: is associated with lower levels of mutans streptococci17; is highly protective of the teeth18-20; predicts tooth-brushing habits in later childhood21-23; and is a very specific behavior amenable to change.24,25
Approximately two thirds (26 of 41) of the parents who discussed the age at which they began brushing their child's teeth said they began before the child's first birthday. No single explanation emerged as a majority reason for initiating brushing. The most common reason was an external cue—the eruption of the child's first tooth. The next most common reasons reflected behavioral beliefs, followed by normative expectations including advice from early childhood educators, health professionals, or peers.
Nearly all (91%) parents thought the recommendation to brush a child's teeth twice a day was realistic. Only slightly more than half (55%), however, reported that they achieved this goal. This finding could, in fact, be an overestimate due to social desirability response bias, a limitation of research that relies on self-report. Other parent-reported tooth-brushing data are similar. For example, Vargas and colleagues26 published a study of parents of children enrolled in Head Start centers in Maryland in which 65% of parents reported brushing “more than once a day.” The findings of Pine et al.6 included brushing frequency reported by parents of 3½- to 4½-year-olds; 50% of the US Caucasian sample reported brushing at least twice a day. Other studies8 have reported that brushing frequency increases with child's age. We did not find this to be true. In the present study, the ages of children whose parents said they had not yet begun brushing their children's teeth ranged from 1- to 5-years-old.
Parents' responses to open-ended questions about sources of support and barriers to twice daily tooth-brushing were analyzed using a mixed-model approach. At the conclusion of our open coding, we organized the codes in terms of the integrative model and found that the 2 schemes were congruent. Evidence for each behavioral determinant specified by the model was revealed in the data. We also found considerable individual differences in what parents described as key determinants. Information about determinants of tooth-brushing could be used to personalize anticipatory guidance given in the dental office and, in turn, strengthen efforts to reduce ECC This type of in-person counseling, called motivational interviewing, has been shown to be superior to traditional health education strategies in encouraging a variety of caries-preventive behaviors in parents of infants.27
Similar to other reports,8,28 many parents said they assisted their children with tooth-brushing. Most often, however, assistance took the form of hands-off supervision; only 11 of 44 parents actually brushed their child's teeth. Several parents described brushing as an activity the children completed on their own. Other studies of mothers of older preschool children found that nearly half describe their children as brushing on their own, without adult participation.29,30 The present study confirms and extends this finding to even younger children. Based on our data, it is clear that many parents do not recognize tooth-brushing as a self-help skill that, like feeding or dressing, develops over time. Similar to those other skills, as the child matures, parents' support must change from brushing their children's teeth to assisting with brushing and brushing in tandem with their children before the child can do this independently. A child's ability to carry out a thorough brushing without the parent's support depends on motor maturity as well as cognitive and linguistic developments (eg, understanding the concepts of back and front, inside and outside). It may be useful to recast tooth-brushing as a developmental skill and teach parents how to support children's stages of learning.
The periodicity schedule for dental visits in the first few years of life recommends visits beginning prior to 1-year-old and continuing twice yearly at minimum.31 This creates numerous opportunities for dental professionals to influence home oral hygiene practices and help parents recognize tooth-brushing as a self-help skill that, not unlike feeding or dressing, improves with the child's motor, social, cognitive, and linguistic maturity.32 Anticipatory guidance need not be confined to the dental office. Community-based early childhood education programs such as Head Start are in a unique position to help ensure children receive the benefits of tooth-brushing by incorporating supervised brushing in their program day and by working with parents to help parents and children develop a twice-daily tooth-brushing habit at home.33
Based on this study's results, the following conclusions can be made:
We acknowledge support from the Northwest/Alaska Center to Reduce Oral Health Disparities (National Institute of Dental and Craniofacial Research grant U54 DE14254). We thank the study's steering committee members, interviewers, and other individuals who helped lead this research, particularly Cheri Raff and Nancy Keaton, and the participating families who gave willingly of their time and expertise.