Initiation and perpetuation of tooth brushing among young children : mixed methods analyses

Abstract

INTRODUCTION: Early childhood caries remains a significant public health problem in Hong Kong. Parental behaviours are key to protecting children’s oral health; and yet little is known of when, how and why these develop.

OBJECTIVES: A qualitative study using a Phenomenological approach was conducted with an initial objective to describe the experiences of Hong Kong parents in caring for their children; including the impact on dental caries. Subsequently, the qualitative study shifted to a Grounded Theory approach with an objective to develop a theory describing the development of tooth brushing habits and to identify potential associating factors. A quantitative study was conducted to verify the theory and provide evidence of the role of these potential factors.

METHODS: The qualitative study was conducted by one-to-one semi-structured interviews with parents selected by a purposive sampling procedure. Two qualitative analytical approaches were undertaken: Phenomenology and Grounded Theory. A longitudinal quantitative study on the ‘initiation’ and ‘perpetuation’ of tooth brushing among children (at age 1 who were followed up at age 2) was undertaken. The relationship of parental factors, social support, environmental stressors and child resistance factors were examined.

RESULTS: The Phenomenological analysis informed the research question of ‘how tooth brushing habits are developed’. The Grounded Theory analyses identified that tooth brushing was not developed in a switch from ‘off’ to ‘on’ manner, and should be conceptualized by an ‘initiation’ and ‘perpetuation’ phase. Moreover, that multiple and interacting factors related to parents/caregivers, social support, environmental factors and child resistance influence tooth brushing habits. In addition, it informed the design of the quantitative study involving 187 parents/caregivers. Most caregivers (68%, 128/187) attempted to ‘initiate’ tooth brushing by age 1 of the child; and this was associated with family monthly income (OR 1.65, 95%CI, 1.07, 2.53, P<0.05). Among them, approximately half (53%, 68/128) were able to ‘perpetuate’ tooth brushing; and this was found to be associated with parental self-efficacy in relation to tooth brushing (PSE-TB scores: OR 1.37, 95%CI 1.18, 1.58, P<0.001) and parental distress (PSI-PD scores: OR 1.09, 95%CI 1.03, 1.16, P<0.01). The response rate to follow-up study was 56%. Most (95.3%) attempted to ‘initiate’ tooth brushing by age 2; and two-thirds (66%) were able to ‘perpetuate’ tooth brushing. Perpetuation of tooth brushing was associated with parental self-efficacy in relation to tooth brushing (PSETB scores: OR 1.43, 95%CI 1.20, 1.72, P<0.001). No baseline factors were associated with the development of daily tooth brushing between age 1 and 2.

CONCLUSIONS: The qualitative study informed the research question and identified a conceptual model for the development of tooth brushing in the Hong Kong context. It illustrated the influences of parental, social support, environmental factors and child resistance in the development of tooth brushing habits. The quantitative study findings supported the qualitative findings of multiple interacting factors in the development of the tooth brushing habits but also illustrated some limitations of the quantitative approach - highlighting the merits of the mixed methods approach.