ORIGINAL Mohebbi ARTICLE et al
Improvements in the Behaviour of Mother-Child Pairs Following Low-cost Oral Health Education Simin Z. Mohebbia/Jorma I. Virtanenb/Miira M. Vehkalahtic Purpose: To determine changes in oral health behaviour following low-cost oral health education among mother-child pairs. Materials and Methods: In this controlled trial, interviews were conducted in a random sample of mothers of 12- to 15-month-olds (N = 242) attending the vaccination offices of public health centres in Tehran, Iran, and the vaccination staff provided oral health education for the mothers belonging to two intervention groups (A and B) and a control. Groups A and B received health education, but group A additionally received two reminders during the 6-month follow-up. The control group received no health education. The mothers’ oral health behaviour and practices with regard to their children were scored at baseline and at the end. Changes in these scores were recorded separately for the mothers and the children and grouped into the categories prominent, minor or no improvement. Statistical evaluation was performed with the chi-square test, ANOVA and logistic regression. Results: Prominent improvement in oral health behaviour was evident in 45% of the mothers and 66% of the children in group A, 29% of the mothers and 31% of the children in group B and in 11% of the mothers and 21% of the children in the control group (P < 0.001). A prominent improvement in the mothers’ practices with regard to their children was related to the mother’s own behavioural improvement (OR = 1.3). The intervention was most successful in group A (OR = 5.1). Conclusion: Improvement in mothers’ oral health behaviour can lead to improved health practices with regard to their children. Oral health education combined with external motivation is a valuable tool for promoting oral health behaviour in mother-child pairs. Key words: early childhood, health behaviour, low-cost health education, mothers, oral health education Oral Health Prev Dent 2014;1:13-19
Submitted for publication: 23.10.12; accepted for publication: 19.12.12
doi: 10.3290/j.ohpd.a31227
T
he adoption of healthy behaviour is essential for moving towards better health, as behavioural factors are the primary contributors to chronic diseases at all ages, and young children have a special status where the onset of behavioural patterns is concerned. In line with the main approach to public health problems, and in particular to those occurring in the early stages of life, emphasis should a
Assistant Professor, Community Oral Health Department, School of Dentistry, Tehran University of Medical Sciences, Iran; Researcher, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland.
b
Professor, Department of Community Dentistry, Institute of Dentistry, University of Oulu, Oulu University Hospital, Oulu, Finland.
c
Adjunct Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Finland; Adjunct Professor, Department of Community Dentistry, Institute of Dentistry, University of Oulu, Oulu, Finland
Correspondence: Dr. Simin Z. Mohebbi, Community Oral Health Department, School of Dentistry, Tehran University of Medical Sciences, 1439955991, Tehran, Iran. Tel. +98-21-8801-5960, Fax: +98-218801-5960. Email:
[email protected] or simin.mohebbi@helsinki.fi
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be placed on the prevention of diseases and the promotion of healthy behaviour among mothers and their toddlers (WHO, 1986; Hobdell et al, 2003). Diet has been highlighted recently because of growing problems with overweight even among children, to the extent that over 40 million children under the age of 5 were estimated to be overweight by the end of 2010 (WHO, 2009). Since many general and oral diseases share the same risk factors, applying the common risk factor approach to health education from early childhood could support children in growing up into healthy adults. In early childhood, this requires avoidance of the premature or frequent intake of foods containing sugars (Marshall et al, 2005) and frequent and nocturnal use of baby bottles containing formula (Hallet and O’Rourke, 2006; Mohebbi et al, 2008) or sweetened drinks (Marshall et al, 2005). In terms of oral hygiene, sharing a spoon with the child and delaying the onset of toothbrushing should be avoided (Kiwanuka et al, 2004).
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The importance of family support in the development of appropriate oral health behaviour in children has been emphasised (Pine et al, 2000). The formation of habits is part of the complex process of socialisation (Petersen, 2007). The family and the mother play the most important role in initiating socialisation in early childhood. In this respect, parents’ beliefs regarding regular toothbrushing for their children and their own toothbrushing, for example, have been positively associated with the oral cleaning behaviour of their children (Okada et al, 2002). Many countries with young populations and minimal health education for children are facing enormous problems, particularly regarding dental diseases (WHO, 2012a). Being one of the countries with a young population and developing oral health services (Pakshir, 2004), Iran is experiencing a large-scale public health challenge in terms of poor oral health in early childhood. We therefore developed a low-cost method for oral health education in a primary healthcare setting (Mohebbi et al, 2009). The present study investigated changes in behaviour following health education for mothers of toddlers. It was hypothesised that an improvement in the mothers’ own health behaviour would also improve their health practices with regard to their children.
MATERIALS AND METHODS Low-cost intervention The target population consisted of 12- to 15-monthold children (N = 242) and their mothers attending the vaccination offices of public health centres in Tehran, Iran. Vaccinations against common childhood diseases are administered at public health centres regardless of socioeconomic status, with resulting coverage across the country ranging from 94% to 98% (WHO 2012b). Prior to the intervention, two members of the health staff in each centre received 1–2 h of training from the dentist who supervised the intervention (Mohebbi et al, 2009). After a baseline interview with each mother, the vaccination staff provided oral health education on the use of sugar and on night feeding and oral hygiene for each mother belonging to the randomly selected intervention groups. Those in group A received a health education pamphlet (Mohebbi et al, 2009) together with 5 minutes of related health instructions. In addition, the staff phoned these
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mothers twice at 2-month intervals to remind them of the health education given. The mothers in group B were only given the pamphlet, with no more explanation than a comment that it would be useful to read it. The controls received no oral health education during the intervention period, but afterwards they received the same pamphlet. The length of the follow-up was 6 months. The main outcome was measured in terms of changes in oral health behaviour of the mothers and their oral health practices with regard to their children between baseline and the end of the trial period. A positive outcome was defined as an improvement in the oral health behaviour of the mother and her oral health practices with regard to her child.
Sampling, randomisation, blinding Using a list provided by the Ministry of Health and Medical Education, 18 out of 102 public health centres in the city of Tehran were randomly selected. The sample size was determined to provide 80% power to recognise a significant difference of 20% in oral health behaviours between the intervention and control groups with a 95% confidence interval (_ = 0.05), prevalence of desirable behaviour of at least 10% and 25%–30% attrition. The baseline data were collected from January to February 2005 and the outcome data 6 months later. Two working days were devoted to each health centre. All the 12- to 15-month-old children and their mothers visiting the centre on these two days were selected, resulting in 10 to 15 children per centre. The exclusion criterion was suffering from any severe condition that could pose a barrier to oral health practices, such as mental retardation or a cleft palate. The health centres were randomly assigned to the three groups: two intervention groups (A and B) and one control group, with six centres in each. This was done with a table of random numbers. A dentist (AA) who was not involved in the interviews supervised the randomisation and intervention processes. Collection of both the pre- and post-intervention data was synchronised with the children’s routine vaccination visits, and the mothers were unaware of the possibility of an interview on the day of their visit to the health centre, while the interviewer (SM) remained blind to the allocation of the groups throughout the study, as the data collection took place in a separate room from the vaccina-
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tions. The staff were instructed to say nothing to the interviewing dentist regarding the intervention. Of the 242 mothers enrolled, 177 (group A, n = 55; group B, n = 59; and controls, n = 63) attended the outcome interview. The baseline characteristics of the children did not differ between the groups. Of those who attended both baseline and outcome examinations, 50% were boys: 40% in group A, 59% in group B and 54% in group C (P = 0.11). The parents’ level of education was low for 12% in group A, 12% in group B and 16% in group C (P= 0.20).
Framework for health education Planning of the health education was based on the Health Belief Model (HBM), which explains that behaviour is directed by perceptions and beliefs and suggests situations in which a person engages in preventive health actions (Overton Dickinson, 2005). Based on the HBM, health education was provided for the mothers in order to improve their behaviour and their health practices with regard to their children. The pamphlet followed the principles of HBM by addressing perceived susceptibility of children to be at risk for ECC, perceived severity of ECC and perceived barriers to maintaining optimal oral home-care. The HBM principle of action was fulfilled by the reminders during the intervention pe-
riod. The pamphlet used simple language so that less-educated parents could also read it. It contained bright colours and illustrations of babies to maintain the mothers’ attention and interest.
Data collection The interview used a structured questionnaire covering selected aspects of the mothers’ oral health behaviour, their oral health practices with regard to their children and the sociodemographic background of the family. Behavioural status at baseline and at the end was described separately for the mothers and the children by combining three dimensions (sugary snacking, sharing a spoon with the child, toothbrushing) for the mothers and five dimensions for their oral health practices with regard to their children (sugary snacking, bottle or breast in the mouth at bedtime, frequency of night feeding, toothbrushing, use of fluoride toothpaste). The replies to the questions on the mothers’ oral health behaviour and practices with regard to their children were categorised and scored, giving greater weight (scores) for oral health-promoting behaviour and emphasising important oral health behavioural aspects (Table 1). The summed scores indicated the level of the mothers’ oral health behaviour and their oral health practices with regard to their children. The theoreti-
Table 1 Oral health behaviour of 12- to 15-month-old children (n = 177) and their mothers in Tehran, Iran, assessed using a structured interview Oral health behaviour
Measured for
Categories formed
Scores* (weights)
Sugary snacking
Child and mother
Less than daily, rarely, never Once a day Twice a day Three times a day or more
3 2 1 0
Bottle or breast in mouth at the bedtime
Child
None Breast or bottle or both
2 0
Frequency of night feeding
Child
No night feeding One to two times a night More than twice a night
3 1 0
Sharing spoon with the child
Mother
No Yes
2 0
Toothbrushing
Child and Mother
More than once a day Once a day Less frequently or never
4 2 0
Use of fluoride toothpaste
Child
Always or quite often Seldom or never
2 0
* Scores weighted for health-promoting behaviour
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cal range of the summed scores was 0–9 for the mothers and 0–14 for the children. The difference in the summed scores between baseline and the end of the study was taken to indicate the behavioural change. For the analyses, the levels of change were categorised as ‘no improvement’, ‘minor improvement’ (increase in one to two scores), and ‘prominent improvement’ (increase in three or more scores). In addition, a dichotomy of ‘any improvement’ vs ‘no improvement’ was used. The interview also covered the children’s gender and the parents’ education, assessed separately for fathers and mothers using a seven-point scale ranging from illiterate to a doctoral degree (Mohebbi et al, 2008). The family’s level of education was defined according to the highest level found among the parents. The economic level of the family’s residential area (affluent/non-affluent according to the Head Office for Education in Tehran) served as an economic indicator.
Ethical consideration The trial was approved by the Ethics Committee of the School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran. The mothers provided their informed written consent to participate. The subjects were identified in the database by a numerical code only.
Group A
Mother
Group B
Mother
Group C
Prominent
Mother
Minor
Statistical analysis The evaluation covered those mother-child pairs who attended the outcome examination. The intracluster correlation coefficient (ICC) was low (P > 0.05), so the concept of a multi-level design was not used. Statistical evaluation was conducted using the chi-square test, one-way ANOVA and Pearson’s correlation coefficient. Logistic regression models served for assessing the magnitude of the factors related to a positive outcome, shown in terms of odds ratios (OR) and their 95% confidence intervals (95% CI). Goodness of fit was assessed by means of the Hosmer and Lemeshow test. A Pvalue of less than 0.05 denoted statistical significance. The data were analysed with SPSS, version 16 (SPSS; Chicago, IL, USA).
RESULTS The mothers’ baseline behavioural scores ranged from 0 to 9 (the theoretical maximum), with the mean group scores as follows: A = 2.6 (SD 1.6), B = 3.2 (SD 2.0) and controls = 3.8 (SD 2.1). The children’s scores, with a theoretical maximum of 14, ranged from 0 to 10; the group means were: A = 2.6 (SD 2.0), B = 2.6 (SD 2.0) and controls = 2.2 (SD 1.7).
None
Child
Child
Child 0
20
60
40
80
100
(%) * Group A: Educational pamphlet, 5-min explanation of oral health instructions, two recall phone calls on oral health instructions. Group B: Educational pamphlet given with the comment that it would be useful to read it. Controls: No oral health-related information during the 6-month period.
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Fig 1 Improvements in mothers’ own oral health behaviour and in their oral health practices with respect to their 12- to 15-month-old children (n=177) following the educational intervention.*
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own health behaviour. Some improvement relative to the controls was found in both groups A (OR = 35.7) and B (OR = 5.2), as was a prominent improvement (group A, OR = 17.5; group B, OR = 5.0). The impacts of improvements in the mothers’ own behaviour on their health practices with regard to their children are shown in Table 3. For all the mothers, their own behavioural improvements (OR = 1.2) and a higher educational level of the family (OR = 1.3) explained ‘any improvements’ in health practices with regard to their children. The mothers own behavioural improvements (OR = 1.3) and a higher educational level of the family (OR = 1.4) explained ‘prominent improvements’ in health practices with regard to the children. When the intervention groups were taken into account,
Improvement in behaviour was found in 62% of the mothers and 58% of the children. The group findings are shown in Fig 1. The behavioural improvement was prominent in 45% of the mothers in group A, 29% in group B and 11% in the controls (P < 0.05); the percentages in the children, these values were 66%, 31% and 21%, respectively (P < 0.001). When the mothers’ behavioural improvement was prominent, 73% of them improved their health practices with regard to their children; the corresponding value for the mothers with minor improvement was 55% and that for mothers with no improvement was 49%. These associations are shown in detail in Table 2. Regarding the mothers, intervention was the strongest factor explaining the improvement in their
Table 2 Improvement in oral health practices with regard to 12- to 15-month-old children (n = 177) in relation to the improvement in their mothers’ behaviour following the educational intervention Improvement in mother’s behaviour Improvement in children’s oral health practices
Prominent n = 49 (%)
Minor n = 61 (%)
None n = 67 (%)
None
27
45
51
Minor
22
18
21
Prominent
51
37
28
Chi-square test: P = 0.08, Pearson’s correlation: l = 0.2.
Table 3 Outcome following the educational intervention: factors associated with any improvement in children’s oral health practices and with prominent improvement vs no improvement as shown by logistic regression models Odds Ratio Estimate of Strength
Standard Error
OR
95.0% CI
P-value
Improvement in mothers’ behaviours*
0.183
0.073
1.2
1.0–1.4
0.012
Parents education *
0.283
0.140
1.3
1.0–1.7
0.043
Residential area: 0 = Affluent, 1 = Non-affluent
0.403
0.339
1.5
0.8–2.9
0.235
Child’s gender: male = 0, female = 1
0.432
0.322
1.5
0.8–2.9
0.180
Improvement in mothers’ behaviours*
0.259
0.088
1.3
1.1–1.5
0.003
Parents education*
0.313
0.150
1.4
1.0–1.8
0.037
Residential area, 0 = affluent, 1 = non-affluent
0.497
0.389
1.6
0.8–3.5
0.202
Child’s gender: male = 0, female = 1
0.287
0.366
1.3
0.6–2.7
0.432
Factors Any improvement (n = 177)
Prominent improvement (n = 140)**
Goodness of fit by Hosmer and Lemeshow, 1) P = 0.7, 2) P = 0.2. * Improvements in mothers’ behaviours and parents’ education were used in their continuous form. ** Those with minor improvement were excluded from ‘prominent improvement.’
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group A was most successful in terms of both prominent improvement (OR = 5.1) and any improvement (OR = 8.0) in the mothers’ health practices with regard to their children. The outcome in group B remained statistically non-significant.
DISCUSSION Our results show that a low-cost educational intervention taking advantage of the HBM was successful in improving the mothers’ own oral health behaviour and consequently their oral health practices with regard to their children. This may in the long term reduce the children’s risk of becoming overweight with all its consequences and result in better general and oral health in childhood, adolescence and adulthood (Petersen, 2007; WHO, 2009). One of the main aspects covered in our educational intervention was the reduction of sugar intake by the mother and child in terms of both the frequency of sugary snacks and nursing habits, the latter indicating the milk sugar load of the child. The alteration of dietary habits is a challenging process, since they originate in behavioural norms and are essentially a matter of common beliefs, values or practices that societies impose on individuals, and mothers or caregivers are unlikely to administer procedures or practice forms of behaviour that are not shared by the community in which they live or the cultural subgroups to which they belong (Horowitz, 1998). Nevertheless, examples from several countries have shown that it is possible to change dietary determinants and thereby affect trends in non-communicable diseases (WHO, 2002). One reason for the success of the present intervention in changing health behaviour might lie in the reminder phone calls provided in accordance with the HBM philosophy, which may have reinforced the education provided and kept the mothers motivated to achieve the dietary transition. The mothers in our trial had very low baseline behavioural scores (around 3 out of 14 for the child and 2 out of 10 for the mother). Since several of the common risk factors for a number of important general chronic diseases and conditions are related to poor oral health behaviour, it would be inefficient and uneconomical to target each disease separately when they have similar origins (Sheiham and Watt, 2000). Therefore, the common risk factor approach has been highly recommended to achieve better control over various chronic diseases. In this respect, promotion of oral health behaviour should
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be integrated into broader health promotion programmes (Petersen and Kwan, 2004). Our results showed the effectiveness of the intervention incorporated into the primary health care providers’ duties in promoting the mothers’ own oral health behaviour and their practices with regard to their children’s oral health. This type of community-based oral health education, delivered in a general health setting, can achieve wider coverage of a population at low cost. Thus, there is an urgent global need to strengthen public health programmes through the implementation of health promotion and effective oral disease prevention measures, and common risk factor approaches ought to be used to integrate oral health into national health programmes (Petersen et al, 2005). The mothers in our series were interviewed using a structured questionnaire to reduce the non-response, misconceptions and errors that might occur with a self-administered questionnaire. Data collection was carried out in a private room to ensure that the mothers were able to concentrate on the interview and also to provide confidentiality for their probable non-desirable responses. However, as in any questionnaire survey, the tendency among the participants to give favourable answers, referred to as social desirability (Sjöström and Holst, 2002), might have affected the results. For the present purposes, we created behavioural indicators to cover a broad range of health behaviour and practices in mothers. In addition, we weighted these aspects of behaviour according to their assumed role in health promotion based on previous research. Sugar intake and other health habits, however, were assessed by means of a single questionnaire and not through a diary, which may have resulted in failure to mention some hidden sources of sugar in the diet or erroneous estimates for other aspects of health behaviour, and can be considered a limitation of the findings.
CONCLUSIONS An improvement in mothers’ behaviour can lead to improved health practices with regard to their children. Low-cost health education combined with external motivation proved to be a valuable tool for promoting health behaviour in mothers and their children.
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ACKNOWLEDGEMENTS This study was supported in part by the Iran Centre for Dental Research. We are grateful to the staff at the public health centres for their excellent collaboration. Our special thanks go to Dr. AA for his supervision of the intervention process.
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