Child and family health nurses' experiences of oral health of preschool children: a qualitative approach

Child and family health nurses’ experiences of oral health ofpreschool children: a qualitative approachjphd_295 1..7

Amit Arora, BDS, MDSc (Hons)1,2; Dina Bedros, BDent2; Sameer Bhole, BDS, MDSc3;Loc Giang Do, DDS, MSc (Dent), PhD4; Jane Scott, B App Sci, Grad Dip Dietetics, MPH, PhD5;Anthony Blinkhorn, BDS, MSc, PhD1; Eli Schwarz, DDS, MPH, PhD6

1 Department of Population Oral Health, Faculty of Dentistry, The University of Sydney, Sydney, Australia2 Bachelors of Dentistry Program, Faculty of Dentistry, The University of Sydney, Sydney, Australia3 Sydney Dental Hospital and Oral Health Services, South West Area Health Service, New South Wales, Australia4 Australian Research Centre for Population Oral Health, The University of Adelaide, Australia5 Nutrition and Dietetics, School of Medicine, Flinders University, Adelaide, Australia6 Department of Community Dentistry, Oregon Health and Science University, Oregon, USA

Abstract

Objectives: The objective of this study was to explore Child and Family HealthNurses’ work-related experiences of dental disease in young children.Methods: Child and Family Health Nurses (n = 21) who recruited new mothers toan ongoing birth cohort study that began in South Western Sydney, Australia wereinvited to take part in a qualitative study. A semi-structured, in-depth interviewtechnique was used to explore their experiences of preschool child oral health andhow this affects their working lives. Interviews were audio-recorded, transcribedverbatim, and analyzed using a thematic analysis.Results: The nurses considered dental caries to be a significant health issue for youngchildren and their families. They thought that the burden of dental disease in pre-school children was underestimated in disadvantaged and multicultural popula-tions. In addition, they reported that parents were often unaware of the diseaseprocess and were ignorant of the relationship between bottle feeding and dentalcaries. Once the parents were informed about their child’s poor oral health, they hadfeelings of anger, despair, and guilt.Conclusions: This study highlights that oral health problems are a significantsegment of the child health problems identified by nurses in their daily work. Thenurses perceived the problem of dental caries to be one of a lack of parental knowl-edge, and families should be educated not only on “what” but also on “how” to feedtheir children. The primary healthcare team should work collaboratively to educatefamilies in a culturally appropriate way.

Introduction

Dental caries is one of the most prevalent chronic childhooddiseases worldwide and, as such, is a major public healthproblem (1-3). In Australia, it was reported in the 2002 ChildDental Health Survey that the number of decayed, missing, orfilled teeth for 5-year-olds was 1.83 (1). Alarmingly, it was

observed that over 40 percent of 5-year-olds had one or moredecayed or missing teeth, and 10 percent of the child popula-tion were found to have more than seven decayed teeth (1).This problem is not unique to Australia. In the UK, successivenationalchilddentalhealthsurveyshaveshownlittlechangeincaries prevalence in 5-year-old children over the last 20 years(3). In the United States, the National Health and Nutrition

Keywordsearly childhood caries; disadvantaged; dentalcaries; qualitative research.

CorrespondenceDr. Amit Arora, Level 6, Sydney Dental Hospital,Faculty of Dentistry, The University of Sydney, 2Chalmers Street, Surry Hills, NSW 2010,Australia. Tel.: +61 2 8821 4371; Fax: +61 28821 4366; e-mail: [email protected] Arora is with the Department ofPopulation Oral Health, Faculty of Dentistry,The University of Sydney and Bachelors ofDentistry Program, Faculty of Dentistry, TheUniversity of Sydney. Dina Bedros is with theBachelors of Dentistry Program, Faculty ofDentistry, The University of Sydney. SameerBhole is with the Sydney Dental Hospital andOral Health Services, South West Area HealthService. Loc Giang Do is with the AustralianResearch Centre for Population Oral Health,The University of Adelaide. Jane Scott is withthe Nutrition and Dietetics, School of Medicine,Flinders University. Anthony Blinkhorn is withthe Department of Population Oral Health,Faculty of Dentistry, The University of Sydney.Eli Schwarz is with the Department ofCommunity Dentistry, Oregon Health andScience University.

Received: 5/10/2011; accepted: 12/2/2011.

doi: 10.1111/j.1752-7325.2011.00295.x

Journal of Public Health Dentistry . ISSN 0022-4006

1Journal of Public Health Dentistry •• (2011) ••–•• © 2011 American Association of Public Health Dentistry

ExaminationSurveystellasimilarstory(2).From1988to1994and from 1999 to 2002, there was no change in the prevalenceof dental caries among children aged 2-11 years (2). Oralhealth professionals may quantify dental disease in epidemio-logical surveys but this does not reveal the financial and emo-tional impact of dental caries on individual families (4-6).

If decayed primary teeth are left untreated, it can lead tochildhood distress, affecting the growth and cognitive devel-opment of children (7), and early childhood caries (ECC) isalso a strong predictor for dental problems in permanent teeth(8). Because young children are often uncooperative, dentaltreatment under a general anesthetic is often the only viableoption to ensure that treatment is completed (4,5).This placesan enormous burden on dental hospital services, with exten-sive waiting periods,and the majority of patients on those listsare under 5 years of age.This causes stress and anxiety to fami-lies and a financial drain on the public dental services tocombat a major epidemic of dental caries in children.

The key factors associated with the development of ECCare well known (4-6), and these include:

• frequency and duration of exposure to fermentablecarbohydrates,

• the age at which cariogenic bacteria colonize a child’s oralcavity,

• the level of exposure to fluoride, and

• the quality of tooth enamel.There is sufficient evidence to show that preventive oral

health promotion messages are robust and deliver a provenbenefit (9). The main difficulty is to ensure that the appropri-ate preventive behaviors are established as teeth erupt; hence,there is a need to focus advice on parents with children under2 years of age (10). However, it has been reported that only12 percent of 2-year-old Western Australians have ever visiteda dental professional (11). Similarly, research in Victoria,Aus-tralia reported that infants were taken to a primary healthcareservice provider around 35 times in their first year of life, butnone of these visits were to a dental professional (12). It wasalsonotedthat70 percentof thesevisitswereeithertoageneralmedical practitioner or to Child and Family Health Nurse(CFHN) (11). Therefore, the primary healthcare setting pre-sents practical opportunities for early dental health education,counseling, and anticipatory guidance (13,14). In light of thisinformation,a model of shared care involving members of theprimary care team such as general medical practitioners and,in particular, CFHN has been proposed for health promotion,anticipatory guidance, and early intervention (13-15).

In order for the Mouradian model of shared care (15) to beeffective in reducing the burden of ECC, the oral healthpromotion messages delivered by primary healthcare pro-fessionals must be consistent, evidence based, and tailored to“at-risk” communities (16). However, this is challenginggiven that the evidence shows that there is little communica-tion between Australian healthcare professionals and the

dental team (17). Furthermore, there is limited undergradu-ate and postgraduate training in oral health for Australiannondental healthcare professionals, unlike the United States,where recently some schools have integrated an oral healthcurriculum for students undergoing training in nursing (18).

In New South Wales, Australia, where this study wascarried out, the current approach to reducing the burden ofECC is the “Lift the Lip” program delivered by CFHN toparents (19). This program screens preschool children andthose with early signs of tooth decay are referred for prioritydental care.Although the“Lift the Lip”program has become awell-accepted part of CFHNs’ activities, there is little infor-mation available on how these primary healthcare profes-sionals perceive the impact of dental disease on their workinglives This article aims to analyze CFHNs’ experiences andreflections on the oral health of preschool children in thecontext of the families for whom they cared.

Methods

Background

The study is nested within a birth cohort study that recruited1,033 mothers with newborn children in South West Sydneyin 2010 (20,21). The purpose of the main study is to investi-gate the relationship between early childhood feedingpractices and dental caries in preschool children. CFHNsrecruited new mothers for the cohort study at the first postna-tal home visit. They willingly collaborated in the recruitmentprocess because of their concerns about the dental health ofthe young children with whom they come in contact.

Study design

A qualitative research design was used based on semi-structured in-depth interviews. This approach has been usedin the past to gain an understanding of the experiences of con-sumers and health professionals on a wide range of topics (22).Indeed,qualitative research has recently been used in dentistryto explore the perceptions of dental professionals working indeprived areas (23). The research design is useful because itprovides an in-depth understanding of complex health phe-nomena (24), and its flexibility gives the researcher an oppor-tunity to undertake simultaneous data collection and analysis.

Sample

We contacted Nurse Unit Managers in South Western Sydney,a disadvantaged area of the city, to obtain details of theCFHNs who could represent all geographical sectors ofthe area. We telephoned the CFHNs (n = 21) to explain thepurpose of the investigation and sent them an informationpack. All the nurses initially agreed to participate, but two

Nurses’ experiences of oral health of preschool children A. Arora et al.

2 Journal of Public Health Dentistry •• (2011) ••–•• © 2011 American Association of Public Health Dentistry

could not be contacted for interview despite repeatedattempts and were excluded. It has been shown that, for ahomogeneous sample, six to eight interviews are sufficient toreach data saturation, i.e.,“the point at which additional datadoes not improve understanding of the phenomenon understudy” (25). We interviewed a larger number of nurses(n = 19) because we adopted a maximum variation samplingstrategy to enrich our data quality (26).

In-depth interviews

Two researchers (AA and DB) conducted the in-depth inter-views, which were audio-recorded and transcribed verbatimto be coded. The researchers used an interview guide(Table 1) that covered topics relevant to the oral health ofyoung children and their families. The questions were modi-fied, and additional items were added iteratively as the inter-views progressed to clarify emerging concepts (27).

Data analysis

To improve the rigor and credibility of our research, the sametwo researchers (AA and DB) undertook every phase of dataanalysis, including interview debriefing, transcript coding,data display, and interpretation. The debriefings were in theform of written notes made by the interviewer following theinterview, which helped to prepare for subsequent interviews.The two researchers coded the transcripts individually, one(DB) using manual coding and the other (AA) using NVivo 9(QSR International, Cambridge, MA, USA) software, andtheir findings were compared. The codes were then examinedthrough an iterative process and regrouped into three broadthemes. A thematic analysis was used, which is a “method ofidentifying, analysing and reporting patterns within data”(28).

Ethics approval

The study received ethics approval from the Human ResearchEthics Committee of Sydney South West Local HealthNetwork and the University of Sydney.

Results

Three main themes emerged from the interviews: nurses’experiences of dental issues in young children, parents’ per-ceptions of their child’s oral health, and parents’ feelingsupon learning about their child’s poor oral health.

Theme 1: Nurses’ experiences of dentalissues in young children

The majority of the nurses reported that the families whosechildren presented with dental caries were mostly from alower socioeconomic background, with financial constraints.The nurses also commented that the number of children pre-senting with dental caries differed, in some cases quite signifi-cantly, between the richer and poorer areas. The severity ofthe decay in terms of the number of teeth affected was per-ceived to be influenced by deprivation.

Yes I think they could be of lower socio-economic status. Ithink the other families might have a dentist or they go to thedentist themselves. But I think the others are struggling anddentists are dear (i.e., expensive). (ID: 13)In [suburb A] now, I just moved here a few weeks ago, Ihaven’t seen any but when I was in [suburb B], I was seeingthem like every week. I remember an 18 month old who hadteeth with big cavities. But here [suburb A], families go forpreventive care. (ID: 02)

The nurses were also aware that, for many families, Englishwas their second language and felt that the advice given tothem was not sensitive to their cultural norms.

Um . . . a couple of mine were from a non-English-speaking background and thought that juices and milks wereimportant in their diet. (ID: 09)

The nurses observed that children belonging to families froman Asian or a Middle-Eastern background suffered noticeablymore from dental caries.

We see a lot of Vietnamese clients, and it’s much morecommon in their culture to use the bottles at a later agedespite what they may have been told beforehand,they still tend to do it. It’s hard to change the habit.(ID: 03)Ah yes! Lebanese and Chinese, some English background aswell but majority with dental decay are Asians. And theTurkish love putting custard in the bottle. (ID: 06)

There was a general consensus that a large number of childrenwith oral health issues go unreported. Families tend to asknurses for general advice regularly until their child is6 months old; however, clinic attendance drops as the childages.

We tend to see babies, and clinical attendance drops off asthe children get older. They probably don’t come at the agewhere they’re starting to show caries. (ID: 17)

Table 1 Interview Guide

Semi-structured interview questionsWhat are common dental problems you observe in young children?

How often do you see problems of this kind?Are there any gender differences you observe?Do you notice anything common in these families? (e.g.,

socio-demographics)What do the family members or children usually complain of?What do the family members perceive as the possible cause of dental

problems?What do the family members perceive as ways to avoid or prevent

dental problems?

A. Arora et al. Nurses’ experiences of oral health of preschool children


Theme 2: Parents’ perceptions of their child’soral health

Most nurses reported that parents whose children had dentalcaries did not report any problems because the children didnot complain of any pain.

No, [the parents or the child] don’t complain. They’reunaware, which is quite interesting. They don’t see it as aproblem because they think it’s their primaries, not theirpermanents. And because they’re not in pain, they don’tsee it as a problem. Normally, I’d lift up their lip andhave a good look at their teeth. It’s not uncommon to seecavities in 4-year-olds when they open their mouth.(ID: 16)

Some nurses also reported that parents whose children haddental caries complained mainly of difficulties with brushingthe child’s teeth, poor appearance of the teeth, distress, andloss of sleep.

Quite often it’s pain that worries them, but a few areconcerned about appearance as well (ID: 14)

The nurses thought that the majority of parents lacked thecorrect knowledge regarding the cause of dental caries andthat they linked their child’s dental caries to inadequate toothcleaning. Most parents did not realize that caries is also linkedto inappropriate feeding habits.

I don’t think they give much thought on the feeding practicesparticularly bottle feeding. I don’t think they even thinkabout what they are actually drinking and eating.They’ve got no concept, like they don’t think about it.They think it’s healthy whatever they’re drinking – milkand juice. Yeah and they would have had bottles for yearswith milk or cordial. They also had the perception thatjuice was healthy. When I would talk to them about juice,they’d argue with me, “but it’s juice, it’s good for them!”They just think that if they brush their teeth they’ll be fine.(ID: 08)It’s also the grandparents, they are putting you know honeyon dummies!! My goodness, you know! You are stilllooking at 3-year-olds having a dummy or a bottle or both.(ID: 02)

The nurses reported that the parents receive oral health infor-mation either at antenatal classes or at the first postnatal visit.Some nurses pointed out that they noticed a difference inparents’ eagerness to receive health information and knowl-edge of dental health depending on their level of educationand the suburb in which they lived.

Again in [suburb B] they bottle feed a lot. Over here [suburbA], I have not come across any of them who bottle feedduring the night or are running around, walking aroundwith a bottle. (ID: 02)Uh, it is from the hospital end or even antenatally.Because the first visit is really hard work as we have somuch stuff to do . . . They tend to be the ones that can

cope with the information and are keen to do it . . . .thatcome to mother’s group and do all those sorts of things.The more not educated as well, that kind of people.(ID: 14)

In addition to reporting the excessive use of bottles and thefrequent use of juice or soft drinks, some nurses attributeddental caries to the practice by some mothers to breastfeedfrequently throughout the night or for several years.

Well . . . I was in a bit of a shock with this one. You’d thinkthat breastfeeding wouldn’t do it, but because she wasconstantly on the breast the whole night which was theproblem. And I went through diet and everything andit was ok, it wasn’t anything else, it was the breastfeeding.(ID: 01)

Theme 3: Parents’ feelings upon learningabout their child’s poor oral health

When the nurses spoke to the parents about their child’s poororal health and the likely cause, they reported feelings ofdespair, anger, and a sense of guilt.

Well when I told her that it was the feeding, she was reallysurprised and shocked. It was horror, she didn’t expect it.Some of them are blasé, some of them are overwhelmed withother general issues that they have already, some of them arequite distressed. (ID: 18)Oh devastated, oh you know like “my goodness, did I?”You know? Yes they feel really upset about it. They feelguilty. Yes one of the mothers she felt so bad, you know shefelt so bad. She’s like “I didn’t realise that milk had somuch sugar”, and I said you know, see how the teeth aregone because the milk settles in there in the night time.(ID: 02)

The nurses also reported that some parents were not veryworried because they knew their children would have anotherset of teeth.

Well some just say “well it’s their baby teeth”, and when youexplain that it can affect their adult teeth they’re a bit,“Oh!”, so yeah. (ID: 09)

The cost of treatment required was one of the first thingsparents worried about.

They would worry about the cost, would be the first thingevery single time. These were poor people. (ID: 16)I think they’re concerned, but whether they do anything ornot is different. That’s why I refer them, especially the lowersocio-economic people and culturally and linguisticallydifferent families. They might not have much money youknow. (ID: 13)

Discussion

The CFHN is an integral member of the primary healthcareteam in Australia. In addition to providing support and



guidance for mothers of young children, they provide a sur-veillance service, and most children are asymptomatic (12)when they visit a clinic. This qualitative study revealed thatCFHNs believe that dental caries is a major problem foryoung children and their families in disadvantaged commu-nities. However, when these families presented to a CFHN,they lacked basic oral health information.

The nurses reported that children with low socioeconomicstatus or from a culturally diverse background were morelikely to have poor oral health and that the burden of dentalcaries in young children was underestimated in the disadvan-taged communities. Several epidemiological studies havereported similar findings associated with disadvantaged com-munities (4-6,29). They were concerned that many familiesmade contact only during the first few months of their child’slife and then discontinued the visits. This has been noted byresearchers in the United States (29) and is a significantbarrier to the early detection of dental caries. Early oral healthadvice is therefore essential to prevent the problem of ECCbefore it begins. In addition, the nurses observed that theother barrier to education was that the families were not givenculturally sensitive advice. As a result, in most cases, familiesfrom non-English-speaking backgrounds relied on their ownconventional approaches to raising their children. The nursesagreed that there is a great need for multilingual educationalresources. It has been noted, however, that direct translationof health promotion leaflets can cause numerous problems,as they may be culturally inappropriate, or contain transla-tion errors or comments that can cause confusion or bemisleading (30).

It is interesting to note that parents who presented to thenurses were often unaware of the caries process occurring intheir child because their main concern often related only toappearance. Even when the appearance of teeth was compro-mised because of caries, the majority of the parents did notrecognize this as a disease process. The link between stainedor “unusual looking” teeth and caries was not readily recog-nized. The presence of pain was linked with decay, and theabsence of pain was interpreted as lack of any significantdental problem. Some parents recognized that some form oforal hygiene was important for preventing decay, but mostdid not appreciate the role of diet, in particular bottle use.Furthermore, a Scottish study reported that although parentsunderstood that there was some link between diet, toothbrushing, and dental caries, their application of that knowl-edge was limited (31).

This study also highlighted the lack of knowledge of ECCamong the nurses. Despite the multifactorial etiology ofECC, suboptimal exposure to fluoride, transmission of cari-ogenic bacteria, and poor plaque control were not the centerof attention in the interviews. Feeding habits were the onlykey discussion points raised in our interviews. Night-timebottle use and prolonged and frequent breastfeeding were

considered by some nurses as etiological agents. While thenurses’ knowledge about the prolonged night-time bottleuse was generally sound, their beliefs related to breastfeed-ing highlights a gap in the knowledge of at least some of thisgroup. A recent systematic review concluded that breast-feeding, in particular frequent night-time feeds and pro-longed duration, is not associated with dental caries (32).Our study has clearly shown that nurses in South WesternSydney require more detailed advice on helping parents toprevent ECC.

The nurses reported that parents gave their children milkand fruit juice in the belief that it was good for them. Itshould be noted, for clarification purposes, that milk andfruit juice are promoted in the Australian Guide to HealthyEating as part of a healthy diet for preschool children (33).The problem is not with the feeding of milk and juice per sebut with the method of delivery, in particular the prolongeduse of infant feeding bottles and night-time bottle feeds.The research literature indicates that “bottle-use” behavioris often difficult to change (34) because parents are con-cerned about their children receiving sufficient nutrition(35). On the other hand, Freeman and Stevens (36),who used a grounded theory approach to conceptualizeprolonged bottle feeding behaviors in young children,concluded that mothers used bottles to “buy time” awayfrom crying children to make them quiet. As with previousfindings, the nurses reported that mothers wanted whatwas the best nutrition for their children (37), but they feltoverwhelmed by difficulties in implementing healthybehaviors (38). This highlights the need for parents to beadvised both on “what” to feed but also on “how” to feedtheir children.

When the nurses offered advice about the caries process,the parents were affected both emotionally and financially.The nurses reported that most parents were upset and feltguilty when they realized that their feeding decisions played amajor role in the initiation and progression of their child’stooth decay. A major concern for families was the cost oftreatment, which made them reluctant to seek professionaldental care even though their child had tooth decay. This is adisturbing finding as untreated caries progresses and requiresmore extensive and costly treatment later on, creating anincreasing burden on families who are already strugglingfinancially (29).

The preferred method of data collection was an in-depthsemi-structured interview because it gave the interviewersan advantage, allowing for interaction and detailed under-standing, and gave the participants an opportunity to askquestions (39). A potential limitation of this study was thatthe interviews were limited to the CFHNs in Sydney SouthWest. However, there is no reason to think that the findingswill be different in other disadvantaged areas. Futureresearch is indicated to gain an understanding from other



health professionals such as pediatricians or generalpractitioners, who are likely to have regular contact withdisadvantaged families. They can potentially play a vital rolein providing simple dental advice to families with youngchildren.

Conclusions

Oral health problems constitute a considerable segment ofthe child health problems identified by nurses in their dailywork. The nurses perceive the problem of dental caries to bechiefly a lack of parental knowledge especially in terms of“what” and “how” to feed their children. The challenge is tocapture and educate families in a culturally appropriate wayusing a team approach including nursing and oral health pro-fessionals. Barriers in providing these necessary early mea-sures include the lack of early dental healthcare visits becauseparents are concerned about costs.

Acknowledgments

This project was funded by the Australian National Healthand Medical Research Council Project Grant (1033213);Centre for Oral Health Strategy, NSW Health; and by an Aus-tralian Dental Research Foundation grant. Dr. Amit Arorawas supported by the Oral Health Foundation and the Uni-versity of Sydney International Research Scholarship. We sin-cerely thank Dr. María Florencia Amigó, Senior ResearchFellow in Macquarie University,Australia, for her feedback onthe semi-structured interview guide development. We thankAssociate Professor John Eastwood, Nurse Unit Managers,the Child and Family Health Nurses for their support and Ms.Ramona Grimm for administrative assistance. The authorshave no conflicts of interest.

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Child and family health nurses' experiences of oral health of preschool children: a qualitative approach