‘I can’t relate it to teeth’: a qualitative approach to evaluate oral health education materials for preschool children in New South Wales, Australia

DOI: 10.1111/j.1365-263X.2011.01195.x

oral health education materials
‘I can’t relate it to teeth’: a qualitative approach to evaluate
for preschool children inNew South Wales, Australia

AMIT ARORA1,2, MICHELLE A. MCNAB2, MATTHEW W. LEWIS2, GLEN HILTON3,4, ANTHONY S.BLINKHORN1 & ELI SCHWARZ5

1Department of Population Oral Health, Faculty of Dentistry, The University of Sydney, Westmead, NSW, Australia,2Bachelors of Dentistry Program, Faculty of Dentistry, The University of Sydney, Surry Hills, NSW, Australia, 3School of

Psychology, Faculty of Science and IT, University of Newcastle, Newcastle, Australia, 4Pain Management Research Institute,

Kolling Institute of Medical Research, Faculty of Medicine, The University of Sydney, Sydney, Australia, and 5Department

of Community Dentistry, Oregon Health and Science University, Portland, OR, USA

International Journal of Paediatric Dentistry 2012; 22:

302–309

Background. Early Childhood Caries is a signifi-

cant public health issue worldwide. Although

much is known about the aetiology of dental car-

ies, there is limited evidence on the understanding

of caregivers on readily available early childhood

oral health education materials.

Aim. The purpose of this study was to record how

parents cope with dental health education materi-

als for preschool children commonly available in

New South Wales, Australia.

Design. This qualitative study was nested within a

large cohort study in South Western Sydney.

English-speaking mothers (n = 24) with young

children were approached for a face-to-face, semi-

structured interview at their homes. Two dental

leaflets designed by NSW Health to give advice on

Correspondence to:

Dr Amit Arora, Faculty of Dentistry, The University of

Sydney Level 6, 2 Chalmers Street, Sydney Dental

Hospital, Surry Hills, NSW 2010, Australia.

E-mail: [email protected]

302 International Journal of Pa

monitoring young children’s oral health were sent

to mothers prior to the interview. Interviews were

recorded and subsequently transcribed verbatim.

Transcripts were analysed by interview debriefing

and a thematic coding.

Results. Mothers generally reported that the leaf-

lets were easy to read but noted that the informa-

tion pertaining to bottle feeding was confusing.

Furthermore, they were unable to understand

terms such as ‘fluoride’ and ‘fissure sealants’.

Early childhood nutrition and infant teething

were inadequately addressed, and mothers pre-

ferred pictorial presentations to improve their

understanding of oral health.

Conclusions. Producers of health education leaflets

should keep the messages simple and straightfor-

ward, avoid the use of medical jargon, and use

pictorial aids to improve communication with

parents.

Introduction

Early Childhood Caries is a significant public

health issue worldwide1. In 1996, 39% of

6-year-old Australian children had dental car-

ies2, and it has been reported that, since then,

the caries prevalence in children in all States

and Territories has increased3. The most recent

Child Dental Health Survey of Australia

reported that 45% of 5-year-olds had one or

more decayed or missing teeth, and 10% of

those children examined were found to have

more than seven decayed teeth4. The problem

is not unique to Australia, as successive

national child dental health surveys in the Uni-

ted Kingdom and the United States have shown

little change in caries prevalence in 5-year-old

children over the last two decades5,6. Although

much is known about the aetiology of dental

caries, there is limited evidence on the under-

standing of caregivers on readily available early

childhood oral health education materials.

The promulgation of health education

messages to improve oral health for both

individuals and their families has been well-

established7. The practice of health behaviours,

however, is greatly influenced by personal and

� 2011 The Authors

ediatric Dentistry � 2011 BSPD, IAPD and Blackwell Publishing Ltd

Evaluation of dental leaflets 303

community social norms, which can be related

to social class and education8. It has been

noted elsewhere that poor literacy can impede

an individual’s ability to obtain, understand,

and act upon health information9,10 to make

adequate health care decisions, and in recent

years, this has led to increasing interest in

the exploration of the relationship between

literacy and health outcomes11.

More recently, the importance of poor

health literacy has been recognised interna-

tionally. The national survey of English liter-

acy in United States, which assessed adults

ability to perform literacy tasks using written

health-related information, reported that

30 million adults have no more than most

basic health literacy skills, and another

47 million can only perform simple everyday

tasks12. In 2006, the Adult Literacy and Life

Skills Survey, conducted by the Australian

Bureau of Statistics, documented that 59% of

the population aged between 15 and 74 years

had scored below a level of literacy regarded

as optimal for health maintenance and noted

that people with the poorest health literacy

are often from a lower socio-economic class,

have lower income and ⁄or education, are

migrants from non-English-speaking countries

and live farther from metropolitan centres13.

The results of these national surveys clearly

indicate that poor literacy is an obstacle to

the comprehension of health information,

especially when it includes the new concepts

or unfamiliar vocabulary common in health

education materials14. The situation becomes

overly complex for young children, because

they must depend on their caregivers for

behaviours that influence oral health out-

comes14. Therefore, improvement in dental

health education materials is one of the con-

crete methods of increasing oral health

knowledge, and combining these with other

health promotion interventions can help to

reduce oral health disparities.

The Centre for Oral Health Strategy, New

South Wales (NSW) Health commissioned the

University of Sydney to record how parents

cope with commonly available dental health

education materials for preschool children in

NSW, Australia, and to identify barriers which

prevent them from practicing the advice given.


International Journal of Paediatric Dentistry � 2011 BSPD, IAPD and Bla

Materials and methods

Study background

This study was nested within a population-

based cohort study that begun in 2010 to assess

the relationship between early childhood feed-

ing practices and dental caries in preschool

children living in disadvantaged areas of South

Western Sydney15. As a part of the cohort

study, two commonly used leaflets designed by

NSW Health, giving dental advice on taking

care of children’s teeth, were sent by post to

the parents. The two leaflets were as follows:

‘Teach your baby to drink from a cup’

and ‘NSW Messages for a Healthy Mouth’.

Study design

A qualitative research approach was under-

taken to explore caregivers’ understanding of

the leaflets, which has been proven to be a

useful way to gain an in-depth understanding

of a complex social phenomenon, especially

in disadvantaged communities16.

The flexibility of qualitative research design

allowed for simultaneous data collection and

analysis and provided an opportunity for new

themes to emerge, as noted by other

authors17.

Sampling

We used a purposive sampling strategy,

which is commonly used in qualitative

research to select study participants17. From

the cohort study, mother-infant dyads

(n = 24) whose first language was English

were randomly selected for a home interview

from postcodes considered as ‘disadvantaged’

according to the Australian 2006 Socio Eco-

nomic Index for Areas rankings18. The study

sample was recruited until a point of data sat-

uration19, when no new information was

being introduced and shared with the

researchers. Conventionally, it has been

reported elsewhere that six to eight inter-

views are sufficient for a homogenous sample

in qualitative research19; however, our data

quality was enhanced by the use of a maxi-

mum variation sampling strategy20. The

ckwell Publishing Ltd

Table 1. Socio-demographic characteristics of the studyparticipants.

Socio-demographic characteristic N

Number of childrenOne 15Two or more 9

Marital statusMarried 13Single 5Living with a partner 6

Mother’s educationYear 12 or less 11College or University 13

Employment statusCurrently or previously employed 18Pensioners or unemployed 6

304 A. Arora et al.

socio-demographic characteristics of the study

sample are presented in the Table 1.

Interviews

In-depth interviews with parents were con-

ducted at their homes for approximately an

hour to record the parents’ opinions and under-

standing of the leaflets. We chose to do face-to-

face interviews, as it gave the interviewers the

advantage of developing a good rapport with

the participants, facilitated interactions

between parties and gave the participants an

opportunity to ask about any issues raised21.

Data analysis

All interviews were electronically recorded,

immediately debriefed and subsequently tran-

scribed. Interview debriefing served to evalu-

ate the data collection, summarise the main

findings and helped to prepare for subsequent

interviews. Three researchers were involved

in data analysis and coded the interviews

independently. The principal researcher (AA)

used Nvivo 9 (QSR International, Cambridge,

MA, USA) for thematic coding, and the other

two researchers (ML and MM) used manual

thematic coding independently. An investiga-

tor triangulation approach, whereby all three

researchers independently analysed the results

prior to collating the information, was used

to check and validate all interpretations, to

ensure that interpretations were not influ-

enced by researchers’ pre-existing views,

International Journal of Pa

which increased the rigour and credibility of

the study results17.

Ethics approval

Ethics approval for this study was obtained

from the Human Research Ethics Committees

of Sydney South West Local Health District

and the University of Sydney.

Results

All participants had at least one child (ages

ranged from 6 to 18 months). Analysis of the

data resulted in the identification of four

main themes.

Theme one: Ability to read and understand

Mothers generally reported that the content of

the leaflets was easy to read and understand.

Most were able to summarise the key messages

in each leaflet and thought that the leaflets

were a good reminder of basic health informa-

tion. Some mothers indicated that the leaflets

were good for new parents who have little

support from experienced parents or nurses.

‘I think it just reinforced basic information as it was

like one of those things I knew, but I like to be

reminded. You know, when you’re a new mum,

you’re like bombarded.’ (ID 106, mother aged

35 years, 1 child)

’If you were a new parent it explains what they

should be doing and what they shouldn’t be doing

... so it would be useful, some people don’t have any-

one else to tell them what to do, or advise them.’ (ID

367, mother aged 23 years, 1 child)

Despite the fact that the majority of the

mothers indicated that reading the leaflets

was a ‘reinforcement’ of what they already

knew, most stated that they learned some-

thing new from each leaflet.

‘The fact of knowing not to put them to bed with the

bottle ... (I knew) not to do that, but I didn’t know

that it could lead to ear infections, dental decay, and

iron deficiency. I didn’t know that was related.’ (ID

418, mother aged 32 years, 3 children)




‘I found it very useful in terms of the sippy cup and

the (valves), that’s something I hadn’t heard before’

(ID 19, mother aged 39 years, 1 child)

‘I wasn’t sure when children should have their first

dentist appointment and when they should start

brushing with toothpaste.’ (ID 541, mother aged

37 years, 1 child)

Although mothers indicated that they were

able to understand the leaflets, they noted

that it will be difficult for them to change

behaviours as their child grows older.

‘I think it’s just difficult to break a habit, he likes to

drink his milk in a bottle lying down. I tried intro-

ducing a cup and he doesn’t like it.’ (ID 367,

mother aged 23 years, 1 child)

‘For the time it is all okay, as I am the one who deci-

des what to give him. However, when he gets big-

ger, I know it will be difficult as he will be asking

(for) chocolates, ice cream, lollies etc. You know ...

every time you go shopping to Woolworths they pro-

mote sugary things.’ (ID 166, mother aged

34 years, 1 child)

Most participants did not require any help

from others in understanding the content of

the leaflets. A few indicated that while

attempting to find more information on the

Internet, they were confronted with conflict-

ing and confusing information. The help in

these cases was obtained from the partici-

pant’s spouse or the child and family health

nurses. Several participants had some diffi-

culty understanding the dental jargon in the

leaflets, particularly the term ‘sealant’. There

was also some confusion with the term

‘fluoride’, and its impact on their infant’s

teeth, reflecting the need for use of simpler

terms.

‘What’s a sealant? (I didn’t understand) I didn’t

realize you can get like a filling without drilling’


‘What does ‘Lift the Lip’ mean? And I didn’t under-

stand about fluoride and how can it help child’s

teeth’ (ID 562, mother aged 22 years, 1 child)



Theme two: Inappropriate content and the use of

language

Some mothers expressed their concerns that

the language used was confusing, particularly

with the information regarding putting young

children to bed with a bottle of milk. They

believed that the language used made the

message unclear and did not address situa-

tions such as the baby falling asleep while

feeding in a cot or while being held in the

mother’s arms.

‘I think I wouldn’t even mention bottle ... even with

water ... I think ‘don’t put them to bed with a bot-

tle’ would be better’ (ID 367, mother aged

23 years, 1 child)

There were some comments on the need

for clarification regarding the messages,

because mothers believed that if the key mes-

sage is related to dental health, the language

used should be made clearer.

‘I’m still not relating the bottle stuff to dentistry so

maybe that should be clearer... it’s about teaching

them to drink from a cup and I wouldn’t say the

overall message is dentistry or teeth.’ (ID 712,

mother aged 28 years, 1 child)

‘Like if someone said to me ‘tooth decay’, I still

don’t know what that would mean – like does it

mean they have to have all their teeth ripped out? ...

I would just like a bit more information ...’ (ID


‘I wasn’t clear about how a smoke free environment

affects teeth ... I would prefer to know why if possi-

ble’ (ID 166, mother aged 34 years, 1 child)

Some parents were concerned that the

recommendation of breastfeeding babies for

6 months was unrealistic and did not take

into account mothers who are unable to

breastfeed or have work commitments. Moth-

ers also indicated that it could be distressing

for parents to see a timeframe for infant-feed-

ing milestones.

‘It does shit me every time I see ‘breastmilk is best

for your baby’ ... the guilt factor for those of us who


306 A. Arora et al.

couldn’t breastfeed’ (ID 106, mother aged

35 years, 1 child)

‘Some babies are different. Like it says start eating

from a spoon by 6 months – some babies start eating

at 4 months ... maybe just put approximately’ (ID


Theme three: Illustrations and layout

Mothers believed that the appearance of the

leaflets was a crucial factor in their decision

to pick them up and read them. In general, it

was believed that the design, layout, and

fonts used had an impact on maintaining the

interest of the reader.

‘Each section is divided into quite a clear section and

it gives more detailed information. It’s quite clear

and good, I like the divisions of the sections … I

liked the layout – divided with clear information for

each period, and what was required for that period.’

(ID 53, mother aged 37 years, 2 children)

The presentation of the leaflets, in particu-

lar the colours and illustrations used, was also

important in maintaining the interest of the

majority of the participants.

‘That has clear, simple messages. The layout is

enhanced with nice clear pictorial information and

things are organized in an easy to read, easy to fol-

low manner.’ (ID 443, mother aged 31 years, 1

child)

‘The colours were appealing, I liked the fact that

things were categorised – that made it easy for me to

read ... I liked that the categories were colour coded’


Some mothers, however, stated that the

amount of content in the leaflets was an

issue, because they indicated that lengthier

leaflets would not be read by many parents

because of their busy lifestyles.

‘There is a lot of information, and while I’m happy

to read all this stuff ... I wonder about other people.

New mums just might – it may be a little bit too

much information there for them’ (ID 367, mother

aged 23 years, 1 child)


Theme four: Dental problems inappropriately

addressed

Some mothers expressed confusion on the

relevance of some of the information to den-

tistry, because they considered that the infor-

mation provided was vague.

‘It says prolonged use of the dummy, how long is pro-

longed?’ (ID 979, mother aged 35 years, 2 chil-

dren)

Mothers expressed their interest in informa-

tion related to the diet and nutrition of young

children, because they felt that this was not

covered in enough detail in the leaflets.

‘Maybe (it should include) what foods to avoid’ (ID


‘Is there anything here about juices? I think it is

important for children to know that they shouldn’t

have juices straight, it says what to have but doesn’t

explain why’ (ID 19, mother aged 39 years, 1

child)

Although the advice given in the leaflets

was welcomed by mothers, they noted that it

would be worthwhile to give alternate sug-

gestions for teething issues, because that was

of great concern to their family life.

‘I guess when the child is teething, I guess advice …So what are good things to do, what are not so good

things to do, what things should you avoid? Maybe

some suggestions other than teething rings that

could be used, because I guess a lot of parents have

issues with teething’ (ID 874, mother aged

31 years, 2 children)

Mothers were also unaware of the ‘rules’

for toothbrushing, particularly when tooth-

paste should be introduced, and suggested the

use of pictures to illustrate this. They also

wanted more information on access to pri-

mary health care providers, but most felt that

this was limited, with only a few dentist’s

comfortable seeing infants and toddlers.

‘Maybe it should include how to brush properly –

with pictures to show how much toothpaste to use




and the areas to brush. Give some visual infor-

mation of what will happen if you don’t brush

your teeth.’ (ID 53, mother aged 37 years, 2

children)

‘The leaflet suggested visiting a health professional,

but there don’t seem to be a lot of options for a child

as young as one-year-old as a lot of general dentists

aren’t comfortable treating kids.’ (ID 166, mother

aged 34 years, 1 child)

Discussion

This study provided a snapshot of the opin-

ions of mothers with young children on the

dental health education material commonly

available in NSW, Australia. In general,

mothers were able to read and understand

the leaflets but noted that some information

was confusing, especially regarding bottle

feeding, fluoride, and fissure sealants. Early

childhood nutrition and infant teething were

inadequately addressed, and mothers pre-

ferred pictorial presentations to improve their

understanding of oral health.

Although the mothers in our study were

able to understand most of the information

provided in the leaflets, they were unable to

understand the usefulness of terms such as

‘sealant’ and ‘fluoride’ and suggested the use

of simpler terminology. Richman et al.22 have

recently assessed caregiver oral health literacy

and reported that although parents are able

to read, they are unable to comprehend the

purpose of medical and dental jargon used in

routine communication. In our study, moth-

ers noted that the message on the use of a

bottle was confusing and suggested that it

should be clearly stated as, ‘Don’t put your

child to bed with a bottle’, rather than ‘Put

your baby to bed without a bottle’. As with

previous findings, mothers in our study

wanted what was best for their children23,

but they felt overwhelmed by the difficulties

of implementing healthy behaviours24. Family

and work commitments seemed to pose sig-

nificant obstacles to healthy oral health

behaviours, as noted by other researchers25.

Some caregivers also raised concerns that the

marketing culture of sugary snacks will



potentially be a difficulty in the future as the

children grow26.

In our study, the physical appearance of the

leaflets was a crucial factor in the mothers’

decision to pick them up and read them. Fur-

thermore, mothers recommended that the pic-

torial presentation of key health messages was

useful, because it helped them to understand

the information. This finding is supported by

research in experimental psychology and

marketing, which indicates that humans have

a cognitive preference for picture-based,

rather than text-based, information: the so-

called ‘picture superiority effect’27. Some

researchers have argued that the presentation

of information within a leaflet will affect the

readers’ interest in and retention of the

information28. Dowse and Ehlers29 utilised the

pictorial presentation of medication instruc-

tions and reported that it was a useful aid in

improving reader recall, comprehension and

adherence. Research in dental public health

also recommends that the use of appropriate

presentation of leaflets is worthwhile in

implementing behavioural change30; how-

ever, Tones31 warns that health education

alone will not achieve sustained behavioural

change. This was further assessed by Kay and

Locker32 in a systematic review to assess

the effectiveness of oral health education,

which concluded that health education

alone is ineffective in bringing about behavio-

ural change and needs to be supplemented

with other health promotion interventions

such as the use of fluoride. Thus, although

education alone may not facilitate behavioural

change, the results of this study clearly iden-

tify significant barriers to optimal oral health

education.

There were several limitations to this study.

The use of a small convenience sample of

caregivers limits the generalisation of our

findings to the broad range of literacy skills

shared among disadvantaged families. The

participants’ level of understanding was mea-

sured only by their requirement for help and

a personal description of the difficulty of the

leaflet to be read, and variations among par-

ticipants may have resulted in a self-reporting

bias. Furthermore, we did not use an objec-

tive measure to test English language fluency;


308 A. Arora et al.

however, all parents were able to converse

adequately in English. Finally, the interviews

were limited to English-speaking parents and

may have limited application to different cul-

tural settings, because of differences in under-

standing and cultural beliefs, which may

influence health behaviours. This study is a

preliminary study; future studies should eval-

uate the use of qualitative research in differ-

ent cultural settings.

What this paper adds

• Parents of young children are confronted with confus-

ing information on healthy behaviours.

• Producers of health information leaflets should use

straightforward messages and avoid the use of medical

jargon to improve communication with parents.

• Developers of leaflets must consider their potential

user groups when designing leaflets, as aesthetics of a

leaflet was identified as the primary factor that deter-

mined whether a parent would pick it up and read

it.

Why is this paper important for paediatric dentists

• Paediatric dentists should avoid the use of jargon such

as ‘fissure sealants’ and ‘fluoride’ when communicat-

ing with parents.

• Paediatric dentists should give simple advice to parents

of young children.

• Paediatric dentists should provide succinct information

to parents and use pictorial aids to improve their

understanding on oral health.

Acknowledgements

We sincerely thank Dr Marıa Florencia Amigo,

Senior Research Fellow at Macquarie Univer-

sity, Australia, for her feedback on the

semi-structured interviews. We thank Ms

Ramona Grimm, Department of Population

Oral Health, The University of Sydney for

her administrative help. We thank the study

participants. This project is funded by the

Centre for Oral Health Strategy, NSW Health

Australian Dental Research Foundation; Syd-

ney South West Local Health District; Austra-

lian National Health and Medical Research

Council (Project Grant -1033213). We thank

the Global Child Dental Health Taskforce to

support the project. Dr Amit Arora was

supported by the Oral Health Foundation

and the University of Sydney International

Research Scholarship.


Conflict of interest

The authors declare no conflict of interest.

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Documents

‘I can’t relate it to teeth’: a qualitative approach to evaluate oral health education materials for preschool children in New South Wales, Australia