Proefschrift Duijster

FAMILY MATTERSThe role of parental and family-related psychosocial factors in childhood dental caries

Denise Duijster

FAM

ILY MATTERS - D

ENISE D

UIJSTER

InvItatIon

to the Public Defense of my Doctoral Thesis

FamIly matters

The role of parental and family-related psychosocial factors in childhood dental caries

on Friday, 6th of February 2015 at 13:00 hrs,

The Aula of the University of Amsterdam,

Singel 411 in Amsterdam.

You are cordially invited to the reception after the

public defense.

Denise [email protected]

06-18393249

Family matters

The role of parental and family-related psychosocial

factors in childhood dental caries

Denise Duijster

The studies presented in this thesis were carried out at the department of Preventive Dentistry and Social Dentistry and Behavioural Sciences at the Academic Center for Dentistry Amsterdam (ACTA), the combined faculty of the University of Amsterdam and the VU University of Amsterdam, The Netherlands.

This thesis was supported by The Academic Center for Dentistry Amsterdam (ACTA), TNO, Menzis Zorgverzekeraar and Ivoren Kruis.

ISBN: 978-94-6108-873-4Layout and printed by Gildeprint – Enschede, The NetherlandsCover design and illustrations by Denise Duijster, inspired by Daniel EgneusCopyright © Denise Duijster

Family matters

The role of parental and family-related psychosocial

factors in childhood dental caries

ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad van doctoraan de Universiteit van Amsterdamop gezag van de Rector Magnificus

prof. dr. D.C. van den Boomten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Aula der Universiteitop vrijdag 6 februari 2015, te 13:00 uur.

door

Denise Duijstergeboren te Rotterdam

Promotiecommissie

Promotores: Prof. dr. C. van Loveren Universiteit van Amsterdam Prof. dr. G.H.W. Verrips Universiteit van Amsterdam, TNO

Overige leden: Prof. dr. W. Marcenes Queen Mary University Prof. dr. J. Hoogstraten Universiteit van Amsterdam Prof. dr. G.J. Truin Radboud Universiteit Prof. dr. G.J.M.G. van der Heijden Universiteit van Amsterdam Dr. A.A. Schuller Rijksuniversiteit Groningen, TNO Dr. M.C.M. Gemert-Schriks Universiteit van Amsterdam

Faculteit der Tandheelkunde

contents

Chapter 1 General introduction 11

Chapter 2 Family relationships as an explanatory variable in childhood dental caries: a systematic review of measures 25

Chapter 3 The role of family functioning in childhood dental caries 59

Chapter 4 Modelling community, family and individual determinants of childhood dental caries 87

Chapter 5 The relationship between parenting, family interaction and childhood dental caries: a case-control study 109

Chapter 6 Parental and family-related influences on dental caries in children of Dutch, Moroccan and Turkish origin 131

Chapter 7 Parents’ views on the influences on children’s oral health behaviours and their ideas for caries preventive interventions: a qualitative study 155

Chapter 8 General discussion 179

Chapter 9 Summary / Samenvatting 195

Chapter 10 Acknowledgements / Dankwoord 207

Appendices List of publications 217 Curriculum Vitae 219

There I am standing by the shore of swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to the shore and apply artificial respiration. Just when he begins to breath, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, without end, goes the sequence. You know I am so busy jumping in pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in! (McKinaly, 1994).

1 General IntroductIon

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General Introduction

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1A decrease in dental caries prevalence and severity has been observed in many Western countries over the last 30-40 years, yet significant levels of dental disease persist (1). In fact, dental caries is still the most common chronic childhood disease worldwide, in spite of considerable investment in dental research and oral health care services (2). In Western countries, the prevalence of dental caries in young children varies from approximately 40% in The Netherlands and Scandinavia to 80-90% among children from Eastern European countries and poorer districts in The United States (3, 4), leading to lost days of schooling and reduced quality of life as a result of pain, discomfort and impairment of function associated with dental caries (5). These effects are most marked in children from poor and disadvantaged populations and certain minority ethnic groups, as they are experiencing disproportionately higher levels of dental disease (6-8). In The Netherlands, the greatest burden of dental caries lies on children from lower socioeconomic status (SES) and those of Turkish and Moroccan origin (9, 10). These profound socioeconomic and ethnic inequalities in childhood dental caries present a major public health problem. Hence, there is need to generate and build on evidence for the development of preventive strategies to achieve further improvements in children’s dental health, with particular reference to reducing these inequalities.

Despite advances in curative and preventive techniques in dentistry, clinical services alone will never eradicate dental diseases (11). The costs of dental care are high, with total expenditure on treatment and clinical prevention often exceeding that for other diseases, including cancer, heart disease and stroke (12). This is a disturbing fact, given that much of the burden of dental caries is preventable through the use of fluoride and the reduction of sugar consumption. Therefore, the delivery of daily fluoride and the controlling of sugary intakes should be the core focus of interventions aimed at improving children’s dental health.

Limitations of the traditional oral health education approach in caries prevention For many decades, the traditional paradigm for caries prevention has been dominated by an individualistic behavioural approach, which focuses on changing people’s lifestyle through oral health education and awareness raising (13). There are three basic educational objectives: the cognitive objective (concerned with the provision of information and increasing knowledge), the affective objective (concerned with changing attitudes, beliefs, values and opinions), and the behavioural objective (concerned with the development of skills). The underlying assumption of the educational approach is that equipped knowledge and skills will induce motivation and action to change behaviours to prevent the development of dental caries. However, systematic reviews have reported on the limited effectiveness of oral health education methods in producing sustained improvements in dental health outcomes, especially if solely focused on the cognitive objective and/or the development of technical tooth brushing skills (14, 15). These reviews concluded that health information can improve dental health knowledge, but the effects on long-term behaviour change

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are limited and evidence for reduced caries levels is very weak. Furthermore, educative interventions may actually widen inequalities, as higher SES groups are likely to benefit more from these interventions than their lower social status counterparts (16). The main reason for the limited effectiveness of educative interventions is that they lack a sound theoretical base. Knowledge may be a necessary but rarely sufficient component to achieve sustained behaviour change, as it is of little value when opportunities and resources to change do not exist (11). Many educative interventions ignore the broader context that determines patterns of behaviours. An impressive body of research exists to demonstrate the underlying influence of psychological, social, cultural, economic and environmental determinants on children’s oral hygiene behaviours, dietary patterns and dental attendance (17-21). Therefore, a paradigm shift in caries prevention is needed away from the purely educational approach to one which addresses the underlying determinants of childhood dental caries, ‘the causes of the causes’.

Principles for effective caries preventionEvidence-based and early interventionIt is generally accepted that the prevention of dental caries should commence from a young age and should be supported by evidence. Key evidence-based messages for caries prevention include twice daily tooth brushing from an early age with fluoride toothpaste, and reducing the frequency of consuming sugary foods and drinks to a maximum of 5-7 times a day (22).

Preventive strategies: The high-risk approach, the population approach and the directed population approachThere are two types of preventive strategies: the high-risk approach and the population approach (23). The high risk approach is a commonly adopted strategy for the prevention of dental caries (24). This approach aims to target interventions towards individuals or groups at high risk of developing dental caries, who have been identified through screening based on their current caries status or markers of the disease. The advantage of this approach is that the preventive intervention is appropriate to the individual or group concerned who has a high probability of future disease. However, a review on current dental screening tests found that none of them have an acceptable level of sensitivity, specificity and predictive power, which makes it difficult to accurately identify individuals with greater risk of future caries development (25). Another recognized limitation is that this approach fails to deal with the majority of new caries lesions that occur in ‘lower-risk’ individuals and groups.

The population approach aims to reduce the level of risk in the whole population through the implementation of public health measures and strategies. This approach addresses the underlying determinants of disease for the whole population, i.e. by seeking general change in behavioural norms and social values (e.g. the wide scale use of fluoride toothpaste), rather



15

1than attempting to change individual behaviours (23). An alternative option is the directed population approach, which focuses attention on higher risk subpopulations that are defined on the basis of epidemiological and sociodemographic data. It is now increasingly recognized that the directed population approach, combining qualities of the high-risk and population approach, is a favourable and practical strategy for caries prevention (24).

The Ottawa Charter: Key areas of health promotion actionThe World Health Organization (WHO) organized the first International Conference on Health Promotion in Ottawa 1986, as a response to the growing expectations for a modern health promotion movement around the world. At this conference, a series of essential approaches to disease prevention were discussed, which were published in a consensus statement, known as ‘The Ottawa Charter of Health Promotion’ (26). The Ottawa Charter outlined five key areas of action:

1. Building healthy public policy: Focusing attention on the health impact of public policies from all sectors at either national or local level, including legislation & regulation, fiscal measures and taxation.

2. Creating supportive environments: To minimize the unhealthy impact of the environment and identifying opportunities to make changes beneficial to health, e.g. through organizational change.

3. Strengthening community action: Empowering individuals and communities in the process of defining priorities, making decisions and implementing strategies to achieve better health, e.g. by mobilizing human and material community resources.

4. Developing personal skills: Enabling individuals to take action to promote their health (moving beyond the transmission of information), by supporting the development of personal and social skills.

5. Reorienting oral health services: Placing emphasis on the importance of, and capacity for, disease prevention, rather than the provision of curative and clinical services, e.g. through training health personnel and financial rewarding of preventive services.

Developing personal skills: the role of parents and the familyDeveloping personal skills is one of the fundamental aspects for the prevention of childhood dental caries. It is important to enable individuals to take control over their own dental health, by supporting the development of skills that allows them to engage in behaviours that are conducive to dental health (27). Establishing dentally healthy behaviours from a very early age is vital to ensure a child’s dental health, as these behaviours mostly endure throughout adulthood, providing lifelong protection against dental decay (28). The family likely plays a fundamental role in the initiation and maintenance of children’s oral health-related behaviours.

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It provides the child’s proximate home environment that promotes certain behaviours, expectations, beliefs and social norms. Parental and family-related influences on childhood dental caries have been documented in several studies (29). Clear evidence exists on the association between parents’ financial, social and educational disadvantage and poor dental health in children (30-32). Furthermore, parents’ own dental behaviours (33-37) and their oral health-related knowledge, beliefs and self-efficacy are known to impact on how they care for the dental health of their child. Parental psychosocial factors that have been demonstrated to negatively affect children’s dental health include maternal depression, low sense of coherence and parental stress (38-40). However, research into family-related determinants of childhood dental caries has mostly been considered from a parental perspective in relation to sociodemographic characteristics (e.g. parental SES, education and income) and parental cognitions, attitudes and, to a lesser extent, psychosocial attributes. The role of the broader family environment in the development of childhood dental caries, such as the emotional quality of family relationships and parent-child interactions, family functioning, and parents’ use of specific parenting practices, has attracted substantially less attention. Yet, elsewhere it is widely recognized that strong family relationships and positive parent-child interactions are essential for children’s social and emotional development and well-being (41). There is also a growing body of research that has demonstrated the influence of these parental and family-related factors on children’s general health, with particular reference to childhood obesity (42, 43). For example, poor family functioning and ineffective parenting (in particular parenting characterized by high levels of demand along with low levels of warmth and positive involvement) are known to be related to higher rates of childhood obesity and an unhealthy diet, including lower fruit and vegetable consumption, higher caloric intake and lower frequency of eating breakfast (43-47). Hence, it is plausible that these parental and family-related aspects are also important factors that add further explanation to the development of childhood dental caries, in addition to the sociodemographic, behavioural and cognitive influences already identified.

Furthermore, only a few studies have reported on the role of parental and family-related factors in explaining socioeconomic inequalities in childhood dental caries, and the operative pathways through which these various factors affect children’s dental health (17, 48, 49). These studies are mainly conceptual, suggesting complex pathways between family behaviours, living conditions and the broader society that were indirectly linked to children’s dental health. Yet, none of these conceptual associations have been empirically investigated. As a result, we do not have a sufficient understanding of the underlying factors and mechanisms in the family environment that impact on the establishment of dentally healthy behaviours in children, and this is obstructing our progress of developing effective strategies to improve children’s dental health and reduce socioeconomic inequalities.



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1The aim and structure of this thesisThe foregoing led to the current research project, which aimed to explore parental and family-related psychosocial determinants of childhood dental caries, and their potential role in socioeconomic inequalities in children’s dental health. Triangulation of methods was employed to investigate the research question, involving both quantitative research methods (self-report questionnaires and video-observations), as well as qualitative research methods (focus group interviews).

Chapter 2 contains a systematic review of self-report psychometric measures of family functioning, which were evaluated in terms of their psychometric support, constructs measured and potential utility in oral health research. Chapter 3 describes a cross-sectional study of 630 5- to 6-year old children, in which the relationship between family functioning and childhood dental caries was explored, using self-report questionnaires. A further objective was to investigate whether family functioning mediated the relationship between SES and childhood dental caries. In chapter 4, data from chapter 3 were used to model pathways and inter-relationships among community, family and individual determinants of childhood dental caries. In chapter 5, the relationship between parenting practices, parent-child interaction and childhood dental caries was investigated, using video-observations of parent-child interactions in a case-control study design. Chapter 6 describes a case-control study in which the relationship of various parental and family-related factors (including parental attributes, parenting practices and family functioning) with childhood dental caries was explored in a sample of children from Dutch, Turkish and Moroccan origin. In this study, both self-report methods and observational ratings were used. In chapter 7, focus group interviews were conducted with parents to explore their perceptions of factors influencing children’s oral health behaviours and their ideas for caries preventive interventions. Chapter 8 contains the general discussion and describes recommendations for potential interventions to prevent the development of dental caries in children. Chapter 9 summarizes the study findings and conclusions of this thesis.

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reFerences

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cohesion and dental caries in Brazilian school children. Soc Sci Med 2001;53:915–25. 21. Reisine ST, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community

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systematic review of the literature. Community Dental Health 2004;21 (supplement):71–85



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123. Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992.24. Batchelor PA, Sheiham A. The distribution of dental caries in schoolchildren: a critique of the high-

risk caries prevention strategy for populations. BMC Oral Health;6:3. 25. Hausen H. Caries prediction – state of the art. Community Dent Oral Epidemiol 1997;25:87–96. 26. World Health Organization. The Ottawa Charter for Health Promotion. Geneva: World Health

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Establishing and Maintaining Tooth-Brushing Routines with Infants and Preschoolers. Int J Environ Res Public Health 2014;11:6808–26.

29. Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0-6 years: A systematic review of the literature. J Dent 2012;40:873–885.

30. Slade G, Sanders A, Bill C, Do L. Risk factors for dental caries in the five-year-old South Australian population. Aus Dent J 2006;51:130–9.

31. Fontana M, Jackson R, Eckert G, Swigonski N, Chin J, Zandona AF, et al. Identification of caries risk factors in toddlers. J Dent Res 2011;90:209–14.

32. Oliveira LB, Sheiham A, Bönecker M. Exploring the association of dental caries with social factors and nutritional status in Brazilian preschool children. Eur J Oral Sci 2008;116:37–43.

33. Agarwal V, Nagarajappa R, Keshavappa SB, Lingesha RT. Association of maternal risk factors with early childhood caries in schoolchildren of Moradabad, India. International J Paediatr Dent 2011;21:382–8.

34. Wigen TI, Wang NJ. Caries and background factors in Norwegian and immigrant 5-year-old children. Community Dent Oral Epidemiol 2010;38:19–28.

35. Litt MD, Reisine S, Tinanoff N. Multidimensional model of dental caries development in low-income preschool children. Public Health Rep 1995;110:607–17.

36. Adair PM, Pine CM, Burnside G, Nicoll AD, Gillett A, Anwar S et al. Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economically diverse groups. Community Dent Health 2004;21(supplement):86–95.

37. Finlayson TL, Siefert K, Ismail AI, Sohn W. Psychosocial factors and early childhood caries among low-income African-American children in Detroit. Community Dent Oral Epidemiol 2007;35:439–48.

38. Seow WK, Clifford H, Battistutta D, Morawska a, Holcombe T. Case-control study of early childhood caries in Australia. Caries Res 2009;43:25–35.

39. Bonanato K, Paiva SM, Pordeus IA, Ramos-Jorge ML, Barbabela D, Allison PJ. Relationship between mothers’ sense of coherence and oral health status of preschool children. Caries Res 2009;43:103–9.

40. Menon I, Nagarajappa R, Ramesh G, Tak M. Parental stress as a predictor of early childhood caries among preschool children in India. Int J Paediatr Dent DOI: 10.1111/j.1365-263X.2012.01238.x

41. Zubrick SR, Williams AA, Silburn SR, Vimpani G. Indicators of social and family functioning. Department of Family and Community Services. Commonwealth of Australia 2000.

42. Wilkins SC, Kendrick OW, Stitt KR, Stinett N, Hammarlund VA: Family functioning is related to overweight in children. J Am Diet Assoc 1998;98:572–4.

43. Rhee K. Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. Ann Am Acad Pol Soc Sci 2008;615:11–37.

44. van der Horst K, Kremers S, Fereirra I, Singh A, Oenema A, Brug J. Perceived parenting style and practices and the consumption of suger-sweetened beverages by adolescents. Health Educ Res 2007;22:295–304.

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45. Arredondo EM, Elder JP, Ayala GX, Campbell N, Baquero B, Duerksen S. Is parenting style related to children’s healthy eating and physical activity in Latino families? Health Educ Res 2006, 21, 862–71.

46. Patrick H, Nicklas TA, Hughes SO, Morales M. The benefits of authoritative feeding style: Caregiver feeding styles and children’s food consumption patterns. Appetite 2005;44:243–9.

47. Wake M, Nicholson JM, Hardy P, Smith K. Preschooler obesity and parenting styles of mothers and fathers: Australian national population study. Pediatr 2007;120: 1520–7.

48. Pine CM, Adair PM, Nicoll AD, Burnside G, Petersen PE, Beighton D et al. Developing explanatory models of health inequalities in childhood dental caries. Community Dent Health 2004;21(Suppl.1):86–95.

49. Seow WK. Environmental, maternal, and child factors which contribute to early childhood caries: a unifying conceptual model. Int J Paediatr Dent 2012;22:157–68.



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2 FamIly relatIonshIps as an explanatory

VarIable In chIldhood dental carIes: a systematIc reVIew oF measures

Denise Duijster Lucy O’Malley

Sarah ElisonCor van Loveren

Wagner MarcenesPauline AdairCynthia Pine

Published in Caries Research 2013;47(supplement1):22-39.

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abstract

It is widely acknowledged that parental beliefs (self-efficacy) about oral health and parental oral health-related behaviours play a fundamental role in the establishment of preventative behaviours that will mitigate against the development of childhood dental caries. However, little attention has been given to the wider perspective of family functioning and family relationships on child oral health. For oral health researchers, exploration of this association requires the use of reliable, valid and appropriate assessment tools to measure family relationships. In order to promote methodologically sound research in oral health, this systematic review aims to provide a guide on self-report psychometric measures of family functioning that may be suitable to utilize when exploring childhood dental caries. This systematic review has identified 29 self-report measures of family functioning and evaluated them in terms of their psychometric support, constructs measured and potential utility for oral health research. The majority of the measures reported adequate levels of reliability and construct validity. Construct evaluation of the measures identified five core domains of family functioning, namely ‘communication’, ‘cohesion/engagement’, ‘control’, ‘involvement’ and ‘authoritative/rigid parenting style’. The constructs were subsequently evaluated with respect to their potential relevance to child oral health. Herewith this review provides a framework to guide future research to explore family functioning in furthering our understanding of the development of childhood dental caries.


A Systematic Review Of Family Functioning Measures

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2

introduction

Childhood dental caries is a multifactorial disease with identified key risk factors ranging from the biological to the social and psychological (1). Explanatory models of childhood dental caries, incorporating a life course framework, acknowledge the fundamental role of family relationships on child oral health outcomes and in shaping children’s oral health behaviours (2-4). Key oral health behaviours, namely sugar consumption and oral hygiene routines, are acquired at home during early life (5-7), setting the child on a pathway to good or poor oral health as a result. Maternal psychosocial factors have been demonstrated to influence children’s dental health and oral health practices. These include both cognitive aspects, such as knowledge, attitudes and parental self-efficacy to undertake key health behaviours including establishing healthy routines (8-11), as well as broader factors involving maternal stress and material and social deprivation (12-14). Good marital quality as assessed by parent-child and partner-partner relationships, including domains of communication, trust, emotional and practical support, has been reported to have a protective effect on children’s oral health (15).

Elsewhere, it is widely recognized that good family functioning and strong family relationships are essential for children’s physical, social and emotional development and well-being (16). There is a growing body of research demonstrating the influence of family functioning on children’s medical health, for example its relationship with childhood obesity (17, 18). However, in oral health research, there has been limited exploration of the potential influence of family functioning factors, including relevant dimensions of family functioning, on the development of childhood dental caries. These factors may add further explanation to the development of childhood dental caries, additional to the cognitive, psychosocial and behavioural predictors already identified, or they may act as separate mediators or moderators of risk.

According to the Family System Theory, families are conceptualized as dynamic systems of family members that interact with one another, aiming to adjust to the developmental needs and maintenance of its members (19, 20). The family system comprises dyadic subsystems, such as parent-child, partner-partner and sibling-sibling relationships. Several theories of family functioning exist to provide a framework to explore how the family system potentially influences developmental outcomes, including child health and related health behaviours (21-23). A functioning family generally refers to a family that is able to manage daily life and crisis tasks in the context of warm and affective family interactions, through clear communication and well-defined roles and boundaries. Hence, poor functioning families are characterized as inflexible and disorganized, having high levels of conflict, poor affective relationships and behavioural control and weak maintenance of family boundaries.

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As the success of preventative interventions for childhood caries relies on adherence to key behaviours, such as twice-daily tooth brushing with a fluoride toothpaste, control of sugary intakes and regular dental attendance for preventative dental care, the role of the family is vital. In this context, prevention of childhood dental caries should be addressed from a broader perspective, including targeting family functioning factors with emphasis on the social and emotional context in which health behaviours of individuals are developed and sustained. Therefore, it is essential to have a comprehensive understanding of the underlying mechanisms that affect the adoption of oral health promoting behaviours throughout the life course, with particular focus on the early childhood environment where habitual behaviours are initiated.

To further our understanding, reliable and accurate assessment of the family in oral health research requires insight in the key domains that might be relevant to the behaviours in question. Given the lack of research of family functioning factors in relation to predicting childhood dental caries and the myriad of measures to choose from, this paper aims to evaluate self-report measures of family functioning and assess their psychometric properties, using a systematic review approach. Particular focus is placed on discussing the measures and the domains that might be suitable for oral health research to further explore the determinants of childhood dental caries and that, therefore, could have the potential to translate into effective interventions relating to its prevention.

materials and methods

The review was conducted in three parts. Firstly, a systematic review was undertaken to identify family functioning measures. Secondly, each measure was assessed for methodological quality in terms of development, reliability and validity. Finally, the domains measured by the instruments were identified and collated.

Systematic literature searchInclusion criteriaTo identify the family functioning measures, the following criteria were applied:

• Type of studies: any cross-sectional or longitudinal study that was concerned with the original development or further validation of a measure of general or emotional family functioning.

• Type of measures: the instrument had to be a self-report measure of general or emotional family functioning that included the parent-child relationship and had standardized questions and answer responses. The measure had to be suitable for use with parents/caregivers of a child aged between 3 to 12 years.

• Only measures that had items detailed sufficiently in the publication or from the developers’ additional key references were included.



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2

Exclusion criteria• Family functioning studies that did not develop or validate a measure.• Non-peer-reviewed studies or those published in languages other than English.• Measures of cognitive family functioning (e.g. parenting beliefs, self-efficacy). • Measures of family functioning developed for specific clinical populations or special

groups (e.g. families with chronically ill children, stepfamilies). • Measures of family functioning that only included adult-relationships (e.g. marital

quality).

Search strategyA search strategy was drawn up for use in MEDLINE and this strategy was adjusted accordingly for use in the other databases selected. Databases searched were: MEDLINE via OVID (1946 to present); PsychInfo via OVID (1806 to present); Health and Psychosocial Instruments via OVID (1985 to present); International Bibliography of the Social Sciences via ProQuest (1951 to present) and CINAHL via EBSCO (1981 to present). The following search strategy was used in MEDLINE:

1. (family or families) adj (function* or dynamic or conflict* or dysfunction or interact* or communicat* or environment* or cohesion* relationship* or satisfaction or impact* or coping)

2. exp Family Relations/3. (parent* or mother* or maternal or father* or paternal) adj3 (disciplin* or permissive*

or role* or influen*)4. (sibling* or father or paternal or mother or maternal) adj (child) adj (relations)5. (parental or parenting or child rearing) adj (style* or attitude* or expectation* or skill*

or behavio* or role*)6. 1 OR 2 OR 3 OR 4 OR 57. exp Test Validity/ or exp Rating Scales/ or exp Psychometrics/ or exp Test

Construction/ or exp Test Reliability/8. scale* or psychometric* or questionnaire* or test or measurement* instrument*) adj

(develop* or construct* or valid* or standardi* or reliabili* or rating*)9. 7 OR 810. (child* or infant* or toddler* or pre-school* or preschool* or baby or babies or

teenage* or adolescent*).af.11. 6 AND 9 AND 1012. Limit 11 to English language, Human.

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Chapter 2

30

Study selectionThe screening process was managed via Excel and was carried out by three authors (DD, SE, LO). All results were double screened independently and disagreements were resolved by group discussion. References were initially screened on the basis of the title and abstract. Full text papers were located for all included and remaining unclear papers. The three authors hand searched the reference lists of all included studies for the key source and relevant measurement development references and/or validation references, and citation tracking was carried out on these papers.

Evaluation of measuresThe type of family functioning measure was recorded and assigned to one of three categories: ‘general/emotional family functioning’, ‘dyadic relationships that focussed specifically on parent-child’ and ‘specific areas/dimensions of family functioning’. Characteristics of the measures were then recorded in two ways: psychometric evaluation and domain evaluation.

Psychometric evaluationGiven the lack of a suitable quality rating scale for measurement papers, the psychometric properties of each measure were described in relation to each of the following:Type of reliability and validity DefinitionInternal consistency The consistency of results across items of the same construct. Test-retest reliability The consistency of a measure between two different occasions. Concurrent validity The degree to which a measure correlates with a previously validated

measure of the same construct.Discriminant validity The extent to which a measure can distinguish between theoretically

different groups.Convergent validity The degree to which a measure correlates with a measure that it is

theoretically predicted to correlate with.Predictive validity A measure’s ability to predict outcomes of a measure or event at

some time in the future. Content validity The extent to which a measure represents all aspects of a construct.

Domain evaluationWhere feasible, the type of domains assessed by each measure was extracted, as well as information of how they were developed and whether the domains were developed from statistical analysis (factor analysis) or by expert opinion. To identify core domains of family functioning, the domains were ordered according to the construct they represented, and frequencies of the domains were counted across papers.



31

2

Data extraction strategyAll identified measures were evaluated by three authors (DD; SE; LO) in terms of item development procedures, study population used and psychometric properties, including measure development and validity.

Dealing with lack of informationSupplementary papers were searched for additional information where this was lacking in the key reference. If information was still not available, it was recorded as ‘not reported’.

Method of analysis and synthesisThe data was synthesized in a narrative way and presented in structured tables for each included measure. The aim here was to provide an overview of the characteristics of family functioning measures including psychometric properties and range of domains measured.

results

A flow diagram of the screening process is presented in Figure 1. The database search generated 2381 results, 72 of which were duplicates. From the total of 2309 references, 1739 references were excluded through screening of titles and abstracts. Full text papers of the remaining 570 references were assessed for eligibility. After review of the papers, 29 measures were identified that fitted the inclusion criteria; 10 of these were measures of ‘general/emotional family functioning’, 4 were measures of ‘dyadic relationships focusing specifically on the parent/child’ and 15 were measures of ‘specific areas/dimensions of family functioning’.

Characteristics of measuresTable 1 summarizes the characteristics of the family functioning measures. The measures of ‘general/emotional family functioning’ evaluate different dimensions of a family’s overall functioning and/or the family environment. The measures of dyadic relationships assess parents’ perceptions about their relationship with their child and vice versa. The majority of the measures of ‘specific areas/dimensions of family functioning’ are designed to measure parenting behaviour and/or parenting style (n = 9, 60%). Other measures falling under this category are measures of e.g. family routines, family stress and security in the family.

Most of the measures are to be completed by the parents. Two measures consist of two forms; one for completion by the parent and one for completion by the child (37, 45). The average number of items per measure is 41, ranging from 5 to 120 items.

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Chapter 2

32

Tabl

e 1.

Des

crip

tion

of th

e fa

mily

func

tioni

ng m

easu

res

sele

cted

for i

nclu

sion

in th

e re

view

. M

easu

reKe

y re

fere

nce

Desc

riptio

n of

the

cons

truct

Num

ber o

f ite

ms

Mea

sure

s of

gen

eral

/em

otio

nal f

amily

func

tioni

ng

Fam

ily A

dapt

abilit

y an

d C

ohes

ion

Eval

utio

n Sc

ale

(FAC

ES-IV

)

Ols

on e

t al.,

200

6 (2

5)A

mea

sure

of f

amily

coh

esio

n an

d ad

apta

bilit

y, as

wel

l as

perc

eive

d an

d id

eal f

amily

fu

nctio

ning

.84

Fam

ily A

PGAR

Smilk

stei

n, 1

978

(26)

A m

easu

re o

f fam

ily fu

nctio

ning

as

perc

eive

d by

the

patie

nt.

5Fa

mily

Ass

essm

ent D

evic

e (F

AD)

Epst

ein

et a

l., 1

983(

27)

A m

easu

re th

at d

istin

guis

hes

betw

een

heal

thy

and

unhe

alth

y fa

mily

func

tioni

ng o

n se

ven

clin

ical

ly re

leva

nt d

imen

sion

s.60

Fam

ily A

sses

smen

t Mea

sure

(F

AM-II

I)Sk

inne

r et a

l., 1

983

(28)

A m

easu

re o

f fam

ily s

treng

ths

and

wea

knes

ses.

G

ener

al s

cale

: 50

Dyad

ic s

cale

: 42

Self-

ratin

g sc

ale:

42

Fam

ily D

ynam

ics

Mea

sure

(F

DM-II

)La

sky

et a

l., 1

985

(29)

A m

easu

re o

f fam

ily d

ynam

ics.

62

Fam

ily E

nviro

nmen

t Sca

le

(FES

)M

oos

and

Moo

s, 1

986

(30)

A m

easu

re fo

r sys

tem

atic

ass

essm

ent o

f the

soc

ial e

nviro

nmen

t or c

limat

e of

the

fam

ily u

nit.

90

Fam

ily F

unct

ioni

ng S

tyle

Sc

ale

(FFS

S)Tr

ivet

te e

t al.,

199

4 (3

1)A

mea

sure

to a

sses

s th

e ex

tent

to w

hich

a fa

mily

- in

divi

dual

s or

a g

roup

- be

lieve

s th

eir f

amily

is c

hara

cter

ized

by d

iffer

ent s

treng

ths,

cap

abilit

ies

and

com

pete

ncie

s.

26

Fam

ily R

elat

ions

hip

Scal

e (F

RS)

Tola

n et

al.,

199

7 (3

2)A

mea

sure

of f

amily

rela

tions

hip

char

acte

ristic

s, a

sses

sing

dim

ensi

ons

of fa

mily

fu

nctio

ning

and

bel

iefs

. 35

Feet

ham

Fam

ily F

unct

ioni

ng

Surv

ey (F

FFS)

Robe

rts a

nd F

eeth

am,

1982

(33)

A m

easu

re th

at c

an b

e ch

arac

teriz

ed b

y th

e w

ay it

ena

bles

ass

essm

ent n

ot o

nly

of

intra

-fam

ily re

latio

nshi

ps b

ut a

lso

of in

ter-f

amily

rela

tions

hips

. 21

Self-

repo

rt Fa

mily

Inve

ntor

y (S

FI)

Hud

son,

198

2 (3

4)A

mea

sure

to a

sses

s th

e m

agni

tude

of a

pro

blem

in fa

mily

mem

bers

’ rel

atio

nshi

ps

as s

een

by th

e re

spon

dent

– m

easu

re o

f int

ra-fa

milia

l stre

ss.

25

Mea

sure

s of

dya

dic

rela

tions

hips

, inc

ludi

ng th

e pa

rent

-chi

ld re

latio

nshi

p

Auto

nom

y an

d Re

late

dnes

s In

vent

ory

(ARI

)H

all a

nd K

iern

an, 1

992

(35)

A m

easu

re o

f the

qua

lity

of p

rimar

y in

timat

e re

latio

nshi

ps, a

sses

sing

bot

h po

sitiv

e an

d ne

gativ

e di

men

sion

s of

any

type

of d

yadi

c re

latio

nshi

p.30

Fam

ily P

eer R

elat

ions

hip

Que

stio

nnai

re (F

PRQ

)El

lison

, 198

3 (3

6)A

mea

sure

to a

sses

s th

e qu

ality

of p

aren

tal s

uppo

rt as

per

ceiv

ed b

y bo

th th

e pa

rent

an

d th

e ch

ild.

18

Pare

nt-C

hild

Inte

ract

ion

Que

stio

nnai

re (P

ACH

IQ)

Lang

e et

al.,

199

8 (3

7)A

mea

sure

to a

sses

s ho

w p

aren

ts v

iew

the

rela

tions

hip

with

thei

r chi

1dre

n an

d ho

w

child

ren

eval

uate

thei

r rel

atio

nshi

p w

ith th

eir p

aren

ts.

Pare

nt v

ersi

on: 2

1C

hild

ver

sion

: 25

Pare

nt-C

hild

Rel

atio

nshi

p In

vent

ory

(PC

RI)

Coff

man

et a

l., 2

006

(38)

A m

easu

re to

ass

ess

mot

hers

’ and

fath

ers’

per

cept

ions

of t

heir

rela

tions

hips

with

th

eir c

hild

ren.

78



33

2

Mea

sure

s of

spe

cific

are

as/d

imen

sions

of f

amily

func

tioni

ng

Alab

ama

Pare

ntin

g Q

uest

ionn

aire

(APQ

)Sh

elto

n et

al.,

199

6 (3

9)A

mea

sure

to a

sses

s th

e m

ost i

mpo

rtant

asp

ects

of p

aren

ting

prac

tices

rela

ted

to

disr

uptiv

e be

havi

our p

robl

ems

in c

hild

ren.

42

Auth

orita

tive

Pare

ntin

g In

dex

(API

)Ja

ckso

n et

al.,

199

8 (4

0)A

mea

sure

of a

utho

ritat

ive

pare

ntin

g; a

sses

sing

chi

ldre

n’s

perc

eptio

ns o

f par

entin

g be

havi

ours

. 16

Chi

ld R

earin

g Pr

actic

es

Repo

rt (C

RPR)

Rick

el a

nd B

iasa

tti, 1

982

(41)

A m

easu

re to

ass

ess

com

mon

and

unc

omm

on d

imen

sion

s in

soc

ializ

atio

n.

Addr

esse

s pa

rent

al a

ttitu

des

and

beha

viou

rs to

war

d ch

ild re

arin

g pr

actic

es.

40

Chi

ldre

n’s

Repo

rt of

Par

enta

l Be

havi

or In

vent

ory

(CRP

BI)

Rask

in e

t al.,

197

1 (4

2)A

mea

sure

of c

hild

ren’

s pe

rcep

tions

of p

aren

ting

beha

viou

r.90

Fam

ily R

outin

es In

vent

ory

(FRI

)Je

nsen

et a

l., 1

983

(43)

A m

easu

re to

ass

ess

the

exte

nt o

f stre

ngth

-pro

mot

ing

rout

iniza

tion

in th

e da

ily li

fe

of a

fam

ily.

28

Fam

ily U

npre

dict

abilit

y Sc

ale

(FU

S)Ro

ss a

nd H

ill, 2

000

(44)

A m

easu

re o

f fam

ily u

npre

dict

abilit

y to

und

erst

and

the

pres

ence

and

pot

entia

l co

nseq

uenc

es o

f con

curre

nt fa

mily

dys

func

tion.

22

Loeb

er Y

outh

Que

stio

nnai

re

(LYQ

)Ja

cob

et a

l., 2

000

(45)

A m

easu

re fo

r ass

essi

ng p

aren

ting

prac

tices

invo

lvin

g pr

e-ad

oles

cent

and

ad

oles

cent

chi

ldre

n.Pa

rent

form

: 58

Chi

ld fo

rm: 5

0

Pare

nt B

ehav

ior I

nven

tory

(P

BI)

Love

joy

et a

l., 1

999

(46)

A m

easu

re o

f par

ent b

ehav

iour

for u

se w

ith th

e pa

rent

s of

pre

-sch

ool a

ge o

f you

ng

scho

ol a

ge c

hild

ren.

31

Pare

nt P

ract

ices

Sca

le (P

PS)

Stra

yhor

n an

d W

eidm

an,

1988

(47)

A m

easu

re o

f par

ents

’ pat

tern

s of

inte

ract

ion

with

thei

r pre

scho

ol c

hild

ren.

34

Pare

nt S

ucce

ss In

dica

tor

(PSI

, 1)

Col

linsw

orth

et a

l., 1

996

(48)

A m

easu

re o

f par

ent p

erfo

rman

ce.

60

Pare

ntal

Aut

horit

y Q

uest

ionn

aire

(PAQ

)Bu

ri, 1

991

(49)

A m

easu

re o

f Bau

mrin

d’s

pare

ntin

g st

yle

prot

otyp

es (p

erm

issi

vene

ss,

auth

orita

riani

sm, a

utho

ritat

iven

ess)

.30

Pare

ntal

Em

otio

nal D

ista

nce

and

Invo

lvem

ent S

cale

s (P

EDIS

)

Kiris

ci e

t al.,

200

1 (5

0)Tw

o sc

ales

to a

sses

s pa

rent

al n

egle

ct (e

mot

iona

l dis

tanc

e, E

D, a

nd p

aren

tal

invo

lvem

ent,

PI).

ED

: 22

PI: 1

1

Pare

ntin

g Sc

ale

(PS)

Arno

ld e

t al.,

199

3 (5

1)A

mea

sure

to a

sses

s dy

sfun

ctio

nal d

isci

plin

e pr

actic

es in

par

ents

of y

oung

chi

ldre

n.30

Pare

ntin

g St

ress

Inde

x (P

SI,

2)Ab

idin

, 199

5 (5

2)A

mea

sure

des

igne

d to

ass

ess

the

degr

ee a

nd c

ause

of s

tress

in th

e pa

rent

–chi

ld

rela

tions

hip.

O

rigin

al fo

rm: 1

20Sh

ort f

orm

: 36

Secu

rity

in th

e Fa

mily

Sys

tem

(S

IFS)

Form

an a

nd D

avie

s, 2

005

(53)

A m

easu

re to

ass

ess

child

ren’

s ap

prai

sals

of s

ecur

ity in

thei

r fam

ily a

s a

who

le.

24

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Chapter 2

34

Figure 1. Screening process of the systematic literature review by titles, abstracts and full papers.

Psychometric evaluation In Table 2, detailed information is given about the reliability and validity of the measures.

ReliabilityFor 28 measures (97%), the internal consistency reliability was calculated, mostly by reporting Cronbach’s α. Most of these were above an acceptable level of α = 0.7 (24). One measure failed to report internal consistency data (43).

Test-retest reliability was reported for just over half of the measures (n = 18, 62%). In these studies, the time interval to assess test-retest correlations ranged from 1 week to 12 months, with the majority of studies assessing test-retest over a 2-week to 1-month period.

ValidityMost of the measures had at least one type of validity (concurrent, discriminant, convergent or predictive) reported for them (n = 27, 93%) and followed a correlational approach for concurrent validity. The main method of correlation/validation was with one or more similar family functioning/family relationship measures. The main mode for discriminant validation was to distinguish between those with problematic or clinical behaviours and those who did not have these behaviours.



35

2

Tabl

e 2.

Psy

chom

etric

eva

luat

ion

of th

e fa

mily

func

tioni

ng m

easu

res.

M

easu

reKe

y an

d ad

ditio

nal

refe

renc

esRe

liabi

lity

Valid

ityIn

tern

al

cons

iste

ncy

Test

Re-

test

Con

curre

ntDi

scrim

inan

tO

ther

Mea

sure

s of

gen

eral

/em

otio

nal f

amily

func

tioni

ng

Fam

ily A

dapt

abilit

y an

d C

ohes

ion

Eval

uatio

n Sc

ale

(FAC

ES IV

)

Ols

on e

t al.,

200

6 (2

5)

Addi

tiona

l:O

lson

and

Gor

all,

2003

(5

4); O

lson

, 201

1 (5

5)

α =

0.77

– 0

.89.

r = 0

.83

– 0.

93

(3 w

eeks

).C

orre

latio

ns w

ith S

FI, F

AD a

nd F

amily

Sa

tisfa

ctio

n Sc

ale

(FSS

).Ba

lanc

ed c

ohes

ion;

r =

0.89

– 0

.98

Bala

nced

flex

ibilit

y; r

= 0.

91 –

0.9

9 Di

seng

aged

; r =

-0.8

4 –

-0.9

3C

haot

ic; r

= -0

.67

– -0

.71.

Disc

rimin

ates

bet

wee

n pr

oble

m a

nd n

on-p

robl

em

fam

ilies

(bas

ed o

n se

lf-re

porte

d fa

mily

sat

isfa

ctio

n,

SFI a

nd F

AD).

Con

verg

ent:

Cor

rela

tions

with

Chi

ldre

n’s

Repo

rt of

Par

enta

l Beh

avio

ur In

vent

ory

(CRP

BI-3

0), P

erce

ived

Par

enta

l an

d C

olle

ctiv

e Fa

mily

Sel

f-Effi

cacy

Sc

ales

(PPS

ES a

nd P

CFE

S) w

ith

mot

hers

with

chi

ldre

n w

ith c

ance

r. Th

e Fa

mily

APG

ARSm

ilkst

ein,

197

8 (2

6)

Addi

tiona

l: Au

stin

and

Hub

erty

, 19

89 (5

6)

α =

0.80

– 0

.86

(tota

l acr

oss

stud

ies)

.

r = 0

.83.

Cor

rela

tions

with

Fam

ily F

unct

ion

Inde

x (F

FI);

r = 0

.80.

Cor

rela

tions

with

ther

apis

t ass

esse

d fa

mily

func

tion;

r =

0.64

.

Not

repo

rted.

Not

repo

rted.

Fam

ily A

sses

smen

t De

vice

(FAD

)Ep

stei

n et

al.,

198

3 (2

7)

Addi

tiona

l:M

iller e

t al.,

198

5 (5

7);

Kaba

coff

et a

l., 1

990

(58)

α =

0.57

/0.6

9 –

0.83

/0.8

6.r =

0.6

6 –

0.71

(o

ne w

eek)

.C

orre

latio

ns w

ith F

amily

Uni

t Inv

ento

ry

(FU

I) an

d FA

CES

II.

FAD

Gen

eral

func

tioni

ng w

ith F

UI

Inte

grat

ion;

r =

0.75

. FA

D C

omm

unic

atio

n w

ith F

UI C

opin

g;

r = 0

.53.

FAD

Prob

lem

sol

ving

with

FAC

ES

Adap

tabi

lity;

r =

0.53

. FA

D Aff

ectiv

e in

volv

emen

t with

FAC

ES

Coh

esio

n; r

= 0.

41.

Dist

ingu

ishe

s be

twee

n cl

inic

al a

nd n

on-c

linic

al

grou

ps.

Not

repo

rted.

Fam

ily A

sses

smen

t M

easu

re (F

AM-II

I)Sk

inne

r et a

l., 1

983

(28)

Addi

tiona

l: G

ondo

li an

d Ja

cob,

199

3 (5

9); J

acob

, 199

5 (6

0);

Skin

ner e

t al.,

200

0 (6

1)

A =

adul

ts,

C =

chi

ldre

n.G

ener

al S

cale

; A:

α =

0.9

3C

: α =

0.9

4Dy

adic

Sca

le;

A: α

= 0

.95

C: α

= 0

.94

Self-

Ratin

g Sc

ale;

A:

α =

0.9

8C

: α =

0.8

6.

Subs

cale

s:

α =

0.47

- 0.

87.

Chi

ldre

n;r =

0.6

6M

othe

rs;

r = 0

.57

Fa

ther

s;r =

0.5

6(1

2 da

ys).

Cor

rela

tions

with

FAC

ES, F

ES a

nd

Fam

ily c

once

pt Q

Sor

t;

Idea

lizat

ion;

r =

0.94

, Coh

esio

n; r

= 0.

82,

Expr

essi

vene

ss; r

= 0

.83.

Cor

rela

tions

with

FAC

ES; F

ES a

nd F

AD.

FAC

ES C

ohes

ion;

r =

-0.3

9 –

-0.5

5,FE

S, 7

out

of 1

0 su

bsca

les;

r =

-0.2

1 –

-0.6

3,FA

D, a

ll su

bsca

les;

r =

0.38

– 0

.73.

Dist

ingu

ishe

s pr

oble

m fr

om

non-

prob

lem

fam

ilies,

as

wel

l as

norm

al fa

milie

s,

from

fam

ilies

with

a

depr

esse

d fa

ther

or a

n al

coho

lic fa

ther

.

Not

repo

rted.

R1R2R3R4R5R6R7R8R9


Chapter 2

36

Mea

sure

Key

and

addi

tiona

l re

fere

nces

Relia

bilit

yVa

lidity

Inte

rnal

co

nsis

tenc

yTe

st R

e-te

stC

oncu

rrent

Disc

rimin

ant

Oth

er

Fam

ily D

ynam

ics

Mea

sure

(FDM

-II)

Las

ky e

t al.,

198

5 (2

9)

Addi

tiona

l;H

akul

inen

et a

l., 1

999

(62)

; Ras

k et

al.,

200

3 (6

3); N

elso

n, 2

003

(64)

α =

0.46

/0.6

0 –

0.84

/0.8

8.

Not

repo

rted.

Poor

cor

rela

tions

with

FFS

S; r

= 0.

31.

Not

repo

rted.

C

onte

nt:

Dete

rmin

ed b

y a

pane

l of e

xper

ts.

Fam

ilyEn

viro

nmen

t Sca

le

(FES

)

Moo

s an

d M

oos,

198

6 (3

0) Ad

ditio

nal:

Dick

erso

n an

d C

oyne

, 19

87 (6

5); O

liver

et a

l, 19

88 (6

6); M

oos,

199

0 (6

7); M

unet

-Vila

ro a

nd

Egan

, 199

0 (6

8)

α =

0.28

/0.3

3 –

0.49

/0.7

5.

r = 0

.73

– 0.

86

(2 m

onth

s)r =

0.6

6 –

0.78

(4

mon

ths)

r = 0

.59

– 0.

76

(12

mon

ths)

.

Cor

rela

tions

with

FAD

and

FAC

ES II

. FE

S C

ohes

ion

with

FAD

Affe

ctiv

e In

volv

emen

t; r =

-0.7

1 an

d w

ith F

ACES

II

Coh

esio

n; r

= 0.

86.

FES

Con

trol w

ith F

AD B

ehav

iour

al

cont

rol;

r = 0

.37.

Dist

ingu

ishe

s be

twee

n fa

milie

s of

dep

ress

ed

patie

nts

and

cont

rols

, as

wel

l as

func

tiona

l and

dy

sfun

ctio

nal f

amilie

s.

Pred

ictiv

e:

Asso

ciat

ions

with

ada

ptat

ion

to c

hron

ic c

hild

hood

illn

esse

s,

treat

men

t out

com

es o

f dep

ress

ion,

al

coho

lism

and

med

ical

&

psyc

hiat

ric d

isor

ders

.

Fam

ily F

unct

ioni

ng

Styl

e Sc

ale

(FFS

S)Tr

ivet

te e

t al.,

199

4 (3

1)

Addi

tiona

l:Tr

ivet

te e

t al.,

199

0 (6

9)

α =

0.7

7 –

0.85

. N

ot re

porte

d.

Cor

rela

tions

with

Fam

ily H

ardi

ness

Inde

x (F

HI).

FF

SS T

otal

sca

le s

core

with

FH

I; r =

0.2

5 –

r =0.

67.

FFSS

Com

mitm

ent w

ith F

HI

Coo

rdin

ated

com

mitm

ent;

r = 0

.44.

Not

repo

rted.

C

onve

rgen

t:C

orre

latio

ns w

ith p

erso

nal w

ell-

bein

g (P

sych

olog

ical

Wel

l-bei

ng

Inde

x, P

WI)

and

fam

ilial w

ell-

bein

g (M

aste

ry a

nd H

ealth

of

Fam

ily In

vent

ory

of R

esou

rces

&

Man

agem

ent,

FIRM

). Fa

mily

Rel

atio

nshi

p Sc

ale

(FRS

)To

lan

et a

l., 1

997

(32)

α =

0.54

– 0

.87.

N

ot re

porte

d.

Not

repo

rted.

Not

repo

rted.

Con

verg

ent:

As

soci

atio

ns w

ith d

epre

ssio

n an

d ag

gres

sion

(mea

sure

d by

the

Chi

ld

Beha

vior

Che

cklis

t, C

BCL)

. Fe

etha

m F

amily

Fu

nctio

ning

Sca

le

(FFF

S)

Robe

rts a

nd F

eeth

am,

1982

(33)

α =

0.81

.N

ot re

porte

d.

Cor

rela

tions

with

Fam

ily F

unct

ioni

ng

Inde

x (F

FI);

r = -0

.54.

N

ot re

porte

d.

Con

tent

:Es

tabl

ishe

d vi

a a

pane

l of e

xper

ts

(chr

onic

chi

ld il

l hea

lth a

nd fa

mily

th

eory

).

Tabl

e 2.

Con

tinue

d



37

2

Self-

Repo

rt Fa

mily

In

vent

ory

(SFI

)

Hud

son,

198

2 (3

4)

Addi

tiona

l:Be

aver

s et

al.,

198

5 (7

0)

Gre

en a

nd B

agar

ozzi,

19

87 (7

1); G

rote

vant

an

d C

arls

on, 1

987

(72)

; Be

aver

s an

d H

amps

on,

2003

(73)

α =

0.84

– 0

.93

(acr

oss

stud

ies)

.r = 0

.44

– 0.

85(a

cros

s 30

an

d 90

day

pe

riods

).

Cor

rela

tions

with

FAD

; r =

0.7

7 an

d FA

CES

III C

ohes

ion;

r =

- 0.6

7.

SFI F

amily

hea

lth w

ith F

ACES

II

Coh

esio

n; r

= 0.

82 a

nd F

ACES

II

Adap

tabi

lity;

r =

0.64

.

Cor

rela

tions

with

Blo

om’s

Fam

ily

Func

tioni

ng S

cale

; Coh

esio

n; r

= 0.

59,

Expr

essi

on; r

= 0

.53,

Idea

lizat

ion;

r =

0.76

, Low

con

flict

; r =

-0.4

9, a

nd L

ow

exte

rnal

locu

s of

con

trol;

r = -0

.54.

Dist

ingu

ishe

s cl

inic

al fr

om

non-

clin

ical

fam

ilies,

as

wel

l as

fam

ilies

with

mem

bers

w

ith a

lcoh

olis

m fr

om

fam

ilies

with

out.

Not

repo

rted.

Mea

sure

s of

dya

dic

rela

tions

hips

, inc

ludi

ng th

e pa

rent

-chi

ld re

latio

nshi

pAu

tono

my

and

Rela

tedn

ess

Inve

ntor

y (A

RI)

Hal

l and

Kie

rnan

, 199

2 (3

5)α

= 0.

90 (t

otal

sc

ale)

.N

ot re

porte

d.

Cor

rela

tions

with

Mod

ified

Dya

dic

Adju

stm

ent S

ubsc

ales

; r =

0.2

8 –

0.61

.N

ot re

porte

d.

Not

repo

rted.

Fam

ily P

eer

Rela

tions

hip

Que

stio

nnai

re

(FPR

Q)

Ellis

on, 1

983

(36)

Addi

tiona

l:El

lison

, 198

5 (7

4)

α =

0.65

– 0

.92.

α

= 0.

89 (t

otal

sc

ale)

.

r = 0

.64

– 0.

85N

ot re

porte

d.

Not

repo

rted.

Not

repo

rted.

Pare

nt-C

hild

In

tera

ctio

n Q

uest

ionn

aire

(P

ACH

IQ)

Lang

e et

al.,

199

8 (3

7)

Addi

tiona

l:La

nge

et a

l., 2

002

(75)

α =

0.71

/0.7

6 –

0.85

/0.8

9.

PAC

HIQ

-Re

vise

d:

α =

0.78

/0.8

1 –

0.90

/0.9

5.

r = 0

.72

– 0.

84(2

wee

ks).

Cor

rela

tions

with

CRP

R.

CRP

R N

urtu

ranc

e; r

= 0.

49 –

0.5

7C

RPR

Rest

rictiv

enes

s;

r = -0

.31

– -0

.34.

Dist

ingu

ishe

s be

twee

n fa

milie

s w

ith a

n al

coho

l-de

pend

ent p

aren

t and

no

n-al

coho

lic fa

milie

s.

Not

repo

rted.

Pare

nt-C

hild

Re

latio

nshi

p In

vent

ory

(PC

RI)

Coff

man

et a

l., 2

006

(38)

Addi

tiona

l:G

erar

d, 1

994

(76)

α =

0.47

/.54

– 0.

82/0

.88.

r =

0.5

8 –

0.82

. C

orre

latio

ns w

ith F

ES.

PCRI

Invo

lvem

ent w

ith F

ES C

ohes

ion;

r =

0.40

– 0

.49.

PCRI

Sat

isfa

ctio

n w

ith F

ES C

ohes

ion;

r =

0.4

5.

PCRI

Lim

it se

tting

and

FES

Con

flict

; r =

-0

.32

– -0

.41

Not

repo

rted.

C

onve

rgen

t: St

rong

cor

rela

tions

with

the

Net

wor

k of

Rel

atio

nshi

ps In

vent

ory

(NRI

) and

Sel

f-Des

crip

tion

Que

stio

nnai

re-II

(SDQ

-II).

Mea

sure

s of

spe

cific

are

as/d

imen

sions

of f

amily

func

tioni

ngAl

abam

a Pa

rent

ing

Que

stio

nnai

re (A

PQ)

Shel

ton

et a

l., 1

996

(39)

Addi

tiona

l:Da

dds

et a

l, 20

03 (7

7)

Pare

nt fo

rm:

α =

0.46

– 0

.80.

C

hild

form

:α

= 0.

44 –

0.8

3.

Pare

nt fo

rm.

r = 0

.84

– 0.

91

(2 w

eeks

).

Cor

rela

tions

with

the

Con

duct

Pro

blem

s (C

P) s

cale

of t

he S

treng

ths

and

Diffi

culti

es Q

uest

ionn

aire

(SDQ

). AP

Q In

cons

iste

nt D

isci

plin

e; r

= 0.

31,

APQ

Cor

pora

l Pun

ishm

ent;

r = 0

.24.

Dist

ingu

ishe

s be

twee

n fa

milie

s w

ith c

hild

ren

with

be

havi

our d

isor

ders

and

no

rmal

con

trol f

amilie

s.

Not

repo

rted.

R1R2R3R4R5R6R7R8R9


Chapter 2

38

Mea

sure

Key

and

addi

tiona

l re

fere

nces

Relia

bilit

yVa

lidity

Inte

rnal

co

nsis

tenc

yTe

st R

e-te

stC

oncu

rrent

Disc

rimin

ant

Oth

er

Chi

ld R

earin

g Pr

actic

es R

epor

t (C

RPR)

Rick

el a

nd B

iasa

tti, 1

982

(41)

Addi

tiona

l:Bl

ock,

196

5 (7

8); D

ékov

ic

et a

l., 1

991

(79)

α =

0.61

/0.8

5 –

0.73

/0.8

4.r =

0.3

8 - 0

.85

(acr

oss

seve

ral

stud

ies)

.

Not

repo

rted.

Si

gnifi

cant

diff

eren

ces

wer

e fo

und

betw

een

fam

ilies

with

acc

epte

d an

d re

ject

ed

child

ren.

Con

verg

ent :

Stro

ng c

orre

latio

ns b

etw

een

rest

rictiv

e an

d au

thor

itaria

n re

porti

ng in

the

CRP

R an

d ob

serv

ed p

aren

t beh

avio

ur.

Auth

orita

rian

and

auth

orita

tive

repo

rting

in th

e C

RPR

corre

spon

d w

ith c

hild

rear

ing

prac

tices

.C

hild

ren’

s Re

port

of

Pare

ntal

Beh

avio

r In

vent

ory

(CRP

BI)

Ras

kin

et a

l., 1

971

(42)

Addi

tiona

l:Sa

fford

et a

l., 2

007

(80)

α =

0.8

1 –

0.94

.N

ot re

porte

d.

Cor

rela

tions

with

the

Pare

ntal

Bon

ding

In

dex

(PBI

).C

RPBI

Pos

itive

invo

lvem

ent w

ith P

BI

Car

e; r

= 0.

83 –

0.8

6.

CRP

BI N

egat

ive

cont

rol w

ith P

BI

Ove

rpro

tect

ion;

r =

0.56

– 0

.57.

Nor

mal

adu

lts p

erce

ive

thei

r par

ents

as

mor

e po

sitiv

ely

invo

lved

, les

s la

x in

app

lyin

g di

scip

line

and

usin

g le

ss n

egat

ive

appr

oach

es to

con

trol t

han

depr

esse

d pa

tient

s.

Not

repo

rted.

Fam

ily R

outin

es

Inve

ntor

y (F

RI)

Jens

en e

t al,

1983

(43)

Addi

tiona

l:Bo

yce

et a

l., 1

983

(81)

; Kn

ight

et a

l., 1

992

(82)

; C

hurc

hill

and

Ston

eman

, 20

04 (8

3)

Not

repo

rted.

r =

0.7

4 - 0

.79

(1 m

onth

).C

orre

latio

ns w

ith F

ES C

ohes

ion,

O

rgan

izatio

n, C

ontro

l and

Con

flict

; r

(rang

e) =

-0.1

8 –

0.36

.

Disc

rimin

ates

bet

wee

n de

pres

sed

and

non-

depr

esse

d m

othe

rs o

n C

ente

r for

Epi

dem

iolo

gic

Stud

ies

Depr

essi

on S

cale

(C

ES-D

).

Not

repo

rted.

The

Fam

ily

Unp

redi

ctab

ility

Scal

e (F

US)

Ross

and

Hill,

200

0 (4

4)α

= 0.

79 –

0.8

5.

Info

rmed

to b

e go

od (d

etai

ls

wer

e no

t re

porte

d).

Cor

rela

tions

with

FAD

: FU

S To

tal s

cale

with

FAD

Gen

eral

Fu

nctio

ning

sca

le; r

= 0

.59

FUS

Nur

tura

nce

with

FAD

Affe

ctiv

e re

gula

tion;

r =

0.47

.

Neg

ativ

e co

rrela

tions

with

the

FRI;

r = -

0.71

.

Alco

holic

par

ents

repo

rted

sign

ifica

ntly

hig

her

scor

es o

n th

e Di

scip

line,

N

urtu

ranc

e an

d M

oney

sc

ales

and

on

the

over

all

scal

e th

an n

orm

al p

aren

ts.

Con

verg

ent:

Cor

rela

tions

with

Pare

nts’

func

tioni

ng (m

easu

red

by th

e Br

ief S

ympt

oms

Inve

ntor

y).

Som

e si

gnifi

cant

ass

ocia

tions

be

twee

n ch

ildre

n’s

func

tioni

ng

(mea

sure

d by

par

enta

l rep

ort)

and

FUS.

Lo

eber

You

th

Que

stio

nnai

re (L

YQ)

Jaco

b et

al.,

200

0 (4

5)Pa

rent

form

: α

= 0.

26/0

.49

– 0.

71/0

.75.

Chi

ld fo

rm:

α =

0.35

/0.3

6 –

0.59

/0.7

1.

r = 0

.59

– 0.

82.

Cor

rela

tions

bet

wee

n LY

Q (p

aren

t for

m)

and

FES.

LY

Q A

ffect

with

FES

Affe

ct;

r = 0

.27

– 0.

53.

LYQ

Affe

ct w

ith F

ES A

ctiv

ities

; r

= 0.

48 –

0.5

3LY

Q C

ontro

l with

FES

Con

trol;

r = 0

.28

– 0.

30.

Not

repo

rted.

C

onve

rgen

t:C

orre

latio

ns w

ith th

e C

hild

Be

havi

or C

heck

list (

CBC

L);

LYQ

Affe

ct w

ith C

BCL

Exte

rnal

izing

; r =

-.43

.LY

Q A

ffect

with

CBC

L So

cial

co

mpe

tenc

e; r

= .3

9.

Tabl

e 2.

Con

tinue

d



39

2

Pare

nt B

ehav

ior

Inve

ntor

y (P

BI)

Love

joy

et a

l., 1

999

(46)

α =

0.81

– 0

.83.

r =

0.6

9 –

0.74

.C

orre

latio

ns w

ith P

aren

ting

Stre

ss In

dex

(PSI

-SF)

: PB

I Sup

porti

ve/e

ngag

ed p

aren

ting

with

PS

I-SF

Tota

l stre

ss; r

= -0

.53

PBI H

ostil

e/co

erci

ve p

aren

ting

with

PSI

-SF

Diffi

cult

child

; r =

0.5

9.

Cor

rela

tions

with

Pos

itive

and

Neg

ativ

e Aff

ect S

ched

ule

(PAN

AS).

PBI S

uppo

rtive

/eng

aged

par

entin

g w

ith

PAN

AS P

ositi

ve a

ffect

; r =

0.5

9.PB

I Hos

tile/

coer

cive

par

entin

g w

ith

PAN

AS N

egat

ive

affec

t; r =

0.4

4.

Cor

rela

tions

with

obs

erve

d be

havi

ours

. Ra

nge

r = -.

32 –

.54.

Disc

rimin

ates

mat

erna

l be

havi

our i

n pl

ay a

nd ta

sk

situ

atio

ns (p

<0.0

01).

Con

verg

ent:

Cor

rela

tions

with

Eyb

erg

Chi

ld

Beha

viou

r Inv

ento

ry (E

CBI

); PB

I Su

ppor

tive/

enga

ged

pare

ntin

g; r

= -0

.40,

PBI H

ostil

e/co

erci

ve p

aren

ting;

r =

0.61

.

Pare

nt P

ract

ices

Sc

ale

(PPS

)St

rayh

orn

and

Wei

dman

, 19

88 (4

7)α

= 0

.78

– 0.

79St

able

ove

r a 6

m

onth

per

iod

(det

ails

wer

e no

t rep

orte

d).

Cor

rela

tions

bet

wee

n ob

serv

ed

mea

sure

s of

par

ent p

ract

ices

and

sco

res

on th

e PP

S.

Not

repo

rted.

C

onve

rgen

t:Si

gnifi

cant

ass

ocia

tions

bet

wee

n

child

beh

avio

ural

out

com

e m

easu

res

(Beh

ar P

resc

hool

Be

havi

our Q

uest

ionn

aire

, Chi

ld

Beha

viou

r Che

cklis

t, C

BCL)

and

sc

ores

on

the

PPS.

Pare

nt S

ucce

ss

Indi

cato

r(P

SI, 1

)

Col

linsw

orth

et a

l., 1

996.

(4

8)

Addi

tiona

l:St

rom

et a

l., 1

998

(84)

; Be

cker

t et a

l., 2

007

(85)

α =

0.7

5/0.

84 –

0.

92/0

.95.

N

ot re

porte

d.

Not

repo

rted.

N

ot re

porte

d.

N

ot re

porte

d.

Pare

ntal

Aut

horit

y Q

uest

ionn

aire

(PAQ

)Bu

ri, 1

991

(49)

Addi

tiona

l:Re

itman

et a

l., 2

002a

(8

6)

α =

0.7

4/0.

75

–0.8

5/0.

87.

PAQ

-Rev

ised

(P

AQ-R

):α

= 0

.56/

0.77

–

0.72

/0.7

6.

r = 0

.78

– .9

2.

(2 w

eeks

).

PAQ

-R:

r = 0

.54

– 0.

88

(1 m

onth

).

Cor

rela

tions

with

Par

enta

l Nur

tura

nce

Scal

e (P

NS)

. PA

Q a

utho

ritat

iven

ess

with

PN

S N

urtu

ranc

e; r

= 0.

56 –

0.6

8PA

Q A

utho

ritar

iani

sm w

ith P

NS

Nur

tura

nce;

r =

- 0.3

6 –

-0.5

3

PAQ

-R:

Cor

rela

tions

with

PS

and

PCRI

.PA

Q-R

Per

mis

sive

ness

with

PS

Laxn

ess;

r =

0.2

6.

PAQ

-R A

utho

ritat

ive

with

PC

RI

Com

mun

icat

ion;

r =

0.34

.

Disc

rimin

ates

bet

wee

n pa

rent

ing

styl

es a

s m

easu

red

by th

e PA

Q.

Not

repo

rted.

R1R2R3R4R5R6R7R8R9


Chapter 2

40

Mea

sure

Key

and

addi

tiona

l re

fere

nces

Relia

bilit

yVa

lidity

Inte

rnal

co

nsis

tenc

yTe

st R

e-te

stC

oncu

rrent

Disc

rimin

ant

Oth

er

Pare

ntin

g Sc

ale

(PS)

Arno

ld e

t al.,

199

3 (5

1) α

= 0

.63

– 0.

84.

r = 0

.79

– 0.

84

(2 w

eeks

). C

orre

latio

ns w

ith o

bser

ved

pare

nt

and

child

beh

avio

ur (m

othe

r-chi

ld

inte

ract

ions

); r =

0.3

2 –

0.79

.

Dist

ingu

ishe

s be

twee

n no

n-cl

inic

al m

othe

rs a

nd

mot

hers

who

rece

ived

tre

atm

ent f

or h

avin

g ex

trem

e di

fficu

lties

with

ha

ndlin

g th

eir c

hild

ren.

Con

verg

ent:

Cor

rela

tions

with

Chi

ld B

ehav

ior

Che

cklis

t (C

BCL)

.PS

Lax

ness

with

CBC

L; r

= .4

1, P

S O

verre

activ

ity w

ith C

BCL;

r =

.54.

Si

gnifi

cant

cor

rela

tions

with

Loc

ke-

Wal

lace

Mar

ital A

djus

tmen

t Tes

t (S

MAT

). Pa

rent

ing

Stre

ss

Inde

x (P

SI, 2

)

Abid

in, 1

995

(52)

Addi

tiona

l:M

ash

et a

l., 1

983

(87)

; M

cKay

et a

l., 1

996

(88)

; Lo

yd a

nd A

bidi

n, 1

985

(89)

; Has

kett

et a

l., 2

006

(90)

; Rei

tman

et a

l.,

2002

b (9

1)

PSI:

α =

0.55

– 0

.95.

PSI-S

F:α

= .8

0 –

.87.

PSI:

r = 0

.63

- 0.9

1

PSI-S

F:

r = 0

.68

- 0.8

5.

PSI:

Sub-

scal

es c

orre

late

with

obs

erva

tiona

l co

ding

sch

edul

e m

easu

res

e.g.

M

arsc

hak

Inte

ract

ion

Met

hod;

r (ra

nge)

=

-0.3

3 - 0

.86.

PSI-S

F:C

orre

late

s w

ith g

loba

l Sym

ptom

C

heck

list-9

0-Re

vise

d (S

CL-

90-R

): r =

0.

54.

PSI:

Disc

rimin

ates

bet

wee

n pa

rent

s at

risk

and

not

at

risk

of p

aren

ting

prob

lem

s.

Disc

rimin

ates

bet

wee

n ab

usiv

e an

d no

n-ab

usiv

e pa

rent

s.

PSI-S

F:

Disc

rimin

ates

bet

wee

n ab

usiv

e an

d no

n-ab

usiv

e pa

rent

s.

Con

verg

ent:

PSI-S

F:C

orre

latio

ns w

ith E

yber

g C

hild

Be

havi

our I

nven

tory

(EC

BI)

Inte

nsity

sca

le; r

= .3

1 –

0.61

.

Secu

rity

in th

e Fa

mily

Sys

tem

sc

ales

(SIF

S)

Form

an a

nd D

avie

s,

2005

(53)

α =

0.82

– 0

.88.

r =

0.7

5 –

0.82

(2

wee

ks).

Cor

rela

tions

with

Chi

ldre

n’s

Perc

eptio

n of

Inte

rpar

enta

l Con

flict

Sca

le (C

PIC

). SI

FS P

reoc

cupa

tion

with

CPI

C; r

= 0

.54.

SIFS

Dis

enga

gem

ent a

nd C

PIC

; r =

0.

53.

Not

repo

rted.

C

onve

rgen

t:Su

bsca

les

of S

IFS

corre

late

d w

ith

fam

ily c

hara

cter

istic

s (m

easu

red

by

self-

repo

rt fro

m c

hild

ren,

par

ents

an

d te

ache

rs).

Pred

ictiv

e:A

6 m

onth

follo

w-u

p - c

hild

re

spon

ses

to s

imul

atio

ns o

f fam

ily

confl

ict s

how

ed th

e sc

ale

to h

ave

mod

erat

e pr

edic

tive

pow

er.

Mul

tiple

regr

essi

on re

veal

ed

the

scal

e fa

ctor

s to

pro

duce

a

sign

ifica

nt p

redi

ctiv

e m

odel

.

Tabl

e 2.

Con

tinue

d



41

2

Domain evaluationThe domain evaluation and development of the family functioning measures are summarized in Table 3. There was a lot of variability in the number of domains across family functioning measures. The number of domains ranged from none to ten with a median of four. The domains covered a diverse range of areas related to family relationships resulting in 54 separate domains identified. Domains with the highest frequencies across papers were ‘communication’ (27-29, 31, 32, 34, 38, 48) and ‘cohesion/engagement’ (25, 30-32, 34, 36, 46, 53), which were included in eight measures; followed by ‘control’ (27, 28, 30, 35, 38, 42, 45), which was included in seven measures. Next popular came ‘involvement’ (27, 28, 38, 39, 42, 49) and ‘authoritarian/rigid parenting style’ (25, 37, 40, 41, 46, 49), which were included in six measures.

All of the measures had a solid basis for item development with most being derived from family functioning or related theory, literature review or empirical studies with families or a combination of any of these. Only one measure was developed from expert review (38). Theories used were diverse and ranged from models of family/parental functioning, family/parental relationships, social support, attachment, stress and coping, and general socio-ecological models.

Most of the domains in the measures were developed statistically by either factor analysis/confirmatory factor analysis or principal component analysis. Four of the measures did not report how the domains were developed (26, 36, 39, 47).

R1R2R3R4R5R6R7R8R9


Chapter 2

42

Tabl

e 3.

Dom

ain

eval

uatio

n of

the

fam

ily fu

nctio

ning

mea

sure

s.M

easu

reKe

y re

fere

nce

Dom

ains

Item

dev

elop

men

tDo

mai

n de

velo

pmen

tM

easu

res

of g

ener

al/e

mot

iona

l fam

ily fu

nctio

ning

Fa

mily

Ada

ptab

ility

and

Coh

esio

n Ev

alua

tion

Scal

e (F

ACES

IV)

Ols

on e

t al.,

20

06 (2

5)C

ohes

ion

Scal

e; E

nmes

hed,

Coh

esio

n ba

lanc

ed,

Dise

ngag

ed.

Flex

ibilit

y Sc

ale;

Cha

otic

, Fle

xibi

lity

bala

nced

, Rig

id.

Base

d on

the

Circ

umpl

ex

Mod

el o

f Mar

ital a

nd F

amily

Sy

stem

s.

- Fa

ctor

Ana

lysi

s.-

Con

firm

ator

y Fa

ctor

An

alys

is.

The

Fam

ily A

PGAR

Smilk

stei

n,

1978

(26)

Adap

tatio

n, P

artn

ersh

ip, G

row

th, A

ffect

ion,

Res

olve

.Ba

sed

on F

amily

Sys

tem

Th

eory

, The

Stre

ss a

nd C

opin

g Th

eory

and

lite

ratu

re re

view

.

Not

repo

rted.

Fam

ily A

sses

smen

t De

vice

(FAD

)Ep

stei

n et

al.,

19

83 (2

7)Pr

oble

m s

olvi

ng, C

omm

unic

atio

n, R

oles

, Affe

ctiv

e Re

spon

sive

ness

, Affe

ctiv

e in

volv

emen

t, Be

havi

our

cont

rol,

Gen

eral

func

tioni

ng.

Base

d on

the

McM

aste

r Mod

el

of F

amily

Fun

ctio

ning

.-

Con

firm

ator

y Fa

ctor

An

alys

is.

- Pr

inci

pal C

ompo

nent

An

alys

is.

Fam

ily A

sses

smen

t M

easu

re (F

AM-II

I)Sk

inne

r et a

l.,

1983

(28)

Task

acc

ompl

ishm

ent,

Role

per

form

ance

, C

omm

unic

atio

n, A

ffect

ive

expr

essi

on, I

nvol

vem

ent,

Con

trol,

Valu

es a

nd n

orm

s.

Base

d on

the

Proc

ess

Mod

el

of F

amily

, dev

elop

ed fr

om th

e Fa

mily

Cat

egor

ies

sche

ma.

- Ex

plor

ator

y Fa

ctor

Ana

lysi

s.-

Con

firm

ator

y Fa

ctor

An

alys

is.

Fam

ily D

ynam

ics

Mea

sure

(FDM

-II)

Las

ky e

t al.,

19

85 (2

9)In

divi

dual

izatio

n –

Enm

eshm

ent,

Cle

ar c

omm

unic

atio

n –

Dist

orte

d co

mm

unic

atio

n, S

tabi

lity

– Di

sorg

aniza

tion,

Fl

exib

ility

– Ri

gidi

ty, M

utua

lity

– Is

olat

ion,

Rec

ipro

city

–

Role

con

flict

.

Base

d on

a s

yste

m-th

eore

tical

m

odel

of a

hea

lthy

fam

ily c

ycle

by

Bar

nhill

(92)

.

- Fa

ctor

Ana

lysi

s w

ith v

arim

ax

rota

tion.

Fam

ily E

nviro

nmen

t Sc

ale

(FES

) M

oos

and

Moo

s, 1

986

(30)

Inte

rper

sona

l Rel

atio

nshi

ps; C

ohes

ion,

Ex

pres

sive

ness

, Con

flict

.Pe

rson

al G

row

th; I

ndep

ende

nce,

Ach

ieve

men

t or

ient

atio

n, In

telle

ctua

l-cul

tura

l orie

ntat

ion,

Act

ive-

recr

eatio

nal o

rient

atio

n, M

oral

-relig

ious

em

phas

is.

Syst

ems

Mai

nten

ance

; Org

aniza

tion,

Con

trol.

Base

d on

obs

erva

tions

and

in

terv

iew

s w

ith fa

milie

s. U

sed

Soci

al E

colo

gica

l The

ory

and

Gen

eral

Sys

tem

s Th

eory

, bu

t lac

ks a

theo

ry o

f fam

ily

func

tioni

ng.

- Ex

plor

ator

y an

d C

onfir

mat

ory

Fact

or

Anal

ysis

.

Fam

ily F

unct

ioni

ng

Styl

e Sc

ale

(FFS

S)Tr

ivet

te e

t al.,

19

94 (3

1)

Com

mitm

ent,

Coh

esio

n, C

omm

unic

atio

n,

Com

pete

nce,

Cop

ing.

Base

d on

lite

ratu

re re

view

on

fam

ily s

treng

ths.

Dev

elop

ed

as a

par

t of a

fam

ily-c

ente

red

asse

ssm

ent a

nd in

terv

entio

n m

odel

(93)

.

- Pr

inci

pal C

ompo

nent

An

alys

is.

Fam

ily R

elat

ions

hip

Scal

e (F

RS)

Tola

n et

al.,

19

97 (3

2)Be

liefs

Abo

ut F

amily

, Coh

esio

n, S

hare

d De

vian

t Be

liefs

, Sup

port,

Org

aniza

tion,

Com

mun

icat

ion.

Base

d on

lite

ratu

re re

view

and

a

theo

ry o

f fam

ily re

latio

nshi

p ch

arac

teris

tics

(94)

.

- Ex

plor

ator

y an

d C

onfir

mat

ory

Fact

or

Anal

ysis

.-

Prin

cipa

l Com

pone

nt

Anal

ysis

.-

LISR

EL S

truct

ural

Equ

atio

n M

odel

ling.



43

2

Tabl

e 3.

Dom

ain

eval

uatio

n of

the

fam

ily fu

nctio

ning

mea

sure

s.M

easu

reKe

y re

fere

nce

Dom

ains

Item

dev

elop

men

tDo

mai

n de

velo

pmen

tM

easu

res

of g

ener

al/e

mot

iona

l fam

ily fu

nctio

ning

Fa

mily

Ada

ptab

ility

and

Coh

esio

n Ev

alua

tion

Scal

e (F

ACES

IV)

Ols

on e

t al.,

20

06 (2

5)C

ohes

ion

Scal

e; E

nmes

hed,

Coh

esio

n ba

lanc

ed,

Dise

ngag

ed.

Flex

ibilit

y Sc

ale;

Cha

otic

, Fle

xibi

lity

bala

nced

, Rig

id.

Base

d on

the

Circ

umpl

ex

Mod

el o

f Mar

ital a

nd F

amily

Sy

stem

s.

- Fa

ctor

Ana

lysi

s.-

Con

firm

ator

y Fa

ctor

An

alys

is.

The

Fam

ily A

PGAR

Smilk

stei

n,

1978

(26)

Adap

tatio

n, P

artn

ersh

ip, G

row

th, A

ffect

ion,

Res

olve

.Ba

sed

on F

amily

Sys

tem

Th

eory

, The

Stre

ss a

nd C

opin

g Th

eory

and

lite

ratu

re re

view

.

Not

repo

rted.

Fam

ily A

sses

smen

t De

vice

(FAD

)Ep

stei

n et

al.,

19

83 (2

7)Pr

oble

m s

olvi

ng, C

omm

unic

atio

n, R

oles

, Affe

ctiv

e Re

spon

sive

ness

, Affe

ctiv

e in

volv

emen

t, Be

havi

our

cont

rol,

Gen

eral

func

tioni

ng.

Base

d on

the

McM

aste

r Mod

el

of F

amily

Fun

ctio

ning

.-

Con

firm

ator

y Fa

ctor

An

alys

is.

- Pr

inci

pal C

ompo

nent

An

alys

is.

Fam

ily A

sses

smen

t M

easu

re (F

AM-II

I)Sk

inne

r et a

l.,

1983

(28)

Task

acc

ompl

ishm

ent,

Role

per

form

ance

, C

omm

unic

atio

n, A

ffect

ive

expr

essi

on, I

nvol

vem

ent,

Con

trol,

Valu

es a

nd n

orm

s.

Base

d on

the

Proc

ess

Mod

el

of F

amily

, dev

elop

ed fr

om th

e Fa

mily

Cat

egor

ies

sche

ma.

- Ex

plor

ator

y Fa

ctor

Ana

lysi

s.-

Con

firm

ator

y Fa

ctor

An

alys

is.

Fam

ily D

ynam

ics

Mea

sure

(FDM

-II)

Las

ky e

t al.,

19

85 (2

9)In

divi

dual

izatio

n –

Enm

eshm

ent,

Cle

ar c

omm

unic

atio

n –

Dist

orte

d co

mm

unic

atio

n, S

tabi

lity

– Di

sorg

aniza

tion,

Fl

exib

ility

– Ri

gidi

ty, M

utua

lity

– Is

olat

ion,

Rec

ipro

city

–

Role

con

flict

.

Base

d on

a s

yste

m-th

eore

tical

m

odel

of a

hea

lthy

fam

ily c

ycle

by

Bar

nhill

(92)

.

- Fa

ctor

Ana

lysi

s w

ith v

arim

ax

rota

tion.

Fam

ily E

nviro

nmen

t Sc

ale

(FES

) M

oos

and

Moo

s, 1

986

(30)

Inte

rper

sona

l Rel

atio

nshi

ps; C

ohes

ion,

Ex

pres

sive

ness

, Con

flict

.Pe

rson

al G

row

th; I

ndep

ende

nce,

Ach

ieve

men

t or

ient

atio

n, In

telle

ctua

l-cul

tura

l orie

ntat

ion,

Act

ive-

recr

eatio

nal o

rient

atio

n, M

oral

-relig

ious

em

phas

is.

Syst

ems

Mai

nten

ance

; Org

aniza

tion,

Con

trol.

Base

d on

obs

erva

tions

and

in

terv

iew

s w

ith fa

milie

s. U

sed

Soci

al E

colo

gica

l The

ory

and

Gen

eral

Sys

tem

s Th

eory

, bu

t lac

ks a

theo

ry o

f fam

ily

func

tioni

ng.

- Ex

plor

ator

y an

d C

onfir

mat

ory

Fact

or

Anal

ysis

.

Fam

ily F

unct

ioni

ng

Styl

e Sc

ale

(FFS

S)Tr

ivet

te e

t al.,

19

94 (3

1)

Com

mitm

ent,

Coh

esio

n, C

omm

unic

atio

n,

Com

pete

nce,

Cop

ing.

Base

d on

lite

ratu

re re

view

on

fam

ily s

treng

ths.

Dev

elop

ed

as a

par

t of a

fam

ily-c

ente

red

asse

ssm

ent a

nd in

terv

entio

n m

odel

(93)

.

- Pr

inci

pal C

ompo

nent

An

alys

is.

Fam

ily R

elat

ions

hip

Scal

e (F

RS)

Tola

n et

al.,

19

97 (3

2)Be

liefs

Abo

ut F

amily

, Coh

esio

n, S

hare

d De

vian

t Be

liefs

, Sup

port,

Org

aniza

tion,

Com

mun

icat

ion.

Base

d on

lite

ratu

re re

view

and

a

theo

ry o

f fam

ily re

latio

nshi

p ch

arac

teris

tics

(94)

.

- Ex

plor

ator

y an

d C

onfir

mat

ory

Fact

or

Anal

ysis

.-

Prin

cipa

l Com

pone

nt

Anal

ysis

.-

LISR

EL S

truct

ural

Equ

atio

n M

odel

ling.

Feet

ham

Fam

ily

Func

tioni

ng S

cale

(F

FFS)

Robe

rts a

nd

Feet

ham

, 198

2 (3

3)

3 ar

eas

of fa

mily

func

tions

as

rela

tions

hips

;•

Rel

atio

nshi

ps b

etw

een

the

fam

ily a

nd th

e br

oade

r so

cial

uni

ts•

The

rela

tions

hips

bet

wee

n th

e fa

mily

and

su

bsys

tem

s an

d •

The

rela

tions

hips

bet

wee

n th

e fa

mily

and

eac

h in

divi

dual

.

Base

d on

the

Fam

ily

Ecol

ogic

al F

ram

ewor

ks.

Deve

lope

d ou

t of F

amily

Fu

nctio

ning

lite

ratu

re a

nd

clin

ical

obs

erva

tions

of

fam

ilies

who

had

infa

nts

affec

ted

by m

yelo

dysp

laia

.

- Fa

ctor

Ana

lysi

s w

ith v

arim

ax

rota

tion.

Mea

sure

s of

dya

dic

rela

tions

hips

, inc

ludi

ng th

e pa

rent

-chi

ld re

latio

nshi

pAu

tono

my

and

Rela

tedn

ess

Inve

ntor

y (A

RI)

Hal

l and

Ki

erna

n, 1

992

(35)

Supp

ort/p

ositi

ve re

gard

, Dom

inan

ce/c

ontro

l.Ite

ms

deriv

ed fr

om th

e M

arita

l Au

tono

my

and

Rela

tedn

ess

Inve

ntor

y w

ith a

dditi

onal

ite

ms

base

d on

soc

ial s

uppo

rt lit

erat

ure

and

earli

er m

easu

res

of s

ocia

l rel

atio

nshi

ps.

- Pr

inci

pal C

ompo

nent

An

alys

is w

ith v

arim

ax

rota

tion.

Fam

ily P

eer

Rela

tions

hip

Que

stio

nnai

re

(FPR

Q)

Ellis

on, 1

983

(36)

.

Toge

ther

ness

, Nur

tura

nce

– Di

sclo

sure

, Pee

r re

latio

nshi

ps.

Base

d on

inte

rvie

ws

with

30

fam

ilies

and

liter

atur

e re

view

. Th

eore

tical

ly b

ased

on

an

ecol

ogic

al m

odel

of s

ocia

l su

ppor

t.

Not

repo

rted.

Pare

nt-C

hild

In

tera

ctio

n Q

uest

ionn

aire

(P

ACH

IQ)

Lang

e et

al.,

19

98 (3

7)Au

thor

ity (P

ACH

IQ-R

: Con

flict

reso

lutio

n), A

ccep

tanc

e. B

ased

on

3 di

men

sion

s;

auth

ority

, acc

epta

nce

and

dem

ocra

tic c

omm

unic

atio

n sk

ills, d

eriv

ed fr

om li

tera

ture

re

view

.

- C

onfir

mat

ory

Fact

or

Anal

ysis

. -

Prin

cipa

l Com

pone

nt

Anal

ysis

.

Pare

nt-C

hild

Re

latio

nshi

p In

vent

ory

(PC

RI)

Coff

man

et a

l.,

2006

(38)

Satis

fact

ion,

Invo

lvem

ent,

Com

mun

icat

ion,

Lim

it se

tting

, Aut

onom

y. Ba

sed

on e

xper

t rev

iew.

- C

onfir

mat

ory

Fact

or

Anal

ysis

.

Mea

sure

s of

spe

cific

are

as/d

imen

sions

of f

amily

func

tioni

ngAl

abam

a Pa

rent

ing

Que

stio

nnai

re (A

PQ)

Shel

ton

et a

l.,

1996

(39)

Invo

lvem

ent,

Posi

tive

Pare

ntin

g, P

oor M

onito

ring/

Supe

rvis

ion,

Inco

nsis

tent

Dis

cipl

ine,

Cor

pora

l Pu

nish

men

t.

Base

d on

lite

ratu

re re

view

an

d ite

ms

from

stu

dies

and

un

publ

ishe

d in

terv

iew

s fro

m

Loeb

er e

t al.

(95)

stu

dies

from

C

apal

di a

nd P

atte

rson

et a

l. (9

6) a

nd th

e C

RPBI

.

Not

repo

rted.

R1R2R3R4R5R6R7R8R9


Chapter 2

44

Mea

sure

Key

refe

renc

eDo

mai

nsIte

m d

evel

opm

ent

Dom

ain

deve

lopm

ent

Auth

orita

tive

Pare

ntin

g In

dex

(API

)Ja

ckso

n et

al.,

19

98 (4

0)De

man

ding

ness

, Res

pons

iven

ess.

(Res

ultin

g in

aut

horit

ativ

e, a

utho

ritar

ian,

indu

lgen

t, or

ne

glec

tful p

aren

ting)

.

Base

d on

Bau

mrin

d’s

Theo

ry

of A

utho

ritat

ive

Pare

ntin

g.-

Expl

orat

ory

Fact

or A

naly

sis

usin

g pr

inci

pal c

ompo

nent

ex

tract

ion

and

obliq

ue

rota

tion.

Chi

ld R

earin

g Pr

actic

es R

epor

t (C

RPR)

Rick

el a

nd

Bias

atti,

198

2 (4

1)

Rest

rictiv

enes

s an

d au

thor

itaria

n, N

urtu

ranc

e an

d au

thor

itativ

e.Ba

sed

on o

bser

vatio

n of

pa

rent

s an

d ch

ildre

n in

di

ffere

nt e

xper

imen

tal s

ettin

gs.-

Prin

cipa

l Com

pone

nt F

acto

r An

alys

is w

ith v

arim

ax

rota

tion)

.-

Con

firm

ator

y fa

ctor

ana

lysi

s.

Chi

ldre

n’s

Repo

rt of

Pa

rent

al B

ehav

ior

Inve

ntor

y (C

RPBI

)

Ras

kin

et a

l.,

1971

(42)

Posi

tive

invo

lvem

ent,

Neg

ativ

e co

ntro

l, La

x di

scip

line.

Sh

orte

ned

vers

ion

of

Scha

efer

’s or

igin

al 1

92-it

em

CRP

BI s

cale

.

- Fa

ctor

Ana

lysi

s w

ith v

arim

ax

rota

tion.

Fam

ily R

outin

es

Inve

ntor

y (F

RI)

Jens

en e

t al.,

19

83 (4

3)

Exte

nt, I

mpo

rtanc

e.Ba

sed

on li

tera

ture

revi

ew

(theo

ry),

fam

ily-p

artic

ipan

t ob

serv

atio

ns a

nd s

emi-

stru

ctur

ed in

terv

iew

s w

ith

fam

ilies.

- C

onfir

mat

ory

Fact

or

Anal

ysis

usi

ng S

truct

ural

M

odel

ling.

The

Fam

ily

Unp

redi

ctab

ility

Scal

e (F

US)

Ross

and

Hill,

20

00 (4

4)Di

scip

line,

Nur

tura

nce,

Mea

ls, M

oney

.Ba

sed

on A

ttach

men

t The

ory

and

Lear

ned

Hel

ples

snes

s Th

eory

. Ite

ms

wer

e de

velo

ped

by a

n ex

pert

pane

l.

- Pr

inci

pal C

ompo

nent

Fac

tor

Anal

ysis

with

var

imax

ro

tatio

n.-

Con

firm

ator

y Fa

ctor

An

alys

is.

Loeb

er Y

outh

Q

uest

ionn

aire

(LYQ

)Ja

cob

et a

l.,

2000

(45)

Affec

t, C

ontro

l.De

velo

ped

in 1

987

for t

he

purp

ose

of a

long

itudi

nal

com

mun

ity s

tudy

.

- Ex

plor

ator

y an

d C

onfir

mat

ory

Fact

ors

Anal

ysis

.Pa

rent

Beh

avio

r In

vent

ory

(PBI

)Lo

vejo

y et

al.,

19

99 (4

6) H

ostil

e/co

erci

ve p

aren

ting,

Sup

porti

ve/e

ngag

ed

pare

ntin

g.Ba

sed

on li

tera

ture

revi

ew

and

item

s w

ere

deriv

ed

from

exi

stin

g se

lf-re

port

and

obse

rvat

iona

l mea

sure

s of

pa

rent

ing

beha

viou

r.

- Pr

inci

pal C

ompo

nent

An

alys

is w

ith o

bliq

ue

rota

tion.

-

Con

firm

ator

y Fa

ctor

An

alys

is.

Pare

nt P

ract

ices

Sc

ale

(PPS

)St

rayh

orn

and

Wei

dman

, 198

8 (4

7)

No

dom

ains

. De

velo

ped

thro

ugh

clin

ical

ex

perie

nce

and

prev

ious

em

piric

al d

ata.

Not

repo

rted.

Tabl

e 3.

Con

tinue

d



45

2

Pare

nt S

ucce

ss

Indi

cato

r(P

SI, 1

)

Col

linsw

orth

et

al.,

1996

(48)

Com

mun

icat

ion,

Tim

e, S

atis

fact

ion,

Tea

chin

g,

Frus

tratio

n, In

form

atio

n ne

eds.

Base

d on

the

findi

ngs

of

a br

oad

base

d op

en-e

nd

surv

ey a

dmin

iste

red

by 2

893

subj

ects

.

- Pr

inci

pal C

ompo

nent

An

alys

is w

ith v

arim

ax

rota

tion.

Pare

ntal

Aut

horit

y Q

uest

ionn

aire

(PAQ

)Bu

ri, 1

991

(49)

Perm

issi

vene

ss, A

utho

ritar

iani

sm, A

utho

ritat

iven

ess.

Base

d on

Bau

mrin

d’s

Theo

ry

of A

utho

ritat

ive

Pare

ntin

g an

d a

n ex

pert

pane

l of

prof

essi

onal

s in

psy

chol

ogy,

educ

atio

n an

d so

ciol

ogy.

- Pr

inci

pal C

ompo

nent

An

alys

is w

ith v

arim

ax

rota

tion.

Pare

ntal

Em

otio

nal

Dist

ance

and

In

volv

emen

t Sca

les

(PED

IS)

Kiris

ci e

t al.,

20

01 (5

0)2

scal

es: E

mot

iona

l dis

tanc

e sc

ale,

Par

enta

l in

volv

emen

t sca

le.

No

dom

ains

.

Deriv

ed fr

om it

ems

from

the

Pare

ntal

Beh

avio

r Inv

ento

ry

and

Area

s of

Cha

nge

Que

stio

nnai

re.

- C

onfir

mat

ory

Fact

or

Anal

ysis

(to

test

for t

he

scal

es’ u

nidi

men

sion

ality

).

Pare

ntin

g Sc

ale

(PS)

Arno

ld e

t al.,

19

93 (5

1)La

xnes

s, O

verre

activ

ity, V

erbo

sity

.Ba

sed

on li

tera

ture

and

re

view

of t

rans

crip

ts o

f pa

rent

s di

scus

sing

dis

cipl

ine

prac

tices

.

- Pr

inci

pal C

ompo

nent

Fac

tor

Anal

ysis

with

var

imax

ro

tatio

n.

Pare

ntin

g St

ress

In

dex

(PSI

, 2)

Abid

in, 1

995

(52)

Dim

ensi

ons

Pare

nt D

omai

n: D

epre

ssio

n, A

ttach

men

t, Ro

le re

stric

tion,

Sen

se o

f com

pete

nce,

Soc

ial

isol

atio

n, R

elat

ions

hip

with

spo

use,

Par

enta

l hea

lth.

Dim

ensi

ons

Chi

ld D

omai

n: A

dapt

abilit

y, Ac

cept

abilit

y, De

man

ding

ness

, Moo

d, D

istra

ctab

ility/

hype

ract

ivity

, Re

info

rces

par

ent.

PSI-S

F; P

aren

tal d

istre

ss, P

aren

t–ch

ild d

ysfu

nctio

nal

inte

ract

ion,

Diffi

cult

child

.

Base

d on

a th

eore

tical

m

odel

of t

he d

eter

min

ants

of

dys

func

tiona

l par

entin

g (5

2), l

itera

ture

revi

ew, c

linic

al

expe

rienc

e an

d an

exp

ert

pane

l.

PSI-S

F:

- Ex

plor

ator

y &

Con

firm

ator

y Fa

ctor

Ana

lysi

s.

Secu

rity

in th

e Fa

mily

Sy

stem

sc

ales

(SIF

S)

Form

an a

nd

Davi

es, 2

005

(53)

Preo

ccup

atio

n, S

ecur

ity, D

isen

gage

men

t.De

velo

pmen

t was

gui

ded

by th

e em

otio

nal s

ecur

ity

hypo

thes

is (9

7) a

nd

Atta

chm

ent T

heor

y (9

8).

- Ex

plor

ator

y Fa

ctor

Ana

lysi

s w

ith o

bliq

ue ro

tatio

n.-

Con

firm

ator

y Fa

ctor

An

alys

is.

R1R2R3R4R5R6R7R8R9


Chapter 2

46

discussion

This systematic review describes 29 self-report psychometric measures of family functioning and family relationships that might be suitable for use in oral health research with the aim of exploring the role of emotional family factors in the prediction of childhood dental caries.

Many theoretical models of childhood dental caries have incorporated family functioning as an important factor that exerts a (theoretical) influence on the development of child oral health and the adoption of associated preventative oral health behaviours (4, 99). However, the influence of family relationships on childhood dental caries have been least explored in dental studies. The role of the family has more often been considered from a behavioural, cognitive and, to a lesser extent, a psychosocial perspective in relation to e.g. parental oral health practices, parental knowledge and attitudes and parental social status, rather than from the quality of family relations. Other studies which have explored family factors have shown that family structure and household composition are significantly related to childhood dental caries (100), but again focus is not on the emotional side of family functioning, i.e. quality of relations with family members.

Yet, these studies provide evidence to suggest that additionally, the emotional aspects of the family environment, including broader family behaviours and family functioning/climate, are important factors that may add further explanation to the development of childhood dental caries. There are several theoretical mechanisms by which the quality of parent-child, partner-partner and sibling-sibling relations may contribute to child oral health. For example, positive family interactions may directly promote the adoption of dentally healthy behaviours through the provision of a supportive and organized family environment in which roles and family tasks are well-defined and daily routines are managed. The emotional quality of family relations, such as cohesion, affective expression and bonding between family members, may indirectly affect oral health behaviours through mediating/moderating emotional influence on parental discipline practices and behavioural expectations. The strong link between family functioning and a child’s general health, in particular childhood obesity that shares common risk factors with other non-communicable diseases such as dental caries (16, 18, 101), further supports the plausibility of a relation between family functioning/relationships and childhood dental caries. The existing body of literature and the remaining gaps in understanding the influences of emotional family factors on children’s oral health therefore indicates a relevant area for future oral health research.

Using reliable and accurate assessment tools to measure family functioning is essential for generating valuable data in childhood dental caries research. This study identified and evaluated 29 self-report measures of family functioning that are available to oral health researchers who wish to explore emotional family factors in relation to childhood dental caries. While the majority of the measures demonstrate adequate levels of internal consistency and



47

2

provide some form of evidence of construct validity and most derive strength from their basis in theoretical models, literature review and/or empirical studies with families, it is not clear which would be most useful in oral health research.

Therefore, in addition to evaluating the psychometric properties of a measure, the rationale for selecting an appropriate assessment tool for oral health research requires a conception of the domains of family functioning that may be relevant for further exploration of the determinants of childhood dental caries. The domain evaluation of the family functioning measures revealed five most commonly used domains; ‘communication’, ‘cohesion/engagement’, ‘control’, ‘involvement’ and ‘authoritative/rigid parenting style’, suggesting that these are the core dimensions that would be useful when measuring family relationships. However, between all 54 identified domains of family functioning there is considerable overlap in the constructs measured, for example, the domains ‘cohesion’ and ‘involvement’ share overlap with ‘closeness’ and ‘attachment’, and the domain ‘control’ shares similarities with ‘boundaries/limit setting’ and ‘discipline’.

There is evidence from oral health literature to suggest that the domains ‘control’ and ‘parenting style/parenting practices’ are domains that may be related to childhood dental caries. For example, parents’ oral-health-related locus of control and self-efficacy (forms of an individual’s perceived ability to control behaviours) and parental indulgent/permissive behaviours towards tooth brushing and sugar-snacking are both strong predictors of childhood dental caries (8, 11, 102). Another study has shown that the level of routines and flexibility of people’s daily activities influences tooth brushing behaviour (103), indicating the potential importance of the family functioning domains ‘organization’, ‘structure’ and ‘routines’ in child oral health. Studies using the Parenting Stress Index (PSI) have demonstrated that the domain ‘total parenting stress’ was associated with higher levels of dental caries in children (13, 104, 105). However, the majority of the identified family functioning domains are emotional factors that focus on interpersonal interactions within the family, such as ‘cohesion/engagement’, ‘involvement’, ‘communication’, and also less common domains such as ‘conflict’ and ‘affect’.

Due to the paucity of previous research into the role of these emotional family factors in childhood dental caries, there is a limited evidence base from which to define whether these domains of family functioning are relevant for oral health research. Yet, studies on childhood obesity indicated that several emotional family factors were associated with healthy dietary behaviours in youth, such as higher fruit and vegetable intake, lower caloric intake, lower intake of sugar-sweetened beverages and higher frequency of eating breakfast (18, 106, 107). These emotional family factors particularly included warmth of family interactions, such as family cohesion, emotional bonding and nurturance, and authoritative parenting style, which is classified as high displays of emotional warmth and involvement, as well as moderate displays of parental discipline and control. The evidence from oral health and

R1R2R3R4R5R6R7R8R9


Chapter 2

48

obesity literature provides a conception of family functioning domains that may also be relevant in the development of childhood dental caries. Therefore, the authors recommend that research into the role of family relationships in childhood dental caries should commence with exploring this association in empirical studies, preferably using measures that cover domains of family warmth and involvement, authoritative/rigid parenting style, control/discipline, organization, flexibility and communication. Examples of psychometrically sound measures that include these domains and may therefore be useful for oral health research are; the Family Adaptability and Cohesion Evaluation Scale (25), the Family Assessment Device (27), the Family Assessment Measure III (28), the Alabama Parenting Questionnaire (39) and the Parental Authority Questionnaire (49).

There are however a few methodological issues with regard to the development of the family functioning measures that should be acknowledged when selecting a measure of family functioning. Most of the family functioning measures have been developed in a clinical or therapeutic context, designed to discriminate between ‘normal’ families and families with dysfunctional or clinical behaviours. However, in oral health research, the majority of the children with dental caries may come from normative families that do not necessarily have clinical or behavioural problems. Therefore, research into the relationship between family functioning and preventative oral health behaviours requires measures that are sensitive to distinguish between different levels of normal/reasonable family functioning within normative families. Also, due to their development in clinical or therapeutic settings, the measures that are designed to identify family dysfunction may have included intrusive items (e.g. items asking about use of punitive punishment), therefore parents may be more resistant to fully complete the measure when these are used for oral health research purposes in community or dental settings. These issues advocate for the development of a new or revised measure of family relationships that is more suitable for studying preventative oral health behaviours in oral health research.

In conclusion, research exploring how family relationships may mediate or moderate the development of childhood dental caries requires the use of reliable, valid and appropriate measures. In order to help oral health researchers in the selection process, this systematic review evaluated 29 measures of family functioning in terms of their psychometric support and the constructs measured. The identification and evaluation of the most relevant domains of family functioning provide guidance in determining the constructs that may be relevant for oral health research, either for the selection of a pre-existing measure of family functioning or for guiding the early-stage scale development of a new family functioning measure suitable for oral health research. The exploration of family relationships in relation to child oral health could contribute to the understanding of the underlying determinants of childhood dental caries that may have the potential to translate into effective theory-driven oral health promotion interventions.



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acknowledgements

Denise Duijster thanks Menzis Health Insurer, The Netherlands for support towards her doctoral research.

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3 the role oF FamIly FunctIonInG In

chIldhood dental carIes

Denise Duijster Erik Verrips

Cor van Loveren

Published in Community Dentistry and Oral Epidemiology 2014;42:193–205.

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abstract

This study investigated the relationship between family functioning and childhood dental caries. Further objectives were (i) to explore whether oral hygiene behaviours could account for a possible association between family functioning dimensions and childhood dental caries and (ii) to explore whether family functioning could mediate the relationship between sociodemographic factors and childhood dental caries. A random sample of 630 5- to 6-year-old children was recruited from six large paediatric dental centers in The Netherlands. Children’s dmft scores were extracted from personal dental records. A parental questionnaire and the Gezinsvragenlijst (translation: Family Questionnaire) were used to collect data on sociodemographic characteristics, oral hygiene behaviours and family functioning. Family functioning was assessed on five dimensions: responsiveness, communication, organization, partner-relation and social network. Associations with dmft were analysed using multilevel modeling. Bivariate analysis showed that children from normal functioning families on the dimensions responsiveness, communication, organization and social network had significantly lower dmft scores compared to children from dysfunctional families. Poorer family functioning on all dimensions was associated with an increased likelihood of engaging in less favourable oral hygiene behaviours. Children with lower educated mothers, immigrant children and children of higher birth order were more likely to come from poorer functioning families. In multivariate analysis, organization remained a significant predictor of dmft after adjusting for the other family functioning dimensions and the mother’s education level, but it lost statistical significance after adjustment for oral hygiene behaviours. In conclusion, a relationship between family functioning and childhood dental caries was found, which may have operated via oral hygiene behaviours. Family functioning modestly explained socioeconomic inequalities in child oral health. Organization appeared to be the most important dimension of family functioning that influenced children’s caries experience.


Family Functioning And Dental Caries

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introduction

Over the past few decades marked improvements in children’s oral health have been observed in Western countries. Widening social inequalities in child oral health however exist: children from lower socioeconomic position, deprived regions and certain minority ethnic groups are experiencing disproportionately higher levels of oral disease (1-4). Key risk behaviours, including less than twice daily tooth brushing and sugar-snacking between meals, explain a part of the socioeconomic disparities in child oral health as, like oral health, oral health-related behaviours are socially patterned (4-6). Moreover, there is increasing acknowledgement that individual behaviours are shaped by broader psychosocial, economic and environmental conditions, which implies that the determinants of oral health inequalities are more complex than explained by direct proximal behaviours (7-12). Therefore, the development of oral health promotion efforts to reduce inequalities in child oral health requires a better understanding of the intermediary mechanisms that account for the strong socioeconomic gradient in child oral health.

A factor that may mediate the relationship between social conditions, oral health behaviours and child oral health is the family environment. It is widely acknowledged that parents play a pivotal role in the establishment of oral health promoting behaviours that prevent against the development of childhood dental caries (13). Parents’ own dental behaviours and their oral health-related attitudes, including parental self-efficacy and locus of control, impact on how parents care for the dental health of their child (14-18). Parental psychosocial factors that have been demonstrated to negatively affect child oral health include maternal depression, low sense of coherence, indulgent parenting and parental stress (19-24). The structure of the family is also associated with children’s dental health. Higher levels of caries were found in children from single-parent families, larger households and children of higher birth order (13, 25).

In summary, the current literature clearly points to the important role of family factors in the development of childhood dental caries. Yet, the majority of studies that investigated family factors in oral health research have focussed on parental characteristics, including parental cognitions, attitudes and, to a lesser extent, psychosocial attributes. Studies linking the broader family environment and family functioning to child oral health are however sparse. Family functioning refers to the evaluation of interactions between family members at a systemic level such as parent-child, partner-partner and sibling-sibling relationships, and how these relationships interact with one another to influence overall family functioning (26, 27). The dimensions that capture the most elemental components of family functioning include communication, organization, control, cohesion/engagement, involvement, conflict and task accomplishment (28, 29).

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Family functioning is known to be associated with various components of child development and physical and mental health outcomes, including childhood obesity (30-33). There are several plausible mechanisms by which family functioning could also affect child oral health. For example, a positive family environment could promote the adoption and maintenance of dentally healthy behaviours through the provision of a supportive, flexible and organized family environment where roles and boundaries are well-defined. Indirectly, the emotional quality of family relationships, such as the involvement and affective interaction between family members, could influence parents’ behavioural expectations and discipline practices, such as whether they are permissive or demanding towards their child’s behaviours (28). Since few studies have investigated these relationships empirically, the aim of this study was to evaluate the association between family functioning dimensions and childhood dental caries in a sample of five to six-year-old children in The Netherlands. Further objectives were (i) to explore whether oral hygiene behaviours could account for a possible association between family functioning dimensions and childhood dental caries and (ii) to explore whether family functioning could mediate the relationship between sociodemographic factors and childhood dental caries.


Data were collected between June 2011 and March 2012. The Medical Ethical Committee of the Vrije Universiteit Amsterdam declared that, according to the WMO (Dutch law for medical research involving human subjects), ethical approval for this study was not needed.

Study sampleThe children in the study were recruited from six large paediatric dental centers located in Enschede, Utrecht, Den Haag, Rijswijk, Zoetermeer and Nijmegen. The centers have a large and diverse patient population, as they work in partnership with elementary schools where they provide dental services in mobile units or they collect children from schools for treatment at the centre. Of the eleven centers in The Netherlands, six centers that varied greatly in terms of socioeconomic location and the proportion of immigrant children in their catchment area were selected for the conduction of the study. A power calculation indicated that a sample of 594 children would be necessary to explore the association between children’s dmft-scores and the independent variables. This calculation used the following parameters: 80% of power, 5% level of significance, a standard deviation of 4.1 dmft based on caries levels in 5-year-old children in the 2006 Dutch National Oral Health Survey (34), a difference of 1 dmft to be detected, 15% excess due to multivariate analysis and 10% excess to allow for missing data. From each of the paediatric dental centers 200 children were selected using simple random sampling. Five-year-old children were included who had had their latest



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dental visit within six months before the time of selection. Children raised at boarding schools and those attending schools for children with special educational needs were excluded from the sample selection. In cases of twins, only one child was selected.

Data collectionAn informative letter about the study and a questionnaire was mailed to the home address of the children. Parents were asked to complete the questionnaire and to provide written consent to use their child’s clinical dental health records from the paediatric dental centers. To increase the response, a prepaid return envelope was attached and participants received a monetary incentive (10 euros). Non-respondents were first sent a reminder by mail after three weeks, followed by a reminder by telephone after a further three weeks. Non-participating parents were asked to answer two questions by telephone concerning the highest completed level of education of the child’s mother and her country of birth.

Dental health dataChildren’s dental health data were obtained from personal dental health records from the paediatric dental centers. Each of the dental centers had their own systematic way of registering data to ensure that the records were up-to-date and complete. The dental status of the primary dentition of the participating children was extracted from the dental health records, using data from the latest dental visit. The dmft score was calculated by adding the number of decayed, missing and filled teeth. Missing teeth were only scored if records indicated they were extracted due to caries. Missing teeth due to dental trauma, hypomineralization, agenesis or routine exfoliation were not included in the dmft scores. Enamel caries lesions were also not included.

Self-reported dataA self-administered parental questionnaire was used to collect sociodemographic, psychosocial and behavioural data. The estimated time to complete the questionnaire was twenty to thirty minutes. Sociodemographic variables included the child’s age, sex and ethnicity, the mother’s highest completed level of education and family structure. The mother’s education level was categorized into (i) lower education (no education, elementary school and secondary school - lower level), (ii) medium education (secondary school - higher level and further education - lower level) and (iii) higher education (further education - higher level and university). Lower education, medium education and higher education equals 0–12 years of education, 13–15 years of education and 16 or more years of education, respectively. The ethnicity variable classified children as (i) native if the mother of the child was born in The Netherlands, or (ii) immigrant if the mother was a ‘first-generation’ immigrant from any other country. Family structure was assessed by two variables describing the birth order of

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the child and whether the parent raised their child alone or with a partner. The oral hygiene behaviours studied were tooth brushing frequency, the age tooth

brushing was started, supervised tooth brushing and re-brushing by a parent. Parents who reported that they always brushed their child’s teeth for them were grouped in the categories ‘always supervising brushing’ and ‘always re-brushing their child’s teeth’. The behavioural items were selected from a questionnaire developed by Pine et al. (35).

The psychosocial variable family functioning was assessed by the Gezinsvragenlijst (GVL, translation; Family Questionnaire) (36). The GVL is a validated psychometric measure to assess the quality of family relationships and parental support of children aged between 4 and 18 years. It assesses family functioning on five dimensions; responsiveness, communication, organization, partner-relation and social network. Responsiveness reflects the extent to which parents respond to the developmental emotional, cognitive and social needs of their child. Communication refers to interaction between the parent and the child with respect to trust and empathy, conflict, openness of communication and parents’ behavioural control. Organization refers to the degree of structure, routines and assignment of roles in the family, as well as the family’s ability to resolve problems. Partner-relation is defined as the quality of the relationship between parents or caregivers. Social network relates to the extent to which the family can rely on support from people in their social environment, such as friends, family and neighbours. The measure is designed to be completed by a parent or caregiver. It consists of 45 items (9 items per subscale), each of which is responded to on a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. Single parents did not complete the 9 items on partner-relation. Responses to the 9 items per subscale were summed, generating scores ranging from 9 to 45, with higher scores indicating poorer functioning. For each of the subscales, ‘functional-dysfunctional’ cut-off scores were determined by the original authors based on normative data, categorizing the subscales into normal, subclinical and clinical functioning. Cut-off values for responsiveness, communication, organization, partner-relation and social network were ≥ 16, 22, 18, 18 and 22 for subclinical functioning respectively, and ≥ 19, 26, 21, 22 and 25 for clinical functioning respectively. Psychometric studies, using a large representative sample of the Dutch population, demonstrated that the GVL is internally consistent with alphas ranging from 0.83 to 0.95 and reliable over a period of 3–4 week (36). The GVL successfully discriminated between families with and without children with socio-emotional behavioural problems and tests for concurrent validity yielded moderate to strong correlations between GVL subscales and subscales of a measure of similar constructs. Cronbach’s alphas for the GVL in this study ranged from 0.78 to 0.89 and intercorrelations between subscales ranged from 0.38 and 0.74, which were similar to those observed by the original authors.

The items developed by Pine et al. were translated into Dutch and back-translated (35). The entire questionnaire was pilot-tested. A translated Arabic and Turkish version



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of the questionnaire was sent to children with an Arabic/Moroccan and Turkish surname, respectively.

Statistical analysisBivariate associations between family functioning dimensions and dmft, oral hygiene behaviours and sociodemographic characteristics were assessed using the Kruskal-Wallis test and the Mantel Haenzel χ²-test for trend. The family functioning dimensions were analysed as categorical variables (normal, subclinical and clinical functioning).

A series of multilevel models were conducted for dmft that were alternatively adjusted for family functioning dimensions, oral hygiene behaviours and sociodemographic characteristics. Because individuals (first level) were nested in paediatric dental centers (second level), multilevel modeling was used to control for the possible effect of clustered differences within the sample. A first model included only the family functioning dimensions that were significantly associated with dmft in the bivariate analysis. The first model was subsequently extended 1) by adding oral hygiene behaviours (model 2), to explore whether oral hygiene behaviours account for a relationship between family functioning and childhood dental caries, and 2) by adding the mother’s education level (model 3), to explore whether family functioning accounts for a relationship between the mother’s education level and childhood dental caries. The final model (model 4) included family functioning dimensions, oral hygiene behaviours and all sociodemographic characteristics. All entered variables were categorical variables of which the reference category consisted of the category with the largest number of children. The intraclass correlation coefficient (ICC) was calculated to indicate the percentage in dmft that is due to differences between paediatric dental centers. The remaining proportion is between-individual variation. A P-value of ≤0.05 was regarded as statistically significant.

Missing values for variables resulted in data for different numbers of participants being analysed for different variables. In case of one missing item per family functioning subscale, the mean value of the 8 completed items was calculated and added to the sum of the 8 items. results

Of the 1200 randomly selected children, 1169 were successfully contacted. Of those, 630 children participated in the study (response rate = 53.9%). The mother’s education level and the proportion of mothers from Dutch origin were significantly higher in the participant group compared to the non-participant group. Seventy-nine percent of the questionnaires was completed by the mother, 18.4% by the father and 2.3% by another caregiver, mainly a foster parent or a stepparent. For 97% of the children, the time between the completion of the questionnaire and the latest dental visit from which dental health data were extracted

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was less than 6 months (maximum of 10 months). There were missing data for some of the items in the questionnaire, with a maximum of 3.2% missing data for the ‘age brushing was started’.

Descriptive analysisThe distribution of sample characteristics is presented in Table 1. Children were aged between 5 years and 1 month and 6 years and 8 months, and 51.6% of them were males. A large proportion of children were immigrants (44.2%). Common ethnicities were Moroccan (n = 61, 9.8%), Turkish (n = 59, 9.5%) and Surinamese (n = 32, 5.2%). The majority of parents reported favourable oral hygiene behaviours, for example, 83.4% of parents indicated that their child’s teeth were brushed twice or more often per day. Yet, there were marked differences in dental decay experience among the children studied. Three-hundred and thirty three children (51.9%) were caries free. The mean dmft of all children was 2.2 ± 3.1 (range 0-14) and the mean dmft of children with dental caries was 4.7 ± 3.1. There was considerable variation in children’s dental caries status among the six dental centers, with the mean dmft ranging from 1.3 ± 2.5 in Zoetermeer to 4.4 ± 4.1 in Den Haag.



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Table 1. Description of sociodemographic characteristics, dental health data and oral hygiene behaviours.Variables n (%) mean ± SD (range)SociodemographicsLocation of dental clinic

Enschede 105 (17)Utrecht 100 (16)Den Haag 83 (13)Rijswijk 108 (17)Zoetermeer 111 (18)Nijmegen 123 (20)

Age (years) 6.0 ± 0.3 (5.1-6.7)Sex

Girl 305 (48)Boy 325 (52)

Education level (mother)Higher education 236 (39)Medium education 222(36)Lower education 155 (25)

Ethnicity Native 346 (56)Immigrant 274 (44)

Relationship status caregiverWith partner 526 (85)Single 94 (15)

Birth order of the child1st child 243 (40)2nd child 242 (40)3rd child 97 (16)≥ 4th child 31 (5)

Child dental health status Dmft 2.2 ± 3.1 (0-14)Oral hygiene behavioursBrushing frequency

Twice or more per day 522 (83)Once or less per day 104 (17)

Age brushing was startedLess than one-year old 339 (56)1-2 years old 199 (33)2-3 years old 55 (9)3 years or older 13 (2)

Supervised brushingAlways (or only the parent brushes) 457 (73)Often 131 (21)Occasionally / never 42 (7)

Re-brushingAlways (or only the parent brushes) 309 (49)Often 132 (21)Occasionally 150 (24)Never 39 (6)

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Bivariate analysisThe majority of children (71.1% to 79.6%) were from families that functioned normally on the family functioning dimensions. Children from families with normal scores for responsiveness, communication, organization and social network had significantly less dental caries than children from families with subclinical and/or clinical scores (Table 2). No relationship was found for the quality of the partner relationship with children’s dental caries status.

Table 2. Distribution of mean dmft by family functioning.

Subscalen (%)

Subscale scoremean ± SD

Caries free (%)

dmftmean (95% CI) P-value*

ResponsivenessNormal 488 (79.6) 11.1 ± 1.9 57 1.9 (1.7 - 2.2) <0.001Subclinical 91 (14.8) 16.9 ± 0.8 46 2.9 (2.1 - 3.6)Clinical 34 (5,6) 21.2 ± 3.2 29 3.9 (2.5 - 5.4)

CommunicationNormal 467 (76.2) 15.8 ± 3.5 55 2.0 (1.7 - 2.2) 0.05Subclinical 107 (17.5) 23.4 ± 1.1 49 2.6 (2.0 - 3.3)Clinical 39 (6.3) 28.5 ± 3.1 46 3.6 (2.2 - 5.1)

OrganizationNormal 434 (71.1) 13.3 ± 2.6 55 1.9 (1.6 - 2.2) <0.001Subclinical 134 (22.0) 18.8 ± 0.8 55 2.3 (1.8 - 2.9)Clinical 42 (6.9) 23.0 ± 3.3 31 4.2 (3.0 - 5.5)

Partner-relationNormal 380 (72,2) 12.3 ± 2.6 57 1.9 (1.6 - 2.2) 0.50Subclinical 102 (19.4) 19.1 ± 1.1 54 2.3 (1.7 - 3.0)Clinical 44 (8.4) 25.0 ± 3.4 50 2.5 (1.4 - 3.6)

Social networkNormal 461 (75.2) 14.3 ± 3.5 56 1.9 (1.7 - 2.2) 0.02Subclinical 80 (13.1) 22.2 ± 1.1 48 2.9 (2.2 - 3.7)Clinical 72 (11.7) 29.2 ± 4.2 44 2.9 (2.0 - 3.7)

*Kruskal-Wallis Test



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All family functioning dimensions were significantly associated with several oral hygiene behaviours (Table 3). Children from normal functioning families were more likely to start brushing at a younger age compared to children with subclinical and/or clinical family functioning. The parents of children in normal functioning families were also more likely to brush their child’s teeth for them, or to supervise the brushing while the child brushed by themself and/or re-brush the child’s teeth. The proportion of children who brushed their teeth twice or more per day was significantly higher in children from well-organized families. Results of the Mantel Haenzel χ²-test indicate that the abovementioned associations followed a trend, suggesting that deteriorating family functioning was associated with an increased likelihood of engaging in less favourable oral hygiene behaviours.

The family functioning dimensions were significantly related to the educational level of the child’s mother (except for partner-relation), the child’s ethnicity and the birth order of the child (Table 4). Children with lower-educated mothers, immigrant children and children of higher birth order had an increased likelihood of being from a poorer functioning family. Family functioning did not significantly differ between single parents and those who raised their child with a partner.

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Table 3. Distribution (%) of oral hygiene behaviours by family functioning.Brushing frequency Age brushing was started

≥ 2 timesa day (%)

≤ 1 timesa day (%) P-value

<1 years old (%)

1-2 years old (%)

2-3 years old (%)

≥ 3 years old (%) P-value

Responsiveness

Normal 84 16 60 32 7 2

Subclinical 82 18 39 40 17 3

Clinical 74 27 0.13 37 37 20 7 <0.001*

Communication

Normal 85 16 59 32 8 1

Subclinical 80 20 50 35 11 5

Clinical 79 21 0.20 32 44 21 3 <0.001*

Organization

Normal 87 14 61 31 7 1

Subclinical 80 20 44 42 12 2

Clinical 64 36 <0.001 49 21 21 10 <0.001*

Partner-relation

Normal 84 16 59 33 7 2

Subclinical 80 20 46 35 16 3

Clinical 79 21 0.34 56 27 15 2 0.02*

Social network

Normal 85 15 60 32 7 1

Subclinical 84 17 53 28 13 6

Clinical 76 24 0.10 32 46 19 3 <0.001

Mantel Haenzel χ²-test for trend* >20% of cells have expected count less than 5.



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Table 3. Distribution (%) of oral hygiene behaviours by family functioning.Brushing frequency Age brushing was started

≥ 2 timesa day (%)

≤ 1 timesa day (%) P-value

<1 years old (%)

1-2 years old (%)

2-3 years old (%)

≥ 3 years old (%) P-value

Responsiveness

Normal 84 16 60 32 7 2

Subclinical 82 18 39 40 17 3

Clinical 74 27 0.13 37 37 20 7 <0.001*

Communication

Normal 85 16 59 32 8 1

Subclinical 80 20 50 35 11 5

Clinical 79 21 0.20 32 44 21 3 <0.001*

Organization

Normal 87 14 61 31 7 1

Subclinical 80 20 44 42 12 2

Clinical 64 36 <0.001 49 21 21 10 <0.001*

Partner-relation

Normal 84 16 59 33 7 2

Subclinical 80 20 46 35 16 3

Clinical 79 21 0.34 56 27 15 2 0.02*

Social network

Normal 85 15 60 32 7 1

Subclinical 84 17 53 28 13 6

Clinical 76 24 0.10 32 46 19 3 <0.001

Mantel Haenzel χ²-test for trend* >20% of cells have expected count less than 5.

Supervised brushing Re-brushing

Always/ parent (%)

Often (%)

Occasionally /Never (%) P-value

Always/ parent (%) Often (%) Occasionally (%)

Never (%) P-value

76 19 5 53 20 23 6

62 28 11 32 30 32 7

41 38 21 <0.001 35 21 27 18 <0.001

77 18 5 53 20 22 5

59 31 10 36 23 31 10

51 33 15 <0.001 31 28 31 10 <0.001

76 19 5 52 21 22 6

66 26 8 43 23 26 8

52 26 21 <0.001 29 19 43 10 <0.001

76 19 6 52 21 21 6

62 24 15 40 25 28 7

61 32 7 <0.01 34 21 36 9 <0.01

76 19 5 52 21 22 5

61 28 11 35 21 33 11

58 29 13 <0.001 39 21 28 13 <0.001

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Table 4. Distribution (%) of participants with normal, subclinical and clinical family functioning by sociodemographic characteristics.

Responsiveness CommunicationN(%) S(%) C(%) P-value N(%) S(%) C(%) P-value

Education levelHigher education 86 11 3 84 13 3Medium education 80 16 5 74 20 6Lower education 70 19 11 <0.001 69 20 11 <0.001

Ethnicity (mother)Native 90 8 2 84 13 3Immigrant 66 24 10 <0.001 66 24 11 <0.001

Relationship status caregiverWith partner 80 15 5 77 16 7Single 80 13 7 0.84 71 25 5 0.50

Birth order of the child1st child 86 10 4 82 12 62nd child 77 17 6 75 20 53rd child 78 16 6 71 22 7≥ 4th child 57 30 13 <0.01 71 19 10 0.04

Mantel Haenzel χ²-test for trend



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Table 4. Distribution (%) of participants with normal, subclinical and clinical family functioning by sociodemographic characteristics.

Responsiveness CommunicationN(%) S(%) C(%) P-value N(%) S(%) C(%) P-value

Education levelHigher education 86 11 3 84 13 3Medium education 80 16 5 74 20 6Lower education 70 19 11 <0.001 69 20 11 <0.001

Ethnicity (mother)Native 90 8 2 84 13 3Immigrant 66 24 10 <0.001 66 24 11 <0.001

Relationship status caregiverWith partner 80 15 5 77 16 7Single 80 13 7 0.84 71 25 5 0.50

Birth order of the child1st child 86 10 4 82 12 62nd child 77 17 6 75 20 53rd child 78 16 6 71 22 7≥ 4th child 57 30 13 <0.01 71 19 10 0.04

Mantel Haenzel χ²-test for trend

Organization Partner-relation Social networkN(%) S(%) C(%) P-value N(%) S(%) C(%) P-value N(%) S(%) C(%) P-value

75 22 3 77 14 9 80 9 1170 22 8 76 17 7 78 13 966 22 12 0.01 62 30 .8 0.08 62 19 19 <0.01

80 17 3 79 14 7 89 8 360 29 12 <0.001 63 27 10 <0.01 57 19 23 <0.001

70 23 7 N/A N/A N/A 76 14 1176 16 8 0.48 N/A N/A N/A N/A 74 10 16 0.43

75 19 6 79 13 9 80 12 870 25 6 70 24 7 72 14 1466 21 13 66 24 10 74 12 1367 23 10 0.04 64 27 9 0.06 67 13 20 0.02

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Multivariate analysisBivariate linear regression analysis showed that sociodemographic characteristics, oral hygiene behaviours and family functioning dimensions were significantly associated with dmft (Table 5).

In multilevel analysis, the association between organization and dmft remained statistically significant after adjusting for the other family functioning dimensions, while responsiveness, communication and social network did not (Table 5, model 1). Deteriorating organization was associated with 0.48 (0.01–0.95) increase in children’s dmft. After adjustment for oral hygiene behaviours, the association between organization and dmft lost its statistical significance (Table 5, model 2). Yet, organization remained significantly associated with dmft after adjusting for the mother’s education level, while the association between the mother’s education level and dmft slightly attenuated (from ß = 0.98 to ß = 0.85) (Table 5, model 3). In the final model, the mother’s education level, the age brushing was started and the child’s birth order remained significant predictors of dmft (Table 5, model 4). One level decrease in the mother’s education, one year increase in the age brushing was started and being of one child higher birth order was associated with 0.70 (0.37–1.03), 0.78 (0.42–1.14) and 0.35 (0.06–0.64) increase in dmft, respectively. All other variables lost their statistical significance in the final multivariate model. The random effects variance show that 7.3% to 7.8% of the variance in dmft occurred between dental centers and 92.3%–92.7% occurred at individual level. The model explained 16.1% of the variation in dmft.

Plotting the residuals of the models versus the predicted values showed that the assumptions of linearity and constant variance were not violated. However, the normal probability plot showed that the error distribution had moderate kurtosis, which may have caused a small underestimation of the statistical significance.



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Tabl

e 5.

Biv

aria

te lin

ear r

egre

ssio

n an

d m

ultil

evel

regr

essi

on o

f fam

ily fu

nctio

ning

, ora

l hyg

iene

beh

avio

urs a

nd so

ciod

emog

raph

ic c

hara

cter

istic

s on

mea

n dm

ft.

Una

djus

ted

Mod

el 1

Mod

el 2

Mod

el 3

Mod

el 4

Varia

bles

dmft

ß (9

5% C

I)dm

ft ß

(95%

CI)

dmft

ß (9

5% C

I)dm

ft ß

(95%

CI)

dmft

ß (9

5% C

I)Re

spon

sive

ness

1.00

(0

.56

- 1.4

7) **

*0.

37

(-0.2

0 - 0

.94)

0.28

(-0

.99

- 1.5

5)0.

27

(-0.3

0 - 0

.84)

0.2

0 (

-0.3

9 - 0

.79)

Com

mun

icat

ion

0.78

(0

.35

- 1.2

0) **

*0.

39

(-0.0

5 - 0

.83)

0.24

(-0

.34

- 0.8

2)0.

23

(-0.2

1 - 0

.67)

0.1

3 (

-0.3

5 - 0

.61)

Org

aniza

tion

0.87

(0

.48

- 1.2

9) **

*0.

48

(0.0

1 - 0

.95)

*0.

31

(-0.1

5 - 0

.77)

0.50

(0

.03

- 0.9

7) *

0.2

9 (

-0.2

0 - 0

.78)

Soci

al n

etw

ork

0.57

(0

.21

- 0.9

3) **

0.10

(-0

.28

- 0.4

8)-0

.11

(-0.

50 -

0.28

)0.

07

(-0.3

1 - 0

.45)

-0.1

6 (

-0.5

7 - 0

.25)

Brus

hing

freq

uenc

y0.

70

(0.0

4 - 1

.36)

*-0

.15

(-0.

83 -

0.53

) 0

.11

(-0

.58

- 0.8

0)Ag

e br

ushi

ng w

as s

tarte

d1.

26

(0.9

4 - 1

.58)

***

0.84

(0

.49

- 1.1

9) **

* 0

.78

(0.

42 -

1.14

) ***

Supe

rvis

ed b

rush

ing

0.94

(0

.53

- 1.3

4) **

*0.

39

(-0.0

7 - 0

.85)

0.2

2 (

-0.2

4 - 0

.68)

Re-b

rush

ing

0.41

(0

.16

- 0.6

6) **

0.04

(-0

.23

- 0.3

1) 0

.01

(-0

.27

- 0.2

9)Ed

ucat

ion

leve

l (m

othe

r)0.

98

(0.6

8 - 1

.29)

***

0.85

(0

.54

- 1.1

6) **

* 0

.70

(0.

37 -

1.03

) ***

Ethn

icity

(mot

her)

1.22

(0

.71

- 1.7

1) **

* 0

.17

(-0

.41

- 0.7

5)Re

latio

nshi

p st

atus

car

egiv

er1.

03

(0.3

3 - 1

.72)

**

0.3

9 (

-0.3

1 - 1

.09)

Birth

ord

er0.

55

(0.2

6 - 0

.84)

***

0.3

5 (

0.06

- 0.

64) *

Rand

om e

ffect

sIn

divi

dual

leve

l var

ianc

eN

/A8.

728.

388.

35 8

.05

Dent

al c

linic

leve

l var

ianc

eN

/A0.

740.

670.

61 0

.63

ICC

(%)

N/A

7.8

7.4

6.8

7.3

Mod

el 1

: Adj

uste

d fo

r fam

ily fu

nctio

ning

dim

ensi

ons.

Mod

el 2

: Mod

el 1

add

ition

ally

adj

uste

d fo

r ora

l hyg

iene

beh

avio

urs.

Mod

el 3

: Mod

el 1

add

ition

ally

ad

just

ed fo

r the

mot

her’s

edu

catio

n le

vel.

Mod

el 4

: Mod

el 1

add

ition

ally

adj

uste

d fo

r ora

l hyg

iene

beh

avio

urs

and

soci

odem

ogra

phic

cha

ract

eris

tics

(incl

udin

g th

e m

othe

r’s e

duca

tion

leve

l).

***P<

0.00

1, **

P<0.

01, *

P<0.

05.

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discussion

This study found a bivariate association between family functioning and childhood dental caries among 5- to 6-year-old children in The Netherlands. Children from poorer functioning families on the dimensions responsiveness, communication, organization and social network had higher levels of dental decay than children from normal functioning families. The same children were also more likely to engage in less favourable oral hygiene behaviours. After adjusting for oral hygiene behaviours, the relationship between family functioning and dental caries lost its statistical significance. These findings both support the postulated mechanism that the relationship between family functioning and childhood dental caries may operate via oral hygiene behaviours.

This study also explored whether family functioning could account for socioeconomic inequalities in childhood dental caries. The mother’s highest completed level of education was used as an indicator of socioeconomic position (4). A graded association between the mother’s education level and family functioning was found; children with a lower educated mother had an increased likelihood of being from a poorer functioning family. Since poorer functioning was in turn associated with higher levels of dental decay, it seems plausible that family functioning mediates the relationship between socioeconomic conditions and childhood dental caries. Furthermore, the association between family functioning and childhood dental caries remained significant after adjustment for the mother’s education level, while the relationship between the mother’s education level and childhood dental caries slightly attenuated. This implies that family functioning modestly explained socioeconomic inequalities in childhood dental caries.

Family organization appeared to be the most important dimension of family functioning that impacted on children’s caries experience. Aspects of organization included the establishment of routines, the assignment of roles, abiding to rules and the family’s ability to resolve problems. An explanation of how routines may affect child oral health is, for example, through moderating influence on oral hygiene behaviours, as these are behaviours that are habitually performed and built into daily activities. This was partially supported by Abegg et al. who showed that routines and flexibility of daily activities were associated with tooth-cleaning frequency in adults (37). It is also conceivable that when roles of family members are well-defined, shared family tasks, such as parental supervision during tooth brushing, are more likely to be performed on a regular basis. Family functioning in the dimension of efficient problem solving has been demonstrated to be a protective factor against severe periodontitis in adults (38). Yet, no studies have empirically investigated the relationship between the aforementioned aspects of family organization and childhood dental caries.

The dimensions responsiveness, communication and social network did not remain significantly associated with dental caries after adjustment for organization and for each



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other. Still, they were moderately correlated with organization (r = 0.56, r = 0.47 and r = 0.45, respectively), which indicates that poorly organized families were also more likely to function poorly on the other dimensions. This could mean that the bivariate associations between responsiveness, communication and social network with dmft were due to their correlation with organization, or that the several dimensions collectively affected children’s caries experience in dysfunctional families. For example, in some families with poor organization, it may have been that other factors, such as high levels of conflict and discord, poor affective and unresponsive relationships, low levels of behavioural control and weak social networks, simultaneously impacted on children’s oral health. The importance of good social networks and support for adolescents’ and adults’ oral health has already been demonstrated by several studies (39, 40). In contrast to the findings by Marcenes et al. (41), this study could not find an association between the quality of the partner-relation and children’s caries experience.

The findings of this study should be considered in the context of its methodological strengths and weaknesses. This study used a random sample of children from six large paediatric dental centers, including children from all socioeconomic groups and children with different ethnic backgrounds. Still, its generalizability is limited, because the non-response rate was relatively high and because children that don’t visit the dentist or children that go to a general dental practice were not included. Although a representative sample is preferred, this sample was adequate for testing the hypothesis of this study. A potential limitation of this study is that dental health data were collected from personal dental records, rather than obtained from clinical examinations by calibrated examiners. Yet, Hausen et al. (42) demonstrated that dental health data collected from personal records were not decisively inferior to those obtained by trained examiners. Another shortcoming is that this study did not address dietary factors. Data on dietary behaviours were however collected, such as the daily frequency of sugary intakes between meals, but they were not associated with dmft. This could be due to response bias or due to the poor discriminatory power of dietary behaviours, since there was little variation in reported levels of sugar consumption within the sample. Another potential reason could be that parents were not aware of all sugary intakes of their child between meals, as they are not always around their child. A limitation of oral hygiene behaviours is that children whose parents always brushed their teeth for them were assigned to the same category as children whose parents always supervised the brushing or re-brushed their child’s teeth. Categories were combined as both parental approaches likely resulted in similar oral hygiene outcomes; however, both approaches could have different implications for the development of self-directed oral hygiene behaviours of children over time. A strength of this study was the use of a valid and reliable instrument to measure family functioning. Nonetheless, there are a few challenges that arise when using self-report measures of family functioning. This includes the extent to which socially desirable answers

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could have interfered in the interpretation of the results. Another issue is that only one parent, often the mother, completed the questionnaire. Therefore, data on family functioning solely relied on the point of view of one individual family member, which may have yielded a distorted view of the family functioning as a whole. However, the inter-rater agreement between the father’s and mother’s reports on the GVL was explored by the original authors and they demonstrated reasonably high levels of agreement (36). A further issue is that most family functioning measures, including the GVL, were developed in a therapeutic setting, designed to discriminate between normal families and clinical families. However, dental caries was also prevalent among children from normative families that did not have clinical or dysfunctional problems. More sensitive measures of family functioning are needed in future research to explore whether differences in family functioning within normative families may also influence childhood dental caries, or whether family functioning only affects the oral health of children above a clinical threshold. Finally, this was a cross sectional study that cannot provide evidence on causal relationships and temporal precedence of variables. Since explanatory variables and childhood dental caries were measured at a single point in time, bi-directional effects may exist. Another issue is the measurement of time-varying variables at one point of time. Childhood dental caries is a multifactorial disease that develops by the interaction of variables over time. This study explored the role of family functioning in childhood dental caries as a static characteristic of the family. However, families are dynamic systems that undergo continual evolvement in structure and function. Transitions that occur in families, such as the aging of children and changes in family member composition, require families to adapt in order to maintain on-going functions. Also, stressful life events, such as separation, unemployment, chronic illness or depression, may affect the functioning of families. Therefore, family functioning at the time of measurement may not have been a representative reflection of the functioning of the family over the past years, which could impede the demonstration of an association between family functioning and childhood dental caries in cross sectional studies.

Internationally, it is well-established that the prevention of oral diseases should commence early in life when habitual health behaviours are initiated. There is growing recognition that strategies to promote oral health should be directed at changing both the broader structural determinants, as well as modifiable intermediary determinants of oral health inequalities (12, 43). In terms of the prevention of childhood dental caries, it is of particular importance that a supportive early life environment is created that promotes the adoption and maintenance of healthy behaviours. Findings of this study indicate that a potentially important variable to consider in caries preventive programs include components to improve family functioning. A review on child obesity indicated that the integration of family system components in obesity prevention programs, including parenting and family functioning variables, resulted in sustained health behaviour change and weight loss in obese children (44). Future studies



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should determine whether the development of horizontal programs directed at improving family functioning have the potential to effectively improve parents’ and children’s health behaviours that are relevant to both childhood dental caries and general health outcomes.

In conclusion, the present study found that family functioning, in particular family organization, was associated with childhood dental caries. This relationship may have operated via oral hygiene behaviours. Results modestly supported the hypothesis that family functioning explains socioeconomic inequalities in child oral health. Findings of this study suggest that family organization is a potentially important determinant of childhood dental caries that should be considered in the development of oral health promoting programs.

acknowledgements

This study was financially supported by Menzis Health Insurance, The Netherlands. We would like to thank the Jeugdtandverzorging Enschede, Utrecht, Den Haag, Zoetermeer and Nijmegen for their assistance.

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4 modellInG communIty, FamIly and IndIVIdual determInants oF chIldhood dental carIes

Denise Duijster Cor van Loveren Elise Dusseldorp

Erik Verrips

Published in European Journal of Oral Sciences 2014;122:125–33.

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abstract

This cross-sectional study empirically tested a theoretical model of pathways and interrelationships among community, family and individual determinants of childhood dental caries in a sample of 630 6-year old children from The Netherlands. Children’s decayed, missing and filled teeth (dmft) scores were extracted from dental records. A validated parental questionnaire was used to collect data on sociodemographic characteristics, psychosocial factors and oral hygiene behaviours. Data about neighbourhood quality was obtained from the Dutch Central Bureau of Statistics. Structural equation modelling indicated that the model was valid after applying a few modifications. In the revised model, lower maternal education level was related to poorer family organization, lower levels of social support, lower dental self-efficacy and an external dental health locus of control. These, in turn, were associated with poorer oral hygiene behaviours, which were linked to higher levels of childhood dental caries. In addition, lower maternal education level and poorer neighbourhood quality were directly associated with higher caries levels in children. This model advances our understanding of determinants of childhood dental caries and the pathways in which they operate. Conception of these pathways is essential for guiding the development of caries preventive programs for children. Clues for further development of the model are suggested.


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introduction

Historically, biological and behavioural risk factors have been the major focus of researchers exploring the causes of childhood dental caries. In recent years, empirical attention has shifted towards investigating the broader social context in which children’s oral health behaviours are shaped and biology is affected, known as the underlying social determinants of childhood dental caries (1, 2). To date, there is a substantial body of scientific literature to demonstrate that the social and economic conditions in which children are born, grow and live have a fundamental impact on their dental health status (3, 4). Evidence is also starting to emerge on the important role of parental and familial psychosocial factors in children’s caries experience, such as parents’ dental attitudes and beliefs and parental stress (5-7).

Most research into the determinants of childhood dental caries concentrated on predicting direct effects of single factors on children’s caries experience, often after controlling for other factors in multiple regression analysis (8). The problem with this approach is that the interplay among various socioeconomic, psychosocial, behavioural and biological factors is not explored. Nor does it clarify the operational pathways through which these factors collectively affect children’s caries levels. Yet, conception of these pathways is necessary for guiding public health policy and for providing direction for caries preventive interventions.

In recent years, several theoretical models have been developed that conceptualize the influences on various oral health outcomes (9-12). These models suggest a multilevel approach to investigating oral health, and describe interlinking causal pathways between a broad range of determinants, rather than direct causal pathways. Furthermore, a number of empirical studies have utilized structural equation modelling to model causal pathways between a range of social, psychological and (bio-) behavioural factors and their relationship with several oral health outcomes. Structural equation modelling is a statistical technique that permits simultaneous testing of interrelationships amongst a number of variables using sample data, thereby making this a useful technique for testing and modifying conceptual models.

A small number of these studies have empirically modelled the factors that are specific to the development of childhood dental caries. A multidimensional model by Litt et al. (13) demonstrated that the development of childhood dental caries was partly determined by mutans streptococci levels, which were influenced by the child’s cariogenic diet, which was, in turn, predicted by parents’ dental self-efficacy. Other factors that accounted for children’s caries experience were parent’s dental knowledge, life stress, education level and ethnicity. In another model by Nelson et al. (14), maternal enabling factors during a child’s early life, such as cognitive abilities and education, were associated with maternal coping and levels of stress, which subsequently affected a child’s dental attendance and oral health behaviours in later adolescence. Three other models also documented the contribution of psychosocial

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factors, such as sense of coherence, health locus of control (LoC), self-esteem and social support, in understanding oral health outcomes (15-17). However, in these respective studies oral health outcomes referred to children’s oral health-related quality of life or to oral health behaviours, oral functional status and quality of life of adolescents.

A well-known conceptual model of influences on children’s oral health outcomes is that by Fisher-Owens et al. (9). This comprehensive model suggests that genetic and biological factors, the social and physical environment, health behaviours, and dental and medical care influence children’s oral health at community, family and individual levels. It provides a framework for research and draws on a solid foundation of public health literature and oral health research. Yet, the model does not specify the exact pathways by which factors are linked to children’s oral health outcomes. Therefore, this study modelled plausible pathways and interrelationships among community, family and individual determinants of childhood dental caries under the conceptual model of Fisher-Owens and coworkers (Figure 1). This theoretical model was inclusive of those determinants identified in previous research as important factors influencing children’s caries experience (18-20). Pathways between factors were based on previous conceptual and empirical models, suggesting that social and environmental determinants impact on oral health outcomes via mediating psychosocial factors which, in turn, affect behaviours and lifestyle practices (10, 14, 15). In the model, the mother’s education level (an indicator of socioeconomic status), ethnicity and neighbourhood quality are interrelated and are suggested to impact on parental and familial psychosocial factors, including family functioning in the dimension of organization, social support, dental self-efficacy and dental health LoC. These, in turn, are postulated to affect oral hygiene behaviours, which directly influence childhood dental caries. The aim of this study was to test the validity of this theoretical model in a sample of six-year-old children from The Netherlands, using structural equation modelling. In the event of poor validity of the model, a further objective was to explore whether modifications to the model, within Fisher-Owens’ framework, would improve its validity.



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Study sampleParticipants were 6-year old children from six large paediatric dental centers located in various socioeconomic regions in The Netherlands. Six-year-olds were chosen to study the determinants of childhood dental caries, because enough time had passed for caries to develop in the deciduous teeth and most permanent teeth had not yet been erupted. A total of 1169 children were selected using simple random sampling (response rate = 53.9%, n = 630). This study was part of a project for which a power calculation indicated that a sample of 594 children was required (18). According to MacCollum et al. (21), this sample size would be adequate to evaluate data-model fit of a model with degrees of freedom (df) = 12 and a power of 0.80 for an α<0.05-level test associated with the root mean square error of approximation (RMSEA). Parents reported ‘no interest’ or ‘being too busy’ as main reasons for non-participation. The mother’s education level and the proportion of mothers from Dutch origin were significantly lower in the non-participant group compared to the participant group.

Of the 630 children that participated in the study (325 boys, 305 girls), the mean age was 6.0 ± 0.3 years. A large proportion of children had immigrant parents (n = 278, 44.2%). Common ethnicities were Moroccan, Turkish and Surinamese. Three hundred and thirty-three children (51.9%) were caries free [decayed, missing and filled teeth (dmft) score = 0]. Of those children with dental caries (dmft ≥ 1), the mean dmft ± SD score was 4.7 ± 3.1 (range 1-14).

Data collectionData were collected between June 2011 and March 2012. An informative letter about the study and a questionnaire was mailed to the home address of the selected children. Parents were asked to complete and return the questionnaire and to provide written consent to use their child’s clinical dental health records from the paediatric dental centers. Non-respondents were sent a first reminder by mail after three weeks; if they failed to respond they received a second reminder by telephone after a further three weeks. The Medical Ethics Committee of the Vrije Universiteit Amsterdam provided consent for the implementation of this study .

Clinical dental data

Dental health statusChildren’s dental health data were obtained from personal dental health records from the paediatric dental centers. The dental status of children’s primary dentition was extracted, using data from the latest dental visit. The dmft score was calculated by adding the number of decayed, missing (because of caries), and filled teeth. Enamel caries lesions were not included.



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Sociodemographic, psychosocial, behavioural and environmental data

A self-administered parental questionnaire was used to collect sociodemographic, psychosocial and behavioural data.

Oral hygiene behavioursThe questionnaire included four questions on oral hygiene behaviours, including tooth brushing frequency (‘three or more times a day’, ‘twice a day’, ‘once a day’, ‘less than once a day’), the age brushing was started (‘less than one year old’, ‘1-2 years old’, ‘2-3 years old’, ‘older than 3 years’), frequency of supervised tooth brushing (‘always’, ‘often’, ‘sometimes’, ‘never’) and frequency of re-brushing by a parent (‘always’, ‘often’, ‘sometimes’, ‘never’). For each question the most favourable answering option was coded ‘1’ and the least favourable answering option was coded ‘4’. A total oral hygiene score was computed, generating scores ranging from 4 to 16, with higher scores indicating poorer oral hygiene.

Family organization and social supportFamily organization and social support were assessed by the Gezinsvragenlijst (GVL, translation ‘Family Questionnaire’); a validated psychometric measure to assess family functioning and the quality of family relationships (18, 22). Family organization refers to the degree of structure, routines and assignment of roles in the family, as well as the family’s ability to resolve problems. Examples of items of this construct are: “In our home, the tasks (work, household) are clear and definite distributed” and “In our family, it is important that you stick to rules and agreements”. Social support relates to the extent to which the family can rely on support from people in their social environment. Examples of items measuring this construct include: “We regularly visit or do things together with friends or acquaintances” and “For jobs or advice we can count on support from family or friends”. Both dimensions contained 9 items, each of which was responded to on a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. Responses to the 9 items were summed, generating scores from 9 to 45, with higher scores indicating poorer family organization and poorer social support.

Parental dental self-efficacy and dental health locus of controlThe questionnaire items on dental self-efficacy and dental health LoC were taken from a validated questionnaire developed by Pine et al. (11). Dental self-efficacy refers to parents’ confidence in their ability to engage in healthy oral hygiene practices for their child. Examples of items of this construct include: “When our child is tired, it can be a struggle to brush his/her teeth” and “It is not worth it to battle with our child to brush his/her teeth twice a day”. Dental health LoC is defined as parents’ belief in their ability to control the dental

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health of their child: health-external persons interpret health as dependent on outside forces (e.g. relying on luck or chance, genetics), while health-internal persons believe that health is determined by one’s own behaviour. Examples of items measuring this construct are: “No matter what we do, our child is likely to get tooth decay” and “It is just bad luck if our child gets tooth decay”. Exploratory factor analysis with varimax rotation yielded a five-item scale for dental self-efficacy and a four-item scale for dental health LoC. Each item was measured on a 5-point Likert scale, ranging from ‘strongly agree’ to ‘strongly disagree’. A total score was computed for dental self-efficacy and dental health LoC, ranging from 5 to 25 and 4 to 16, respectively. Higher scores reflected a lower dental self-efficacy and a more external LoC.

The mother’s education level and ethnic backgroundThe question related to the mother’s highest completed level of education contained seven answering options: ‘university’, ‘further education (higher level)’, ‘secondary school (higher level)’, ‘further education (lower level)’, ‘secondary school (lower level)’, ‘elementary school’ and ‘no education’. These were coded from 1 to 7, respectively. The ethnicity variable classified children as ‘native’ if the mother of the child was born in The Netherlands or ‘immigrant’ if the mother was a first-generation immigrant from any other country.

Neighbourhood qualityData about neighbourhood quality were obtained from the Dutch Central Bureau of Statistics (CBS) (23). The neighbourhood was defined based on postal code area. CBS determined the quality of the neighbourhood on the basis of 49 indicators, which measured six underlying dimensions; housing, public space, public facilities, demographics, social cohesion and safety. CBS subsequently classified neighbourhood quality into four categories; ‘very positive’, ‘positive’, ‘moderately positive’ and ‘moderate’, which were coded from 1 to 4 respectively.

Statistical analysisStructural equation modelling was used to test the fit of the theoretical path model, using R version 2.14.2 (R Foundation for Statistical Computing, Vienna, Austria: package lavaan, Rosseel, 2012) (24). Structural equation modelling is a statistical technique which integrates factor analysis and multiple regression analysis and permits simultaneous testing of interrelationships among a number of potentially inter-dependent variables (25). The main a-priori hypotheses were (Figure 1):

(i) Childhood dental caries = β1 · oral hygiene behaviour + e1.

(ii) Oral hygiene behaviour = (β2 · social support) + (β3 · family organization) + (β4 · parental self-efficacy) + (β5 · parental LoC) + e2.

(iii) Social support = (β6 · ethnicity) + (β7 · mother’s education level) + (β8 · neighbourhood quality) + e3.



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(iv) Family organization = (β9 · ethnicity) + (β10 · mother’s education level) + (β11 · neighbourhood quality) + e4.

(v) Parental self-efficacy = (β12 · ethnicity) + (β13 · mother’s education level) + (β14 · neighbourhood quality) + e5.

(vi) Parental LoC = (β15 · ethnicity) + (β16 · mother’s education level) + (β17 · neighbourhood quality) + e6.

Preliminary analysisBefore testing the path model, the questionnaire items of the measurement models for social support, family organization, dental self-efficacy and dental health LoC were each evaluated in terms of internal consistency and acceptability of the factor structure by means of confirmatory factor analysis. An acceptable factor structure of a variable allows this variable to be tested in the path model as a manifest variable using the total score of a subscale, as opposed to including each specific questionnaire item of the variable in the path model.

To verify whether the factors that were included in the theoretical model were indeed determinants of childhood dental caries in the study sample, associations between each model variable (continuous and discretized) and the dmft score were first univariately tested using Pearson correlation and the Kruskal-Wallis test, respectively.

Path analysisAll variables in the theoretical path model were included as continuous variables, except for the dichotomous variable ethnicity. The variables social support, family organization, dental self-efficacy and dental health LoC referred to the total score of each subscale. The univariate distributions of all variables in the theoretical path model (except for ethnicity) were checked for normality, using standard errors of √(6/n) and √(24/n) to evaluate the skewness and kurtosis values, respectively. Because of the presence of non-normally distributed variables, the path model was first evaluated using square-root transformed variables and second, by using the corrections of Satorra and Bentler (26) (i.e. robust estimates of goodness-of-fit indices and standard errors). As both methods produced similar fit, this paper will report Satorra-Bentler adjusted standardized path coefficients of non-transformed variables. The following goodness-of-fit measures were examined to determine the adequacy of model fit to the data: the root mean square error of approximation (RMSEA), the standardized root mean square residual (SRMR), the comparative fit index (CFI) and the chi-square/df ratio and its probability value. RMSEA and SRMR values of less than 0.06 are considered to indicate good fit, and values of less than 0.08 reflect adequate fit (27). CFI values greater than 0.95 indicate a good fit (27). A non-significant chi-square value reflects a good fit. However, it should be noted that the chi-square value is sensitive to sample size. With large samples, models are more likely to be significant and substantively trivial discrepancies can lead to rejection of an

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otherwise satisfactory model. Therefore, the chi-square statistic should not be the sole basis for determining model fit (28).

results

Measurement modelsGoodness-of-fit measures indicated a good factor structure of the measurement models for family organization, dental self-efficacy and dental health LoC (Table 1). The fit of the measurement model for social support was not optimal (CFI = 0.92, RMSEA = 0.11, SRMR = 0.05), therefore testing of the study model requires some discretion in the interpretation of path model parameters related to social support. Internal consistency of variables ranged from Cronbach’s α = 0.62 to α = 0.89.

Table 1. Fit statistics (Confirmatory Factor Analysis) and internal consistency for social support, family organization, dental self-efficacy and dental health locus of control.

Statistic Social support Family organiza-tion

Dental self-efficacy Dental health locus of control

CFI 0.92 0.95 0.99 1.00RMSEA (90% CI) 0.11 (0.10 – 0.12) 0.06 (0.05 – 0.07) 0.02 (<0.01 – 0.06) <0.01 (<0.01 – 0.06)SRMR 0.05 0.04 0.02 0.01χ2/df ratio (P-value) (215.10/27) (<0.001) 84.95/27 (<0.001) 5.83/5 (0.32) 1.02/2 (0.60)Cronbach’s α 0.89 0.78 0.62 0.64

CFI: Comparative Fit IndexRMSEA (90% CI): Root Mean Square Error of Approximation and the 90% confidence interval SRMR: Standardized Root Mean Square ResidualCFI values greater than 0.95 indicate a good fit. RMSEA and SRMR values of less than 0.06 are considered to indicate good fit, and values of less than 0.08 reflect adequate fit. A non-significant χ2

reflects a good fit.

Univariate associations All variables in the theoretical path model were univariately associated with dmft-scores (Table 2). In Table 2, variables are discretized and the mean dmft and standard deviation per category is presented. The continuous total scores of oral hygiene behaviours, family organization, social support, dental self-efficacy and dental health LoC (as included in the path model) were also significantly associated with dmft, with correlations ranging from r = 0.15 to r = 0.26 (results not shown).



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Table 2. Distribution of mean dmft by model variables.

Variable

n

Range of the total score of the questionnaire subscale

Mean dmft score (95% CI) P-value*

Oral hygiene behavioura

Excellent 159 4-5 1.3 (0.9-1.6) <0.001Good 148 6 1.8 (1.3-2.3)Fair 180 7-8 2.5 (2.0-3.0)Poor 115 9-16 3.4 (2.7-4.1)

Parental self-efficacya

Very high 213 5-8 1.4 (1.1-1.8) <0.001Moderately high 130 9-10 2.0 (1.5-2.5)Moderately low 131 11-12 2.8 (2.2-3.4)Very low 136 13-25 3.1 (2.4-3.7)

Parental locus of controlaMainly internal 74 4-6 1.6 (0.9-2.3) <0.001Somewhat internal 189 7-8 1.7 (1.3-2.1)Somewhat external 176 9-10 2.0 (1.5-2.4)Mainly external 177 11-20 3.1 (2.5-3.6)

Family organizationb

Normal 434 9-17 1.9 (1.6-2.2) <0.001Subclinical 134 18-20 2.3 (1.8-2.9)Clinical 42 21-45 4.2 (3.0-5.5)

Social supportb

Normal 461 9-21 1.9 (1.7-2.2) 0.02Subclinical 80 22-24 2.9 (2.2-3.7)Clinical 72 25-45 2.9 (2.0-3.7)

The mother’s education levelUniversity 83 1.3 (0.7-1.9) <0.001Further education (higher level) 153 1.4 (1.0-1.8)Secondary school (higher level) 62 1.8 (1.1-2.5)Further education (lower level) 160 2.4 (1.9-2.9)Secondary school (lower level) 101 2.9 (2.3-3.5)Elementary school 38 4.0 (2.8-5.2)No education 16 4.6 (2.3-7.0)

EthnicityNative 346 1.7 (1.4-1.9) <0.001Immigrant 274 2.9 (2.5-3.3)

Neighbourhood qualityVery positive 114 1.7 (1.1-2.2) <0.001Positive 279 1.8 (1.4-2.1)Moderately positive 162 2.9 (2.3-3.4)Moderate 65 3.4 (2.6-4.1)

* Kruskal-Wallis testa Discretization of groups based on quartiles. b Discretization of groups based on normative cut-off values determined by the original authors of the Gezinsvragenlijst (GVL).

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Path modelAnalysis of the theoretical path model (Figure 1) indicated poor fit; CFI = 0.89, RMSEA = 0.10 (90% CI: 0.08–0.12), SRMR = 0.07, χ2/df ratio = 111.14/14 (P < 0.001). The model was subsequently modified according to the following steps. First, regression coefficients demonstrated that none of the paths with ethnicity were statistically significant when the mother’s education level was also included in the model. This implied that excluding ethnicity from the model could help model fit. The rationale for excluding ethnicity is in line with previous studies that have demonstrated that there were no differences in dental caries experience among minority ethnic groups of the same socioeconomic status (29), which suggests that the inclusion of ethnicity as a variable for childhood dental caries may not be relevant.

Second, inspection of the standardized residual matrix revealed that the ill fit of the model was partially caused by the omission of two paths; one path between mother’s education level and childhood dental caries, and one path between neighbourhood quality and childhood dental caries. Furthermore, the paths linking neighbourhood quality to family organization, social support, dental self-efficacy and dental health LoC were not statistically significant, which also indicated that a path between neighbourhood quality and childhood dental caries, instead of paths linking neighbourhood quality to psychosocial factors, would improve model fit. A conceptual rationale for this modification is that the neighbourhood may influence children’s caries experience through several other variables that were not included in the model (e.g. environmental factors that may impact on children’s dietary behaviours), rather than via the included psychosocial factors that affect children’s oral hygiene behaviours (30).

Finally, the standardized residual matrix revealed that the model could be improved by allowing dental self-efficacy to correlate with family organization and social support. The model was revised by applying these modifications (Figure 2, Table 3). The revised path model yielded a good fit; CFI = 0.95, RMSEA = 0.06 (90% CI: 0.04–0.08), SRMR = 0.04, χ2/df ratio = 44.99/12 (P<0.001). In this model, lower maternal education level was related to poorer family organization, lower levels of social support, lower dental self-efficacy and a more external dental health LoC. These, in turn, were associated with poorer oral hygiene behaviours, which were related to higher levels of childhood dental caries. In addition, lower maternal education level and poorer neighbourhood quality were directly associated with higher caries levels in children. The corresponding numerical solutions were:

(i) Predicted childhood dental caries = (0.19 · oral hygiene behaviour) + (0.22 · the mother’s education level) + (0.13 · neighbourhood quality).

(ii) Predicted oral hygiene behaviours = (0.10 · social support) + (0.13 · family organization) + 0.36 · parental self-efficacy) + (0.05 · parental LoC).



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Table 3. Standardized and unstandardized path coefficients of the revised model.

Effects

Standardized path coefficient (β)

Unstandardized path coefficient

SE 95% CI P-value 1-R2

Childhood dental caries 0.87Oral hygiene behaviours 0.19 0.31 0.07 0.18 – 0.44 <0.001The mother’s education level 0.22 0.43 0.08 0.27 – 0.59 <0.001Neighbourhood quality 0.13 0.43 0.14 0.15 – 0.71 <0.01

Oral hygiene behaviours 0.77Social support 0.10 0.03 0.01 0.01 – 0.05 <0.001Family organization 0.13 0.06 0.02 0.02 – 0.10 0.27Dental self-efficacy 0.36 0.21 0.03 0.15 – 0.27 <0.01Dental health locus of control 0.05 0.03 0.03 - 0.02 – 0.08 0.02

Social support 0.93The mother’s education level 0.12 0.54 0.16 0.22 – 0.86 <0.001

Family organization 0.97The mother’s education level 0.08 0.22 0.10 0.02 – 0.42 <0.001

Dental self-efficacy 0.87The mother’s education level 0.28 0.56 0.08 0.40 – 0.72 0.04

Dental health locus of control 0.82The mother’s education level 0.26 0.43 0.07 0.30 – 0.56 <0.001

SE: standard error of the unstandardized path coefficient, 95% CI: 95% confidence interval of the unstandardized path coefficient.

All pathways were statistically significant, except for the path between dental health LoC and oral hygiene behaviours (p=0.27). A path between dental health LoC and childhood dental caries would have better fit the data, however, for conceptual reasons it was decided to retain the path between dental health LoC and oral hygiene behaviours. The revised model explained 22.6% of variance in oral hygiene behaviours and 12.6% of variance in childhood dental caries.

discussion

This study modelled pathways and interrelationships among community, family and individual determinants of childhood dental caries. Findings of this study provided empirical support for components of Fisher-Owens’ conceptual framework of the influences on children’s oral health (9). A great strength of this study was that determinants of childhood dental caries were analysed using structural equation modelling. Structural equation modelling has the



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advantage over standard regression techniques that it allows the exploration of complex pathways between the factors that add to caries development, rather than treating all factors as isolated predictors of dental caries. Structural equation modelling thereby yields findings which are more useful for understanding and explaining the mechanisms that contribute to the development of dental caries in children. Of particular relevance is that potential intermediary mechanisms that link social conditions to childhood dental caries were clarified: findings suggested that it is plausible that the mother’s education level indirectly influences children’s oral hygiene behaviours and subsequently children’s caries experience through an impact on interrelated parental and familial psychosocial factors. The results of this study concur with findings by Nelson et al. (14) and Dorri et al. (15), who also demonstrated that psychosocial factors mediated the relationship between parental education and oral health behaviours. This study and the findings by Dorri et al. both indicate that social support is an important psychosocial predictor of oral hygiene behaviours, although in the model by Nelson et al. social support was directly related to levels of dental decay. In line with Litt et al. (13), this study demonstrated that parents’ dental self-efficacy is another important factor that affects children’s caries experience, which acts via an impact on health behaviours. In contrast to their findings, ethnicity did not significantly contribute to the explanation of childhood dental caries in this study sample. This may be a consequence of the different ethnic groups that were represented in both studies (i.e. mainly Hispanic and Black children in the study by Litt et al. (13) versus mainly Moroccan, Turkish and Surinamese children in this study).

The present study suggested that there is a persistent direct relationship between the mother’s education level and childhood dental caries. The same applied to the direct relationship between neighbourhood quality and dental caries in children. Yet, evidently, their influence on children’s caries experience must act via a number of intermediary factors, which suggests that important factors were omitted in the present study. For example, neighbourhoods may influence childhood dental caries directly through the availability of (un)healthy foods and access to dental care (30, 31). Indirectly, the degree of safety, social cohesion and availability of public resources may affect children’s oral health practices via an influence on parents’ level of stress, social support, health standards and sense of positivism (32, 33). Examples of psychosocial factors that may link the mother’s education level to childhood dental caries include dental knowledge, maternal depression and anxiety, sense of coherence and marital quality (5, 16, 34-36). Furthermore, in the present model, the effect of (psycho-) social factors on children’s caries levels was assumed to operate via one individual factor, namely oral hygiene behaviour. However, it is well-known that dietary behaviours and biological factors are also important in the development of childhood dental caries (37). Therefore, the model could be further developed by adding aforementioned factors to the model, which will likely increase the model’s explanatory power.

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A few methodological caveats should be considered when interpreting the findings of this model. The model was tested using a large sample with considerable variation in the mother’s education level and children’s ethnic background, living environment and dental caries levels. Still, its generalizability is limited, because children who did not visit the dentist were not included and the non-response rate was relatively high. Furthermore, this study was cross-sectional with data measured at a single time point. Although variables were modelled in the sequence of their expected operational order, this ordering does not imply causal effect or provides evidence on temporal precedence of variables (38). It is important to recognize that reciprocal relationships and feedback loops may exist and that the exact role of variables (e.g. whether they have an indirect (mediating) effect or act as moderators, confounders or independent factors) should be further investigated (39). Moreover, the effects of variables on childhood dental caries may change over time, as families move around, social networks and neighbourhoods change and families are affected by alterations in life circumstances, stressful events, and natural transitions, such as the ageing of family members (40). Therefore, the measurement of variables at the time of this study may not have been an accurate reflection of the variables over the past years. Finally, the operationalization of contextual factors, including the mother’s education level as an indicator of socioeconomic status and neighbourhood quality, had its limitations, as they were measured as individual attributes, while in fact they are partial indicators of several life circumstances and events resulting from broader social and economic living conditions (8). The abovementioned issues may explain why mainly moderate associations between factors were demonstrated in the model. Exploration of the exact role of factors over time and determination of causal and reciprocal effects requires future studies that are longitudinal in design. Such studies would allow validation of the present model, and enables further development of the model by integrating bio-behavioural pathways and by including additional psychosocial and contextual factors.

The results of this study provide some direction for the development of interventions to prevent childhood dental caries. There is growing recognition that traditional health promotion methods, solely placing emphasis on changing oral health behaviours through dental health education, are largely ineffective in achieving sustained oral health gains (41). More promising are theory-driven interventions that are underpinned by sound frameworks of oral health determinants. For example, a recent study by Nammontri et al. (42) demonstrated that children’s gingival health and oral health-related quality of life could be improved by a psychosocial school-based intervention that enhanced children’s sense of coherence. Findings of this study imply that parental and familial psychosocial factors, such as parents’ self-efficacy and family functioning, may be important components to consider in caries preventive interventions. Several interventions studies have already demonstrated that the integration of family system components in obesity prevention programs, including parenting and family functioning variables, resulted in sustained health behaviour change and weight



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loss in obese children (43). Future studies should determine whether efforts to improve parental and familial psychosocial factors also have the potential to prevent childhood dental caries.

In conclusion, this study presented a valid model of the pathways and interrelationships among community, family and individual determinants of childhood dental caries. Conception of these pathways is essential for guiding public health policy and the development of interventions to prevent dental caries in children. Clues for further expansion of the model in future research are suggested.

acknowledgements

This study was financially supported by Menzis health insurer, The Netherlands. The authors declare that they have no conflict of interest.

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3. Peres MA, Latorre MRDO, Sheiham A, Peres KGA, Barros FC, Hernandez PG, Maas AMN, Romano RM, Victora CG. Social and biological early life influences on severity of dental caries in children aged 6 years. Community Dent Oral Epidemiol 2005;33:53–63.

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7. Reisine ST, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26(Suppl 1):32–44.

8. Newton JT, Bower EJ. The social determinants of oral health: new approaches to conceptualizing and researching complex causal networks. Community Dent Oral Epidemiol 2005;33:25–34.

9. Fisher-Owens SA, Gansky, SA, Platt LJ, Weintraub JA, Soobader MJ, Bramlett MD, Newacheck PW. Influences on children’s oral health: a conceptual model. Pediatrics 2007;120:510–20.

10. Holst D, Schuller AA, Aleksejuniené J, Eriksen HM. Caries in populations-a theoretical, causal approach. Eur J Oral Sci 2001;109:143–8.




14. Nelson S, Lee W, Albert JM, Singer LT. Early maternal psychosocial factors are predictors for adolescent caries. J Dent Res 2012;91:859–64.

15. Dorri M, Sheiham A, Watt RG. Modelling the factors influencing general and oral hygiene behaviours in adolescents. Int J Paediatr Dent 2010;20:261–9.

16. Baker SR, Mat A, Robinson PG. What psychosocial factor’s influence adolescents’ oral health? J Dent Res 2010;89:1230–5.

17. Gururatana O, Baker SR, Robinson PG. Determinants of children’s oral health-related quality of life over time. Community Dent Oral Epidemiol 2013;28:232-7.

18. Duijster D, Verrips GHW, van Loveren C. The role of family functioning in childhood dental caries. Community Dent Oral Epidemiol 2014;42:193–205.

19. Finlayson TL, Siefert K, Ismail KA, Sohn W. Maternal self-efficacy and 1-5-year-old children’s brushing habits. Community Dent Oral Epidemiol 2007;35:272–81.


21. MacCallum, RC, Browne MW, Sugawara HM. Power analysis and determination of sample size for covariance structure modeling. Psychol Methods 1996;1:130–49.



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22. Scholte E, Van der Ploeg J. The Family Questionnaire: A measure to assess the quality of family functioning. J Fam Issues 2013, DOI: 10.1177/0192513X13506707.

23. CBS Statline (2012). http://www.leefbaarometer.nl (accessed: March, 2013).24. Rosseel Y. Lavaan: an R pacakge for structural equation modeling. J Stat Softw 2012;14:1-36.

http://www.jstatsoft.org/v48/i02/.25. Kline RB. Principles and practice of structural equation modelling, 2nd edition. New York: The

Guildford Press, 2005. 26. Satorra A, Bentler PM. Scaling corrections for chi-square statistics in covariance structure

analysis. Proc Am Stat Assoc 1988;308–13.27. Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional

criteria versus new alternatives. Structural Equation Modelling 1999;6:1–55.28. Loehlin JC. Latent variable models: an introduction to factor, path and structural equation analysis,

4th edition. Hillsdale: Laurence Erlbaum Associates, 2004. 29. Watt RG, Sheiham A. Inequalities in oral health: a review of the evidence and recommendations for

action. Br Dent J 1999;187:6–12. 30. Aida J, Ando Y, Oosaka M, Niimi K, Morita M. Contributions of social context to inequality in dental

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31. Sisson KL. Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol 2007;35:81–8.

32. Tellez M, Sohn W, Burt BA, Ismail AI. Assessment of the relationship between neighborhood characteristics and dental caries severity among low-income African-Americans: a multilevel approach. J Public Health Dent 2006;66:30–6.

33. Turrell G, Sanders AE, Slade GD, Spencer AJ, Marcenes W. The independent contribution of neighborhood disadvantage and individual-level socioeconomic position to self-reported oral health: a multilevel analysis. Community Dent Oral Epidemiol 2007;35:195–206.


35. Marcenes W, Sheiham A. The relationship between marital quality and oral health status. Psychol Health 1996;11:357–69.

36. Seow WK, Clifford H, Battistutta D, Morawska A, Holcombe T. Case-control study of early childhood caries in Australia. Caries Res 2009;43:25–35.

37. Gussy MG, Waters E, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Paediatr Child Health 2006;42:37–43.

38. Holland PW. Causal inference, path analysis, and recursive structural equation models. Sociol Methodol 1988;18:449–84.

39. Hayes AF: Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Commun Monogr 2009;76:408–20.

40. Tutty LM. Theoretical and practical issues in selecting a measure of family functioning. Res Soc Work Pract 1995;5:80–106.

41. Kay L, Locker D. Is dental health education effective? A systematic review of current evidence. Community Dent Oral Epidemiol 1996;31:3–24.

42. Nammontri O, Robinson PG, Baker SR. Enhancing oral health via sense of coherence: A cluster-randomized trial. J Dent Res 2013;92:26–31.


5 the relatIonshIp between parentInG, FamIly InteractIon and chIldhood dental carIes: a case-control study

Maddelon de Jong-LentersDenise Duijster

Meike BruistJill Thijssen

Corine de Ruiter

Published in Social Science and Medicine 2014;116:49–55.

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abstract

The aim of this case-control study was to explore the relationship between parenting practices, parent-child interaction and childhood dental caries, using a sample of 5- to 8-year old children from the Netherlands. Cases were defined as children with four or more decayed, missing or filled teeth and controls were caries free. Cases (n = 28) and controls (n = 26) were recruited from a referral centre for paediatric dental care and a general dental practice, respectively. Parenting practices and parent-child interactions of the child’s primary caregiver were observed using Structured Interaction Tasks and subsequently rated on seven dimensions: positive involvement, encouragement, problem-solving, discipline, monitoring, coercion and interpersonal atmosphere. All Structured Interaction Tasks were videotaped, and coded by trained and calibrated observers blind to the dental condition. Differences in parenting dimensions between cases and controls were analysed using multivariate analysis of variance, independent samples T-tests, χ2-tests and multiple logistic regression analyses. Controls had significantly higher scores on the dimensions positive involvement, encouragement, problem-solving and interpersonal atmosphere, compared to cases. Parents of controls were also less likely to show coercive behaviours. These associations remained statistically significant after adjustment for the mother’s education level, tooth brushing frequency and the frequency of consuming sugary foods and drinks, except for coercion. There was no significant difference in discipline between cases and controls. In conclusion, this case-control study found a significant relationship between parenting practices, parent-child interaction quality and childhood dental caries. Our findings suggest that parenting practices may be an important factor to consider in caries preventive programs.


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introduction

Early childhood is a critical phase in which important foundations for lifelong health are laid (1). It is empirically established that the conditions in which children grow up leave an indelible imprint on the health of an individual throughout the lifespan (2, 3). For example, relatively stable patterns of health-related behaviours are acquired at home during early life (e.g., fruit and vegetable intake, sugar-snacking, physical activity and oral hygiene), and these patterns are difficult to change in adulthood (4). Parents play a pivotal role in the initiation and maintenance of these health-related behaviours. They shape their children’s behaviours, attitudes and social norms through modelling, the use of specific parenting practices and more broadly through interpersonal interactions within the family (5).

Parenting practices are the ways by which parents, intentionally and unintentionally, influence their child’s development. Effective parenting practices include the parent’s ability to encourage self-control and responsible behaviour in their child through parental direction, monitoring, and disciplinary efforts in the context of warm and affectionate family interactions (6, 7). A large body of evidence has demonstrated that effective parenting and supportive family interactions are associated with positive childhood outcomes, such as higher academic achievement, better psychosocial and emotional development, less disruptive child behaviours, fewer depressive symptoms and higher self-esteem (8-12). In terms of physical health, ineffective parenting (in particular parenting characterized by high levels of demand along with low levels of warmth and positive involvement) is related to higher rates of childhood obesity and an unhealthy diet, including lower fruit and vegetable consumption, higher caloric intake and lower frequency of eating breakfast (5, 13-16).

There is reason to believe that parenting practices and family interactions may also affect another common child health problem: dental caries. The role of parents is vital in establishing specific behaviours related to childhood dental caries, including children’s oral hygiene and frequency of sugar consumption (17). However, studies that have investigated the influence of parenting practices and, more broadly, family relationships on children’s dental health are scarce. One study by Duijster et al. (18) found that children with good family functioning and family relationships in terms of organization, communication, responsiveness and social networks, had lower levels of dental decay and better oral hygiene compared to children with poor family relationships. Interestingly, in terms of parenting in particular, the studies that have been conducted in this area were unable to demonstrate an association between specific parenting styles and children’s caries experience and adolescents’ oral hygiene behaviours (19, 20).

In the latter studies, self-report questionnaires were used to measure parenting practices, which may have resulted in the absence of the expected association between parenting and child dental health. Although these questionnaires were validated and psychometrically

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sound, there are some limitations to self-report methods (21, 22). For example, parents’ self-report could be biased by their own beliefs and perspectives, and therefore may not reflect actual behaviours. Moreover, there is a tendency of parents to answer questions in a socially desirable manner by over-reporting ‘good’ behaviours and under-reporting ‘bad’ behaviours (23). Furthermore, most parenting questionnaires have been developed in a clinical context, designed to discriminate between problem and non-problem families. Yet, the majority of children with dental caries probably come from normative families whose children do not necessarily have significant clinical or behavioural problems (18). Questions remain whether self-report methods are sensitive enough to distinguish between different parenting practices relevant to caries development within the normative range.

An alternative method of assessing parenting practices and family interaction that overcomes these limitations is parent-child observation. This method involves asking family members to perform a number of standardized tasks in which parenting and family interaction are subsequently rated by a trained observer, external to the family. Some researchers claim this method generates more objective and thus more valid data (24). Therefore, the aim of this study was to explore the relationship between parenting practices, parent-child interaction and childhood dental caries, using observations in a case-control study design.


Approval for this study was obtained from The Central Committee on Research Involving Human Subjects, The Netherlands (CCMO). Prior to the commencement of the study, written informed consent was sought from the parent of the child that was selected for the study.

Study sampleThis case-control study was conducted in The Netherlands from February to August 2013. Cases were defined as children with four or more decayed, missing or filled deciduous and/or permanent teeth (dmft/DMFT ≥ 4). This value was chosen as it represents both the mean dmft and the median dmft of five-year-old children in the Netherlands with dental caries (25). For each case, an age-matched (+/- 4 months) and sex-matched control was recruited. Controls were children who were caries free in both their deciduous and permanent dentition (dmft/DMFT = 0). Both cases and controls were between 5 and 8 years old at the time of selection and they were of Dutch origin. Children were considered of Dutch origin when both their parents were born in The Netherlands. Children diagnosed with emotional and behavioural disorders (e.g. autism spectrum disorders and conduct problems), children with special needs and children with missing teeth due to dental trauma or teeth with enamel defects, were excluded from study selection. Only one child per family was included. Cases and controls were recruited from a referral centre for paediatric dental care and a general



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dental practice, respectively. First, an information letter about the study was sent to the home address of all selected children. Subsequently, parents of the children were invited to participate by telephone.

In order to detect a difference in parenting practices and parent-child interaction between cases and controls (if present), a power calculation indicated that a minimal sample of 42 children would be necessary. This calculation was based on the following parameters: 90% power, 5% level of significance and a standard deviation of 4.1 dmft based on caries levels in 5-year-old children in the 2006 Dutch National Oral Health Survey (25). Data collectionDental health statusChildren’s dmft/DMFT scores were extracted from personal dental health records from the referral centre for paediatric dental care and the general dental practice. The diagnosis of dental caries was based on clinical examinations, supported by dental x-rays. Both practices employed two dental practitioners. Data were registered in a standardized way to ensure that the records were up-to-date and complete. The dmft/DMFT score was computed by adding the number of decayed, missing and filled teeth. Missing teeth were only scored if records indicated that they were extracted due to caries. Missing teeth due to dental trauma, hypomineralization, agenesis or routine exfoliation were not included in the dmft/DMFT scores. Enamel caries lesions were also not included. Data from the latest dental visit were used to compute dmft/DMFT scores. For all children, the latest dental visit had been no more than six months before the time of data collection for the purposes of this study.

Parenting practices and parent-child interactionParenting practices and parent-child interaction were observed using Structured Interaction Tasks (SIT) (26-28). This observational method derives strength from its basis in the Social Interaction Learning model (29). On the one hand, this model describes effective parenting practices (involvement, encouragement, problem solving, monitoring and discipline) that positively impact on children’s socio-emotional development and behaviours. On the other hand, it includes coercive parenting practices that can have negative consequences for the child’s development.

The SIT contained seven structured tasks which were performed by the child and its primary caregiver in a quiet room at the referral centre for paediatric dental care. Tasks included: planning a fun activity for the weekend (3 min), problem solving on a topic selected by the parent (5 min), drawing a picture of their house (7 min), a snack break (5 min), problem solving on a topic selected by the child (5 min), teaching tasks (9 min), and a monitoring task in which the parent interviewed the child about a moment when the child was not in the parent’s direct presence (5 min). The tasks were designed to elicit a variety of parenting

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practices. For example, the teaching tasks were designed to be a grade level beyond the child’s current grade -provoking frustration in the child-, which provided the opportunity to observe the parent’s response.

All observations were videotaped. They were evaluated using a coding system developed by Maastricht University in consort with researchers from Oregon Social Learning Center, based on the original Coder Impressions (30). The coding system contained specific items for each SIT task, as well as general items related to the overall interaction between parent and child during the full session. Items measured seven underlying dimensions of parenting practices and parent-child interaction: positive involvement (12 items), encouragement (20 items), problem-solving (27 items), discipline (26 items), monitoring (5 items), coercion (16 items) and interpersonal atmosphere (24 items).

• Positive involvement refers to the degree to which family interactions are characterized by warmth, empathy and positive affect. It also relates to whether parents show an active interest in their child’s experiences.

• Encouragement reflects the extent to which parents stimulate their child’s independence through positive endorsement, reinforcement and offering help when necessary.

• Problem-solving describes parents’ ability to generate solutions that are feasible and acceptable to the child. It also reflects the extent to which parents and children are open to each other’s viewpoints and are both involved in the decision making process.

• Discipline relates to parents’ adequacy of setting appropriate limits for their child, and their efficiency in responding to their child’s unacceptable behaviours in terms of timing, consistency, intensity and clear use of instructions/commands.

• Monitoring refers to parental supervision, such as whether parents keep close track of what is occupying the child on a day-to-day basis (e.g., friends, activities, interests).

• Coercion defines the degree to which parents have the tendency to criticize their children, be overly strict and demanding and use harsh and inconsistent disciplinary actions.

• Interpersonal atmosphere describes the extent to which parent-child interactions are pleasant, comfortable and free of conflict and frustration.

Items were scored on a 5-point Likert-scale. A cumulative score for each dimension was computed, with higher scores reflecting more positive involvement and encouragement, more effective problem-solving ability and discipline practices, better monitoring, more coercive behaviour and a more positive interpersonal atmosphere. Cronbach α’s for the seven dimensions were 0.77, 0.92, 0.95, 0.91, 0.38, 0.30 and 0.86, respectively. The low internal consistency for coercion was due to limited variance on a number of items related



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to this dimension, as parents rarely showed coercive behaviours. Therefore, coercion was categorized by dividing the distribution of scores into three groups (range = 26–38): ‘not coercive’ (scores 26–29), ‘slightly coercive’ (scores 30–33), ‘quite coercive’ (scores 34–38). The low internal consistency for monitoring was partially due to the low number of items composing this dimension. The reliability of this dimension was insufficient and therefore it was decided not to include the monitoring dimension in further analyses.

All observations were coded by one trained and calibrated observer who was blind to the dental condition (case or control). A random selection of 12 observations (22%) was double coded by a second blind observer for a reliability check. The percentage agreement between coders (difference in scores = 0, and difference in scores = 0 or 1) was 71.7% and 92.4%, respectively. The intra-class correlation was 0.91.

Sociodemographic characteristics and oral health behavioursA self-administered parental questionnaire (18 items) was used to collect data on sociodemographic characteristics and children’s oral health-related behaviours. Sociodemographic variables included parental income, the number of children in the household and the mother’s highest completed level of education. The mother’s education level was categorized into ‘lower education’ (0–12 years of education), ‘medium education’ (13–15 years of education) and ‘higher education’ (16 years or more years). The oral health behaviours studied were: tooth brushing frequency, age tooth brushing was started, re-brushing by a parent, supervised tooth brushing, frequency of consumption of sugary foods between meals and frequency of consumption of sugary drinks between meals. One question referred to the parent’s self-reported oral health, which was responded to on a 5-point Likert-scale from ‘very poor’ to ‘excellent’.

Statistical analysisStatistical analysis was carried out using SPSS (Version 20, IBM Corp.). Associations between parenting practices and parent-child interaction (in short: parenting dimensions) were examined using the Pearson correlation test. To analyse the relationship between parenting dimensions and childhood dental caries, various statistical methods were used. First, multivariate analysis of variance (MANOVA) was performed to assess the multivariate association of the dental condition (case or control) and all parenting dimensions. Second, mean scores of each parenting dimension, except for coercion, were compared between cases and controls using independent samples T-tests. For coercion, the χ²-test was used to analyse the difference in distribution of coercive behaviours between cases and controls. Finally, a series of logistic regression analyses were conducted for parenting dimensions with the dental condition (case vs. control) as the dependent variable. First, crude odds ratio’s (OR’s) and 95% confidence intervals (95% CI) were estimated for bivariate associations

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between each parenting dimension and the dental condition. These associations were subsequently adjusted for a number of sociodemographic characteristics and oral health behaviours that were unevenly distributed between cases and controls (model 1). A P-value of < 0.05 was regarded as significant.

results

Description of the study sampleThe sample consisted of 54 children (28 cases and 26 controls) and their primary caregivers (50 mothers, 4 fathers). For two cases an age and sex-matched control could not be found. Cases had an average of 6.8 ± 1.8 decayed, missing or filled teeth (range = 4–12), while controls had no caries experience. The mean age of all children was 7.3 ± 1.0 years and boys and girls were equally represented in both groups (cases and controls). The distribution of sample characteristics for the two groups is presented in Table 1. The educational level of the mother was significantly lower in cases than in controls. In terms of oral health behaviours, cases reported more frequent consumption of sugary foods and drinks between meals, compared to controls. They were also less likely to brush their teeth twice a day, however, this difference did not reach statistical significance. Cases did not differ from controls in the age tooth brushing was started, the frequency of supervised brushing or re-brushing by a parent, number of children in the household, parental income and parent’s self-reported oral health.

Analysis of parenting practices and parent-child interactionCorrelation matrixTable 2 shows that all parenting dimensions, except for some dimensions with discipline, were moderately to strongly inter-correlated. In particular, high scores on encouragement were strongly associated with high scores on positive involvement and problem-solving, and with low scores on coercion (r = 0.71, r = 0.70 and r = -0.68, respectively).



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Table 1. Distribution of sociodemographic characteristics, oral health behaviours and parental oral health status between cases and controls.

Cases (n = 28) Controls (n = 26)Variables n (%) n (%) P*SociodemographicsSeks

Girl 14 (50.0) 13 (50.0) 1.00Boy 14 (50.0) 13 (50.0)

Education level (mother)aHigher education 0 (0.0) 12 (46.2) <0.001Medium education 12 (50.0) 11 (42.3)Lower education 12 (50.0) 3 (11.5)

Income b

Above modal 6 (25.0) 11 (42.3) 0.38Modal 13 (54.2) 12 (46.2)Below modal 5 (20.8) 3 (11.5)

Number of children in the householda

1 child 6 (25.0) 5 (19.2) 0.872 children 10 (41.7) 11 (42.3)3 or more children 8 (33.3) 10 (38.5)

Oral health behavioursTooth brushing frequencya

Twice or more per day 19 (79.2) 25 (96.2) 0.07Once or less per day 5 (20.8) 1 (3.8)

Age tooth brushing was starteda

Less than one-year old 16 (66.7) 21 (80.8) 0.261 years old or older 8 (33.3) 5 (19.2)

Re-brushing by a parentOften-always 14 (58.3) 14 (53.8) 0.49Never-sometimes 10 (41.7) 12 (46.2)

Supervised tooth brushingOften-always 21 (87.5) 24 (92.3) 0.46Never-sometimes 3 (12.5) 2 (7.7)

Frequency of sugary foods between mealsa

Twice or less per day 7 (29.2) 22 (84.6) <0.001Three times or more per day 17 (70.8) 4 (15.4)

Frequency of sugary drinks between mealsa

Twice or less per day 10 (41.7) 19 (73.1) 0.03Three times or more per day 14 (58.3) 7 (26.9)

Parent’s oral health statusParental self-rated oral healtha

Good to excellent 12 (50.0) 18 (69.2) 0.17Very poor to fair 12 (50.0) 8 (30.8)

*χ²-testa missing data for 4 children

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Table 2. Correlation matrix of dimensions of ‘parenting practices and parent-child interaction’.

1. 2. 3. 4. 5. 6.

1. Positive involvement --2. Encouragement 0.71* --3. Problem solving 0.50* 0.70* --4. Discipline 0.12 0.34 0.41* --5. Coerciona 0-.51* -0.68* -0.51* 0.16 --6. Interpersonal atmosphere 0.38* 0.50* 0.65* 0.43* -0.48* --

Pearson correlation, *P < 0.01a Categorized into three groups; ‘not coercive’, ‘slightly coercive’ and ‘quite coercive’.

Associations with childhood dental cariesMean scores on the parenting dimensions between cases and controls are presented in Table 3 and the distribution of coercive behaviours between cases and controls is shown in Table 4. The MANOVA showed a significant multivariate effect for the dental condition (case or control) on parenting practices and parent-child interaction: F(7,46) = 8.56, P < 0.001. Controls had significantly higher scores on the dimensions positive involvement, encouragement, problem-solving and interpersonal atmosphere, compared to cases. Parents of controls were also less likely to show coercive behaviours compared to cases. There was no significant difference in discipline between cases and controls.

Table 3. Mean scores and standard deviations of dimensions of ‘parenting practices and parent-child interaction’ between cases and controls.

Cases (n = 28) Controls (n = 26)Dimensions mean ± SD range mean ± SD range P*Positive involvement 50.4 ± 4.6 36-58 54.1 ± 3.0 49-60 <0.001 Encouragement 74.4 ± 9.1 56-92 87.3 ± 7.9 64-96 <0.001 Problem solving 89.2 ± 11.6 70-123 112.9 ± 15.0 63-129 <0.001 Discipline 123.3 ± 11.5 80-130 127.3 ± 6.4 101-130 0.13Interpersonal atmosphere 98.2 ± 8.3 69-109 105.9 ± 3.0 95-111 <0.001

* Independent samples T-test

Table 4. Distribution (n, %) of coercive behaviours between cases and controls.

Cases (n = 28) Controls (n = 26)Dimensions n % n % P*Not coercive 10 35.7 16 61.5 <0.001 Slightly coercive 9 32.1 9 34.6Quite coercive 9 32.1 1 3.8

* X²-test



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Similar bivariate associations were found when the relationship between parenting dimensions and the dental condition was analysed using logistic regression (Table 5). Crude OR’s show that higher scores on the dimensions positive involvement, encouragement, problem-solving and interpersonal atmosphere were associated with a decreased likelihood of being a case compared to a control, while higher scores for coercion increased the chances of being a case compared to a control. After adjustment for the mother’s education level, tooth brushing frequency and the frequency of sugary foods and drinks between meals, positive involvement (borderline significant), encouragement, problem-solving and interpersonal atmosphere remained significantly associated with the dental condition, while coercion did not (Table 5, models 1–6).

Table 5. The association of ‘parenting practices and parent-child interaction’ with childhood dental caries; the relative odds and 95% confidence intervals of being a ‘case’ compared to a ‘control’.

Dimensions OR (95% CI)a Bb SEc Wald-test P*Goodness of fitc

Crude Positive involvement 0.72 (0.58 – 0.88) -0.33 0.11 9.75 0.002 0.73Encouragement 0.84 (0.77 – 0.92) -0.17 0.05 13.56 <0.001 0.29Problem solving 0.89 (0.85 – 0.94) -0.11 0.03 16.43 <0.001 0.39Discipline 0.94 (0.86 – 1.02) -0.06 0.04 2.09 0.15 0.18Coercion 2.81 (1.25 – 6.31) 1.03 0.41 6.21 0.01 0.23Interpersonal atmosphere 0.74 (0.62 – 0.88) -0.31 0.09 11.26 0.001 0.59

Model 1e Positive involvement 0.73 (0.53 – 1.01) -0.32 0.17 3.56 0.06 0.62Model 2e Encouragement 0.86 (0.75 – 0.99) -0.15 0.07 4.73 0.03 0.92Model 3e Problem solving 0.93 (0.87 – 0.99) -0.08 0.03 5.41 0.02 0.38Model 4e Discipline 1.00 (0.90 – 1.12) 0.004 0.06 0.006 0.94 0.99Model 5e Coercionf 3.51 (0.73 – 16.84) -0.42 0.18 5.13 0.02 0.57Model 6e Interpersonal atmosphere 0.66 (0.46 – 0.95) 1.26 0.80 2.46 0.12 0.85

* Logistic regressiona OR (95% CI) = odds ratio (95% confidence interval) b B = partial logistic regression coefficientc SE = standard error of the partial slope coefficientd Hosmer and Lemeshow goodness of fit test. e Model 1-6: Each dimension of ‘parenting practices and parent-child interaction’ separately adjusted for the mother’s education level, tooth brushing frequency, the frequency of sugary foods between meals and the frequency of sugary drinks between meals.f Categorized into three groups; ‘not coercive’, ‘slightly coercive’ and ‘quite coercive’.

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discussion

This study found a significant relationship between parenting practices, parent-child interaction and childhood dental caries in a sample of 5- to 8-year old children from the Netherlands. Parenting on the dimensions positive involvement, encouragement, problem-solving, coercion and interpersonal atmosphere was more favourable in caries free children compared to children with four or more decayed, missing of filled teeth.

Notably, in this study, parenting on the dimension discipline did not significantly differ between children with and without caries. This could be attributed to the fact that discipline practices could only be scored when the child showed problem behaviour during the SIT observations. If the child did not show any difficult behaviour, the highest score for each of the discipline items was accorded. In this study, 33 children (61.1%) did not show any problem behaviours, therefore there was little variation in scores for discipline, impeding the possible demonstration of a significant difference between cases and controls.

Oral health behaviours are presumably an important mediating factor in the relationship between parenting practices, family interactions and children’s caries experience. There are several plausible mechanisms by which parenting practices and family interactions could influence children’s oral health behaviours and subsequently their oral health. For example, it has been shown that coercive parenting, characterized by inconsistent, ambiguous, and highly demanding discipline practices and irritable, angry affect, is associated with a higher degree of resistance and non-compliance in children (31, 32). Patterson et al. (33) termed these rigid coercive sequences, which have also been demonstrated empirically (34, 35). One could argue that these children are also less likely to comply with oral health behaviours imposed by the parents. Studies have also shown that this type of parenting has been related with an increased risk of childhood obesity and conduct problems (12, 36). Opposed to coercive parents, overly permissive parents who have little control over their child’s behaviours, may be more likely to be indulgent towards their child’s wishes (e.g., when they want sweets) and avoid arguments when their child does not want to co-operate (e.g., when they do not want to brush their teeth) (37).

Our findings of low positive involvement, encouragement and problem solving in cases versus controls, suggest that parents of children with dental caries lack adequate positive parenting skills. On the other hand, a structured and supportive home environment, in which parents set appropriate and clear boundaries in the context of warm and affective interactions, could stimulate children to engage in healthy behaviours. For instance, it has been demonstrated that parents who reinforce proper behaviours with rewards or praising words are more likely to have children with healthy eating habits (38). Also, parental involvement in general may concur with monitoring children’s dietary intake and supervising children’s tooth brushing. However, it should be noted that the impact of parenting practices



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and family interactions on children’s oral health may depend, in part, on characteristics of the child. For example, Spitz et al. (39) have shown that children with difficult temperament had an increased risk of dental caries. This may create a vicious cycle, in which children’s problem behaviours may, in turn, influence children’s parenting practices (40).

To the best of the authors’ knowledge, this is the first study that was able to demonstrate an association between observed parenting practices and childhood dental caries. One of the strengths of this study was that observational methods were used, which were sensitive to detect subtle nuances in parenting practices within a normative range. Another advantage of observational methods is that they are free of reporting bias such as social desirability. The method used in this study captured the most relevant aspects of parenting practices according to the Social Interaction Learning model.

However, the findings of this study must be considered in the context of its limitations. With observational methods, there is a risk that the results are biased by the interpretation of the observer. In the present study, this risk was limited, as both coders were blind to the child’s condition and inter-coder agreement was high. Another potential limitation is that observed interactions could have been influenced by the ‘observer effect’, in which the presence of the observer or a video camera may cause individuals to behave in an unnatural manner (21). Therefore, observed behaviours may not reflect actual behaviours that are usually performed at home. Furthermore, only the interaction between the primary caregiver and the child was assessed. However, the primary caregiver was considered most important, as he/she spends the most time with the child.

Another potential limitation of case-control designs is the risk of selection bias. Cases were selected from a referral centre for paediatric dental care, while controls were recruited from a general dental practice. Therefore, cases and controls may not have been completely comparable. This potential bias was partly eliminated by matching cases and controls for sex and age and by adjusting for important confounding factors, including the mother’s education level and oral health behaviours. The participant-rate of this study was relatively high (78.3%), and possible sampling bias could not be determined. However, the generalizability of this study is confined, since only children of Dutch origin were included. Therefore, findings of this study could not be applied to families with diverse ethnic backgrounds, as positive parenting practices and family interactions may be defined differently depending on culture and social norms. Additionally, no conclusions on causality and temporal sequence of variables can be deduced from this case-control study. This study explored the relationship between parenting practices, parent-child interaction and childhood dental caries, using data that was collected at a single point in time. However, childhood dental caries is a chronic disease, which develops through the interaction of various oral health behaviours over time. These are habitual behaviours that are often initiated and established in the child’s early years. Therefore, parenting practices and family interactions are expected to be most influential on

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children’s oral health behaviours at the time that these behaviours are introduced into the child’s life. In this study, parenting practices and family interactions were measured when caries had already been developed, assuming that these are trait characteristics of the parent that are relatively stable over time. Prior research has shown that parenting practices are temporally stable (41, 42). The evidence for temporal stability is quite strong, although there is also proof of statistically significant but smaller bi-directional effects between parenting and child behaviour (43). Still, parenting practices as measured at the time of this study may not be entirely representative of parenting practices in a child’s early life. Longitudinal studies are needed to explore the role of parenting practices and family interactions in the initiation and maintenance of children’s oral health behaviours and their influence on the development of childhood dental caries over the years. Furthermore, it would be interesting to investigate the role of parenting practices in relation to socioeconomic inequalities in children’s dental health. There is clear evidence of a strong relationship between socioeconomic status and childhood dental caries. It is plausible that these socioeconomic conditions indirectly influence children’s oral health behaviours and subsequently their caries experience through an impact on parenting practices.

In conclusion, this case-control study found a strong relationship between parenting practices, parent-child interaction and childhood dental caries. High levels of coercion were associated with less parental involvement, such as lack of encouragement, positive affect and problem solving. This combination of suboptimal parenting behaviours may denote a form of neglect. In this sense, caries could be a warning sign for suboptimal parenting, which could compromise a child’s general physical and psychological well-being. The study points to a need for further study into the possible causal association between ineffective parenting and dental caries. The findings of this study provide some direction for the development of caries preventive programs. There is growing recognition that interventions to prevent dental decay in children should be directed at changing the underlying determinants of childhood dental caries, such as parental dental self-efficacy (44, 45), Locus of Control (46) and sense of coherence (47). Results of this study suggest that parenting practices may be another important determinant to consider in caries preventive interventions. Future studies should ascertain whether programs that incorporate components to improve parenting practices and family interactions are effective in preventing dental caries in children. Furthermore, it would be interesting to investigate whether such health promotion initiatives have the potential to benefit both children’s oral health and other health-related outcomes, including mental health.



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acknowledgements

The authors would like to thank Jessica de Mooij for helping with the data collection, Nadine Gijzen for guiding the SIT-training and for double coding the observations, prof. G.H.W. Verrips for his useful input for this study and prof. A. de Jongh for facilitating the writing of this paper.

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20. Seow WK, Clifford H, Battistutta D, Morawska A, Holcombe T. Case-control study of early childhood caries in Australia. Caries Res 2009;43:25–35.

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29. Forgatch MS, Bullock BM, Patterson GR. From theory to practice: Increasing effective parenting through role-play. In: Steiner H, editor: Handbook of mental health interventions in children and adolescents: An integrated developmental approach. New York: Jossey-Bass, 2004;782–812.

30. Forgatch MS, Knutson NM, Mayne T. Coder impressions of ODS lab tasks. Eugene: Oregon Social Learning Center, 1992.

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32. Lytton H. Correlates of compliance and the rudiments of conscience in two-year-old boys. Can J Behav Sci 1977;9:242–51.

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34. Granic I. Hollenstein T. Dynamic systems methods for models for developmental psychopathology. Dev Psychopathol 2003;15:641–69.

35. Jones R, Patterson GR, Reid JR. Naturalistic observation in clinical assessment. In: McReynolds P, editor: Advances in psychological assessment (Vol. 3). San Francisco: Jossey-Bass, 1975;42–95.


37. Skeie MS, Riordan PJ, Klock KS, Espelid I. Parental risk attitudes and caries-related behaviours among immigrant and western native children in Oslo. Community Dent Oral Epidemiol 2006;34:103–13.

38. Stark LJ, Collins FL Jr, Osnes PG, Stokes TF. Using reinforcement and cueing to increase healthy snack food choices in preschoolers. J Appl Behav Anal 1986;19:367–79.

39. Spitz AS, Weber-Gasparoni K, Kanellis MJ, Qian F. Child temperament and risk factors for early childhood caries. J Dent Child 2006;73:98–104.

40. Patterson GR. Coercive Family Process. Eugene: Castalia, 1982. 41. Clerkin SM, Marks DJ, Policaro KL, Halperin, JM. Psychometric properties of the Alabama

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42. Shaffer A, Lidhiem O, Kolko DJ, Trentacosta CJ. Bidirectional relations between parenting practices and child externalizing behavior: a cross-lagged panel analysis in the context of a psychosocial treatment and 3-year follow-up. J Abnorm Child Psychol 2013;411:199–210.

43. Lansford JE, Criss MM, Laird RD, Shaw DS, Pettit GS, Bates JE, et al. Reciprocal relations between parents’ physical discipline and children’s externalizing behavior during middle childhood and adolescence. Dev Psychopathol 2011;23:225–38.

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45. Finlayson TL, Siefert K, Ismail AI, Sohn W. Maternal self-efficacy and 1-5-year-old children’s brushing habits. Community Dent Oral Epidemiol 2007;35: 272–81.

46. Lenčová E, Pikhart H, Broukal Z, Tsakos G. Relationship between parental locus of control and caries experience in preschool children - cross-sectional survey. BMC Public Health 2008;8:208.

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6 parental and FamIly-related InFluences

on dental carIes In chIldren oF dutch, moroccan and turkIsh orIGIn

Denise Duijster Maddelon de Jong-Lenters

Corine de RuiterJill Thijssen

Cor van LoverenErik Verrips

Published in Community Dentistry and Oral Epidemiology 2014; doi: 10.1111/cdeo.12134.

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abstract

The aim of this cross-sectional study was to investigate the relationship between parental and family-related factors and childhood dental caries in a sample of 5- to 6-year old children of Dutch, Moroccan and Turkish origin. Furthermore, the relationship of parental and family-related factors with social class and ethnicity was examined. The study sample included 92 parent-child dyads (46 cases and 46 controls), which were recruited from a large paediatric dental centre in The Hague, The Netherlands. Cases were children with four or more decayed, missing or filled teeth and controls were caries free. Validated questionnaires were used to collect data on sociodemographic characteristics, oral health behaviours, parents’ dental self-efficacy and locus of control (LoC), parenting practices and family functioning. Parenting practices were also assessed using structured video observations of parent-child interactions. Parents of controls had a more internal LoC and they were more likely to show positive (observed) parenting in terms of positive involvement, encouragement and problem solving, compared to cases (P < 0.05). Lower social class was significantly associated with a lower dental self-efficacy, a more external LoC and poorer parenting practices. Furthermore, LoC was more external in Moroccan and Turkish parents, compared to Dutch parents. In conclusion, parents’ internal LoC and observed positive parenting practices on the dimensions positive involvement, encouragement and problem solving were important indicators of dental health in children of Dutch, Moroccan origin and Turkish. Findings suggest that these parental factors are potential mediators of socioeconomic inequalities in children’s dental health.


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introduction

Although significant improvements in children’s oral health have occurred in many Western countries over the last 30 years, oral health inequalities have emerged as a major public health challenge (1, 2). Higher levels of dental caries are found among children from lower socioeconomic backgrounds and certain ethnic minority groups (3, 4). In The Netherlands, the prevalence and severity of dental caries is highest among Dutch children from lower social classes and children of Moroccan and Turkish origin (5, 6). These latter ethnic groups constitute 12-20% of the population in the larger cities in The Netherlands and they are overrepresented in the lower socioeconomic strata (7).

High risk populations apparently fail to sufficiently benefit from conventional approaches in caries prevention. These approaches often focus on achieving individual behaviour change through dental health education and awareness raising programmes. The assumption of these approaches is that children and/or parents will alter their behaviour once they acquire the relevant knowledge and motivation (8). However, systematic reviews have reported on the limited effectiveness of educational interventions to produce sustained improvements in oral health outcomes, particularly in those from lower socioeconomic position and ethnic minority groups (9, 10). Therefore, a paradigm shift in caries prevention is needed towards innovative strategies that address the underlying determinants of childhood dental caries. The development of such strategies requires understanding of the full range of oral health determinants and the mechanisms by which socioeconomic conditions and ethnicity affect children’s dental health.

One factor that plays an important role in the development of childhood dental caries is the family (11). The family provides the child’s proximate home environment that promotes certain oral health-related behaviours, expectations, beliefs and social norms. Parental attributes, parenting practices and overall family functioning all capture components of the family system, yet, they are distinct constructs that may differentially influence children’s caries experience. Parental attributes are characteristics of the parents that may influence the quality of the home environment. Examples of parental attributes that were associated with higher levels of childhood dental caries include parental stress (12, 13), low sense of coherence (14, 15), maternal depression (16), low dental self-efficacy (17-19) and an external dental health-related locus of control (LoC) (17, 20). Parenting practices refer to parental behaviours specifically directed towards raising the child. A recent study reported a significant relationship between parenting practices and children’s oral health outcomes (21), while two other studies did not (16, 22). Broader family functioning measures relate to the evaluation of interactions between family members at a systemic level, such as parent-child, parent-parent and sibling-sibling relationships, and how these relationships interact to influence overall family functioning (23). Two studies reported that good family functioning,

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i.e., in terms of responsiveness, involvement, communication and organization/structure, was significantly associated with lower levels of dental decay, better oral hygiene and less frequent consumption of sugary foods in children (24, 25).

In summary, the literature acknowledges a range of parental and family factors as possible mediators of caries development in children, yet the evidence relies on few empirical studies. Furthermore, it remains unclear whether these factors could explain socioeconomic and ethnic inequalities in the prevalence of childhood dental caries. Therefore, the aim of this study was to explore the relationship between parental and family-related factors (parents’ dental self-efficacy and LoC, parenting practices and family functioning) and childhood dental caries in a sample of 5- to 6-year old children of Dutch, Moroccan and Turkish origin. A further objective was to explore the relationship of parental and family-related factors with social class and ethnicity. The hypothesis of this study was that parents of caries free children (controls) had a higher dental self-efficacy, a more internal LoC and more positive parenting practices and family functioning, compared to children with dental caries (cases). Furthermore, it was hypothesized that these parental and family-related factors were more favourable in parents from higher social classes and those of Dutch origin, compared to parents from lower social classes and those of Moroccan or Turkish origin, respectively.


Ethical approval for this study was obtained from The Central Committee on Research Involving Human Subjects, The Netherlands (CCMO). Prior to data collection, all participating parents provided written informed consent.

Study sample Data for this study were collected between September 2013 and March 2014. Participants were recruited from a large paediatric dental care centre in The Hague, The Netherlands. The centre works in partnership with elementary schools and has clinics in different geographical regions in the city that vary in terms of socioeconomic level and immigrant population.

All 5- and 6-year old children that were of Dutch, Moroccan and Turkish origin were selected. Children were considered of Dutch origin if both their parents were born in The Netherlands. Children were classified as Moroccan or Turkish if (i) both their parents were first-generation immigrants, or (ii) if one parent was a first-generation immigrant and one parent was a second-generation immigrant. Subsequently, children were selected and allocated according to their dental condition into two groups: cases and controls. Cases were defined as children with at least four decayed, missing or filled deciduous teeth (dmft score ≥ 4), irrespective of the condition of the permanent teeth, because the number of erupted permanent teeth varied among children. Controls had no decayed, missing or filled



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teeth in both their deciduous and permanent dentition (dmft/DMFT = 0, referred to as ‘caries free’). A dmft value of 4 was chosen to define cases, because it corresponds with the mean and median dmft of 5-year-old children with dental caries in the 2006 Dutch National Oral Health Survey (26). Children diagnosed with emotional and behavioural disorders (e.g., autism spectrum disorders), children with special needs and children with tooth enamel defects were excluded from study selection. Only one child per family was included. The sample size was determined on the basis of a previously conducted study by de Jong-Lenters et al. (21). This study found statistically significant differences in parenting practices between cases and controls with an effect size of d = 0.90 or higher. Given this effect size, a power calculation indicated that a minimum sample of 50 children would be sufficient to detect differences in parenting variables between cases and controls, based on 90% of power and 5% level of significance. However, the sample size of this study was increased further to ensure enough participants in the socioeconomic and ethnic subgroups to be compared.

An information letter about the study was sent to the home address of all eligible children (n = 271; 165 cases and 106 controls). The parents of the children were subsequently contacted by telephone and kindly requested to participate. A total of 92 parent-child dyads participated in the study, including 46 cases and 46 controls (response rate = 34%). Common reasons for non-participation in the ethnic minority groups were the language barrier and difficulties with transportation to the dental care centre, while the Dutch group reported no interest and/or no time as main reasons for non-participation. The response rate varied from 13% in Turkish cases to 57% in Dutch controls. Participation involved a 90-minute visit of the child and a parent to the paediatric dental care centre. Incentives for the study included a monetary voucher for the parent (20 euro’s) and a small gift and oral hygiene kit for the child.

Data collectionDental health dataChildren’s dmft(/DMFT) scores were obtained from personal dental health records from the paediatric dental centre. The diagnosis of dental caries was based on clinical examinations (supported by dental x-rays), which were performed by dentists working at the centre. The centre registers data in a protocolled manner to ensure that records are up-to-date and complete. The dental status of children’s primary dentition was extracted using data from the last dental visit, which had been no more than six months before the time of data collection of this study. The dmft(/DMFT) score was calculated by adding the number of decayed (at the dentine level), missing (due to caries), and filled teeth. Data extraction was performed by one researcher (DD), who holds a Bachelor of Science degree in Dentistry.

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Sociodemographic and behavioural dataA parental self-report questionnaire was used to collect data on sociodemographic characteristics and oral health behaviours. Sociodemographic variables included the mother’s highest completed level of education, family income and family structure. The mother’s education level was used as an indicator for social class and was categorized into (i) lower education (no education, elementary school and secondary school at lower level), (ii) medium education (secondary school at higher level and further education at lower level) and (iii) higher education (further education at higher level and university). The oral health behaviours measured were tooth brushing frequency, the age tooth brushing was started, parental involvement with tooth brushing and the frequency of consuming sugary foods and drinks between meals. Fluoride toothpaste is the only source of fluoride in The Netherlands. Since 99% of children in The Netherlands are brushing with fluoride toothpaste, tooth brushing frequency also reflects fluoride use.

Parental and family-related variablesTable 1 presents an overview of parental and family-related variables measured in this study. For each variable a definition is described.

Parental oral health-related attributesParents’ dental self-efficacy and dental health LoC were measured using a validated questionnaire developed by Pine et al. (27). This questionnaire assesses parental beliefs and attitudes associated with children’s oral health behaviours, including sugar snacking and tooth brushing with fluoride toothpaste.



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Parenting practicesDifferent approaches to measuring parenting practices have been devised, which include self-report questionnaires (“insider’s view”) and observational methods that rely on ratings from an observer external to the family (“outsider’s view”). Since there is little congruence in parenting assessment between these two methodologies (28), both observational and self-report methods were used to measure parenting practices in this study.

The self-report Alabama Parenting Questionnaire (APQ) was used to measure parenting practices on three dimensions: involvement, positive parenting and inconsistent discipline (29). The APQ was designed to tap the most important aspects of parenting practices related to disruptive behaviour problems in children. The measure demonstrated adequate levels of reliability and construct validity (29).

Parenting practices were also observed using Structured Interaction Tasks (SIT) (30-32). This observational method measures relevant aspects of parenting practices known to impact on children’s socio-emotional development and behaviours. The SIT contains seven structured tasks which are performed by the child and the parent in a quiet room at the paediatric dental care centre. Tasks include: planning a fun activity for the weekend (3 min), problem solving on a topic selected by the parent (5 min), drawing a picture of their home (7 min), snack break (5 min), problem solving on a topic selected by the child (5 min), teaching/learning tasks (9 min), and a monitoring task in which the parent interviews the child about a moment when the child was not in the parent’s direct presence (5 min). All parent-child interactions were videotaped. The video material was rated using an objective coding system, based on the Coder Impressions (33). The coding system contains specific items for each SIT task, as well as general items related to the overall quality of the interaction between parent and child during the entire session. Items measure six underlying dimensions of parenting practices: positive involvement, encouragement, problem solving, discipline, coercion and interpersonal atmosphere. All observations were coded by one trained and calibrated observer who was blind to the dental condition. A random selection of 12 observations (13%) was double coded by a second blind observer for a reliability check. The percentage agreement between coders (difference in scores = 0, and difference in scores = 0 or 1) was 72.5% and 94.4%, respectively. The intra-class correlation was 0.88.

Family functioningFamily organization and social network were assessed by the Gezinsvragenlijst (GVL, translation ‘Family Questionnaire’), a validated measure to assess family functioning and the quality of family relationships (24, 34). Psychometric evaluation supported the reliability and the validity of the GVL (34).



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The questionnaire items by Pine et al. and the APQ-items were translated into Dutch and back-translated. The self-report questionnaires were interview-administered if a parent was illiterate. All items of the questionnaire by Pine et al., the APQ, the SIT and the GVL were measured on a 5-point Likert scale. A cumulative score for each dimension was computed. The number of items per dimension, the range of the scores, the direction of scores and the internal consistency for each variable in the present sample are presented in Table 1.

Statistical analysisStatistical analysis was carried out using SPSS (Version 20, IBM Corp.). Independent samples T-tests were performed to compare mean scores of parental and family-related variables between cases and controls. Furthermore, logistic regression analysis was conducted for the association of parental and family-related variables with the dental condition as the dependent variable (control vs. case). To test whether social class and ethnicity modified the effects of parental and family-related variables on the dental condition, interaction terms with social class and ethnicity were introduced into the regression models. Presence of interactions was subsequently examined using the likelihood ratio test. Differences in parental and family-related variables between socioeconomic groups and Dutch, Moroccan and Turkish groups were compared using analysis of variance (ANOVA). A P-value of < 0.05 was considered significant.

results

Description of the sampleThe study sample included 92 parent-child dyads (46 cases and 46 controls), consisting of 35 Dutch children (14 cases and 21 controls), 31 Moroccan children (18 cases and 13 controls) and 26 Turkish children (14 cases and 12 controls). Seventy-four percent of the participating parents were biological mothers and 26% were biological fathers. The mean age of the children was 6.1 ± 0.5 years (range = 5.3-6.9). Cases had an average dmft of 6.5 ± 2.3 (range = 4-12), while controls had a mean dmft/DMFT of 0.0 ± 0.0. Sample characteristics are summarized in Table 2. Girls were significantly overrepresented in cases (69.6%) compared to controls (47.8%). Cases and controls did not differ significantly in mother’s education level, family income, birth order of the child and relationship status of the parents. In terms of oral health behaviours, cases reported more frequent consumption of sugary foods between meals compared to controls (although this was only a trend, P = 0.06), but this was not the case for consumption of sugary drinks. There were no statistical differences in tooth brushing frequency, age tooth brushing was started and parental involvement with tooth brushing between cases and controls.

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Table 2. Distribution of sociodemographic characteristics and oral health behaviours between cases and controls.

Controls (n = 46) Cases (n = 46)Variables n (%) n (%) P*SociodemographicsEthnicity

Dutch 21 (45.7) 14 (30.4) 0.31Moroccan 13 (28.3) 18 (39.1)Turkish 12 (26.1) 14 (30.4)

SexBoy 24 (52.2) 14 (30.4) 0.03Girl 22 (47.8) 32 (69.6)

Education level (mother)Lower education 16 (35.6) 23 (50.0) 0.20Medium education 13 (28.9) 14 (30.4)Higher education 16 (35.6) 9 (19.6)

Family incomeBelow modal 16 (36.4) 24 (52.2) 0.22Modal 17 (38.6) 16 (34.8)Above modal 11 (25.0) 6 (13.0)

Birth order3rd child or more 9 (20.5) 12 (27.3) 0.602nd child 19 (43.2) 20 (45.5)1st child 16 (36.4) 12 (27.3)

Relationship statusSingle 8 (17.8) 13 (28.9) 0.21With partner 37 (87.2) 32 (71.1)

Oral health behavioursTooth brushing frequency

(Often) less than twice a day 17 (37.8) 20 (45.5) 0.46Always twice a day or more 28 (62.2) 24 (54.5)

Age tooth brushing was startedTwo years old or older 5 (11.1) 6 (14.3) 0.90Between one and two years old 15 (33.3) 14 (33.3)Less than one year old 25 (55.6) 22 (52.4)

Parental involvement with tooth brushingNever – sometimes 13 (32.5) 13 (30.2) 0.82Often – always 27 (67.5) 30 (69.8)

Frequency of sugary foods between mealsThree times or more per day 15 (33.3) 23 (52.3) 0.07Twice or less per day 30 (66.7) 21 (47.7)

Frequency of sugary drinks between mealsThree times or more per day 15 (33.3) 21 (47.7) 0.17Twice or less per day 30 (66.7) 23 (52.3)

* χ²-test



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Correlations between parental and family-related factorsA correlation matrix of all parental and family-related factors is presented in Table 3. A higher dental self-efficacy was significantly associated with a more internal LoC (Pearson’s r = 0.41). Dental self-efficacy and LoC were also moderately correlated with several (observed) parenting dimensions, including positive involvement, encouragement and problem solving. The majority of the SIT dimensions were moderately to strongly intercorrelated. In particular, strong associations were found for encouragement with problem solving and coercion (r = 0.59 and r = -0.59, respectively), and for problem solving with interpersonal atmosphere (r = 0.60).

As expected, there was limited congruence between parenting practices measured with the APQ (self-report method) and parenting practices measured with the SIT (observational method). Correlations were r = 0.24 (significant at P = 0.03) for APQ-involvement and SIT- positive involvement, r = 0.06 (not significant) for APQ-positive parenting and SIT-encouragement and r = -0.31 (significant at P = 0.003) for APQ-inconsistent discipline and SIT-discipline.

Differences in parental and family-related factors between cases and controlsParents’ LoC was significantly more internal in controls than in cases, but parents’ dental self-efficacy did not differ significantly between cases and controls (Table 4). In terms of parenting practices, the SIT dimensions positive involvement, encouragement and problem solving were significantly higher in controls than in cases. Yet, there were no significant differences between cases and controls on any of the APQ dimensions and on the SIT dimensions discipline, coercion and interpersonal atmosphere. Furthermore, cases did not differ significantly from controls in the quality of family organization and social network.

Similar associations were found when the association of parental and family-related dimensions with the dental condition was examined using logistic regression (results not shown). Sex-adjusted Odds Ratio’s and 95% confidence intervals were 0.92 (0.86 – 0.98), 0.91 (0.82 – 0.99), 0.93 (0.88 – 0.98) and 0.95 (0.92 – 0.98) for LoC and the SIT dimensions positive involvement, encouragement and problem-solving, respectively, indicating that higher scores on these dimensions were associated with a decreased likelihood of being a case compared to a control. There was no evidence for an interaction with social class or ethnicity: the effect of parental and family-related factors on children’s dental condition did not differ significantly across socioeconomic and ethnic strata.

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Tabl

e 3:

Cor

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180.

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etw

ork.



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Table 4. Mean scores and standard deviations of parental oral health-related attributes, parenting practices and family functioning between cases and controls.

Controls (n = 46) Cases (n = 46)Variables mean ± SD range mean ± SD range P*

Oral health-related attributesDental self-efficacy 35.2 ± 5.8 22-45 34.4 ± 4.8 24-45 0.49Dental health locus of control 31.7 ± 6.8 12-44 27.3 ± 7.6 10-39 0.005

Parenting practices (APQ)Involvement 41.5 ± 4.8 27-50 40.7 ± 4.0 31-48 0.37Positive parenting 26.1 ± 2.4 21-30 26.4 ± 2.8 21-30 0.59Inconsistent discipline 16.0 ± 3.0 10-22 14.9 ± 3.4 7-22 0.13

Parenting practices (SIT)Positive involvement 51.5 ± 4.5 41-59 49.2 ± 4.8 39-59 0.03Encouragement 78.7 ± 8.0 62-92 73.7 ± 8.7 59-87 0.007Problem solving 102.3 ± 12.6 73-128 92.9 ± 13.7 52-119 0.001Discipline 122.0 ± 4.9 104-125 121.3 ± 6.9 95-125 0.59Coercion 20.6 ± 4.1 16-34 21.8 ± 4.8 16-34 0.22Interpersonal atmosphere 109.9 ± 5.5 94-120 108.7 ± 5.8 81-117 0.33

Family functioningOrganization 40.0 ± 3.2 34-45 39.4 ± 4.3 28-45 0.42Social network 38.2 ± 5.9 20-45 37.1 ± 7.0 16-45 0.45

* Independent samples T-test

The relationship of parental and family-related factors with social class and ethnicitySocial class was significantly associated with parental oral health-related attributes and all SIT dimensions, except discipline (Table 5). Parents of children from higher social classes had a higher dental self-efficacy and a more internal LoC. They also showed higher levels of positive involvement and encouragement, better problem solving and a better interpersonal atmosphere during interactions with their child, and they were less likely to show coercive behaviours. The association between social class and the APQ dimension involvement was borderline significant. No significant associations were found for social class with the APQ dimensions positive parenting and discipline, nor with family functioning.

Dutch parents had a more internal LoC (32.7 ± 5.8) compared to Moroccan parents (29.0 ± 7.4, P = 0.004) and compared to Turkish parents (25.5 ± 7.9, P < 0.001). All other parental and family-related factors were not significantly different between Dutch, Moroccan and Turkish parents (results not shown).

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Table 5. Mean scores and standard deviations of parental oral health-related attributes, parenting practices and family functioning between children with lower, medium and higher educated mothers.

Low (n = 39) Medium (n = 27) High (n = 25)Variables mean ± SD mean ± SD mean ± SD P*

Oral health-related attributesDental self-efficacy 33.5 ± 5.5 34.6 ± 5.8 36.9 ± 5.2 0.04Dental health locus of control 24.8 ± 7.7 32.0 ± 4.8 34.2 ± 5.1 <0.001

Parenting practices (APQ)Involvement 39.9 ± 3.7 41.6 ± 5.2 42.4 ± 4.2 0.06Positive parenting 26.1 ± 2.7 26.9 ± 2.1 25.8 ± 2.7 0.27Inconsistent discipline 15.7 ± 3.2 15.5 ± 3.7 14.9 ± 2.8 0.63

Parenting practices (SIT)Positive involvement 48.7 ± 4.8 50.4 ± 4.2 52.6 ± 4.6 0.006Encouragement 71.2 ± 8.3 78.0 ± 6.9 81.3 ± 7.4 <0.001Problem solving 90.3 ± 13.0 100.2 ± 11.5 104.9 ± 13.1 <0.001Discipline 120.6 ± 7.1 122.7 ± 4.5 122.1 ± 5.5 0.36Coercion 23.0 ± 4.9 20.1 ± 3.6 19.8 ± 3.9 0.006Interpersonal atmosphere 107.0 ± 7.2 110.6 ± 3.5 111.3 ± 3.5 0.004

Family functioningOrganization 38.9 ± 4.3 40.3 ± 3.7 40.1 ± 3.0 0.28Social network 36.7 ± 7.3 38.5 ± 5.6 38.4 ± 5.9 0.43

* One-way ANOVA

discussion

This cross-sectional study found that parents’ dental health LoC and observed parenting practices were significantly associated with childhood dental caries in a sample of 5- to 6-year old children of Dutch, Moroccan and Turkish origin. Parents of caries free children had a more internal LoC regarding dental health and they were more likely to show positive parenting practices in terms of positive involvement, encouragement and problem solving, compared to parents of children with four or more decayed, missing or filled teeth.

Interestingly, several observed parenting practices (measured with the SIT) were significantly associated with childhood dental caries, while similar parenting practices measured through self-report (with the APQ) were not. In line with this, the observational ratings did not correlate strongly with self-report ratings of parenting practices. Findings from other dental health studies are equivocal: one study reported strong differences in observed



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parenting practices between children with and without dental caries (21), while two studies using self-report methods (the Parenting Scale and the Authoritative Parenting Index) did not find an association between parenting and children’s oral health outcomes (16, 22). Thus, the question is raised: which findings are more valid? The abovementioned studies, including the present study, used well-validated self-report family measures with good psychometric properties. Still, there is considerable discussion regarding the advantages and disadvantages of using self-report methods vs. observational methods for parenting assessment (28, 35). Self-report methods rely on parents’ own beliefs and perceptions of their parenting behaviour. However, it is generally accepted that these can be quite distinct from actual behaviours (36). Furthermore, there may be a tendency of parents to answer questions about their parenting in a socially desirable manner. Structured observational methods do not possess these limitations and have the advantage that all participants receive the exact same standardized instruction. However, with observational ratings there is a risk that results may be biased by the interpretation of the observer, yet this was limited in the present study, because coders were blind to the child’s dental condition and inter-coder agreement was high.

Another issue with self-report parenting assessment is that most parenting measures have been developed for use in a clinical context, designed to distinguish between ‘problem families’ and ‘non-problem families’. Yet, in oral health research, the majority of the participating families are normative families that do not necessarily have clinical problems. Therefore, the self-report methods used in oral health studies may not have been sensitive enough to discriminate among parenting practices within the normative range. The current study demonstrated a significant and meaningful relationship between observed parenting practices and childhood dental caries. This suggests that observational ratings are able to detect subtle nuances in parenting practices that are relevant to caries development. Thus, it seems that research into parenting behaviours in relation to oral health outcomes may better rely on objective observational methods, rather than self-report ratings.

Oral health behaviours likely play an important mediating role in the relationship between parental factors and children’s caries experience. The role of parents is central in shaping children’s behaviours, attitudes and social norms regarding oral health (11). Their perceptions of LoC, or judgment about their ability to control their child’s dental health, can be an important argument for why they engage in oral health promoting behaviours for their children. Parenting practices provide the context in which parents’ intended oral health promoting behaviours are delivered and interpreted by the child. For example, positive parenting practices may directly enhance children’s uptake of healthy habits through modelling and reinforcing proper behaviours (e.g., with rewards or praising words) (37), and through monitoring and controlling children’s dietary intake and oral hygiene habits. Furthermore, it has been shown that behavioural directions are most accepted by the child when the parent displays moderate levels of strictness and when the child experiences greater involvement or warmth from the

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parent (38, 39). On the other hand, ineffective parenting (characterized by highly demanding disciplining practices, and low levels of positive interaction) has been associated with a higher degree of resistance and non-compliance in children (40, 41), which may have similar effects on children’s compliance with oral health behaviours. Ineffective parenting has also been related to an unhealthy diet and childhood obesity, including higher caloric intake, lower fruit and vegetable consumption and lower frequency of eating breakfast (38, 42-45). Our findings of lower levels of positive involvement, encouragement and problem solving in children with dental caries, compared to caries free children, suggest that ineffective parenting also affects children’s dental health.

There is clear evidence for a socioeconomic gradient in childhood dental caries, yet the underlying mechanisms that account for the strong relationship between social class and children’s caries experience are not fully understood. It is plausible that parenting and family factors are partially responsible for socioeconomic inequalities in children’s dental health, as parenting and family factors are known to be socially patterned (46, 47). The current study confirmed an association between parental and family-related factors and socioeconomic status: being from a lower social class increased the likelihood of having parents with less favourable oral health-related attributes and parenting practices. These, in turn, were associated with an increased risk of dental caries in children, which supports the potential mediating role of parents’ oral health-related attributes and parenting practices in the relationship between socioeconomic conditions and childhood dental caries. The mediating role of family factors has been conceptualized in a theoretical model by Fisher-Owens et al. (48) and empirically tested in a structural path model (49). This model implies that social conditions indirectly influence children’s oral health behaviours and subsequently children’s caries experience through an impact on inter-related parental and family factors. Parents’ LoC was significantly more external in parents of Moroccan and Turkish backgrounds, compared to Dutch backgrounds, which could contribute to the explanation of ethnic variation in children’s caries experience. However, whether this factor plays a mediating role in ethnic inequalities in children’s dental health, in addition to other explanatory variables, including SES, should be further investigated in a sufficiently large sample using structural equation modelling.

One of the evident strengths of this study was the use of reliable and valid instruments to measure parental and family-related factors. The instruments had good psychometric properties and they derive strength from their basis in theoretical models. A novel approach was that both observational and self-report methods were used, providing multiple perspectives of the family. Furthermore, this study included a unique study sample with a large proportion of children from lower social class and from Moroccan and Turkish origin, which are difficult groups to recruit for research purposes. However, some potential limitations should be taken into account. Limitations include the relatively small sample size of the subgroups and the



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limited generalizability. Children from a general dental practice and children whose parents don’t speak the Dutch language were not included and the non-response rate was relatively high. Nevertheless, the current study sample was appropriate for testing the hypotheses, and the number of included participants was sufficient to detect statistically significant differences with an effect size d = 0.45, a power of 0.80 and a significance level of α = 0.05. Notably, there were no significant differences in social class between caries free children and children with dental decay. The absence of an expected difference in caries level in relation to social class could perhaps be attributed to selection bias and the fact that children with and without dental caries were recruited from the same patient population of the paediatric dental care centre. In addition, no conclusions on temporal and causal associations of variables can be deduced from this cross-sectional study. Despite evidence for temporal stability of parenting and family functioning (50, 51), life events and transitions that occur in the family may affect parental and family-related factors over time. Prospective, longitudinal studies are therefore needed to investigate the role of parental and family-related factors in the initiation of children’s oral health behaviours and the development of childhood dental caries over the years. Such an approach will also allow in depth-examination of the mediating or moderating effects of these family factors on socioeconomic inequalities in childhood dental caries.

In conclusion, parents’ internal belief of their ability to control their child’s dental health, and observed positive parenting practices on the dimensions of positive involvement, encouragement and problem solving, were important indicators of dental health in children of Dutch, Moroccan and Turkish origin. Findings of this study indicate that these parental factors are potential mediators of socioeconomic inequalities in children’s dental health. The important influence of parents on childhood dental caries supports the design of health promotion strategies that intervene at this level to further reduce caries levels in children, especially in those at higher risk.

acknowledgements

This study was financially supported by Menzis Health Insurer, The Netherlands. The authors thank Sanne Bax and Sinica Cheung for helping with data collection, Nadine Gijzen for guiding the SIT-training and for double coding the observations, and all parents and children who participated in the study. We also gratefully acknowledge the support from the Jeugdtandzorg Den Haag, especially Hans Berendsen, Helga Wissenburg and Sylvia Gossen.

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reFerences




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13. Menon I, Nagarajappa R, Ramesh G, Tak M. Parental stress as a predictor of early childhood caries among preschool children in India. Int J Paediatr Dent 2013;23:160–5.


15. Qiu RM, Wong MCM, Lo ECM, Lin HC. Relationship between children’s oral health-related behaviors and their caregiver’s sense of coherence. BMC Public Health 2013;13:239.


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21. de Jong-Lenters M, Duijster D, Bruist M, Thijssen J, de Ruiter C. The relationship between parenting, family interaction and childhood dental caries: a case-control study. Soc Sci Med 2014;116:49–55.

22. Aleksejūnienė J, Brukienė V. Parenting style, locus of control, and oral hygiene in adolescents. Medicina (Kaunas) 2012;48:102–8.

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25. Nanjappa S. Family functioning and frequency of sugar consumption by 3 and 4 year old children in Outer North East London. PhD thesis, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 2012.

26. Poorterman JHG, Schuller AA. Tandheelkundige verzorging Jeugdige Ziekenfondsverzekerden (TJZ). Eindmeting 2005. Academisch Centrum Tandheelkunde Amsterdam, TNO Kwaliteit van Leven, Amsterdam/Leiden 2006.

27. Pine CM, Adair PM, Nicoll AD, Burnside G, Petersen PE, Beighton D, et al. Developing explanatory models of health inequalities in childhood dental caries. Community Dent Health 2004;21(Suppl.1):86–95.

28. Hampson RB, Beavers WR, Hulgus YF. Insiders’ and outsiders’ views of family: The assessment of family competence and style. J Fam Psychol 1989;3:118–36.

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30. Forgatch MS, DeGarmo DS. Parenting through change: An effective prevention program for single mothers. J Consult Clin Psychol 1999;67: 711–24.

31. DeGarmo DS, Forgatch MS. Efficacy of parent training for stepfathers: From playful spectator and polite stranger to effective stepfathering. Parent Sci Pract 2007;7:331–55.

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33. Forgatch MS, Knutson NM, Mayne T. Coder impressions of ODS lab tasks. Eugene: Oregon Social Learning Center, 1992.

34. Scholte E, Van der Ploeg J. The Family Questionnaire: A measure to assess the quality of family functioning. J Fam Issues 2013;doi:10.1177/0192513X13506707.

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37. Stark LJ, Collins FL Jr, Osnes PG, Stokes TF. Using reinforcement and cueing to increase healthy snack food choices in preschoolers. J Appl Behav Anal 1986;19:367–79.

38. Rhee K: Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. Ann Am Acad Pol Soc Sci 2008;615:11–37.




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42. Kremers SP, Brug J, de Vries H, Engels RCME. Parenting style and adolescent fruit consumption. Appetite 2003;41:43–50.


44. Arredondo EM, Elder JP, Ayala GX, Campbell N, Baquero B, Duerksen S. Is parenting style related to children’s healthy eating and physical activity in Latino families? Health Educ Res 2006;21:862–71.

45. Wake M, Nicholson JM, Hardy P, Smith K. Preschooler obesity and parenting styles of mothers and fathers: Australian national population study. Pediatrics 2007;120:1520–7.

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47. Brown J, Cohen P, Johnson JG, Salzinger S. A longitudinal analysis of risk factors for child maltreatment: findings of a 17 year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse Neglect 1998;22:1065–78.


49. Duijster D, van Loveren C, Dusseldorp E, Verrips GHW. Modelling community, family and individual determinants of childhood dental caries. Eur J Oral Sci 2014;122:125–33.

50. Clerkin SM, Marks DJ, Policaro KL, Halperin JM. Psychometric properties of the Alabama parenting questionnare-preschool revision. J Clin Adolesc Psychol 2007;36: 19–28.

51. Shaffer A, Lidhiem O, Kolko DJ, Trentacosta CJ. Bidirectional relations between parenting practices and child externalizing behavior: a cross-lagged panel analysis in the context of a psychosocial treatment and 3-year follow-up. J Abnorm Child Psychol 2013;411:199–210.



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7 parents’ VIews on the InFluences on chIldren’s

oral health behaVIours and theIr Ideas For carIes preVentIVe InterVentIons: a QualItatIVe study

Denise Duijster Maddelon de Jong-Lenters

Erik VerripsCor van Loveren

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abstract

The prevention of childhood dental caries relies on adherence to key behaviours, including twice daily tooth brushing with fluoride toothpaste and reducing the consumption of sugary foods and drinks. The aim of this qualitative study was to explore parents’ perceptions of factors that influence these oral health behaviours in children. A further objective was to explore parents’ desires and recommendations for interventions to support parents in the establishment of dentally healthy behaviours in their child. Six focus group interviews were conducted, including a total of 39 parents of 7-year old children. Analysis of interview transcripts identified various factors, operating at child, family and community level, that were perceived to impact on children’s oral health behaviours. Primary influences were related to parental attributes and the family environment, including parental knowledge, perceptions, self-efficacy and control, parenting strategies and family organization. Children’s sugar consumption was also heavily influenced by factors external to the family, such as the school and social environment. Parents suggested several recommendations for interventions to improve children’s oral health behaviours, many of their ideas concerning the desire to receive clear and tailored oral health information, starting from a child’s early age. However, while knowledge may be a prerequisite for parents to engage in dentally healthy behaviours, many may need support in overcoming barriers to successfully implement them. The qualitative data derived from this study are useful to inform new approaches for caries prevention in children.


A Qualititave Study On Caries Prevention

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introduction

Dental caries is a common childhood disease with a range of biological and behavioural risk factors involved in its aetiology (1). Children are most likely to develop caries if they acquire Streptococcus Mutans at a young age, which can largely be compensated by other parameters, such as good oral hygiene and a non-cariogenic diet (2, 3). Therefore, the prevention of childhood dental caries mainly relies on adherence to key behavioural messages, including twice daily tooth brushing from an early age with fluoride toothpaste and reducing the frequency of consuming sugary foods and drinks (4). However, it is increasingly recognized that knowledge of these messages alone does rarely lead to sustained behaviour change in individuals (5), because simple oral health behaviours are enmeshed in more complex daily habits which are largely determined by a broad scope of psychosocial, economic and environmental factors (6). In this context, efforts to prevent childhood dental caries cannot narrowly focus on individuals and their biology and behaviours alone, but should consider the underlying determinants of children’s dental health as well.

This increased appreciation has led to articles conceptualizing and exploring the broader influences on the development of childhood dental caries. A comprehensive conceptual model by Fisher-Owens et al. (7) acknowledges a wide range of determinants of children’s oral health and oral health-related behaviours, such as parents’ health beliefs, practices and coping skills (8-10), family functioning (11) and composition (12, 13), social support (11, 14) and more distal factors, such as the living environment (15, 16), culture (17), social capital (18) and the (dental) health care system (19). These determinants are suggested to operate at both child, family and community level, with interactions occurring across the various levels of influence.

Although empirical evidence on children’s dental health determinants is emerging, there is still much that is not understood about the way factors and processes affect children’s dental health. Understanding can be augmented by qualitative research of exploring parental perspectives on the influences of childhood dental caries (20). Given the role of parents as principal regulators of children’s dietary intake and the important role of the family environment in shaping children’s oral hygiene habits, it is important to document their views. Qualitative methods can provide a rich and holistic description of parents’ experiences, opinions and perspectives about the context in which children’s oral health behaviours are developed, and the support that is needed to change these behaviours. This data can be useful to inform new approaches for caries prevention in children.

There are a few qualitative studies which sought to explore parental perspectives on children’s dental health (17, 21-25), yet these studies mainly focussed on influences on children’s tooth brushing behaviours or attitudes towards the significance of children’s dental health, or they referred to specific population groups. Therefore, the present study conducted

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focus group interviews with parents of 7-year-old children from The Netherlands, with the aim to explore their perceptions of factors (barriers and facilitators) that influence children’s oral health behaviours. The oral health behaviours studied were twice daily tooth brushing with fluoride toothpaste and reducing children’s consumption of sugary foods and drinks. A further objective was to explore parents’ desires and recommendations for interventions to support parents in the establishment of dentally healthy behaviours in children.


Approval for this study was obtained from The Medical Ethical Committee of the Vrije Universiteit Amsterdam, The Netherlands. Prior to data collection, all participating parents provided written informed consent.

Study design and sampling procedureQualitative focus group interviews were conducted between November 2012 and July 2013. Participants were parents of children who had previously taken part in a quantitative cross-sectional study in 2011-2012, which was set up to investigate family-related determinants of childhood dental caries (11). In this quantitative study, a stratified random sample of 630 6-year old children was recruited from paediatric dental centres located in various regions in The Netherlands. Data on sociodemographic characteristics, oral health behaviours and family variables were collected using validated parental questionnaires. Children’s dental health status, expressed as the number of decayed, missing and filled teeth (dmft score), was extracted from personal dental records.

For the present study, a purposive sampling technique was used to select a subgroup of parents to participate in the focus group interviews. Selection was based on parents’ ethnic background, socioeconomic status (SES), geographical region and their child’s dental health status. This was done to ensure that a diverse range of views was adequately represented and to create homogeneous focus groups of people who share similar cultural and socioeconomic characteristics. Separate focus group interviews were held with parents who were born in The Netherlands, parents who were first-generation immigrants from Turkey, and parents who were first-generation immigrants from Morocco. These two latter ethnic groups were targeted, because they constitute 12-20% of the population in the larger cities in The Netherlands (26), and the caries prevalence among children from these ethnic groups is relatively high (27). Focus groups with Dutch parents were stratified by SES. The mother’s highest completed level of education was used as an indicator for SES, which categorized parents into a low SES group (no education, elementary school, secondary school at lower level and further education at lower level) and a high SES group (secondary school at higher level, further education at higher level and University). The focus groups



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with Turkish and Moroccan parents were not stratified by SES, because the majority of first-generation immigrants from Turkey and Morocco that participated in the quantitative study were from low SES as determined by their education level. Furthermore, within each focus group, parents of caries free children (dmft = 0), parents of children with moderate levels of dental caries (dmft ≥ 1 < 4) and parents of children with high levels of dental caries (dmft > 4) were purposively selected. Focus group interviews were held in four different geographical areas in which a paediatric dental centre was located, namely in Zoetermeer, Enschede, Den Haag and Utrecht. The areas vary greatly in terms of socioeconomic location and the proportion of immigrants living in the area.

All selected parents were informed about the study by telephone and requested to participate. Parents who agreed to participate (response-rate: 36%) received a confirmation letter at their home address, informing them about the aim, procedure and appointment details of the study. Only one parent per family was requested to take part. A monetary voucher of 25 euro’s was given as an incentive to participants.

Characteristics of focus groups and participantsSix focus group interviews were conducted, including two focus group interviews with Dutch parents of high SES, two focus group interviews with Dutch parents of low SES, one focus group interview with Turkish parents and one focus group interview with Moroccan parents. A total number of 39 parents participated in the study, ranging from 4 to 10 parents per focus group session. The mean age of the parents’ selected child was 7.2 ± 0.5 years. The characteristics of participants are described in Table 1.

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Tabl

e 1.

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eris

tics

of p

artic

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ts p

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cus

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terv

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.

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(n =

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72

14

22

18 (4

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36

31

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43

32

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Data collectionA semi-structured interview guide was developed to ensure consistency in data collection among focus group interviews, yet allowing the sessions to be flexible to optimize the natural flow of conversation about views and ideas in the groups. The interview guide included a list of topics for discussion (based on the dental scientific literature) and a series of open-ended questions, reducing the chance of priming and bias. The questions were designed to elicit discussion among parents about factors they perceived to influence children’s oral health behaviours (i.e. twice daily tooth brushing and reducing the consumption of sugary foods and drinks), and to stimulate discussion about desires and recommendations for interventions to support parents in establishing dentally healthy behaviours in their child. The questions were pilot-tested for clarity, comprehension and suitability in one focus group interview with parents working at ACTA, department of ‘Social Dentristry’ and one with Turkish and Moroccan students.

The focus group interviews were performed in a quiet room at a paediatric dental centre, and lasted between 75 and 120 minutes (mean time: 100 minutes), including a 15-minute break. All focus group interviews were conducted by a moderator (DD, MSc in Dental Public Health, PhD-student and trained in conducting qualitative research), who guided the discussion, and an assistant moderator (MdJL, MSc in Paediatric Dentistry, PhD-student and working as a paediatric dentist), who took field notes and made sure that all participants contributed to the discussion. All focus group interviews were audio-recorded and transcribed verbatim.

Data analysisContent analysis was employed to analyse and interpret the content of the data. First, open coding was done through reading the transcripts and assigning codes line by line, forming the initial coding scheme. Secondly, related codes were sorted and clustered codes to identify themes. Identified themes of factors influencing children’s oral health behaviours were subsequently mapped to child level influences, family level influences and community level influences of Fisher-Owens’ model (7). MAXQDA (software for qualitative data analysis, 1989-2014, VERBI Software - Consult - Sozialforschung GmbH, Berlin, Germany) was used to manage the data analysis.

The open coding of all transcripts was performed by one author (DD). The initial coding scheme and the identified themes were evaluated and discussed in various group sessions with the remaining authors (MdJL, EV and CvL) until consensus was reached.

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results

Influences on children’s oral health behavioursParents described a variety of influences that could benefit or hinder the establishment of dentally healthy behaviours in children. Analysis of the focus group interviews identified nine themes of influences on children’s tooth brushing behaviour and eleven themes of influences on children’s consumption of sugary foods and drinks. The themes are described below in the context in which they were discussed in the focus group sessions, and they are illustrated with interview quotes of parents (sentences in italic). Influences on children’s tooth brushing behaviour and children’s consumption of sugary foods and drinks are schematically presented in Figure 1 and 2 respectively, in which influences are mapped to child, family and community levels.

Twice daily tooth brushing with fluoride toothpaste‘Parental perceptions’ and ‘Social norm’In general, all parents acknowledged the value and importance of twice daily tooth brushing with fluoride toothpaste to maintain good oral health for their child. In most families parents managed to brush their children’s teeth twice a day, usually in the morning before or after breakfast and in the evening before bedtime. Parents perceived twice daily tooth brushing as a generally accepted standard of behaviour (social norm). However, many of the parents whose children had caries experience did not believe that oral hygiene efforts could fully prevent their child from getting tooth decay (external locus of control). They often related childhood dental caries to causes outside the parent’s and child’s control, such as chance, genetics or health problems in childhood: “It must be the genes of my husband, because my teeth are fine…” and “When my son was four years old they had to extract six teeth. I think his teeth were bad because he’d been given lots of antibiotics for asthma when he was young”.

‘Family organization & structure’In each focus group interview, most parents agreed that routines and structure in the family were very important to manage twice daily tooth brushing in children. One parent said: “Some children are always ten minutes late at school because their families don’t have routines and structure. These are often the same children that haven’t had breakfast and haven’t brushed their teeth”. The majority of parents reported that tooth brushing was embedded into a ritual of routinized daily activities, such as washing and getting dressed. Habituation helped to successfully implement the behaviour: “I’ve never perceived tooth brushing to be difficult because it’s such an automatism. The children are just used to it”.



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Figure 1. Factors influencing twice daily tooth brushing with fluoride toothpaste in children

Figure 2. Factors influencing children’s consumption of sugary foods and drinks.

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‘Parental self-efficacy’, ‘Child behaviour & compliance’ and ‘Parenting strategies’Many parents expressed that they felt confident in their ability to successfully establish twice daily tooth brushing for their child, indicating they had a high dental self-efficacy: “...It’s just perseverance. Her teeth are always brushed twice a day”. In the course of the interviews, however, almost two-third of the parents described situations in which they experienced difficulties with tooth brushing. Common barriers included lack of time and child non-compliance. In each focus group interview, a few parents admitted that they sometimes skipped brushing their child’s teeth due to time constraints or a busy schedule. Tooth brushing in the morning was considered more challenging than in the evening. “Mornings are often busy, especially when we both have to go to work. It needs planning. We’re in a hurry to brush their teeth and then the brushing is not always done very thoroughly” and “I don’t have time to brush their teeth in the morning. I mean… I leave at 7am and I have to dress two children, make breakfast for them, and so on. Of course I have a partner, but he’s like; Ah, don’t worry…”. To facilitate tooth brushing in the morning, a few parents had placed an extra toothbrush downstairs, so that after breakfast children did not have to go upstairs to brush their teeth.

Another barrier was associated with difficult child behaviour and non-compliance in response to tooth brushing. Approximately half of the parents stated that it was sometimes a struggle to brush their child’s teeth, e.g. due to resistant behaviour, tantrums, pain during teething or tiredness of the child: “For a time period I had this strong-willed toddler who was convinced he could do it all by himself. He just wouldn’t allow me to brush his teeth for him”. Two parents said they sometimes rather avoided conflict in those situations, than to persist on tooth brushing: “When he’s uncooperative in the morning I’m not always going to battle with him. Certainly not me, no.” Other parents reported various parenting strategies to cope with children’s non-compliant behaviour towards tooth brushing. Around a quarter of parents tried to maximize compliance using positive reinforcement (e.g. giving compliments or providing rewards, such as a sticker or new tooth brush) or by turning tooth brushing into an easy / enjoyable activity (e.g. singing a song, using a tooth brushing poster with icons, setting an alarm, counting along): “For a while it was a real struggle to brush her teeth, until we let go a little and tried to make it more positive by giving compliments”. One parent said she used disciplinary restrictions, such as withholding privileges, to realize twice daily tooth brushing. A few parents used rigid disciplinary strategies by physically restraining the child to ensure that tooth brushing was properly performed: “…I just held her in head lock for two minutes…”. Moreover, many parents agreed that it is essential to be consistent when disciplining their child: “Eventually, you are the boss. I believe it’s very important not to give in to your child, because then it will always try to push boundaries”.



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‘Role modelling’ and ‘Parental control & supervision’The majority of parents said they intended to monitor their child’s tooth brushing routines, either by brushing their child’s teeth for them, by re-brushing their child’s teeth or by supervising the child during brushing: “First, he gets to brush by himself and then I re-brush his teeth. That’s something I really try to pursue.” Two parents perceived that brushing their own teeth in their child’s presence encouraged the child to brush too, by functioning as an example or role model for their child. A few parents mentioned not to supervise their children’s tooth brushing habits: “I’m not around when they brush their teeth. I am already downstairs when they’re in the bathroom, so I have no clue how well they are brushing their teeth”.

Many parents reported greater involvement in their children’s oral hygiene when children were young, which helped to control the behaviour. With growing age, children were considered more autonomous and more responsible for their own dental health, resulting in less parental involvement and control: “When they are young you help them with everything, including tooth brushing. As they get older and more independent, they can brush their own teeth, and then you have to be very careful that those two minutes don’t become 1, 2, 3…10, done!”.

‘Parental knowledge’A considerable number of parents were insecure about details of knowledge concerning tooth brushing, which became apparent from questions they raised during the interviews (e.g. the best type of tooth brush, the recommended age to allow children to brush by themselves, etc.). Some parents had been given complicated advice, such as ‘not to brush within 30 minutes after eating or drinking’, or ‘not to brush before breakfast’ or ‘to be careful about the child swallowing toothpaste’, which made it difficult to adhere to advice.

Reducing the frequency of consuming sugary foods and drinks‘Parental knowledge’ and ‘Parental perceptions’Many parents recognized the importance of reducing children’s intake of sugary foods and drinks to prevent dental caries in children. Most of these parents had been given advice by their dentist to limit the frequency of sugar consumption to a maximum of 5 times a day. However, there was quite some confusion among parents which foods and drinks are considered ‘unhealthy’ for their child’s teeth: “Yes, but what are sugary foods? I mean… Is a multigrain biscuit also considered ‘sugary’?”. Furthermore, a few parents had been given dietary advice by their dentist that was in conflict with dietary messages that are important for their child’s general health and development: “One of the things the dentist told me is that fruits can be bad for your child’s teeth. So you think you are doing it right by giving your child healthy foods, and then it turns out…”. These unclear and conflicting messages were perceived as barriers to adhere to the advice.

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More than two-third of the parents intended to control their child’s intake of sugary foods and drinks, not only to maintain good oral health for their child, but also from a general health perspective. However, there was also a number of parents, especially in the Turkish and Moroccan focus group, who did not concern about their child’s diet from an oral health perspective, because they did not believe that sugary foods and drinks were damaging for their child’s teeth: “It’s often attributed to sugars and sweets, but that’s just nonsense!”.

‘Child food preferences’Parents cited that the difficulty of controlling children’s sugar consumption partially depended on child-related factors. Preference for certain foods and drinks (e.g. having a sweet tooth) and children disliking healthy foods or being ‘picky eaters’ were considered barriers to realising a healthy diet.

‘Parental self-efficacy’Around one-third of the parents reported that they felt efficacious in controlling their child’s intake of sugary foods and drinks. They were confident about their ability to provide a healthy diet by giving their child healthy foods and drinks to school, by restricting the daily frequency of consuming sugars and by providing healthy alternatives when their child asked for sweets: “If they are really hungry I tell them to eat an apple or a cracker with cheese. At least that’s a little justified”. However, the majority of parents admitted that they did not always feel competent to adhere to dietary advice given by their dentist. Some of the parents believed that the advice was infeasible. A common barrier was related to coping with children’s behaviours, wishes and conflict, for example, when children kept asking for sweets: “…Of course it sometimes happens that I give in to my child when she keeps nagging for sweets. Obviously. We’re humans, right?”. Parental emotions also played a role. Some parents felt guilty to give their child healthy foods and drinks that they dislike: “I would feel very sorry for him when he opens his mug at school and he would see it has water in it…”.

‘Family organization & structure’ and ‘Parental control at home’Parents differed in opinion about the difficulty of reducing the frequency of sugar consumption at home. Mainly the parents with a high self-efficacy (especially the Dutch parents of high SES) experienced little difficulty in controlling children’s intake of sugary foods and drinks when they are indoors. Perceived facilitators included family structure and parents’ ability to monitor their child’s dietary intake at home. Many of these parents said to have a regular and routinized daily eating pattern: “It’s a standard routine. They have breakfast in the morning, they have one healthy snack and lunch at school, and after school they have one more snack or piece of fruit before dinner. That’s it…”. Having family meals together was believed to add structure to children’s dietary patterns. The same parents also reported to have clear



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rules and agreements at home about sugar-snacking: “It’s very easy. They know when they can have a snack or sweets. They are familiar with the rules and, I mean, there is just no debate about that” and “They are not allowed to take snacks from the kitchen cupboard. They know they always have to ask first…”. Many of these parents also agreed that parental monitoring helped to control their child’s sugar consumption at home, because they were able to supervise children in their direct presence.

In contrast, there were also many parents (more often those from lower SES and ethnic groups) who perceived barriers to limit their child’s consumption of sugary foods and drinks at home, in particularly in the weekends. These parents described less daily structure and less clarity and consistency of rules and agreements about sugar-snacking: “In the weekend …Oh well, than I also take something when I have an appetite for food” and “He just gets candy or cookies when he asks for it and I think; Yes, now it’s ok”. Furthermore, many of them reported situations at home in which they felt unable to monitor their child’s diet, e.g. when they are not in their child’s direct presence or when they can’t pay attention because they are occupied with other activities at home: “In the weekends, it often happens that they wake up earlier than we do, and then they’ve already had a biscuit-breakfast”.

‘Social environment (family, friends, neighbours, etc.)’Many parents agreed that they had little control over their child’s dietary intake when children were outdoors. Almost half of the parents reported that children were often indulged with sweets and snacks when visiting neighbours, grandparents or food shops, such as the bakery or butcher: “Grandparents are the worst of course. It’s unbelievable how much food they get when they’re visiting. Always lots of crisps and sweets during the day... And often my mother also puts down a bowl of candy in the evening. She just likes to spoil them”. In case of an exception, this was often not seen as a problem. However, parents expressed concern when children frequently visited friends or family where they applied different norms and rules about sugar-snacking, or if someone who regularly looked after the children used different rules: “My mother was often babysitting and I found it very hard to ask her to follow my rules and advice, because I didn’t want to offend her…”.

‘School environment’Interestingly, many of the parents who felt it was relatively easy to control children’s sugar intake at home reported many barriers to ensure a healthy diet at school. They perceived a lot of peer pressure from other parents who gave their child sweets or unhealthy snacks to school: “I’ve seen what parents give their children to school; chocolate bars, almond cakes, it’s shocking!” and “It’s not mandatory to give your child a snack to school, but the 10 ‘o clock snack-break is obviously a very social thing. And of course it’s not very nice for him when he’s the only one who doesn’t have something yummy”. These parents commented that schools

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undermined their efforts at providing a healthy diet. Yet, other parents, mainly those who reported barriers at home, expressed the belief that school helped to limit children’s sugar consumption due to routinized structure and dietary regulations at school: “On weekdays it’s much easier to reduce the number of eating and drinking moments, because at school they have fixed mealtimes. It’s just routine” and “At our school we have a newsletter in which parents are explicitly advised to give children fruit or a vegetable snack to school”.

Birthday treats were seen as a barrier to ensure a healthy diet at school. Furthermore, a few parents expressed concern about children’s increasing autonomy with growing age: “I don’t want to know what’s going to happen when they’re going to high school. I mean… the gulls know exactly at what time children have lunch break… Children throw their sandwiches into the trash bin and they use their pocket money to buy their own food at the school canteen…”. ‘Supermarket’, ‘Commercials & television’ and ‘Affordability of foods & drinks’A few parents acknowledged the impact of commercials, television and supermarkets on children’s dietary wishes, however, most of them said this did not influence their purchasing behaviour, or only on exceptional occasions: “…They’re certainly influenced by commercials. That’s where they get their ideas from, as well as from their classmates. They often come with suggestions ‘Mom, I’ve seen this, can you buy that next time?’. I sometimes do when it’s a holiday for example”.

Only one parent said that prices influenced what foods and drinks she bought for her children, but not in a health adverse way: “I live on a very tight budget, so I really have to be cautious with how I spend my money. First I buy the things I need, such as fresh fruits, vegetables, bread and meat, and if I have money left I can buy extra’s, such as potato chips or chocolate eggs for Easter”.

Recommendations for interventions to improve children’s oral health behavioursParents discussed various options they perceived to be potentially useful for improving children’s oral health behaviours and for providing parental support. Table 2 presents an overview of desired or recommended interventions and perceived problems per organization or health profession.

Many parents reported that (dental) health care professionals spend little time on informing parents about caries prevention, and they felt that attention and subsidies for public oral health promotion has decreased over the years. The majority of parents expressed the desire to receive adequate oral health information, starting early in a child’s life. Common requests were to receive (tailored) plain advice and simple tips on practices they could perform to optimize a healthy dentition for their child (e.g. using stickers as a daily incentive or an alarm to facilitate brushing, placing a tooth brush downstairs, receiving tips on non-cariogenic snacks), and they wanted to feel heard and supported by the person providing the health information,



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rather than feeling blamed: “It’s so frustrating when you get an accusing comment, such as ‘Are you really re-brushing his teeth?’ Immediately! It would be much more helpful if they say ‘Well, this is already going ok, but this could need some attention’. A positive approach, you know…”. Some of the parents who received health education in group sessions reported positive experiences: “I really enjoyed the health information sessions that they organized at the dental centre. I really learned a lot and I’m still benefitting from them”. The provision of oral health information was mainly considered the responsibility of dental professionals, since it’s their area of expertise, and the responsibility of child health centres, as they reach a large proportion of parents who regularly visit the centres to monitor their child’s health and growth from a very early age. Problems of and opportunities for interventions to improve children’s oral health behaviours at the dentist or the child health centre are summarized in Table 2. Other suggestions to receive oral health information included information leaflets (e.g. from health insurance companies) and dental health education in group sessions at Kindergarten or day care centres.

Parents also discussed opportunities to improve children’s oral health behaviours via schools. Some parents suggested that oral health education at schools or theme days about oral health may be useful to raise awareness about oral health in children. However, there were also a number of parents who questioned the long-term benefit of school health education, especially when parents were not involved: “… No, that’s only temporary. You can’t expect children to start brushing their teeth until they’re 6, 7 or 8 years old after only one class. That’s really up to the parent to get that done”. Other recommendations at schools involved the introduction of fruit days and the implementation of dietary regulations.

A few parents discussed the option of collaborating with institutions, such as child welfare or youth care services, to provide parental support for families who experience multiple difficulties with raising their child: “If a parent doesn’t succeed to get his or her child’s teeth brushed then there might be more problems concerning parenting in general. Perhaps child welfare could provide help in these situations, because this is beyond the ability of the dentist”.

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Tabl

e 2.

Par

ents

’ vie

ws

on p

robl

ems

of a

nd o

ppor

tuni

ties

for

inte

rven

tions

to s

uppo

rt p

aren

ts in

est

ablis

hing

den

tally

hea

lthy

beha

viou

rs in

ch

ildre

n.

Leve

l of p

reve

ntio

nPr

oble

ms

Opp

ortu

nitie

s

Dent

al p

rofe

ssio

nals

Age

of c

hild

ren:

late

adv

ice

Enco

urag

ing

dent

al v

isits

at a

n ea

rly a

ge

Ineff

ectiv

e de

ntal

hea

lth e

duca

tion

and

advi

ce:

insu

ffici

ent a

dvic

e, c

ompl

icat

ed a

nd c

onfli

ctin

g m

essa

ges,

no

tailo

red

advi

ce

Impr

ovin

g th

e co

nten

t of d

enta

l hea

lth e

duca

tion

and

advi

ce:

sim

ple

mes

sage

s, ta

ilore

d ad

vice

s

Dent

al h

ealth

edu

catio

n: n

o lo

ng te

rm e

ffect

on

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viou

r cha

nge

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g th

e de

liver

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den

tal h

ealth

edu

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n an

d ad

vice

: in

crea

sing

atte

ntio

n an

d ex

pres

sion

of u

nder

stan

ding

Deliv

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g de

ntal

hea

lth e

duca

tion

and

advi

ce in

gro

up

disc

ussi

ons

Prov

idin

g In

form

atio

n le

aflet

s

Chi

ld h

ealth

cen

ters

No

or li

mite

d pr

iorit

y fo

r ora

l hea

lth p

rom

otio

nIn

crea

sing

aw

aren

ess

of o

ral h

ealth

: pro

vidi

ng in

form

atio

n le

aflet

s or

sho

win

g vi

deo’

s

Ineff

ectiv

e de

ntal

hea

lth e

duca

tion

and

advi

ce:

insu

ffici

ent a

dvic

e, c

onfli

ctin

g m

essa

ges

(ora

l hea

lth –

ge

nera

l hea

lth),

no ta

ilore

d ad

vice

Inte

grat

ing

dent

al h

ealth

edu

catio

n an

d ad

vice

into

gen

eral

co

nsul

tatio

n vi

sits

Refe

rring

to a

(pae

diat

ric) d

entis

t at a

n ea

rly a

ge

Kind

erga

rten

/ Day

car

e ce

ntre

sDe

liver

ing

dent

al h

ealth

edu

catio

n an

d ad

vice

to p

aren

ts in

gr

oup

disc

ussi

ons

at th

e da

y ca

re c

ente

r

Scho

ols

Age

of c

hild

ren:

late

adv

ice

and

prev

entio

nDe

liver

ing

dent

al h

ealth

edu

catio

n an

d ad

vice

at s

choo

ls

Dent

al h

ealth

edu

catio

n: n

o lo

ng te

rm e

ffect

on

beha

viou

r cha

nge

Impl

emen

ting

diet

ary

regu

latio

ns a

t sch

ools

Prom

otin

g fru

it da

ys a

t sch

ools

Hea

lth In

sura

nce

com

pani

esPr

ovid

ing

info

rmat

ion

leafl

ets

and

oral

hyg

iene

tool

s

Chi

ld w

elfa

re /

yout

h ca

re

serv

ices

Col

labo

ratin

g be

twee

n de

ntal

pro

fess

iona

ls a

nd c

hild

wel

fare

: pr

ovid

ing

pare

ntin

g su

ppor

t.



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7

discussion

This qualitative study provided a rich description of parents’ views about the influences on children’s oral health behaviours, which contribute to the understanding of the underlying factors and processes that are involved in the establishment of twice daily tooth brushing with fluoride toothpaste and controlling the consumption of sugary foods and drinks. Parents in the focus group interviews identified many factors, operating at child, family and community levels, which they perceived to impact on children’s oral health behaviours. The influences they reported largely correspond with associations already proposed in the dental literature (7, 28, 29). Herewith, findings of this qualitative study provide further support for the determinants of childhood dental caries that have already been suggested conceptually and/or studied quantitatively. Primary influences on children’s tooth brushing behaviour and sugar consumption were related to parental attributes and the family environment, including parental knowledge, perceptions, self-efficacy and control, parenting strategies and family organization. Similar factors of influence at the parent and family level have previously been reported in three qualitative studies, which sought to explore influences on tooth brushing routines with infants (25) and young children (24), and the processes that influence parental adoption of dentally healthy behaviours following a child’s dental treatment under general anaesthesia (21). Furthermore, many extra-familial factors were found to influence children’s consumption of sugary foods and drinks, including the social environment and organizational factors, such as school regulations and supermarkets. This concurs with findings from the obesity literature on factors influencing children’s dietary behaviours (30).

In each focus group interview, generally the same themes of influences were discussed, however, there was variation in the way parents interpreted these factors to influence children’s oral health behaviours. An example: parents who felt efficacious in controlling their child’s sugary intake (especially Dutch parents of high SES) often attributed this to facilitators at home, such as daily structure and parental monitoring, while external influences outside the parent’s control were often considered barriers to limit their child’s sugar consumption. In contrast, there were other parents (more often those from lower SES and ethnic groups) who perceived many difficulties with the organization, time management and monitoring at home, which hindered their efforts to reduce their child’s frequency of consuming sugary foods and drinks. In many instances, these parents did also not believe that their actions could fully prevent their child from getting tooth decay, e.g. due to genetic or biological predisposition. This example highlight that the influences on children’s oral health behaviours are likely to be complex, with a range of beliefs and parental, family, environmental and organizational factors being inter-related and operating via complex interactions, rather than each factor having an isolated influence. It also suggests that, depending on the context, similar factors could either act as facilitators or barriers to the establishment of dentally healthy behaviours in children, which plausibly have a synergistic effect.

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To the author’s knowledge, this was the first qualitative study that sought to explore parents’ desires and recommendations for interventions to improve children’s oral health behaviours, with findings yielding insights that are useful to consider when developing or improving caries preventive strategies for children. It appeared from the focus group sessions that vast majority of parents were acquainted with preventative oral health messages related to twice daily tooth brushing and reducing the consumption of sugary foods and drinks. Most parents said they were motivated to adhere to these health messages, however, this had been complicated by the provision of conflicting and complex advice. This inconsistency in advice has also been acknowledged in a review describing a wide diversity in recommendations on tooth brushing methods by dental associations, professionals, companies and texts (31). Parents suggested several recommendations for interventions to improve children’s oral health behaviours, many of their ideas concerning the desire to receive clear (and tailored) oral health information, starting from a child’s early age. Some parents particularly expressed the desire to be informed about why some children develop dental caries despite their efforts, and they wanted to feel heard and understood, rather than feeling blamed. These wishes can be important to consider for improvement of the content and delivery of oral health education methods. However, while knowledge can be a prerequisite to engage in dentally healthy behaviours, there is limited evidence for the effectiveness of a purely educative approach in achieving long term behaviour change (5, 32). The current study demonstrated that many parents who possessed sufficient knowledge and motivation still reported many barriers to adhere to the advice, which suggests that where parents accept preventive health messages, many need support in implementing them. Therefore, caries preventive strategies may be more effective when targeting barriers that are modifiable and amendable to practical intervention. Since most barriers were identified at the parent and family level, it follows that interventions incorporating components to change parental self-efficacy and control, parenting practices and family organization may be beneficial in the prevention of childhood dental caries.

The findings of the current study should be considered in the light of some limitations. First, the generalizability of findings is limited by the qualitative nature of the study. Not all views may have been adequately represented, because parents of children who visit a regular dental practice and Turkish and Moroccan parents who do not speak the Dutch language were not included and participating parents may have been more interested in the topic of this study. Furthermore, the sample size was relatively small, yet data analysis indicated that similar themes of influences emerged in each focus group, meaning that additional participants would likely not have added new information enriching the depth or scope of the data. Secondly, parental responses may have been influenced by the opinions and perceptions of more vocal parents, or they could have responded in a socially-desirable manner. Finally, qualitative data does not allow quantification of associations between



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identified influences and children’s oral health (behaviours), and how these influences differ on the basis of socioeconomic position, ethnic background or geographical location. However, the findings of this study are useful in providing a theoretical base for quantitative oral health research, including the identification of important areas for future exploration and guiding the development of valid measures.

In conclusion, this qualitative study provided depth and detail regarding parental views on the influences on children oral health behaviours. Findings highlight that various factors at the parent and family level were significantly influential on children’s tooth brushing behaviour and children’s consumption of sugary foods and drinks, while the latter behaviour was also heavily influenced by external factors. Insights into these influences and parents’ ideas for interventions are useful to inform new approaches for caries prevention in children.

acknowledgements

This study was financially supported by Menzis Health Insurer, The Netherlands. The authors thank Armin Alambeigi and Manon Kromwijk-Smits for guiding the pilot focus groups with Turkish and Moroccan students. We also gratefully acknowledge the support from the Jeugdtandzorg Den Haag, Enschede, Utrecht and Zoetermeer.

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reFerences


2. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dental Health 2004;21 (supplement):71–85.

3. Vanobbergen J, Martens L, Lesaffre E, Bogaerts K, Declerck D. Assessing risk indicators for dental caries in the primary dentition. Community Dent Oral Epidemiol 2001;29:424–34.

4. Department of Health, the British Association for the Study of Community Dentistry. Delivering Better Oral Health: An evidence-based toolkit for prevention (2nd edition), 2009.




8. Reisine ST, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26(Suppl 1):32–44.




12. Crall JJ, Edelstein B, Tinanoff N. Relationship of microbiological, social, and environmental variables to caries status in young children. Pediatr Dent 1990;12:233–6.

13. Nicolau B, Marcenes W, Bartley M, Sheiham A. A life course approach to assessing causes of dental caries experience: the relationship between biological, behavioural, socio-economic and psychological conditions and caries in adolescents. Caries Res 2003;37:319–26.

14. Dorri M, Sheiham A, Watt R. The influence of peer social networks on toothbrushing behaviour in Iranian adolescents in Mashhad. Community Dent Oral Epidemiol 2010;38:498–506.

15. Pattussi MP, Marcenes W, Croucher R, Sheiham A. Social deprivation, income inequality, social cohesion and dental caries in Brazilian school children. Soc Sci Med 2001;53:915–25.

16. Aida J, Ando Y, Oosaka M, Niimi K, Morita M. Contributions of social context to inequality in dental caries: a multilevel analysis of Japanese 3-year-old children. Community Dent Oral Epidemiol 2008;36:149–56.

17. Hilton IV, Stephen S, Barker JC, Weintraub JA. Cultural factors and children’s oral health care: a qualitative study of carers of young children. Community Dent Oral Epidemiol 2007;35:429–38.

18. Pattussi MP, Hardy R, Sheiham A. The potential impact of neighborhood empowerment on dental caries among adolescents. Community Dent Oral Epidemiol 2006;34:344–50.

19. Kim YO, Telleen S. Predictors of the utilization of oral health services by children of low-income families in the United States: beliefs, cost, or provider? Taehan Kanho Hakhoe Chi 2004;34:1460–7.




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21. Amin MS, Harrison RL. Understanding patents’ oral health behaviours for their young children. Qual Health Res 2009;19:116–27.

22. Hoeft KS, Masterson EE, Barker JC. Mexican American mothers’ initiation and understanding of home oral hygiene for young children. Pediatr Dent 2009;31:395–404.

23. Nations MK, Calvasina PG, Martin MN, Dias HF. Cultural significance of primary teeth for caregivers in northeast Brazil. Cad Saude Publica 2008;24:800–8.

24. Huebner CE, Riedy CA. Behavioral determinants of brushing young children’s teeth: implications for anticipatory guidance. Pediatr Dentist 2010;32:48–55.

25. Elison S, Norgate S, Dugdill L, Pine C. Maternally perceived barriers to and facilitators of establishing and maintaining tooth brushing routines with infants and preschoolers. Int J Res Env Public Health 2014;11:6808–26.

26. CBS Statline (2014). http://www.cbs.nl/nl-NL/menu/themas/dossiers/allochtonen/ cijfers/extra/aandeel-allochtonen.htm (accessed: April, 2014).




30. Pocock M, Trivedi D, Wills W, Bunn F, Magnusson J. Parental perceptions regarding healthy behavior for preventing overweight and obesity in young children: a systematic review of qualitative studies. Obes Rev 2010;11:338–53.

31. Wainwright J, Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. Br Dent J 2014;217:E5.

32. Kay L, Locker D. A systematic review of the effectiveness of health promotion aimed at promoting oral health. London: Health Education Authority, 1997.

8 General dIscussIon

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General Discussion

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In the first part of this chapter the research findings of this thesis are discussed. The second part of this chapter describes recommendations for new approaches in childhood caries prevention in light of the findings of this thesis.

Discussion of research findingsIn recent years, research into the aetiology of childhood dental caries has moved beyond the exploration of biological and behavioural risk factors towards investigating the underlying determinants of childhood dental caries (1). When the present research project started, the role of parents as mediators/moderators of risk had been increasingly acknowledged in the dental literature, however, focus had been on the association between dental caries and sociodemographic factors (e.g. parental education, socioeconomic status (SES) and income), and parental behaviours, knowledge, attitudes and beliefs (2). Important family-related psychosocial factors had rarely been considered when investigating dental caries aetiology. Therefore, the primary aim of this thesis was to explore parental and family-related psychosocial determinants of childhood dental caries. Findings showed that parental attributes in relation to dental self-efficacy and LoC, and dimensions of parenting practices, parent-child interaction and family functioning were significantly associated with caries levels in 5- to 8-year old children in The Netherlands. Herewith, this thesis provided evidence that psychosocial aspects of the broader family environment, including family organization and the emotional quality of family relationships and interactions, are important factors that add further explanation to the development of childhood dental caries, in addition to parents’ sociodemographic, behavioural and cognitive influences already identified.

A secondary aim of this thesis was to explore the potential role of parental and family-related factors in socioeconomic inequalities in childhood dental caries – an area that had been addressed in conceptual models (3-6), but had not yet been empirically investigated. Findings of chapter 3 and 6 of this thesis demonstrated that lower education of the mother was associated with a lower dental-self-efficacy, a more external locus of control (LoC), less positive parenting practices and poorer family functioning. These were in turn associated with higher levels of dental decay in children, which supports their potentially mediating effect in linking features of social life to childhood dental caries. This was confirmed by a structural equation model (chapter 4), which implied that SES indirectly influences children’s oral hygiene behaviours and subsequently children’s caries experience through an impact on interrelated parental and family-related factors. However, findings indicated that these factors alone unlikely provide a sufficient explanation for the SES-dental caries relationship.

Chapter 3, 4 and 7 provide evidence to suggest that oral health behaviours are intermediate factors in the relationship between parental and family-related factors and childhood dental caries. Parents play a central role in shaping children’s oral health behaviours and related attitudes and social norms. Their beliefs and judgement about their ability to control their

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child’s dental health is likely to affect their efforts to establish dentally healthy behaviours in their child. Parenting practices provide the context in which parents’ intended oral health messages are delivered and interpreted by the child. For example, coercive parenting, characterized by highly demanding discipline practices and low levels of warmth, is associated with higher degree of resistance and non-compliance in children (7, 8), which may also impact on children’s compliance towards oral health messages. On the other hand, positive parenting practices, such as monitoring and reinforcement of proper behaviours, and positive involvement, may enhance the uptake of dentally healthy behaviours. In terms of broader family functioning, it is likely that the adoption of good oral health behaviours is stimulated in a supportive and organized home environment in which roles and boundaries are well-defined and daily routines are managed.

Triangulation of research methodsA strength of this thesis was that triangulation of methods was performed to measure parental and family-related factors, using self-report, observational and qualitative methods. The results of all three methods denoted the important influence of parents and the family on the development of childhood dental caries, although conclusions were not always consistent between studies and were depending on the method employed.

The study in chapter 3, in which self-report methods were used, showed that children from dysfunctional families had significantly higher dmft scores compared to children from normal functioning families, although the demonstration of this association could not be reproduced in a smaller sample (chapter 6). The findings from chapter 3 could imply that family functioning only affects children’s dental health above a clinical threshold. However, the used measure was specifically designed to distinguish between normal and clinical families (9), while the majority of children with dental caries came from normative families that did not necessarily have clinical problems. This could infer that the measure may not have been sensitive enough to distinguish between different levels of family functioning within the normative range. This could have been further complicated by the fact that self-report ratings may have been biased by parents’ own perceptions and social desirable answering.

The aforementioned limitations of self-report family measures may also explain why studies by Seow et al. (10), Aleksejuniene et al. (11) and the study in chapter 6 could not find an association between self-reported parenting and children’s oral health outcomes. On the other hand, a strong and consistent relationship between parenting practices and childhood dental caries was demonstrated using more objective observational methods (chapter 5 and 6), which suggests that observational ratings are able to detect subtle nuances in parenting practices within the normative range that are relevant to caries development.

Evidence of the influence of parents and the family on childhood dental caries was supplemented by qualitative data of parental perspectives on the factors influencing


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children’s dental health behaviours. Although the nature of qualitative data does not allow quantification of associations, the added value lies in the provision of a rich and detailed description of parents’ experiences and opinions about the context in which children’s dental health behaviours are developed, which furthered our understanding of the factors and processes that influence children’s dental health.

Limitations of the research projectThe findings of this thesis should be considered in the context of its methodological strengths and weaknesses. The studies in this thesis used samples in which children from different socioeconomic position, ethnic backgrounds and geographical regions were represented, with all samples including both caries free children and children with moderate to high levels of dental caries. Herewith, the samples were opportune for testing the aims and objectives of this research project of relating various explanatory variables to caries experience of children, taking their sociodemographic characteristics into account. However, it should be noted that the generalizability of the studies was limited, because the non-response in each study was relatively high and children were mainly recruited from paediatric dental centres whose patient populations are not representative of the Dutch population.

Another potential limitation is that children’s dental health data were collected from patient records of the dental centres, rather than obtained from clinical examinations by trained and calibrated dentists. The validity of data from personal records could be confined by the fact that the data was recorded by many unstandardized dentists, who may have evaluated children’s dental health differently. However, this was minimized by the fact that the dental health status of each child was systematically recorded at each dental check-up, ensuring complete and uniform records. Furthermore, it could be argued that patient records actually produced more valid data compared to clinical examinations, as bite-wing radiographs were used to determine dental health status, in addition to visual inspection alone. Therefore, both methods of data collection have their limitations in which errors are likely to occur. Sëppa et al. (12) and Hausen et al. (13) compared dental data collected from patient records to those obtained by trained examiners and concluded that DMF-values from patient records were fairly similar to those based on clinical examinations. These studies suggest that the dental health data in this study could be appropriately used for research purposes of those of this thesis.

Finally, the studies in these thesis were cross-sectional that cannot provide evidence for causal and temporal relationships. The associations between parental and family-related factors and childhood dental caries were explored using data that was collected at a single point in time. However, childhood dental caries is a chronic disease, which develops through the interaction of various oral health behaviours over time. These are habitual behaviours that are often established in a child’s early years (14). Therefore, parental and family-related

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factors are expected to be most influential on children’s oral health behaviours at the time that these behaviours are introduced into the child’s life. In this thesis, parental and family-related factors were measured when dental caries had already been developed, assuming that these are trait characteristics that are fairly stable over time. And although the evidence for temporal stability of these factors is quite strong (15), they may have changed over the years due to alterations in life circumstances and stressful situations, such as divorce or unemployment, and natural transitions, such as the ageing of family members. Therefore, the measurement of parental and family-related factors at the time of these studies may not have been an accurate reflection of these factors in a child’s early life. Longitudinal studies are needed to explore the role of parental and family-related factors in the initiation and maintenance of children’s oral health behaviours and their influence on the development of childhood dental caries over the years.

Recommendations for the development of caries preventive interventions for childrenThis thesis started by stressing the need for a paradigm shift in dental caries prevention if further improvements in children’s dental health are to be achieved in Western countries. It is safe to conclude from evidence of systematic reviews that the dominating health education approach in caries prevention alone will not be successful in producing further reductions in children’s caries levels at a population level, nor in reducing the socioeconomic equity gap in childhood dental caries (16). Therefore, more of the same approach is no longer an option. Efforts should be made to develop innovative preventive interventions that do not narrowly focus on individuals and their risk behaviours alone, but they should be directed towards addressing the underlying determinants of childhood dental caries as well (17).

The identification of determinants The first step in tackling childhood dental caries is to secure scientific information on the determinants that influence the performance of key oral health behaviours in children, including the establishment of twice daily tooth brushing with fluoride toothpaste and the reduction of consuming sugary foods and drinks. These determinants are known to compose a complex web of influences, ranging from individual factors, to broader family, social and political/organizational factors (1). This complexity provides a challenging formulation to develop caries preventive interventions. Therefore, it is necessary to select a subset of potentially modifiable determinants within this web (i.e. ‘change targets’) that, when addressed, will likely translate into beneficial changes in children’s oral health behaviours and subsequently children’s dental health. This is where the results of this thesis become highly valuable. Findings clearly highlight that the ‘family matters’ in the development of childhood dental caries. Both the existing dental literature and the results of this thesis point to the importance of several parental and family components in determining children’s


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dental health, including parental psychosocial attributes, parenting practices, the emotional quality of family relationships and broader family functioning. These findings provide a strong rationale for incorporating these family components in efforts to prevent childhood dental caries. Interventions need to engage parents and offer them skills through which they can foster the establishment of dentally healthy behaviours in children, i.e. through direct parental practices or indirectly through the creation of a supportive family environment. The parental and family-related determinants that are relevant candidates for intervention include:

(i) Parental cognitions and attributes• Dental health-related knowledge, awareness and concerns• Dental health LoC• Dental self-efficacy

(ii) Parenting practices • Family warmth / involvement and encouragement• Monitoring and control• Problem solving and shared decision making

(iii) Family functioning• Organization, structure and routines

(iv) Social support of parents and the family

Selecting methods of behaviour change The next step in the development of caries preventive interventions is to find methods of behaviour change, which refer to strategies designed to change one or several specified determinants (18). Ideally, the choice of method should be underpinned by theory and should be considered on the basis of evidence from previous interventions. With respect to the determinants listed above, focus should be on reviewing successful and unsuccessful components of interventions that are known to be family-based. Family-based interventions are defined by active parent involvement in children’s disease prevention, which focus on targeting multiple family members rather than that of the child alone (19).

In dentistry, there are several programs that used a family-based approach to prevent caries development in children. These particularly focused on targeting cognitive determinants, by attempting to increase parents’ dental health-related knowledge, skills, awareness, motivation and self-efficacy. Some of the methods and messages used in these programs have shown promise in effectively preventing tooth decay in young children (20). These include anticipatory guidance in the prenatal and postnatal period (educating and instructing practical aspects of oral health care) (21), motivational interviewing (person-centered counselling, exploring reasons for change and barriers to change) (22, 23) and peer-led group discussions among a small group of parents (24).

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However, there are no dental interventions that emphasize a broader family system framework to prevent childhood dental caries, e.g. by incorporating components that target general parenting skills and family functioning as contexts of change. Yet, such a framework is promising in part, because of evidence showing that interventions using a broader family systems approach have been effective in the treatment and prevention of other childhood diseases, including childhood obesity. A systematic review on weight loss interventions in overweight children (25) concluded that many programs that integrated components on parenting styles (e.g. promoting authoritative parenting), parenting skills (e.g. training of parenting skills, such as monitoring and reinforcement) and child management principles (e.g. encouraging positive child health behaviours) showed a positive effect on youth weight loss (26-29). The latter method is based on principles of the Social Learning Theory, which postulates that children learn behaviours via observation, modelling and imitation, which can be reinforced by rewards and/or punishment (30). Tanas et al. (31) targeted parental modelling and reinforcement in a home environment setting, rather than a clinical setting, and also showed significant reductions in children’s body mass index (BMI). Parent problem solving has been considered another important element in the treatment of childhood obesity. However, problem solving training for parents and children did not improve weight loss outcomes in addition to a standard family-based program that involved training of parenting skills (32). Fewer studies have explored the possible benefit of improving overall family functioning and family structure in weight loss programs. These studies used family therapy to promote a positive emotional family climate and to improve the provision of structure and boundary setting in the home environment (33, 34). Evaluation of these programs demonstrated significant reductions and significantly smaller increases in children’s BMI.

Family components have also been considered in obesity prevention programs, which tended to reach the family through group-based approaches by organizing activities at school, existing community centers or clinical settings, or through take-home materials (25, 35-36). The majority of these programs demonstrated positive outcomes related to physical activity and diet. However, in accordance with caries preventive programs, none of the obesity prevention programs intervened on broader family factors, such as parenting skills, child management strategies, or family functioning variables.

The evidence from previous behaviour change programs in the dental and obesity literature provides guidance for selecting methods of behaviour change in future caries preventive interventions. Family components that have proven successful in reducing childhood obesity may also have the potential to effectively prevent childhood dental caries, especially since both diseases share similar risk behaviours and have many underlying determinants in common. Based on review of the dental and obesity literature, an overview is presented of possible methods of behaviour change and implementation strategies (process of delivery) for each of the listed determinants that are potentially relevant to consider in the


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development of caries preventive interventions for children (Table 1). Ideally, programs should target multiple components (which could be tailored to the targeted individual or group) and use a combination of strategies to increase its potential effectiveness. Considerations for program development and planning also include decisions on the method of delivery (e.g. individual-based or group-based, frequency of sessions, etc.), the setting of implementation (e.g. a clinical setting, such as a dental practice or child health offices, or community centers) and executive personnel (e.g. dental or non-dental professionals). These decisions are largely dependent on the defined target population and existing infrastructure and resources available that can be utilized. Furthermore, appropriate resources and methods should be directed towards the evaluation and monitoring of these programs.

concluding remark

Family matters in the development of childhood dental caries. Results of thesis showed that parental attributes in relation to dental self-efficacy and LoC, and dimensions of parenting practices, parent-child interaction and family functioning were important indicators of dental decay in children 5- to 8-year old children in The Netherlands. Given the relevance of these family factors in children’s dental health outcomes, evaluating and implementing theoretically driven approaches to incorporate the family can guide future efforts to prevent childhood dental caries. Recommendations for potential methods of behaviour change are provided based on promising findings from obesity treatment and prevention programs. Herewith, this thesis contribute to a scientific foundation for informing the development of innovative caries preventive programs that will hopefully lead to children enjoying better dental health!

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Tabl

e 1.

Mat

rix o

f det

erm

inan

ts a

nd p

ossi

ble

met

hods

of b

ehav

iour

cha

nge

and

impl

emen

tatio

n st

rate

gies

for c

arie

s pr

even

tive

inte

rven

tions

.

Det

erm

inan

tsM

etho

ds o

f beh

avio

ur c

hang

eIm

plem

enta

tion

stra

tegi

esPa

rent

al c

ogni

tions

and

attr

ibut

es•

Know

ledg

e bu

ildin

g an

d de

ntal

ski

ll de

velo

pmen

t•

Antic

ipat

ory

guid

ance

for p

regn

ant

mot

hers

/ pa

rent

s of

new

born

s•

Awar

enes

s ra

isin

g

•M

otiv

atio

nal i

nter

view

ing

•C

omm

unic

atin

g ke

y or

al h

ealth

mes

sage

s; m

odel

ling/

dem

onst

ratin

g be

havi

ours

and

tech

niqu

es•

Inst

ruct

ing

prac

tical

asp

ects

of o

ral h

ealth

car

e

•In

crea

sing

par

ents

’ ris

k pe

rcep

tions

; pro

vidi

ng

info

rmat

ion

abou

t cau

ses

and

cons

eque

nces

of

dise

ase;

dis

cuss

ing

pare

nts’

ow

n co

ntrib

utio

n to

ch

ildre

n’s

dent

al h

eath

•Pe

rson

-cen

tere

d co

unse

lling,

exp

lorin

g re

ason

s fo

r ch

ange

and

bar

riers

to c

hang

e

Dent

al h

ealth

-rela

ted

know

ledg

e,

awar

enes

s an

d co

ncer

ns

Dent

al h

ealth

LoC

Dent

al s

elf-e

ffica

cy

Pare

ntin

g pr

actic

es•

Com

mun

icat

ion

skills

trai

ning

•Be

havi

oura

l rei

nfor

cem

ent

•M

odel

ling

•Pr

oble

m s

olvi

ng tr

aini

ng•

Goa

l Set

ting

•De

velo

ping

par

entin

g sk

ills to

pos

itive

ly d

eliv

er h

ealth

m

essa

ges,

e.g

. by

prai

sing

and

com

plim

entin

g•

Pare

ntal

mod

ellin

g of

beh

avio

ur; r

ewar

ding

pos

itive

ch

ild b

ehav

iour

, pun

ishi

ng n

egat

ive

child

beh

avio

urs

•En

cour

agin

g pa

rent

al s

uper

visi

on•

Trai

ning

con

flict

reso

lutio

n sk

ills•

Setti

ng a

chie

vabl

e go

als;

pla

nnin

g

Fam

ily w

arm

th /

invo

lvem

ent a

nd

enco

urag

emen

t

Mon

itorin

g an

d co

ntro

lPr

oble

m s

olvi

ng a

nd s

hare

d de

cisi

on

mak

ing

Fam

ily fu

nctio

ning

•H

abitu

al c

hang

e•

Setti

ng a

ppro

pria

te b

ound

arie

s•

Prov

idin

g ta

ilore

d tip

s to

est

ablis

h da

ily ro

utin

es•

Defin

ing

clea

r rul

es a

nd c

omm

unic

atin

g co

nseq

uenc

esO

rgan

izatio

n, s

truct

ure

and

rout

ines

Soci

al s

uppo

rt•

Peer

-led

grou

p di

scus

sion

s•

Disc

ussi

ng e

xper

ienc

es a

nd p

rovi

ding

feed

back

; sh

arin

g ba

rrier

s an

d tip

s to

ove

rcom

e th

ese


General Discussion

189

8

reFerences









9. Scholte E, Van der Ploeg J. The Family Questionnaire: A measure to assess the quality of family functioning. J Fam Issues 2013;doi:10.1177/0192513X13506707.


11. Aleksejūnienė J, Brukienė V. Parenting style, locus of control, and oral hygiene in adolescents. Medicina (Kaunas) 2012;48:102–8.

12. Seppä L, Hausen H, Pöllänen L, Helasharju K, Kärkkäinen S. Past caries recordings made in Public Dental Health Care Centers as predictors of caries prevalence in early adolescence. Community Dent Oral Epidemiol 1989;17:277–81.

13. Hausen H, Kärkkäinen S, Seppä L. Caries data collected from public health records compared with data based on examinations by trained examiners. Caries Res 2001;35:360–5.

14. Aunger R. Tooth brushing as routine behavior. Int Dent J 2007;57:364–76.15. Shaffer A, Lidhiem O, Kolko DJ, Trentacosta CJ. Bidirectional relations between parenting practices

and child externalizing behavior: a cross-lagged panel analysis in the context of a psychosocial treatment and 3-year follow-up. J Abnorm Child Psychol 2013;411:199–210.



18. Bartholomew K, Parcel GS, Kok G, Gottleib NH. Planning Health Promotion Programmes: An intervention mapping approach. San Francisco: Jossey-Bass; 2006.

19. Kitzmann KM, Beech BM. Family-based interventions for pediatric obesity: Methodological and conceptual challenges from family psychology. J Fam Psychol 2006; 20:175–89.

20. Rogers JG. Evidence-based oral health promotion resource. Prevention and Population Health Branch, Government of Victoria, Department of Health, Melbourne, 2011.

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21. Thoele MJ, Asche SE, Rindal DB, Fortman KK. Oral health program preferences among pregnant women in a managed care organization, J Public Health Dent 2008;68:174–7.

22. Yevlahova D, Satur J. Models for individual oral health promotion and their effectiveness: a systematic review. Aus Dent J 2009;54:190–7.

23. Arrow P, Raheb J, Miller M. Brief oral health promotion intervention among parents of young children to reduce early childhood dental decay. BMC Public Health 2013;13:245.

24. Vachirarojpisan T, Shinada K, Kawaguchi Y. The process and outcome of a programme for preventing early childhood caries in Thailand, Community Dent Health 2005;22:253–9.


26. Golan M, Kaufman V, Shahar DR. Childhood obesity treatment: Targeting parents exclusively v. parents and children. Br J Nutr 2006;95:1008–15.

27. Epstein LH, McKenzie SJ, Valoski A, Klein KR, Wing RR. Effects of mastery criteria and contingent reinforcement for family-based child weight control. Addict Behav 1994;19:135–145.

28. Israel AC, Stolmaker L, Andrian CA. The effects of training parents in general child management skills on a behavioral weight loss program for children. Behav Ther, 1985;16:169–180.

29. Janicke DM, Sallinen BJ, Perri MG, Lutes LD, Huerta M, Silverstein JH, et al. Comparison of parent-only vs family-based interventions for overweight children in underserved rural settings: Outcomes from project STORY. Arch Pediatr Adolesc Med 2008;162:1119–25.

30. Bandura A (1977). Social Learning Theory. Oxford, England: Prentice-Hall.31. Tanas R, Marcolongo R, Pedretti S, Gilli G. A familybased education program for obesity: A three-

year study. BMC Pediatr 2007;7:33.32. Epstein LH, Paluch RA, Gordy CC, Saelens BE, Ernst MM. Problem solving in the treatment of

childhood obesity. J Consult Clin Psychol 2000;68:717–21.33. Nowicka P, Hoglund P, Pietrobelli A, Lissau I, Flodmark C. Family weight school treatment: 1-year

results in obese adolescents. Int J Pediatr Obes 2008;3:141–7.34. Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention of progression to severe obesity in a

group of obese schoolchildren treated with family therapy. Pediatr 1993; 91:880–4.35. Beech BM, Klesges RC, Kumanyika SK, Murray DM, Klesges L, McClanahan B, et al. Child- and

parenttargeted interventions: The Memphis GEMS pilot study. Ethn Dis, 2003;13(Suppl 1):40–53.36. Ransdell LB, Taylor A, Oakland D, Schmidt J, Moyer-Mileur L, Shultz B. Daughters and mothers

exercising together: Effects of home- and community-based programs. Med Sci Sports Exerc 2003;35:286–96.


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9 summary / samenVattInG

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Summary / Samenvatting

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summary in english

The aim of this thesis was to explore parental and family-related psychosocial determinants of childhood dental caries, and their potential role in socioeconomic inequalities in children’s dental health.

First, a systematic review on self-report psychometric measures of family functioning was conducted, in order to promote accurate and methodologically sound assessment of the family in oral health research (chapter 2). The majority of 29 identified measures reported adequate levels of reliability and construct validity. Furthermore, the constructs of family functioning were evaluated with respect to their potential relevance to childhood dental caries. Based on the construct evaluation, it was recommended that research into the role of family relationships in childhood dental caries should commence using measures that cover dimensions of family warmth and involvement, authoritative/rigid parenting style, control/discipline, organization, flexibility and communication. Herewith, this review provides a framework to guide future exploration of family-related determinants of childhood dental caries.

Chapter 3 describes the results of a cross sectional study in which the relationship between family functioning and childhood dental caries was investigated, using a random sample of 5- to 6-year old children from six paediatric dental centers in The Netherlands. Data on sociodemographic characteristics, oral hygiene behaviours and psychosocial factors, including family functioning, were collected using parental questionnaires and the Gezinsvragenlijst (GVL). Children’s number of decayed, missing and filled teeth (dmft score) were obtained from personal dental records. Results showed that children from dysfunctional families on the dimensions responsiveness, communication, organization and social network had significantly higher dmft scores compared to children from normal functioning families. The same children were also more likely to engage in less favourable oral hygiene behaviours. Furthermore, multivariate analysis indicated that family functioning modestly explained socioeconomic inequalities in childhood dental caries. Findings of this study suggests that family functioning is a potentially important determinant of childhood dental caries that should be considered in the development of caries preventive strategies.

In chapter 4, data of chapter 3 were used to model pathways and interrelationships among community, family and individual determinants of childhood dental caries by means of structural equation modelling. This study yielded a valid model, in which lower maternal education level was related to poorer family organization, lower levels of social support, lower dental self-efficacy and an external dental health locus of control (LoC). These, in turn, were associated with poorer oral hygiene behaviours, which were linked to higher levels of childhood dental caries. In addition, lower maternal education level and poorer neighbourhood quality were directly associated with higher caries levels in children. This model advances our

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understanding of determinants of childhood dental caries and the pathways in which they operate. Clues for further development of the model are suggested.

Chapter 5 describes a case-control study, in which structured video observations of parent-child interactions were performed to investigate the relationship between parenting practices, parent-child interaction and childhood dental caries in 5- to 8-year old children from The Netherlands. The sample included 28 cases (children with a dmft ≥ 4) and 26 controls (children with a dmft/DMFT = 0). Parenting was significantly more positive on the dimensions positive involvement, encouragement, problem-solving and interpersonal atmosphere in controls compared to cases. Parents of controls were also less likely to show coercive parenting behaviours. These findings support the development of interventions that incorporate components to improve aspects of parenting practices to prevent dental decay in children.

A similar case-control study to the aforementioned was conducted in a large paediatric dental centre in The Hague, The Netherlands (chapter 6). This study aimed to explore the relationship between several parental and family-related factors and dental caries in children of Dutch, Turkish and Moroccan origin. The sample consisted of 46 cases (dmft ≥ 4) from a referral centre for paediatric dental care and 46 controls (dmft/DMFT = 0) from a regular dental practice. Data on parents’ dental self-efficacy, LoC and family functioning were measured using validated questionnaires used in chapter 3 and 4. Parenting practices were assessed by structured video observations of parent-child interactions (used in chapter 5) and by the self-report Alabama Parenting Questionnaire. In line with the previous chapters, parents’ internal LoC and observed positive parenting practices on the dimensions positive involvement, encouragement and problem-solving were significant indicators of dental health in children. However, self-reported parenting practices and family functioning were not associated with childhood dental caries. Furthermore, lower social class was significantly associated with a lower dental self-efficacy, a more external LoC and poorer parenting practices, which indicates that that these parental factors are potential mediators of socioeconomic inequalities in childhood dental caries.

Chapter 7 contains the results of a qualitative study, in which six focus group interviews were conducted to explore parents’ views about the influences on children’s oral health behaviours. A further objective was to investigate parents’ desires and recommendations for interventions to support parents in the establishment of dentally healthy behaviours in their child. Parents reported many factors, operating at child, family and community levels, which they perceived to impact on children’s oral health behaviours. Primary influences were related to parental attributes and the family environment, including parental knowledge, perceptions, self-efficacy and control, parenting strategies and family organization. Children’s sugar consumption was also heavily influenced by factors external to the family, such as the school and social environment. Parents suggested several recommendations for interventions



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to improve children’s oral health behaviours, many of their ideas concerning the desire to receive clear and tailored oral health information. The qualitative data derived from this study are useful to inform new approaches for caries prevention in children.

In conclusion, this thesis showed that the family matters in the development of childhood dental caries. Parental attributes in relation to dental self-efficacy and LoC, and dimensions of parenting practices, parent-child interaction and family functioning were important indicators of dental decay in children 5- to 8-year old children in The Netherlands. A vital next step is to evaluate whether interventions that incorporate these family components have the potential to effectively prevent dental caries in children and reduce socioeconomic inequalities in children’s dental health.

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nederlandse samenvatting

Het doel van dit promotieonderzoek was om te bestuderen welke psychosociale factoren rond ouders en het gezin van invloed zijn op de aanwezigheid van cariës bij kinderen, en hoe deze factoren mogelijk een rol spelen in het verklaren van sociaaleconomische verschillen in de mondgezondheid van kinderen.

Voor het bestuderen van het gezin in is het van uiterst belang dat meetinstrumenten worden gebruikt die bepaalde kwaliteitseigenschappen bezitten. Daarom is eerst een systematisch literatuuronderzoek uitgevoerd naar bestaande vragenlijsten om het gezinsfunctioneren in kaart te brengen (hoofdstuk 2). Totaal zijn 29 vragenlijsten geïdentificeerd, waarvan de meerderheid aan de psychometrische kwaliteitseisen voldeed. Daarnaast is geëvalueerd welke constructen van gezinsfunctioneren mogelijk relevant zijn voor tandheelkundig onderzoek. De aanbeveling luidde om onderzoek eerst te benaderen vanuit de volgende dimensies: warmte en betrokkenheid van het gezin, autoritatieve/rigide opvoeding, zeggenschap en disciplineren, gezinsorganisatie, flexibiliteit en communicatie. Dit literatuuroverzicht geeft hiermee richting aan voor toekomstig onderzoek naar de relatie tussen het gezin en mondgezondheid van kinderen.

Hoofdstuk 3 beschrijft de resultaten van een cross-sectionele studie, waarbij 630 zesjarige kinderen uit verschillende Jeugdtandzorgcentra in Nederland zijn onderzocht. Gevalideerde vragenlijsten zijn gebruikt om sociaaldemografische eigenschappen, mondgezondheidsgedragingen, het gezinsfunctioneren en opvattingen van ouders met betrekking tot mondgezondheid vast te stellen. Tandheelkundige gegevens zijn verkregen uit het patiëntenbestand en zijn uitgedrukt in het aantal carieuze, missende en gevulde elementen (dmft-score). De studie toonde aan dat kinderen uit goed functionerende gezinnen op het gebied van communicatie, organisatie, responsiviteit en het sociale netwerk significant minder cariës hadden dan kinderen uit minder goed functionerende gezinnen. Dit was voornamelijk het geval voor de dimensie organisatie, zoals de mate van routine en structuur binnen het gezin. Bovendien bleek een slechter gezinsfunctioneren geassocieerd te zijn met een lagere poetsfrequentie, een hogere leeftijd waarop werd begonnen met poetsen en minder betrokkenheid van de ouder bij het poetsen. Multivariate analyse toonde aan dat sociaaleconomische verschillen in cariës matig werden verklaard door het gezinsfunctioneren. Bevindingen suggereren dat gezinsfunctioneren een belangrijke determinant is van cariës bij kinderen dat moet worden overwogen in de ontwikkeling van cariëspreventieve programma’s.

In hoofdstuk 4 zijn de data uit hoofdstuk 3 gebruikt om de paden en onderlinge relaties tussen maatschappelijke, gezinsgerelateerde en individuele determinanten van cariës te modelleren, door middel van structural equation modelling. Deze studie resulteerde in een valide model, waarin een lager opleidingsniveau van de moeder was geassocieerd met een slechtere gezinsorganisatie, minder sociale steun voor het gezin, een lagere eigen-

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effectiviteit van de ouder (vertrouwen in eigen ‘kunnen’ om goed poetsgedrag uit te voeren bij het kind) en een meer externe locus of control (LoC) (de opvatting dat cariës afhankelijk is van ‘slechte genen’, pech of toeval). Deze waren op hun beurt geassocieerd met minder gunstig mondhygiënegedrag, wat verband hield met een hogere mate van cariës bij kinderen. Daarnaast was een lager opleidingsniveau van de moeder en een slechte buurtkwaliteit direct geassocieerd met hogere cariësniveaus bij kinderen. Dit model bevordert inzicht in de determinanten van cariës bij kinderen en de paden waarin zij invloed uitoefenen. Aanknopingspunten voor verdere ontwikkeling van het model zijn voorgesteld.

Vervolgens is een case-controle onderzoek uitgevoerd, waarin gestructureerde video-observaties zijn gebruikt om de relatie tussen opvoedingsstrategieën, ouder-kindinteractie en cariës bij 5- tot 8-jarige Nederlandse kinderen te bestuderen (hoofdstuk 5). De steekproef betrof 28 ‘cases’ uit een verwijspraktijk voor kindertandheelkunde (cariësactieve kinderen met een dmft-score ≥ 4) en 26 ‘controls’ uit een reguliere tandartspraktijk (cariësvrije kinderen met een dmft/DMFT-score = 0). Uit de studie kwam naar voren dat ouders van cariësvrije kinderen significant gunstigere opvoedingsstrategieën lieten zien met betrekking tot positieve betrokkenheid (tonen van interesse en warmte), positieve bekrachtiging (stimuleren en complimenteren), probleemoplossend vermogen en interpersoonlijke sfeer, dan ouders van cariësactieve kinderen. Bovendien was een overdreven strenge en dwingende manier van disciplineren, in combinatie met weinig uiting van warmte, geassocieerd met een hogere kans op aanwezigheid van cariës bij kinderen. Deze bevindingen pleiten voor de ontwikkeling van interventies gericht op het ondersteunen van opvoeding om cariës bij kinderen te voorkomen.

Een gelijksoortig case-controle onderzoek is verricht in het Jeugdtandzorgcentrum Den Haag (hoofdstuk 6), waarin meerdere factoren rond ouders en het gezin werden bestudeerd in relatie tot cariës bij kinderen van Nederlandse, Turkse en Marokkaanse afkomst. De steekproef bestond uit 46 ‘cases’ (dmft ≥ 4) en 46 controls (dmft/DMFT = 0). De gevalideerde vragenlijsten uit hoofdstuk 3 en 4 zijn gebruikt om het gezinsfunctioneren en de eigen-effectiviteit en LoC van ouders vast te stellen. Opvoedingsstrategieën zijn in kaart gebracht door zowel gestructureerde video-observaties (gebruikt in hoofdstuk 5) als de Alabama Parenting Questionnaire. Resultaten bevestigden dat een interne LoC van ouders en gunstige (geobserveerde) opvoedingsstrategieën op de dimensies positieve betrokkenheid, positieve bekrachtiging en probleemoplossend vermogen significante indicatoren waren van een goede mondgezondheid van kinderen. Zelf-gerapporteerde opvoedingsstrategieën en het gezinsfunctioneren hielden echter geen verband met de aanwezigheid van cariës bij kinderen. Verder was een lagere sociaaleconomische status significant geassocieerd met een lagere eigen-effectiviteit, een meer externe LoC en minder gunstige opvoedingsstrategieën, wat er op wijst dat deze factoren mogelijke mediatoren zijn van sociaaleconomische verschillen in de mondgezondheid van kinderen.



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Hoofdstuk 7 beschrijft de resultaten van een kwalitatieve studie, waarbij zes focusgroepinterviews zijn uitgevoerd om de opvattingen van ouders te verkennen over invloeden op het mondgezondheidsgedrag van kinderen. Daarnaast is onderzocht welke wensen en aanbevelingen ouders hadden voor interventies om gemakkelijker tot goede zelfzorg bij kinderen te komen. Ouders beschouwden vele factoren omtrent het kind, het gezin en de maatschappij als invloedrijk op de mondgezondheid van kinderen. De voornaamste factoren hielden verband met eigenschappen van de ouder en de gezinsomgeving, zoals kennis, opvattingen, eigen-effectiviteit en zeggenschap van de ouder, opvoedingsstrategieën en gezinsorganisatie. De consumptie van zoetigheid werd ook sterk beïnvloed door factoren buiten het gezin, zoals de school en sociale leefomgeving. Ouders suggereerden een aantal aanbevelingen voor interventies om zelfzorg van kinderen te bevorderen. Veel van deze ideeën betrof de wens om eenduidige, heldere en afgestemde mondgezondheidsinformatie te ontvangen. De kwalitatieve gegevens verkregen uit deze studie zijn nuttig voor de ontwikkeling van nieuwe benaderingen voor cariëspreventie bij kinderen.

In hoofdstuk 8 worden de bevindingen van hoofdstuk 2 tot en met 7 bediscussieerd en worden aanbevelingen beschreven voor de ontwikkeling van mogelijk cariëspreventieve interventies.

Concluderend kan worden gesteld dat het gezin een belangrijke rol inneemt in de ontwikkeling van cariës bij kinderen. De eigen-effectiviteit en LoC van de ouder, en dimensies van opvoedingsstrategieën, ouder-kindinteractie en gezinsfunctioneren bleken belangrijke indicatoren van cariës bij 5- tot 8-jarige kinderen in Nederland. De volgende stap betreft het evalueren of interventies die aangrijpen op deze gezinsfactoren succesvol zijn in zowel het bevorderen van de mondgezondheid van kinderen, als het reduceren van sociaaleconomische gezondheidsverschillen in de cariësstatus van kinderen.

10 acknowledGements / dankwoord

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Het is zover: de laatste pagina’s van dit proefschrift mogen geschreven worden. Tijd om terug te kijken op de fijne jaren als promovendus en mijn dank te betuigen aan iedereen die heeft bijgedragen aan de totstandkoming van dit proefschrift.

Op de eerste plaats een woord van dank aan beide promotoren, Prof. dr. Cor van Loveren en prof. dr. Erik Verrips. Ik heb onze samenwerking van het prille begin tot het eind als zeer prettig ervaren. Met jullie verscheidenheid aan eigenschappen en expertise, en ieder zijn eigen wijze van begeleiden, vormden jullie een gouden combinatie. De vrijheid die jullie me hebben gegeven om het promotietraject deels naar eigen interesses en inzichten in te vullen, waardeer ik zeer. In het begin lagen onze ideeën over cariëspreventie nog weleens uiteen, deels verklaarbaar door mijn achtergrond uit Londen. Dit leidde tot interessante en zeker ook plezierige discussies. Na vier jaar onderzoek kunnen we, denk ik, constateren dat we veel meer op één lijn zijn komen te zitten, waarvan het resultaat nu voor ons ligt. Dit proefschrift betekent hiermee hopelijk niet het einde van deze onderzoekslijn, maar juist een aanzet tot vervolg!

Beste Cor, ik heb het altijd zeer gewaardeerd dat ik je altijd makkelijk kon bereiken als ik behoefte had aan afstemming. Met jouw scherpzinnige blik daagde je me uit kritisch naar mijn eigen tekst te blijven kijken en altijd verder te denken over de wijze waarop de resultaten zich vertalen naar de maatschappij. Ook heb ik veel bewondering voor jouw creatieve en vernieuwende kijk op de tandheelkundige preventie, waarbij je tegen de conventies in durft te gaan. Ik hoop dat ik me deze kwaliteit van jou nog meer eigen kan maken! Daarnaast wist je wetenschap soms leuk te combineren met humor. Een voorbeeld dat me bij is gebleven: tijdens het IADR congres werd een staafdiagram gepresenteerd waarin zichtbaar was dat de mate van cariës aanzienlijk steeg naarmate de sociaaleconomische status afnam. De vraag werd gesteld hoe we dit steile verloop kunnen afzwakken, waarop jij met de eenvoudige oplossing kwam: ‘Door de kolommen breder te maken’.

Beste Erik, altijd als we elkaar spraken over het onderzoek was je enthousiasme merkbaar en dat werkte zeer aanstekelijk. Jouw positieve houding en optimisme gaven me het vertrouwen dat ik op de goede weg zat. Af en toe was je wel eens genoodzaakt om me streng toe te spreken als ik me te veel liet afleiden door andere, niet-promotie-gerelateerde, werkzaamheden. Dat had ik dan ook even nodig. Het laatste jaar van het promotietraject zagen we elkaar helaas minder wegens je gezondheid, maar desondanks ben je altijd betrokken gebleven. Daarnaast heb je je veel ingezet om me in contact te brengen met mensen die mij met mijn onderzoek verder konden helpen. Dank daarvoor!

Lieve Maddelon, door jou heb ik aan het promoveren zoveel extra plezier beleefd! Een groot deel van deze onderzoeksreis hebben we samen gedaan. Ideeën voor studies ontstonden in de ‘hop on, hop off’ bus in Rome en café ‘Van der Werff’ in Leiden. Ze werden verder

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besproken op de derde verdieping van het Gortergebouw, tijdens congresreisjes naar Londen en Malta en op weg van Amsterdam naar Enschede. De resultaten zijn opgeschreven in het vakantiehuisje van Prof. dr. Ad de Jongh te Loenen aan de Vecht. Ik ben ontzettend blij met onze fijne samenwerking, waarbij we elkaar altijd perfect weten aan te vullen en te enthousiasmeren. Naast een leuke collega ben je ook een goede vriendin geworden. Nu op naar de afronding van jouw proefschrift en dan kunnen we samen verder de doctorale wijde wereld in!

Collega’s heb ik er velen, zowel binnen ACTA als daarbuiten. Maar in het bijzonder gaat mijn dank uit naar alle collega’s van de sectie Sociale Tandheelkunde en Voorlichtingskunde. Beste Hanny, ik heb altijd op je kunnen rekenen. Bedankt voor je enorme ondersteuning, de vrolijke gesprekken en voor alles wat je me hebt bijgeleerd. Zonder jouw hulp zou mijn promotietraject er ongetwijfeld een stuk chaotischer uit hebben gezien. De mede-promovendi van de afdeling: Caroline (kamergenoot), Marieke en Janneke. Lieve meiden, ik heb vier hele leuke jaren beleefd met jullie als collega’s. Dank voor al jullie adviezen, en vooral ook voor de ‘minder serieuze’ en gezellige momenten tussendoor. Ik heb veel met jullie gelachen en ook erg veel aan jullie gehad. Irene en Arjen, ik waardeer het zeer dat ik altijd bij jullie mocht aankloppen voor advies. Jullie hebben me laten zien dat hard werken, humor, en een borrel op zijn tijd goed samen gaan. Ook Ronald, Jan den D, Erik Verrips, Ad, Geert, Josef en oud-collega’s Jacobien, Jan P, Erik Vermaire, Denise, Michiel, Johan, Michel en Carrie horen hier uiteraard genoemd te worden. Door jullie oprechte interesse, jullie betrokkenheid en de goede onderlinge sfeer ben ik nooit een dag met tegenzin naar mijn werk gegaan. Dit heeft me terdege doen beseffen wat een bijzondere en fijne afdeling dit is! Veel dank!

Ook Prof. dr. Fred Rozema, Thijs, Willem en Margreet van de afdeling Medisch Tandheelkundige Interactie wil ik hier graag bedanken. De gezamenlijke lunch- en koffiemomenten, en het delen van de gang op de vijfde verdieping, maakte dat het voelde alsof we onderdeel waren van dezelfde afdeling.

Tevens wil ik hier een woord van dank achterlaten voor al mijn collega’s op de afdeling Preventieve Tandheelkunde. Hoewel mijn werkplek zich niet op de 13e verdieping bevond, en mijn project enigszins buiten de gebruikelijke onderzoekslijn viel, heb ik me wel altijd verbonden gevoeld met de afdeling. Door jullie diversiteit aan expertise daagden jullie mij uit om mijn onderzoek vanuit een ander oogpunt te benaderen. Deze kritische blik en blijk van interesse tijdens presentaties heb ik erg op prijs gesteld.

De collega’s van TNO wil ik graag bedanken voor de positieve bijdrage die zij hebben geleverd aan de totstandkoming van dit proefschrift. Beste Annemarie Schuller, hartelijk dank voor de nuttige discussies waarin je met me meedacht over de opzet en uitvoering van mijn onderzoek. Beste Elise Dusseldorf, ik ben erg dankbaar voor jouw inzet om mij deels de kunst van Structural Equation Modelling te leren. Dankzij jouw hulp hebben we gezamenlijk een mooi artikel kunnen schrijven.



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Daarnaast heeft mijn promotietraject ook waardevolle samenwerkingen opgeleverd met collega’s buiten ACTA en TNO.

Dear Prof. dr. Cynthia Pine and Prof. dr. Wagner Marcenes from Queen Mary University London, Prof. dr. Pauline Adair from Strathclyde University, and Sarah Elison and Lucy O’Malley, I am thankful that I was able to work with you on a symposium at the IADR conference in Brazil, 2012, which also resulted in a publication in Caries Research. Dear Wagner, we both share the interest of exploring the family in oral health research, therefore I am grateful that you accepted the invitation to be a member of my doctorate committee.

Beste Prof. dr. Corine de Ruiter en Jill Thijsen, in 2012 begonnen we een bijzondere samenwerking, waarbij expertise in de tandheelkunde, klinische psychologie en opvoedkunde werden gebundeld. Hiermee won dit proefschrift een belangrijke dimensie. Ik dank jullie zeer voor jullie bereidheid om jullie onderzoeksmethoden met ons te delen en voor jullie essentiele bijdrage aan de twee publicaties die we samen hebben geschreven.

Mijn bijzondere dank gaat uit naar Menzis Zorgverzekeraars, die door middel van financiële steun dit promotieonderzoek mogelijk heeft gemaakt. Beste Anda Geerdink, de inzet en het doorzettingsvermogen dat je hebt getoond om dit onderzoek te honoreren is bewonderingswaardig. Ik heb veel aan jou te danken!

Hieruit volgt ook een woord van dank voor de leden van de begeleidingscommissie. Beste Bart Fledderus en Gert Stel, jullie deelname in de commissie en jullie suggesties en vertrouwen heb ik zeer gewaardeerd. Onze bijeenkomsten met Anda en mijn promotoren waren altijd iets om naar uit te kijken.

Het Ivoren Kruis wil ik bedanken voor de inzet die de vereniging heeft getoond om dit onderzoek te realiseren. Beste Ronald Bos en Mariëlle Nap, hartelijk dank voor jullie medewerking en de bereidheid om te helpen met de verspreiding van de resultaten onder de tandheelkundige professie. Veel dank ben ik ook verschuldigd aan de Jeugdtandverzorging Enschede en Zoetermeer, Tand-wiel Jeugdtandverzorging, Mondzorg voor kids - centrum Nijmegen en Jeugdtandzorg West voor het beschikbaar stellen van patiënten voor het onderzoek. Speciale dank gaat uit naar Han Verhoeven, Hans Berendsen, Helga Wissenburg, Sylvia Gossen, Sandra-An van Drecht en Abigail Verlinden voor jullie enthousiasme en volledige support.

De studenten die hun Bachelor- en Masterscriptie bij mij gedaan hebben wil ik ook niet onvermeld laten. Armin Alambeigi, Manon Kromwijk-Smits, Sinica Cheung en Sanne Bax, dank voor jullie inzet en nuttige bijdrage. Met jullie hulp zijn twee hoofdstukken uit dit proefschrift mogelijk gemaakt.

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Daarnaast wil ik alle leden van de leescommissie (Prof. dr. Wagner Marcenes, Prof. dr. Gert-Jan Truin, Prof. dr. Geert van der Heijden, Prof. dr. Johan Hoogstraten, dr. Annemarie Schuller en dr. Martine Gemert-Schriks) hartelijk danken voor het kritisch beoordelen van de 200 pagina’s, die mijn inspanningen van de afgelopen vier jaar beschrijven.

Tijdens mijn promotieonderzoek heb ik met veel plezier in het promovendi-overleg van ACTA gezeten. Beste Catherine, Jenny, Greetje, Tjitske, Sabrina, Francis, Janice, Gert-Jan, Dongyun, Sepanta en Ilona, bedankt voor de gezellige tijd en voor alles wat we gezamenlijk hebben bereikt.

Ook wil ik graag een aantal mensen noemen die niet direct betrokken zijn geweest bij mijn promotieonderzoek, maar die wel belangrijk zijn geweest om te kunnen komen waar ik nu ben.

Beste Prof. dr. Bruno Loos, hartelijk dank voor de ervaringen die ik op heb mogen doen als student-assistent op de afdeling Parodontologie, en voor de eerste aanzet die u mij heeft gegeven om de onderzoeksrichting op te gaan.

Dear Prof. dr. Aubrey Sheiham, Prof. dr. Richard Watt, dr. George Tsakos and Prof. dr. Martin Hobdell from University College London, I would like to express my deepest appreciation for your excellent teaching in dental public health. You’ve awakened my interest in oral epidemiology and public health research, and shaped my thinking about concepts in oral health promotion. Your wisdom, modern ideas and enthusiasm have been a great source of inspiration and motivation, and I hope we can continue working together in the future.

Dear Bella Monse, I am most grateful for the opportunities you have given me to work with you on very interesting, relevant and high-quality research, including the Weight Gain Study in 2010 and the current Regional Fit for School Health Outcomes Study. I admire your passionate commitment and creative approach in school health promotion, and I feel privileged that I can directly learn from you. Thank you for the great experiences and for your trust in me.

In this context I also like to say ‘Vielen Dank’ / ‘Salamat po’ to my new colleagues at GIZ: Jed Dimaisip, Mitch Majini, Kristina Müller, Nicole Siegmund and Johann Leonardia from the Regional team, my colleagues from the ARMM-team and the admin team, prof. dr. Wim van Palenstein and Habib Benzian. It is a real pleasure working with you!

Als laatste, maar minstens zo belangrijk, wil ik mijn lieve familie en vrienden bedanken voor jullie steun, getoonde interesse en leuke afleiding. Daarbij wil ik een paar namen in het bijzonder noemen.

Mijn paranimfen, Rory en Irene, wat ben ik blij dat ik jullie aan mijn zijde mag hebben op 6 februari 2015! Rory, mijn vriendschap met jou en Rick is me ontzettend dierbaar. Tijdens de



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introductieweek van de studie Tandheelkunde leerden wij elkaar kennen, en nu, ruim tien jaar later, sta je me bij op deze belangrijke dag. Irene, als fijne collega ben ik heel dankbaar dat jij de andere plaats van paranimf op je hebt willen nemen. Beiden denken jullie enthousiast met me mee, en beiden zijn jullie in voor een leuk feestje. Ik had geen betere combinatie kunnen wensen!

‘Mijnheren’, lieve Rory, Rick, Jonathan, Leo, Bart, Andres, Bas en Martijn, naast het leven als promovendus was er gelukkig ook ruimte voor een sociaal leven, en jullie maakten daar een belangrijk deel van uit. Jullie vormen een geweldige vriendengroep waarbij ik helemaal mezelf kan zijn. Ik ben gek op jullie. Lieve Amanda, jouw oprechte interesse, onze waardevolle en hilarische gesprekken en je attente gebaren maken jou een zeer geliefde vriendin. Ik weet dat ik altijd op je kan rekenen. Dank daarvoor! Mijn schoolvriendinnen, Elise, Mariëlle en Marjolein, ondanks dat we allemaal een eigen weg zijn ingeslagen, hebben we nog steeds een indrukwekkende vriendschap. Dank voor alle fijne momenten en de momenten die ongetwijfeld nog zullen volgen. Bertine, roomy, na jaren van samenwonen ken je mij als geen ander. Wat hebben we een fantastische tijd beleefd. Dank je dat je er voor me was toen ik de moeilijke keuze maakte om te stoppen met mijn studie Tandheelkunde. Olivia, I am grateful for the friendship we still have after our great year together in London.

Allerliefste oma, u bent me er een(d)je. Met de leeftijd van 94 jaar verkeert u nog in uitstekende gezondheid. Ik ben heel blij met de goede band die we hebben en ik kom dan ook altijd met graag bij u over de vloer. Bedankt voor al uw goede zorgen en wijsheden. Yannick, mijn lieve broer, en je vriendin Imme, wat ben ik blij dat wij het zo goed met elkaar kunnen vinden! Bedankt voor alles. Ten slotte, mijn geliefde ouders. Ik kan jullie niet genoeg bedanken voor alle kansen die jullie mij hebben gegeven en voor jullie onvoorwaardelijke steun. Uiteindelijk hebben jullie mij altijd aangemoedigd om mijn passies in werk te volgen en ik weet dat jullie trots zijn op waar het mij heeft gebracht. Dank voor alles, voor al die jaren, voor alle liefde, voor zoveel!

A lIst oF publIcatIons

currIculum VItae

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List Of Publications

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list oF Publications

In this thesis:

Duijster D, de Jong-Lenters M, de Ruiter C, Thijssen J, van Loveren C, Verrips, GHW. Parental and family-related influences on dental caries in children of Dutch, Moroccan and Turkish origin. Community Dent Oral Epidemiol 2014; doi: 10.1111/cdeo.12134 (Epub ahead of print).

(Chapter 6 in this thesis)

de Jong-Lenters M, Duijster D, Bruist MA, Thijssen J, de Ruiter C. The relationship between parenting, family interaction and childhood dental caries: a case-control study. Soc Sci Med 2014;116:49–55.


Duijster D, van Loveren C, Dusseldorp E, Verrips GHW. Modelling community, family and individual determinants of childhood dental caries. Eur J Oral Sci 2014;122:125–33.


Duijster D, Verrips GHW, van Loveren C. The role of family functioning in childhooddental caries. Community Dent Oral Epidemiol 2014;42:193–205.


Duijster D, O’Malley L, Elison SN, van Loveren C, Marcenes W, Adair PM, Pine C. Family relationships as an explanatory variable of childhood dental caries: a systematic review of measures. Caries Res 2013;47(suppl.1):22-39.


Other publications

Rouxel P, Duijster D, Tsakos G, Watt RG. Oral health of female prisoners in HMP Holloway: implications for oral health in UK prisons. Br Dent J 2013;214:627-632.

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Duijster D, Sheiham A, Hobdell MH, Itchon G, Monse B. Associations between oral health-related impacts and rate of weight gain after extraction of pulpally involved teeth in underweight preschool Filipino children. BMC Public Health 2013;13:533.

Monse B, Duijster D, Sheiham A, Grijalva-Eternod CS, van Palenstein-Helderman W, Hobdell MH. The effects of extraction of pulpally involved primary teeth on weight, height and BMI in underweight Filipino children. A cluster randomized clinical trial. BMC Public Health 2012;12:725.


Curriculum Vitae

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curriculum vitae

Denise Duijster was born on the 3rd of July, 1986 in Rotterdam, The Netherlands. She started to study Dentistry at The Academic Center for Dentistry Amsterdam (ACTA) in September 2004 and obtained her Bachelor’s degree in 2008. During her undergraduate years, she worked halftime at a general dental practice for 1.5 years to gain clinical experience. Her interest in dental research started at the department of Periodontology, where she worked for one year as a research assistant on a project on biomarkers of systemic inflammation in relation to aggressive periodontitis.

After starting the Master’s programme at ACTA dental school in 2008, she decided to change her career path from clinical dentistry to dental research and population health. In September 2010 she obtained a postgraduate Master’s degree in Dental Public Health (with distinction) at the University College London (UCL). Afterwards, she returned to ACTA to work fulltime on her PhD project, titled ‘Family matters – the role of parental and family-related psychosocial factors in childhood dental caries’. During her PhD, she was teaching statistics and research methods to 1st year dental students.

Since September 2014, she is working as a researcher for the Gesellschaft für Internationale Zusammenarbeit (GIZ, the German governmental organization for international development) and UCL. Her work involves the impact evaluation of the Fit for School health programme on nutritional, dental and parasitological outcomes in children, as well as water, sanitation and hygiene in schools, in Indonesia, Lao and Cambodia. She is based in Manila, The Philippines.

FAMILY MATTERSThe role of parental and family-related psychosocial factors in childhood dental caries

Denise Duijster

FAM

ILY MATTERS - D

ENISE D

UIJSTER

InvItatIon

to the Public Defense of my Doctoral Thesis

FamIly matters

The role of parental and family-related psychosocial factors in childhood dental caries

on Friday, 6th of February 2015 at 13:00 hrs,

The Aula of the University of Amsterdam,

Singel 411 in Amsterdam.

You are cordially invited to the reception after the

public defense.

Denise [email protected]

06-18393249

Documents

Proefschrift Duijster