Behavioral Denial Science

Influence of social norms on toothbrushing behavior of preschool children ANTHONY S, BLINKHORN

Dental Health Unit, University Dental Hospital of Manchester, Manchester, England Blinkhorn, A. S.: Influence of social norms on tootlibrushiii,!^ beliavior in jMeschool ehildren, Connnunity Dent. Oral Epidemiol. 1978: 6: 222-226. Abstract — Two hundred and eighty mothers of ])res(liool ehildren were interviewed in order to deterniiiie first, their ehildren's toothbrushinir habits and secondly, their expectations conrerniii,g the brushing behavior of preschool ehildren in general. The influence of social and deinogra|>hic factors on ehildren's brushing lieliavior was also investigated. Tbe results showed that t.he jjractice of toothbrushing is widespread and mothers phiy the central role in teaching the lirushing routine. However, the social norms concerning oral hygiene were imprecise, indicating that mothers had no social sup|:)ort for teaching their ehildren to brush and no inforinalion on how brnsliing should be carried out. Dental heahh educators should encourage mothers of young children to develop ]5ositive attitudes towards toothbrushing and teach thciii the eorreet techniciue. Keywords: socioeeonomic faetors; toothbrushing. Anthony S. Blinkhorn, Lanee Burn Health Centre, Cluirchill Way, Salford, Manchester M6 5AU, England (Accepted for publication 22 July 1978)

The prevention of the two major oral conditions of dental caries and periodontal disease depends tnainly on the manner in which individuals conduct their daily lives, highlighting the importance of dental health education in the prevention of disease. A better understanding of the factors which influence pattem.s of behavior would greatly aid health educators in their efforts to establish sensible oral hygiene and eatitig habits. Since both major dental diseases become established in childhood, health educators have concentrated mainly on modifying the beliavior of schoolchildren and adolescents. This is of practical value as these groups are already undergoing formal education. Although this would seem to be a sensible approach, more serious consideration would lead to the realization that the establishtnent of daily Iiealth praetices must depend upon a suitable home environment. However, there is little information on

why or when parents become aware that their children's tnouths need care and attention, although this is probably during the preschool years. Patterns of behavior learnt duritig this time arc deeply ingrained and re.sistant to chatige (1) atid mothers have a primary role in this learning situation. This implies that attempts at changing an individuals behavior at a later stage of developmerit may well prove difficult because of earlier influence in tho home. Thus, the development of sound oral health habits in early childhood would appear to be importatit, but the lack of knowledge concernitig mothers' opinions and behavior in relation to tho dental health of their young children suggests tho need for futidamental research in order to develop more soundly based health education programs. The process whereby parents transmit and children internalize routines of behavior is termed primary socialization (2), Ba.sically, pritnary sociali-

Toothhrushino and social norms 223 zation enables a child, through physical and social contact, to be integrated into society. It also acts as an instrument of social cotitrol by teaching nornts of behavior currently accepted iti the child's immediate community, Nortns are itiformal, shared expectations that society imposes on individtials ( 3 ) , controlling their behavior and ciisuriug that the society ftinctions adequately by rendering a standard of predictability in relationships between individuals. Mothers are unhkely to teach their children practices which they feel will not be accepted or supported by their community; they adhere to the current norms of behavior of their group (4, b). Norms can be ttsed to encourage the acquisition and maititenancc of a routine of behavior such as toothbrushing by an individual within a group. Patterns of behavior once learned in early childhood and established as routines eliminate the need to make con.scious decisions and allow individuals to manage other social problems with a minimum of stress. A health education study requires a simple practical framework to support theoretical concepts. In the field of dental health, toothbrushing wotild seem to fill this role, for it is a routitie which is easily recognized and remembered, it can be performed without the need to make repeated decisions and indicates an interest in the mouth. As it is an imposed routiue, there is no inner drive to brush, so it can be initiated at varying times duriug a child's development. The toothbrushing routine must, therefore, be established without the aid of physiological motivation, its introduction being the direct responsibility of the parents, depending on their personal interest and on the influence .of current societal norms about toothbrushing. For these reasons a study was carried out of a population of mothers whose children were undergoing the primary socialization process in order to establish when and for what reasons they introduced their children to the toothbrushing regimen. During this period the primary dentition fully erupts, while rapid development of the powers of communicatioti makes childreti capable of intertializing the transmitted routities of behavior. An investigation was also made into the mothers' opinions on the current societal norms relating to prcschool children's toothbrushitig habits in order to assess whether there was a social norm related to oral hygiene.

MATERIAL AND METHODS SAMPLE A random sani])le of 342 mothers with ]n'eschool children aged between 2 and 4 years was obtained from an Area Health Authority's notification of births; 33 (9.7 %) mothers were not contacted, 21 (6.1 %) refused to participate in the study and 288 (84.2 %) were iiUen'iewed. Inforinalion was gathered by trained interviewers using a stnictured interview sihedule. The inten'iew was designed to investigate first, the child's toothbrushing behavior as reported by the mot her and secondly, the mother's ex]>ectations concerning the social norms related to toothbrushing for yonng children in her eonnnunity. The sample of mothers was stratified according to geogra|5hic location, one grou]:i being drawn from an upper niiddleelass coiiiinuter suburb and the second from a clearance overspill estate in a rather isolated loeation. The inten'iewers also oblained social and demographic data by questioning each mother about her eniployinent status, age, the number of children in her family, husband's occupation, her dental visiting i^attern and denture-wearing history.

STATISTICAL DESIGN The collected data are described in the form of frequency distributions. Contingency tables are presented and inferences drawn following the application of the chi-square lest. As ap])i-oxiinalely 400 tests of significance were conducted on the complete study data, a number of false positive conclusions can be expected. In order to reduce the problem to a low level, a difference was regarded as significant only when the ])robabiHty of making a false positive error was less tlian I in 100 (a = 0.01). It is apjM-eciated that this automatically increased the chances of drawing a false negative conclusion, but in view of the possible iin])lication of the conclusions to exjjenditure on health education this risk is considered justifiable.

RESULTS Of the total sample of mothers (288), 9\.Q% (262) reported that their children owned and

Table I. Cbildren's toothbnisb ownership as reported by mothers Expeeted (social norm)

Actual

% Own a bnish No brush Don't know

262 26

91.0 9.0

165 19 104

57.3 6.6 36.1

Total

288

100.0

288

100,0

224

Bt.INKtIORN

Table 2. Age at which children begin brushing as reported by mothers (26 children not brushing) Expci ted (social norm)

Actual n

Tal:)le 4, Frequency of toothbrushing amongst children as reported by mothers

%

n

Up to 2 years 2-3 years 3-4 years Don't know

155 61 42 4

59.2 23.3 16,0 1,5

3t 7 27 197

Total

262

lOtl.O

262

100,0

used a toothbrush, indicating that the actual process of toothbrushing amongst preschool children is wide.spread. However, a social norm was not clearly perceived, for as many as 36,1 %> (104) of the mothers were unable to comment on the expected pattern of toothbrushing among preschool children (Table 1). Of the children who owned a brush, 59.2 % (155) had, according to their mothers, begun brushing at or before the age of 2 years, but no clear pattern of behavior was evident (Table 2). Their uncertainty is emphasized by the fact that 75,2 % (197) of the mothers had uo definite idea at what age other children begin brushing their teeth, thus failing to demonstrate a clear social norm. Nearly half the mothers whose children brushed (43,9 % ; 115) checked their children's mouths on a daily basis to asse.ss the level of oral cleanliness, contrasting markedly with their opinions of mothers in general (Table 3), Here again there was clear evidence of a poorly developed social norm within this group; mothers who do check their children's

Table 3. Mothers who re]M5rted cheeking their ehildren's mouths every day Expected (social norm)

Actual

n

7"

It

J X daily 2 X daily No set. time Don't know

87 122 53

33.2 46.6 20,2

8 15 3 236

3.1 5.7 1.1 90.1

Total

262

100.0

262

100.0

% 11,8 2.7 10.3 75,2

n

%

n

Yes No Don't know

115 147

43,9 56,1

6 64 192

2.3 24.4 73.3

Total

262

100,0

262

100.0

%

Ex|)ected (social norm)

Actn al

%

mouths can expect little positive, general support from within their community, 62,9 % (165) of the mothers iu this study believed tliat they played the most important part in establishing the toothbrushing habit, this belief being supported to some extent by the social norm, as 43,9 7" (115) expected mothers in general to be the mo.st important person establishing the habit, but once again the majority (56.1 % ; 147) of the mothers did uot perceive a social norm. Only 9,9 % ( 2 6 ) were able to comment on the frequency of toothbru.shing amongst preschool children in general and this tinceitaitity was reflected iu the children's reported brushing behavior which showed a wide variation indicating that there was no clearly defined and accepted pattern of behavior (Table 4), The mothers gave two main reasons why their children were using a toothbrush; first, to maintain oral cleanliness ( 4 5 , 8 % ; 168) and secondly, to prevent dental decay (25,3%.; 93), It was disappointing to find that only 20.1 % (58) of the total sample of mothers had received any advice on how to look after their children's teeth. Not only is there uo clearly defined social support for some aspects of oral hygiene but the dental and allied health professionals have failed to assist the mothers who are interested in caring for their children's teeth. Geographic location was found to influetice toothbrush ownership; those mothers whose children did not own a toothbrush beitig more likely {P

Influence of social norms on toothbrushing behavior of preschool children.

Behavioral Denial Science Influence of social norms on toothbrushing behavior of preschool children ANTHONY S, BLINKHORN Dental Health Unit, Univers...
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