Rural Latino farmworker fathers' understanding of children's oral hygiene practices

Sample

The sample included 20 immigrant men, 15 of whom had origins in Mexico, while the other 5 came from El Salvador. Their average age was 38±6.4 years; and they had spent a mean of 15±6.9 years in the U.S. These fathers report having a low level of educational achievement, a mean of 5.5±1.6 years of schooling, and being employed in farmwork, either as fieldhands or as truckers delivering produce from farm to distributor. The men presently head families that are primarily low-income, with an average annual income at or below federal poverty level ($US24,000). Almost one-third (30%) of these parents and most (89%) of their children had health insurance, mainly public insurance through the federal Medicaid program. The participating families had an average of 3.3±1.8 children each, with 65 children total. The mean age of the youngest child per family was 3±2.1 years.

Fathers’ knowledge base as context for this study

In general, fathers assigned much less value to dental health when compared to the overall health of the body. The fathers interviewed had very limited knowledge regarding basic oral hygiene concepts and the etiology of dental disease. This lack of knowledge underlies their scant involvement in their children’s oral hygiene practices, and partially explains why the fathers accept so little responsibility for this aspect of their children’s health. Also, they struggled greatly to define what a “cavity” is, what it looks like, and the significance of such a condition.

The fathers assigned much greater importance to general health (ie visiting a physician) than to dental health (visiting a dentist), a thought illustrated by this father of four young children:

“I see teeth problems as something that affects you, but it’s not like a problem with your body, like, for example, pneumonia or a cough, when you have to be caring for your child. Your teeth may hurt for a little while and you can put up with it for a day or two…I think a toothache is very different from a cough, a cold, or an infection.” [MCG011]

Similar thoughts were shared by various fathers, suggesting a generalized lack of understanding of dental conditions and the possible repercussions of neglecting diseased teeth. Problems in the mouth were seen as being isolated from conditions of the body. Teeth were described as being functional, yet replaceable:

“Dental health is important, but you can eat without teeth. You can get a bridge. But if something in your body is damaged, it’s very difficult to replace it.” [MCG03]

And to another father, his wife’s complete lack of molars was of little concern:

“She [wife] has never been [to the dentist] because she has never had any problems. She doesn’t have any molars.” [MCG08]

These fathers generally had more interaction with the family physician than with the family dentist. While several fathers recounted visits with a primary care provider, very few could remember any direct interaction with a dentist, further verifying that less value is accorded to oral health. However, they do assign importance to teeth, especially their children’s. Nine of thirteen who responded to a direct question declared their children’s teeth to be much more important than their own.

The fathers’ harbored many misconceptions about the etiology, appearance, and significance of dental caries. Only one father correctly identified the role of bacteria in caries etiology. The majority of the fathers, however, had great trouble giving a definition and usually cited “food getting stuck on the teeth” and a lack of oral hygiene as the main causes. When asked “what does a cavity look like?” or “how do you know when your child has a cavity?”, the responses were many and varied. The most common indicator of caries given was “stains” [brown, yellow, black] on the teeth, which they also related to “black dots” on the teeth. To many of the fathers, however, having a “cavity” was different than having tooth “decay,” with the former preceding the latter. This father described his understanding of the process:

“With decay you see black dots, and then you see a hole and it starts to hurt…With a cavity, the tooth isn’t decayed yet. I think it’s part of the process. When you have the black dots, if you poke it with something, it becomes a dent on the tooth. That’s a sign that the tooth is very damaged…a cavity is just the start of that. Black dots form when the tooth has decayed already” [MCG011].

Four fathers cited gingival bleeding as the principal sign that their child had cavities. Another eight fathers reported yellowing of teeth “near the gumline” and redness of the gums as principal indicators of cavities, mistaking plaque accumulation and periodontal irritation for cavity formation. Finally, one father cited bad breath as the principal indicator. When asked if cavities could threaten the general health of their children, the majority concluded that cavities affect a child’s ability to eat, thus affecting their overall health. However, only three fathers made reference to the risk of infectious spread from a carious tooth.

Responsibility for overseeing children’s oral health

In response to the question “who is responsible for taking care of your children’s teeth?” fathers almost unanimously (18 of 19) agreed that their wives mainly performed this task. Most men indicated that they did occasionally help out, too; only one man denied any involvement at all in his children’s oral health activities.

The most common reason men provided for the mother being primarily responsible for their children’s oral health was because the mother did not work and was at home all day with the children. Therefore, she was available for taking care of the daily tasks that concerned the children. During the interviews, men reported that a father’s responsibility is to work to provide for the family’s material needs, a thought illustrated by these two fathers:

“Well, I could say that it was my wife because she is the one that is at home with them. I go to work in the morning and I get home at night.” [MCG03]

“…she’s with the children more. I work. I leave home early and when I get home I am tired.” [MCG07]

The fathers expressed complete support for the daily care activities and treatment decisions made for their children by their wives. Some men reported that on occasion they and their wives discussed how much they could afford to pay for oral health care for a specific problem, or to devise a timetable for when needed treatment could be undertaken. Generally, however, men affirmed their wives’ actions and took little direct action with respect to their children’s oral health.

A major and important exception stemmed from the fact that most of their wives did not drive. Therefore, the fathers themselves many times drove their children to and from dental appointments, especially when this involved trips to pediatric specialists located some 70 miles away.²⁹ On such occasions, a father would accompany his wife and child into the dental office and participate first-hand in decision-making and discussion with the health professional.

Despite the men’s generalized lack of participation in supervising their children’s oral health, the fathers were very aware of oral health needs and of the dental treatments their children had undergone. In response to questions such as “tell me about your children’s teeth,” and “how have their [children’s] experiences with dentists been?” these fathers were able to discuss the condition of their children’s teeth. Of the19 fathers whose children had past dental treatments, 17 talked in detail about those treatments. Reasons for visiting the dentist, the child’s experience of going to the dentist for the first time, and even which specific teeth were worked on were all subjects about which the fathers elaborated.

This father, for example, talked about his child’s broken tooth and the way he and his wife deliberated about whether to visit the dentist or not:

R: “That's the problem he has at the moment. His tooth is broken. He had gotten fillings in some of his molars before. It seems that one of them is opening up again.”

I: “So, what are you going to do? Do you plan to take him in to get it fixed?”

R: “Well, a bit later, yes. We [indicating he and his wife] are just seeing if it's going to fall out. We're waiting to see what they [dentist] recommend, to see what we can do; if we should just wait for it to fall out or what.” [MCG07]

Another father recalled specific details about his son’s experience with a local pediatric dentist:

I: “Where did you take him when you took him to the dentist?”

R: “I took him to a specialist… for children. That specialist only treats children up to five years of age.”

I: “Here in [name of rural town]?”

R: “In Fresno [large city some distance away]. He [the dentist] took some molars out, he put in some crowns and he put some without metal in the front…there were about six teeth that were fixed.” [MCG01]

A third father recounted how many fillings his son had received at his last dental visit:

R: “Well, we were taking our son to…the clinic. He had to get some fillings. I think that the reason was because he eats a lot of candy.”

I: “He eats a lot of candy?”

R: “Yes, and he got caries and all that.”

I: “How many fillings did he get?”

R: “I think they [dentist] said they were going to do 10, but in the end they only did 8.” [MCG05]

When to Initiate Home Oral Hygiene Practices

These Latino fathers generally agreed that a child should begin oral hygiene practices at a young age. When asked to specify more exactly what age, men responded with a wide range from approximately 6 months of age to 4 years. However, the average age of tooth brushing initiation that these men reported was 2±0.99 years. This is much later than the age recommended by the American Dental Association (ADA), which encourages tooth brushing upon eruption of the first baby tooth.³⁵

Of the 18 fathers who responded to this question, 10 recommended oral hygiene initiation after age 2. The major reason being given for this was that all baby teeth should be allowed to erupt before beginning to brush, as this man noted:

I: “…at what age should a child start to look after his own teeth?”

R: “…I think that once all their teeth have come in, then they should start looking after them, according to what I believe.” [MCG015]

A second father agreed with this assessment, saying:

I: “At what age should you starting caring for their [children’s] teeth?”

R: “…I suppose that it should be from the time when a parent sees that all their teeth have come out and formed. That’s when you should start taking care of them.” [MCG01]

Another reason given for a later start was that children should begin to brush their teeth only when they are going to school and have learned to do it properly:

R: “Only when you see that they are already going to school…that’s when you start to tell them [to brush their teeth].” [MCG08]

Hygiene Assistance Given to Children

When asked, “at what age can your child take care of his/her teeth on their own, without adult supervision?” the average age reported by these fathers was 4.1±2.3 years, with a range of 1–10 years. These responses veer from the ADA recommendation, which advises parents to assist with their children’s brushing until age 6 or 7.³⁶

Actual physical assistance given to children during their home oral hygiene practices appeared to be very limited, and if given at all, was given almost exclusively by the mothers. The frequency and degree of such help appears to be minimal though: ten fathers described the mothers’ participation as being given “sometimes,” two men said their wives assisted the children “once in a while”, and one man stated “twice a week.” Only 1 man denied that his children received any assistance at all:

I: “Do you or your wife supervise them?”

R: “No.”

I: “Neither?”

R: “No. They brush their own teeth and that’s it.” [MCG06]

Many of the fathers reported that their wives assisted their children with oral hygiene, but the amount of help given depended entirely on the child’s age. Much more help was given to children aged 2 years and younger, as 9 fathers reported help for this age group. Assistance was commonly provided at bath time by the mother, often with a finger brush:

“My wife brushes my daughter’s [2 years old] teeth with a finger brush and she cleans them.” [MCG05]

“Every time she bathes him [1 year old], she brushes them. She uses a toothbrush that you put on your finger. She brushes them.” [MCG03]

On the other hand, only 3 fathers reported hygiene assistance given to their children older than 2 years. One father did report help given to his six year-old:

“He [6 year-old son] brushes them, but when we see he hasn’t done it well, we do it. If he doesn’t brush them well, she [mother] does it for him.” [MCG09]

Generally, though, the fathers reported no assistance was given to their school-aged children. Fathers assigned great significance to oral hygiene instruction given to their children at school. For many parents, their children learning to brush at school related to the age at which they stopped giving assistance. The following 3 quotations demonstrate this:

“[I help]…very rarely…Like I said, they teach them at school too. They [children] know how to brush their teeth well.” [MCG03]

“The 4 year old also does it himself because they taught him how to do it at school.” [MCG012]

I: “Up to what age did you help them?” (with tooth brushing)

R: “Until they were 4 years old and then at that point they started going to school. They taught them there too.” [wife of MCG018]

The concept of “parental supervision” within these families appears to vary widely among the fathers. They clearly recognized their children’s need for help in regards to oral hygiene, and some fathers connected the idea of supervision with direct participation in their children’s oral hygiene practices. Many fathers (11 out of 20), however, directly associated “supervision” of their children’s oral hygiene routines with giving their children a verbal reminder. In lieu of actual demonstration, example of brushing, or physical aid, fathers believed that simply telling their children to brush adequately fulfilled this parental responsibility. This father, for example, connected “supervision” with “verbal reminder”, reporting that his children were supervised every time they brush their teeth:

I: “Of all the times they brush their teeth, how many of those times are they supervised?”

R: “All of the times.”

I: “Always?”

R: “Yes, always. In the morning, she [Mother] tells them and they brush their teeth. They go in one by one and that’s how they brush their teeth.” [MCG09]

And here a father describes the supervision of his 1 year-old son’s brushing:

I: “What do you do to look after your children’s teeth?”

R: “With this small one, she [Mother] tells him, in the evening, to brush his teeth…he grabs his toothbrush and cleans them himself.” [MCG017]

While many fathers agreed that some form of parental supervision is important, the most prevalent idea of “to supervise” comprised “to remind.” Monitoring a child’s oral hygiene techniques or habits for effectiveness of brushing was rarely if ever performed:

“I think it is important that they are supervised, but I rarely do that…she [Mother] does it more. She tells them to brush their teeth, but she doesn’t ask them to open their mouth afterwards to check. She just tells them to brush their teeth and that’s it.” [MCG011]

Fathers clearly associated telling their children to brush with fulfillment of parental responsibility, even if no other instruction or help was given:

“A child can’t automatically know how to look after his teeth. We’re there to constantly tell him to brush his teeth.” [MCG015]

Seven fathers recognized that simply telling their children to brush their teeth was not always an effective preventive measure. This thought is illustrated here:

R: “We sometimes watch them or tell them how to brush their teeth, that they should brush them 3 times per day. We tell them, before going to school….that they have to brush their teeth.”

I: “So you tell them to do that, but do they always do it?”

R: “No, in truth, no. Not always.” [MCG07]

Limitations

Limitations of this study include having a small convenience sample, social desirability and recall biases, and a single rural location. The interviewer expected reticence from the fathers and supposed that this would be a potential limitation of the study. However, quite the opposite proved to be true. Mostly likely because of gender concordance between interviewer and interviewee, the fathers were very easily approached and openly shared their experiences. In instances when the men provided socially undesirable answers, they would often follow their comments with “why should I lie to you?” This congenial transparency made the interview process very enjoyable.

Despite its limitations, this study expands the present literature in important ways. It is the first to contribute knowledge about what Latino fathers know and do with respect to their children’s oral hygiene. As such, it forms a basis for the development of future research aimed at uncovering in greater detail the role of Latino immigrant fathers in providing for their children’s oral health needs.

Further exploration is critical if we hope to improve the oral health of this population. Upon comparing this study’s results with those of other, larger studies conducted principally with women,^{29, 32} it is clear that rural Latino men and women have unique explanatory models for how dental disease develops and sometimes interpret symptoms differently. Thus, while most studies investigate women’s views and actions and present them as “parental” views, studies should also include men who have distinct patterns of thought and behavior. Fathers are pivotal in the decision-making process, and many times are key facilitators of a dental visit by being able to drive the children to their appointments. Thus, their opinions are significant and their input is relevant. In order to include this set of parents in research, studies may want to focus on finding these fathers at home in the evenings, on weekends, and at other times, and to employ male bilingual interviewers.