This small sample of urban low-income families provides a unique glimpse into what really happens in the homes of young children under the age of three. Most studies to date in this age group rely on self-report or observations conducted in a clinical or research setting. While these settings attempt to replicate the home environment, they are artificial and limited in their comparability to real homes. Homes are comforting and familiar to young children, making them more likely to demonstrate their routines accurately [11]. Observations in homes also accommodate the tremendous variability in home layouts and routines, allowing for the recognition of physical barriers (e.g., small bathrooms, limited counter space) and objective verification of equipment and supplies. Our study demonstrates that observation of brushing routines and equipment is acceptable to some families and feasible from a data collection standpoint. Even video-recording of behaviors was accepted although this proved to be logistically challenging in many of the small bathrooms. The data collected from objective observations provided additional detail and allowed for verification of parent-reported accuracy.
While not objectively verified, our sample’s parent report of brushing frequency was comparable to results from Washington State and Australia [12, 13]. In National Health and Nutrition Examination Survey (NHANES) 2014 data, 62% of parents/caregivers of children 3–4 years old report brushing twice a day or more which is comparable to our results even though our age range is under three years old [14]. Commonly reported barriers to brushing are lack of time and an uncooperative child [15], emphasizing the critical role of the caregiver in the brushing process [16]. Parent assistance with brushing was reported as a universal practice for participants in our study, although some parents reported they did not always help. The results of other studies with young children suggest these children are likely expected to brush on their own frequently. Parents in a rural Washington State community sample reported 10% of children under the age of five brushed without assistance [13]. In a small sample of two-year-old children in Scotland, home video-recording of brushing showed that the majority of brushing was done by children alone [17]. We do not know if this was because they thought the children were competent to brush on their own or because the parents did not have the time or interest.
Our sample’s average brushing time was 62.4 s, which is similar to higher income mainly non-Hispanic white children observed in a dental clinic in Seattle where the average brushing duration observed was 71 s [16]. The challenge with these data is brushing duration is not always a continuous activity. Children start and stop, often removing and re-inserting the brush multiple times [17]. This is not necessarily a bad thing; although the toothbrush may be removed from the mouth, fluoride toothpaste has the opportunity to remain on the teeth during these pauses. Parent report of brushing duration varied in its accuracy. Very likely parents misjudge total time, but they also may vary in their definitions of the start and end points of brushing. Our data suggest that objective measurement of brushing is optimal, and that clear start and stop points for brushing should be defined from the start.
While fluoridated toothpaste is recommended for young children [18], its use is rarely measured [14, 19]. Sixty-one percent of our parents reported they did not use fluoridated toothpaste or did not know if they did for their children, and yet 74% of the child toothpaste observed had fluoride. We expected a smaller proportion of families would use fluoridated toothpaste because of the robust marketing of fluoride-free toothpaste to babies. We could find no other literature demonstrating this lack of concordance between reported and observed use of fluoride toothpaste. Our results suggest that in this low-income population, many parents were unaware of fluoride recommendations, controversies, and advertising and therefore were unintentional in their use of fluoridated toothpaste. Parents accurately reported the quantity of toothpaste used and mostly this was in alignment with recommendations for the child’s age [20, 21]. This is in contrast to research conducted by others, where parents incorrectly reported the amount of toothpaste used and consistently applied larger quantities of toothpaste than was recommended [22, 23]. We expected more chaotic homes and more sharing of equipment than was observed. This is likely because the families that volunteered for the study were motivated regarding oral health and knew we were coming to observe these behaviors.
We saw interesting differences between families recruited from pediatric dental clinics and medical clinics. We assumed families from pediatric dental clinics would be more aware of oral health recommendations, although they might have been in the dental clinics because their children already had oral health problems. Our numbers are small but suggest slightly worse caries and less support for families from the dental clinics.
While the majority of families allowed video recording, the collection of adequate video data for abstraction was challenging due to the small bathrooms; therefore, we ultimately decided video recordings were not necessary to document brushing behaviors and equipment for the CO-OP Chicago clinical trial. However, we recognize the advantage of video recordings to capture behavioral interactions, specifically parent-child behaviors. Our direct observations did not capture child-parent interactions during brushing, but this domain is very important in order to ensure proper brushing technique and behavior maintenance [15,16,17], suggesting a role for video recording in other studies.
We recognize this study has limitations. Families that allow us into their homes are assumed to be more motivated by oral health behaviors than general populations, especially families recruited from pediatric dental clinics, which is observed in our data. Our sample was not homogenous; families recruited from pediatric dental clinics reported more children had caries and that daily life interfered more with their ability to care for their child’s teeth compared to other parents. Families cleaned and prepared for the home observations, demonstrating the influence of social desirability. Social desirability can affect both self-report and behaviors. Also, as with most observed research, the responses of families that volunteer are often influenced by the process of being observed and may demonstrate volunteer bias. Because of this, we assume behaviors and self-reported rates of behaviors are actually worse than what we measured for average low-income families in Chicago. Another concern is that behaviors conducted under observation may be different from those that normally occur, although observations in natural settings such as the home have been shown to not be affected by the presence of an observer [11]. Our sample was primarily Hispanic, urban, and low-income which is not generalizable to other populations. Finally, our sample size was small.
Despite these limitations, our results demonstrate the feasibility of observing tooth brushing behaviors of young children in homes of low-income families. Observed behaviors are more accurate than self-report for most components of brushing and serve to highlight some of the knowledge issues facing parents, such as the role of fluoride. Home observation also opens a window into some of the creative ways low-income families carry out recommendations, such as how parents position children in the bathrooms or brush in other rooms. This must be placed into the context of community acceptability of home visits. Only 24% of eligible participants had an actual home observation conducted. Formative work conducted by CO-OP Chicago and others suggest a range of reasons why individuals agree or do not agree to home visits. Families appreciate the convenience and intimacy of home visits, but they are also afraid of being judged and are nervous (for safety reasons) to let strangers into their homes [24, 25]. Early tooth brushing with attention to family dynamics, proper technique and fluoride toothpaste protects against caries and establishes lifelong behaviors [26, 27]. Further research is needed to describe and support parenting behaviors regarding effective brushing in the home environment where these behaviors begin and are sustained.
