SUBJECTS, MATERIALS AND METHODS

TOP ABSTRACT PUBLIC HEALTH POLICIES SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The design and undertaking of this study followed the ethical guidelines for conducting studies at the Autonomous University of Campeche in Mexico.

Study population, sample and design. The study design and population have been outlined elsewhere.^7,8 Briefly, we conducted a cross-sectional study of 6- to 12-year-olds attending elementary schools in Campeche (the capital city of the state of Campeche in the southeast littoral of the Gulf of Mexico). We randomly selected four public schools with an enrollment of 1,603 students. After reaching an agreement with teachers and principals, we distributed informed consent letters to all parents of children attending the schools. After applying the inclusion criteria (children born in Campeche City and residing there all of their lives, between 6 and 12 years of age, attending any of the selected schools and having a mother or guardian who signed the letter of informed consent) and exclusion criteria (the mother refused to participate in the study or the child was outside the age range), 1,373 children were included in the study (85.7 percent of the original sample of 1,603).

Study variables and data collection. We collected data regarding variables via a structured questionnaire addressed to the mothers (disseminated and retrieved through the schools). The dependent variable was toothbrushing frequency, which we categorized as 0 (fewer than three times per day) and 1 ( three times per day). Independent variables were year of birth, sex, whether the child had received any type of dental care in the 12 months preceding data collection, the overall attitude of the mother toward the importance of the child’s oral health (a variable previously designed and validated in relevant population groups)^9–11 and the mother’s highest level of education. The questionnaire also collected data regarding the child’s dental health and oral health status, but these variables are not relevant to the analyses in this report.

Statistical analyses. Descriptive and bivariate analyses. We performed an exploratory analysis for each variable to evaluate data integrity and to describe the study population in general. We calculated estimates of central tendency and dispersion measures for continuous variables. In the case of categorical variables, we calculated frequencies and percentages for each category. For the bivariate analyses, we performed the ² test, Mann-Whitney test and/or non-parametric tests for trend, depending on the measurement scales (that is, ordinal, categorical, continuous scales) for each variable. In addition, we used bivariate logistic regression to analyze all variables to determine which ones were associated with toothbrushing frequency.

Multivariate analysis. To determine which variables were more closely associated with toothbrushing frequency and to control for potential confounding variables, we created a logistic binary regression multivariate model. The associative strength of the model is expressed in odds ratios (ORs), with 95 percent confidence intervals (CIs). We included only those variables with bivariate analysis results (P < .20) in the final model. We conducted the variance inflation factor test to analyze the data and avoid multi-collinearity, if any, on independent variables. We tested all interactions of theoretical interest and included them if the statistical significance was less than .15. In addition, we performed link tests to determine if the logit of the variable was a linear combination of independent variables. We conducted the Hosmer-Lemeshow goodness-of-fit test in the final model, with P > .10 as the cutoff-point statistic.¹² In both bivariate and multivariate analyses, we estimated the CIs with robust standard errors. The reason we did this is because the observed data were children at school (cluster); therefore, observations within a cluster could be correlated (because the children were exposed to the same factors, such as environment, food, beverages), whereas observations across clusters were not necessarily correlated.¹³ We conducted the statistical analyses by using software (STATA 8.2, StataCorp, College Station, Texas).

	RESULTS

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Table 1 shows the descriptive analyses of variables studied. Bivariate analyses indicated that variables associated with different toothbrushing frequency patterns (P < .05) were sex, mother’s attitude toward the importance of the child’s oral health, having received dental care in the previous 12 months and the mother’s level of education. We further ascertained that the mothers’ level of schooling was higher among those with a positive attitude than among those with a negative attitude (P < .001; mean ± standard deviation, 9.34 ± 4.7 years versus 7.79 ± 4.05 years), as well as among mothers whose children received dental care in the previous 12 months compared with those whose children did not (P < .001; 9.23 ± 4.12 years versus 8.31 ± 4.05 years) (data not shown).

	DISCUSSION

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This study of Mexican schoolchildren found that the overall frequency of toothbrushing (with tooth-paste) was relatively high (81.7 percent brushed three or more times per day), and that sociodemo-graphic and behavioral characteristics of the mother were associated with more frequent toothbrushing by the child.

Policy patchwork. As with other national health policies, oral health programs in Mexico could be characterized as a patchwork of initiatives, addressing various public health aspects of oral health. Overall, recent oral health policies have acknowledged that epidemiologically important oral diseases are common.^14,15 Since 1998, the Oral Health Program has had priority status.¹⁶ Independent evaluations of research in preventive dentistry that pertain directly to Mexico for the last couple of decades substantiate the significance of caries and periodontal diseases as the main challenges to good oral health and function; however, the reviewers reported that the epidemiologic data in this research were limited.^17,18

The National Health Program 2001–2006^14,15 attempted to integrate the diverse aspects of the policy patchwork into a coherent system by emphasizing oral health promotion; strengthening health systems and clinical care delivery throughout the country; expanding activities envisioned in the biannual national oral health weeks; supporting dental health education programs targeting schoolchildren; calling for support of oral health research; advocating the use of alternative restorative treatment as a means to increase dental services in remote areas (or areas with poor clinical services); and improving the performance of the fluoridated domestic salt program through better coordination across all levels of government and with other institutions. Although these general objectives are, of course, desirable, the lack of specific mechanisms, resources and timelines for attaining specified goals is cause for concern.

Model of oral health care. Among those mechanisms that might not have been defined explicitly is the role of individualized dental hygiene regimens in the overall health policy scenario. In 1990, the general directorate of health promotion from Mexico’s Ministry of Health launched a model to improve oral health among schoolchildren, seeking to incorporate into one program the basic programs addressing education, prevention, rehabilitation and health promotion.¹⁹ Within the model, more positive information, attitudes and practices were identified and subsequently put into operation in the National Educational Program Against Caries and Periodontal Pathoses Among School Children and Preschoolers.²⁰

In terms of the factors associated with toothbrushing practices, various studies have found that socioeconomic indicators seem to play a leading role in modifying behavioral patterns.

Under the umbrella of the Mexican Official Norm (Norma Oficial Mexicana) NOM-013-SSA2-1994 to prevent and bring under control oral diseases, the health systems had, at least in theory, a unified scheme to identify methods and techniques for preventing and treating oral diseases, as well as to promote and maintain good oral health status.^21–24 However, none of these documents (that is, the NOMs) used, to any measurable extent, the information available to improve individual prevention practices (such as frequency of dental recall appointments, toothbrushing patterns, use of fluoridated toothpastes and dental flossing habits). Cultural or literacy modifiers also were omitted in the plan outlined in NOM-013-SSA2-1994.

We believe that our research data may provide a framework for beginning to determine how toothbrushing patterns, health education and health promotion should be positioned within national and local programs to make them more relevant, practical and effective across diverse settings. In our study, we found that many children brushed their teeth with considerable frequency; however, because of the lassitude shown in the literature toward classifying age groups, this self-reported practice may or may not be similar to that reported elsewhere.^2,3 For example, Petersen and colleagues²⁵ reported that 88 percent of Thai children aged 6 to 12 years brushed their teeth at least once a day; by contrast, Villalobos-Rodelo and colleagues⁶ reported that only 54 percent of Mexican children did the same.

In terms of the factors associated with toothbrushing practices, various studies have found that socioeconomic indicators seem to play a leading role in modifying behavioral patterns.^6,26,27 In this study, we used the mother’s highest level of education (an often used and largely valid proxy of socioeconomic status), which was associated significantly with toothbrushing frequency among children. Our finding that girls brushed more often than boys is coincident with the results of studies in Mexico⁶ and elsewhere.^2,27 How this sex gap came about is unclear, and the available data do not enable us to identify definitive mechanisms.

International studies. Few studies in the international literature have looked at the clinical and nonclinical variables associated closely with oral hygiene practices in this age group. Although the recency of dental visits (that is, within the previous 12 months) was associated positively with more frequent toothbrushing (just as Al-Shammari and colleagues²⁷ pointed out), we wonder whether this association simply reflects the role of the dentist in providing health and hygiene information to the child. The fact that the mother’s attitude toward the importance of her child’s dental health was associated with toothbrushing only in conjunction with a recent dental visit suggests that complex events are at play. Future studies should investigate these factors in detail, taking into account differences and interactions across age groups, levels of literacy, socioeconomic levels and regional variations within Mexico, as well as attempt to identify causal relationships.

We have found that mothers’ characteristics may function as predictors of the oral health status of their children^{7–11,28–31}; given the increasing evidence that social factors modify processes and values within health phenomena,^28–32 it becomes more apparent that mothers (and other primary caregivers) should be involved in planning and implementing the programs and policies that address oral health education and oral health promotion for children.

Study limitations. There are certain caveats to this study. Although they do not undermine its methodological design, they do suggest that direct extrapolations to other Mexican population groups are unwarranted. The schools involved in this study are located in an urban area, and they have ongoing access to a preventive dentistry program. This suggests that toothbrushing patterns and the level of dental awareness in our study population might be more positive compared with those in other populations. On the basis of previous study results, this caveat gains further salience.^8,11,28,29 Finally, as with any other cross-sectional study, our design may have been affected by temporal ambiguity, thus making it difficult to draw firm conclusions about which variables precede other variables. Consequently, readers should not derive any direct cause-and-effect relationships from this study.

	CONCLUSION

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Clinicians should keep in mind that certain characteristics of mothers are associated strongly with patterns of oral hygiene in their children. We found that toothbrushing patterns in this study population generally were favorable, and they were associated with certain social and socioeconomic factors reported in the literature. Furthermore, features of the mother with regard to the child’s oral health are differentially associated with toothbrushing trends, particularly under more desirable patterns of dental attendance. Although we could not determine the reasons for such dental attendance, it seems pertinent to incorporate findings such as ours in the design, planning, implementation and monitoring of programs that support good oral health behaviors among children.