Preadolescents and Their Mothers as Oral Health-Promoting Actors : Non-biologic Determinants of Oral Health among Turkish and Finnish Preadolescents

Is oral health becoming a part of the global health culture? Oral health seems to turn out to be part of the global health culture, according to the findings of a thesis-research, Institute of Dentistry, University of Helsinki. The thesis is entitled as “Preadolescents and Their Mothers as Oral Health-Promoting Actors: Non-biologic Determinants of Oral Health among Turkish and Finnish Preadolescents.” The research was supervised by Prof.Murtomaa and led by Dr.A.Basak Cinar. It was conducted as a cross-sectional study of 611 Turkish and 223 Finnish school preadolescents in Istanbul and Helsinki, from the fourth, fifth, and sixth grades, aged 10 to 12, based on self-administered and pre-tested health behavior questionnaires for them and their mothers as well as the youth’s oral health records. Clinically assessed dental status (DMFT) and self-reported oral health of Turkish preadolescents was significantly poorer than the Finns`. A similar association occurred for well-being measures (height and weight, self-esteem), but not for school performance. Turkish preadolescents were more dentally anxious and reported lower mean values of toothbrushing self-efficacy and dietary self-efficacy than did Finns. The Turks less frequently reported recommended oral health behaviors (twice daily or more toothbrushing, sweet consumption on 2 days or less/week, decreased between-meal sweet consumption) than did the Finns. Turkish mothers reported less frequently dental health as being above average and recommended oral health behaviors as well as regular dental visits. Their mean values for dental anxiety was higher and self-efficacy on implementation of twice-daily toothbrushing were lower than those of the Finnish. Despite these differences between the Turks and Finns, the associations found in common for all preadolescents, regardless of cultural differences and different oral health care systems, assessed for the first time in a holistic framework, were as follows: There seems to be interrelation between oral health and general-well being (body height-weight measures, school performance, and self-esteem) among preadolescents: • The body height was an explanatory factor for dental health, underlining the possible common life-course factors for dental health and general well-being. • Better school performance, high levels of self-esteem and self-efficacy were interrelated and they contributed to good oral health. • Good school performance was a common predictor for twice-daily toothbrushing. Self-efficacy and maternal modelling have significant role for maintenance and improvement of both oral- and general health- related behaviors. In addition, there is need for integration of self-efficacy based approaches to promote better oral health. • All preadolescents with high levels of self-efficacy were more likely to report more frequent twice-daily toothbrushing and less frequent sweet consumption. • All preadolescents were likely to imitate toothbrushing and sweet consumption behaviors of their mothers. • High levels of self-efficacy contributed to low dental anxiety in various patterns in both groups. As a conclusion: • Many health-detrimental behaviors arise from the school age years and are unlikely to change later. Schools have powerful influences on children’s development and well-being. Therefore, oral health promotion in schools should be integrated into general health promotion, school curricula, and other activities. • Health promotion messages should be reinforced in schools, enabling children and their families to develop lifelong sustainable positive health-related skills (self-esteem, self-efficacy) and behaviors. • Placing more emphasis on behavioral sciences, preventive approaches, and community-based education during undergraduate studies should encourage social responsibility and health-promoting roles among dentists. Attempts to increase general well-being and to reduce oral health inequalities among preadolescents will remain unsuccessful if the individual factors, as well as maternal and societal influences, are not considered by psycho-social holistic approaches.

The present study aimed to investigate how non-biologic determinants of oral health (behavior, cognition, and affect, maternal and societal influences) are interrelated with each other and with oral health among preadolescents in two different oral health care and cultural settings, Turkey and Finland. In addition, the association of their general well-being with their oral health was assessed. The cross-sectional study of Turkish (n=611) and Finnish (n=223) school preadolescents in Istanbul and Helsinki, from the fourth, fifth, and sixth grades, aged 10 to 12, was based on self-administered and pre-tested health behavior questionnaires for them and their mothers as well as the youth’s oral health records. Both questionnaires assessed self-reported dental health and oral health behaviors along with cognitive-affective factors (self-efficacy and dental anxiety). In addition, health behavior questionnaires for preadolescents (PHBQ) included questions of self-esteem and self-reported gingival health, whereas those for mothers (MHBQ) surveyed societal factors, dietary habits and body-weight of preadolescents. PHBQ were completed in classes, whereas MHBQ were carried to and from home. Dental examinations in Turkey based on World Health Organisation (WHO) criteria (1997) were carried out in the classrooms 2 weeks after the questionnaire survey by two calibrated pediatric dentists. Finns´ oral health data came with permission from records at the Helsinki City Health Department. Among the Turks, response rate for PHBQ was 97% (n=591) and 87% for the MHBQ (n=533). The corresponding Finnish rates were 65% (n=223) and 53% (n=182). Participation in oral health examinations was 95% for the Turkish (n=584) and 65% for the Finnish (n=223). Clinically assessed dental status (DMFT) and self-reported oral health of Turkish preadolescents was significantly poorer than the Finns`. A similar association occurred for well-being measures (height and weight, self-esteem), but not for school performance. Turkish preadolescents were more dentally anxious and reported lower mean values of toothbrushing self-efficacy (TBSE) and dietary self-efficacy (DSE) than did Finns. The Turks less frequently reported recommended oral health behaviors (twice daily or more toothbrushing, sweet consumption on 2 days or less/week, decreased between-meal sweet consumption) than did the Finns. In both groups, those with high TBSE were more likely to practice the recommended toothbrushing. Similarly, all with high DSE were more likely to report recommended toothbrushing and sweet consumption. High levels of TBSE and DSE contributed to low dental anxiety in various patterns in both groups. Turkish mothers less frequently reported dental health as being above average and recommended oral health behaviors as well as regular dental visits (once within 12 months). Their mean values for dental anxiety were higher and self-efficacy on implementation of twice-daily toothbrushing were lower than for the Finnish mothers. All preadolescents were likely to imitate toothbrushing and sweet consumption behaviors of their mothers. In both groups, those who reported high TBSE were more likely to have mothers who practiced recommended toothbrushing. Among Finns, high maternal self-efficacy and low dental anxiety contributed positively to preadolescent’s recommended toothbrushing and high TBSE. Among the Turks, high maternal dental anxiety contributed to that of their children. Among Turks, the mothers of public school preadolescents reported a poorer societal profile and oral health behaviors than did mothers of private school preadolescents. Public school preadolescents were more likely to imitate non-recommended toothbrushing and sweet-consumption behaviors of their mothers, whereas their counterparts in private school followed a similar trend for recommended maternal toothbrushing behavior. Self-esteem and school performance were positively correlated with TBSE and DSE in both groups. Clustering between high self-esteem and low preadolescent- and maternal dental anxiety occurred in various patterns for Turks and Finns. Societal factors contributed to self-esteem among the Turks. Among all preadolescents, good school performance was a common predictor for recommended toothbrushing. Oral health and well-being of preadolescents were interrelated. In both groups, DMFT was negatively correlated with better school performance. Body height and the societal factors were the common explanatory variables accounting for DMFT s. TBSE and school performance contributed positively to self-reported dental health, in common, among all preadolescents. High self-esteem and less frequent maternal sweet consumption among Finns, decreased number of children in the family, and recommended preadolescent toothbrushing among Turks were the other contributors to self-reported good dental health. In the present study, non-biologic determinants of oral health were interrelated and related to well-being measures in various patterns, and these all contributed to the oral health of preadolescents. Based on these findings, a need exists for improvement in Turkish preadolescents’ and their mothers’ oral health behaviors, cognition, and affect. The paired associations separately studied in the literature; self-efficacy─behavior, child─mother health behavior, general well-being─oral health, self-esteem─school performance, were all found in a holistic theoretical framework, regardless of different cultural, socio-economic, and health-care systems in the two countries, Turkey and Finland. This may indicate that the respective associations are turning out to be part of the global health culture, and therefore a need exists for similar further research including the complex interaction pathways between these associations in countries with different developmental, cultural, and health-care characteristics. Clarifying these complex relations by psychosocial holistic approaches in different cultural settings and socio-economic contexts may provide a multidimensional understanding of preadolescents’ oral health behavior that will provide enhancement of their well-being and oral health.