10.59987/ads/2012.2.69-74
Aims. The study is focused on the analysis of knowledge, attitudes and behaviors of Italian mothers in regards to their oral health, deepening the understanding of how the initiation of habits and behaviors for a healthy lifestyle may influence the empowerment process of their children.
Methods. The questionnaire was composed by 14 sections and has been conducted using an online questionnaire on the mothers association’s website. Reliability analysis was tested and content validity was evaluated using Cronbach’s alpha to check internal consistency with the intention to obtain no misunderstanding results. Statistical analysis was performed through SPSS 19.0.
Results. The total number of the compiled questionnaires was 192. The highest value of the Cronbach’s alpha is obtainable in Section 13 (Quality of Life in relation to dental health between 8-17 years old kids) with a value of 0.998 (on 5 items). The total value of the Cronbach’s alpha considering the part of questionnaire dedicated only to the mothers that have more than 18 years old children is 0.490 on 116 items. Considering all the sections of the questionnaire on 134 items and 127 questions, we get an alpha value of 0.784.
Conclusions. The questionnaire for the mothers showed a good reliability in the pilot study and it seems it made good results in terms of internal coherence and validity. The online administration allowed the opportunity to optimize the data collection avoiding complications with papers and it offers potentially, a tool able to rapidly gather a vast sample in which to perfect other studies.
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Annali di stomatologia
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Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study
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Original Article
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2012-06-01
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Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study
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                                                                                                 Original article


Knowledge, attitudes and behavior of Italian mothers
towards oral health: questionnaire validation and results
of a pilot study




                                                                                        li
                                                                                     na
Gianna Maria Nardi ,Rdh1                                  134 items and 127 questions, we get an alpha value
Guglielmo Giraldi, MD2                                    of 0.784.
Paola Lastella, Rdh 1                                     Conclusions. The questionnaire for the mothers
Giuseppe La Torre, MD, Mph, Msc, Dsc2                     showed a good reliability in the pilot study and it




                                                                                  io
Emilia Saugo, B.Sc.N.3                                    seems it made good results in terms of internal co-
Francesca Ferri, J.S.D.3                                  herence and validity. The online administration al-
Luciano Pacifici, MD, DDs1                                lowed the opportunity to optimize the data collection




                                                                               az
Livia Ottolenghi, DDs1                                    avoiding complications with papers and it offers po-
Fabrizio Guerra, MD, DDs, Phd1                            tentially, a tool able to rapidly gather a vast sample
Antonella Polimeni, MD, DDs1                              in which to perfect other studies.
                                                          Key words: Knowledge, attitudes, behavior, Italian




                                                                  n
1
   Department of Oral and Maxillo Facial Sciences,        mothers, oral health.
“Sapienza” University of Rome, Italy




                                                               er
2
  Department of Public Health and Infectious Diseases,
“Sapienza” University of Rome, Italy                      Introduction
3
  Italian National Association of Mothers
                                                          With the extension of the average life in industrialized

Corresponding Author:
Paola Lastella, Md
                                                  nt      countries, the current epidemiological picture has been
                                                          delineated, characterized by the prevalence of chronic
                                                          degenerative diseases. Their role assumed in the de-
                                                iI
Department of Oral and Maxillofacial Sciences             terminism of multiple factors, especially behavioral and
Via Caserta, 6 00161 Roma, Italy                          lifestyle factors, requires the focusing of attention on
Phone: +39 06 49918151                                    the promotion of health. This is founded not only on the
                                              on

e-mail: paolalastella@yahoo.it                            study of health determinants but also on the public medi-
                                                          cal programs that have proven their efficacy and on the
                                                          fight against inequalities, and it entails the collaboration
                                                          of the medical system with other sections of society to
                                      i


Summary                                                   develop improvements in favor of health (1).
                                   iz


                                                          The European Union Council recognizes that unhealthy
Aims. The study is focused on the analysis of knowl-      lifestyles contribute in a noteworthy and growing way to
edge, attitudes and behaviors of Italian mothers in       the severity of diseases. Improvement of health condi-
                   Ed




regards to their oral health, deepening the under-        tions of the population is therefore a main end for the
standing of how the initiation of habits and behav-       states that are members of the European Council and
iors for a healthy lifestyle may influence the empow-     to its adherents. Healthier lifestyles could lead not only
erment process of their children.                         to better health conditions and the decrease of disease
Methods. The questionnaire was composed by 14             but, in the context of ever growing health prices, to better
sections and has been conducted using an online           disease prevention. It’s a good investment and it’s also a
 IC




questionnaire on the mothers association’s website.       very profitable approach in terms of costs (2).
Reliability analysis was tested and content valid-        Damaging behaviors create diseases that are a burden
ity was evaluated using Cronbach’s alpha to check         for health and social systems therefore, in order to fight
C




internal consistency with the intention to obtain no      them political action is necessary:
misunderstanding results. Statistical analysis was           • to encourage mobility and physical exercise in peo-
performed through SPSS 19.0.                                 ple (public transportation and urban green);
Results. The total number of the compiled ques-              • to support the consumption of fruits and vegetables;
©




tionnaires was 192. The highest value of the Cron-           • to reduce the percentage of salt, sugars, and fats
bach’s alpha is obtainable in Section 13 (Quality of         in food;
Life in relation to dental health between 8-17 years         • to reduce the amount of highly caloric food in the diet;
old kids) with a value of 0.998 (on 5 items). The total      • to reduce the abuse of alcohol (3).
value of the Cronbach’s alpha considering the part        Poor oral hygiene is the main cause of gum disease,
of questionnaire dedicated only to the mothers that       a chronic infection of the tissue surrounding the teeth.
have more than 18 years old children is 0.490 on 116      It’s one of the most prevalent chronic diseases and it
items.                                                    is associated with a reduced systemic inflammatory re-
Considering all the sections of the questionnaire on      sponse (4), as well as the increase in the concentration

Annali di Stomatologia 2012; III (2): 69-74                                                                         69
G. M. Nardi et al.



of the reactive protein C and other inflammatory bio-
markers (5,6).                                                 Structure of the questionnaire
The transfer of bacterial endotoxins and the action of         The questionnaire which was anonymous, was a combi-
chemical mediators of the inflammation produced by the         nation of many scientifically proven questionnaires, that
mother, may have a role in causing premature and un-           take into account different ways to express the concept




                                                                                             li
derweight births (7).                                          of health, from the practical and technical side to the
Regular teeth brushing is considered the best preven-          psychological aspects that provide the foundation of the




                                                                                          na
tion for the control of dental plaque. Brushing teeth with     behavior of a person.
a fluorine toothpaste twice a day is the current medical       These are the questionnaires used as the reference
advice (5,8). Flossing and regular dental check-ups are        for the final one used in this study: SF12 Question-
equally important in order to keep oral health (9).            naire (evaluation of life style) (19), IPAQ Questionnaire




                                                                                       io
There is currently a large focus on the beginning of gum       (physical activity evaluation) (20), HU-DBI questionnaire
disease during infancy (10), as a matter of fact in the oral   (Hiroshima University, Dental Behavior Inventory) (21),
health field, it is already well-known that psychosocial,      EGOHID Questionnaire (European Global Oral Health




                                                                                    az
cognitive maternal-behavioral factors are associated           Indicators Development Project) (22).
with the oral behavior of children like teeth brushing (11).   The questions are about topics that concern not only
The adoption of good habits during childhood begins at         personal life habits like physical activity, alcohol con-
home with the parents, especially with the mother who          sumption and smoking habits, and oral hygiene habits,




                                                                       n
becomes the main reference of behavior (12) and it’s           but they are aimed at revealing the level of knowledge
also well-known that the social state (13) and even eth-       about some different topics like prevention, therapies,




                                                                    er
nicity (14) may influence the level of oral health.            aesthetic factors and the anxiety level of receiving a
Motivating mothers to assume the correct behavior for          clinical treatment.
oral health and assuming a better life style in general,       The questionnaire is composed by the following sec-
may produce positive changes that would determine an           tions:

                                            nt
increase in the long term benefits for the health of both
mother and child (15).
In the last years the number of people who use the Web
                                                               Section 1 - Anamnestic and social-demographic.
                                                               Section 2 - (Part1) Attention to the mothers’ oral hygiene;
                                          iI
increased substantially. The Web is used for multiple          (Part2) Protections and oral hygiene habits and preven-
medical means (16) and for patients who use it primar-         tive behaviors.
ily as a source of information about their health (17,18).     Section 3 - Risk factors, habits.
                                        on

Because of the fact that the Web is a huge mass com-           Section 4 - Level of oral health.
munication system, it can be used as a big collector of        Section 5 – Oral health related quality of life.
data on statistical medical surveys and for studies about      Section 6 – Quality of Life evaluation.
the habits and behaviors of a population.                      Section 7 - Physical Activity evaluation.
                                i


                                                               Section 8 - Oral health level of 3-17 years old kids.
                             iz


Aim of the study                                               Section 9 - Community programs for 3-17 years.
The aim of the present work is to realize a study that is      Section 10 - Attitudes and risk factors of 5-17 years old
focused on the analysis of knowledge, attitudes and be-        kids and 12-17 years.
                     Ed




haviors of Italian mothers in regards to their oral health.    Section 11 - Dental assistance sources.
This work, made in collaboration with the Department           Section 12 - Preventive visit for pregnant women.
of Dentistry and Maxillary-Facial Sciences, the Depart-        Section 13 - Oral health related quality of life in 8-17
ment of Public Health and Infectious Diseases of the           years old kids.
“Sapienza” University of Rome, the National Association        Section 14 - Orthodontic and dental traumas.
of Mothers and the Academy of Dentistry and Dentistry
 IC




Prevention “Il Chirone”, presents the first results of an      Statistical analysis
initial study, that will carry on the analysis of important    The descriptive analysis uses averages and standard
statistical data about the behaviors of the mothers in         deviations for quantitative variables and frequencies for
C




regards to their own oral health, deepening the under-         qualitative variables.
standing of how the initiation of habits and behaviors for     To measure the internal coherence of the items group-
a healthy lifestyle may influence the empowerment pro-         ing the α of Cronbach has been used and, in order to
cess of their children, meaning the education and volun-       check if some elements didn’t cohere with the rest of
©




tary embracing of good health rules.                           the scale and should therefore be discarded, an analysis
                                                               of reliability has been performed. Adding and eliminat-
                                                               ing the elements one by one created the total correlation
Materials and methods                                          between the items and the alpha variability between the
                                                               elements. When Cronbach’s alpha is equal to 1 it means
Participant and setting                                        that the questions have an almost identical construct,
This survey has been conducted using an online ques-           with consequential coherence. Generally, a value of an
tionnaire on the mothers association’s website (www.as-        alpha of 0.7 is considered acceptable (23).
sociazionemamme.it) in which 192 mothers participated.         The data collected has been put in a database cre-

70                                                                                   Annali di Stomatologia 2012; III (2): 69-74
Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study



ated with Excel and analyzed with SPSS for Windows                     of the mothers and the career category to which they
(release 19). The analysis was made only on the items                  belong,
with a response level higher than 15% and the sections
already validated in the literature have been excluded                 Validation of the questionnaire
from the analysis. The level of significance was fixed in              In Table 1 is reported the analysis of the questionnaire




                                                                                                       li
p<0.05.                                                                by sections.
                                                                       The highest value of the alpha of Cronbach is obtainable




                                                                                                    na
                                                                       in section 13 - Oral health related quality of life between
Results                                                                8-17 year old kids - with a value of 0.998 (5 items). In this
                                                                       section 61.5% of mothers declare ignorance about how
The total number of the compiled questionnaires was                    often their own children
                                                                                           13      find difficulty eating, or feel pain,




                                                                                                 io
192.                                                                   tension or embarrassment because of dental problems.
                                                                       Section 10 - Attitudes and risk factors of 5-17 year old
                                                                       children and 12-17 year old children - shows a value of




                                                                                              az
                                                                            13
                                                                       alpha of 0.969 (15 items). 83.3% of mothers answered
                                                                       no to the question of whether their kids brush their teeth
                                                                       each time they eat, and they answered “never” to the
                                                                       question of if their kids smoke.




                                                                                n
                                                                       In section 8 - Health level of children between 3-17 - the
                                                                       value of alpha is 0.881 (3 items). 62.5% of the moth-




                                                                             er
                                                                       ers didn’t know with what frequency their own child
                                                                       brushes his or her teeth, 64.1% and 63.5% didn’t know
                                                                       respectively if the toothpaste used was fluoride based
FigureFig.2
        1 - -Marital status
              Education level of the
                                 themothers.
                                     mothers.
                                                                       or if fluoride was used in other forms in addition to the
     Fig.2 - Education level of the mothers.

                                                    nt                 toothpaste.
                                                                       In section 9 - Community programs of 3-17 year old chil-
                                                                       dren - the result is a value of an alpha of 0.771 (3 items).
                                                  iI
                                                                       To the question of if there is a program of disease pre-
                                                                       vention for dental health for kids at school, 63% of moth-
                                                                       ers didn’t know what to answer and 22.9 % answered
                                                on

                                                                       no; 62.5% didn’t know or wasn’t sure if their own kids
                                                                       were visited by a dentist in the last 12 months for the
                                                                       prevention of oral diseases.
                                                                       Section 5 - Oral health related quality of life - had a value
                                                  i


                                                                       of alpha of 0.761 (8 items). Regarding some sides about
                                               iz


                                                                       oral health in the last 12 months, 83.9% of mothers nev-
Figure 2 - Education level of the mothers.                             er found
                                                                              14  difficulties to eat because of mouth problems,
                                                                       81.3% never felt pain to their teeth and gums, almost
                       Ed




                                                                       never for 68.2% and for the 67.2% of mothers the con-
                                                                       dition of their teeth was cause for embarrassment and
                                                                       they avoided smiling.
                                                                       Section 3 - Risk factors and habits - (27 items, al-
                                                                       pha=0.773) reveals that 67.6% of mothers ate more than
 IC




                                                                       6 times a day. 72.3% of the sample ate between 5 and
                                                                       9 portions of bread each week, pasta was consumed by
     Fig. 3 - Employment of the mothers.                               81.9% at the most four times a week, beans were not
                                                                       eaten by 64.9% of the mothers during the week, fruit
C




                                                                       (consumed up to nine times a week) and vegetables
      Fig. 3 - Employment of the mothers.                              (up to four times a week) were consumed by 74.5%, red
Figure 3 - Employment of the mothers.
                                                                       meat by 68.1% up to 9 portions a week in respect to
                                                                       88.3% that consumed at the most four portions of white
©




                                                                       meat, cheese and fish are consumed up to four times a
The mothers involved had an average age of 45.9 years                  week by 89.4 % and finally 67% of mothers don’t con-
(SD 12.5). Figure 1 describes the marital status of the                sume any amount of sweets during the week. 92.6% of
mothers. 15.6 % of the sample refers to those affected                 mothers say they don’t smoke and 92% don’t drink al-
by diabetes and 12% to those with cardiovascular dis-                  cohol.
eases, particularly hypertension (9.4%). In regards to                 Considering section 12 - Preventive visit for pregnant
the number of children, 44.8% of the mothers had just                  women - (2 items, alfa =0.720) it appears that 72.9% of
one, 34.9% two kids, only 1.6% had four.                               mothers were never visited by a dentist during their last
Figures 2 and 3 show respectively the level of education               pregnancy.

Annali di Stomatologia 2012; III (2): 69-74                                                                                          71
  Table 1 – Analysis of the questionnaire by sections: number of questions, number of items and value of
G. M. Nardi et al.
  Cronbach’s alpha.


                                                                                    Number of             Number of              α
  Sections of questionnaire
                                                                                    questions                 items           value
  Section 1. Anamnestic and social-demographic.                                         13                      10             0.555




                                                                                                       li
                     Part 1. Attention to the mothers' oral hygiene.                    28                      28             0.564




                                                                                                    na
  Section 2.         Part 2. Protections and oral hygiene habits and
                                                                                        18                      18            -0.330
                     preventive behaviors.
  Section 3. Risk factors, habits.                                                      10                      27             0.733




                                                                                                 io
  Section 4. Level of oral health.                                                       3                      2              0.586
  Section 5. Oral health related quality of life.                                        8                      8              0.761




                                                                                              az
  Sections of questions for mothers who have children
                                                                                         6                      5             -0.266
  with less 18 years
  Section 8. Oral health level of 3-17 years old kids.                                   4                      3              0.881




                                                                               n
  Section 9. Community programs for 3-17 years.                                          5                      3              0.771




                                                                            er
  Section 10. Attitudes and risk factors of 5-17 years old kids and 12-
                                                                                         6                      15             0.969
  17 years.
  Section 11. Dental assistance sources.                                                 4                      4              0.609

                                                 nt
  Section 12. Preventive visit for pregnant women.
  Section 13. Oral health related quality of life in 8-17 years old kids.
                                                                                         3
                                                                                         6
                                                                                                                2
                                                                                                                5
                                                                                                                               0.720
                                                                                                                               0.998
                                               iI
  Section 14. Orthodontic and dental traumas.                                           13                      6              0.133
  Total considering all sections                                                        127                    134             0.784
                                             on

Table 1 - Analysis of the questionnaire by sections: number of questions, number of items and value of Cronbach’s alpha.
                                                                       tist less then a year ago, 84.7% of those, for a check up.
                                    i


                                                                       68.1% declared not having a dentist located less then 30
                                 iz


In section 11 - Dental Assistance Sources - (4 items, alfa             minutes from home or the place of work.
0.609) 97% of the mothers declared that 75.4% of their                 The total value of the alpha of Cronbach, considering
own children never went to the dentist because of a lack               the part of questionnaire dedicated only to the mothers
                     Ed




of revealing diseases in the last year.                                that have more than 18 years old children, is 0.490 on
By the answers in section 4 - Dental health level - (2                 116 items.
items, alfa = 0.586) it shows that 9% of mothers have                  In total, considering all the sections of the questionnaire
20 or more natural teeth and that 98.4% doesn’t have                   on 134 items and 127 questions, we get an alpha value
dentures.                                                              of 0.784.
Mothers that answered section 2 - Attention to oral
 IC




health of the mother - declared that 63.7% of them never
taught their children dental hygiene; 65.8% didn’t know                Discussion
if there is a relation between oral health and general
C




health and 65.8% didn’t know if a check up by the dentist              The World Health Organization asked to begin cam-
or hygienist would be useful. 82.6% of the mothers actu-               paigns for the promotion of healthy lifestyles aimed at
   Fig.
ally do 1go- Marital  statusand
             to the dentist, of the mothers.
                                brush their teeth carefully.           the promotion of corrective intervention to these “modifi-
69.5% think that they can brush their teeth in a satis-                able” risk factors that are at the base of the major inci-
©




factory way without using toothpaste and 84.7% declare                 dents of serious diseases (24).
that bad breath is a problem that worries them. 75.3% of               Often oral health is considered not relevant (25), instead
the mothers also referred to brushing their teeth twice a              the correlation between periodontal pathologies, heart
day, 72.1% brush them less then 2 minutes, and 95.8%                   disease and adverse pregnancy outcomes is significant;
use a manual toothbrush. The toothbrush is changed ev-                 the mechanism that links oral health to the preceding is
ery 6 months by 73.2% of the mothers, 79.5% don’t use                  systemic inflammation (26).
mouthwash habitually. Floss is used only by 27.4% of                   The main goal of periodontal disease prevention is the
the mothers but in 64.2% of cases with a daily frequency.              checkup and inhibition of bacterial plaque creation in the
79.5% of the mothers declared having been to the den-                  patients, and between the different strategies of preven-

72                                                                                            Annali di Stomatologia 2012; III (2): 69-74
Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study



tion the most significant portion of these is about activi-            sults about the evaluation of risk that mothers’ behaviors
ties that promote dental self-care. The growth and the                 may have on their children’s dental health.
development of a child is a continuous process that has
to create an indipendent individual (27) and children                  Acknowledgements: We are grateful to the Italian National As-
showed to adopt behaviors and food preferences of their                sociation of Mothers for their cooperative and assistance.




                                                                                                        li
mother since the beginning of infancy (28,29).
Talking about the consumption of sweets, for example,




                                                                                                     na
a relationship seems to exist between children’s habits                References
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