What is the role of early years childcare staff in promoting and discussing children's oral health behaviours? An investigation of parent’s views

doi:10.21203/rs.3.rs-5013499/v1

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Research Article

What is the role of early years childcare staff in promoting and discussing children's oral health behaviours? An investigation of parent’s views

https://doi.org/10.21203/rs.3.rs-5013499/v1

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Baackground:

The primary reason children in the UK are referred to hospitals for general anaesthetic is to have their teeth removed due to tooth decay. Tooth decay is a non-communicable disease which can be prevented through healthy behaviours such as brushing at least twice a day with fluoride toothpaste, reducing the frequency of sugar consumption throughout the day and regular dental check-ups. Recently, oral health became a mandatory component of the England Early Years Settings' (EYS) framework. Successful implementation of this public health strategy necessitates involvement from parents and carers, however their views currently remain unexplored. Therefore, we aim to investigate parents' views about the role of EYS and childcare providers in promoting and discussing children’s oral health behaviours.

Method:

Semi-structured interviews were conducted in English and Arabic with 14 parents (11 mothers, 3 fathers) with at least one child under five years enrolled in any EYS (nurseries, preschools, Sure Start centres) in England. Participants were recruited through EYS settings and using online social media. Data were analysed using an inductive and latent thematic analysis.

Results:

The analysis was organized into three overarching themes: 1) Parental knowledge limited by indirect communication with staff, 2) EYS suitable to support oral health but .... and 3) EYS as a partner to support children’s oral health

Conclusion

Parents have limited awareness of oral health activities in EYS. They acknowledge that EYS staff can influence children's oral health behaviours, yet also report communication barriers with EYS staff. Early years communication is primarily uni-directional, which shapes parents' views about EYS staff's responsibility and credibility to support their children’s oral health. To overcome these barriers, staff need training and support to effectively engage parents.

Dental caries (tooth decay) remain a significant health issue amongst preschool children worldwide [1]. The last National Dental Epidemiology Programmes survey of five year old children in England in 2022 showed that 29.3% of children had dental caries, and on average, they had at least three untreated teeth with deep decay [2]. Dental caries negatively impact the oral health-related quality of life of preschool children and their parents [3], school performance and school attendance in children [4]. The cost of dental caries treatment poses a large economic burden on the healthcare system [5].

Childhood is a crucial opportunity to acquire knowledge, skills and behaviours that affect health [6, 7]. The two to six year age period encompasses the transition from childhood dependence to the rising autonomy and social and cognitive skills of school-age children [8]. Dietary and tooth brushing behaviours and other health patterns are firmly established at preschool age, and any unhelpful dental behaviours such as having fizzy drinks in the bottle or using dummies developed at this age can be challenging to alter as the child develops [9]. A growing body of literature recognises the importance of oral health during childhood [5, 10–14]. Therefore, oral health behaviours (e.g. tooth brushing, reducing sugar intake) should be adopted early in life to prevent caries.

Parents experience difficulty accessing dental services for their children [15], and the COVID-19 pandemic exacerbated the issue; in March 2020, dental services were highly disrupted and limited to urgent care [16, 17]. An estimated 19 million fewer treatments were delivered in 2020 compared to the same period in 2019 in England [18]. Further, a dramatic decline (98%) in dental services used by children during lockdown has been demonstrated [19]. A recent study found that the number of children referred for dental general anaesthesia in North West England significantly declined during the lockdown period (April-June) 2020, compared to the same period the year before (XX,2022). There is still no resolution; children and parents still have difficulty getting appointments [20]. Hence alternative additional routes to preventative oral health care are urgently needed.

In the context of difficulty in accessing timely dental care, it is likely that children will not only miss routine check-ups but also teachable moments for promoting healthy oral behaviours. Teachable moments are opportunities to motivate individuals to adopt risk-reducing health behaviours spontaneously [21]; routine dental check-ups in the NHS offer those opportunities (XX, 2022). CM McBride, KM Emmons and IM Lipkus [21] identified three elements that make the teachable moments effective these are increasing the perception of personal risk and outcome expectations, redefining self-concept or social role and prompting strong effective or emotional responses. The health behaviours associated with children’s oral health that can be discussed inside dental clinics include oral hygiene practices, diet and sugar consumption, and attendance at routine appointments (XX, 2022). However, with the limited access to such services it is imperative to find teachable opportunities beyond dental clinics to provide oral health support for children and their parents.

The early year's foundation stage (EYFS) framework sets the standards to ensure that children aged from birth to five learn and develop well and are kept healthy and safe [22]. It has been argued that it is possible to minimise or even eradicate dental caries in children by targeting children and parents in childhood centres [23, 24]. The UK government therefore consulted 2452 representatives from different positions (teachers, parents, managers, local authorities and others) to seek their views on incorporating oral health within the early years framework to promote children’s oral health [25]. The responses were mixed; some respondents agreed oral health should be included in early years settings, while others disagreed, believing that oral health care was the exclusive remit of parents and healthcare professionals [25]. There was no indication of which stakeholders (ie EYS versus Parents) accepted and disagreed with the idea. Further, no research has systematically explored the reasons underpinning these differing views.

In response to the consultation, oral health was included within the framework, with each setting being able to determine its own requirement [25]. These changes were introduced in September 2021 [22]. However, the guidance lacks specificity on how EYS should promote oral health: 'The provider must promote the good health, including the oral health, of children attending the setting' [26: p.32]. It is important to understand how EYS integrate oral health into their activities and how families perceive those activities.

This study aims to investigate parents' views about the role of EYS and childcare providers in promoting oral health, whether there are any opportunities to provide behaviour change conversations at EYS, and if they could mitigate the difficulty of accessing dental services as well as parents’ perspective about those conversations.

A qualitative study comprising individual semi-structured interviews with parents of children aged under five enrolled in any early-year settings in England was conducted. This study received ethical approval from the Ethics Committee at the University of Manchester (2022-13824-24563) and (2023-17885-31309).

Participants and recruitment

Participants were recruited through social media advertising and visiting Sure Start centres. The eligibility criteria were adults aged 18 years or over who were caregivers of at least one child enrolled in an EYS in England. Participants needed to be fluent in English or Arabic. Recruitment took place between July to September 2022.

There are different types of EYS in England to meet the needs of different ages and socioeconomic groups. These include nurseries, preschools, Sure Start centres, childminders and Madrassas. At the time of recruitment, all three and four-year-olds in the UK received up to 15 hours of free early education and childcare per week for 38 weeks of the year [27], with proposals to extend this in near future for working parents of children aged nine months and above. [28]

Interested participants were provided with an information sheet and given the opportunity to ask questions and seek further information before being asked to consent to participate in the study. Participants provided written or verbal informed consent prior to enrolment in the study. Demographic information included postcode of children’s EYS type, number of children enrolled in EYS, children’s age, whether children are registered with a dentist, when was their last dental visit and reason for visit, parent’s work status, parent age, gender and ethnicity. The postcode was converted to an Index of Multiple Deprivation (IMD) decile for children’s settings. IMD deciles toward one mean more deprived area, and decile ten the least [29]. The information sheet, demographic questionnaire and consent form were translated into Arabic, and participants had the option of undertaking the interview in Arabic or English. A £10 high street voucher was emailed to each participant after the interview as a thank you for their contribution.

Data collection

The interviewer followed a topic guide that comprised of open-ended questions and prompts. The topic guide covered five topics: current oral health support and activities provided by EYS for their children, parents’ perception of oral health inclusion to EYS framework, their experience in receiving any oral health related promotion from EYS staff, exploring the communication and relationship with EYS staff and their acceptance to have any oral behaviour change conversations with EYS staff, also implementation oral health related behaviours at home. (Please refer to supplementary document 1)

Interviews lasted for 18 to 79 Minutes (the mean = 38 minutes). Fourteen parents were interviewed; eight interviews were conducted in Arabic, and six in English. One interview was conducted face-to-face; the rest were conducted online using the video conferencing software Zoom. Different advantages have been identified in the literature of conducting the interviews online; these include access to wider participants, time effectiveness, and cost-effectiveness [30], which allows participants to fit the interviews into their busy schedules and save on travel expenses and commute time [31, 32].

Interviews were audio-recorded and transcribed verbatim, and any identifying information e.g. names and places, were removed. All interviews were conducted by the first author, who is a bilingual female, non-parent researcher with a clinical background in dentistry. The three other members of the research team were also female. They were academic psychologists. All were parents, and one had a child in an EYS at the time of data collection.

Arabic interviews were transcribed and analysed in the original language, and then the quotes were translated into English using a stepwise approach. By analysing data in the same language it was collected in, the meaning of the data can be preserved during analysis [33, 34] and the cheeking accuracy of the translation can be measured more efficiently using small chunks of text. The first author translated all the quotes to English to maximise the translation reliability [35, 36]. In the second step, two bilingual translators independently assessed the translated quotes using different criteria that were developed previously and suggested any changes, if any. Then all meet and discuss until we agree on the translation. Finally, another bilingual individual translated the English version back to Arabic to ensure the meaning was not lost in the process [37]. Then, the other members compared it with the original Arabic quote to ensure the meaning was not lost. Detailed information about the translation approach can be found in a separate publication (XXX, in prep)

Data analysis

Analysis followed V Braun and V Clarke [38] reflexive thematic analysis approach (RTA). In phase one, interviews were read repeatedly, allowing the lead researcher to become familiar and engaged with the data. In phase two, a more formal coding process was conducted, which involved discussion with the research team. The scripts were organised and coded using a computer-assisted qualitative data analysis software [39], as this kind of software provides an organised storage system that can easily and quickly access the materials and export the codebook [40]. In phases three and four, themes were generated, developed, reviewed, and discussed with all contributing authors. In phase five, we further refined the developed themes, including defining and naming them. Reporting findings were considered through all phases rather than as a discrete phase. All members were involved in this process; the report was organised and drafted by the lead researcher and reviewed, offered feedback and edited by the other authors.

The fourteen parents comprised 11 mothers and 3 fathers. Participants had a total of 19 children (range 1-3 per participant). A summary of participant’s and children’s information is provided in Table 1.

Table 1 Participants’ demographics information

Parent’s information (Total =14)
Age range	23 to 39 years (mean = 29)
Region	North-West England (n=6) Yorkshire and the Humber (5) South-West England (1) East Midlands (1) London (1)
Parents’ ethnicities	Arab (n=8) African (3) Asian (2) White (1).
Children information Total (19)
Children’s age range	22 months to 5 years (mean= 3.3 years)
Children’s setting types	Preschools (n= 7) Nurseries (11) Sure Start centres (1)
IMD decile for children’s settings	1 to 5 (more deprived) (n=16) 6-10 (least deprived) (3)
Dentist registration	Registered (n= 12) Not registered (7)

Table 1 is about here

Three themes were developed to reflect parent’s views about the role of EYS and childcare providers in promoting children’s oral health (see Figure 1). Participants quotes are presented within the text to illustrate these themes.

Figure 1 is about here

1. Parental knowledge limited by indirect communication with staff

This theme is organised into two subthemes: oral health (OH) is not currently part of the EYS, and EYS relies on one-way communication. The first subtheme reports current OH activities conducted at EYS that parents are aware of and what resources and information are delivered to them. The second subthemes focuses on the nature of communication arising between parents and EYS staff.

Parents’ awareness of OH in EYS

No parent was aware that oral health was part of the EYS framework. ‘No, no, no, not that I remember, P10’. A few parents recalled EYS delivering some OH activities, however these were described as ad hoc and focused primarily on tooth-brushing and providing toothbrush-related goody bags. A minority of parents reported that their child brushed their teeth at their EYS.

Parents reported that much of their thoughts about what oral health care occurred within EYS was assumed and they were uncertain about what, if any, oral health-related activities occurred, e.g. a mother asked her children during the interview. ‘I don’t know. Should I ask, wait, let me ask, P6’

‘Frankly, I am not sure, but usually, I mean my daughter, when she knows new thing, when she learns new things, she say, “mum”, for example, “the school said this, the Ms said this.” So, she tell me. But, about this point (oral health) honestly, I am not sure. And always, when I enter the nursery, I see all the toys they (the children) play with. So, mostly, there are kitchen stuff. Kitchen stuff, building blocks, and stuff like this. I never happen to come across, for example, mouth model or toothbrush, or anything like that. I mean, I didn't see this type of education, P9’.

Parents often did not recall receiving resources and information regarding oral health ‘I don’t think I have ever get any information about that’ (P6). Amongst those who did recall receiving resources, these were in the form of a leaflet (paper/digital) which focused on effective toothbrushing, how to choose the toothpaste and toothbrushing, sugar consumption and breastfeeding. Parents considered that leaflets alone were insufficient as they needed someone to explain to them how to use that information, and further support from EYS staff was necessary. Specific barriers to accessing the information given included not being able to understand as they had insufficient English, difficulty finding time to read them, and having to keep them away from children who tend to tear or draw on them. Parents also felt uncertain how to use the resources staff had given them.

‘Then they give you with a storybook in it and all the information about brushing children’s teeth but they don’t tell you like, they give you a paper and showing you how to do it but they don’t do it physically with you there, P4’

‘I believe they should have more classes and speak to parents individually, rather than just giving them leaflets to read by themselves because like other parents, they wouldn’t know how to read, P6’

EYS relies on one-way communication

While parents interact with staff in multiple situations (e.g. drop-off/pick-up, one-to-one meetings, inductions, parent events) most communication was occurs in written form. This included parents receiving emails, a daily logbook, mobile applications, Facebook communities and websites. Email was the most used method staff communicated information , which participants preferred as it was convenient, familiar and could be referred to repeatedly if needed. ‘Because I’m busy and the email does not defy me, P5’. Emails could also however be missed as there was a lot of traffic, often irrelevant, information dense or poorly formatted and unengaging. Altogether parents were overwhelmed by the information received and discouraged from sifting through it to identify what, if any, actions were required of them. In this context information relating to tooth-kind activities or actions was easily missed.

‘They sent to you like this: everything in black AND bold. Everything black AND bold. You will not understand anything. They say this staff had relocated, we hired a new teacher, and so on. So what? The toilet water was shut off, so? You know, I do not want to know all that, (P2)’

2. EYS suitable to support OH but ...

This theme focuses on exploring parents’ views about the suitability of EYS to support children’s oral health and is organised into two subthemes. The first focuses on parents' views on the role of EYS' and their appropriateness for conducting OH activities, and the second focuses on EYS staff's credibility in delivering oral health messages to them.

Considering the role of EYS

Parents viewed EYS as having two fundamental purposes, which influenced their views about how appropriate this setting is for conducting OH activities. Some parents viewed EYS as a place of safety to care for children whilst parents were unable to, others viewed it primarily as a place of education and learning for the child. Some saw EYS as having both functions.

‘I do not care about the extra things they do. Because for example, the goal is for the boy to go to the nursery is to be in a good place, learn and interact. Did you understand? I am not expecting anything else from them, if we could say, (P2)’.

The cost of the EYS determines the level of service parents expected, with a belief that more expensive settings would provide a wider range of services. Parents considered oral health and its activities as a luxury and hence more likely to be expected in more expensive settings. Few parents expected toothbrushing to be incorporated into EYS because children spent all day at EYS and tended to have at least one meal there.

‘I expect it might be the private (EYS) that has very good services, for example. I expect they are the ones implementing this thing (oral health activties), I don't know, P9’.

‘I expect because the girl (her daughter), will have a meal, and there will be eating, and there will be a meal-time in there. I expect that they will request from me a toothbrush and toothpaste. This is my expectation, but it was not included (In the list they asked the parents to bring), P12’

Most participants were concerned about toothbrushing at EYS, with hygiene being a key concern. Parents worried that children might exchange their toothbrushes, how they would be stored, and how they could brush while they have limited sinks.

‘schools are like clean but you never know, germs can be everywhere and they’re unseen,P4.’

Parents were also highly concerned about the safety of fluoride and its impact on their children's health. Moreover, parents thought brushing at EYS wouldn't provide additional benefits since their children already brush twice daily at home, and some linked it to the dental guidelines. ‘I guess the general guidelines that we've gotten in the UK is that you just need to brush your teeth two times a day,P10’. Some also believed that introducing toothbrushing later to older children can be more effective as they can better understand its importance. Others highlighted the difficulty of controlling multiple children at once or thought the staff did not have the capacity for this additional task. This view was understandable as some parents had experienced a lack of staff, leading to occasions when parents were asked not to bring children as the setting had to close.,

While most parents were concerned about toothbrushing at EYS, a few parents highlighted how the inclusion of oral health activities positively impacts children and parents. Parents noticed that brushing at EYS encouraged their children to brush at home, and children were more likely to remind their parents to brush when parents forgot. These parents noticed that children brushed more regularly at home during term time compared to school holidays. One parent described choosing to implement the same brushing technique used at EYS at home. Further, parents found that toothbrushing reward charts provided by their children's settings encouraged their children to brush at home and maintain the habit.

‘she wasn't that excited about it at first. And then all of a sudden, she came home and she was excited about it and she would do it. And she would do it for the proper amount of time and without us having to like really ask her to do it. So we attribute that to doing it at school and doing that with her friends,P10’

EYS staff credibility to deliver OH messages

Parents reported that it did not occur to them to ask EYS staff about oral health. Some explained this was because they had no prior oral health-related conversations. They believed that the relevant professionals to discuss oral health with are dentist or health visitors. Other sources of oral health information were online via YouTube, NHS websites, parenting websites and from other parents within their social network.

‘I feel like I search for the information from its source, either I look online on the websites that talk about children and their development. Or possibly ask the health visitor about specific things. Which I did previously. P7’

Some participants reported only accepting oral health advice and conversations from dental healthcare professionals, whereas others were content to accept conversations from EYS staff around basic information regarding children's oral health. Parents emphasised the importance of tailoring any information given to them since not all parents have the same level of awareness and health literacy. Participants argued that staff should have additional training in oral health in order to undertake such activities and that going beyond their expertise was potentially harmful or could ‘cause chaos’ (P12). In contrast, other participants, argued that there was no need for specialist training because everyone should know the basics of oral health.

‘I’m not really sure about that but I think like something related to oral health, like a certification. I don’t know if there's any certificate. Usually they always have some kind of like a safety certification. Maybe this one is from a dental or oral health certification,P6’.

3. EYS as a partner to support children’s oral health

This theme focuses on how parents view EYS settings as a place to support their children’s oral health and what characteristics make them an effective partner in this endeavour.

Although all participants believed that their children’s oral health was primarily a parent’s responsibility, several felt that the EYS staff could share this role with them. There were several reasons why staff were valued for their input. Children spend most of their day (and at least one meal) at the EYS; staff have the required skills to convince children to do any tasks they ask them to do e,g, toothbrushing and teach them appropriately; early education is more likely to stay with children for a lifetime; participants argued that children tend to follow their teachers' instructions more than their parents'.

‘the more you teach your children from a young age, as they grow up, they know what they’re doing, P4’

The child is encouraged by the teacher because the teacher helps the child and encourages him even more than the mother., P13’.

Moreover, parents argued that there was added benefit to working as a parent-educator team and that having a consistent approach helped children generalise healthy behaviours across the settings.

‘the more we're all involved in promoting good health, the better,P10’

‘When there is a cooperation from the parents, and an acceptance from EYS, or if they incorporate it in their curriculum. The child will have the mindset to do it (toothbrushing/ oral care). I have to do it because it is a must. Regardless of the place I’m at. Either I was home or at school, P12’.

Parents believed that children would benefit from incorporating oral health into the EYS framework for many reasons. First, it would provide children with essential knowledge regarding oral health, particularly for children of caregivers with less knowledge. Second, children are curious and want to know why they must do certain things, such as brushing their teeth. Third, by including oral health in the EYS framework, parents believed that children would learn the importance of oral health if they heard the same information from two sources, ie their caregiver and their teacher.

‘The EYS, by incorporating this (oral health) in the curriculum, is considered a positive step as it will satisfy the child's curiosity. It will answer their whys and provide the children with the required information that they need. So they will have belive from the inside to do this (oral care) as a part of thier health. (P8)’.

‘they like to also teach them at school. It will give the kids some kind of like, you know, reassurance that it’s important to do it properly like that,P10’

Some participants believed toothbrushing at EYS would make a positive difference. Brushing with their peers help encourage children to brush. Also, children tend to impress their teachers, and the praise received from their teachers encourages them to brush.

‘Because the child's nature loves to imitate his friends, when the teacher asks them to imitate each other in brushing their teeth, they will take it as an approach for the rest of their lives. (P13)

In contrast, a small minority of the participants believed that staff at EYS should not have any responsibility for their children's oral health. This was for two main reasons: they linked the responsibility with clinical examination and hence the sole remit of a dental practitioner, or they believed responsibility means unfairly placing a burden on staff if oral health issues occur. ‘to say that they are the responsible person is a bit too heavy,P6’

Parents did not know that oral health now forms part of EYS framework and were at most aware of a very limited provision of oral health activities within the setting. What awareness they had came largely via their children rather than directly from care setting staff. Hygiene and safety were the main concerns parents had about conducting supervised toothbrushing at EYS. Some parents did not consider approaching EYS staff for support with their children’s oral health, did not view EYS staff as being credible or qualified, and were reluctant to accept oral health advice from a non-dental healthcare professional. However, there were others who believed that EYS staff share responsibility for supporting their children’s oral health since the children spent most of their day in their care. Parents whose children's setting did provide some oral health activities reported a positive impact on them and their children.

Communication between parents and EYS staff was reported to be both verbal and written. However, the health education information provided was often unengaging and frequently overlooked. Although EYS primarily communicated with parents via emails, the number of emails and their contents and formatting discouraged parents from reading them. The use of digital tools for communication, such as Emails, has many advantages, as they are efficient, immediate, and offer equal access to parents [41]. However, it remains often a one-way transfer of information; may not address the variation in the linguistic competence of parents, and it is guided by staff intentions rather than parents’ needs, expectations and intentions [41]. These findings suggest that staff need to be guided on how to communicate more effectively using digital communication and tailor it to parents' intentions.

Indirect communication via children was considered a barrier to parent communication in educational settings (XX, 2022). Successful implementation of healthy lifestyle interventions requires two-way communication between home and school (XX, 2020). The child is the centre of communication between parents and staff in childcare settings [42]. Indeed, parents in our study relied on their children to know about what happened to their children with regard to oral health care and education. It seems children are partly filling the gap in parent and staff problematic communication. So, any communication about the child can be considered triadic communication, which involves dyadic interaction between all parties. This also has been examined within dental settings [43]. In school settings it is likely to be inadequate and fail to address the concerns that parents have. An interactive intervention that engages children, parents, and staff may be needed.

Parents’ expect EYS to be a place of education and/or caregiving. These beliefs played a significant role in how acceptable they found staff involvement in supporting children's oral health. E Henderson and G Rubin [44] report that parents see preschools as responsible for learning and creating a supportive environment for children. The lack of parental involvement and awareness can be due to the fact that parents are not informed and not involved in EYS activities and changes, as none of the parents were aware of incorporating oral health as a mandatory component. E Henderson and G Rubin [44] outlined two barriers to involving parents in oral health activities in EYSs: the type of relationship between EYPs and parents and the fact that parents do not prioritise oral health. Therefore staff in EYS need to work on parents' involvement and establish a partnership. Education Scotland [45] developed a comprehensive toolkit that guides EYS staff to parental involvement and engagement in their settings. The toolkit consisted of 11 sections talking about different topics such as the benefits of involving parents in the children’s learning, home and school partnerships, and parental representation, with ideas about activities that can done with parent groups. Yet, the toolkit lacks clarity on how to navigate and utilize the various sections, as many topics overlap. Providing a more structured guide on how to approach the toolkit could enhance its usability for users.

Some parents in the current study reported they were willing to receive basic oral health messages from the staff. It is important for parents to be approached in a non-judgmental manner. Parents accept healthy advice from staff in their children's settings if it is not perceived as being told what to do [46]. This could also explain why some parents may opt to seek information online, in order to avoid feeling judged. It has been emphasised that staff need to build up a relationship with the parent before promoting health by ensuring that their approach is non-threatening, approachable, and not preachy to engage parents in conversations [44]. So, it appears that staff need a variety of skills to engage parents in a meaningful oral health discussion without damaging the trusting relationship needed in a caregiving setting.

Hygiene and fluoride safety were the main two concerns that parents had against implementing supervised toothbrushing at EYS. Parent concerns regarding hygiene might have been exacerbated by COVID-19 pandemic and differentially worry different groups of parents. In a study by Woodland et al. (2021), parents who lived in the North of England or who were from black, Asian and ethnic minority backgrounds were least likely to send their children back to their education settings when they reopened after the lockdown. This might be reflected in the parents in this study as they were mostly from these groups.

There is potential to address parent’s safety concerns if they have better awareness of how settings implement supervised toothbrushing and follow a protocol/scheme/and is stocktake by oral health improvement teams which are commissioned by local authorities [47]. Also, the parent could be informed of the dry toothbrushing technique, which do not require use of sinks [48]. Safety concerns also reflect that parents need to know about the correct behaviours for toothbrushing, no need to wash the toothpaste, and children need to spit out the excess, so they benefit from the fluoride [48]. Furthermore, those concerned about fluoride safety need additional support to raise awareness [49].

Study limitations and strength

This is the first study to take an in-depth systematic approach to investigate the views of parents of EYS practice around oral health education. The findings are timely and important evidence to support the existing rollout and proposals for expanding oral health practice at EYS nationwide.

Our study covered a wider diverse group in terms of ethnicity, socio-economic status, and geography; the data were collected in two languages, English and Arabic, and in two manners, in person and virtual. Hence, we enabled the integration of several underrepresented groups into our study described in a recent guide by [50] and this is a vital for high-quality outputs to ensure that research findings are relevant, reproducible, and address the needs of different communities [51]. Yet, it is likely our sample includes more people who are interested in the topic of child oral health and may overestimate parents’ knowledge of and willingness to be involved in oral health conversations with EYS staff, and not capture the full range of parents’ concerns.

Most participants were mothers. Efforts were taken to include fathers, but only three took part. Mothers are still often primary carers and the person in the household who takes on responsibility for oral health care and mothers report a conflict with their partners about their children’s oral hygiene and diets and consider them as more lenient [52]. Fathers’ participation in research is an issue for the broader field and it was important to include their voices which are often overlooked [53, 54].

Implication and Future Direction

The findings reveal the need to intervene to increase EYS's credibility to parents in promoting children’s oral health and additional training and support is needed as to how to communicate more effectively with parents about oral health care in ways that are engaging and acceptable. Further work is needed to investigate other stakeholders, in particular EYS staff, as they are key actors in implementing oral health education and care. This could help us to understand how best to intervene to improve communication and better support families with a view to reducing and preventing harmful dental diseases.

This study contributes to the limited evidence base by providing a clearer understanding of parents’ views on the current practice of oral health activities and communication to promote children’s oral health at EYS. Parents reported limited awareness of oral health activities in the EYS curriculum and multiple barriers to useful communication Meaning current oral health-related conversations from EYS professionals is limited and ineffective. Although parents believe that children's oral health is primarily their responsibility, there is a willingness to accept that EYS staff involvement in supporting child oral health behaviour change. To achieve this however will involve resources and support for EYS staff on how to communicate effectively with parents regarding their children’s oral health.

Ethical statement

This study received ethical approval from the Division of Psychology and Mental Health Ethics Committee at the University of Manchester (2022-13824-24563) and (2023-17885-31309). All participants provided written and/or verbal informed consent prior to enrolment in the study.

Clinical Trial Number

Not applicable

Funding

This study has been completed as part of the first author’s PhD, which is funded by the University of Ha’il, Ha’il, Saudi Arabia, and the Saudi Arabian Cultural Bureau in the UK.

Author Contribution

Study conception and design: Dalil Alshammari, Joanna Goldthorpe, and Sarah Peters; data collection: Dalil Alshammari; analysis and interpretation of results: Dalil Alshammari, Sarah Peters, Nia Coupe, and Joanna Goldthopre; draft manuscript preparation: Dalil Alshammari, Sarah Peters, Nia Coupe and Joanna Goldthorpe. All authors reviewed the results and approved the final version of the manuscript.

Acknowledgement

We would like to thank all parents for their contributions to our study.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Sheiham A, Watt RG: The Common Risk Factor Approach: a rational basis for promoting oral health. Community Dentistry and Oral Epidemiology 2000, 28(6):399-406.
National Dental Epidemiology Programme (NDEP) for England: oral health survey of 5 year old children 2022 [https://www.gov.uk/government/statistics/oral-health-survey-of-5-year-old-children-2022/national-dental-epidemiology-programme-ndep-for-england-oral-health-survey-of-5-year-old-children-2022]
Abanto J, Carvalho TS, Mendes FM, Wanderley MT, Bönecker M, Raggio DP: Impact of oral diseases and disorders on oral health-related quality of life of preschool children. Community Dentistry and Oral Epidemiology 2011, 39(2):105-114.
Rebelo MAB, Rebelo Vieira JM, Pereira JV, Quadros LN, Vettore MV: Does oral health influence school performance and school attendance? A systematic review and meta-analysis. International Journal of Paediatric Dentistry 2019, 29(2):138-148.
Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreno CC, Kearns C et al: Oral diseases: a global public health challenge. Lancet 2019, 394(10194):249-260.
Sigaud CHDS, Santos BRD, Costa P, Toriyama ATM: Promoting oral care in the preschool child: effects of a playful learning intervention. Revista Brasileira de Enfermagem 2017, 70(3):519-525.
Cooper AM, Coffey M, Dugdill L: Challenges in designing, conducting, and reporting oral health behavioral intervention studies in primary school age children: methodological issues. Pragmatic and Observational Research 2014:43.
Campbell SB: Behavior Problems in Preschool Children: A Review of Recent Research. Journal of Child Psychology and Psychiatry 1995, 36(1):113-149.
Rayner J, Holt R, Blinkhorn FD, Karen: British Society of Paediatric Dentistry: a policy document on oral health care in preschool children. International Journal of Paediatric Dentistry 2003, 13(4):279-285.
Broder HL: Children’s oral health-related quality of life. Community Dentistry and Oral Epidemiolology 2007, 35:5-7.
Blumenshine SL, Vann WF, Gizlice Z, Lee JY: Children's School Performance: Impact of General and Oral Health. Journal of Public Health Dentistry 2008, 68(2):82-87.
American Academy of Pediatric: Maintaining and improving the oral health of young children. Pediatrics 2014, 134(6):1224-1229.
Heilmann A, Tsakos G, Watt RG: Oral Health Over the Life Course. In., edn.: Springer International Publishing; 2015: 39-59.
Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, Soobader MJ, Bramlett MD, Newacheck PW: Influences on children's oral health: a conceptual model. Pediatrics 2007, 120(3):e510-520.
Steele J: NHS dental services in England. London: Department of Health 2009, 5:6.
Okike I, Reid A, Woonsam K, Dickenson A: COVID-19 and the impact on child dental services in the UK. BMJ Paediatrics Open 2021, 5(1):e000853.
Zaitoun H, Kandiah P, Yesudian G, Rodd H: COVID-19: implications for paediatric dental general anaesthetic services. Faculty Dental Journal 2020, 11(3):114-119.
Dentists: Government holds the key to restore services to millions [https://bda.org/news-centre/press-releases/dentists-government-holds-the-key-to-restore-services-to-millions]
Stennett M, Tsakos G: The impact of the COVID-19 pandemic on oral health inequalities and access to oral healthcare in England. British Dental Journal 2022, 232(2):109-114.
UK Parliament: NHS dentistry: Ninth Report of Session 2022–23. In. Edited by Committee HaSC; 2023.
McBride CM, Emmons KM, Lipkus IM: Understanding the potential of teachable moments: the case of smoking cessation. Health Education Research 2003, 18(2):156-170.
Guidance: Changes to the early years foundation stage (EYFS) framework [https://www.gov.uk/government/publications/changes-to-the-early-years-foundation-stage-eyfs-framework/changes-to-the-early-years-foundation-stage-eyfs-framework]
Baltacı E, Baygın Ö, Tüzüner T, Korkmaz FM: Evaluation of the knowledge, attitudes and behaviors of pre-school teachers on oral and dental health in the city center of Trabzon. European Oral Research 2019, 53(1).
Public Health England: Delivering Supervised Toothbrushing for Two, Three and Four Year Olds in Early Years Settings. In: “SMILES 4CHILDREN”. PHE; 2016.
Department for Education: Early Years Foundation Stage Reforms : Government consultation response. In. Edited by Department for Education; 2020.
Department of Education: Statutory framework for the early years foundation stage Setting the standards for learning, development and care for children from birth to five. . In.: GOV.UK; 2021: 53.
Childcare and parenting : Includes giving birth, fostering, adopting, benefits for children, childcare and schools [https://www.gov.uk/browse/childcare-parenting]
Free childcare: How we are tackling the cost of childcare [https://educationhub.blog.gov.uk/2023/06/01/free-childcare-how-we-tackling-the-cost-of-childcare/]
GOV.UK: National statistics English indices of deprivation 2019. In. Edited by Ministry of Housing CLG; 2019.
Archibald M, Ambagtsheer R, Casey M, Lawless M: Using Zoom Videoconferencing for Qualitative Data Collection: Perceptions and Experiences of Researchers and Participants. International Journal of Qualitative Methods 2019, 18:160940691987459.
Keen S, Lomeli-Rodriguez M, Joffe H: From Challenge to Opportunity: Virtual Qualitative Research During COVID-19 and Beyond. International Journal of Qualitative Methods 2022, 21:16094069221105075.
Janghorban R, Roudsari RL, Taghipour A: Skype interviewing: The new generation of online synchronous interview in qualitative research. International Journal of Qualitative Studies on Health and Well-being 2014, 9(1):24152.
Aloudah NM: Qualitative research in the Arabic language. When should translations to English occur? A literature review. Exploratory Research in Clinical and Social Pharmacy 2022, 6:100153.
Liamputtong P: Performing Qualitative Cross-Cultural Research. Cambridge, UNITED KINGDOM: Cambridge University Press; 2010.
Twinn S: An exploratory study examining the influence of translation on the validity and reliability of qualitative data in nursing research. Journal of Advanced Nursing 1997, 26(2):418-423.
Kapborg I, Bertero C: Using an interpreter in qualitative interviews: does it threaten validity? Nursing Inquiry 2002, 9(1):52-56.
McKenna L: Translation of research interviews: Do we have a problem with qualitative rigor? Nurse Author & Editor 2022, 32(1):1-3.
Braun V, Clarke V: Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health 2019, 11(4):589-597.
MAXQDA: Interview Analysis with MAXQDA. In.; 2023.
Creswell J: Qualitative Inquiry & Reserch Design: Choosing Among Five Approaches, Second edn: SAGE; 2007.
Riddersporre B, Stier J: Preschool Heads’ Notions of Digitalized Staff–Parent Communication: The Need to Move from Monocultural to Intercultural Communication in Multicultural Sweden. Journal of Intercultural Communication 2022, 22(1):1-16.
Radichozo E: Communication Patterns in Preschool Education Institutions - Practical Examples. Materia Socio Medica 2014, 26(5):343.
Yuan S, Humphris G, MacPherson L, Ross A, Freeman R: Development of an interaction coding scheme (PaeD-TrICS) to record the triadic communication behaviours in preventive dental consultations with preschool child patients and families: a video-based observational study. BMC Oral Health 2019, 19:162.
Henderson E, Rubin G: A model of roles and responsibilities in oral health promotion based on perspectives of a community-based initiative for pre-school children in the UK. British Dental Journal 2014, 216(5):E11-E11.
Engaging parents and families - A toolkit for practitioners [https://education.gov.scot/resources/engaging-parents-and-families-a-toolkit-for-practitioners/]
McSweeney LA, Rapley T, Summerbell CD, Haighton CA, Adamson AJ: Perceptions of nursery staff and parent views of healthy eating promotion in preschool settings: an exploratory qualitative study. BMC Public Health 2016, 16(1).
Public Health England (ed.): Oral health improvement programmes commissioned by local authorities. London: Public Health England; 2018.
Public Health England: Improving oral health: A toolkit to support commissioning of supervised toothbrushing programmes in early years and school settings. In. Edited by England PH. London; 2016: 27.
Lubojanski A, Piesiak-Panczyszyn D, Zakrzewski W, Dobrzynski W, Szymonowicz M, Rybak Z, Mielan B, Wiglusz RJ, Watras A, Dobrzynski M: The Safety of Fluoride Compounds and Their Effect on the Human Body—A Narrative Review. Materials 2023, 16(3):1242.
NHS Engalnd: Increasing diversity in research participation: A good practice guide for engaging with underrepresented groups. In.; 2023.
Medical Research Council: Embedding Diversity in Research Design: Diversity and inclusion in the design of research involving human participants. In.; 2022.
Burgette JM, Trivedi AV, Dahl ZT, Weyant RJ, McNeil DW, Foxman B, Marazita ML: Mother's Experience of Conflict Within Their Family Social Network when Advocating for Children's oral Health. Matern Child Health J 2023, 27(1):151-157.
Davison KK, Charles JN, Khandpur N, Nelson TJ: Fathers’ Perceived Reasons for Their Underrepresentation in Child Health Research and Strategies to Increase Their Involvement. Maternal and Child Health Journal 2017, 21(2):267-274.
Yaremych HE, Persky S: Recruiting Fathers for Parenting Research: An Evaluation of Eight Recruitment Methods and an Exploration of Fathers' Motivations for Participation. Parenting, science and practice 2023, 23(1):1-32.

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What is the role of early years childcare staff in promoting and discussing children's oral health behaviours? An investigation of parent’s views

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