4.1. Study 1: Discussion
The themes discussed in the focus groups suggested more similarities than differences between U.S. and Grenadian parents. Grenadian parents have a strong desire to instill healthy behaviors within their children and experience many of the same issues as low-income US parents. Grenadian families are often single-parent homes, which poses challenges to financial stability and parental supervision of children.
The differences lie mainly in oral health. Grenadian families are less likely to seek preventive dental care and have a more fatalistic view of oral health outcomes. Grenadians also report culture-specific health-promotion behaviors, such as chewing on sugar cane, which exposes the teeth to elevated sugar levels. This causes caries, but it also stimulates saliva and mechanically removes debris, which can help prevent caries. Generally, chewing on sugar cane slightly increases the risk of cavities, but only with a small effect size [24
The similarities that emerged suggest that measures of family functioning and oral health might perform similarly in Grenadian families as they do in American samples [8
], which suggests U.S. prevention approaches that leverage the relation between family functioning and child oral health might be applicable to Grenadian families. Therefore, Study 2 was conducted to obtain quantitative information about Grenadian oral health behaviors and to assess whether the measures and prevention approaches from American studies would function as expected.
4.2. Study 2: Discussion
Parent and child oral health behaviors were significantly associated with one another, suggesting that parents and children perform similar oral hygiene routines. It should be noted that parental reports of brushing length are surprisingly high. Whereas, American parents report that children brush 1.78 times per day (SD
= 0.53) and for 1.61 min (SD
= 1.0), Grenadian parents are reporting 1.51 times per day (SD
= 0.61) but for 2.33 min (SD
= 1.05). It is possible that this reflects a true difference in brushing behaviors or that social desirability influenced the validity of these data. Additionally, research shows a significant difference between the length of time individuals believe they brush and actual time spent brushing (more than 134 s versus less than 84 s, respectively) [26
A majority of participants were single parents, and those in relationships reported fairly low relationship satisfaction. Child externalizing and internalizing behaviors were significantly positively associated, indicating an expected, more general, construct of child problems. Finally, as expected, those who were more satisfied in their adult relationships reported fewer problems with their children.
There were indications that oral health and family variables were associated in ways consistent with emerging findings with American samples [8
]. Those with higher relationship satisfaction endorsed longer adult flossing, and child internalizing problems were associated with adult tooth loss to decay and injury. Although there was no significant association between over-reactive discipline and child brushing frequency, the effect size (r
= −0.26) is what we might expect. This is consistent with previous findings that high-conflict family environments can be linked to poorer oral health outcomes, and victims of physical or emotional aggression had higher adult caries [6
]. Having greater relationship stress or child behavior problems is a stressor to the family and likely takes up family resources, leading to worse oral health maintenance. However, there were some unexpected findings. Child internalizing and externalizing behavior was positively associated with adult oral health, and adult relationship satisfaction was negatively associated with child brushing time. It is not clear whether these unexpected findings are attributable to measurement error (e.g., response biases), culturally specific properties of the measures, or whether the constructs themselves are differently related across the two cultural contexts. Furthermore, because this is not a clinical sample, the rates of internalizing and externalizing problems are relatively low.
Over-reactive parenting was common, suggesting harsh discipline continues to be normative among Grenadian families. Parenting style was not associated with relationship satisfaction, child problems, or any oral health measures, and the parenting subscales had poor reliability estimates in this sample. It is possible that these scales are not a good fit for the Grenadian parents, and that more culturally appropriate parenting measures need to be developed. These findings might also indicate that because harsh parenting is culturally normative, it is less systematically impactful on child outcomes. A multi-method approach would help bring clarity.
The observational coding of parent-child interactions revealed no significant associations with self-reported parenting behaviors, or with other relationship or oral health behaviors. Observations of warmth indicated mostly neutral interactions between parents and children, with moderate parental responsiveness. These averages are lower than we have observed in American samples; it may be that we were less successful in evoking naturalistic, generalizable interactions in this analog situation, or that coding warmth and responsiveness in Grenadian families should be adjusted to account for cultural differences in expressiveness.
Oral hygiene, relationship satisfaction, and child behavior measures seem to have functioned well in this sample, showing associations among family stressors and oral health. Further development of culturally sensitive parenting self-report measures and parent-child observation protocols would help identify specific family constructs that could be targeted in oral-health behavior interventions. The openness and interest regarding oral health during the motivational interviews suggests that further development of family-friendly behavioral health interventions would be well-received.
Limitations of this study should be noted. Both studies were convenience samples that might limit generalizability of the findings. Furthermore, the sample size for Study 2, although typical for observational studies, does not provide power only to detect small effect sizes. The motivational interviewing portion of Study 2, given its modest size, should be interpreted as a pilot study.