Knowledge, attitude and practice towards oral health in parents and teachers of kindergarten students: a cross-sectional survey

Abstract

Objectives

This study aimed to explore the relationship between oral health and the knowledge, attitudes and practices (KAP) of parents and teachers of kindergarten students towards oral health.

Design

This web-based cross-sectional survey was conducted in Ningbo City from February 2023 to March 2023.

Setting

The study targets parents and teachers of kindergarten students in Ningbo City (five kindergartens selected using convenience sampling). The research aimed to explore the relationships between oral health practices, knowledge and attitudes among parents and teachers.

Participants

A total of 540 valid questionnaires were collected from parents and teachers. Clear definitions of selection, entry and exclusion criteria were followed to ensure comprehensive data collection.

Outcome measures

Assessment of oral health KAP among parents and teachers and correlation between KAP levels and students’ oral hygiene habits.

Results

Key findings include comparatively high levels of oral health knowledge among parents (7.29±1.74), positive attitudes towards oral health (23.69±2.97), and commendable practices (51.92±4.76). The structural equation model suggested a direct positive influence of attitude (β=0.27, p<0.001) and knowledge (β=0.51, p<0.001) on practice. Daily habits were also influenced indirectly by both attitude (β=0.10, p<0.001) and knowledge (β=0.20, p<0.001).

Conclusions

The study underscores the significant effect of parents’ and teachers’ KAP on kindergarten students’ oral health. The unknown representativeness of the sample necessitates caution in generalisation; nonetheless, the findings highlight the importance of enhancing oral health education and implementing targeted interventions to improve hygiene practices, with the potential to decrease dental caries prevalence among children. Collaborative efforts are essential in promoting effective oral health practices among young populations.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study focuses on exploring the influence of both parents and teachers on kindergarten students’ oral hygiene habits and provides valuable insight into the multifaceted approach required for effective oral health promotion.

• Statistical analysis, including structural equation modelling, allowed for the identification of significant links between knowledge, attitudes and practice (KAP) levels and oral hygiene habits, adding depth to the study’s conclusions, and the clear definitions of selection, entry and exclusion criteria contribute to the methodological rigour of the study, enhancing its credibility and validity.

• The study’s reliance on convenience sampling of kindergartens and the limited response rates may introduce potential sampling biases, which could affect the representativeness of the sample.

• Reliance on self-reported data through questionnaires may introduce response bias, affecting the accuracy of the reported KAP related to oral health.

• The study’s focus on a specific geographic location (Ningbo City) may restrict the generalisability of the findings to broader populations, necessitating caution when extrapolating the results to other settings.

Introduction

Oral health is the absence of various detrimental conditions of the stomatognathic system, such as periodontal diseases, dental caries, oral or throat cancer and other impairments that hinder essential oral functions.¹ Inadequate oral hygiene habits have been directly linked to an increased risk of developing chronic oral diseases.² In particular, dental caries is influenced by various risk factors such as unhealthy dietary patterns, inadequate tooth brushing practices and the level of oral hygiene knowledge among children, parents and teachers.3,5 A recent study reported a 60% prevalence of dental caries among 12-year-old children, with a mean decayed, filled and missing teeth (DFMT) index of 1.846.⁶ Moreover, the treatment requirement for 6-year-olds has reached 76.28%, highlighting the persisting concern for dental caries prevention.⁶

Oral health behaviours, beliefs and attitudes formed during childhood offer an instrument for enhancing oral health in children and adolescents.⁷ Given the limited autonomy and control children have over their behaviours in home and school environments,⁸ parents and teachers play a pivotal role in shaping young children’s health practices.^{9 10} Notably, observations indicate that children whose parents possess a higher level of oral health knowledge and adopt appropriate practices tend to exhibit improved DMFT scores.¹¹ A recent cross-sectional study that included families with children aged 5–7 in Hong Kong reported a direct effect of mothers’ oral health behaviour (tooth brushing frequency, use of dental floss and regular dental visits) on their children’s oral health.¹² Another study, conducted among intermediate schoolchildren in Saudi Arabia, confirmed that oral health practices in children are notably influenced by adults’ beliefs and attitudes towards dental health.¹³

The knowledge, attitude and practice (KAP) research methodology is widely employed to assess a specific target population’s perceptions regarding a particular topic.¹⁴ The KAP questionnaires are commonly used to probe the mechanisms of health education.^{15 16} For instance, studies investigating dental KAP proposed several educational solutions for healthy adults,^{17 18} pregnant women¹⁹ or care-dependent residents of nursing homes.²⁰ Oral health promotion based on the KAP methodology could facilitate the identification of potential misconceptions, barriers and avenues for behavioural change, lowering the social and financial burden of dental care and treatment.²¹ With the increasing global interest in the topic, further research is required to investigate the associations between children’s oral health and the health beliefs of adults in their lives.²² Based on the above, this study aimed to explore the relationship between oral health and the KAP of parents and teachers of kindergarten students towards oral health.

Methods

Study design and participants

This cross-sectional study was carried out in Ningbo City from February 2023 to March 2023, involving parents and teachers of kindergarten students. The inclusion criteria for the parents were as follows: (1) parents of children attending the kindergarten, (2) parents with children capable of participating in the oral examination, (3) parents willing to partake in the study and provide written informed consent and (4) age >18 years. The exclusion criteria for the parents were as follows: (1) parents unable to complete the questionnaire survey, (2) parents with questionnaire completion time less than 100 s and (3) questionnaires containing outliers. The inclusion criteria for the teachers were as follows: (1) kindergarten teachers, (2) teachers willing to participate and provide written informed consent and (3) age >18 years. Their exclusion criteria were as follows: (1) teachers unable to complete the questionnaire survey, (2) questionnaires with a completion time of less than 100 s and (3) questionnaires containing outliers.

The study obtained ethical approval from the Ethics Committee of Ningbo N0. 2 Hospital (Approval number: SL-NBEY-KY-2022-146-01), and informed consent was obtained from all study participants.

Patient and public involvement

Neither parents nor teachers were involved in the planning of the study or the development of the questionnaire. However, before the study began, teachers were invited to participate in the tests to evaluate the reliability and internal consistency of the questionnaire and were encouraged to provide feedback. To improve engagement, direct phone communication and coordination with class teachers were employed. Additionally, parents received educational materials on oral health after completing the questionnaire. For those who expressed a desire to learn more about the study, detailed explanations were provided. Participants will also be informed of the study’s results following its publication.

Questionnaire and quality control

In accordance with the Oral Health Guidelines for Chinese Residents, two questionnaires (one for parents and another for teachers) were self-designed. The content validity of the questionnaires was assessed and refined with inputs from experts in disease control and paediatric dentistry, who worked with authors. The suitability for factor analysis was checked using the Kaiser–Meyer–Olkin test score (0.776) and confirmatory model fit analysis (root mean square error of approximation of 0.046, standardised root mean squared residual of 0.060, comparative fit index of 0.856 and Tucker–Lewis index of 0.838) – all indicating acceptable model fit for factor analysis. The parent questionnaire encompassed the following (online supplemental material, parent questionnaire): (1) demographic characteristics (age, sex, residence type, education, work status, income, etc.), (2) knowledge dimension (nine questions, scoring 1 point for correct answers and 0 for incorrect or unclear responses, with a total possible score range of 0–9), (3) attitudes (six questions, using a 5-point Likert scale, with a total possible score range of 6–30), (4) practices dimension (nine questions, employing a 5-point Likert scale where ‘strongly agree’ equals 5 and ‘strongly disagree’ equals 1; for questions 4 and 5–9, where ‘strongly agree’ equals one and ‘strongly disagree’ equals 5, yielding a total possible score range of 13–65) and (5) students’ daily oral hygiene habits (19 questions, with questions 5 and 11–19 using a 5-point Likert scale; other questions do not assign values). The teacher questionnaire (online supplemental material, teacher questionnaire) included (1) demographic characteristics (age, sex, residence type, education, work experience, etc.), (2) knowledge dimension (10 questions, scoring 1 point for correct answers and 0 for incorrect or unclear responses, with a total possible score range of 0–10), (3) practices dimension (nine questions, with questions 2–9 using a 5-point Likert scale, and no score for question 1, resulting in a total possible score range of 8–40) and (4) students’ oral hygiene habits in kindergarten (eight questions, where questions 4–8 used a 5-point Likert scale; question 1 scored 5 points for ‘yes’ and 0 points for ‘no’; question 2 scored 5 points for more than two times, 3 for one time and 1 for none; question 3 scored 5 points for one time, 3 for 2–3 times and 1 for more than three times, yielding a total possible score range of 8–40). Higher scores indicated better knowledge, more positive attitudes and more proactive practices. The research team reviewed all questionnaires for coherence and completeness.

Dental caries diagnostic criteria adhered to WHO standards, identifying symptoms such as changes in tooth colour, shape and texture, softening of dental groove lesion bases, enamel or wall softening and a ‘sticky feeling’ when probed.

Questionnaire distribution and validation

An online questionnaire was developed using the WeChat-based Questionnaire Star applet, ensuring mandatory completion and single submission per IP address (all data were coded to protect participants’ survey anonymity and confidentiality).

A convenience sample of kindergartens in Jiangbei, Haishu and Yinzhou districts of Ningbo City was selected. Of the approximately 200 kindergartens in the area, 20 were contacted, primarily based on their accessibility and initial responsiveness. Prior to the study’s commencement, several kindergartens were contacted, and all five kindergartens that were willing to cooperate with the study were included. All teachers received the questionnaires, and all parents who satisfied the inclusion criteria received survey questionnaires through their homeroom teacher. To enhance participation, direct phone contact and coordination through class teachers were implemented. A preliminary test (101 responses) yielded Cronbach’s α of 0.732, indicating strong internal consistency.

Sample size calculations (post-study)

The authors initially aimed to collect as many responses as possible without a predetermined sample size. However, a post-study sample size calculation based on item–respondent theory, using a respondent-to-item ratio of 1:5 to 1:20 for the 39-item questionnaire, determined that a sufficient sample size would range from 196 to 780 participants. With 540 respondents included, the study fell within this range, ensuring methodological rigour, statistical reliability and transparency in validating the adequacy of the sample size.

Statistical analysis

The statistical analysis was performed using Stata 17.0 (Stata Corporation, College Station, TX, USA). Quantitative indicators were presented as mean±SD, and group comparisons used t-tests or ANOVA. Categorical indicators were presented as n (%). Structural equation modelling (SEM) was applied to test the hypotheses: (1) direct impact of parents’ knowledge on attitudes and practices, (2) direct influence of parents’ attitudes on practices, (3) effect of parents’ practices on students’ daily oral hygiene habits, (4) relationship between teachers’ knowledge and teachers’ practices, along with students’ oral hygiene habits during kindergarten, and (5) direct influences of students’ daily oral hygiene habits and oral hygiene habits during kindergarten on students’ dental status (decay–missing score (total number of dental caries, missing teeth and fillings), parental KAP scores, daily habit score, teacher knowledge and practice score and child habit score were used as variables). The Bonferroni correction was applied to adjust for multiple comparisons. All statistical tests were two-sided, with p values<0.05 considered indicative of significant differences.

Results

Demographic characteristics and knowledge, attitudes and practices of parents

The questionnaire was distributed among 840 parents, and 694 responses were collected, yielding a response rate of 82.6%. Out of the questionnaires returned, 124 were excluded due to mismatches, 12 due to outliers, 10 due to missing values and eight due to duplicate names. This resulted in 540 valid questionnaires, yielding a validity rate of 77.8% (valid responses: 64.3% of total invited; online supplemental figure 1). The demographic characteristics are presented in table 1. In terms of caregivers involved in the child’s daily life, a substantial majority (n=511, 94.63%) were the child’s parents, with additional involvement from grandparents (n=239, 44.26%) and maternal grandparents (n=140, 25.93%). Notably, educational levels of both the child’s father and mother varied significantly, with categories including primary school and below, middle school, high school/technical secondary school and junior college/undergraduate. The work status of the child’s father included enterprise employees (n=276, 51.11%), individuals (n=115, 21.3%) and others (n=149, 27.59%). Similarly, the work status of the child’s mother comprised enterprise employees (n=254, 47.04%), individuals (n=71, 13.15%) and others (n=215, 39.81%). By sex distribution, 89 (16.48%) were male, and 451 (83.52%) were female. The mean age of the participants was 35.73±4.70 years. Residence varied across rural (n=172, 31.85%), urban (n=260, 48.15%) and suburban (n=108, 20%) categories. Dental caries status indicated no dental caries in 281 (52.04%) participants, dental caries treated in 190 (35.19%) and untreated dental caries or multiple tooth extractions in 69 (12.78%). Child medical insurance types included New Rural Cooperative Medical Insurance (n=126, 23.33%), basic medical insurance for urban residents (n=408, 75.56%), commercial insurance (n=69, 12.78%) and no insurance (n=19, 3.52%). Lastly, regarding the family members’ regular smoking around the child in the last 5 years, 117 (21.67%) had exposure, and 423 (78.33%) had no exposure. The KAP dimensions of the parents are provided in online supplemental table 2. In terms of knowledge, parents demonstrated high awareness, with correctness rates ranging from 60.56% to 98.15%. Attitude responses indicated concern for oral health, notably perceiving the harm of smoking (55.19%) and acknowledging the importance of treating decay in milk teeth (44.81%). Practices revealed positive oral hygiene behaviours, such as regular tooth brushing (66.85%) and timely toothbrush renewal (52.04%). However, certain practices like kissing the child mouth-to-mouth (52.04%) and using adult chopsticks to feed the child (94.63%) might pose potential risks.

Table 1. Demographic characteristics and KAP of parents.

n=540	N (%)	Knowledge score		Attitude score		Practice score
		Mean±SD	P	Mean±SD	P	Mean±SD	P
Total		7.29±1.74		23.69±2.97		51.92±4.76
Child’s sex			0.161		0.175		0.324
Male	268 (49.63)	7.36±1.81		23.48±3.10		51.70±4.69
Female	272 (50.37)	7.23±1.66		23.89±2.82		52.13±4.82
Number of siblings			0.013		0.001		0.012
0	249 (46.11)	7.50±1.57		24.05±2.89		52.34±4.60
1	224 (41.48)	7.24±1.77		23.65±2.69		51.79±4.73
≥2	67 (12.41)	6.70±2.05		22.49±3.77		50.76±5.22
Who are the people in the family that look after the child’s daily life (multiple choice)
Child’s parents	511 (94.63)
Grandparents	239 (44.26)
Maternal grandparents	140 (25.93)
Others (relatives, babysitters, etc.)	15 (2.78)
Education of the child’s father			<0.001		0.001		0.201
Primary school and below	65 (12.04)	6.44±1.63		23.10±3.29		50.87±4.09
Middle school	126 (23.33)	7.04±1.72		23.08±3.00		51.89±4.93
High school/technical secondary school	333 (61.67)	7.51±1.67		24.02±2.71		52.10±4.82
Junior college/undergraduate	16 (2.96)	8.18±2.22		23.93±5.09		52.43±4.33
Education of the child’s mother			<0.001		<0.001		0.442
Primary school and below	65 (12.04)	6.23±1.72		23.35±3.26		51.04±4.72
Middle school	106 (19.63)	6.98±1.63		22.75±3.06		52.16±4.92
High school/technical secondary school	353 (65.37)	7.55±1.70		24.00±2.85		51.98±4.73
Junior college/undergraduate	16 (2.96)	7.93±1.18		24.43±2.25		52.43±4.33
Work status of the child’s father			0.864		0.031		0.888
Enterprise employees	276 (51.11)	7.30±1.62		23.95±2.77		51.83±4.91
Individuals	115 (21.3)	7.30±1.87		23.06±3.14		52.05±4.78
Others	149 (27.59)	7.26±1.84		23.69±3.12		51.97±4.47
Work status of the child’s mother			0.547		0.029		0.420
Enterprise employees	254 (47.04)	7.40±1.59		24.06±2.59		52.12±4.61
Individuals	71 (13.15)	6.98±2.11		22.97±3.50		52.12±5.09
Others	215 (39.81)	7.26±1.76		23.49±3.14		51.60±4.82
Sex			0.114		0.792		0.299
Male	89 (16.48)	7.12±1.65		23.93±3.49		51.33±5.32
Female	451 (83.52)	7.33±1.75		23.64±2.86		52.03±4.63
Age, years	35.73±4.70
Residence			0.001		0.008		0.009
Rural	172 (31.85)	7.20±1.73		23.39±3.11		51.68±4.95
Urban	260 (48.15)	7.51±1.70		24.12±2.74		52.46±4.68
Suburban	108 (20)	6.92±1.78		23.13±3.14		50.99±4.47
Dental caries			<0.001		0.076		0.002
No dental caries	281 (52.04)	6.90±1.84		23.67±3.28		52.22±4.58
Had dental caries but treated	190 (35.19)	7.85±1.37		23.96±2.50		52.26±4.66
Had untreated dental caries or had multiple tooth extractions	69 (12.78)	7.33±1.77		23±2.73		49.71±5.17
Child medical insurance type
New Rural Cooperative Medical Insurance	126 (23.33)
Basic medical insurance for urban residents	408 (75.56)
Commercial insurance	69 (12.78)
No	19 (3.52)
Whether the family members have smoked regularly (>5 min per day on average) when they were around the child during the last 5 years.			0.904		0.753		<0.001
Yes	117 (21.67)	7.32±1.66		23.61±2.98		49.89±4.91
No	423 (78.33)	7.28±1.76		23.71±2.97		52.47±4.56

KAP, knowledge, attitudes and practices.

Knowledge dimension of parents

Te mean knowledge score of parents was 7.29±1.74. Statistically significant findings included a correlation between knowledge scores and the number of siblings (p=0.013), educational levels of the child’s father (p<0.001) and mother (p<0.001) and residence (p=0.001). Specifically, as the number of siblings increased, there was a decline in knowledge scores. Parents’ higher educational levels were associated with high knowledge scores, and urban residence showed a positive effect on knowledge. Additionally, dental caries status showed a significant association with knowledge scores (p<0.001), with lower scores observed in participants with untreated dental caries or multiple tooth extractions.

Attitude dimension of parents

The mean attitude score was 23.69±2.97. Statistically significant associations were found with the number of siblings (p=0.001), educational levels of the child’s father (p=0.001) and work status of the child’s father (p=0.031). Participants with fewer siblings, higher educational levels of fathers and enterprise-employee fathers exhibited more positive attitudes.

Practice dimension of parents

The mean practice score was 51.92±4.76. Significant correlations were observed with the number of siblings (p=0.012), educational levels of the child’s father (p=0.201) and mother (p=0.442), work status of the child’s father (p=0.888) and residence (p=0.009). As the number of siblings increased, practice scores declined, and parents’ higher educational levels were associated with more proactive practices. Urban residence exhibited a positive effect on practices. Importantly, dental caries status demonstrated a significant association with practice scores (p=0.002), with participants having untreated dental caries or multiple tooth extractions exhibiting lower scores. Additionally, family members’ regular smoking around the child significantly influenced the practice scores (p<0.001), with lower scores observed in families with regular smokers.

Oral hygiene and lifestyle habits of parents

Data on the oral hygiene and lifestyle habits of the parents are presented in table 2. A substantial majority of parents engaged in breastfeeding (75.00%) and bottle-feeding (68.15%) practices, with 10% reporting the bottle-feeding habit of biting down on a pacifier to sleep. Notably, over half of the parents (52.96%) indicated post-feeding oral cleaning practices using gauze or rinsing with water. Regarding tooth brushing habits, a significant proportion (76.67%) reported their children adopting this practice since the emergence of milk teeth, with an average starting age of 2.37±1.08 years among bottle-fed children. Preventive measures such as dental groove sealants (18.15%) and fluoride coating (31.85%) were reported. Fluoride toothpaste usage varied, with 24.07% always using it, whereas 8.15% never did. Parents’ involvement in assisting children with tooth brushing exhibited diverse patterns. The frequency and duration of tooth brushing practices showcased varied patterns, with 71.67% brushing for 1–3 min and 63.33%

Table 2. Oral hygiene and lifestyle habits of parents.

Items, n (%)
1. How the child is fed: (multiple choice)	Breast-feeding	Bottle-feeding
	405 (75.00)	368 (68.15)
1.1 If bottle-feeding, does the child have the habit of biting down on the pacifier to sleep?	Yes	No
	54 (10)	483 (89.44)
1.2 Is the mouth cleaned with gauze or rinsed with drinking water after feeding?	Yes	No
	286 (52.96)	254 (47.04)
2. Has your child had the habit of brushing his/her teeth since the milk teeth emerged?	414 (76.67)	126 (23.33)
2.1 Age at which the child started brushing, years old	2.37±1.08
3. Has your child received a dental groove sealant to prevent dental caries?	98 (18.15)	442 (81.85)
4. Has your child received any other preventive measures against dental caries such as fluoride coating?	172 (31.85)	368 (68.15)
5. How often does your child use fluoride toothpaste?	Always	Often	Sometimes	Rarely	Never
	130 (24.07)	138 (25.56)	127 (23.52)	101 (18.7)	44 (8.15)
6. Which of the following is closer to the situation where parents help children brush their teeth?	Parents help the child brush again after he/she has brushed	Parents help their child brush his/her teeth	Brush by himself /herself
	161 (29.81)	113 (20.93)	266 (49.26)
7. How long does it take your child to brush his or her teeth each time?	≥3 min	1–3 min	<1 min
	80 (14.81)	387 (71.67)	73 (13.52)
8. How long and how often does your child brush his or her teeth each day?	Three times a day or more	One time in the morning and one time in the evening	Only one time in the evening	Only one time in the morning
	13 (2.41)	342 (63.33)	119 (22.04)	66 (12.22)
9. What is your child’s brushing method?	Rotating	Vertical brushing	Horizontal brushing	No fixed method	No brushing
	61 (11.3)	88 (16.3)	99 (18.33)	290 (53.7)	2 (0.37)
10. Does your child drink an adequate amount of water every day?	Yes	No
	437 (80.93)	103 (19.07)
	Always	Often	Sometimes	Rarely	Never
11. How often does your child rinse or brush his or her teeth after a meal or a sweet treat?	51 (9.44)	88 (16.3)	175 (32.41)	196 (36.3)	30 (5.56)
12. How often do you use floss to help your child remove the food lodged in the teeth?	47 (8.7)	47 (8.7)	117 (21.67)	175 (32.41)	154 (28.52)
13. In the past 12 months, how often has your child had a toothache or discomfort?	16 (2.96)	12 (2.22)	61 (11.3)	177 (32.78)	274 (50.74)
14. In the past 12 months, how often did you take your child for a dental check-up?	41 (7.59)	55 (10.19)	138 (25.56)	171 (31.67)	135 (25)
15. Does your child eat regularly and eat on his/her own without being picky about what he/she eats?	88 (16.3)	171 (31.67)	160 (29.63)	110 (20.37)	11 (2.04)
16. How often does your child eat before bedtime after brushing his/her teeth?	14 (2.59)	43 (7.96)	107 (19.81)	209 (38.7)	167 (30.93)
17. How often does your child sleep with food in his or her mouth?	10 (1.85)	9 (1.67)	15 (2.78)	64 (11.85)	442 (81.85)
18. Your child prefers fine grains (flour, rice, etc.) to coarse fibre grains.	52 (9.63)	115 (21.3)	197 (36.48)	132 (24.44)	44 (8.15)
19. How often does your child eat sweets (biscuits, desserts, candy, beverages, etc.) per day?	37 (6.85)	153 (28.33)	235 (43.52)	108 (20)	7 (1.3)

Demographic characteristics, knowledge and practices of teachers

All 130 teachers at the five kindergartens were invited to participate. A total of 83 questionnaires were completed on time (response rate, 63.8%); of the questionnaires returned, 9 were excluded due to missing data, resulting in 74 valid questionnaires (validity rate, 89.2%; valid responses, 56.9% of total invited; online supplemental figure 2).

Online supplemental table 1 outlines key demographic characteristics of the 74 teachers involved. Predominantly, the teaching cohort was composed of female teachers (91.43%), with an average age of 33.77 years. Most teachers reside in urban areas (62.86%), hold junior college or undergraduate degrees (91.43%) and have significant work experience, with 51.43% having 10 years or more. The majority work in public kindergartens (78.57%).

Knowledge and practice of teachers are provided in online supplemental table 3. Teachers displayed a commendable knowledge level, with correctness rates ranging from 85.71% to 98.57%, emphasising the preventive effects of fluoride-containing products and proper dental care practices. Practices revealed positive behaviours, such as regular dental check-ups (71.43%) and toothbrush renewal (55.71%). However, some teachers reported habits like frequent sweet consumption (45.71%) and inadequate use of oral irrigators (47.14%).

Oral hygiene habits of students

The examination of oral hygiene habits among students, as delineated in table 3, sheds light on critical aspects influencing their oral health. The majority of kindergarten students undergo daily oral health assessments during kindergarten check-ups (91.43%). Notably, kindergartens frequently incorporate oral health education into their curriculum, with 90% providing education more than two times a year. The frequency of snack consumption among students varied, with 70% eating snacks once a day, whereas 22.86% indulged more than three times a day. A substantial portion of students (62.86%) included dessert in their daily snacks, and 45.71% favoured fine grains over processed foods. Oral hygiene practices after meals demonstrated positive habits, as 67.14% of students rinsed their mouths or brushed their teeth after lunch. Additionally, a significant proportion maintained oral hygiene after consuming sticky snacks and desserts (60%). However, some students exhibited habits of eating before naptime (84.29%). These findings underscore the relevance of incorporating targeted oral health education interventions in kindergartens to reinforce positive oral hygiene practices among students.

Table 3. Oral hygiene habits of students.

Items, n (%)
1. Are children’s oral health conditions included in the daily kindergarten check-ups?	Yes	No
	64 (91.43)	6 (8.57)
2. How many times per year do kindergartens provide oral health education to children?	>2	1	0
	63 (90)	7 (10)	0 (0)
3. How many times a day do kindergarten students eat snacks?	1	2–3	＞3
	49 (70)	5 (7.14)	16 (22.86)
	Always	Often	Sometimes	Rarely	Never
4. Kindergarten students have dessert for their daily snack.	2 (2.86)	5 (7.14)	44 (62.86)	17 (24.29)	2 (2.86)
5. Kindergarten students eat more fine grains (flour, rice, etc.) than coarse processed foods.	6 (8.57)	14 (20)	32 (45.71)	14 (20)	4 (5.71)
6. Kindergarten students rinse their mouth/brush their teeth after lunch.	47 (67.14)	14 (20)	6 (8.57)	2 (2.86)	1 (1.43)
7. Kindergarten students rinse their mouth or brush their teeth after eating sticky snacks and desserts.	42 (60)	17 (24.29)	8 (11.43)	2 (2.86)	1 (1.43)
8. Kindergarten students will eat before naptime.	2 (2.86)	1 (1.43)	1 (1.43)	7 (10)	59 (84.29)

Structural equation modelling

The results of the pathway analysis and SEM are presented in table 4 and figure 1. Notably, the total effects (β) and their corresponding significance levels (P) reveal the comprehensive effect of each pathway. In the relationship between practice and attitude), there is a significant total effect (β=0.27, p<0.001), indicating a direct positive influence of attitude on practice. Similarly, the effect of knowledge on practice is substantial (β=0.51, p<0.001), with a significant direct effect (β=0.33, p=0.007) and an indirect effect (β=0.18, p<0.001) through attitude. The link between attitude and knowledge is robust (β=0.65, p<0.001), suggesting a significant positive association. Daily habits (DH) are influenced directly by practice (β=0.39, p<0.001) and indirectly by both attitude (β=0.10, p<0.001) and knowledge (β=0.20, p<0.001). The decay–missing teeth (DMT) are negatively affected by practice (β=−0.04, p<0.001), attitude (β=−0.01, p<0.001) and daily habits (β=−0.10, p=0.001) and positively influenced by child habits (β=0.19, p<0.001), tooth practice (β=0.02, p=0.001) and tooth knowledge (β=0.09, p=0.001). Furthermore, child habits are positively affected by tooth practice (β=0.13, p=0.001) and influenced by tooth knowledge (β=0.48, p<0.001) with direct (β=0.31, p=0.004) and indirect (β=0.17, p=0.002) effects. Finally, tooth practice is significantly influenced by tooth knowledge (β=1.26, p<0.001), highlighting the pivotal role of knowledge in shaping oral health practices.

Table 4. Results of the pathway analysis.

Model paths		Total effects		Direct effect		Indirect effect
		β (95% CI)	P	β (95% CI)	P	β (95% CI)	P
PPractice <-
	PAttitude	0.27 (0.13,0.41)	<0.001	0.27 (0.13,0.41)	<0.001	—	—
	PKnowledge	0.51 (0.28,0.74)	<0.001	0.33 (0.09,0.57)	0.007	0.18 (0.08,0.28)	<0.001
PAttitude <-
	PKnowledge	0.65 (0.51,0.78)	<0.001	0.65 (0.51,0.78)	<0.001	—	—
Daily_habits <-
	PPractice	0.39 (0.32,0.45)	<0.001	0.39 (0.32,0.45)	<0.001	—	—
	PAttitude	0.10 (0.05,0.16)	<0.001	—	—	0.10 (0.05,0.16)	<0.001
	PKnowledge	0.20 (0.10,0.29)	<0.001	—	—	0.20 (0.10,0.29)	<0.001
Decaymissing <-
	PPractice	−0.04 (−0.04, 0.03)	<0.001	—	—	−0.04 (−0.04, 0.03)	<0.001
	PAttitude	−0.01 (−0.01, 0.005)	<0.001	—	—	−0.01 (−0.01, 0.05)	<0.001
	Daily_habits	−0.10 (−0.16, 0.04)	0.001	−0.10 (−0.16, 0.04)	0.001	—	—
	Child_habits	0.19 (0.10,0.28)	<0.001	0.19 (0.10,0.28)	<0.001	—	—
	TPractice	0.02 (0.01,0.04)	0.001	—	—	0.02 (0.01,0.04)	0.001
	PKnowledge	−0.02 (−0.03, 0.005)	0.009	—	—	−0.02 (−0.03, 0.005)	0.009
	TKnowledge	0.09 (0.03,0.15)	0.001	—	—	0.09 (0.03,0.15)	0.001
Child_habits <-
	TPractice	0.13 (0.05,0.21)	0.001	0.13 (0.05,0.21)	0.001	—	—
	TKnowledge	0.48 (0.29,0.66)	<0.001	0.31 (0.10,0.52)	0.004	0.17 (0.06,0.27)	0.002
TPractice <-
	TKnowledge	1.26 (1.07,1.45)	<0.001	1.26 (1.07,1.45)	<0.001	—	—

Figure 1. Structural equation model for the relationship between knowledge, attitudes and practices.

Discussion

This study comprehensively assessed the KAP of the parents and teachers of kindergarten students regarding oral health. Parents generally possessed a solid knowledge base, maintained a moderately positive attitude and exhibited commendable practices towards oral health. Teachers demonstrated satisfactory knowledge and a positive attitude; however, their practices were less commendable. The study underscored the pivotal role of parents’ and teachers’ KAP in preventing oral disorders and provided valuable theoretical guidance for enhancing the oral health of kindergarten students.

The study’s findings revealed that parents with certain characteristics displayed notably higher knowledge scores. Specifically, parents with only one child, those with higher educational levels, urban residency and treated dental caries exhibited higher knowledge scores. An inverse correlation between the number of children in a family and parents’ KAP scores was observed, suggesting that parents with more children might potentially overlook the oral health in their offspring. Additionally, participants with higher educational levels tended to attain higher knowledge scores, possibly due to increased exposure to health-related information. The association between urban residency, higher income levels and high knowledge scores could be attributed to the prevalence of oral health promotion programmes in urban areas and greater access to dental check-ups facilitated by higher income.^{23 24} This aligns with the findings of the study by Tiwari et al conducted in India among 371 children with carious teeth that reported better oral health conditions in higher income regions.²⁴ This study also assessed participants’ dental health status, revealing a significant link between participants’ knowledge and their dental caries status. This implies that individuals with treated dental caries might pay more attention to oral health knowledge, suggesting that proactively seeking health-related information could contribute to improved oral health. However, relying on self-reported questionnaires to gather data on KAP can introduce response bias, particularly social desirability bias, where participants may exaggerate positive practices or attitudes. Although efforts were made to ensure the validity and reliability of the data collected, only a cautious interpretation of the findings is discussed.

In this study, parents with a junior college/undergraduate educational level were more likely to exhibit higher attitude scores, consistent with the results of a previous study that, based on 1019 data sets derived from several consumer quality index studies, highlighted a direct relationship between patients' educational levels and the importance they attach to healthcare.²⁵ Furthermore, both parents employed in enterprises demonstrated better attitudes towards oral health compared with those who were self-employed or engaged in other occupations. This suggests that individuals with a more stable income may demonstrate increased attention towards oral health matters. Moreover, respondents residing in urban areas exhibited higher attitude scores than those living in other regions. This trend could be attributed to the amplified promotion of oral health knowledge and the availability of convenient medical services in urban areas.

Parents with only child, living in urban areas, with treated dental caries and no family members smoking around the child demonstrated higher practice scores. According to a 2022 UK study, conducted among 848 mothers, parents with multiple children pay less attention to health than those with one child,²⁶ which is consistent with the findings of the present study: parents with fewer children could pay more attention to the oral health of a child, and the oral health-associated practices of themselves and their child might be improved. The findings are in line with those of knowledge and attitude found in the present study, indicating that the number of children could affect the KAP of parents towards oral health and that parents in China have not attached enough importance to oral health, especially for children. This is also consistent with the results of a previous study reporting that for parents of preschool children in China, oral health is only a secondary concern.²⁷ Similar to the results of knowledge and attitude, the results of the practice assessment showed that parents who lived in urban areas had higher practice scores, supporting the results of a previous study on 309 parents and caregivers of preschool children in central Trinidad, reporting a higher prevalence of oral disorders in economically disadvantaged areas.²⁸ Moreover, the score distribution showed that the practice scores were closely associated with the dental health status. In this study, parents who had dental caries and received treatment were more likely to have higher practice scores, in line with the results of a previous study, indicating that the awareness of tooth protection of those participants might have been raised after the onset or the treatment.²⁹ Therefore, in the present study, parents from rural areas who had more than one child and had not received treatment for dental caries may place less importance on oral health and would benefit from targeted education.

This study illuminated a generally high awareness and moderately positive disposition towards oral health among parents, indicating a solid foundation on which to build and improve oral health practices within the familial context. Despite this, certain practices that could inadvertently facilitate the transmission of oral pathogens, such as mouth-to-mouth contact and the sharing of utensils with children, were notably prevalent. This discrepancy points to a critical need for targeted educational programmes that specifically address these behaviours, emphasising their potential to harm children’s oral health. Additionally, the influence of socioeconomic variables, like the educational attainment of parents and the urban or rural context of their residence, on oral health KAP underscores the necessity for nuanced, contextually tailored oral health education and intervention strategies. These programmes should also tackle the issue of second-hand smoke and its detrimental effects on children’s oral health, advocating for smoke-free environments at home. In particular, incorporating oral health education into the curriculum, supported by evidence linking increased knowledge to better oral care habits, was shown to empower students and their parents to adopt lifelong healthy behaviours.^{3 30} Implementing supervised toothbrushing programmes in schools also demonstrated to be effective in significantly improving oral hygiene practices and reducing dental caries rates in children.³¹

In this regard, kindergarten serves as a crucial environment for promoting healthy eating habits and an active lifestyle.^{32 33} In this study, most kindergarten teachers demonstrated accurate knowledge, with correctness rates ranging from 85.71% to 98.57%. However, the individual-level response rates indicated a higher participation among parents than among teachers, suggesting potential differences in survey engagement, availability or interest between the two groups. In addition, the actual practice scores of teachers were generally lower. Merely 5.71% of teachers reported regular visits to a dental clinic at least once every 6 months or daily use of an oral irrigator. Additionally, only 12.86% of teachers engaged in daily flossing. Furthermore, high proportions of the teachers reported occasional or rare rinsing of their mouth or brushing their teeth after meals. Although the students in the kindergarten exhibited commendable oral hygiene habits, teachers must serve as role models and exemplify healthy habits for their students.³⁴ Our results revealed areas of concern, including children’s habits that could undermine oral health, such as frequent consumption of sweets and inadequate oral hygiene practices, notably the under-use of oral irrigators. These findings suggest that even among individuals with a good understanding of oral health, there is room for improvement in translating this knowledge into consistent, healthy practices. Thus, workshops for teachers should aim to bridge the gap between knowledge and practice, emphasising the importance of a balanced diet, comprehensive oral hygiene practices (including the effective use of oral irrigators), and the adoption of strategies to minimise sweet consumption. By equipping teachers with the knowledge and tools to model and teach these practices, they can significantly influence their students’ oral health behaviours.¹⁰ In addition, schools may host oral health campaigns that allow students directly engage with activities promoting healthy eating, highlight the importance of thorough oral hygiene following meals and present the risks associated with frequent snacking on sugary or sticky foods. Being interactive and educational, these campaigns can play a crucial role in shaping students’ oral health habits.

This study marks the initial endeavour to evaluate the oral health KAP of parents and kindergarten teachers. However, certain limitations should be acknowledged. First, the sample size was relatively small, warranting the inclusion of larger sample sizes for future research. Additionally, a sample size calculation was not conducted before the study commenced, as the goal was to gather as many completed questionnaires as possible. Although a post-study calculation based on item–response theory indicated that the number of respondents was sufficient, the absence of pre-study sample size estimation could be considered a limitation. Second, kindergartens were selected based on accessibility and willingness to participate, which, along with the comparatively low response rate among contacted kindergartens (25%), may have introduced selection bias. While some kindergartens declined participation, the specific reasons – such as privacy concerns and time constraints – were not formally assessed and remain speculative. Additionally, as only five out of approximately 200 kindergartens in Ningbo participated, the generalisability of the findings to other schools in the region may be limited, despite the statistically justified sample size and internally validated analyses. Third, the test–retest reliability of the questionnaire was not assessed, which might prevent the evaluation of the questionnaire’s stability over time. Future research should include repeated measurements to ensure the consistency of responses and enhance the reliability of the findings. Finally, the reliance on self-reported questionnaires for collecting data on KAP introduces the potential for response bias, including social desirability bias, where participants may over-report positive practices or attitudes. Taking into consideration limitations that influence the clarity and interpretation of the study’s findings, future studies should aim to recruit a broader sample of schools to improve external validity and ensure greater generalisability.

Conclusions

This study assessed the KAP of parents and teachers regarding oral health. While the parents and teachers of kindergarten children displayed reasonable oral health knowledge and positive attitudes towards preventive oral healthcare, there remains room for improvement in their oral health practices. The findings underscore the importance of fostering healthy lifestyles as a preventive measure against oral disorders. Both educational institutions and households play pivotal roles in transitioning unhealthy oral habits to healthier ones among children. These insights should guide the development of targeted and effective health promotion programmes aimed at enhancing oral health and promoting broader behavioural changes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.