Mother’s Perceived Social Support and Children’s Dental Caries in Northern Appalachia

Abstract

Purpose.

We examined whether perceived social support among mothers with high levels of dental caries was associated with her child experiencing high levels of dental caries.

Methods.

In West Virginia and Pennsylvania from 2002–2009, we interviewed mothers and conducted clinical exams on their children aged 1 to 6 years. We analyzed 250 mother-child dyads where the mother had high dental caries. Mothers reported perceived social support across four domains (appraisal, tangible, self-esteem, belonging) from the Interpersonal Support Evaluation List instrument (ISEL), with higher scores representing greater support. We examined the association between each social support domain and the probability of high child dental caries.

Results.

27% of children (67/250) had high dental caries, and the odds of children having high caries was lower by 7% for every one point increase in the ISEL appraisal score (OR=0.93; 95% CI=0.88, 0.99). Tangible, self-esteem and belonging social support ISEL sub-scales were not significantly associated with high child dental caries (P>0.05).

Conclusions.

Among mothers with high dental caries, there is modest evidence that appraisal support – the perceived availability of someone to talk to about problems – is associated with a lower odds of their children having high dental caries.

INTRODUCTION

Social support is defined as the perceived support that an individual can draw upon to cope with daily problems.¹ It is a sense of confidence that a person possesses to ask others for help with everyday challenges. The prevention of dental caries, the most common chronic disease in childhood, requires daily maintenance by caregivers, and therefore may be dependent on caregivers’ social support. For example, brushing a young child’s teeth can be challenging for caregivers.² Therefore, caregivers may construe tooth-brushing as a daily problem for which the caregiver needs social support to cope. Social support is one of many social processes within the umbrella term of social capital, which is “the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance or recognition.”³

Overall, the findings related to the association between caregiver social support and child oral health outcomes are conflicting. While there is evidence that caregiver social support is associated with positive oral health outcomes in children,^4–9 the relationship is not consistent across the literature.^{10, 11}

With regards to a positive relationship between caregiver social support and child oral health outcomes, Latina immigrant mothers with social support, particularly related to material, and emotional aid , used more dental services for their children.^5,3 High neighborhood social capital is associated with improved child oral health status⁷ and decreased odds of adolescent dental trauma.¹² Similarly, indicators of high social capital, such as church attendance and community empowerment are associated with decreased gingival bleeding⁸ and a decreased likelihood of high DMFT rates among adolescents.¹² Conversely, children of mothers with low social capital have a decreased likelihood of preventive dental visits and an increased likelihood of unmet dental needs.⁴ Kruger and colleagues also found that mothers with low neighborhood social capital had increased odds of having no child dental visits in the past year.⁶

On the other hand, there is literature to the contrary, describing that the relationship between caregiver social support and child oral health outcomes is not always beneficial.^10,11 In a study performed by Qui and colleagues, caregiver social support was not associated with child sugary snack consumption, child tooth-brushing frequency or child dental use.¹¹ When the literature is expanded to adults, there is evidence that “adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care.”¹⁰

To add clarity to our current understanding of the relationship between caregiver social support and their children’s dental caries experience, we sought to examine the association between caregiver social support and child oral health outcomes under two conditions that would highlight the role of social support: 1) In the setting of Northern Appalachia, where mothers may have strong social ties^{13, 14} but experience significant barriers to promoting optimal child oral health, such as low socio-economic status, private non-fluoridated water supplies, cariogenic dietary practices and poor access to dental services;¹⁵ and 2) among mothers with a high level of dental caries, because there is evidence of vertical transmission of dental caries between mothers and their children^{16, 17} and that mothers’ behaviors can prevent this vertical transmission in young children.^{18, 19}

We examined whether perceived social support among mothers with high levels of dental caries was associated with her child also experiencing high levels of dental caries. We hypothesized that mothers with higher perceived social support would have significantly lower odds of her children having high dental caries. As a specific example, we hypothesized that tangible aid, such as healthy foods and transportation to dental appointments, would have a positive impact on child dental caries, particularly in the setting of Northern Appalachia, where mothers face numerous obstacles to accessing healthy foods and child dental services.

METHODS

Data Sample

We used data from the Center for Oral Health Research in Appalachia (COHRA), particularly the COHRA1 study, a cross-sectional investigation undertaken to explore the contributing factors for oral diseases in children in Northern Appalachia. The COHRA1 study was conducted in West Virginia and Pennsylvania from 2002–2009. Families were recruited in two central West Virginia counties (Webster and Nicholas) and three western Pennsylvania counties (Washington, McKean, Allegheny). These sites were selected because they were representative of rural and urban Appalachia and had the infrastructure necessary to support this study, including active community advisory boards and established ties to either the University of Pittsburgh or West Virginia University. Participants were recruited by radio and newspaper announcements and flyers distributed at community sites as described in a previous publication.²⁰ Trained interviewers administered structured in-person interviews with caregivers and conducted clinical exams on both the caregivers and the children. This study was approved by the Institutional Review Boards at the University of Pittsburgh and West Virginia University, and informed consent was obtained from all participants.

We limited our analytic sample to mother-child dyads where the child was under 6 years-old and the mother had high levels of dental caries, defined as greater than the 75^th percentile of DMFT by age category according to the 2003–2004 National Health and Nutrition Examination Survey (NHANES). Our final analytic sample was comprised of 250 mother-child dyads.

Measures

We developed a definition of high dental caries experience as greater than the 75^th percentile of DMFT/dft by age category according to the 2003–2004 NHANES. In the absence of a valid and reliable cutoff for “high” dental caries in the literature that could be applied to our study population, we created an age-adjusted definition of high dental caries a priori based on a national dataset, NHANES, that could be applied to both the mother and the child. Additional benefits of using a national dataset as the benchmark for high dental caries are that it is based on a larger sample and is generalizable to the country as a whole. Using this approach, we defined “high” dental caries as greater than the level of caries that 75% of the population experience in each age category as determined using calibrated clinical exams from NHANES. This 75th percentile cut off for high dental caries was a dft of 1 for all of the children in the sample, which range from age 1 through 5. The 75th percentile cut off for high dental caries in mothers was a DMFT of 6 for ages 18 to 22, DMFT of 8 for ages 23–27, DMFT of 10 for ages 28 to 32, DMFT of 11 for ages 33 to 37 and DMFT of 15 for ages 38 to 42. Using this definition of high dental caries, we created our study sample by only including mothers with high dental caries. Furthermore, we created a binary main dependent variable in this study from this definition of high dental caries: children with high dental caries versus children without high dental caries.

The independent variable, mother’s perceived social support, was measured using Interpersonal Support Evaluation List (ISEL), which was the predominant social support measure at the time of the study design.^{21, 22} The purpose of the ISEL is to assess respondents’ overall measure of perceived support as well as the perceived availability of the following four separate functions of social support: 1) Appraisal Support – someone to discuss issues of personal importance; 2) Tangible Support –material aid; 3) Belonging Support – others to interact with socially; and 4) Self-Esteem Support – others with whom one compares favorably (Table 3). Each of the four domains is a theoretically-derived subscale that measures conceptually distinct dimensions thought to buffer the effects of stressful events. The ISEL has strong psychometric properties, both as a summary score and by individual domains.^{21, 22}

Table 3.

The Four Domains of the Interpersonal Support Evaluation List (ISEL) Instrument used to Measure Mother’s Perceived Social Support in the Center for Oral Health Research in Appalachia Study.

ISEL Domain	Description	Example Question
Appraisal	Discuss Issues	“There are several people that I trust to help solve mv problems.”
Belonging	Social Interaction	“When I feel lonelv, there are several people I can talk to”
Tangible	Material Aid	“If I needed help fixing an appliance or repairing mv car, there is someone who would help me.”
Self-Esteem	Positive Self-comparisons	“Most of mv friends are more interesting than I am.” “There is someone who takes pride in mv accomplishments.”

Each of the four ISEL domains is comprised of 10 questions, resulting in a 40-items total. Items are rated on a 4-point scale (definitely true, probably true, probably false, and definitely false) and scored from zero to three. Therefore, each domain was scored on a 30-point scale with higher scores representing more perceived social support.

Data Analyses

Descriptive statistics and graphics were used to explore the proportion of high dental caries among mothers and children as well as the distribution of ISEL score by each of the four ISEL domains. We examined the association between each of the four ISEL social support domains (appraisal, tangible, belonging, self-esteem) and the probability of high child dental caries using four separate logistic regression models. We controlled for clustering of dyads within families (n=128) using generalized estimating equations. All analyses were conducted using STATA 15 (StataCorp, College Station, TX).

RESULTS

The sociodemographic characteristics of our analytic sample (N=250) are presented in Table 1 corresponding to the main outcome, high child dental caries. Among mothers with high dental caries, 27% of children (67/250) had high dental caries (Table 1). Children with high dental caries were older compared to children who did not have high dental caries (mean age 3.7 vs 2.3 years) (p<0.01) (Table 1). A higher percentage of children with high dental caries were insured by Medicaid or the Children’s Health Insurance Program (87% vs. 66%) (p<0.01) (Table 1).

Table 1.

Child Characteristics of the Center for Oral Health Research in Appalachia Study Population Among Mothers with High^∞ Dental Caries, by High and Not High Child Dental Caries Groups (N=250).

Characteristic	High Child Dental Caries (n=67)	Not High Child Dental Caries (n=183)	p-value†
Age (months) [mean, SD (range)]	3.7 ± 1.1	2.3 ± 1.4	<0.01
Male	52.2%	49.7%	0.72
Race and ethnicity
White	86.6%	90.2%	0.60
Non-White	11.9%	9.8%
Missing	1.5%	0.0%
Enrolled in Medicaid or CHIP Insurance	86.6%	66.1%	<0.01

N=number of subjects in stratum, SD=standard deviation.

^∞High dental caries was defined as greater than the 75^th percentile of DMFT (mother) or dft (child) by age category according to the 2003–2004 National Health and Nutrition Examination Survey.

^†The p-values are for chi-square tests or t-tests comparing high child dental caries and not high child dental caries groups.

In our descriptive findings, the mean ISEL appraisal score was 20 for children with high dental caries, compared to 22.5 for children who did not have high dental caries (p<0.05) (Figure 1). There was no difference in the mother’s ISEL domain scores for belonging, tangible and self-esteem social support between children with and without high dental caries (p>0.05) (Figure 1).

Figure 1.

Bar Chart of Mother’s Social Support by High Dental Caries in the Child, Among the Mothers with High Dental Caries in the Center for Oral Health Research in Appalachia Study (N=250). *p<0.05. Note: Mother’s Social Support was measured using the Interpersonal Support Evaluation List Score, which has four individual domains (appraisal, tangible, belonging, self-esteem) scored on a 30-point scale with higher scores representing more perceived social support.

In our logistic regression accounting for family clusters, the odds of children having high caries decreased as the mother’s ISEL appraisal social support increased (OR= 0.93; 95% CI = 0.88, 0.99) (p=0.03) (Table 2). The odds of children having high caries was lower by 7% for every one-point increase in ISEL appraisal score. In contrast, there was no significant relationship between mother’s ISEL belonging, tangible or self-esteem social support scores and the odds of her child having high dental caries (Table 2).

Table 2.

Estimated Odds Ratios for Mother’s Social Support Domains^† on the Presence of High Dental Caries in her Child using Separate Logistic Regressions^‡ in the Center for Oral Health Research in Appalachia Study (N=250)

Social Support Domain	OR (95% CI)	p-value
Appraisal	0.93* (0.88, 0.99)	0.03
Belonging	0.97 (0.92, 1.03)	0.30
Tangible	0.95 (0.89, 1.01)	0.09
Self-esteem	0.99 (0.92, 1.07)	0.92

OR=odds ratio, CI=confidence interval

^†Mother’s perceived availability of social support was measured using the Interpersonal Support Evaluation List, which is comprised of the following four 10-item domains: Appraisal, Belonging, Tangible and Self-esteem.

^‡The four separate logistic regression models accounted for clustering by family (n=128) and did not adjust for covariates.

DISCUSSION

This study was the first to examine the relationship between mothers’ social support and childrens’ dental caries in Northern Appalachia, a region with high risk of vertical transmission of dental caries, strong social ties and poor access to resources.^13–15 More specifically, this study tested the association between four types of social support (appraisal, tangible, belonging, self-esteem) and high dental caries in children among a subpopulation of mother-child dyads where the mothers had high dental caries. We found modest evidence that appraisal support – the perceived availability of someone to talk to about problems – was associated with lower odds of children having high dental caries among mothers with high levels of dental caries unlike tangible (material aid), belonging (social interaction), and self-esteem (compare favorably to others) support.

This result contrary to our hypothesis that all four types of social support would be associated with a lower odds of having high child dental caries. It should be noted that although three of the four domains for social support were not significant, all four point estimates were below one. This points toward social support being associated with decreased odds of high child dental caries, albeit with weak or very weak evidence for three of the four domains.

Our findings suggest that there are problems for which mothers need support. This is consistent with previous literature that caregivers find brushing a young child’s teeth to be challenging.² Our results suggest that children’s dental caries levels may be decreased by providing a way for families to comfortably express their problems with daily oral health activities, such as frustration with brushing a child’s teeth.

Our results also imply that mothers in Northern Appalachia may be able to cope with challenges to taking care of their child’s oral health, such as tangible resources, if they have a trusted relationship within which they can express their problems. Appraisal social support may be particularly important because the mothers’ trusted relationships may be the central context for gathering information and accessing resources to support her child’s oral health. For example, mothers who have someone to talk to about problems may then receive more information from social connections about different ways to brush a child’s teeth in return. Mothers with appraisal support may also be more likely to have social connections that would direct them to resources, like the internet or oral education events, to make daily child oral health activities less challenging.

It is possible that appraisal support may take a complex pathway to have an impact on children’s oral health, working in concert with other family- and neighborhood-level social processes to impact a child’s oral health behaviors and thereby a child’s oral health outcomes. The need for appraisal social support may diminish if systemic barriers to promoting children’s oral health in Northern Appalachia were addressed. Further research is needed to determine why appraisal support is unique and whether the association found in this study is causal using a comprehensive examination of individual, family and neighborhood social determinants of child oral health using a longitudinal design.

Our results suggest directions for future research related to possible social support interventions. For example, it is possible that oral health providers could foster a relationship in which families can comfortably express their feelings about the difficulties of taking care of their child’s oral health, thereby creating the opportunity for providers to provide appraisal support. Oral health providers could tell families that taking care of a child’s oral health can be very challenging; and that it is normal to talk about the difficulties related to taking care of a child’s teeth and mouth, like daily tooth brushing, with them as well as their friends and family. Additionally, friends and family members of mothers in Northern Appalachia might provide more support if they were fully aware of the importance of the perceived ability to talk about challenges, whether those challenges were or were not related to child’s oral health. Future research can both identify people that mothers reach out to when they encounter challenges in taking care of their child’s oral health and also identify the types of responses that mothers find helpful when they seek appraisal support. An intervention could be designed to have those social connections provide appraisal support using the phrases that mothers find helpful and test whether the children have decreased rates of dental caries.

Our finding was consistent with some of the results from previous research. Nahouraii and colleagues found a positive association between mother’s social support, including emotional aid, and child’s dental utilization.⁵ Reynolds and colleagues examined the impact of the broader construct of social capital and found a positive association with improved parent-reported child oral health status.⁷ While these studies depict similar results, neither examined the relationship between mother’s social support and the ultimate child oral health outcome determined by clinical exam and used in this study: child dental caries experience.

Additionally, we used an independent variable that had strong psychometric properties and was designed to decipher the specific type of social support that could impact child dental caries, thereby adding clarity to the mixed results found in the previous research. There is a possibility that the ‘transmission’ of high dental caries between generations could potentially be broken by intervening specifically on mother’s appraisal support versus other types of social support.

This study should be interpreted in the context of its limitations. First, the study’s cross-sectional design prevented us from determining whether social support was causally related to lower dental caries experience in children. Second, due to the sample size of 250 mother-child dyads, our analysis was limited to adjusting for the high number of family clusters (n=128) and not additional potential confounders on the individual, family and community level. Third, our main outcome variable was defined using the NHANES age categories, which spanned several years but nonetheless provided an age-adjusted definition of high dental caries. Fourth, our main independent variable was a social support scale that was not specific to oral health. Finally, the study may have limited generalizability beyond Northern Appalachia. Despite the limitations of this study, we found a decreased odds of high dental caries in children if the mother had appraisal support.

Our findings add to the growing body of literature on the importance of addressing social determinants of oral health in general, and social support for oral health in particular. The results of this research can help to guide stakeholders to determine how to improve children’s oral health for the most vulnerable mothers and children with limited personal resources. In combination with the literature on social support and child oral health outcomes, the results of our study promote bottom-up efforts in changing children’s oral health status in a population with persistently high dental caries.

Based on this study’s results, the following conclusions can be made:

1. Among mothers with high dental caries in Northern Appalachia, there is modest evidence that appraisal support is associated with a lower odds of her child having high dental caries.

2. Further research is needed to understand why the association between mothers’ appraisal support is distinct from other types of social support – such as tangible, belonging and self-esteem support – on child dental caries.

3. Further research is needed to determine if interventions aimed at increasing mother’s appraisal support are associated with improved child oral health outcomes.