See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/286637583

Influence of children’s oral health promotion on parents’ behaviours,

attitudes and knowledge

Article  in  Acta odontologica Scandinavica · December 2015

DOI: 10.3109/00016357.2015.1122836

CITATIONS READS

9 148

5 authors, including:

Mimmi Tolvanen Vuokko Anna-Marketta Anttonen

University of Oulu University of Oulu
127 PUBLICATIONS   2,460 CITATIONS    115 PUBLICATIONS   1,323 CITATIONS   

SEE PROFILE SEE PROFILE

Satu Lahti
University of Turku
163 PUBLICATIONS   3,990 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Oral health promotion View project

School Oral Health Project Nepal View project

All content following this page was uploaded by Vuokko Anna-Marketta Anttonen on 04 March 2019.

The user has requested enhancement of the downloaded file.

 Acta Odontologica Scandinavica

ISSN: 0001-6357 (Print) 1502-3850 (Online) Journal homepage: https://www.tandfonline.com/loi/iode20

Influence of children’s oral health promotion on

parents’ behaviours, attitudes and knowledge

Mimmi Tolvanen, Vuokko Anttonen, Marja-Leena Mattila, Hannu Hausen &

Satu Lahti

To cite this article: Mimmi Tolvanen, Vuokko Anttonen, Marja-Leena Mattila, Hannu
Hausen & Satu Lahti (2016) Influence of children’s oral health promotion on parents’
behaviours, attitudes and knowledge, Acta Odontologica Scandinavica, 74:5, 321-327, DOI:
10.3109/00016357.2015.1122836

To link to this article: https://doi.org/10.3109/00016357.2015.1122836

Published online: 11 Dec 2015.

Submit your article to this journal

Article views: 438

View Crossmark data

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=iode20
ACTA ODONTOLOGICA SCANDINAVICA, 2016
VOL. 74, NO. 5, 321–327
http://dx.doi.org/10.3109/00016357.2015.1122836

ORIGINAL ARTICLE

Influence of children’s oral health promotion on parents’ behaviours, attitudes

and knowledge
MIMMI TOLVANENa,b, VUOKKO ANTTONENc, MARJA-LEENA MATTILAd,e, HANNU HAUSENf,g, and SATU LAHTIa
a
Department of Community Dentistry, Institute of Dentistry, University of Turku, Turku, Finland; bFinnBrain Study Group, Department of
Psychiatry and Turku Brain and Mind Center, University of Turku, Turku, Finland; cDepartment of Pedodontics, Cariology and Endodontology,
Institute of Dentistry, University of Oulu, Oulu, Finland; dCity of Turku Welfare Division, Public Dental Health Care Clinic, Turku, Finland;
e
Department of Public Health, University of Turku, Turku, Finland; fFinnish Dental Association, Helsinki, Finland; gInstitute of Dentistry, University
of Oulu, Oulu, Finland

ABSTRACT ARTICLE HISTORY

Objective The aim was to compare the changes in parents’ oral health-related behaviour, Received 18 May 2015
knowledge and attitudes in 2001–2003 and 2003–2005, during a 3.4-year-intervention in Pori and in Revised 16 November 2015
the reference area Rauma, Finland. Materials and methods The study population consisted of Accepted 17 November 2015
parents of children who participated in the oral health promotion programme in Pori (all 5th and Published online
6th graders who started the 2001–2002 school year in the town of Pori, n ¼ 1691) and the parents 9 December 2015
of same-aged children in a reference town (n ¼ 807). In 2001–2003, the promotion was targeted KEYWORDS
only to the children in Pori. In 2003–2005, the promotion was targeted also to parents, for example Behaviour; change; children;
via local mass media. The statistical significances of the differences in parents’ self-reported oral health; parents
behaviour, knowledge and attitudes, and changes in these, were evaluated using Mann-Whitney
U-tests and confidence intervals. Results In 2001–2003, the trend in changing behaviours was in
favour of parents in Pori. Mothers in Pori also improved their knowledge and the attitude
‘importance of brushing for health and appearance’. In 2003–2005, the trend in changing
behaviours was rather similar in both towns, which may be due to diffusion of the oral health
intervention to Rauma via the media. Conclusions The results suggest that health promotion
targeted to children, which in previous studies has been shown to be successful in improving
children’s behaviours, also helped their parents in mending their habits.

Introduction The aim of this study was to compare the changes in

Children’s health-related behaviours are influenced by those of
their parents.[1–7] Also children may have active participation
in their family’s health, such as willingness to contribute, and
manage their and their family members’ health and well-
being.[8,9] However, there is very limited knowledge on if and
how children’s behaviours transfer to their parents. It has been
reported that health education activities that children learnt in
school influenced parents’ self-management behaviour of
asthma.[10] Pre-school children were also able to transmit
oral health-related knowledge acquired at school to their
parents and that included a change in oral health routine of
their family members.[11]
In 2001  2005 in Pori, Finland, a 3.4-year community-level
programme of oral health promotion (OHP) using a multi-level
approach was targeted to all children who were 11–12 years
old at the beginning of the study and to the people involved in
their lives. Children exposed to the OHP improved their
behaviours during the follow-up more than children in a
neighbouring town where the children were not exposed to
any specific intervention.[12]
parents’ oral health-related behaviour, knowledge, and atti-
tudes in Pori and in the reference area Rauma in 2001–2003
and 2003–2005. In Pori, the OHP was targeted only to children
in 2001–2003, and also to parents in 2003–2005. We also
wanted to evaluate if the factor structure of attitudes related to
oral health and hygiene among parents was similar to that
among their children.
Materials and methods
The study population consisted of parents of children who
participated in the 3.4-year community level programme of
oral health promotion (OHP) in Pori (n ¼ 1691) and parents of
children in the reference group in Rauma (n ¼ 807), a town
located 50 km from Pori.
In 2001–2005, the OHP was implemented among all 5th and
6th graders (11- and 12-year-olds) in the town of Pori at the
baseline, except for mentally disabled and handicapped
children attending special schools. The OHP aimed (i) to
increase children s knowledge of oral health problems and
their prevention, (ii) to change their oral health-related

CONTACT Mimmi Tolvanen mimmi.tolvanen@utu.fi Department of Community Dentistry, Institute of Dentistry, University of Turku, FIN-20014, Finland

ß 2015 Taylor & Francis

322 M. TOLVANEN ET AL.
behaviour and, in particular, (iii) to provide social support for
the children in the experimental group. The promotion
programme was targeted to the schoolchildren and persons
involved in the children’s everyday life using various
approaches and was carried out in close co-operation with
the local health and school authorities and local media, which
provided good coverage throughout the programme.
The first phase in 2001–2003
The first survey was conducted in Fall 2001 and the second in
Spring 2003. The first phase of the programme was imple-
mented between those time points. In the first phase, the
promotion programme was targeted only to the school-
children. During a pupil-oriented school campaign, children
acquired relevant, sufficient, and correct information by
preparing different oral health promotion projects, and as an
exercise for improving social skills they presented these
projects in different contexts. The main themes were brushing
teeth twice a day with fluoride toothpaste, using xylitol
products after meals, and promoting healthy eating habits,
such as avoiding constant nibbling. Community analyses of the
presence of soft drink or candy vending machines at schools
and possibilities to buy candies or soft drinks elsewhere during
the school day were conducted by school classes. The results
were discussed with the pupils and school nurses.
The second phase in 2003–2005
The second phase of the OHP took place between the second
and the third (Spring 2005) survey. In this latter part of the
study, in addition to children, the OHP was targeted also to
persons involved in the children’s everyday life. The main
themes were increasing the children’s and parents’ knowledge
of oral health hazards in the school environment and
increasing the daily toothbrushing frequency among the
entire community. The parents organized a meeting to discuss
the healthy school environment, such as avoiding vending
machines, encouraging pupils to eat free school lunches and
assessing the availability of drinking water instead of soft
drinks. In the campaign ‘Once a day is not enough’, oral health
personnel provided information on recommended toothbrush-
ing frequency at schools, stores, fairs and in the media. The
local mass media also put healthy school environment
regularly on the agenda. For more details concerning the
OHP, see Tolvanen et al.[12]
In the town of Rauma, Finland, where neither oral health
promotion nor other interventions were implemented, a similar
group of children and parents served as a reference group. The
data for this study were collected using questionnaire surveys
at baseline (2001), in the middle (2003), and 3.4 years after
launching the OHP in Pori (2005) and simultaneously in the
reference area, Rauma.
Questionnaires and respondents
Similar questionnaires were used for children and parents in
both towns. The children filled out the questionnaires at school
and took the parents’ questionnaires home to one of their
parents’ to fill out and returned the questionnaires in sealed
envelopes. Thus, the parents responded independently of the
children. All parents who had filled out any of the question-
naires and answered any of the questions concerning behav-
iours were included in the study. Most of these parents were
mothers. The numbers of children/parents to whom the
questionnaires were administered and the response rates are
presented in Table 1. A great majority of the children remained
in the study population throughout the entire study period,
but every year there were a few new participants and dropouts
due to moving. The same was true for the parents, but we
didn’t ask the same parent to answer every year. For the
reference town, no identification variable was available to
produce longitudinal data. Thus, the data consist of three
separate cross-sectional sets, for which the trends were
compared.
The questionnaires contained structured and open-ended
questions concerning oral-health related behaviours (31 items),
attitudes (17 items), knowledge (five items) and background
information, such as age and parent’s occupational level, which
was measured with open-ended question and dichotomized to
low (blue collar workers) and high (white collar workers).[13]
The questions included in this study have been found to be
reliable [14] and valid [15,16] among children of these parents.
Reliability for behaviours was measured with Cronbach’s alpha,
which was 0.85. Validity was measured with correlations
between reported behaviour and clinically visible plaque and
gingivitis. In the follow-ups, the correlation between gingivitis
and toothbrushing increased with age (11-year-olds, r ¼ 0.09;
12-year-olds, r ¼ 0.13; 13-year-olds, r ¼ 0.26; 14-year-olds,
r ¼ 0.29; 15-year olds, r ¼ 0.40; p50.05, except 11-year-olds).
Measures
The oral health behaviours investigated included consumption
of sugared drinks (soft drinks, sports drinks, juices, chocolate,
sugared tea/coffee), sugared snacks (sweets, candy bars,
chocolate, ice cream, cookies, bakery), and xylitol products
(chewing gum, lozenges), as well as toothbrushing with
fluoride toothpaste and using dental floss. Behaviours were
measured on 7-point Likert-like scales with alternatives that
described the frequency of the behaviour. Alternatives varied
from 34-times a day or more frequently to less than twice a
month or never. Behaviours were recoded to describe the
weekly frequencies: 34 times a day or more frequently ¼ 24.5,
twice a day ¼ 14, once a day ¼ 7, 2–3 times a week ¼ 2.5, once
a week ¼ 1, twice a month ¼ 0.45, less than twice month or
never ¼ 0. This enabled calculation of sum variables for
sugared drinks and snacks and xylitol products.
Knowledge was measured by parents’ agreement on the
correctness of the five statements related to toothbrushing: ‘a
person has to brush his/her teeth twice a day’; ‘a person can
prevent caries lesions by using fluoride toothpaste’; ‘to ensure
a sufficient supply of fluoride, one has to brush teeth with
fluoride toothpaste at least twice a day’; ‘a person can prevent
caries lesions by using xylitol products after meals’; and ‘a
person can reduce the risk of developing new caries lesions by
omitting one sweet snack a day’. The 4-point Likert-scaled reply
 ACTA ODONTOLOGICA SCANDINAVICA 323

alternatives varied from totally agree to totally disagree.
Knowledge variables were the sum scores of these five items,
scaled to have a range of 6–24, where 24 was the best/
healthiest score.
Attitudes of the parents were determined based on their
opinions on 17 items: whether toothbrushing is important: for
avoiding caries lesions (item 1), for avoiding tooth discolour-
ation (item 2), for a fresh feeling in the mouth (item 3), for
better appearance (item 4), for fresh breath (item 5), for
healthy gingiva (item 6), for acceptance by child (item 7), and
for acceptance by spouse (item 8). They were also asked
whether they think toothbrushing is important before going
to work (item 9), visiting a dentist (item 10), participating in
sports/hobbies (item 11), going to a party (item 12), or
meeting their best friends (item 13). In addition, they were
asked whether they would feel bothered if they themselves
(item 14), their child (item 15), their spouse (item 16), or their
friend (item 17) developed caries lesions. The 4-point Likert-
like scaled reply alternatives varied from very important to
not at all important.
In our previous study among children, principal component
analyses (PCA) with varimax rotation revealed four factors
describing the attitudes and explaining 63% of the common
variance.[16] The factors were named as ‘importance of
brushing for social situations’, ‘importance of brushing for
health and appearance’, ‘concern about developing caries
lesions’ and ‘importance of brushing for acceptance’. The items
among children were nearly the same as among parents, with
the following amendments. Children were asked about
parents’ and friends’ acceptance, whilst parents were asked
about child’s and spouse’s acceptance. Children were also
asked about the importance of toothbrushing before going to
school, disco, meeting their girlfriend/boyfriend, and meeting
their best friend. For parents, these four items were replaced by
just three items involving work, a party, and meeting their best
friend. Bother about developing caries lesions concerned their
own, mother’s, father’s and friend’s mouth among children and
their own, child’s, spouse’s and friend’s mouth among parents.
For parents, a similar factor structure as among children would
include items 9–13 in the factor ‘importance of brushing for
social situations’, items 1–6 in ‘importance of brushing for
health and appearance’, items 14–17 in ‘concern about
developing caries lesions’ and items 7–8 in ‘importance of
brushing for acceptance’.
Statistical analyses
For parents’ 2001 data, multiple group CFA (MGCFA) was used
to test for the equivalence of the factorial structure across
children and parents (configural invariance). The fit indexes
used were model chi-square and its significance, normed chi-
square (2/df), normed fit index (NFI), comparative fit index
(CFI) and root mean square error of approximation (RMSEA).
Model 2 should be non-significant and values 2/df55, NFI
and CFI40.90 and RMSEA50.08 indicate a reasonably good
fit .[17]
For attitude factors and knowledge, Cronbach’s alphas were
calculated to assess the reliability of the scales. For further
analyses, attitude variables were coded as sum scores of the
items loading to factor in question. Attitude sum scores were
scaled to have a range of 6–24, 24 being the best/healthiest
score, similar to knowledge. The mean weekly frequencies for
behaviours and mean sum scores for knowledge and attitudes
in 2001, 2003, and 2005, as well as their changes in 2001–2003
and 2003–2005 were evaluated for both towns. The statistical
significances of the differences in parents’ self-reported
behaviour, knowledge and attitudes between the towns were
evaluated with Mann-Whitney U-tests and confidence intervals
and between time points (within the towns) with confidence
intervals. We also conducted generalized linear models for
behaviours, knowledge and attitudes using a combined cross-
sectional dataset and using year and town and their interaction
term as factors. Statistical analyses were conducted using SPSS
16.0 and AMOS 16.0 software. The Ethics Committee of the
Northern Ostrobothnia Hospital District and the City of Pori
gave their approval for the study.
Results
At baseline, there were no statistically significant differences
between the towns in mean ages of the responding parents;
40.0 years among mothers and 42.4 among fathers in Pori, and
39.4 years among mothers and 40.8 among fathers in Rauma.
In Pori, the responding mothers were more likely to have a

Table 1. Description of the population.*

Semester Pori, n (%) Rauma, n (%)
Fall 2001 Population of 5th and 6th graders 1691 807
Questionnaires returned 1527 (90) 693 (86)
Respondent: mother 1332 (87) 581 (84)
Respondent: father 168 (11) 99 (14)
Respondent: else/unknown 27 (2) 13 (2)
Spring 2003 Population of 6th and 7th graders 1651 850
Questionnaires returned 1346 (82) 620 (73)
Respondent: mother 998 (74) 346 (56)
Respondent: father 153 (11) 56 (9)
Respondent: else/unknown 195 (15) 218 (35)
Spring 2005 Population of 8th and 9th graders 1659 827
Questionnaires returned 1292 (78) 523 (63)
Respondent: mother 1083 (84) 434 (83)
Respondent: father 193 (15) 84 (16)
Respondent: else/unknown 16 (1) 5 (1)
*The children were mainly the same during the whole study, just a few new participants and dropouts due to moving. The same was true of
parents, but not the same parent every year.
324 M. TOLVANEN ET AL.
higher occupational level than were the responding mothers in
Rauma (71% vs 66%, p ¼ 0.034). Among the responding fathers,
no such difference was observed (57% vs 58%, respectively).
The results of the MGCFA revealed good fit for the
unconstrained model, indicating configural invariance, i.e.,
the same factor structure across children and parents. All
indicators had relatively high standardized loadings on the
factor they were assumed to load and the correlations between
the latent variables were rather low, indicating good conver-
gent validity and discriminant validity (Figure 1). The model
was good fit for three criteria: NFI ¼ 0.912, CFI ¼ 0.921, and
RMSEA ¼ 0.045 (90% CI ¼ 0.043–0.047), but not according to 2
estimates: 2(226) ¼ 2045.361 (p50.001), 2/df ¼ 9.05.
Cronbach’s alphas were 0.748 for knowledge, 0.800 for
concern about developing caries lesions, 0.728 for the import-
ance of brushing for social situations, 0.699 for the importance
of brushing for health and appearance and 0.835 for the
importance of brushing for acceptance.
The first phase in 2001–2003
At the baseline, the mothers in Rauma were more likely to
consume xylitol products and sugary snacks than were
mothers in Pori; and for sugary snacks, this association
remained throughout the study (Table 2). In 2003, fathers in
Pori were statistically significantly more likely to brush their
teeth more frequently and eat sugary snacks less frequently
than were fathers in Rauma.
During the first phase, the trend in changing behaviours was
in favour of parents in Pori. Compared to Rauma, fathers in Pori
tended to be more successful in changing their behaviours in
four and mothers in all five behaviours studied (Table 2). The
improvements within the towns were statistically significant for
using xylitol products and drinking sugary drinks among
mothers in Pori, for drinking sugary drinks among mothers in
Rauma, and for toothbrushing and using xylitol products
among fathers in Pori. The biggest changes in both towns were
improvements in drinking soft drinks among mothers and
flossing among fathers and, in Pori, also the use of xylitol
products among both parents.
At the baseline in 2001, no statistically significant differences
between the towns were found for knowledge and attitudes,
either among mothers or fathers (Table 3). In 2001–2003
mothers in Pori improved statistically significantly their know-
ledge and the attitude ‘health and appearance’. Thus, in 2003
mothers in Pori had a statistically significantly higher score for
knowledge and the attitude ‘health and appearance’ than had
mothers in Rauma.
The second phase in 2003–2005
In 2003–2005, the trend in changing behaviours was pretty
similar in both towns among both mothers and fathers (Table
2). The statistically significant changes within the towns were
improvements in toothbrushing among mothers in Rauma,
flossing among mothers in Pori and eating sugary snacks
among fathers in Rauma. The biggest changes in both towns
were improvements in flossing among mothers and eating
sugary snacks among fathers and also toothbrushing and
drinking soft drinks among fathers in Rauma.
The differences in knowledge and the attitude ‘health and
appearance’ that emerged in 2003 between mothers in Pori
and Rauma, had faded by 2005, since mothers in Rauma gained
more knowledge and the attitude ‘health and appearance’
relapsed among mothers in Pori (Table 3). The trend in
changing knowledge and attitudes was similar in both towns.
Results of the generalized linear modelling revealed that,
among mothers, statistically significant factors were time for
toothbrushing (p ¼ 0.031), flossing (p ¼ 0.001) and attitude
‘health and appearance’ (p ¼ 0.026), town for eating sugary
snacks (p50.001) and both time and town for using xylitol
products (p-values ¼ 0.027 and 0.002, respectively), for drinking
sugary drinks (p-values50.001 and 0.016, respectively) and for
knowledge (both p-values50.001). Among fathers, statistically
significant factors were time for knowledge (p ¼ 0.044) and
both time and town for eating sugary snacks (p-values ¼ 0.020
and 0.009, respectively).
Discussion
In 2001–2003, the trend in changing behaviours was in favour
of parents in Pori compared to the reference town, Rauma.
During this first phase of the intervention, the OHP was
targeted only to the children in Pori who also improved their
behaviours more than children in Rauma,[12] so the improve-
ments among parents in Pori can be assumed to be a result of
health promotion targeted to children transmitted to their
parents. Mothers in Pori also improved their knowledge and
one of the attitudes, ‘health and appearance’. Some of the
changes were quite small. Still, they should not be considered
meaningless, since even small individual changes that take
place among the whole population may lead to significant
improvements at the population level.[18] Factor analysis
revealed a similar factor structure for attitudes among parents
as was obtained among their children, indicating that, even if
attitudes change due to growing up, the measuring may be
done with similar instruments, easing the studying and
comparison of attitudes.
In the second phase in 2003–2005, the OHP in Pori was
targeted also to other persons involved in the children’s
everyday life, including parents. The intervention was likely to
diffuse also to Rauma, because the local mass media drew
aspects of intervention, especially toothbrushing, regularly on
the agenda, and the towns are located only 50 km apart and
share some local media. Due to this ‘noise’, these results are
hard to interpret when it comes to influencing factors.
The differences between parents in Pori and Rauma at the
second time point and the similarities at the third time point
strengthen the interpretation of the result that children can
transfer knowledge and behaviour to their parents, since the
only exposure parents had between the first two time points
was whatever their children shared with them. At the baseline,
these children were 11–12 years old, entering their early
teenage years and were maybe more likely to share what they
had learned in such a way that it may affect their parents, than
very young children or children in their late teens.

Figure 1. Standardized estimates of the confirmatory factor analysis for the attitudinal factor model.
Even though fathers tended to have unhealthier behaviours
than mothers did, the changes in Pori indicated that, in 2001–
2003, they also tended to be more successful in improving
those, whilst in 2003–2005 mothers tended to be more
successful in improving their behaviours than fathers were. In
Rauma, similar trends could not be seen.
It has previously been reported that children’s health
promotion will influence also parents’ behaviour.[10,11] Our
findings support previous reports that children influence their
parents on the issues emphasized in health promotion
targeted to children, indicating that influencing is reciprocal.
This may create a snowball effect, but, on the other hand, it
may put the child at risk for cross-pressure if influential
intervention is not in line with child’s parents’ thoughts or
behaviours. Children are able to contribute and manage their
own health and well-being as well as that of other family
members and they may function as health promoting
actors.[19,20] The perspective of the children as social actors
will also create ethical demands and responsibility.[21] The
children are then seen not only as the health promoting agent
of their own health, but also the promoters of the health of
their families.
The strengths of our study include large representative
datasets, a long follow-up time and a sufficiently large
reference group to allow us to consider how growing up
ACTA ODONTOLOGICA SCANDINAVICA 325
contributed to the changes. Our data consisted of three
cross-sectional datasets, because we did not have any identi-
fication variable in the reference town, Rauma, and even in Pori
where we have, we didn’t ask the same parent to answer every
year. This also resulted in parental data including mostly
mothers and so few fathers that their results cannot be
generalized. In the children’s data, there were only a few drop-
outs. In the first collection point, 1649 (98%) out of 1691
children returned the questionnaire. Of these 1649 children,
1483 (90%) also returned the last questionnaire, so there were
only 166 (10%) drop-outs. There were no differences in
baseline behaviours between children who were followed-up
throughout the study and those who dropped out during the
follow-up, but the children who dropped out were more likely
to be boys than girls. Those children probably were not at
school the day the questionnaires were filled out or had moved
to another town. The response rates were rather high also
among parents, especially considering that children took the
parents’ questionnaires home and returned them after the
parent had filled it in, presumably independently of the child. If
they had filled it out together with the child, it could lead to
bias, but we think that the children filling in their question-
naires at school reduces the risk of that bias, as well as risk of
proxy reporting. A more probable source of bias is using self-
reports on behaviours, which is often considered to harm
326 M. TOLVANEN ET AL.

Table 2. Mean weekly frequencies of oral health-related behaviors in 2001, 2003 and 2005 and their changes, separately for different towns and time periods and for
mothers and fathers.
Mean Change (95% CI) Change %
Respondent Town 2001 2003 2005 2001–2003 2003–2005 2001–2003 2003–2005
Brushing with Mother Pori 13.1 13.0 13.4 0.1 (0.5–0.3) 0.3 (0.1–0.7) 1 3
fluoride toothpaste Rauma 13.1 12.6 13.3 0.5 (2.9–2.0) 0.7 (0.0–1.4) 4 6
Father Pori 10.9 11.8** 11.1 1.0 (0.0–2.0) 0.8 (1.7–0.2) 9 6
Rauma 10.7 10.0** 11.2 0.7 (2.2–0.8) 1.1 (0.4–2.7) 7 11
Flossing Mother Pori 1.6 1.7 2.2 0.1 (0.2–0.4) 0.5 (0.1–0.8) 5 26
Rauma 1.7 1.7 2.1 0.1 (0.4–0.5) 0.4 (0.2– 0.9) 4 26
Father Pori 0.8 1.0 1.0 0.2 (0.5–0.9) 0.0 (0.6–0.6) 24 1
Rauma 0.6 0.7 0.7 0.1 (0.4–0.6) 0.0 (0.6–0.6) 11 4
Using xylitol products Mother Pori 7.2** 8.1 8.4 1.0 (0.2–1.7) 0.3 (0.6–1.1) 13 3
Rauma 8.6** 8.7 9.4 0.1 (1.2–1.5) 0.7 (0.8–2.2) 2 8
Father Pori 3.9 6.1 6.1 2.2 (0.8–3.7) 0.0 (1.7–1.8) 58 0
Rauma 6.5 6.5 6.3 0.0 (2.8–2.9) 0.2 (3.2–2.9) 0 3
Drinking sugary drinks Mother Pori 15.2 11.5 11.5 3.6 (4.8–2.5) 0.0 (1.1–1.1) 24 0
Rauma 16.0 12.9 12.9 3.1 (5.2–1.0) 0.0 (2.3–2.3) 19 0
Father Pori 18.6 18.9 19.4 0.3 (2.9–3.6) 0.5 (2.8–3.7) 2 2
Rauma 21.8 20.1 16.7 1.7 (4.8–1.4) 3.5 (8.3–.4) 8 17
Eating sugary snacks Mother Pori 6.9** 7.3** 6.9** 0.4 (0.1–0.9) 0.4 (1.0–0.2) 6 6
Rauma 7.9** 8.5** 8.3** 0.6 (0.3–1.5) 0.2 (1.3–1.0) 8 2
Father Pori 7.3 7.0* 6.4 0.3 (1.7–1.2) 0.7 (2.0–0.7) 3 10
Rauma 8.8 9.5* 6.8 0.7 (2.0–3.4) 2.7 (5.2–0.3) 8 29
**p50.01 for difference between the towns; *p50.05 for difference between the towns; Mann-Whitney U-test. Statistically significant changes are in italics. Changes
and change percentages have been calculated by using exact values of the mean frequencies.

Table 3. Sum scores of oral health-related knowledge and attitudes (scale 6–24) in 2001, 2003 and 2005 and their changes, separately for different towns and time
periods and for mothers and fathers.
Mean Change (95% CI) Change %
Respondent Town 2001 2003 2005 2001–2003 2003–2005 2001–2003 2003–2005
Knowledge Mother Pori 21.8 22.4* 22.3 0.6 (0.4–0.8) 0.1 (0.3–0.1) 3 1
Rauma 21.5 21.8* 22.3 0.3 (0.2–0.6) 0.5 (0.1–0.9) 1 2
Father Pori 20.8 21.6 21.7 0.8 (0.0–1.5) 0.2 (0.5–0.8) 4 1
Rauma 20.9 21.2 21.1 0.3 (0.8–1.3) 0.1 (1.1–0.9) 1 0
Concern about developing Mother Pori 18.1 17.9 18.0 0.3 (0.6–0.1) 0.1 (0.3–0.4) 1 0
caries lesions Rauma 17.8 17.8 17.6 0.0 (0.5–0.6) 0.2 (0.8–0.4) 0 1
Father Pori 17.1 17.6 17.2 0.5 (0.4–1.4) 0.4 (1.4–0.5) 3 2
Rauma 17.4 17.7 17.1 0.3 (1.1–1.8) 0.6 (2.1–0.9) 2 3
Importance of brushing for Mother Pori 22.0 22.0 21.9 0.0 (0.2–0.2) 0.0 (0.3–0.2) 0 0
social situations Rauma 22.0 22.0 21.9 0.0 (0.3–0.3) 0.0 (0.4–0.3) 0 0
Father Pori 20.1 20.3 20.3 0.3 (0.5–1.0) 0.0 (0.8–0.7) 1 0
Rauma 20.0 19.7 19.6 0.3 (1.5–0.8) 0.0 (1.3–1.2) 2 0
Importance of brushing for Mother Pori 22.9 23.1* 22.9 0.2 (0.0–0.3) 0.2 (0.4–0.0) 1 1
health and appearance Rauma 22.8 22.9* 23.1 0.1 (0.1–0.3) 0.2 (0.1–0.4) 0 1
Father Pori 22.0 22.0 21.6 0.0 (0.6–0.5) 0.3 (1.0–0.3) 0 2
Rauma 22.2 22.3 22.1 0.1 (0.7–0.8) 0.2 (1.0–0.5) 0 1
Importance of brushing Mother Pori 20.0 19.9 19.5 0.1 (0.5–0.3) 0.4 (0.8–0.0) 1 2
for acceptance Rauma 20.1 20.0 19.9 0.1 (0.7–0.5) 0.2 (0.8–0.5) 0 1
Father Pori 19.7 20.0 19.6 0.2 (0.7–1.2) 0.3 (1.4–0.7) 1 2
Rauma 20.4 19.9 19.0 0.5 (2.0–1.0) 0.9 (2.6–0.7) 2 5
*p50.05 for difference between the towns; Mann-Whitney U-est. Statistically significant changes are in italics. Changes and change percentages have been calculated
by using exact values of the mean frequencies.

validity and reliability, but, in this case, both validity and
reliability were good. Also a possible source of bias are children
who moved to Pori during the study, but we don’t think this
has influenced the results much, because they have been
exposed to the intervention since they moved in.
Another strength of this study is the number of attitudinal
variables, allowing us to use factor analysis as a scientific basis
when defining attitudes, which is more preferable than using
single items when studying attitudes. MGCFA resulted in
significant 2 values. In this case, those can be due to rather
large sample sizes, big correlations in the model, and the four-
class categorical variables, all of which contribute to high 2
values, which indicate that the model should not be rejected
based only on the model chi-square.[17,22] Sample size greater
than 200 has been suggested to provide sufficient statistical
power for this kind of analysis, but in the same time, a 2 value
has been suggested to be highly sensitive to sample size,
especially if the sample size is bigger than 200.[17] Other
indexes used indicated reasonably good fit and good conver-
gent and discriminant validity. We tested only configural
invariance, but not invariance with respect to factor loadings
(metric invariance), because the items were not exactly the
same. We decided to use confidence intervals when evaluating
the statistical significances of the changes. If the CI does not

include zero, the change is statistically significant and the same
is true if the CI’s of two groups do not overlap. We also
conducted generalized linear models with one combined
cross-sectional dataset with time, town and their interaction
as factors. There were differences between the time points and
the towns. None of the interaction terms were statistically
significant, but some were close. This may indicate that the
differences in changes between the towns were not big
enough to be detected, especially since most changes were
similar, even though those occurred in different time periods.
When interpreting the results, it must be kept in mind that this
cross-sectional modelling procedure considers time as a
categorical grouping variable within the data, not as time
points.
The results suggest that successful health promotion
targeted to children may be transferred on to their parents
and also help them in mending their habits. Future oral health
promotions should be targeted, especially for children,
because children are participants and mediators of the health
promotion, not only receivers. The children are the keys for the
future and can carry the results far over many years.
Acknowledgements
This study was supported by The Finnish State Research Funding and
Finnish Dental Society Apollonia. We thank the children, parents and
teachers in Pori and in Rauma, Finland, for their cooperation in this study.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
References
[1] Tuckett D. Sociology as a science. In: Tuckett D, ed. An introduction
to medical sociology. London, UK: Tavistock Publications, 1976/
1980;15.
[2] Rossow I, Rice J. Concordance of parental and adolescent health
behaviors. Soc Sci Med. 1994;38:1299–1305.
[3] Åstrøm AN, Jakobsen R. The effect of parental dental health behavior
on that of their adolescent offspring. Acta Odontol Scand.
1996;54:235–241.
[4] Åstrøm AN. Parental influences on adolescents’ oral health behavior:
two-year follow-up of the Norwegian Longitudinal Health Behavior
Study participants. Eur J Oral Sci. 1998;106:922–930.
View publication stats
ACTA ODONTOLOGICA SCANDINAVICA 327
[5] Mattila ML, Rautava P, Sillanpää M, Paunio P. Caries in five-year-old
children and associations with family-related factors. J Dent Res.
2000;79:875–881.
[6] Poutanen R, Lahti S, Tolvanen M, Hausen H. Parental influence on
children’s oral health-related behavior. Acta Odontol Scand.
2006;64:286–292.
[7] Mattila ML, Rautava P, Ojanlatva A, et al. Will the role of family
influence dental caries among seven-year-old children? Acta Odontol
Scand. 2005;63:73–84.
[8] Kickbush I, Gordon J, Kropf D, O’Toole L. Learning well-being: a policy
priority for children and youth. A process for change. Universal
Education Foundation. Meerbeke, BE: ABC Drukkerij 2011.
[9] Christensen P. Difference and similarity: How children competence is
constituted in illness and its treatment. In: Hutchby I & Moran Ellis J
(eds). Children and social competence: Arenas of action. London, UK:
Falmer Press, 1998; 187–202.
[10] Evans D, Clark NM, Levison MJ, et al. Can children teach their parents
about asthma. Health Educ Behav. 2001;28:500–511.
[11] Garbin CAS, Garbin AJI, dos Santos KT, Lima DP. Oral health
education in schools: promoting health agents. Int J Dent Hygiene.
2009;7:212–216.
[12] Tolvanen M, Lahti S, Poutanen R, et al. Changes in children’s oral
health-related behavior, knowledge and attitudes during a 3.4-yr
randomized clinical trial and oral health-promotion program. Eur J
Oral Sci. 2009;117:390–397.
[13] Statistics Finland 2001. Tilastokeskus 2001. Ammattiluokitus 2001.
Helsinki (in Finnish).
[14] Poutanen R, Lahti S, Hausen H. Oral health-related knowledge,
attitudes, and beliefs among 11 to 12-year-old Finnish schoolchildren
with different oral health behaviors. Acta Odontol Scand. 2005;63:10–
16.
[15] Poutanen R. Boys and girls as health-promoting actors  determin-
ants of oral health-related lifestyle among 11- to 12-year-old
schoolchildren. Acta Universitatis Ouluensis D 942. Oulu: University
of Oulu, 2007. URI: http://herkules.oulu.fi/isbn9789514285615/
[16] Tolvanen M, Lahti S, Hausen H. Changes in toothbrushing
frequency in relation to changes in oral health-related knowledge
and attitudes among children–a longitudinal study. Eur J Oral Sci.
2010;118:284–289.
[17] Kline RB. Principles and practice of structural equation modeling.
New York, NY: Guilford, 2005;73–180.
[18] Rose G. Sick Individuals and Sick Populations. Int J Epidemiol.
1985;14:32–38.
[19] Christensen P. The health-promoting family: a conceptual framework
for future research. Soc Sci Med. 2004;59:377–387.
[20] Montgomery-Andersen RA, Borup I. Family support and the child as
health promoting agent in the Arctic–‘‘the Inuit way’’. Rural Remote
Health. 2012;12:1977
[21] Christensen P, Prout A. Working with ethical symmetry in social
research with children. Childhood. 2002;4:477–497.
[22] Hoe SL. Issues and procedures in adopting structural equation
modeling technique. J Appl Quant Method. 2008;3:76–83.