Keywords
knowledge - attitude - maternal - oral health - children under three
Introduction
Some theories of attitude, including the Health Belief Model and the Theory of Reason
Action, have confirmed the central role of knowledge and attitude in describing behavioral
change.[1]
[2] These aspects are specifically highlighted in assessing the role of parental knowledge
and attitude about their children’s health. Parents play a crucial role in giving
their children the information and support needed to live a healthy life.[3]
Parental knowledge, belief, and attitude about oral health affect children’s dental
cleaning behavior.[4] Furthermore, parental attitude brings a significant positive impact on children’s
dental caries condition and gingival health.[5]
[6] Maternal role in promoting their children’s oral habits and health has been emphasized.[7]
[8]
[9] Despite possible shift of role and responsibility in their family,[10] mothers still play an essential role in shaping their children’s lifestyle, particularly
their oral health.[7]
[9]
To identify the factors related to children’s oral health, further research on maternal
knowledge and attitude about dental and oral health in early age children has been
suggested.[11] A body of research has been conducted to study the vital impact of parental knowledge
and attitude about their oral health on preschool children’s oral health.[12]
[13] Similar studies have also been conducted on school-age children.[14]
[15] Information from these studies is important, especially in societies where mothers
play a crucial role in raising children. Currently, several instruments to measure
maternal knowledge and attitude about oral health in children have been developed
though still very general. Unfortunately, a similar tool that focuses on early-age
children (under 3 years) has yet to be developed. This study aimed to develop a measurement
instrument to assess maternal knowledge and attitude about oral health in children
under 3 years.
Materials and Methods
This research attempted to design a measurement instrument using a descriptive approach
and a survey to obtain data from 150 mothers who live in Bandung Municipality, Indonesia
and have children under 3 years.
Measurement Instrument
The measurement instrument developed in this research was designed to obtain information
about maternal knowledge and attitude about oral health in children under three ([Table 1]). The development of the instrument followed the following steps: measurement instrument
design, content validity, formulation of psychometric characteristics, namely their
validity and reliability. Items concerning knowledge were derived from Bloom’s theory,
based on which knowledge can be broken down into three dimensions: translation, interpretation,
and extrapolation.[16] The items for the attitude instrument were derived from the cognitive-affective-conative
behavioral model.[17]
Table 1
Maternal knowledge and attitude construct
|
Dimension
|
Operating definition
|
Indicator
|
Items
|
|
Knowledge instrument
|
|
Translation
|
Ability to understand a nonliteral statement
|
Mention
differentiate
|
2. 3. 4. 5. 12
|
|
Interpretation
|
Ability to recognize information
|
Exemplify
|
1. 6. 7. 8. 14
|
|
Extrapolation
|
Ability to conclude information
|
Use a concept
|
9. 10. 11. 15
|
|
Attitude instrument
|
|
Cognitive aspect
|
The aspect of recognizing thought, that is, knowledge and belief, based on information
related to dental health
|
Knowledge about disease
Knowledge about healthy life
|
1. 8. 10
|
|
Affective aspect
|
The aspect of emotion related to dental health
|
Attitude toward disease
|
2. 3. 5
|
|
Conative aspect
|
The aspect of attitude involving the tendency to act
|
Attitude toward disease
|
4. 6. 7. 9
|
Assessment
The instrument consists of 25 items and were grouped into knowledge (15 items) and
attitude (10 items). The knowledge instrument used a true-false design ([Table 2]), whereas the attitude instrument used the following Likert 5-point scale: strongly
agree (SA), agree (A), neutral (N), disagree (D), and strongly disagree (SD) ([Table 3]). The instruments were thus designed to achieve the instrument’s aim, namely practicality
and time efficiency. In the knowledge instrument, scores are 1 for a correct answer
and 0 for a wrong answer. The total score for the respondent knowledge was built by
adding 15 items (ranging from 0 to 15). A higher score indicates a more positive knowledge.
In the attitude instrument, for item number 1, 5, 9, and 10, the scores are as follows
SA = 5, A = 4, N = 3, D = 2, and SD = 1. As for item number 2, 3, 4, 6, 7, and 8,
the scores are reverse as follows SA = 1, A = 2, n = 3, D = 4, and SD = 5. The total score for the respondent attitude was built by
adding items (ranging from 10 to 50). A higher score indicates a more positive attitude.
Table 2
Items in the knowledge instrument
|
No.
|
List of statements
|
True
|
False
|
|
1
|
The ideal toothbrushing frequency for children between 2 and 3 years of age is once
a day or whenever they are willing.
|
|
|
|
2
|
The ideal toothbrushing time for children between 2 and 3 years of age is during morning
and afternoon baths.
|
|
|
|
3
|
High frequency of snacking on foods and drinks with high sugar content (chips, biscuits,
sweets, chocolate, and boxed/bottled drinks such as juice/soda/tea) among children
will affect their health and growth.
|
|
|
|
4
|
The toothbrushing method for children between 2 and 3 years of age is to brush the
entire surface of their upper and lower teeth with repeated backward and forward movements.
|
|
|
|
5
|
Mothers must guide their children when they are brushing their teeth because, with
their still limited motoric skills, children at such an age have yet to develop ideal
brushing movements.
|
|
|
|
6
|
To brush your teeth, you must use fluoride toothpaste, placing it along the bristles’
top surface.
|
|
|
|
7
|
It is recommended to give children foods that they like.
|
|
|
|
8
|
After brushing their teeth, children must rinse their mouth to remove the remaining
toothpaste from their mouth.
|
|
|
|
9
|
Frequent snacking (on sugary foods) will accelerate dental cavity formation.
|
|
|
|
10
|
Oral health will not significantly affect children’s overall health and growth.
|
|
|
|
11
|
Visiting a dentist regularly every 6 months is important to prevent dental decay despite
the absence of toothache.
|
|
|
|
12
|
In preventing dental decay, it does not matter how often my child eats as long as
there is no sugar in his/her food.
|
|
|
|
13
|
Frequent toothbrushing can prevent dental decay/cavity.
|
|
|
|
14
|
Dental cavity with no pain in children between 2 and 3 years of age is not a source
of worry because their deciduous teeth will be replaced with permanent teeth when
they grow up.
|
|
|
|
15
|
Dental cavities in children can be prevented only by frequent toothbrushing.
|
|
|
Table 3
Items in the attitude instrument
|
No.
|
List of statements
|
Possible answers
|
|
SA
|
A
|
N
|
D
|
SD
|
|
Abbreviations: A, agree; N, neutral; D, disagree; SA, strongly agree; SD, strongly
disagree.
|
|
1
|
It is important to maintain oral health by brushing teeth twice a day from the age
of 2 to 3.
|
|
|
|
|
|
|
2
|
In my opinion, children between 2 or 3 years of age should not always be attended
when they are brushing their teeth.
|
|
|
|
|
|
|
3
|
In my opinion, types of food will not affect my child’s oral health.
|
|
|
|
|
|
|
4
|
I let my child have snacks when he or she refuses to eat.
|
|
|
|
|
|
|
5
|
It is recommended to brush teeth every day after breakfast and at night before sleep.
|
|
|
|
|
|
|
6
|
For mothers, letting their children eat foods of their choice is better than letting
them eat nothing at all.
|
|
|
|
|
|
|
7
|
I seldom pay attention to my child’s dental condition if there is no complaint.
|
|
|
|
|
|
|
8
|
It is not important for my child to drink milk once a day.
|
|
|
|
|
|
|
9
|
I give my child a balanced diet (rice, meat/fish, vegetable, fruit, and milk) every
day.
|
|
|
|
|
|
|
10
|
Dental pain will affect children’s growth.
|
|
|
|
|
|
Statistical Analysis
Item Analysis
Item analysis is required to determine whether the items in the instrument have been
well formulated. In this research, item analysis was done by calculating each item’s
distinguishing feature based on the item-total correlation. In calculating distinguishing
feature, item-total correlation was used to determine the consistency between an item’s
score and the total score. Consistency was determined based on the coefficient of
correlation between an item and the total score. Since each item in this research
was scored based on Likert scale, correlation coefficient was obtained by using Pearson’s
correlation formula:
Where:
X
1 = total first set score
X
2 = total second set score
X
1 = average X
1 score
X
2 = average X
2 score
σx
1 = standard deviation of X
1
σx
2 = standard deviation of X
2
Validity
Validity indicates whether or not a research instrument can measure the object it
has been designed to measure. The higher its validity, the more accurate the instrument
in measuring its object. Before being put into trial, the instrument had been assessed
by three dentists from the Department of Pediatric Dentistry, a dentist from the Department
of Community Dentistry, and a psychologist from the Department of Social Psychology.
To assess the instrument’s validity, a test was conducted by using Pearson’s bivariate
correlation (Pearson’s product-moment correlation) in SPSS 25.0 software, by which
the score of each item was correlated with the total score. The total score was the
total sum of all item scores. Instrument items that correlate significantly with the
total score would indicate their plausibility to support and illustrate what they
had been designed to express (valid). If r-count was greater than or equal to (≥)
r-table (two-tailed test with sig. 0.05), the instrument or the instrument items correlated
significantly with the total score (valid).[18]
[19]
Reliability
The internal consistency method was used to test the instrument’s reliability. A test
was conducted by measuring the different items of the same instrument. The instrument
has only one measurement version. Therefore, the method was well suited for the test.
Conceptually, the instrument would not result in a total score. Instead, it would
yield the total score for each dimension. Thus, reliability coefficient was to be
calculated as per dimension. Considering that each dimension had only a few items
(10 items per dimension), reliability coefficient was calculated by using the following
α coefficient equation:
Where:
Results
Item Analysis
The distinguishing feature of each item was calculated via intercorrelation Pearson’s
product-moment correlation) by using SPSS 25.0 software, and the results are presented
in [Table 4].
Table 4
Item analysis
|
Dimension
|
Item
|
R
|
Correlation
|
|
Knowledge
|
|
Translation
|
2
|
0.493
|
Moderate
|
|
3
|
0.307
|
Low
|
|
4
|
0.464
|
Moderate
|
|
5
|
0.060
|
Very low
|
|
12
|
0.042
|
Very low
|
|
Interpretation
|
1
|
0.479
|
Moderate
|
|
6
|
0.494
|
Moderate
|
|
7
|
0.441
|
Moderate
|
|
8
|
0.075
|
Very low
|
|
14
|
0.441
|
Moderate
|
|
Extrapolation
|
9
|
0.179
|
Very low
|
|
10
|
0.414
|
Moderate
|
|
11
|
0.253
|
Low
|
|
15
|
0.187
|
Very Low
|
|
Attitude
|
|
Cognitive aspect
|
1
|
0.365
|
Low
|
|
8
|
0.321
|
Low
|
|
10
|
0.117
|
Very Low
|
|
Affective aspect
|
2
|
0.405
|
Medium
|
|
3
|
0.309
|
Low
|
|
5
|
0.236
|
Low
|
|
Conative aspect
|
4
|
0.547
|
Moderate
|
|
6
|
0.510
|
Moderate
|
|
7
|
0.409
|
Moderate
|
|
9
|
0.021
|
Very low
|
Reliability
The reliability test results yielded a Cronbach’s α score of 0.620 for the knowledge
instrument and 0.565 for the attitude instrument. [Table 5] below shows the Cronbach’s α scores yielded if certain items were deleted.
Table 5
Measurement instrument reliability
|
Dimension
|
Item
|
Cronbach’s α if item deleted
|
Criteria
|
|
Knowledge instrument
|
|
Translation
|
2
|
0.586
|
Quite reliable
|
|
3
|
0.611
|
Reliable
|
|
4
|
0.590
|
Quite reliable
|
|
5
|
0.622
|
Reliable
|
|
12
|
0.643
|
Reliable
|
|
Interpretation
|
1
|
0.594
|
Quite reliable
|
|
6
|
0.586
|
Quite reliable
|
|
7
|
0.595
|
Quite reliable
|
|
8
|
0.636
|
Reliable
|
|
14
|
0.629
|
Reliable
|
|
Extrapolation
|
9
|
0.618
|
Reliable
|
|
10
|
0.604
|
Reliable
|
|
11
|
0.616
|
Reliable
|
|
15
|
0.629
|
Reliable
|
|
Attitude instrument
|
|
Cognitive aspect
|
1
|
0.559
|
Quite reliable
|
|
8
|
0.554
|
Quite reliable
|
|
10
|
0.584
|
Quite reliable
|
|
Affective aspect
|
2
|
0.539
|
Quite reliable
|
|
3
|
0.555
|
Quite reliable
|
|
5
|
0.569
|
Quite reliable
|
|
Conative aspect
|
4
|
0.510
|
Quite reliable
|
|
6
|
0.518
|
Quite reliable
|
|
7
|
0.539
|
Quite reliable
|
|
9
|
0.606
|
Reliable
|
Validity
As shown in [Table 6], Pearson’s correlation test yielded valid results for all items.
Table 6
Pearson’s correlation test results
|
Knowledge
|
|
n
|
150
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
rs
|
0.48
|
0.49
|
0.31
|
0.46
|
0.06
|
0.49
|
0.44
|
0.07
|
0.18
|
0.41
|
0.25
|
0.04
|
0.44
|
0.44
|
0.19
|
|
t-hit
|
6.63
|
6.90
|
3.93
|
6.38
|
0.73
|
6.92
|
5.98
|
0.91
|
2.22
|
5.54
|
3.19
|
0.51
|
6.03
|
5.98
|
2.32
|
|
p-Value
|
3E-10
|
7 E-11
|
7E-05
|
1E-09
|
0.232
|
7E-11
|
8E-09
|
0.1823
|
0.014
|
7E-08
|
0.0009
|
0.3047
|
6E-09
|
8E-09
|
0.011
|
|
Category
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
|
Attitude
|
|
n
|
150
|
|
|
|
|
|
|
|
|
|
|
rs
|
0.36
|
0.40
|
0.31
|
0.55
|
0.24
|
0.51
|
0.41
|
0.32
|
0.02
|
0.12
|
|
t-hit
|
4.77
|
5.39
|
3.95
|
7.95
|
2.95
|
7.20
|
5.45
|
4.12
|
0.26
|
1.43
|
|
p-Value
|
2E-06
|
1E07
|
6E-05
|
2E-13
|
0.0018
|
1E-11
|
1E-07
|
3E-05
|
0.3979
|
0.0774
|
|
Category
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Valid
|
Discussion
In this research, we attempted to generate a concept, as well as develop and test
a new set of instruments to measure maternal knowledge and attitude about oral health
in children under three. We developed two instruments, that is, knowledge instrument
and attitude instruments, consisting of 15 and 10 instrument items, respectively ([Tables 2] and [3]). A measurement instrument is considered solid if it meets these three requirements:
well-formulated items, reliability, and validity. A crucial step required in developing
a measurement instrument is item analysis. The term refers to the statistical calculation
and test performed on individual item scores to obtain reliability and validity.[20] The item analysis results showed that the highest-scoring items still fell under
the “medium correlation” category. No items showed a strong correlation. Although
the other items could produce quite self-explanatory results, further tests are still
required with more respondents.
Reliability was tested by means of Cronbach’s α method, using a mathematical equation
to assess measurement reliability level. Reliability test is required to test the
consistency of an instrument and ensure its reliability.[18]
[19] A measurement instrument’s reliability is determined by the α score yielded. The
overall α scores of both the knowledge and attitude instruments were 0.620 (reliable)
and 0.565 (quite reliable). The test results showed that, by and large, all the items
in the knowledge instrument were reliable and those in the latter were quite reliable.
[Table 5] presents each item’s α score in both instruments and the α score when a particular
item was deleted. An instrument’s reliability can be improved by deleting a less valid
item. As shown in the table, deletion of item number 12 item in the translation dimension
of the knowledge instrument yielded a new α score of 0.643. In the attitude instrument,
deletion of item number 9 in the conative dimension resulted in a new α score of 0.606.
However, item deletion would necessitate reconsideration of the adequacy of the items
in the dimension concerned to make the instrument more representative.[19]
Validity test is needed to assess the accuracy of an instrument in performing its
measuring function. In addition, validity refers to the property of an instrument
which indicates that the variable measured is precisely the variable it is designed
to measure.[19] As shown in [Table 6], the validity of an item is distinguished by its correlation with the total score.
The test results revealed that all the items in both instruments were valid. In other
words, all the items are feasible for use in measurement.
Conclusion
Using a basic systematic method and a validity-based approach, we developed instruments
to measure maternal knowledge and attitude about the maintenance of dental health
in children under three. The knowledge and attitude instruments are each a three-dimensional
instrument whose purpose is to reflect important elements of maternal’ perspectives
concerning the maintenance of their under 3-year-old children’s oral health. The instruments
are now applicable for use.
