TOOTHBRUSHING AS A DYADIC PROCESS: INSIGHTS FROM NOVICE CAREGIVERS AND FIRSTBORN INFANTS SARAH NELL ELISON SCHOOL OF HEALTH SCIENCES, UNIVERSITY OF SALFORD, SALFORD, UK Submitted in Partial Fulfilment of the Requirements of the Degree of Doctor of Philosophy, January 2013 1 CONTENTS CONTENTS............................................................................................. I LIST OF TABLES .................................................................................... VI LIST OF FIGURES ................................................................................ VIII ACKNOWLEDGEMENTS ....................................................................... IX ACRONYM GLOSSARY .......................................................................... X ABSTRACT ........................................................................................... XI 1 CHAPTER ONE: GENERAL INTRODUCTION TO THE THESIS .............. 1 1.1 Introduction .............................................................................................................................. 1 1.2 The Importance of Dental Health-Care Routines from Infancy .................................................. 4 1.3 The Value of the Contribution of Developmental Psychology to Understanding Toothbrushing as a Dyadic Process ............................................................................................................................ 8 1.4 Aims of the Thesis ................................................................................................................... 12 1.5 Overview of Thesis Structure .................................................................................................. 15 2 CHAPTER TWO: DISCUSSION OF INFLUENCES ON DYADIC TOOTHBRUSHING ROUTINES: EVIDENCE FROM THE PUBLISHED LITERATURE ....................................................................................... 18 2.1 Introduction ............................................................................................................................ 18 2.1.1 Using Bronfenbrenner’s Ecological Model to Conceptualise Influences on Emergence of Toothbrushing as a Dyadic Process in Infancy ................................................................................... 23 2.2 Conceptualising Potential Influences on the Emergence of Toothbrushing as a Dyadic Process in Infancy ......................................................................................................................................... 28 2.2.1 Potential Influences from the Chronosystem on the Emergence of Toothbrushing as a Dyadic Process ................................................................................................................................... 31 2.2.2 Potential Influences from the Macrosystem on the Emergence of Toothbrushing as a Dyadic Process ................................................................................................................................... 32 2.2.3 Potential Influences from the Exosystem on the Emergence of Toothbrushing as a Dyadic Process 42 2.3 Potential Influences from the Microsystem on the Emergence of Toothbrushing as a Dyadic Process- The Caregiver-Infant Dyad ................................................................................................. 49 i 2.4 Potential Caregiver Influences on the Emergence of Toothbrushing as a Dyadic Process through Infancy................................................................................................................................ 57 2.4.1 Bandura’s Social Learning and Social Cognitive Theories .................................................... 59 2.4.2 An Introduction to Self-Efficacy ........................................................................................... 61 2.4.3 Research Findings Related to the Role of Parental Self-Efficacy on Child Dental Health Outcomes ........................................................................................................................................... 65 2.4.4 Methods of Measuring Parental Self-Efficacy when Researching its Association with Child Dental Health Outcomes ................................................................................................................... 66 2.4.5 The Role of Caregiver Biological Influences on the Emergence of Toothbrushing as a Dyadic Process through Infancy ......................................................................................................... 69 2.4.6 The Role of Caregiver Knowledge on the Emergence of Toothbrushing as a Dyadic Process through Infancy.................................................................................................................................. 69 2.4.7 The Role of Caregiver Parenting Practices on the Emergence of Toothbrushing as a Dyadic Process through Infancy .................................................................................................................... 71 2.4.8 The Role of Caregiver Affective Influences on the Emergence of Toothbrushing as a Dyadic Process through Infancy .................................................................................................................... 74 2.5 Potential Infant Influences on the Emergence of Toothbrushing as a Dyadic Process through Infancy ............................................................................................................................................. 75 2.5.1 The Role of Infant Behaviour in the Emergence of Toothbrushing as a Dyadic Process through Infancy.................................................................................................................................. 77 2.5.2 The Emergence of Tool Use Skills in Infancy ....................................................................... 80 2.5.3 The Emergence of Self-Care Skills in Infancy ....................................................................... 85 2.5.4 The Importance of Adult Supervision during Early Dyadic Toothbrushing ......................... 88 2.6 Summary of Chapter Two ....................................................................................................... 98 2.7 Aims of the Thesis ................................................................................................................. 100 3 CHAPTER THREE: MATERNALLY PERCEIVED BARRIERS AND FACILITATORS OF ESTABLISHING AND MAINTAINING DYADIC TOOTHBRUSHING ROUTINES WITH INFANTS ..................................... 104 3.1 Introduction .......................................................................................................................... 104 3.1.1 Influences on Dyadic Toothbrushing Routines- Findings from Qualitative Interview Studies 106 3.1.2 Practical and Theoretical Issues when Using Qualitative Methods to Explore Perceived Influences on Toothbrushing as a Dyadic Process ........................................................................... 116 3.1.3 Aims of the Study .............................................................................................................. 123 3.2 METHOD ............................................................................................................................... 125 3.2.1 Design ................................................................................................................................ 125 3.2.2 Participants ........................................................................................................................ 125 3.2.3 Materials ............................................................................................................................ 128 3.2.4 Procedure .......................................................................................................................... 128 3.2.5 Interview Schedule ............................................................................................................ 128 3.2.6 Data Coding and Analyses ................................................................................................. 129 3.2.7 Reliability Analyses ............................................................................................................ 132 3.3 FINDINGS .............................................................................................................................. 140 3.3.1 Outline of Main Themes and Sub-Themes ........................................................................ 140 3.3.2 Full Description of Themes and Corresponding Interview Quotes .................................... 142 3.4 DISCUSSION .......................................................................................................................... 170 ii 3.4.1 Overview of main Findings ................................................................................................ 171 3.4.2 Maternal Cognitions around Toothbrushing ..................................................................... 172 3.4.3 Mother and Infant Behaviours around Toothbrushing ..................................................... 176 3.4.4 Limitations to the Study .................................................................................................... 180 3.4.5 Further Study ..................................................................................................................... 182 4 CHAPTER FOUR: DEVELOPMENT OF A TASK-SPECIFIC SCALE TO MEASURE MATERNAL SELF-EFFICACY TO ESTABLISH DYADIC TOOTHBRUSHING WITH FIRST-BORN