Assessment of Parenting Stress and its Relationship with Oral Health Status of Children Aged 6-12 Years in Davangere City - A Cross-sectional Survey

Introduction

Parenting is a special phase of life that an individual passes through.^1,2 Childhood is a critical phase for the establishment of physical, mental, emotional and social health.³ Young children are mostly dependent on their parents, lack of which may lead to devastating effects on the child’s overall development.⁴ It is also evident that healthy practices in children are shaped during this period.^3,5,6 Literature suggests that a broad nexus of parental factors influence the child’s oral health status. The widely acknowledged factors among them are, the parents’ sociodemographic factors, feeding practices, oral health status, knowledge, attitude, beliefs related to oral health and psychosocial factors (depression, anxiety, locus of control and sense of coherence).^1-6

Parenting stress is defined as “the parental perceptions of an imbalance between the demands of parenting and available resources.” It is one of the many factors that contribute to the effectiveness of parenting.⁷ It impacts children’s lives through disruptions in parenting skills and family relationships and is positively correlated with child behavioural and developmental maladjustment.⁸ Higher the parental stress, greater are the child’s problems. High levels of parental stress during a child’s infancy can hinder caregiving quality and potentially disrupt parent-child bonding. Similarly, an infant’s sense of security may be affected by parental stress, particularly if the parent struggles with managing their own emotions or maintaining consistent routines for the child.⁹ If parenting stress affects child health, it is more likely to effect the health maintenance/disease prevention measures. Parents who are under a great deal of stress are more likely to think reactively than proactively regarding their child’s health and oral health.¹⁰ Therefore parenting stress can be an important determinant of children's oral health status.¹¹

On literature evaluation, most of the research done in developing countries has reported parental factors such as income and education being significant risk factors for the poor oral health of the children when compared to other proximal risk factors. Limited studies have elucidated the evidence regarding the relationship between parenting stress and oral health status of the children in Indian context. Hence this study was planned to assess the parenting stress and its relationship with the oral health status of children aged 6 to 12 years in Davangere city.

Materials and Methods

An observational, descriptive, cross-sectional survey was conducted involving parent-child dyads, with children aged 6-12 years, on their first visit to Department of Pedodontics and Preventive Dentistry.

Sample size calculation (n)

There were no previous studies which assessed the relationship between parenting stress and oral health status of children in India. Hence, by considering dental caries as one of the outcome measures, the data was imported from a previous study done to assess the trends in dental caries in Indian children.¹² Prevalence of dental caries in the age group of 6 to 10 years (69%) was considered to calculate the sample size for the present study. The sample size was determined by fixing the type I error (α) at 5% and type II error (β) at 20%, maintaining the power of the study at 80%. It was calculated using the formula, N=4pq/l2, considering the allowable error (L) of 5%. A sample size of 342.24 was obtained which was rounded off to 350. Anticipating the non-response to an extent of 20%, the sample size was increased accordingly. The sample size considered for the present study was n=420 (parent-child dyad). A non-probability, consecutive sampling technique was adopted until the required sample size was achieved. Ethical approval was obtained from the Institutional Ethical Review Board before the start of the study (Ref.No: BDC/Exam/574/2020-21).

Inclusion criteria

Healthy children aged 6-12 years, with no known chronic medical conditions, without any behavioural or cognitive disease, children living with both parents and willing to participate and who were able to sit and cooperate for clinical examination (No history of phobias related to the dental setting) were considered. If there was more than one child in the family in the age group of 6 to 12 years, only one child was selected for the study using lottery method. When both parents accompanied the child, only the parent who provided written informed consent, along with child assent, and who could read either English or Kannada (the local language) was invited to voluntarily participate in the study.

Exclusion criteria

Children with special healthcare needs were identified and excluded using the CSHCN survey screener (Children with Special Health Care Needs).¹³ The rationale for this exclusion is that children with special healthcare needs are at a greater risk for oral diseases and also parenting stress is reportedly high.¹¹

Data Collection

Recording of socio-demographic characteristics

Socio-demographic details related to parents and children were recorded using 12 questions in both open and close-ended format. Data were collected from the responses of the parent who volunteered to participate in the study. The modified Kuppuswamy scale 2022, was used to classify the socioeconomic status.¹⁴

Assessment of parenting stress using Parental Stress Scale (PSS)

The Parental Stress Scale (PSS), an 18 item scale originally developed by Judy Berry and Warren Jones, representing positive and negative components of parenthood was used.¹⁵ It is a self-rated, 5-point Likert-type scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). To compute the parental stress score, the positive items 1, 2, 5, 6, 7, 8, 17, and 18, were reverse scored as follows: (1=5), (2=4), (3=3), (4=2) and (5=1). The item scores were then summed. Higher scores reflected greater parental stress. The possible scores of the PSS ranged between 18 to 90. Scores were categorized as follows: 18-42 (low stress), 43-66 (moderate stress) and 67-90 (high stress).

Validity and reliability of translated version of PSS

Jeevannavar JS had previously conducted a study testing the reliability and validity of the Kannada version of Parental Stress Scale.⁷ They reported an excellent Cronbach’s alpha value of 0.915 and an ICC value of 0.82 for the test-retest reliability. Based on this data, Kannada version of the PSS was identified as a reliable and valid tool.

Training and calibration

The primary investigator was calibrated for clinical examination. Kappa statistics were applied to compute the intra-examiner reliability. The Kappa coefficient scores were 0.88, 0.94 and 0.92 for DMFT/deft index (Decayed, Missing, Filled teeth / decayed, extracted, filled teeth), MGI (Modified Gingival Index) and OHI-S (Oral Hygiene Index-Simplified), respectively. These values reflected a high degree of conformity in observations.

Scheduling of survey

The data collection period spanned approximately for eight months, from March 2022 to October 2022. The survey process was scheduled between 9 am to 4.30 pm on feasible working days to meet the children aged 6 to 12 years and their parents visiting the department of Pedodontics and Preventive Dentistry .

Method of administration of survey questionnaire

The parents who voluntarily provided informed consent to participate in the study were made to sit comfortably in the waiting area of the Pedodontia department. The procedure and purpose of the study were explained to them by the primary investigator. They were given a questionnaire related to parenting stress either in English or Kannada language as per their preference. It was supervised by a trained research assistant. Concurrently, the primary investigator conducted the oral health examination of children for assessing their oral health status.

Assessment of oral health status of the children

Dental caries was assessed using DMFT/deft index with WHO modified criteria.^16-18 Gingival health was assessed using the Modified Gingival Index.¹⁹ Oral hygiene status was assessed using the Oral Hygiene Index- Simplified (OHI-S) in permanent dentition and modified OHI-S in deciduous and mixed dentitions.^20,21

Statistical analyses

The data obtained were compiled systematically in a Microsoft Excel sheet and subjected to statistical analyses using Statistical Package for Social Science (SPSS) software version 20. The significance level was fixed at P <0.05. Descriptive statistics were generated in terms of frequencies, percentages, mean and SD. Chi-square test was used to assess the association between the categorical variables. Spearman’s correlation was used to assess the correlation of categorical variables. Logistic regression model was used to assess the relationship between dichotomized predictor variables (sociodemographic and parenting stress) and binary dependent variable, oral hygiene status.

Results

A total of 420 parent-child dyads visiting the department of Pedodontics and Preventive Dentistry were approached to collect the data as per the determined sample size. The mean age of the children was 8.8±2.0 years. Female children were more in number (54.8%) compared to males (45.2%). The majority of children had one sibling (45.2%), followed by no siblings (26.2%), two siblings (22.6%), three siblings (3.6%), four siblings (1.7%) and five siblings (0.7%). Most of the children in the present study were studying in private schools (78.6%) compared to public schools (21.4%). About 50% of the respondents were from the upper middle socioeconomic class, 23.8% from the upper lower, 22.9% from the lower middle, 2.4% from the lower class and 1% were from the upper class (Figure 1).

Majority of parents reported moderate stress levels (91%) and only 9% reported high stress levels (Table 1). On assessing oral hygiene status of children, more than half showed low caries experience (62.5%). High and no caries experience were seen among 19.2% and 18.1% of children, respectively. When the gingival status of children was assessed using the modified gingival index (MGI), 96.2% showed a milder form of gingivitis, 3.3% showed moderate gingivitis and severe form of gingivitis was seen in 0.5% of children. When the oral hygiene status of children was assessed using the Oral Hygiene Index-Simplified (OHI-S) in permanent and mixed dentitions, the majority of children showed good oral hygiene (57.4%), followed by fair oral hygiene status (30.2%), while 12.4% showed poor oral hygiene status (Figure 2).

The association between parents’ stress levels and children’s caries experience, gingival status and oral hygiene status was found to be statistically insignificant (ꭓ2 = 3.28, P = 0.19), (ꭓ2 = 0.675, P = 0.714) and (ꭓ2 = 0.415, P = 0.937), respectively. A weak positive, non-significant correlation was found between the parents’ stress levels and children’s caries experience (rho = 0.035, P = 0.474) and gingival status (rho = 0.024, P = 0.619). Whereas, a weak inverse, non-significant correlation was found between the parents’ stress levels and children’s oral hygiene status (rho = -0.007, P =0.879) (Table 2).

Further analysis was done to identify the predictors for the children’s oral health status. Factors like parents’ occupation, education, gender, parenting stress, socioeconomic status, number of siblings, type of school, and gender of the child were included in the model. The dependent variables were dichotomized as caries present/absent, gingivitis present/absent, good /poor oral hygiene status. Among all the predictors, mothers’ education level was a statistically significant predictor of the child’s oral health status, with the odds ratio (OR) of 2.931, P <0.05 (Table 3).

Discussion

Home is a child’s first school, and parents are their first teachers. Just as a teacher’s effectiveness shapes the child’s future, effective parenting is crucial for a child’s personality formation, as well as their psychological and social development.^22-24

An enduring, emotional parent-child bond enables children to explore the environment, either intentionally or unintentionally.^25,26 Evidence supports that greater parental support is associated with better health and healthcare service utilization.³ Recently, parenting stress has garnered more attention from the researchers and clinicians compared to other psychosocial factors. Hence much research is oriented towards this.

Parental stress is defined as, ‘the negative emotional experience accompanied by predictable biochemical, physiological, cognitive and behavioural changes, directed either towards altering the stressful event or accommodating to its effects, which parents experience in general’. Parental stress may stem not only from the demands of raising children, but also from social and environmental factors, daily responsibilities and life circumstances, such as limited social support, financial pressures and significant duties involved in parenting.8 Stress is one of the many factors that contribute to the effectiveness of parenting.⁷ Hence, parenting stress can be an important determinant of children's oral health status.¹¹

Among the contextual factors that can influence a child’s oral health outcomes, parenting stress is one that has been relatively less examined in oral epidemio-logical studies. Hence the study aimed to assess parenting stress and its relationship with the oral health status of children aged 6 to 12 years in Davangere city.

Since no previous studies have reported the parenting stress and caries levels among 6-12 year old children, valid comparison could not be made. Hence the present study results were compared with the studies assessing Early childhood caries (ECC) and parenting stress.

In the present study, 91% of parents reported moderate stress and 9% reported high-stress. About 82.1% of children of moderately stressed parents had caries; however, this was not statistically significant. Similar findings were reported in studies done by Jabbarifar et al., Finlayson et al., Gavic et al., Seow et al., who assessed the relation between parenting stress and ECC.^27-30 Contradictory results were noted in the studies by Menon et al., Tang et al., and Quiñonez et al., who reported a statistically significant, strong correlation between ECC and parenting stress.^31-33 Parental stress was reported to be a significant predictor of ECC. This could be attributed to the fact that psychosocial variables and behavioural practices present at the time of stress measurement in various studies might have differed markedly from the present study.²⁷

A surprising finding that emerged in the present study was that parenting stress, which was expected to operate as a risk factor, was instead found to be a protective factor. Among children whose parents reported experiencing high levels of stress in the parenting role, about half of the children showed low caries experience (50%), while 28.9% of children showed high caries experience. This was found to be consistent with the study done by Finlayson et al.²⁸ This could be attributed to the fact that perceived distress in the parenting role reflects greater responsiveness from the parent, better developed coping skills in the face of adversity, or any other adaptive quality. Other reasons could be the higher income, upper middle socioeconomic class, and presence of only one child among the majority of participants (45.2%) in the present study. However, our findings conflict with the studies done by Tang et al., and Quinonez et al., who reported a significant positive association between parenting stress and ECC in bivariate analyses, though it did not contribute independently in multivariate analyses.^32,33 This could be due to the variations in the stress indices used in different studies.

Among the children of parents who reported high stress levels, 94.7% of children had a milder form of gingivitis compared to 5.26% with moderate and none with severe gingivitis (0%). Good oral hygiene status was observed in 60.5% of children, while fair oral hygiene status was found in 26.3% and poor oral hygiene status in 13.1%.

The moderate and high levels of parenting stress reported by parents in the present study could be attributed to the challenges encountered in the process of child-rearing. This stress arises from certain characteristics or behaviours of the child that make it difficult and stressful for the parents to meet their child’s needs. The stress could also be due to parent and family characteristics including emotional, financial, acute and chronic life stressors and events and potential dysfunctions related to different dimensions of parenting function.^8,26

The parental education level and upper-middle socioeconomic status of the family in the present study have been demonstrated to be protective against the child’s oral hygiene status, enabling more positive parent-children interactions and subsequently reducing parenting stress.¹²

The present study is the first of its kind to assess the influence of psychosocial variables like parenting stress on the oral health status of children in Davangere city, Karnataka, India, belonging to the transitional period (6-12 years). The use of psychometrically tested tool (PSS) enhanced the internal validity of the present study. Training and calibration of primary investigator for conducting clinical examination with a high degree of conformity in observations minimized the intra-examiner variability.

The use of cross-sectional design limited the causality. A longitudinal design could help for understanding of temporal and perhaps causal relationships. The use of a self-reported survey questionnaire may not have accurately captured parents’ perceptions of their own parenting stress, potentially obscuring the true relationship among the variables. The study subjects represented a convenience sample of parent-child dyad, and the study was carried out at a single centre in urban area. As a result, the findings may not be representative of the broader parent population. Therefore, there is a potential for selection bias. Assessment of children’s gingival status by visual examination method might have created subjective errors in the interpretation.

Conclusion

Majority of parents reported experiencing moderate levels of parenting stress. When children’s oral health status was assessed, more than half of children who had low caries experience, showed a milder form of gingivitis and good oral hygiene status. The level of parenting stress did not have any influence on the children’s oral health status in the present study.

Conflict of interest

Nil

Acknowledgment

We would like to thank the institution and the parent child dyads who participated in the study.