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Pediatr Dent. Author manuscript; available in PMC 2012 December 20.
Published in final edited form as:
Pediatr Dent. 2010 ; 32(5): 400406.

Rural Latino farmworker fathers' understanding of children's

oral hygiene practices
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Matthew A. Swan, BA1 [Research Analyst], Judith C. Barker, PhD2,* [Professor], and Kristin
S. Hoeft, MPH3 [Research Analyst]
1School of Dentistry, University of California San Francisco, 707 Parnassus Ave., San Francisco,
CA 94143, USA
2Department

of Anthropology, History, & Social Medicine and Center to Address Disparities in

Childrens Oral Health, University of California San Francisco, 3333 California Street, Suite 485,
San Francisco, CA 94143-0850, USA
3Department

of Preventive & Restorative Dental Sciences and Department of Anthropology,

History, & Social Medicine and Center to address Disparities in Childrens Oral Health, University
of California San Francisco, 3333 California Street, Suite 485, San Francisco, CA 94143-0850,
USA

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Abstract
PurposeTo examine rural Latino fathers' understanding of their children's oral hygiene
practices.
MethodsA convenience sample (n=20) of fathers from a small agricultural city in California
was recruited in their homes. Individual qualitative interviews in Spanish were conducted.
Interviews were audio-taped, translated and transcribed. Codes were developed and the text
analyzed for recurrent themes.

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ResultsFathers came from Mexico (n=15) and El Salvador (n=5). Fathers had very little
understanding of the etiology and clinical signs of dental caries. Overall, 18 of 19 fathers reported
that their wife was primarily responsible for taking care of the children's hygiene. Fathers agreed
that children's teeth should be cared for from a young age, considered to be after 2 years. The
fathers described very minimal hygiene assistance given to children by either parent, and often
considered a verbal reminder to be sufficient assistance. Fathers generally thought a child did not
need supervision after about age 4 (range 1 to 11 years).
ConclusionsWhile rural Latino fathers might not actively participate in their children's oral
hygiene, they do place value on it. Men are supportive of dental treatments, albeit later than
recommended. Educational messages aimed at these families will disseminate to the fathers,
indirectly.
Keywords
Latinos; children; fathers; oral health; knowledge

Introduction
Disproportionate dental disease among the Latino population is well documented. (In this
paper, the term Latino is used to refer to those who self-identify as either Hispanic or

Corresponding author. barkerj@dahsm.ucsf.edu, Tel: 415-476-7241, Fax: 415-476-6715.

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Latino as overall, in California, where this study took place, no preference exists between
the two terms.)1 Oral health problems are highly prevalent among migrant farmworker
populations,2,3 with particularly high rates of early childhood caries (ECC) among their
children.46 Research on this topic has elucidated several reasons accounting for these stark
disparities, including barriers to dental care,7, 8 poor parental understanding of caries
etiology or prevention,3,9 low value given to primary teeth,10 and inadequate engagement of
children in oral hygiene practices at home.11, 12

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While some studies have explored how Latino mothers understand and make decisions
regarding their childrens oral health,1317 thus far there is no published research on Latino
fathers understanding of the same. This is likely due to several factors: that men are a
difficult population to recruit and interview during usual weekday work hours, that some
men are uncomfortable being interviewed by women researchers, and a well-established
assumption that depicts the Latino mother as the primary parent interfacing with children,
especially with young children, with the Latino father as peripheral to family childrearing
responsibilities.18,19 This perspective coincides with a more traditional view of Latino
fathers, one that portrays them as strict, reserved, and authoritarian. Mothers, on the other
hand, are traditionally assumed to be quiet, submissive, and subservient in the home.20 This
traditional view is being challenged by contemporary research, however, that has found
Latino couples to be more egalitarian in their distribution of responsibilities. Studies show
that Latino fathers do spend time with their children as nurturing caregivers and active
teachers.2123 Nevertheless, it is clear that despite this apparent increase in father
involvement, in Latino families, mothers still carry the majority of the household burden and
are their childrens principal caretakers responsible for their health.2226

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There is a very small body of research on fathers involvement in childrens oral health.
Broder and colleagues examined the role of 60 inner-city African American fathers in New
Jersey in child rearing and oral health practices, with the goal of evaluating the potential of
fathers to effect change if they were recipients of oral health promotion interventions.27 This
quantitative survey reported that 95% of fathers indicated interest in learning more about
ways to help their children have healthy teeth and gums. These fathers were involved in
their childrens oral hygiene routines with half reporting shared or sole responsibility for
brushing their childrens teeth. While fathers had good factual understanding of their
childrens oral health care practices, they lacked confidence in their ability to prevent
cavities or to stop behaviors that put their children at risk for cavities. In contrast, Reisine
and co-workers reported that 52 African American men living in Detroit claimed good
access to social support and demonstrated a high perceived self-efficacy to take care of their
child's teeth, but possessed limited knowledge on how to prevent oral health problems.28
These small scale studies demonstrate a wide variation in findings, but support the
development and testing of oral health promotion programs which include AfricanAmerican fathers. These issues, especially knowledge of oral health preventive activities,
have not been explored with respect to fathers from other ethnic groups, including Latino
groups.
The dearth of knowledge about Latino fathers is a void that must be filled, as these men
assume critical roles in the Latino family structure. Fathers have long been regarded as the
final decision makers within their households, particularly concerning financial matters.2931
As guardian of the family finances (including insurance and health expenditures),
transportation, and other important resources, the father is pivotal in supporting womens
decisions and providing for the familys needs. This paper examines a particular group rural Latino farmworker fathers understanding of their childrens oral hygiene practices. A
better understanding of Latino fathers views of their childrens oral health is essential if we
are to improve care provided to this population.

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Methods
We used an in-depth qualitative approach to learn more about rural Latino fathers
understanding of and practices related to their childrens oral hygiene. This approach
consisted of 12 hour long semi-structured, open-ended interviews carried out in each of the
fathers homes.

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The study was conducted in a small rural city with a predominantly Latino population, in
Californias agricultural Central Valley. The target population was farmworking fathers who
lived in this city and were: 1) caregivers of children aged 10 or less, with the aim that their
youngest child be aged 5 or less; 2) first- or second- generation immigrants from Mexico or
Central America. We recruited the convenience sample of participants partially from a
randomized list of household addresses generated by a partner study on farmworker
occupational health, but principally through personal contact made by going door-to-door.

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Interested participants were recruited into the study by a male bilingual interviewer (MS),
who obtained written informed consent. All interviews relied on an interview guide
approved by the institutional review board of the University of California, San Francisco.
Interview questions were initially developed from previous studies of Latino immigrant and
low-income populations conceptions of oral disease and experiences with the oral health
care system3, 5, 6, 810 and in consultation with a team of specialists in Latino childrens oral
health. The interview guide had previously been used to generate systematic and reliable
information from a sample of women living in the same town,29, 32 and was adapted as
necessary to fit the mens situation. Interviews documented these fathers understanding of
oral health, both their own and their childrens. Occasionally the wives added comments, but
generally the interviews were with the men only.
Each interview was conducted in Spanish and digitally recorded, then translated and
transcribed. Text data were analyzed using QSR Internationals NVivo 1.1 software
package (QSR International, Doncaster, Victoria, Australia). Following standard qualitative
analytic procedures, three independent researchers engaged in a series of iterative readings
of the text while applying codes. A short list of initial codes based on our study questions
were applied first, and subsequent codes developed and applied as they emerged while rereading the transcripts.33, 34 Codes were used to identify recurrent themes expressed by the
fathers. These themes, illustrated by typical quotes from the men, are presented and
discussed in this paper.

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Results
Sample
The sample included 20 immigrant men, 15 of whom had origins in Mexico, while the other
5 came from El Salvador. Their average age was 386.4 years; and they had spent a mean of
156.9 years in the U.S. These fathers report having a low level of educational achievement,
a mean of 5.51.6 years of schooling, and being employed in farmwork, either as fieldhands
or as truckers delivering produce from farm to distributor. The men presently head families
that are primarily low-income, with an average annual income at or below federal poverty
level ($US24,000). Almost one-third (30%) of these parents and most (89%) of their
children had health insurance, mainly public insurance through the federal Medicaid
program. The participating families had an average of 3.31.8 children each, with 65
children total. The mean age of the youngest child per family was 32.1 years.

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Fathers knowledge base as context for this study

In general, fathers assigned much less value to dental health when compared to the overall
health of the body. The fathers interviewed had very limited knowledge regarding basic oral
hygiene concepts and the etiology of dental disease. This lack of knowledge underlies their
scant involvement in their childrens oral hygiene practices, and partially explains why the
fathers accept so little responsibility for this aspect of their childrens health. Also, they
struggled greatly to define what a cavity is, what it looks like, and the significance of such
a condition.

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The fathers assigned much greater importance to general health (ie visiting a physician) than
to dental health (visiting a dentist), a thought illustrated by this father of four young
children:
I see teeth problems as something that affects you, but its not like a problem with
your body, like, for example, pneumonia or a cough, when you have to be caring
for your child. Your teeth may hurt for a little while and you can put up with it for a
day or twoI think a toothache is very different from a cough, a cold, or an
infection. [MCG011]
Similar thoughts were shared by various fathers, suggesting a generalized lack of
understanding of dental conditions and the possible repercussions of neglecting diseased
teeth. Problems in the mouth were seen as being isolated from conditions of the body. Teeth
were described as being functional, yet replaceable:

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Dental health is important, but you can eat without teeth. You can get a bridge.
But if something in your body is damaged, its very difficult to replace it.
[MCG03]
And to another father, his wifes complete lack of molars was of little concern:
She [wife] has never been [to the dentist] because she has never had any problems.
She doesnt have any molars. [MCG08]

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These fathers generally had more interaction with the family physician than with the family
dentist. While several fathers recounted visits with a primary care provider, very few could
remember any direct interaction with a dentist, further verifying that less value is accorded
to oral health. However, they do assign importance to teeth, especially their childrens. Nine
of thirteen who responded to a direct question declared their childrens teeth to be much
more important than their own.
The fathers harbored many misconceptions about the etiology, appearance, and significance
of dental caries. Only one father correctly identified the role of bacteria in caries etiology.
The majority of the fathers, however, had great trouble giving a definition and usually cited
food getting stuck on the teeth and a lack of oral hygiene as the main causes. When asked
what does a cavity look like? or how do you know when your child has a cavity?, the
responses were many and varied. The most common indicator of caries given was stains
[brown, yellow, black] on the teeth, which they also related to black dots on the teeth. To
many of the fathers, however, having a cavity was different than having tooth decay,
with the former preceding the latter. This father described his understanding of the process:
With decay you see black dots, and then you see a hole and it starts to hurtWith
a cavity, the tooth isnt decayed yet. I think its part of the process. When you have
the black dots, if you poke it with something, it becomes a dent on the tooth. Thats
a sign that the tooth is very damageda cavity is just the start of that. Black dots
form when the tooth has decayed already [MCG011].

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Four fathers cited gingival bleeding as the principal sign that their child had cavities.
Another eight fathers reported yellowing of teeth near the gumline and redness of the
gums as principal indicators of cavities, mistaking plaque accumulation and periodontal
irritation for cavity formation. Finally, one father cited bad breath as the principal indicator.
When asked if cavities could threaten the general health of their children, the majority
concluded that cavities affect a childs ability to eat, thus affecting their overall health.
However, only three fathers made reference to the risk of infectious spread from a carious
tooth.
Responsibility for overseeing childrens oral health

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In response to the question who is responsible for taking care of your childrens teeth?
fathers almost unanimously (18 of 19) agreed that their wives mainly performed this task.
Most men indicated that they did occasionally help out, too; only one man denied any
involvement at all in his childrens oral health activities.
The most common reason men provided for the mother being primarily responsible for their
childrens oral health was because the mother did not work and was at home all day with the
children. Therefore, she was available for taking care of the daily tasks that concerned the
children. During the interviews, men reported that a fathers responsibility is to work to
provide for the familys material needs, a thought illustrated by these two fathers:
Well, I could say that it was my wife because she is the one that is at home with
them. I go to work in the morning and I get home at night. [MCG03]

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shes with the children more. I work. I leave home early and when I get home I
am tired. [MCG07]
The fathers expressed complete support for the daily care activities and treatment decisions
made for their children by their wives. Some men reported that on occasion they and their
wives discussed how much they could afford to pay for oral health care for a specific
problem, or to devise a timetable for when needed treatment could be undertaken. Generally,
however, men affirmed their wives actions and took little direct action with respect to their
childrens oral health.

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A major and important exception stemmed from the fact that most of their wives did not
drive. Therefore, the fathers themselves many times drove their children to and from dental
appointments, especially when this involved trips to pediatric specialists located some 70
miles away.29 On such occasions, a father would accompany his wife and child into the
dental office and participate first-hand in decision-making and discussion with the health
professional.
Despite the mens generalized lack of participation in supervising their childrens oral
health, the fathers were very aware of oral health needs and of the dental treatments their
children had undergone. In response to questions such as tell me about your childrens
teeth, and how have their [childrens] experiences with dentists been? these fathers were
able to discuss the condition of their childrens teeth. Of the19 fathers whose children had
past dental treatments, 17 talked in detail about those treatments. Reasons for visiting the
dentist, the childs experience of going to the dentist for the first time, and even which
specific teeth were worked on were all subjects about which the fathers elaborated.
This father, for example, talked about his childs broken tooth and the way he and his wife
deliberated about whether to visit the dentist or not:

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R: That's the problem he has at the moment. His tooth is broken. He had gotten fillings in
some of his molars before. It seems that one of them is opening up again.
I: So, what are you going to do? Do you plan to take him in to get it fixed?
R: Well, a bit later, yes. We [indicating he and his wife] are just seeing if it's going to fall
out. We're waiting to see what they [dentist] recommend, to see what we can do; if we
should just wait for it to fall out or what. [MCG07]
Another father recalled specific details about his sons experience with a local pediatric
dentist:

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I: Where did you take him when you took him to the dentist?
R: I took him to a specialist for children. That specialist only treats children up to five
years of age.
I: Here in [name of rural town]?
R: In Fresno [large city some distance away]. He [the dentist] took some molars out, he put
in some crowns and he put some without metal in the frontthere were about six teeth that
were fixed. [MCG01]
A third father recounted how many fillings his son had received at his last dental visit:

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R: Well, we were taking our son tothe clinic. He had to get some fillings. I think that the
reason was because he eats a lot of candy.
I: He eats a lot of candy?
R: Yes, and he got caries and all that.
I: How many fillings did he get?
R: I think they [dentist] said they were going to do 10, but in the end they only did 8.
[MCG05]

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When to Initiate Home Oral Hygiene Practices

These Latino fathers generally agreed that a child should begin oral hygiene practices at a
young age. When asked to specify more exactly what age, men responded with a wide range
from approximately 6 months of age to 4 years. However, the average age of tooth brushing
initiation that these men reported was 20.99 years. This is much later than the age
recommended by the American Dental Association (ADA), which encourages tooth
brushing upon eruption of the first baby tooth.35
Of the 18 fathers who responded to this question, 10 recommended oral hygiene initiation
after age 2. The major reason being given for this was that all baby teeth should be allowed
to erupt before beginning to brush, as this man noted:
I: at what age should a child start to look after his own teeth?
R: I think that once all their teeth have come in, then they should start looking after
them, according to what I believe. [MCG015]
A second father agreed with this assessment, saying:
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I: At what age should you starting caring for their [childrens] teeth?
R: I suppose that it should be from the time when a parent sees that all their teeth have
come out and formed. Thats when you should start taking care of them. [MCG01]
Another reason given for a later start was that children should begin to brush their teeth only
when they are going to school and have learned to do it properly:
R: Only when you see that they are already going to schoolthats when you start to tell
them [to brush their teeth]. [MCG08]

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Hygiene Assistance Given to Children

When asked, at what age can your child take care of his/her teeth on their own, without
adult supervision? the average age reported by these fathers was 4.12.3 years, with a
range of 110 years. These responses veer from the ADA recommendation, which advises
parents to assist with their childrens brushing until age 6 or 7.36
Actual physical assistance given to children during their home oral hygiene practices
appeared to be very limited, and if given at all, was given almost exclusively by the mothers.
The frequency and degree of such help appears to be minimal though: ten fathers described
the mothers participation as being given sometimes, two men said their wives assisted the
children once in a while, and one man stated twice a week. Only 1 man denied that his
children received any assistance at all:

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I: Do you or your wife supervise them?

R: No.
I: Neither?
R: No. They brush their own teeth and thats it. [MCG06]
Many of the fathers reported that their wives assisted their children with oral hygiene, but
the amount of help given depended entirely on the childs age. Much more help was given to
children aged 2 years and younger, as 9 fathers reported help for this age group. Assistance
was commonly provided at bath time by the mother, often with a finger brush:

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My wife brushes my daughters [2 years old] teeth with a finger brush and she
cleans them. [MCG05]
Every time she bathes him [1 year old], she brushes them. She uses a toothbrush
that you put on your finger. She brushes them. [MCG03]
On the other hand, only 3 fathers reported hygiene assistance given to their children older
than 2 years. One father did report help given to his six year-old:
He [6 year-old son] brushes them, but when we see he hasnt done it well, we do
it. If he doesnt brush them well, she [mother] does it for him. [MCG09]
Generally, though, the fathers reported no assistance was given to their school-aged
children. Fathers assigned great significance to oral hygiene instruction given to their
children at school. For many parents, their children learning to brush at school related to the
age at which they stopped giving assistance. The following 3 quotations demonstrate this:
[I help]very rarelyLike I said, they teach them at school too. They [children]
know how to brush their teeth well. [MCG03]

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The 4 year old also does it himself because they taught him how to do it at
school. [MCG012]
I: Up to what age did you help them? (with tooth brushing)
R: Until they were 4 years old and then at that point they started going to school. They
taught them there too. [wife of MCG018]

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The concept of parental supervision within these families appears to vary widely among
the fathers. They clearly recognized their childrens need for help in regards to oral hygiene,
and some fathers connected the idea of supervision with direct participation in their
childrens oral hygiene practices. Many fathers (11 out of 20), however, directly associated
supervision of their childrens oral hygiene routines with giving their children a verbal
reminder. In lieu of actual demonstration, example of brushing, or physical aid, fathers
believed that simply telling their children to brush adequately fulfilled this parental
responsibility. This father, for example, connected supervision with verbal reminder,
reporting that his children were supervised every time they brush their teeth:
I: Of all the times they brush their teeth, how many of those times are they supervised?
R: All of the times.
I: Always?

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R: Yes, always. In the morning, she [Mother] tells them and they brush their teeth. They go
in one by one and thats how they brush their teeth. [MCG09]
And here a father describes the supervision of his 1 year-old sons brushing:
I: What do you do to look after your childrens teeth?
R: With this small one, she [Mother] tells him, in the evening, to brush his teethhe grabs
his toothbrush and cleans them himself. [MCG017]
While many fathers agreed that some form of parental supervision is important, the most
prevalent idea of to supervise comprised to remind. Monitoring a childs oral hygiene
techniques or habits for effectiveness of brushing was rarely if ever performed:

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I think it is important that they are supervised, but I rarely do thatshe [Mother]
does it more. She tells them to brush their teeth, but she doesnt ask them to open
their mouth afterwards to check. She just tells them to brush their teeth and thats
it. [MCG011]
Fathers clearly associated telling their children to brush with fulfillment of parental
responsibility, even if no other instruction or help was given:
A child cant automatically know how to look after his teeth. Were there to
constantly tell him to brush his teeth. [MCG015]
Seven fathers recognized that simply telling their children to brush their teeth was not
always an effective preventive measure. This thought is illustrated here:
R: We sometimes watch them or tell them how to brush their teeth, that they should brush
them 3 times per day. We tell them, before going to school.that they have to brush their
teeth.
I: So you tell them to do that, but do they always do it?
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R: No, in truth, no. Not always. [MCG07]

Discussion

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This paper contributes to an understanding of how rural Latino fathers understand the
etiology of childrens dental caries and how they view their responsibility for their
childrens oral health. Clearly, the mother is the primary caregiver in these Latino families,
especially with respect to childrens oral health practices. This is consistent with a wide
literature reporting that Hispanic mothers are the main caregivers to their children and play
the dominant role in terms of health/hygiene.2226 However, it is also clear that these fathers
place great value on their childrens health, including the health of their teeth. The fathers
are very supportive of dental treatments for their children, and in many instances ensure they
stay informed about the specifics of oral health needs and dental treatments received by their
children. This supports findings reported by other scholars (Broder, Reisine) with regard to
African American fathers.27, 28

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While fathers recognize that young children cannot be held fully responsible to remember
and conduct oral hygiene independently, these mens perception of when and how much
assistance is needed is very different from ADA recommendations. Fathers are supportive of
their childrens oral hygiene, but their participation in daily practices is minimal. While the
main oversight of oral hygiene is conducted by mothers, they are generally merely
reminding children to brush their teeth, and rarely physically assisting children, even those
as young as 1 year old. Parental supervision of childrens brushing should be explored in
greater detail, as it appears that for these Latino parents to supervise is understood to mean
remind and it is not perceived as necessary to physically assist or visually check a childs
teeth. This is particularly true once a child attends school and is known to have received oral
hygiene instruction in the classroom. Fathers place great value on school-provided hygiene
instruction and for many, the age at which their children started school was the age at which
they were assumed to be able to brush effectively by themselves.

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These families are initiating oral hygiene routines later than the age recommended by the
ADA (upon eruption of first tooth). While there exists a wide age range for toothbrushing
initiation (6 months to 4 years), the fathers do place value on caring for baby teeth. As
reported in other work on Latino parents, fathers do not recognize the early signs of caries,
not connecting discolored teeth with decay, nor do they understand its etiology.32. Fathers,
though not directly involved in their childrens oral hygiene practices, stay aware of dental
topics through conversations with their wives and other associates. Therefore, programs that
aim to improve the health of rural Latino children, while ideally aimed at both parents,
should especially continue to focus on mothers, with the realization that the information will
indeed disseminate to the fathers indirectly.
Limitations
Limitations of this study include having a small convenience sample, social desirability and
recall biases, and a single rural location. The interviewer expected reticence from the fathers
and supposed that this would be a potential limitation of the study. However, quite the
opposite proved to be true. Mostly likely because of gender concordance between
interviewer and interviewee, the fathers were very easily approached and openly shared their
experiences. In instances when the men provided socially undesirable answers, they would
often follow their comments with why should I lie to you? This congenial transparency
made the interview process very enjoyable.
Despite its limitations, this study expands the present literature in important ways. It is the
first to contribute knowledge about what Latino fathers know and do with respect to their
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childrens oral hygiene. As such, it forms a basis for the development of future research
aimed at uncovering in greater detail the role of Latino immigrant fathers in providing for
their childrens oral health needs.

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Further exploration is critical if we hope to improve the oral health of this population. Upon
comparing this studys results with those of other, larger studies conducted principally with
women,29, 32 it is clear that rural Latino men and women have unique explanatory models
for how dental disease develops and sometimes interpret symptoms differently. Thus, while
most studies investigate womens views and actions and present them as parental views,
studies should also include men who have distinct patterns of thought and behavior. Fathers
are pivotal in the decision-making process, and many times are key facilitators of a dental
visit by being able to drive the children to their appointments. Thus, their opinions are
significant and their input is relevant. In order to include this set of parents in research,
studies may want to focus on finding these fathers at home in the evenings, on weekends,
and at other times, and to employ male bilingual interviewers.

Conclusions
The following conclusions can be drawn based on this studys findings:

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1.

Rural Latino fathers place value on taking care of childrens teeth at a young age.

2.

While rural Latino fathers may not actively participate in their childrens oral
hygiene, they are aware of what takes place both at home and with dental
professionals.

3.

They are supportive of dental treatments for their children, financially and
otherwise.

4.

Many times, supervision of childrens oral hygiene signifies only a verbal

reminder to brush teeth. Children are brushing independently, starting as young as
one year old.

5.

In many families, oral hygiene routines are initiated later than the age
recommended by the ADA (upon eruption of first tooth).

6.

To improve rural Latino childrens health, programs must focus on both parents but
especially on mothers. Educational messages aimed at women will disseminate to
fathers, indirectly.

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Acknowledgments
Support was provided by the National Institute of Dental and Craniofacial Research grant number U54 DE 014251
(Center to Address Disparities in Childrens Oral Health) and CTST grant number T32 DE017249. All authors have
made substantive contribution to this study and/or manuscript, and all have reviewed the final paper prior to its
submission. We would like to also thank Erin Masterson for her helpful comments.

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