Psychosocial, education, economic factors, decision-making ability, and caries status of mothers of children younger than 6 years in suburban Nigeria

A woman’s biology - reproductive function, concentrations of sex hormones, and higher percentage of body fat - have health implications [1]. In addition, genderized behaviors, lifestyle, and life experiences often negatively affect women’s access to health care, use of preventive and curative health care services, and the attitudes of medical personnel towards them [1‐3]. Substantial changes in health occur during and after a woman becomes a mother, and these changes may have implications for women’s oral health [1].

The health and psychological wellbeing of mothers as autonomous rather than reproductive beings is important. Few studies have evaluated the oral health of women caring for their highly dependent infants, toddlers and preschool children. Most studies focused on women’s oral health during pregnancy [4]. Paying attention to the health needs of mothers of young children improves the mothers’ quality of life and has implications for the health and wellbeing of her peers, family, and the community she is part of [5].

The stressful period of young-child care can cause new oral health challenges for women, resulting from a complex interaction between biological [6, 7], behavioral [8] and psychosocial [9‐11] risk factors that are more pronounced during this time. For example, women face increased risk of violence from partners while nursing children, a factor associated with the risk for poor oral hygiene [12], with its corresponding risk for caries [13, 14]. The young-child-care period is also associated with increased risk for financial stress, with increased tendency for mothers to feed on cheap, high-sugar content food [15], a tendency that is also associated with caries development. The risk for postpartum depression [16] may also increase the maternal incidence of caries [17]. Mothers may face negative psychological problems for up to 3 years after childbirth [16].

Women also face emotional stress when they become mothers [18]. Sex differences may exist in parents’ ability to identify and cope with stressors associated with the major life transition of becoming a parent or expanding their families. Studies suggest that women are less able than men to counterbalance the effects of stressors due to differences in their use of personal coping resources such as sense of coherence (https://​www.​ncbi.​nlm.​nih.​gov/​books/​NBK435812/​). Sense of coherence is a concept from the salutogenic health model that reflects an individual’s global orientation to life and captures resiliency and the ability to cope with problems or stressors [19]. Women can, however, mobilize social support to moderate the effect of stress better than men [20‐23]. These psychosocial factors have implications for oral health [24] and are associated with maternal morbidities during the young-child-care period [25‐27].

Possible protective factors from caries for women include education, empowerment and psychosocial factors such as executive function, sense of coherence, and social support [28]. Empowered women can make independent decisions about household activities, including access to healthcare, home purchases, and socialization [29]. The ability to maximize health benefits is enhanced by one’s executive function and sense of coherence. Caries prevalence and severity is lower in women with higher education [19]. Higher executive function is associated with improved dental-related functionality [30, 31] and oral hygiene practice [32]. A higher sense of coherence is associated with improved oral health through improved tooth brushing, utilization of dental services, and reduced smoking [33]. Stress, however, impacts negatively on executive function [34].

With increasing evidence of psychosocial risk and protective factors on health and wellbeing, there is need to generate more data on how these affect oral health, including sex-specific data. Little is known about the oral-health profile of women with children who are heavily dependent on them for care – infants, toddlers and preschool children. This study addresses this gap by examining the association between the psychosocial profile of mothers of 6–71-months-old children and their prevalence of caries.

This is a secondary analysis of a dataset that was collected to determine the association between maternal psychosocial factors and early childhood caries through a household survey and clinical examinations conducted between December 2018 and January 2019. The study was conducted in sub-urban Ife Central Local Government Area of Osun State, one of the 774 local government areas in Nigeria. Study participants were identified through three-level multi-stage cluster sampling that led to recruitment of 1549 mother-child dyads. Folayan et al. [35] have described the sampling method and data collection in detail.

Table 1 lists the socio-demographic characteristics of the study participants. The age range for the mothers was 16–55 years, with mean (standard deviation or SD) age of 31.7 (5.8) years. Most (59.3%) were 25–34 years, had secondary education (63.1%) and earned N18,000 ($49) -N30000 ($84) per month (42.9%). Most participants (68.8%) reported being able to make the three types of decisions autonomously - health care, household purchases, and visits to family and relatives.

Table 2 highlights the results of the test of association between the psychosocial status of the mother and the prevalence of caries. The only psychosocial factor significantly associated with the prevalence of caries was fatalism: more mothers with low fatalism had caries (p = 0.005).

Table 3 highlights the outcome of the logistic regression analysis. The Pseudo R² estimate indicates that about 8% of the variance in mothers who had or did not have caries could be explained by the combination of the independent variables in the model. Mothers who had high levels of stress were twice as likely to have caries as were those whose level of stress was normal (AOR: 2.26; 95% CI: 1.04–4.89; p = 0.039). Also, mothers who had high fatalistic beliefs were less likely to have caries than were those who had low fatalistic beliefs (AOR: 0.40; 95%CI: 0.21–0.75; p = 0.004).

The study findings indicate that parenting stress was a significant risk indicator for caries in mothers with children less than 71 months old, and high fatalistic beliefs were a protective factor. Many reasons can be proffered for the increased risk for caries in mothers who experience parenting stress. All the mothers in this sample had young children who are dependent on their caregivers for all their needs. Younger infants and toddlers have constant needs and little ability to communicate those needs or to independently meet them. It would not be unusual for mothers to report parenting demands as highly stressful, particularly if they are first-time mothers who are navigating this transition for the first time. Even experienced mothers may have parenting stress, and many prioritize their children’s needs over their own [59]. This allocation can include change in feeding behavior of stressed individuals – stressed individuals eat more hyper-palatable (high fat, high sugar) food [60], which increases the risk for obesity and caries [61, 62]. Stress also increases the risk for poor oral hygiene; a risk factor for caries [63].

The inverse relationship between the risk for caries and high fatalism is less clear. Fatalism is associated with reluctance to participate in health-promotion programs and health-care utilization because of the belief that participation will have no positive impact and that poor health outcomes are inevitable [64‐67]. However, the combination of fatalism, religiosity and race/ethnicity may affect the way that fatalism operates due to differences in the locus of control beliefs (being more oriented to internal or external control over events and outcomes) [68, 69]. Nigerians, like most Africans, endorse religious fatalism [70, 71], and religious fatalism is not an inhibitor to healthy behaviors, nor is it disempowering [72, 73]. Fatalism is, however, a complicated construct that is more a coping response to illness and acceptance of what is beyond individual control than an inhibitor of healthy behaviors [74]. This study finding seems to indicate that for African women with young children, high fatalism, which may be tied to their religiosity, reduces their risk for caries. This study did not measure religiosity. This pathway for how maternal fatalism results in reduced risk for caries needs to be studied in-depth using qualitative methods in the future.

In the present study, the prevalence of caries experience among mothers was low and mostly based on untreated caries. Untreated caries increases the risk for new lesions [74] and the count of Streptococcus mutans, which increases the risk of transmission of the organism to children and subsequently their caries risk [75]. Also, the failure of mothers to seek treatment for dental caries likely indicates lower chances of the child utilizing dental preventive care. Despite the overall low caries prevalence, there is a subset of the population where caries problems persist. It is important for health policy planners to study the problems associated with caries in this subset of the population in comparison to the other health needs of mothers and their children. A strategic approach of addressing this caries related problem may be to routinely provide oral health checkups for mothers during pregnancy, and when they visit the clinics for their child health care. This may offer a cost effective healthcare systems dependent approach to manage caries in mothers with young children in resource-limited settings such as those in most African countries.

We found that education, income, and decision-making ability were not associated with caries in mothers of young children in the study population. This could be due to the relative homogeneity in this sample, as most women reported similar levels of educational attainment, modest income and low empowerment. Education and income are social determinants of health that are difficult to modify without substantial policy change. Cultural changes are, however, needed to increase empowerment of women for household decision-making in communities like Nigeria, which are highly patriarchal.

We found no association between the prevalence of caries and mothers’ dental anxiety, general anxiety, depressive symptoms, executive dysfunction, sense of coherence, or social support. This agrees with other studies indicating that adult onset of dental anxiety [76] and general anxiety [77] were not associated with increased risk for caries. In contrast, previous studies showed that depression increases the risk for caries [77], and post-partum depression increases the risk for early childhood caries in young children [78]. The literature on maternal oral health during child-care is sparse, which likely indicates that this subject has not been sufficiently and critically studied. The low caries prevalence in the study population may also mask the effect of these factors on caries.

The study has strengths: First, it used validated scales to assess a wide range of important psychosocial factors. Many of these measures pertain to complex perceptions and constructs that are not unidimensional, that may relate/interact with each other, and that may change over time, so the use of validated scales is essential. Second, psychosocial measures are often not included in oral health research, and when they are, the results have been mixed and the mechanisms by which stressors and resource factors operate are not defined [79‐81]. This study has added information about the association between psychosocial factors and caries in an African population. Third, the study highlights the need for actions to address the caries risk of women who have young children as caries may negatively affect their health and wellbeing and the oral health of their children [82]. Fourth, the study reveals that it may be important that mothers of children 71 months of age and younger who seek care for caries, be screened for stress and appropriately managed because this psychosocial factor has implications beyond the immediate oral health of women.

The study also has limitations: First, the design was cross-sectional, so causal links cannot be made. Also because of the design, it cannot be determined if having young children increases the risk of mothers having new caries lesions or if the measured psychosocial status was induced by childcare. Second, the study sample included mothers beyond the traditional postpartum period, and the stressors and resources studied may operate differently in the immediate postpartum period following a child’s birth. Third, the findings may not be generalizable to all Nigerian mothers of young children or to mothers in other countries.

The prevalence of caries in mothers with children 71 months old and younger in a Nigerian population was 3.3%. High levels of parenting stress is a risk indicator for caries in mothers. High fatalism may be protective of caries. Other psychosocial factors (dental anxiety, general anxiety, depression, executive dysfunction, sense of coherence, and social support) were not associated with caries and maternal education, income and decision-making ability were not risk indicators for caries in the women in our study. The caries risk of women who have young children needs attention because of the possible negative effect on their health and wellbeing and increase the risk of early childhood caries in their children. Longitudinal and qualitative studies are needed to further explore these findings.