







































Children and Teenagers 
ISSN 2576-3709 (Print) ISSN 2576-3717 (Online) 

Vol. 4, No. 3, 2021 
www.scholink.org/ojs/index.php/ct 

26 
 

Original Paper 

Parental Influences on Children’s Oral Health Behaviors, 

Reading Behaviors, and Reading Attitudes Associated with the 

Sharing of a Digital Story from the eBook for Oral Health 

Literacy© Curriculum 
Valerie A. Ubbes1* & Abby Witter2 

1 Miami University, Department of Kinesiology, Nutrition, and Health, Oxford, Ohio, United States 
2 University of Cincinnati, College of Medicine, Cincinnati, Ohio, United States 
* Valerie A. Ubbes, Miami University, Department of Kinesiology, Nutrition, and Health, Oxford, Ohio, 

United States 

 

Received: July 13, 2021          Accepted: July 31, 2021        Online Published: August 22, 2021 

doi:10.22158/ct.v4n3p26                             URL: http://dx.doi.org/10.22158/ct.v4n3p26 

 

Abstract 

This study investigated the relationships between parents and their children on oral health behaviors, 

reading behaviors, reading attitudes, and liking perceptions of one chapter from an eBook curriculum 

intervention. A Qualtrics platform was used to survey 316 parent-child dyads across the United States 

before and after the shared reading of one chapter from the eBook for Oral Health Literacy© entitled 

“Setting Goals for Going to the Dentist”. Participants answered 75 questions about their teeth brushing 

and flossing behaviors, number of cavities, how often they visited libraries and bookstores, enjoyment of 

reading, and perceptions (liking) of the words and pictures of the chapter that they read and heard. 

Statistically significant relationships were found between parents and their children on oral health 

behaviors (χ2 = 49.12, p < 0.001); reading behaviors (χ2 = 10.4, p < 0.01), reading attitudes (χ2 = 8.773, 

p < 0.01), and perception (liking) of the eBook chapter that they read and heard (χ2 = 113.813, p < 0.01). 

Results from 301 parent-child dyads point to the importance of social modeling that parents play in the 

development of their children’s oral health behaviors, reading behaviors, and reading attitudes. Testing 

of additional chapters from the eBook intervention is warranted. 

Keywords 

oral health literacy, oral health behaviors, reading behaviors, reading attitudes, parent-child dyads, 

eBook 



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1. Introduction 

Oral health is a high-priority health issue as indicated by the Healthy People 2030 document which sets 

public health agenda in the United States for the next ten years. Oral health has been a leading health 

indicator for the past decade and the current decade (USDHHS, 2020b), owing to the importance of oral 

health being foundational to overall health. As former Surgeon General Satcher stated “you can’t have 

good oral health if you don’t have good general health” (Lee, Watt, Williams, & Giannobile, 2017). Oral 

health hygiene, intake of water and milk, access to fluoride, and regular dental checkups are important 

factors in oral health promotion (Singleton, Day, Thomas, Schroth, Klejka, Lenaker, and Berner, 2019). 

Parents play important roles in modeling oral health behaviors for their children (Okada, Kawamura, 

Kaihara, Matsuzaki, Kuwahara, Ishidori, & Miura, 2002), and low oral health literacy of parents is 

associated with higher dental caries of their children (Firmino, Ferreira, Martins, Granville-Garcia, Fraiz, 

& Paiva, 2018). Parents with low literacy have less health knowledge and poorer health behaviors 

(DeWalt & Hink, 2009), which may disadvantage the health behaviors and health literacy levels of their 

children who would benefit from healthy role models. Low parent (caregiver) literacy has been 

associated with more cavities and poorer dental health of their children (Miller, Lee, DeWalt, & Vann, 

2010). Adults with limited oral health literacy have poorer oral health status, including more filled 

permanent teeth, more missing teeth due to disease, and increased gum disease (Baskaradoss, 2018). 

Parental behaviors and attitudes toward reading also influence their children’s linguistic and literacy 

development (Niklas, Wirth, Guffler, Drescher, & Ehmig, 2020), including their early reading 

achievement (Abu-Rabia & Yaari, 2012). According to Vygotsky’s Zone of Proximal Development 

(Vygotsky, 1978 & 1986), children are influenced to learn language signs and symbols from their parents, 

peers, and other significant people who are proximally close and interacting with them. Parents, peers, 

and professionals are responsible for scaffolding learning and serving as a guide on the side in helping 

children learn information that they would otherwise not be able to learn by themselves (Leong, Hassan, 

Isa, & Jalil, 2018).  

The home literacy environment has been found to mediate between parental attitudes toward shared 

reading time with their children and their children’s language comprehension and production (Niklas, 

Wirth, Guffler, Drescheer, & Ehmig, 2020). One literacy objective from Healthy People 2030 is to 

increase to greater than 63.2 percent of children whose parents read to them at least four days per week. 

In 2016-17, the National Survey of Children’s Health (NSCH) found that the proportion of children aged 

five years and younger whose family member read to them four or more days per week was 58.3 percent 

(USDHHS, 2020).  

The current project focuses on a reading intervention in which parents and their children share a chapter 

from the eBook for Oral Health Literacy© while the story is read aloud at a pace comfortable for them. 

Reading skills are “related to health knowledge and outcomes” (USDHHS, 2005, p. 181) and are one way 

to increase background knowledge when educating for health (Ubbes, Black, & Ausherman, 2009; 



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Ubbes, 2008; Ubbes, 2002) and educating for science (Kaefer, 2020), leading to the development of 

comprehension or the capability to understand something (Johnson, 1982; Deshpande, 2016). 

Children also attain the knowledge needed to form health habits by observing the social behavioral 

patterns modeled by those around them in different situations (Bandura, 1999), including home literacy 

environments (Niklas, Wirth, Guffler, Drescher, & Ehmig, 2020). Parents often serve as important role 

models for their children when it comes to developing daily health routines that lead to health habits. 

Johnson, Davy, Boyett, Weathers, and Roetzheim (2001) showed that parent knowledge and attitudes for 

certain health practices can have a significant impact on the health of their children. For example, 

positive oral health behaviors in children have been linked to parent reading behaviors in a family. Zullig, 

Ubbes, and Mann (2013) showed that students who saw a parent or caregiver reading in the past two days 

reported a significantly greater number of regular dental checkups than those who had not seen a parent 

or caregiver reading in the past two days. Children living in low-income families are exposed to fewer 

words and less-affirming responses from parents which results in a lower vocabulary for their academic 

lives (Hart & Risley, 2003). Parent’s ability to read dental terminology (word recognition) was not 

associated with vocabulary knowledge or with comprehension. However, vocabulary knowledge about 

oral health was strongly associated with comprehension (Richman, Hueber, Leggott, Mouradian, & 

Mand, 2011). 

Oral health is defined as the quality of an individual’s mouth, teeth, and gums. Oral health is measured by 

the number of dental caries (cavities) and the frequency of teeth brushing and flossing behaviors. An 

individual’s oral health is influenced by the ability to access and understand oral health information and 

apply that information to oral health, which is called oral health literacy (Horowitz & Kleinman, 2008). 

The U.S. Department of Health and Human Services in its report, Healthy People 2010, first defined oral 

health literacy as “the degree to which individuals have the capacity to obtain, process and understand 

basic oral health information and services needed to make appropriate health decisions”. According to an 

earlier report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research 

(USDHHS, 2000b), the above definition addressed functional oral health literacy which includes the 

ability to use and apply knowledge when making oral health decisions and when communicating oral 

health information via speech, conversation, reading, writing, numeracy, speaking, and listening. 

Oral health hygiene is the science of preserving the mouth, teeth, and gums via health-promoting 

practices. The American Association of Pediatric Dentists recommends that children receive regular 

teeth cleaning and exams every six months. Guidelines for oral health hygiene include brushing teeth 

with fluoride toothpaste twice a day, flossing daily, eating a healthy diet that limits sugary beverages and 

snacks, and visiting the dentist regularly for a check-up (American Dental Association, 2021). 

The first purpose of this study was to determine if there was a relationship between parents’ oral health 

behaviors and their child’s oral health behaviors. The second purpose of this study was to determine if 

there was a relationship between parents’ and children’s reading behaviors. The third purpose was to 



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determine if there was a relationship between parents’ and children’s reading attitudes. The fourth 

purpose was to determine if there was a relationship between parents’ perceptions (liking) of one chapter 

from the eBook for Oral Health Literacy© curriculum and their children’s perceptions (liking) of the 

same chapter. 

 

2. Methods 

2.1 Participants 

Participants included 316 parent-child dyads who answered online questions before and after an oral 

health story intervention which was also online. The parent-child dyads came from 43 states in the United 

States. After the data cleaning process, the final data set included a total of 301 parent-child dyads who 

answered separate and sometimes different questions on the Oral Health Survey. 

The parents' ages ranged from 19 to 60, with the mean age being 38.5 years. Parents included 89.8% 

females and 10.2% males. The children ranged in age from 9 to 11 years old, with the mean age being 

10.1 years. Children included 50.2% female and 49.8% males. Participants were from 75% white 

families (n = 239) and 25% minority families. About 9.8% of participants (n = 31) identified as Black, 

African American, or Haitian; 6.3% of participants (n = 20) identified as Hispanic or Latinx; 3.5% of 

participants (n = 11) identified as Asian, Asian American, and Pacific Islanders; 0.9% of participants (n = 

3) identified as American Indian or Alaskan Native; and 3.8% of participants (n = 12) identified as 

another race.  

2.2 Procedures 

Parent-child dyads (n = 316) took an online survey using the Qualtrics platform (Salt Lake City, Utah) 

before and after exposure to one chapter of the eBook for Oral Health Literacy© entitled “Setting Goals 

for Going to the Dentist”. In order to participate, parents had to live with a child between the ages of 9 

and 11 who would also participate in the study. Researchers followed the approved protocol from the 

Institutional Review Board for Human Subjects Research at the referent university. Parents first gave 

consent for their child to participate and then each child gave assent to participate. 

To the best of our knowledge, this study was one of the first to integrate educational curriculum material 

into the national Qualtrics survey platform for use by participants online. Hence, parent-child dyads 

answered a total of 75 questions divided before and after the intervention which included the shared 

reading of one chapter from the eBook for Oral Health Literacy© curriculum. Specifically, the Qualtrics 

survey was presented in a phased process in which the parents began by answering 23 questions about 

personal demographics, oral health behaviors and attitudes, and reading behaviors and attitudes. Parents 

then invited their child to the computer to answer 25 questions about personal demographics, oral health 

behaviors and attitudes, and reading behaviors and attitudes. Next, parent-child dyads read and listened 

to the eBook chapter together known as shared reading. After exposure to the intervention, children 

answered 14 questions about their attitudes toward oral health and the eBook chapter. Then parents 



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answered 13 questions about their attitudes toward the eBook chapter. 

2.3 eBook Curriculum Intervention 

The eBook for Oral Health Literacy© curriculum contains child-centered digital stories, which are 

organized by 17 chapters for learning about oral health hygiene, oral health and nutrition, oral health and 

beverages, and the importance of dental check-ups. The eBook curriculum is available as open-sourced 

educational material (https://dlp.lib.miamioh.edu/ebook/index.html) on the Digital Literacy Partnership 

website @ https://dlp.lib.miamioh.edu/. The eBook curriculum has been evaluated for its readability, 

suitability, understandability, actionability, and gist-based message design (Ubbes, Witter, Kraska, & 

Justus, 2020) and for its eye tracking effects of the visual-textual-lexical page layouts (Ubbes, Coyle, & 

Tzoc, 2018). Each online composition includes ten sequential positive-frame photographs with 

declarative sentences as captions that promote oral health behaviors of children. Each frame requires the 

user to scroll over or touch a sound icon with a cursor in order to activate and hear an audio narration of 

the message on each page. For the purposes of this research, Chapters 14 and 15 were employed and 

selected by the child by their gendered preferences. If the child preferred to read and hear the narration of 

a highly visual account of a child’s life through the actions of a boy’s oral health routine, Chapter 14 was 

chosen. If the child preferred to read and hear the narration of a highly visual account of a girl’s oral 

health routine, Chapter 15 was chosen. The declarative sentences focused on setting goals for going to 

the dentist and were aligned to three salient beliefs from the integrative theory of behavioral prediction 

(Fishbein & Yzer, 2003; Yzer, 2012). Specifically, the second and last pages of the chapter focused on 

self-efficacy belief statements and the middle of the narrative contained three pages each of health 

outcome beliefs and (social) normative beliefs. Peirce (1992) defined beliefs as “rules for action”. 

Pajares (1996, p. 566) suggested “As such, beliefs become the internal rules individuals follow as they 

determine the effort, persistence, and perseverance required to achieve optimally”. 

2.4 Instrument and Measures 

2.4.1 Parent-Related Data 

Survey questions for parental oral health included how often parents brushed their teeth in a week, how 

often parents flossed their teeth in a week and the number of cavities in their lifetime. Survey questions 

for parent reading behaviors included visits to a library in the past year, visits to an online bookstore in 

the past year, self-rated reading ability, and how often parents read books for fun. Survey questions 

pertaining to parent perceptions of the online curriculum included how parents felt about the storyline 

words of the curriculum, how parents felt about the storyline pictures of the curriculum, and if the 

curriculum was written at an appropriate reading level for their child. 

2.4.2 Child-Related Data 

Survey questions for child oral health included how often the children brushed their teeth in the morning 

and at night, if the children flossed their teeth, and how many cavities the children have had in their 

lifetime. Survey questions pertaining to child reading behaviors included how often children read books 



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for fun, if children like to read books on the Internet, children’s self-rated ability to read, children’s visits 

to a library in the past year, and if children like going to the library. Survey questions pertaining to 

children’s perceptions of the online curriculum included how children felt about the storyline words of 

the curriculum, how children felt about the storyline pictures of the curriculum, and if the curriculum was 

written at an appropriate reading level for them. 

2.4.3 Recoding for Binary Indicators 

Most of the survey questions included multiple answer options on a Likert scale. As such, the answers 

were re-coded into binary indicators in order to perform chi square analyses. For example, parents were 

asked “How often did you floss your teeth over the past 7 days?” The answer options included once a day, 

every second day, once a week, and not at all. These answer options were re-coded into binary indicators 

so that the answer “once a day” was re-coded as a “1” indicating that the oral health goal was met, and the 

rest of the answers were re-coded as a “0” indicating that the oral health goal was not met. A similar 

method was employed for questions concerning teeth brushing of parents and children. Oral health goals 

were met if participants brushed their teeth twice a day and flossed once a day. 

Data for the reading behaviors of parents and children were calculated similarly. A “good” reading goal 

was met for the parent if the parent visited the library in the past year, visited an online bookstore in the 

past year, and enjoyed reading. A “good” reading goal was met for the child if the child visited a library in 

the past year, liked going to the library, and enjoyed reading. If one or more of the subcategories were not 

met, then the score for “good” reading behaviors was “0”. Data were excluded whenever responses were 

listed as “not sure” which occurred occasionally for questions about visiting the library or an online 

bookstore.  

2.5 Data Analysis 

Chi square tests were calculated to evaluate the statistical significance of relationships between the 

categorical variables (McHugh, 2013). P-values greater than an alpha of 0.05 meant that the variables 

were independent from each other. A contingency coefficient was also used to measure the association 

between variables. The closer to 1 the contingency coefficient was, the stronger the relationship between 

the two variables. Data analyses were completed in SPSS 25.0 (SPSS, Inc., Chicago, IL).  

 

3. Results 

Results are organized by our four research questions. The first research question asked if there was a 

relationship between the oral health behaviors of parents and the oral health behaviors of their children. 

The second research question analyzed the relationship between the reading behaviors of parents and the 

reading behaviors of their children. The third research question analyzed the relationship between the 

reading attitudes of parents and the reading attitudes of their children. The fourth research question 

investigated the relationship between parents’ liking of the eBook for Oral Health Literacy© chapter and 

their children’s liking of the chapter.  



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Our independent variables were parent oral health behaviors, parent reading behaviors, parent reading 

attitudes, and parent perception of the eBook chapter. Our dependent variables were child oral health 

behaviors, child reading behaviors, child reading attitudes, and child perception of the eBook chapter. 

3.1 Research Question 1: Are Parents’ Oral Health Behaviors Related to their Children’s Oral Health 

Behaviors? 

The first research question examined the relationship between the oral health behaviors of parents with 

the oral health behaviors of their children. Self-reported frequency of teeth brushing and flossing, as well 

as the number of cavities that parents and children have had in their lifetime, were used to evaluate oral 

health behaviors. In addition, self-reported frequency of confidence (self-efficacy) in teeth brushing was 

included. 

 

Table 1. Oral Health Behaviors of Parents and Children (n = 301) 

  Parent Meeting 

Daily Oral Health 

Guideline 

No Yes Total 

Children Meeting 

Daily Oral Health 

Guideline 

        

No   130 61 191 

Yes   28 (17.7%) 82 (57.3%) 110 

Total   158 (52.5%) 143 (47.5%) 301 

 

Table 1 shows that there was a significant relationship between the oral health behaviors of parents and 

the oral health behaviors of their children (χ2 = 49.12, df = 1, p < 0.001). A large percentage of children 

(57.3%, n = 82) had positive oral health behaviors when their parents had positive oral health behaviors 

(47.5%, n = 143). Positive oral health behaviors were defined as brushing teeth twice a day and flossing 

teeth once a day (American Dental Association, 2021). However, only 17.7% (n = 28) of children had 

positive oral health behaviors when their parents did not practice positive oral health behaviors (52.5%, n 

= 158).  

 

 

 

 

 

 

 



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Table 2. Parent Teeth Brushing Behaviors and Children Oral Health Behaviors (n = 301) 

  Parent Positive Teeth 

Brushing Habit 

No Yes Total 

Children 

Positive Oral 

Health Habit 

        

No   31 160 191 

Yes   6 (16.2%) 104 (39.4%) 110 

Total   37 (12.3%) 264 (87.7%) 301 

 

Table 2 shows that there was a significant relationship between the teeth brushing behaviors of parents 

and the overall oral health behaviors of children (χ2 = 6.55, df = 1, p < 0.05). Children had significantly 

better oral health behaviors, as defined as brushing teeth twice a day and flossing teeth once a day, when 

their parents practiced positive teeth brushing behaviors, which was defined as brushing teeth twice a day, 

regardless of parental flossing behaviors. Therefore, oral health behaviors were defined slightly 

differently between the children and their parents. When surveyed, 39.4% of children (n = 104) reported 

positive oral health behaviors when their parents practiced positive teeth brushing behaviors (87.7%, n = 

264). However, only 16.2% of children (n = 6) had positive oral health behaviors when their parents did 

not have positive teeth brushing behaviors (12.2%, n = 37). 

 

Table 3. Parent Flossing Behaviors and Children Oral Health Behaviors (n = 301) 

  Parent Positive 

Flossing Habit 

No Yes Total 

Children Positive 

Oral Health 

Habit 

        

No   124 67 191 

Yes   27 (17.9%) 83 (55.3%) 110 

Total   151 (50.2%) 150 (49.8%) 301 

 

Flossing teeth is considered a positive oral health habit when completed once a day. Table 3 indicates that 

there was a significant relationship between the flossing habits of parents and the oral health behaviors of 

their children (χ² = 43.92, df =1, p < 0.001). When surveyed, 55.3% of children (n = 83) reported good 

oral health habits when their parents practiced good flossing habits (49.8%, n = 150). However, only 



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17.9% of children (n = 27) had positive oral health habits when their parents did not have positive 

flossing habits (50.2%, n = 151). 

 

Table 4. Flossing Behaviors of Parents and Children (n = 301) 

  Parent 

Flossing 

Behaviors 

Every 

second day 

Not at all Once a day Once a 

week 

Total 

Child 

Flossing 

Behaviors 

            

Never   8 20 10 7 45 

Sometimes   36 19 43 24 122 

By myself   15 2 (04.9%) 77 (51.7%) 9 103 

With help   8 0 19 4 31 

Total   67 41 (13.6%) 149 (49.5%) 44 301 

 

Table 4 shows that there was a significant relationship between the flossing behaviors of parents and their 

children (χ2 = 83.042, df =1, p < 0.01). When surveyed, 51.7% of children (n = 77) reported that they 

flossed their teeth by themselves when their parents flossed once a day (49.5%, n = 149). However, only 

4.9% of children (n = 2) reported that they flossed their teeth by themselves when their parents did not 

floss their teeth at all (13.6%, n = 41). The contingency coefficient (0.465) showed a moderate 

relationship between the two variables. 

 

Table 5. Cavity Numbers of Parents and Children (n = 301) 

  Parent Cavity Count 0 1 2 3 4 Total 

Child Cavity Count               

0   57 (69.5%) 16 32 18 43 (46.7%) 166 

1   10 11 16 12 16 65 

2   10 5 7 3 15 40 

3   4 1 1 0 12 18 

4   1 1 2 2 6 12 

Total   82 (27.2%) 34 58 35 92 (30.6%) 301 

 

 



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Table 5 shows that there was a significant relationship between the number of cavities parents have had in 

their lifetime and the number of cavities their children have had (χ2 = 31.321, df = 1, p < 0.05). When 

surveyed, 69.5% of children (n = 57) reported that they had 0 cavities in their lifetime when their parents 

also reported 0 cavities in their lifetime (27.2%, n = 82). However, only 46.7% of children (n = 43) 

reported that they had 0 cavities in their lifetime when their parents had 4 cavities in their lifetime (30.6%, 

n = 92). The contingency coefficient (0.307) showed a moderate relationship between the two variables. 

 

Table 6. Confidence in Teeth Brushing of Parents and Children (n = 301) 

  Parent 

Confidence 

in Teeth 

Brushing 

Confident Not 

confident 

Not 

sure 

Strongly 

confident 

Strongly 

not 

confident 

Total 

Child 

Confidence 

in Teeth 

Brushing 

              

Not confident 

at all 

  1 3 0 1 2 7 

Not very 

confident 

  9 4 7 9 0 29 

Somewhat 

confident 

  40 2 7 31 1 81 

Very 

confident 

  43 (46.2%) 5 6 129 1 (25.0%) 184 

Total   93 (30.9%) 14 20 170 4 (01.3%) 301 

 

Table 6 shows that there was a significant relationship between the confidence of parents in teeth 

brushing and the confidence of their children in teeth brushing (χ2 = 116.600, df = 1, p < 0.01). When 

surveyed, 46.2% of children (n = 43) reported that they were very confident that they could brush their 

teeth twice a day when their parents also reported that they were confident that they could brush their 

teeth twice a day (30.9%, n = 93). However, only 25.0% of children (n = 1) reported that they were very 

confident that they could brush their teeth twice a day when their parents were strongly not confident that 

they could brush their teeth twice a day (1.3%, n = 4). The contingency coefficient (0.528) showed a 

moderately strong relationship between these two variables. 

3.2 Research Question 2: Is there a Relationship between Parents’ Reading Behaviors and their 

Children’s Reading Behaviors? 



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The second research question investigated the relationship between the reading behaviors of parents and 

their children. Self-reported frequency of positive reading habits, visiting a library, and visiting an online 

bookstore were used to evaluate the reading behaviors of parents and children. 

 

Table 7. Reading Behaviors of Parents and Children (n = 301) 

  Parent Positive 

Reading Habit 

No Yes Total 

Children Positive 

Reading Habit 

        

No   50 31 81 

Yes   88 (63.8%) 132 (81.0%) 220 

Total   138 (45.8%) 163 (54.2%) 301 

 

Table 7 shows that there was a significant relationship between the reading behaviors of parents and their 

children (χ2 = 10.4, df = 1, p < 0.01). A large percentage of children (81.0%, n = 132) had positive 

reading behaviors when their parents also practiced positive reading behaviors (54.2%, n = 163). Positive 

reading behaviors for children were defined as visiting a library in the past year, liking the library, and 

enjoyment of reading. Positive reading behaviors for parents were defined as visiting a library in the past 

year, visiting an online bookstore in the past year, and enjoyment of reading. Only 63.8% of children (n = 

88) had positive reading behaviors when their parents did not practice positive reading behaviors (45.8%, 

n = 138). 

 

Table 8. Visiting the Library in Parents and Children (n = 301) 

  Parents Visiting 

Library 

No Yes Total 

Children Visiting 

Library 

        

No   27 3 30 

Yes   33 (55.0%) 238 (98.8%) 271 

Total   60 (19.9%) 241 (80.1 %) 301 

 

Table 8 shows that there was a significant relationship between if parents visited a library in the past year 

and if their children visited a library in the past year (χ2 = 97.677, df = 1, p < 0.001). A large percentage 

of children (98.8%, n = 238) visited the library in the past year when their parents also visited the library 

in the past year (80.1%, n = 241). However, only 55.0% of children (n = 33) visited the library in the past 

year when their parents had not visited a library in the past year (19.9%, n = 60). 



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Table 9. Parents Visiting an Online Bookstore and Whether Children Enjoyed Reading Books 

Online (n = 301) 

  Parents Online 

Bookstore Visit 

No Yes Total 

Children 

Enjoyment of 

Online Book 

Reading 

        

No   52 66 118 

Yes   49 (48.5%) 134 (67.0%) 183 

Total   101 (33.6%) 200 (66.4%) 301 

 

Table 9 indicates that there was a significant relationship between if parents visited an online bookstore 

in the past year and whether their children liked to read books on the Internet (χ2 = 8.8613, df = 1, p < 

0.01). A large percentage of children (67.0%, n = 134) enjoyed reading a book online when their parents 

had visited an online bookstore in the past year (66.4%, n = 200). However, only 48.5% of children (n = 

49) liked to read books online when their parents had not visited an online bookstore in the past year 

(33.6%, n = 101). 

3.3 Research Question 3: Is there a Relationship between Parents’ Reading Attitudes and their Children’s 

Reading Attitudes? 

The third research question investigated the relationship between the reading attitudes of parents and 

their children. Self-reported frequency of reading enjoyment (love of reading) and reading motivations 

(reading for fun) by parents and children were used to evaluate the reading attitudes of participants. 

 

Table 10. Reading Attitudes of Parents and Children (n = 301) 

  Parents Love of 

Reading 

No Yes Total 

Children Love of 

Reading 

        

No   12 50 62 

Yes   15 (55.6%) 224 (81.8%) 249 

Total   27 (09.0%) 274 (91.0%) 301 

 

Table 10 indicates that there was a significant relationship between parents’ attitudes toward the love of 

reading and their children’s attitudes toward the love of reading (χ2 = 8.773, df = 1, p < 0.01). When 

surveyed, 81.8% of children (n = 224) reported that they loved to read given that their parent loved to 



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read (91.0%, n = 274). However, only 55.6% of children (n = 15) indicated that they love to read when 

their parents did not love to read (9.0%, n = 27). 

 

Table 11. Reading Motivations of Parents and Children (n = 301) 

  How Often 

Parents 

Read Books 

For Fun 

Never Often Rarely Sometimes Usually Total 

How Often 

Children 

Read Books 

For Fun 

              

Always   1 (14.3%) 28 12 21 32 (42.7%) 94 

Never   1 1 2 0 1 5 

Often   0 34 6 20 13 73 

Rarely   1 3 4 8 6 22 

Sometimes   4 20 18 42 23 107 

Total   7 (02.3%) 86 42 91 75 (24.9%) 301 

 

Table 11 shows that there was a significant relationship between if parents’ motivation to read was for fun, 

and if children’s motivation to read was for fun (χ2 = 41.451, df = 1, p < 0.01). When surveyed, 42.7% of 

children (n = 32) reported that they always read books for fun given that their parents usually read books 

for fun (24.9%, n = 75). However, only 14.3% of children (n = 1) indicated that they always read books 

for fun when their parents never read books for fun (2.3%, n = 7). The contingency coefficient (0.348) 

showed that there was a moderate relationship between the two variables. 

3.4 Research Question 4: Is there a Relationship between Parents’ Liking of the Oral Health Curriculum 

and their Children’s Liking of the Oral Health Curriculum? 

The fourth research question investigated the relationship between the parents’ liking of one chapter of 

the eBook for Oral Health Literacy© and their children’s liking of the chapter. The parents’ and 

children’s liking of the storyline words and pictures, as well as their perceptions of the story’s reading 

level, were used to evaluate participants’ liking of the curriculum. 

 

 

 

 

 



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Table 12. Parents and Children Liking of the Oral Health Storyline-Words (n = 301) 

  Did Parents Like 

The Storyline 

Words? 

Maybe No Yes Total 

Did Children 

Like The 

Storyline 

Words? 

          

Maybe   7 10 37 54 

No  11 24 17 52 

Yes   4 3 (08.1%) 188 (77.7%) 195 

Total   22 37 (12.3%) 242 (80.4%) 301 

 

Based on Table 12, there was a significant relationship between the proportion of parents and children 

who liked the storyline words of the curriculum (χ2 = 113.813, df = 1, p < 0.01). When surveyed, 77.7% 

of children (n = 188) reported that they liked the storyline words of the curriculum given that their parents 

liked the storyline words (80.4%, n = 242). However, only 8.1% of children (n = 3) indicated that they 

liked the storyline words of the curriculum when their parents did not like the storyline words (12.3%, n 

= 37). The contingency coefficient (0.524) showed that there was a moderately strong relationship 

between parents’ perception of the storyline words and their children’s perception of storyline words. 

 

Table 13. Parents and Children Liking of Oral Health Storyline-Pictures (n = 301) 

  Did Parents 

Like The 

Storyline 

Pictures? 

Maybe No Yes Total 

Did Children Like 

The Storyline 

Pictures? 

          

Maybe   3 6 24 33 

No   9 19 15 43 

Yes   10 12 (32.4%) 203 (83.9%) 225 

Total   22 37 (12.3%) 242 (80.4%) 301 

 

Table 13 shows that there was a significant relationship between parents’ perception of the storyline 

pictures and children’s perception of the pictures (χ2 = 72.985, df = 1, p < 0.01). When surveyed, 83.9% 



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of children (n = 203) reported that they liked the storyline pictures of the curriculum given that their 

parents liked the storyline pictures (80.4%, n = 242). However, only 32.4% of children (n = 12) indicated 

that they liked the storyline pictures of the curriculum when their parents did not like the storyline 

pictures (12.3%, n = 37). The contingency coefficient (0.442) showed that there was a moderate 

relationship between parents’ perception of the curriculum pictures and children’s perception of the 

pictures. 

 

Table 14. Parents and Children Perceptions of Story Reading Level (n = 301) 

 Parents’ 

perception 

Just right for 

my child 

Too easy for 

my child 

Too hard for 

my child 

Total 

Children’s 

perceptions 

          

Just right   140 (88.1%) 11 (08.2%) 2 (25.0%) 153 

Too easy   13 123 0 136 

Too hard   6 0 6 12 

Total   159 (52.8%) 134 (44.5%) 8 (02.7%) 301 

 

As shown in Table 14, there was a significant relationship between parents’ perception of the story 

reading level, and children’s perception of the story reading level (χ2 = 315.060, df =1, p < 0.01). When 

surveyed, 88.1% of children (n = 140) reported that they thought the story reading level was just right 

given that their parents thought that the story reading level was just right for their child (52.8%, n = 159). 

However, only 8.2% of children (n = 11) indicated that the story reading level was just right when their 

parents thought that the story reading level was too easy for their child (44.5%, n = 134), and 25.0% of 

children (n = 2) reported that the story reading level was just right given that their parents thought the 

story reading level was too hard for their child (2.7%, n = 8). The contingency coefficient (0.715) showed 

that there was a strong relationship between parents’ and children’s perception of the story reading level.  

 

4. Discussion 

Given the importance of the family as a social determinant of health (Maynard & Harding, 2010), our 

findings point to the significant role of parents in offering their children opportunities for going to the 

dentist, going to a library, and reading health literacy materials. To date, there has been little emphasis on 

family oral health education (Tseng, Pleasants, Ivey, Sokal-Gutierrez, Kumar, Hoeft, Horowitz, 

Ramos-Gomez, Sodhi, Liu, & Neuhauser, 2021). However, Healthy People 2030 now provides new 

definitions for personal health literacy and organizational health literacy as recognition for the 

importance of multilevel interventions in public health at home, in the community, and at school. 

In the current project, personal health literacy of the parents and the children included their ability to 



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understand goal setting for going to the dentist who could “...inform health-related decisions and actions 

for themselves and others” (Brach & Harris, 2021, p. 1084). The dental clinic is a health organization 

where literacy-rich environments can be implemented to improve oral health literacy of the parent-child 

dyads. To build organizational health literacy, the dental clinic needs to “equitably enable individuals to 

find, understand, and use information and services to inform health-related decisions and actions for 

themselves and others'' (Brach & Harris, 2021, p. 1084). The current oral health literacy intervention 

called the eBook for Oral Health Literacy© could be one way for dental clinics to incorporate decision 

making skills by providing oral health reading materials for their pediatric and adult patients. 

Family-based clinics can also help to boost both individual and institutional health literacy, and in this 

context, oral health literacy.  

There is also a vital need to promote oral health literacy in schools on an organizational level. Unless 

children are in multiple places where they see and talk with dentists in community clinics or in one of the 

2500 school-based health clinics in the United States, there may be continued slow progress in 

developing the oral health behaviors of children if only left to parent messaging and role modeling at 

home. Multiple studies have found that “Low health-related reading and numeracy (i.e., functional health 

literacy) has been associated with poor health outcomes including less use of preventative services, 

higher rates of hospitalization, and poor overall health status” (Lim, Beauchamp, Dodson, O’Hara, 

McPhee, Fulton, Wildey, & Osborne, 2017; Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). 

Therefore, newer interventions that focus on oral health literacy should include ways for parents and 

children to learn together and to learn from each other. 

The current study specifically focused on a skill-based approach to oral health literacy. The curriculum 

intervention emphasized goal setting as a cognitive-behavioral skill while employing reading and 

listening skills to boost oral health literacy. The short one-minute chapter that the parents and children 

read together included ten cues for setting a goal for going to the dentist and for improving oral health 

hygiene. Goal-setting and short- and long-term planning are the most effective strategies for producing 

behavior changes (Michie, Abraham, Whittington, McAteer, & Gupta, 2009; Lim, Beauchamp, Dodson, 

O’Hara, McPhee, Fulton, et al., 2017) and are key cognitive skills for effective health education curricula 

(CDC, 2021a). The eBook for Oral Health Literacy© chapter that was read by the parent-child dyads in 

this study focused on goal setting, which is one of the eight National Health Education Standards that 

students should know and be able to do for school health education because the cognitive skill of goal 

setting increases the adoption of healthy behaviors (CDC, 2021b). As such, “Goal-setting skills are 

essential to help students identify, adopt, and maintain healthy behaviors” (CDC, 2021b). 

The visual-textual story called “Setting Goals for Going to the Dentist” included three main sections. The 

first and last slides were composed as “self-efficacy belief” statements and included: “I believe that I can 

be ready to go to the dentist for a check-up on my mouth, teeth, and gums”, and “I believe that I can have 

a good check-up at my dentist, so I can have healthy teeth and gums”. 



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The second section of three slides included “health outcome belief” statements which explained why the 

behavior was important for health: “I set a goal to get a toothbrush from my dentist when I need one, so I 

can brush my teeth”, “I set a goal to brush my teeth every night with my Mom, so I have a fresh breath 

and clean teeth”, and “I set a goal to visit my dentist 2 times a year, so I know I do not have any holes in 

my teeth (cavities)”. 

The last section of three slides included “normative belief” statements which emphasized social 

interactions with a dentist and peers: “I set a goal to open my mouth wide, so my dentist can see and count 

my 20 teeth”, “I set a goal with my friends to learn the right way to brush on the front and back of each 

tooth”, and “I set a goal to show my dentist my bright smile during my 6 month check-up”.  

By scripting a photographic narrative with different situations and scenarios for practicing oral health 

behaviors, children and their parents were guided by a gain-frame message design that emphasized the 

benefits of self-care while reading the story together. The International Literacy Association (2019) 

suggests that reading together around a blended use of digital and nondigital resources have the potential 

to increase oral language skills between parents and children. Parent-child reading routines on a daily 

basis have been documented to enhance emergent literacy skills as promoted by the national program 

called Reach Out and Read, endorsed by the American Academy of Pediatrics (Diener, Hobson-Rohrer, 

& Byington, 2012). Parents who participated in the Reach Out and Read program, which encourages 

reading books aloud to children every day, were more likely to report that reading was a favorite activity. 

Furthermore, children participating in the shared book reading program with their parents show higher 

receptive and expressive vocabulary scores than children not participating in the pediatric program (High, 

LaGasse, Becker, Ahlgren, & Gardner, 2000; Theriot, Franco, Sisson, Metcalf, Kennedy, & Bada, 2003; 

Sharif, Rieber, & Ozuah, 2002). Multiple studies have found that families with more exposure to the 

Reach Out and Read program showed larger effects in developing literacy skills (Weitzman, Roy, Wallis, 

& Tomlin, 2004; Theriot, Franco, Sisson, Metcalf, Kennedy, & Bada, 2003). 

Positive oral health behaviors are linked to good overall health (USDHHS, 2000b), but a lack of positive 

oral health behaviors and dental checkups have been linked to heart disease (Takahashi, Davey, Yumoto, 

Gibson, & Genco, 2006) and cancer (St. John, Li, Zhou, Denny, Ho, Montemagno et al., 2004). Zullig, 

Ubbes & Mann (2013) showed that higher reading abilities of middle school youth were linked to the 

practice of preventative health behaviors, such as frequent dental checkups. The importance of modeling 

by parents who show positive attitudes and proactive behaviors toward oral health hygiene (Takahashi, 

Davey, Yumoto, Gibson, & Genco, 2006), including children who reported seeing their parents reading in 

the last two days (Zullig, Ubbes, & Mann, 2013), will be able to influence the overall health of children. 

Social cognitive theory (Bandura, 1991 & 1999) is influential in describing human agency which 

supports individuals to self-regulate their actions by planning, making decisions about their behavior, and 

reflecting on their thinking and actions. Reciprocal determinism (Bandura, 1999) is the major principle 

that helps parent-child dyads to negotiate personal health literacy factors, oral health and reading 



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behaviors, and home environments. Children who observed role modeling by their parents for teeth 

brushing and flossing may construct and come to understand the importance of oral health hygiene 

especially when observing these personal behaviors at home in a social context. Children can also select 

the environments where they may brush and floss their teeth or not, depending on whether they are 

encouraged to do so when visiting grandparents, neighbors, and best friends' houses with different 

situational cues for oral hygiene behaviors. In the reciprocal interplay between personal factors, 

behavioral factors, and environmental factors, children need patterned influences to establish daily 

behaviors (Bandura, 1978). Genetics and environmental factors interact to influence individual health 

patterns, especially among mothers with poor self-rated oral health whose children are more likely to 

grow up with poorer oral health (Shearer, Thomson, Broadbent, & Poulton, 2011). The higher the number 

of a mother’s decayed, missing, or filled permanent teeth (DMFT score), the higher the children’s DMFT 

score was for their permanent teeth (Lee, Kim, Lee, & Kim, 2019). Although DMFT tends to increase 

with the age of the child (Singleton, Day, Thomas, Schroth, Klejka, Lenaker, & Berner, 2019), parents 

also need to be educated on the role that cavities play beyond the consequences of decayed teeth of their 

children, which may include reduced nutritional deficiencies and unhealthy body weights (Lee & Vann, 

2012). 

In the current study, parent-child dyads read an eBook that focused on setting goals. Bandura (1999, 2001) 

stated that “goals, rooted in a value system and a sense of personal identity…give meaning and purpose” 

(p. 8) and “…serve as powerful motivators of action” (Bandura, 1991). Health educators need to consider 

the differences between children and their parents when they set goals to go to the dentist for a six-month 

checkup. Children usually go to pediatric dental checkups in a community clinic or a school-based health 

clinic whereas adults usually go to a community dental clinics that cater to their age group. Unfortunately 

from the standpoint of social modeling, children may not see their parents go to a dentist. Also parents 

need to schedule dental appointments for their children or the child will not go to the dentist. The current 

online study asked written questions of the parent-child dyads before and after the oral health literacy 

intervention, which were embedded into a Qualtrics panel study (facilitated for a fee by Qualtrics). This 

maximized the ability of parents and their children to be in one location to discuss the oral health story 

and the social actions of the children regarding their oral health goals. More considerations must be made 

on how to evaluate oral health literacy of parent-child dyads and give them opportunities for sharing 

dental health checkups in virtual and real-time situations. Efficacy beliefs are the foundation of human 

agency (Bandura, 1999, 2001) and influence whether people are able to think optimistically or 

pessimistically to enhance their wellbeing (Bandura, 1999, 2001). In the current study, Table 6 showed 

that parental beliefs in their ability to brush and floss their teeth were significantly associated with their 

children’s ability to perform similar oral health behaviors. With regard to reading behaviors, Table 7 

showed that when a large percentage of children (81%, n = 132) had positive reading behaviors, their 

parents also practiced positive reading behaviors. These results were significant (χ2 = 10.4, p < 0.01). 



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Positive reading behaviors for children were defined as visiting a library in the past year, liking the library, 

and enjoyment of reading, when their parents also practiced positive reading behaviors. Positive reading 

behaviors for parents were defined as visiting a library in the past year, visiting an online bookstore in the 

past year, and enjoyment of reading. Only 63.8% of children (n = 88) had positive reading behaviors 

when their parents did not practice positive reading behaviors. This may speak to the fact that children do 

have positive influences when they have access to school libraries and public libraries (Garces-Bacsal & 

Yeo, 2017) regardless of what reading is observed by parents at home. However, the American Academy 

of Arts & Sciences (2017) has reported a rather bleak picture with regard to the reading behaviors of 

adolescents and younger adults so a shift may be occurring. Americans between the ages of 15 to 44 years 

spend approximately 10 minutes per day reading for personal interest, but they spend almost 3 hours 

watching television and 28 minutes playing games and using computers for leisure. Garces-Bacsal and 

Yeo (2017, p. 248) urge children “to read for pleasure and to identify themselves as readers”, because 

reading helps provide an avenue for “self-construction and self-identification” (Howard, 2011). 

Our study alludes to the enjoyment of reading and going to libraries and bookstores as positive prosocial 

literacy behaviors. Table 8 indicated that there was a significant relationship (χ2 = 97.677, p < 0.001) 

between parents and children who visited a library in the past year with a large percentage of children 

(98.7%, n = 238) reporting a visit to a library when their parents also visited the library in the past year. A 

large percentage of children in the current study (67%, n = 134) enjoyed reading a book online when their 

parents had visited an online bookstore in the past year (χ2 = 8.8613, p < 0.01), and there was a moderate 

but significant relationship between parents’ and children’s motivations to read for fun (χ2 = 41.451, p < 

0.01). Geurtsen (2008) found that children who visited a library reported more leisure time reading than a 

control group of students, and they also held a more positive attitude toward books. Like the eBook for 

Oral Health Literacy©, there remains a need for skill-based curriculum materials to bridge the gap 

between the role of health literacy in educating children and their parents about a variety of health 

behaviors, especially oral health hygiene. More reading materials are needed that show pro-social norms 

among family and friends to help build an emphasis influencing children to read for pleasure while 

learning about reasoned actions for doing healthy habits. Ubbes, Dillhoff, and Maldonado (2018) found 

that reading attitudes toward recreational (leisure) reading differed among children with girls showing 

higher reading attitudes toward academic and recreational reading than boys. Cunningham (2008) has 

argued that reading attitudes are investigated less in comparison to reading comprehension and that 

reading attitudes are important for two reasons: 1) attitude influences the engagement and patience 

needed when reading complexity increases, and 2) poor attitudes of a fluent reader may cause the child to 

choose other activities over reading. In the current study, the reading attitudes of parents had a significant 

positive effect on the reading attitudes of their children, owing to the important contribution that role 

modeling has on the culture of reading in a home environment. Kleijnen, Huysmans, Ligtvoet, and Elbers 

(2017) advocated for children needing access to a reading culture at home, because that culture is an 



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important predictor of reading attitudes and reading behavior. By reading for fun, children can gain a 

sense of pleasure along with cultural and practical knowledge (Cunningham & Stanovich, 1998) and new 

perspectives and solutions about daily life experiences (Kortliever & Lemmens, 2012). 

This is one of the first studies to conduct an online assessment of parents and children reading a story 

together in real time while also answering questions before and after a story intervention about oral 

health hygiene and the importance of a dental checkup. This study demonstrated that there is a significant 

relationship between parent-child attitudes and motivations surrounding reading. For example, Table 14 

showed that there was a strong significant relationship between parents’ perception of the reading level 

needed for the oral health story, and their children’s perception of the reading level as being just right, too 

hard, or too easy (χ2 = 315.060, p < 0.01). Table 13 showed that there was also a significant moderate 

relationship between parents’ perception of the curriculum pictures and children’s perception of the 

pictures (χ2 = 72.985, p < 0.01); this relationship speaks to the value of offering visual-textual reading 

materials to promote oral health literacy, especially photographs where children are demonstrating action. 

Table 13 shows that with the current curriculum intervention, children were also getting auditory cues 

because the stories were read to them and they were able to use the mouse to advance the pages of the 

chapter for tactile and kinesthetic effects. Curricula that helps to develop functional health literacy should 

continue to use multisensory and multimodal cues for action (Ubbes, Coyle, & Tzoc, 2018), while 

building a rich vocabulary of words and promoting the synergistic effects of oral language, written 

language, and body language. This may be especially helpful for children who are actively building 

cognitive-behavioral skills (e.g., goal setting, decision making, communication) with literacy skills (e.g., 

reading, writing, and speaking) across multiple health topics. 

Bus, Leseman, and Keultjes (2000, p. 71) explained parental influence on the reading attitudes and 

motivations of their children by reporting that “when parents do not have important personal needs 

served by reading, they are less inclined to initiate conversations that may make texts enjoyable and 

comprehensible for young, inexperienced readers.” This shows that quality parent interaction with 

children is important in shaping children’s attitudes around reading, and the need for including 

health-related stories that build health literacy. Parents can provide quality interactions by asking 

questions and making comments about the text and pictures, helping the child to understand the story, 

and relating the story to their own life (Bus, Leseman, & Keultjes, 2000). Interactions during shared 

reading are important because “poor readers tire easily, take words literally, read slowly, miss meaning, 

skip over words, and miss the context” (Jamison, 2001, p. 333), which could apply to both adult readers 

and young readers alike. The health literacy materials used in the current study included the use of audio 

narration that supported the parent-child dyads in hearing and thinking about the oral health story to 

improve their understanding (comprehension) of going to the dentist for a checkup. Parents also served 

as co-readers of the survey questions for their child before and after reading the story together with the 

hopes that comprehension would be enhanced. 



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5. Strengths 

One strength of this study was the large sample size of 316 parent-child dyads which were surveyed 

online and given access to the curriculum intervention through a Qualtrics panel (see Qualtrics.com). 

Parent-child dyads were from 43 states in the United States, providing a geographically representative 

sample of parents and their children across the country. 

The second strength of this study was that the oral health story afforded the parent-child dyads a chance 

to view a realistic oral health environment as depicted in ten color photographs rather than simply 

reading ten declarative sentences without oral health pictures. The narrative composition included visual, 

textual, lexical, and gestural communication patterns for each of the ten pages, affording the parent-child 

dyads an authentic, multimodal experience for thinking about their own oral health behaviors as they 

read and listened to the story together. From a design perspective, the electronic story accessed from a 

digital platform represented a new genre of children’s literature that combined narrative storytelling with 

an informational expository text about the importance of oral health hygiene and a dental checkup. 

The third strength of the study was that the oral health literacy intervention helped children to build their 

self-efficacy beliefs, health outcome beliefs, and social norm beliefs for going to a dentist for a checkup. 

Dental checkups have the potential to improve oral health hygiene, boost overall health, prevent chronic 

disease, and reduce dental caries. Individuals with a high number of dental caries have been associated 

with a lower level of oral health literacy (Lee, Divaris, Baker, Rozier, & Vann, 2012). In the current study, 

there was a significant relationship between the number of cavities that parents reported in their lifetime 

and the number of cavities their children had (Table 5). Therefore, the parent-child intervention written as 

a first person narrative to show a photograph of a healthy child believing in their ability to set a goal for 

going to the dentist for a checkup. As shown below, each sentence used a lexical repetition about goal 

setting, beginning with the title page: 

Setting Goals for Going to the Dentist  

“I believe that I can be ready to go to the dentist for a check-up on my mouth, teeth, and gums. I set a goal 

to get a toothbrush from my dentist when I need one, so I can brush my teeth. I set a goal to brush my 

teeth every night with my Mom, so I have a fresh breath and clean teeth. I set a goal to visit my dentist 2 

times a year, so I know I do not have any holes in my teeth (cavities). I set a goal to open my mouth wide, 

so my dentist can see and count my 20 teeth. I set a goal with my friends to learn the right way to brush on 

the front and back of each tooth. I set a goal to show my dentist my bright smile during my 6 month 

check-up. I believe that I can have a good check-up at my dentist, so I can have healthy teeth and gums. 

How about you? Can you set a goal to have a healthy check-up at your dentist too?” 

Since efficacy beliefs are the foundation of human agency (Bandura, 1999, 2001), it is important for 

parents to motivate children to improve their oral health behaviors by brushing, flossing, and going to the 

dentist regularly and by building reading skills to increase vocabulary knowledge and comprehension 

about oral health literacy. Ultimately, parents play a pivotal role in developing the oral health behaviors 



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and oral health literacy of their children. The eBook for Oral Health Literacy© was an educational way to 

prime oral health behaviors and oral health literacy in tandem. Future interventions should look at the 

benefits of using multiple chapters of the curriculum for improving brushing, flossing, rinsing, eating 

fresh foods and beverages, and other oral health habits while “reading to learn” about oral health literacy. 

 

6. Limitations 

The first limitation of the study is that the oral health literacy questions were not pretested so validity and 

reliability of the survey instrument cannot be reported. Because we wanted to survey both parents and the 

children on different items, we did not find an instrument suitable to use from the existing oral health 

literacy tools reported in the literature (Dickson-Swift, Kenny, Farmer, Gussy, & Larkins, 2014), 

including a dearth of instruments in pediatric dentistry for parent-child dyads (Wong, Bridges, Yiu, 

McGrath, Au, & Parthasarathy, 2013; Vann, Lee, Baker, & Divaris, 2010). We sought to assess the 

perceptions of parent-child dyads on their liking of the eBook intervention and found one instrument for 

measuring the functional health literacy of parents in dentistry, but not with parent-child dyads (Gong, 

Lee, Rozier, Pahel, Richman, & Vann, 2007). 

A second limitation of the study is that a significantly larger proportion of the parents surveyed in the 

study identified as female. A significant relationship (p<0.001) was found among the oral health 

behavior of parents and their children (Okada, Kawamura, Kaihara, Matsuzaki, Kuwahara, Ishidori et al., 

2002). Future research will need to increase the participation of fathers in oral health literacy research, 

because the influence of female parent figures may differ from the influence that male parents have on 

their children’s oral health hygiene and their children’s reading behaviors. Oral health research has 

frequently demonstrated the importance of maternal influences on oral health hygiene (Shearer, 

Thomson, Broadbent, & Poulton, 2011; Lee, Kim, Lee, & Kim, 2018; Adil, Eusufzai, Kamruddin, 

Ahmad, Jamayet, Karobari, & Alam, 2020). 

A third limitation of the study is that, while many race ethnicities were represented in the study, 

minorities made up a smaller proportion of those surveyed. Several studies have demonstrated that 

“parent-child joint book reading is sensitive to the cultural background of the family” (Bus, Leseman, & 

Keultjes, 2000; Diener, Hobson-Rohrer, & Byington, 2012). Thus, future research could increase the 

number of participants from different cultural backgrounds to read and respond to the oral health story 

books Psychographics are a qualitative methodology that studies people based on their preferences, 

interests, values, lifestyle choices, and goals. More qualitative methodologies are needed in oral health 

research to ensure that we understand the emotions, attitudes, and beliefs of children and their parents 

regarding their dental routines, daily oral hygiene, and emotions for going to the dentist. Elicitation 

interviews (Erbe, Middlestadt, Lohrmann, & Beckmeyer, 2020) are needed to learn the preferences, 

beliefs, and attitudes of children in health education. As such, structured and semi-structured interviews 

regarding children’s oral health practices (e.g., brushing, flossing, rinsing, and going to a dental check-up) 



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could be used to design even more oral health literacy curricula in the future that are skill-based and 

inclusive to goal setting, decision making, and communication. 

A fourth limitation of the study is that parents and children self-reported their number of cavities due to 

the online nature of the study instead of being assessed with an objective measure by a dental 

professional called the DMFT (decayed, missing, and filled teeth). Among the 316 parents who 

self-reported the number of their cavities they had in a lifetime, the average number of cavities were 3 

(SD 1.59) with a low of 0 cavities and a high of 4 or more cavities. Results showed that 95 (30%) parents 

reported four or more fillings; 36 (11%) reported three fillings; 61 (19%) reported two fillings; and 37 

(12%) reported one filling. No fillings were reported by 86 parents (27%). Research on the oral health 

literacy of parents in multiple countries has been significantly correlated with the mean DMFT score of 

their children (Adil, Eusufzai, Kamruddin, Ahmad, Jamayet, Karobari, & Alam, 2020). The lower the 

parental oral health literacy, the higher the prevalence of caries in their children. Future research could 

implement the eBook for Oral Health Literacy© in school-based health clinics so that dental 

professionals can assess the DMFT of children as an objective measure and help to identify children in 

most need of dental, behavioral, and educational interventions.  

 

7. Recommendation for Future Research 

Future recommendations for research include testing student knowledge and attitudes before and after 

reading several curriculum chapters associated with a theme, e.g., oral health hygiene, oral health and 

nutrition, oral health and beverages, dental checkups, rather than only one chapter as was done in this 

study. Dentists and health educators may benefit by knowing the cumulative effect of many oral health 

literacy chapters on children spanned over several weeks. Future research could also investigate the work 

and career niche of parents because literacy patterns play a role in individual health status. Jaafar, Ab 

Malik, and Al-Kadhim (2020) showed that individuals in health, science, and technology fields had 

better oral health literacy than those individuals with careers in the social sciences. 

The connections between health, oral health, and literacy (e.g., reading and writing) still need further 

development in health education curricula and public health messaging for children and their parents. 

Parent-child dyads will benefit from more environmental prompts, cues, and reminders about oral health 

hygiene through additional digital applications, electronic books, printed books, pamphlets, brochures, 

posters, and billboards so they can read and speak about oral health in a variety of situations and settings 

The more opportunities to see and hear different people of all ages and backgrounds talk about their 

smiles, the health of their teeth, and the benefits of going to a dentist, the better the social norms will be to 

reinforce oral health behaviors of children and their families. To develop skills for oral health literacy, 

children can learn to write their own picture stories about oral health using a design template modeled 

after the eBook for Oral Health Literacy©, which is accessible on the Digital Literacy Partnership 

website (Ubbes, 2021). Children can also practice their vocabulary words, spelling, and reading 



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comprehension by downloading the eBook for Oral Health Literacy© Workbook found at 

@https://dlp.lib.miamioh.edu/ebook/workbook/FullCurriculumWorkbookUbbes&WallaceMay2021Fin

al.pdf associated with each of the 17 stories in order to build their functional health literacy in oral health. 

Future researchers should use the reading comprehension questions in the workbook to determine what 

children actually recall from reading the chapters and correlate those scores with objective assessments 

of decayed, missing, or filled teeth (e.g., DMFT) by dental professionals in school-based health clinics. 

 

8. Conclusion 

This oral health literacy study investigated the association of reading behaviors and oral health behaviors 

when children were educated on setting a goal for a dental checkup as outlined by a Healthy People 2030 

leading health indicator. The study demonstrated that parents had a significant influence on their 

children’s oral health behaviors (e.g., brushing, flossing) and oral health attitudes. The study also showed 

that parents had a significant influence on their children’s reading behaviors and attitudes. Previous 

research has indicated that self-reported reading abilities were associated with better oral health (Zullig, 

Ubbes, & Mann, 2013), linking reading with oral health behaviors. This study reinforced the fact that 

parents have the ability to build the oral health literacy of their children. Reading one story from the 

eBook for Oral Health Literacy© curriculum had a significant effect on the oral health literacy skills of 

children, especially how to set goals and make decisions for the development of their personal health 

literacy. Future studies with parent-child dyads should try to quantify the effect of reading additional 

chapters of the oral health literacy curriculum in order to influence oral health behaviors, attitudes, and 

motivations especially self-efficacy beliefs. 

 

9. Acknowledgements 

We acknowledge the support of Dr. Michael Hughes and his students, e.g., Lindsay Tighe, Yangfeng Shi, 

Wangying Yang, Phuong Ho, Abbie Klinker, and Dani Abramovitz, of Miami University who assisted in 

statistical analysis and interpretation of the research results. 

 

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