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Rural Latino Immigrant Caregivers’ Conceptions of TheirChildren’s Oral DiseaseSarah Horton, PhD; Judith C. Barker, PhD

Abstract

Objective: The aim of this study was to examine Latino immigrant caregivers’explanatory models of the causes of early childhood caries (ECC). Methods: In arural area, we conducted 71 open-ended qualitative interviews with 26 Mexicanimmigrant and 12 Salvadoran immigrant caregivers of children under 6 about thecauses of ECC. Two researchers independently read each interview and classifiedeach interviewee’s response. Results: Caregivers mentioned three biomedicalcauses of oral disease (sweets, poor oral hygiene, and bottle-feeding) and two lay orpopular causes (lack of milk consumption and “bad” genes). Although caregiverswere aware that the consumption of sweet foods causes decay, they expressedparticular confusion about how bottle-feeding causes decay. Nineteen caregiversattributed decay specifically to bottle-feeding, yet 14 believed the cause of decaywas the bottle’s nipple. Seven Mexican immigrant caregivers attributed their chil-dren’s decay specifically to a lack of calcium, and six immigrant caregivers to “badteeth genes.” Conclusions: Conceptions of oral disease derived from the caregiv-ers’ own dental experiences, their conceptions of the body, and interactions withdental professionals. The fact that biomedical explanations dominate the list ofcauses of caries for both groups indicates that the caregivers’ explanatory models oforal disease are powerfully shaped by interactions with health professionals. Immi-grant caregivers’ mistaking of the baby bottle’s nipple as the source of decayindicates the need for more effective oral health promotion. Yet the Mexican immi-grants’ conceptions of a lack of calcium as a major factor in their children’s decaymay illustrate a strong cultural link between teeth and milk.

Key Words: Latino/Hispanic children, rural immigrants, early childhood caries,parental beliefs and behaviors, ethnography, low income, oral health education

IntroductionStudies have long documented the

disproportionate rates of early child-hood caries (ECC) among Latinochildren (1). Research shows thatMexican-American children havehigher rates of decay than US school-children (2-5), and that the US-bornchildren of Mexican immigrants expe-rience more decayed primary teeththan Mexican-American children ingeneral (6). Much research into thereasons why children of Mexicanimmigrants bear a disproportionateburden of oral disease has pointed tobarriers to access and dental utiliza-tion (7,8). Some research suggests

that immigrant parents may have poorknowledge of effective preventivemeasures (9,10), may not understandthe relationship between diet and oraldisease (10), and may accord lowvalue to primary teeth (11). This “lowdental IQ” may, in turn, be exacer-bated by their lack of access to dentalprofessionals (12). Yet little researchto date has examined Latino immi-grant caregivers’ beliefs about thecause of their children’s oral disease,and whence such conceptions derive.It is important to understand differentpopulations’ beliefs about the causesof oral disease because they affectoral health practices (Butani et al.,

unpublished observations), dentalutilization (13), and communicationwith oral health professionals (14,15).

The concept of “explanatorymodels” (15) has long been used toshow that different cultural beliefsabout the origins and nature of aparticular disease lead to differentmethods of managing and prevent-ing it. This concept suggests that car-egivers of different cultural originsmay interpret the causes of oraldisease differently than dental pro-fessionals, and consequently mayadopt different oral health-relatedbehaviors. Explanatory models ofdisease are shaped by the illnessexperiences of the members of agroup, their interactions with healthprofessionals, and their conceptual-ization of the body and how itworks. They often contain elementsof both biomedical and lay or “folk”knowledge (15). Explanatory modelsof oral disease that differ from bio-medical models are not exclusive tominority groups, but may existamong low-income populations withlittle access to oral health education(12-14). An understanding of the dif-ferent explanatory models of oraldisease among groups with a highincidence of oral disease – such aslow-income Latinos – is crucial to thedesign of effective oral health educa-tion programs. It can also help facili-tate dentist–patient communication(14,15), as the dentist can thenaddress misconceptions of oraldisease in the patients’ own terms.

This paper examines Latino immi-grants’ conceptions of their children’soral disease through interviews with

Send correspondence and reprint requests to Sarah Horton, PhD, Department of Anthropology, History, and Social Medicine, University ofCalifornia San Francisco, 3333 California Street, Suite 485, San Francisco, CA 94143-0850. Tel.: 510-590-8773 (mobile phone); Fax: 415-476-6715;e-mail: sarah.horton@ucsf.edu. Sarah Horton is with the Department of Preventive and Restorative Dental Sciences, University of California SanFrancisco. Judith C. Barker is with the Department of Anthropology, History, and Social Medicine, University of California San Francisco. Sourceof support: National Institute of Dental and Craniofacial Research Grant U54 DE 14251 (J. A. Weintraub, DDS, MPH, PI). Manuscript received:3/4/07; accepted for publication: 9/15/07.

Vol. 68, No. 1, Winter 200822

©2008, American Association of Public Health DentistryDOI: 10.1111/j.1752-7325.2007.00078.x

26 Mexican immigrant and 12 Salva-doran immigrant rural caregivers ofUS-born Latino children. Analysis ofthe explanatory models of diseaseamong immigrant parents will helpexplain puzzling aspects of parentalbehavior – for example, why parentsmay allow children to bottle-feed atnight despite health professionals’conflicting advice. Explanatorymodels should not be viewed as“incorrect beliefs,” but rather as logi-cally consistent with the caregivers’cultural background, experiences,social context, and interactions withhealth professionals (15). A betterunderstanding of Mexican and Salva-doran immigrant parents’ models oforal disease will thus help inform thedesign of effective oral health educa-tion messages and improve the deliv-ery of dental care.

MethodsResearch Design. We used an

in-depth qualitative approach to gainan understanding of rural Latinoimmigrant parents’ conceptions oftheir children’s oral disease (Barkerand Horton, unpublished observa-tions). Our approach consisted ofa) in-depth interviews of caregiversabout their beliefs regarding thecauses of their children’s oral disease,supplemented by b) an ethnographicobservation of their oral health-related behaviors. These observationshelped us understand how the car-egivers’ different conceptions of theirchildren’s oral disease led them todifferent forms of preventive dentalcare and dietary behaviors.

Sample Recruitment. We con-ducted this study in a rural commu-nity in California’s Central Valley,which had a high proportion ofimmigrant caregivers. Eligible partici-pants were: a) primary caregiversof at least one child under the age of6; and b) immigrants from LatinAmerica (both Mexico and El Salva-dor). Participants were drawn fromtwo sources: a) two-thirds from arandomized list of householdaddresses generated by a partnerstudy on farmworker occupationalhealth; and b) one-third from twolocal Head Start programs with high

Latino enrollment. We did not screenspecifically for children who haddental caries.

Data Collection: Interviews.Interested participants were screenedfor eligibility and recruited into thestudy by bilingual interview staff,who obtained informed consent. Allinterviews relied on an open-endedinterview guide approved by theinstitutional review board of the Uni-versity of California, San Francisco.Interview questions were developedbased on previous studies of Latinoimmigrant and low-income popula-tions’ conceptions of oral diseaseand experiences with the oral healthcare system (1,5,6,8-14; Butani et al.,unpublished observations), and inconsultation with a team of special-ists in Latino children’s oral health.Interviews examined the caregivers’conceptions of their children’s oralhealth and disease and oral health-related behaviors based on theseconceptions.

Data Collection: Ethnography.Ethnography helped explore howthe caregivers’ explanatory models oforal disease led them to different oralhealth-related behaviors. It includedobservations of oral health-relatedbehaviors during snack time or meal-time and during visits to the dentist.Observations helped complement thedata provided by the interviews andwere conducted with the expressedconsent of the families observed.

Data Analysis. Each interviewwas audio taped, translated, andtranscribed, and all observationsrecorded as typed field notes. Dataanalysis included preparing andcoding the transcripts and field notesand performing qualitative analysison the textual data. Following stan-dard procedures, we developed ashort list of codes related to concep-tions of oral disease and added newcodes when they emerged whilereading the transcripts and fieldnotes (16,17). Two researchers inde-pendently read through the 38 car-egivers’ responses, categorized thecauses of children’s oral disease, andthrough discussion reached consen-sus on discrepant categorizations.Five major categories of the causes of

oral disease were developed. Inter-viewers then analyzed the caregiverresponses by country of origin todiscern the possible differences inconceptions of oral disease betweenMexican and Salvadoran immigrants.

ResultsBetween September 2005 and

May 2006, we conducted a total of 71in-depth interviews with 38 immi-grant caregivers about the causes oftheir children’s oral disease. Twenty-six caregivers (85 percent of thesample) were from Mexico, and 12caregivers were from El Salvador(see Table 1). All participants werethe mother of the focal child. Thiswas a primarily low-income andrecently arrived immigrant popula-tion: The median annual householdincome was $17,000, and the medianlength of residence of caregivers inthe United States was 9 years. Justover one-third of the children (36 of95, or 38 percent) of these caregiverswere under age 6, the prime age atwhich ECC strikes. As a group, thecaregivers had had significant expe-rience with the children’s oraldisease. Most caregivers (23 of 38, or60 percent) reported that their focalchild under age 6 had had experi-ence with caries, eight reported theirchild had no dental visit yet, andseven reported their child had had avisit but no caries as yet.

Caregivers mentioned three bio-medical causes of oral disease andtwo lay or popular causes. The threebiomedical explanations cited wereconsumption of sweets (24 res-ponses), bottle-feeding of infants andtoddlers (23 responses), and lack ofproper oral hygiene (17 responses).Caregivers provided two popularexplanations for the Latino children’soral disease – inadequate intake ofmilk or dietary calcium (7 responses)and “bad genes” (6 responses). Onlythe Mexican immigrant caregiversattributed caries to insufficient milkor calcium intake. While consump-tion of sweets and bottle-feedingresulted in considerable discussion,oral hygiene – “brushing” – wasrarely elaborated beyond that simpleterm.

Latino Caregivers’ Conceptions of Oral Disease 23

Table 1Sociodemographic Characteristics of Caregivers

Mexican (n = 26)* Salvadoran (n = 12)* Total of both groups (n = 38)*

Gender n = 26 n = 12 n = 38Female 26 12 38

Age (years) n = 25 n = 11 n = 36Mean ± SD 30.4 ± 6.2 32.0 ± 7.4 31.1 ± 6.9Median 29 28 29Range 19-47 24-45 19-47

<20 1 0 121-30 15 6 2131+ 9 5 14

Years of education completed n = 25 n = 12 n = 37Mean ± SD 7.1 ± 3.7 3.9 ± 2.8 5.8 ± 3.5Median 9 3.5 6Range 0-14 0-10 0-14

0-3 6 6 124-6 5 5 107-9 10 0 1010-12 2 1 313+ 2 0 2

Annual household income† n = 24 n = 12 n = 36Mean ± SD $17,000 ± 5,700 $18,200 ± 7,400 $17,500 ± 6,400Median 17,500 14,000 16,000Range $8,000-$28,000 $8,000-$36,000 $8,000-$36,000

<$10,000 4 1 5$11,000-$15,000 6 5 11$16,000-$20,000 9 2 11$21,000+ 5 4 9

Marital/partner status n = 25 n = 12 n = 37Mother has partner 24 12 36Mother is single 1 0 1

Years of residence in the United States n = 25 n = 12 n = 37Mean ± SD 8.5 ± 5.6 9.8 ± 2.9 9.0 ± 4.0Median 7 10 9Range 3-22 5-16 3-22

<10 18 7 2510+ 7 5 12

Legal status n = 25 n = 12 n = 37Undocumented 17 3 20Temporary permanent status 0 5 5Asylum 0 1 1Legal permanent resident 7 3 10Citizen 1 0 1

Occupation n = 24 n = 11 n = 35Farmwork 13 11 25Full-time caregiver 10 0 10Other 1 0 1

Rural or urban origin‡ n = 26 n = 12 n = 38Rural origin 21 10 31Urban origin 5 2 7

Children per household n = 26 n = 12 n = 38Mean ± SD 2.7 ± 1.2 2.3 ± 1.1 2.6 ± 1.2Median 3 2 2Range 1-5 1-5 1-5

1 4 3 72 7 5 123 10 3 134 2 0 25 3 1 4

Journal of Public Health Dentistry24

Most women (66 percent) dis-cussed one or two categories ofcause (see Table 2). Two (Mexicanimmigrant) caregivers did not proffera cause for dental caries, and only

one (Mexican immigrant) caregivermentioned all five categories ofcause. Not only did Mexican immi-grant caregivers, in general, display awider range of beliefs about the

cause of dental caries compared withSalvadoran caregivers, but they alsodiscussed more lay causes (seeTable 3). Despite their higher levelof formal education, more Mexicanimmigrant caregivers (33 percent of26) than Salvadoran immigrants (17percent of 12) discussed a mix ofbiomedical and lay or popular per-ceptions of cause (see Table 4).

The fact that biomedically basedperceptions dominate the list ofcauses of caries for both groups indi-cates that the caregivers’ explanatorymodels of oral disease are not merelyculturally based but are powerfullyshaped by their interactions withhealth professionals. Yet, the healtheducation efforts by educators at thefederal Women, Infants, and Children(WIC) nutritional program or by den-tists have only been partially suc-cessful. Although both Mexicanand Salvadoran immigrant caregiverssubscribed to biomedical under-standings of the cause of oraldisease, the women in both groupsexpressed particular confusion abouthow bottle-feeding causes decay. Anunderstanding of the immigrant car-egivers’ explanatory models of oraldisease illuminates the caregivers’different understandings of thecauses of oral disease, as well as the

Table 1Continued

Mexican (n = 26)* Salvadoran (n = 12)* Total of both groups (n = 38)*

Age of youngest child (years) n = 25 n = 11 n = 36Mean ± SD 2.3 ± 1.4 2.6 ± 1.9 2.4 ± 1.5Median 2 2.5 2Range 2 weeks-4 years 6 months-6 years 2 weeks-6 years

<1 6 2 81-2 8 4 123-4+ 11 4 155+ 0 1 1

Age of oldest child¶ (years) n = 23 n = 9 n = 32Mean ± SD 10.2 ± 5.7 9.2 ± 5.2 10.0 ± 5.0Median 10 8.5 9Range 2-24 3-19 2-24

<5 6 3 96-10 9 3 1211+ 8 3 11

* Numbers in individual cells vary slightly as not all participants supplied data to every question.† In 2006, $US.‡ A rural town was defined as having a population of 15,000 or less. An urban area was defined as having a population larger than 15,001.¶ When more than one child lives in a household.SD, standard deviation.

Table 2Number of Perceived Causes of Early Childhood Caries Recognized

by Participants in Each Population Group

Number of perceivedcauses Total (n = 38) Mexican (n = 26) Salvadoran (n = 12)

0 2 2 01 11 6 52 14 9 53 7 5 24 3 3 05 1 1 0

Table 3Perceived Causes of Children’s Oral Disease (Total Number of

Responses by Population Group)

Perceived cause Total (n = 77) Mexican (n = 58) Salvadoran (n = 19)

Biomedical 64 47 17Sweets 24 18 6Bottle drinking 23 16 7

(Nipple of bottle)* (14) (9) (5)Poor oral hygiene 17 13 4

Lay or popular 13 11 2Lack of calcium 7 7 0Bad genes 6 4 2

* Notes a misunderstanding or confusion within the category “bottle drinking,” rather than aseparate category of response.

Latino Caregivers’ Conceptions of Oral Disease 25

solutions they devised based uponthese perceived causes. Moreover,they indicate important areas forintervention by oral health educationprograms and dental professionals.

Biomedical Explanations ofDecay

Consumption of Sweet Substances.Consumption of candies was thesingle most common cause men-tioned by caregivers, with a total of19 responses. Six caregivers ex-pressed awareness of sugar as theoperative agent causing caries, andtwo specifically mentioned adhesionto teeth as an important factor. OneMexican immigrant respondent, forexample, said “it’s from eating candyor things with a lot of sugar that willstay on their teeth,” while anotherexplained “because they eat candyand they do not get their teethbrushed.” A Salvadoran immigrantmother agreed: “The sugar is whatcauses the cavities – candies andsoda.” Caregivers less commonlymentioned juice or soda as sugaryagents that also cause decay, withonly three mentions each.

Bottle-feeding. Nineteen caregiv-ers mentioned bottle-feeding as apossible cause of oral disease, manyrepeating an explanation given tothem by health professionals. Ninecaregivers said that they had learnedthat bottle-feeding can lead to oraldisease from health educators at thefederal WIC nutritional program for

low-income families, and seven car-egivers (including three of the nineWIC attendees) had also heard thisfrom their physician in the UnitedStates. Two had learned this fromdoctors in Mexico when they wereraising Mexico-born children, twohad heard this from friends, and onefrom her mother. Two caregivers –one who was bottle-feeding a7-month-old infant and one who hadexclusively breast-fed her children –said that they had never heard thatbottle-feeding could cause decay.

While many of these mothers hadheard that bottle-feeding can lead tooral disease, they expressed confu-sion about how exactly bottle-feeding harms children’s teeth. Onlythree of 38 caregivers (two Mexicanimmigrants and one Salvadoranimmigrant) identified the prolongedbathing of teeth in the sugary con-tents of the bottle as the primarycause of ECC. Instead, caregiverstypically expressed two differentexplanatory models for how bottle-feeding leads to oral disease – onemodel implicated the structure of thebottle as the cause, whereas theother model implicated prolongedexposure to the bottle itself. Eachexplanatory model of how bottle-feeding leads to oral disease led thecaregivers to adopt different feedingpractices to prevent it.

When asked how bottle-feedingcauses decay, 14 caregivers (nine

Mexican immigrants and five Salva-doran) specifically cited the bottle’snipple as the cause of decay:“Because of the rubber. The rubberwas what the bad part is. It causesteeth to get decayed. And ugly,” saidone Salvadoran immigrant mother.Four other caregivers specificallycited the plastic of the nipple as theharmful agent. As one Salvadoranmother put it: “Well, because theplastic that the nipple has, it’s bad forthe children’s teeth. That has beenmy understanding. That is the reasonI take them off the bottle at an earlyage.”

Caregivers’ conceptions of thenipple as the causative agent in ECCseemed to derive from misunder-standing the health professionals’messages. Two caregivers explicitlyidentified their dentist as the sourceof this information, and two otherscited health educators at WIC.Another two caregivers appeared toconfuse the association of the nipplewith crooked teeth with its role incausing cavities. One caregiverexplained thus: “Because in Mexico[at the clinic] they told us not to givethem so much [nipple] because theirteeth don’t stay straight.”

Five caregivers subscribed to anexplanatory model that instead em-phasized prolonged exposure as away that bottle-feeding can lead tooral disease. A Salvadoran immigrantcaregiver explained: “[M]y momwould always tell me that we shouldnot let children carry the bottle intheir mouth for a long time.” Said aMexican mother: “[B]ecause theysleep with it and they finish the milkand they are still sucking and allthey’re doing is sucking the nipple,they are not drinking anything andthat’s bad.” Three of these five car-egivers emphasized prolonged expo-sure to the bottle at nighttime as theprimary factor. As one Salvadoranimmigrant noted: “They [WIC] saidthat when they fall asleep with thebottle, their teeth get stained andwhen they don’t brush their teeth.”

These two different explanatorymodels of oral disease led the caregiv-ers to adopt different child-feedingpractices. Seven caregivers who

Table 4Perceived Causes of Children’s Oral Disease (by Numbers of

Individual Participants from Each Population Group)

Category Total (n = 36) Mexican (n =24) Salvadoran (n = 12)

Biomedical causes only 25 15 101 biomedical 10 5 52 biomedical 11 8 33 biomedical 4 2 2

Popular causes only(1 cause)

1 1 0

Mixed biomedical andlay causes

10 8 2

1 biomedical + 1 lay 3 1 21 biomedical + 2 lay 1 1 02 biomedical + 1 lay 2 2 02 biomedical + 2 lay 0 0 03 biomedical + 1 lay 3 3 03 biomedical + 2 lay 1 1 0

Journal of Public Health Dentistry26

conceived of the bottle as the cause oftheir children’s decay had chosen toswitch their children to a cup with ahard spout instead. One Mexicanimmigrant caregiver explained: “Yes,because the nipple from the bottlewill ruin his teeth and the cup mouth-piece will not.” Yet three of thesecaregivers said they continued toallow their child to drink from the cupduring the night. One Mexican immi-grant caregiver who gave her childchocolate milk in his cup said: “He’llget up at 2 to 3 in the morning, crying,and he’ll tell me he wants his little cupwith milk and I feel bad and get upand get him his cup.”

Meanwhile, 10 caregivers whowished to avoid their children’s pro-longed exposure to the bottle or cupadopted a practice of removing itfrom their child after the child wasasleep. These caregivers said they fol-lowed this routine without brushingtheir children’s teeth. As a Salvadoranimmigrant caregiver explained: “[I]t’seasier for a child to go to sleep withtheir bottle and if it has sweet drinks,it could affect the teeth. I don’t – I justlet her fall asleep and I take it out andwhen she wakes up she gets it again.”By not understanding that thesubstance inside the bottle and thecontext in which the bottle was con-sumed (at naptime or bedtime) wereboth more important than the bottleitself, these caregivers unknowinglyadopted unhealthy feeding practices.

Partly because of such confusionsabout how exactly bottle-feedingleads to children’s oral disease, threecaregivers openly expressed skepti-cism about the health educators’message. One Salvadoran immigrantmother, for example, explained thatWIC had told her that “their teeth getruined quickly from the rubber on thebottle.” She said this explanation didnot make sense to her: “I think thatsometimes it’s the rubber, but not somuch, but because of the sugars in thebottle.” Yet her uncertainty of theexact mechanism by which the bottlecauses decay deepened because ofher own experience with her chil-dren. “I don’t think it’s the bottlebecause my older son didn’t drinkfrom the bottle and he still has cavi-

ties,” she noted. For this reason, shecontinued to bottle-feed her youngestdaughter. Similarly, a Mexican immi-grant mother reported: “Well, I did notlike him to drink out of the bottlebecause the dentist said that thenipple would rot his teeth. I thinkthat’s not true, though, because [hergranddaughter] had a lot of cavities[and] she never drank out of a bottle.”Caregivers thus tested their explana-tory models of the causes of theirchildren’s oral disease by assessingthe reasonableness of the health edu-cators’ models and by comparingthose models with their personalexperiences. As a result of the mis-communication or misunderstandingthat distorted the health educators’message, these caregivers sometimesdismissed the explanatory models oftheir children’s oral disease offered byhealth professionals.

Popular Explanations of DecayLack of Milk or Calcium. Seven

caregivers, all Mexican immigrants,explicitly mentioned a link betweenlow calcium intake and oral disease.Two caregivers specifically attributedtheir own children’s ECC to a possi-bly inadequate intake of milk. One,for example, said: “I did not breast-feed. Sometimes I think that’s whythey have teeth problems – maybenot enough calcium but I don’tknow.” Similarly, another caregiversaid of her son’s experience: “Hmm,well, the truth – I don’t know whyhe has so many dental problemsbecause since he’s small he got cavi-ties, but rarely did he eat candy. Ithink it was because he did not haveenough calcium.”

Two mothers attributed their chil-dren’s ECC to their own lack of con-sumption of sufficient milk whilepregnant. Both perceived calciumintake as important as oral hygieneand that consumption of sugaryfoods caused caries. For example,one mother of a girl who drank twoto three bottles of juice each nightand subsequently developed severeECC at the age of 11

2explained her

daughter’s oral disease this way: “Ithink it’s from lack of calcium. Yes,like the [multivitamins] that they gaveme [at the clinic] I really did not take

them. That’s why I think that thishappened to her.” This mother hadheard from friends that bottle-feeding also caused decay, yet main-tained that her lack of sufficientcalcium intake while pregnant wasthe main cause of her child’s ECC.

This linkage between milk andchildren’s teeth may be culturallybased, as illustrated by the word for“baby teeth” in Spanish: “dientes deleche,” or literally, “milk teeth.” In theinterviews, we asked the caregivers toexplain why they thought primaryteeth are called “milk teeth.” Twentyof the 26 Mexican immigrant care-givers confirmed a perceived linkbetween milk, or calcium, and thephysical health of “baby” teeth. Onecaregiver explained: “They areformed from the mother’s milk. That’swhy teeth have a lot to do with milk.”Meanwhile, another Mexican car-egiver said that baby teeth wereformed from milk, the child’s staplefood, whereas adult teeth are formed“from food.” Another caregiver rea-soned that the consumption of milkis linked to the “strength” of teeth,saying that teeth may break notbecause they are “decayed” but ratherbecause they are “weak” because of alack of sufficient calcium.

Because caregivers perceivedinadequate calcium intake as animportant cause of oral disease, someadopted feeding practices to encour-age milk consumption. Three caregiv-ers explicitly said they encouragedtheir children to consume large quan-tities of milk to avoid oral disease.One caregiver, for example, com-mented: “Well, like when they eatsomething sweet, I tell them to go andbrush their teeth and also to drink alot of milk.” These perceptions high-light an important area for oral healtheducation.

“Bad Genes” and the Futility ofPrevention. Six caregivers specifi-cally attributed their children’sdecay to “bad teeth” that may beinherited genetically. These caregiv-ers dismissed other biomedicalfactors that might lead to decay infavor of heredity. Reflecting on whyone of her three daughters haddeveloped oral disease while the

Latino Caregivers’ Conceptions of Oral Disease 27

other two had not, one Mexicanimmigrant mother declared: “Well, Ido not know – maybe they alreadyhave that in them because they eatcandy, but they really do not eat alot of candy.” Similarly, a Salva-doran immigrant mother who waspuzzled by her daughters’ pro-nounced ECC attributed it to herhusband’s family: “I don’t knowwhether it’s because of my hus-band’s family, because a lot of themhave had dental problems, theyhave a lot of cavities.” While sus-ceptibility to dental caries mayindeed have a genetic component,these caregivers instead posit gen-etics as the overriding factor indetermining decay. One Mexicanimmigrant mother put this bluntly.Stating that there was no singleenvironmental factor “to blame” forher children’s cavities, she attributedtheir caries purely to heredity: “Ithink that it’s something genetic,that that’s whose teeth are going toget bad no matter what.”

Four caregivers whose childrenhad developed ECC expressed asense of powerlessness over theirchildren’s dental decay. One Salva-doran mother, for example, venturedthat perhaps her daughters’ cariesresulted from “bad luck.” Thissense of futility derived from thecaregivers’ lack of understanding ofthe mechanisms of dental decay, anincomprehension that was bolsteredby the health educators’ unsuccessfulexplanations of the cause of cavities.For example, one Mexican immigrantmother said that she still did notunderstand what led her son todevelop severe decay at age 1.5,although her dentist had told her itwas caused by his consuming severalbottles of milk each night. Unclearhow bottle drinking relates to ECC,this mother said: “The truth is I don’tknow [what caused it] becausewhen he was smaller he hardly atecandy. . . . If we knew what caused itwe would prevent it.” The caregivers’sense of powerlessness over theirchildren’s ECC suggests communica-tion gaps between caregivers andhealth professionals that sustainedhealth education could address.

DiscussionThis paper has contributed to

an understanding of Mexican andSalvadoran immigrants’ explanatorymodels of children’s oral disease.Because qualitative interviews allowthe caregivers to express their under-standings of the relationship be-tween specific behaviors and oraldisease in their own language, theyare valuable in identifying unknownoral health beliefs and gauging thegroups’ oral health knowledge. Theyallow for a complex understandingof the explanatory models of illnesscausation and treatment, which maycontain elements of both biomedicaland lay knowledge.

The most commonly cited expla-nation for the children’s oral diseasewas the consumption of sweet foods,with 19 caregivers defining sweetfoods specifically as “candy.” The car-egivers were less aware of soda andjuice as contributors to oral disease.While caregivers did commonly citebiomedical explanations for chil-dren’s decay, they expressed particu-lar confusion about how bottle-feeding leads to decay. Fourteen ofthe 19 caregivers who mentionedbottle-feeding as a cause of decayattributed it to the bottle’s nipple,whereas five attributed decay to pro-longed exposure to the bottle. To ourknowledge, the association betweendecay and the bottle’s nipple has notyet been reported. Each differentexplanatory model of oral diseaseled the caregivers to adopt specificfeeding practices to avoid the per-ceived cause of decay, such as switch-ing from a bottle to a cup with a hardspout or removing the child’s bottlewhen the child fell asleep. These mis-understandings of how bottle-feedingcauses oral disease thus led the car-egivers to adopt further unhealthypractices. Meanwhile, seven caregiv-ers – all Mexican immigrants – men-tioned the consumption of milk as astrong protective factor in avoidingoral disease.

While some differences existedbetween the Mexican and Salvadoranimmigrant caregivers’ explanatorymodels of oral disease and oralhealth-related practices, the explana-

tions offered by both groups ofmothers are remarkably similar. Yetthe similarity in both groups’ expla-nations does not necessarily derivefrom a shared “Latino culture.” Simi-larities between the two groups ofparticipants could also reflect therestricted access to a limited pool ofhealth educators or dental profes-sionals, a high degree of social inter-action among residents, or a relativelack of socioeconomic differentiationin this low-income immigrant com-munity. Generalizations to all Latinosshould be undertaken cautiously.Urban Latino populations, those inother socioeconomic strata, or thosein other geographic regions of thecountry could well express quite dif-ferent views.

Nonetheless, these findings pointto distinct areas in which continuedhealth education is not only neces-sary but could be more effectivelydelivered and reinforced. Eighteencaregivers mentioned health profes-sionals as the source of their knowl-edge of how bottle-feeding causesdecay, while only three mentionedpeers. The caregivers’ confusion ofthe nipple as the source of decaymay derive from health educators’distillation of a complex health pre-vention message into a simple andmemorable slogan – that, forexample, the nipple “is bad forteeth.” Yet because they misunder-stand the precise mechanism ofdecay, many caregivers adoptunhealthy feeding practices basedupon these messages. Others dismissthe harm that bottle-feeding cancause because of the message’sapparent lack of sense. This confu-sion illustrates the need for moreeffective oral health education pro-grams and for a better understandingof the caregivers’ explanatory modelsof oral disease, so as to better guideoral health education programs toredress such misconceptions.

AcknowledgmentsThis study was supported by a

grant from the National Institute ofDental and Craniofacial Research(NIH/NIDCR U54 DE 14251) tothe Center to Address Disparities in

Journal of Public Health Dentistry28

Children’s Oral Health (CAN DOCenter) at the University of California,San Francisco (Jane A. Weintraub,DDS, MPH, principal investigator).Judith C. Barker, PhD, is principalinvestigator of the CAN DO Center’sProject 5 “Hispanic Oral Health: ARural and Urban Ethnography,” thespecific study upon which this articleis based.

We would like to thank Azucena(Susie) Ordorica, who conducted 20of the interviews with immigrantcaregivers and translated and tran-scribed all the interviews. We alsothank Pedro Arista and Kristin Hoeftwho helped with data analysis.Finally, we thank Jane A. Weintraub,DDS, MPH, who commented exten-sively on this article and has sup-ported the project throughout.

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