Family Medicine & Primary Care Review 2019; 21(1): 53–57 https://doi.org/10.5114/fmpcr.2019.

82974

ISSN 1734-3402, eISSN 2449-8580

ORIGINAL PAPERS © Copyright by Wydawnictwo Continuo

The role of attitude, subjective norm, and perceived

behavioral control (PBC) of mothers on teaching toothbrushing
to preschool children – based on the Theory of Planned
Behavior: a cross-sectional study
R. Darmawan Setijanto1, A–G, Taufan Bramantoro1, A–G,
ORCID iD: 0000-0003-0719-4189

Retno Palupi 1, B, F
, Atika Hanani2, A, B, E, F
1
Departement of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
2
Graduate Student, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
A – Study Design, B – Data Collection, C – Statistical Analysis, D – Data Interpretation, E – Manuscript Preparation, F – Literature
Search, G – Funds Collection

Summary Background. Indonesia has reported high prevalence and severity of early childhood caries (ECC). This is at 90% at age
3–5 years with higher mean of decay extraction or filling of teeth (def-t). Preschool children are one of the most vulnerable groups to
dental and oral disease because they generally still not have proper behavior with regard to maintaining their oral health. Parental care
is an important factor as it serves as the basis of the formation of behaviors that support or do not support childhood oral hygiene. One
well-validated theory commonly used to test human attitudes and behaviors is the Theory of Planned Behavior.
Objectives. Based on the Theory of Planned Behavior, to describe the behavior of mothers on teaching toothbrushing to preschool
children.
Material and methods. We undertook a cross-sectional analytic study with sample size 218 of mothers of kindergarten children in
Surabaya. We obtained our data by giving a questionnaire to mothers that consists of 35 semi open ended and closed ended questions.
Results. The variables of Theory of Planned Behavior which showed significant effect on intention to act were attitude and PBC with
p-value < 0.005. Subsequently, attitude, subjective norms, and PBC were tested together to measure the influence to intention – which
resulted in a R2 of 0.37.
Conclusions. Attitudes and PBC are the most dominant factors in improving the intentions and behavior of mothers towards teaching
effective toothbrushing practices to their children.
Key words: dental caries, child, preschool, mothers, behavior, behavioral research.

Setijanto RD, Bramantoro T, Palupi R, Hanani A. The role of attitude, subjective norm, and perceived behavioral control (PBC) of mothers
on teaching toothbrushing to preschool children – based on the Theory of Planned Behavior: a cross-sectional study. Fam Med Prim
Care Rev 2019; 21(1): 53–57, doi: https://doi.org/10.5114/fmpcr.2019.82974.

Background Alpers classifies three main factors: teeth, microorganisms, sub-

strates, and one additional factor, that is time. In addition to
Dental caries are one of the most common dental health the main factors in the mouth, there are external predisposing
problems in the Indonesian community. The 2013 Basic Health factors such as age, sex, socioeconomic status, oral hygiene, and
cariogenic foods [2]. Dental health education should be intro-
Research (RISKESDAS) report stated that the average prevalence
duced as early as possible to the child, so they understand how
of Indonesian dental and oral problems is 25.9%, whereas the
to correctly maintain healthy teeth and mouth. Preschool aged
average caries index is 4.6%. Dental caries not only occured in
children are one of the most vulnerable groups to dental and
adults, but also in children. Indeed, childhood dental caries are
oral diseases due to lack of behavior or habit that support den-
the most complained of dental health problems. The prevalence tal health [3]. In this case, the role of parents is very significant
of caries in preschool children (aged 3–5 years) in Indonesia is in maintaining the health and hygiene of children’s teeth and
reported to be 90.5% in urban areas and 95.9% in rural areas [1]. mouth. Attitudes and behaviors of parents who are the closest
Early Childhood Caries (ECC) continues to be a worldwide to the child with regard to health care give a very significant
pandemic disease. The prevalence of affected children aged effect on the attitude and behavior of their offspring. A person
3–5 years old varies to continent and country. Cambodia and who has a high level of education will have good knowledge
Indonesia have reported a high prevalence and severity of ECC, and attitude about health, so that it will affect his/her drive to
which reaches a figure of 90% at aged 3–5 years old – with healthy lifestyles [4].
a higher mean def-t. The Indonesian Dentists Association (PDGI) states that child
Diseases and abnormalities of teeth in school-aged children dental hygiene involves interaction between children, parents
are one of the interferences of children growth and develop- and dentists. Herein, the influence of parents is instrumental
ment process. The most common dental health problem in in shaping the behavior of children. Attitudes and behavior of
children is dental caries. Dental caries is an infectious disease parents, especially the mother (who is usually the closest to
that damages tooth structure. The process occurs because of the child in maintaining dental health), have a significant effect
a number of factors in the mouth that interact with each other. on the behavior of children [5]. Dental-wise, a child should get

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 54 R.D. Setijanto et al. • Role of attitude, subjective norm, and PBC based on TPB

serious attention from the parents even though they still have a questionnaire adapted from the guidelines for the preparation
deciduous teeth. This is because the condition of the deciduous of TPB questionnaires by Ajzen. Questions were compiled based
teeth will determine the growth of the child’s permanent teeth. on TPB components, namely, actions, intentions, attitudes,
However, many parents assume that deciduous teeth are tem- subjective norms, and perceived control, with questions total-
porary and will be replaced by permanent teeth, so they often ing 35. Likert data scales were applied to determine the behav-
assume that damage to the deciduous tooth is not a problem. ior of mothers on how to teach tooth brushing to preschool.
In the parenting decision model, Hoover-Dempsey and The questionnaire measures the effect of the theory construct
Sandler identified role construct as a fundamental variable that about intention to improve oral hygiene behavior.
influences parental decision. Role construct relates to how pa-
rental accountability or responsibility perceives themselves in Variables
relation to their child’s behavior. Hoover-Dempsey and Sandler
proposed that parental construct about the role of parents are All the variables were measured consistently. Hence, the
strongly influenced by the definition of parent roles and their higher average score reflects more positive attitudes, positive
beliefs about child development, child nurture, and what par- subjective norms, and higher perceived behavior control toward
ents expect [6]. The role of parents is crucial as the basis for the oral health behaviors.
formation of supportive or not supportive behaviors of child oral
hygiene [7]. While young children aged 4–5 years depend mainly Statistical analysis
on adults on decisions about their health, parental actions can
impact on behaviors shown by children and adolescents at a lat- Data was analyzed by calculating Correlation and Linear Test
er stage in their lives when they are able to make their own deci- Regression of components of planned behavior theory where
sions about their health [8]. One well-validated decision-making the result of p-value less than 0.05 is considered as statistically
model commonly used to test attitudes and behavior is the significant.
Theory of Planned Behavior (TPB). TPB suggests that intentions
affecting behavior are influenced by attitudes (assessment of
behavior as something that is advantageous/disadvantageous), Results
subjective norms (perceptions of social pressure to do or not to
The result of participant characteristic data is shown in
do a behavior) and perceived behavior control (PBC, perceived
Table 1. Firstly, the mother’s degree of formal education was
eases/difficulties to act a behavior), with PBC directly predicting
classified into 2 categories: basic education (elementary school/
a behavior. In TPB, past behavior is also often included as an ad-
/junior high school/senior high school) which consisted of
ditional predictor of people’s intentions and behaviors [9].
69.73% of total sample, and higher education which reached
30.28% of total sample. Secondly, the employment status of
Objectives the mother was categorized as working (45.41%) or not working
(54.59%). Thirdly, the percentage of maternal income per month
The aim of this study was to predict using the theory of was classified into 3 categories: IDR < 1.000.000 (22,94%), IDR
planned behavior, the behavior of mothers to teaching tooth- 1.000.000–3.000.000 (55.51%) and IDR > 3.000.000 (21.56%).
brushing to preschool children. Based on the construction of
Theory Planned Behavior, the better attitudes and subjective
norms associated with involvement in behavior and the greater Table 1. Sample characteristics
the perceived control, the more likely it is that a person will form
Variables Descriptions Total
an intention to behave. Finally, intentions are expected to lead
to behavioral performance as long as people are actually able to Number %
do so, that is, where they have actual control over the behavior. (n)
Education basic education 152 69.73
(elementary school/junior
Material and methods high school/senior high
school)
Study design higher education 66 30.28
This study were performed via a protocol approved by the Employment not working 119 54.59
Health Research Ethical Clearance Commission Faculty of Dental working 99 45.41
Medicine, Universitas Airlangga, with ethical approval number: Salary < IDR 1.000.000 50 22.94
No. 109/HRECC.FODM/VII/2017. We used cross sectional de-
sign in this study. IDR 1.000.000– 121 55.51
Family Medicine & Primary Care Review 2019; 21(1)

–IDR 3.000.000
Participants > IDR 3.000.000 47 21.56

The cross sectional study recruited a maternal group with In Table 2, we analyzed the data using the Mann–Whitney
the following inclusion criteria: biological parent of kindergar- test. The education variable toward the subjective norms had
ten children in Surabaya city. The sample used in this study was p-value < 0.05, which means there was a difference in higher edu-
the mothers of kindergarten-aged children who were randomly cation and lower education to them. The education variable to-
determined from each region in the city of Surabaya: East, West, ward attitude, perceived behavior control, intention and behavior
Central, North and South. The number of samples used in this variables, however, showed p-value > 0.05, which indicates that
study was 218. The sample characteristics are shown in Table 1. there was no difference in higher education and lower education
The study was conducted from June 2017 until July 2018. Before to variables other than the subjective norms. Furthermore, the
the conducted study, each participant was requested to com- employment variable showed p-value > 0.05 towards all com-
plete a form of concent. ponents of the theory of planned behavior, hence, there was no
difference between working and not working to the components
Setting of planned behavior theory. Lastly, the income variable showed
p-value > 0.05 towards all components of the theory of planned
To collect the data, we asked participants to fill-in the ques- behavior, which means there was no difference between salary
tionnaire. This study uses a research instrument in the form of levels to the components of planned behavior theory.
 R.D. Setijanto et al. • Role of attitude, subjective norm, and PBC based on TPB 55

Table 2. The mean and standard deviation of TPB with socio-demographic

Socio-demographic Attitude toward Subjective norms Perceived behavior Intention Behavior
behavior control
Mean SD p Mean SD p Mean SD p Mean SD p Mean SD p
Education high 28 3.62 0.446 55.48 20.377 0.016 26.36 4.23 0.669 28.67 3.125 0.43 4.36 0.922 0.117
low 27.68 3.096 62.88 19.978 26.05 4.335 28.14 3.143 4.56 0.77
Employ- not working 27.76 2.951 0.571 58.9 19.366 0.115 26.26 4.412 0.372 28.54 2.81 0.165 4.56 0.732 0.441
ment working 27.79 3.609 58.9 19.366 26.01 4.171 28.01 3.489 4.42 0.916
Salary IDR < 1.000.000 27.9 2.306 0.391 61.7 20.528 0.764 26.82 3.415 0.615 28.12 3.075 0.924 4.7 0.505 0.168
IDR 1.000.000– 27.5 3.795 61.16 19.881 25.82 4.592 28.23 3.366 4.49 0.857
– IDR 3.000.000
IDR > 3.000.000 28.36 2.506 58.17 21.526 26.28 4.342 28.66 2.59 4.32 0.958

p-value significant at < 0.05.

In the table above, the effect of higher education on atti- Table 4. Association of Theory of Planned Behavior variables
tude variables, PBC and intention had a higher mean compared toward intention
with lower educational levels, while basic education to subjec-
tive norms and behavior variables showed a higher mean com- r2 p

Correlation

Regression
coefficient

coefficient
regression
p ANOVA
Variables
pared with higher education. Towards the attitude variable,
being employed had higher mean compared with being unem-
ployed, whereas unemployed participants toward PBC, inten-
tion and behavior variables had higher mean. Participants that Attitude < 0.0001 0.376 0.570 < 0.0001* 0.601
had income IDR > 3.000.000 toward attitude and intentions had
a higher mean compared to lower income earneers. The Spear- Subjective -0.101 0.074 0.033
man correlation of this study is shown in Table 3. norms
Perceived 0.109 0.081 0.340
Table 3. Correlation test of TPB components Behavior
Control
Attitude Subjective PBC Inten- Behav-
norm tion ior * p-value significant at < 0.05.
Attitude 1
Subjective 1 Attitude
norm 0.601
0.283
PBC 1 Intention
Subjective 0.033 Behavior
Intention 0.478* 0.069 0.409* 1 norms
0.340
Behavior 0.416* 0.399* 1
PBC 0.369
* p-value significant at < 0.05.
Figure 2. Linear regression test of TPB components
Attitude
Figure 2 showed that among the variables, attitude had
Subjective
Intention
Behavior most significant relationship to intention (with p < 0.0001).
norms

PBC
Discussion
Based on the construction of the Theory of Planned Behav-
Figure 1. The hypothesis of relationship among TPB components ior, in this study, the most powerful variables affecting inten-
tion were attitude and perceived behavior control. In the above,
correlation statistic test showed the result of attitude toward
Family Medicine & Primary Care Review 2019; 21(1)

Based on Figure 1, we could see in Table 3 that the attitude behavior. This being positive at 0.478 with p-value < 0.0001.
variable had a significant relationship with the intention vari- Hence, the attitude variable had a significant effect on intention.
able, with p-value < 0.05 and correlation coefficient (r) 0.478. What is more, the result of the correlation coefficient on the
This means attitude had significant relationship with intention. PBC variable was positive (0.409) with p-value < 0.0001. Based
In addition, the subjective norm had no significant relationship on this, it could be concluded that there was a significant effect
with intention – with p-value at 0.312 and correlation coeffi- of PBC to intention.
cient (r) of 0.069, which means the subjective norm had no sig- The possibility of bias from the use of questionnaires in this
nificant relationship with intention. Perceived behavioral con- study has been overcome through validity and reliability test-
trol had, however, a significant relationship with intention, with ing, so we assume that the results of this study do not provide
p-value < 0.05 and correlation coefficient (r) 0.409. This implies biased results.
that PBC had a significant relationship with the intention. Fur- The results of the above analysis showed that there were
thermore, intention had a significant relationship with behavior two variables that had significant influence on intention. The
– with p-value < 0.05 and correlation coefficient (r) 0.399, albeit higher the attitude (attitude toward behavior) and the PBC of
intention had a less significant relationship with behavior. Sub- a person, the higher the intention of the mother in teaching
sequently, PBC had a significant relationship with behavior, with children to brush their teeth. In the context of families, children
p-value < 0.05 and correlation coefficient (r) 0.416. Thus, PBC should not be regarded merely as passive care recipients in the
had a significant relationship with behavior. daily routine of health measures, as they do play active roles
 56 R.D. Setijanto et al. • Role of attitude, subjective norm, and PBC based on TPB

in making healthy choices [10]. Mothers definitely contribute the skills to process certain health-related information and to
to healthy family activities. Thus, families, especially mothers, interact with health institutions and professionals. This then
should promote the health of their children and their children’s leads to less positive attitudes [19]. In general, attitudinal levels
ability to develop a healthy lifestyle. The significant influence of of receiving, responding, respecting and being responsible is dif-
the mother’s attitudes toward the oral health of children can be ferentiated into positive and negative.
attributed to the impact of their attitudes toward the behavior The influence of PBC variables are noticeable when the
of their children [11]. This refers to the deep interactions be- mother is faced with circumstances in which she must choose to
tween mother and child, and supports the mother’s role as an teach her children to brush their teeth properly and correctly or
important source of perception and acceptance of children to not. As mentioned earlier, PBC is a level of perception of one’s
attitudes, values, and behaviors, especially during critical times own ability to perform an action related to risks or constraints.
in establishing attitudes and beliefs and shaping individual PBC in the context of this study is related to the ability of the
health behaviors [12]. mother. The positive impacts if children are taught to brush their
Based on the results of the analysis, this study was consid- teeth properly go beyond possessing strong teeth and fresh
ered successful enough to reveal the factors that affect the in- breath, but the mouth is also clean enough from the germs and
tention. The dominant factors influencing mother’s behavior in bacteria that cause dental and oral diseases and general health
teaching toothbrushing to children are factors that are purely problems [14]. Thus, it is hoped that the mother is able to up-
derived from within oneself, namely: individual attitudes and in- hold the postive health-care of her children, especially in dental
dividual self-control on the other hand, the results of this study and oral practices, because mothers are considered role models
indicate that external factors such as the influence of others in their child’s health behavior in transferring acceptable values,
(subjective norms) do not affect the participants [13]. norms and behaviors [20]. Therefore, parents, especially moth-
The effect of the attitude variable on intention can explain ers, function as social models for children.
the problem of overcoming tooth and mouth problems in chil- Dental caries is a disease that evolved through the biological
dren. Thus, due attention and supervision of parents (especially interactions of acidic bacteria root complex, fermentable car-
mothers) is required to control and support child in proper oral bohydrates and host factors such as teeth and saliva [21]. For
care activity. In this attitude variable, mother must hold the be- decades, species of acidogenic bacteria Streptococcus mutans
lief that by teaching effective tooth brushing to children, that have been considered the main causal agents of dental caries.
child will be protected from dental and mouth disease [14]. This process occurs so slowly that most children and parents are
Attitude is the reaction or response of a person to stimula- unaware of and ignore the presence of dental plaques that can
tion or to an object. Mothers have an important role in prevent- cause tartar so that many children have dental defects that are
ing caries disease in that they transmit habits and rituals. To be mostly dental caries, which is frightening to everyone, especially
effective, they must have good knowledge about oral car and parents [15].
cary prevention. The overall attitude of mothers and attitudes The absence of the influence of factors or subjective norm
toward their child’s oral hygiene has been associated with car- variable in this study can be explained from the context of the
ies occurrence and oral hygiene status, and a mother’s positive study subjects. The subjective norm is the influence of the envi-
attitude has been shown to result in increased teeth brushing, ronment or the people who are considered important to some-
decreased caries lesions and better oral hygiene [13, 14]. Fac- one. In the context of the mother, the person who is predicted
tors influencing attitudes include personal experience, socio- to have great influence in various ways is a husband’s friend [12].
economic status, mass media, knowledge and religion. However, it turns out that in teaching toothbrushing in children,
Knowledge or cognitive is a very important domain in shap- those closest people have no significant effect. When associated
ing the action of someone (overt behavior) because knowledge with the two other variables that affect intention, the results are
is one predisposing factor of the formation of a whole attitude not s significant subjective norm variable to support the opinion
or total attitude based on the three components of the belief that the behavior of the mother in teaching toothbrushing on
idea, the conception of an object and the tendency to act (tend the child is very dependent upon the thoughts and internal fac-
to behave). According to [15], low knowledge will tend to be tors within the individual.
negative in determining attitudes and high knowledge will be
positive in determining attitude. This result is in accordance
with Skeie et al., where mothers with low levels of education Conclusions
tend to have a tooth attitude that not good.
There are several possible explanations for poor teeth at- In Surabaya, when mothers teachs toothbrushing behav-
titudes in older people with low levels of education. The norms iors to their preschool-aged children, based on the Theory of
and attitudes of parents may be influenced by the norms of Planned Behavior, such behavior is closely related to attitude
child care existing in their community and transmitted from and perceived behavior control variables. In the study it was
one generation to another [16, 17]. In parents with low levels found that the subjective norms variable is not related to the
Family Medicine & Primary Care Review 2019; 21(1)

of education, oral health may not be assessed positively and im- mother’s behavior. In this study, although the mother’s sur-
portantly [18]. Moreover, if economic constraints exist in daily rounding environment does not support the teaching of tooth-
life, good oral health habits may not be a parental priority. In brushing tochildren, mothers having positive attitudes and in-
addition, parents with low levels of education also often lack tention will teach toothbrushing to their children.

Source of funding: This work was funded from the authors’ own resources.
Conflicts of interest: The authors declare no conflicts of interest.

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Tables: 4
Figures: 2
References: 21

Received: 11.07.2018
Reviewed: 9.08.2018
Accepted: 28.09.2018

Address for correspondence:

Taufan Bramantoro, DDS, MPH, PhD
Department of Dental Public Health
Faculty of Dental Medicine
Universitas Airlangga
Jl. Mayjend Prof Dr Moestopo 47
60132 Surabaya
Indonesia
Tel.: (+62 31) 5030255, 5020256
E-mail: taufan-b@fkg.unair.ac.id
Family Medicine & Primary Care Review 2019; 21(1)