Child Cariogenic Diet and Parental Oral Health Literacy Level Between American and Brazilian Families

Child Cariogenic Diet and Parental Oral Health Literacy Level Between American and Brazilian Families | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Child Cariogenic Diet and Parental Oral Health Literacy Level Between American and Brazilian Families Bruna Leticia Vessoni Menoncin, Aline Fabris de Araújo Crema, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5339307/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To comparethe cariogenic diets of children and parental OHL levels between American and Brazilian families. Methods: Participating in this cross-sectional study were the parents/guardians of 946 children aged 2 to 5, Brazilian parents of children. There were 672 Brazilian parents of Brazilian children (BB), 203 American parents of American children (AA) and 61 Brazilian parents of American children (BA). A self-administered questionnaire about sociodemographic aspects and children’s oral health conditions was administered. Food practices were analyzed using a specific questionnaire. The parental mealtime action scale (PMAS) scores for daily fruit and vegetable availability, the snacks consumption model, and the snacks limit were collected. Parental OHL levels were assessed by the Oral Health Literacy Adult Questionnaire (OHL-AQ). Multiple comparison tests with the Kruskal‒Wallis post hoc test and Bonferroni correction were used for numerical variable analysis. For categorical variables, chi-square tests were performed. Results : The AA and BA groups had more training in healthcare, more work in health-related areas and were more likely to be in a stable union when married than the BB group. Children of group AA or BA consumed more cariogenic food than those of BB group. The daily fruit and vegetable availability was greater in the AA group than in the other groups. Compared with those of BB, the snake modeling domain and snack limits of AA and BA were greater. The OHL of BA was greater than that of BB and was more similar to that of AA. Conclusion: American children of Brazilian parents are closer to the eating habits of American children of American parents than to Brazilian children of Brazilian parents. Health literacy Eating behavior Population characteristics Preschool children Immigrant parents Figures Figure 1 INTRODUCTION Oral health literacy (OHL) is defined as an individual’s ability to obtain, process, and understand information essential for making appropriate decisions regarding oral health [ 1 ]. Individuals’ OHL levels impact their ability to read and understand written texts, efficiently communicate information related to oral health, use health systems, and maintain their own health [ 2 ]. Considering parental OHL, this ability also includes maintaining children’s oral health. Inadequate parental OHL is associated with a greater incidence of dental caries in children [ 3 , 4 , 5 ]. Food choices are strongly associated with oral health [ 6 ] and can be influenced by OHL levels [ 7 ]. In addition, it is between 2 and 5 years of age that the child learns about food choices and starts to have food preferences based on food items that were exposed during this period [ 8 ]. In this way, it is understandable that parental eating habits are a model of eating behavior for their children [ 9 , 10 ]. The current understanding of OHL includes cultural factors [ 11 ]. Cariogenic diet is also influenced by culture and location and social and economic development. In regard to children’s eating practices, parents can affect their children’s diet by making some food items more accessible than others [ 6 ]. In addition, snack consumption may vary by nutrient content and portion size [ 12 ]. Knowing that children’s oral conditions are affected among disadvantaged individuals and populations, such as parents, where parents are born, who grow, who live and who work [ 13 ], and considering that OHL levels and food consumption probably vary according to the country in which a family lives and that migration background is a discrete risk factor for lower oral health and OHL [ 14 ]. This study aimed to compare the cariogenic diet and parental oral health literacy levels of children between American and Brazilian families. MATERIALS AND METHODS 1.1.1 Participants The cross-sectional observational survey was conducted in Curitiba, Brazil, and in Boston, USA. Curitiba is the capital city of the state of Paraná. There were an estimated 1,948,626 inhabitants in 2020. The city has a very high human development index (HDI) of 0.823 and a Gini index of household income per capita of 0.05752, with a yearly per capita income of R$18.972,48 [15]. Boston, the most populous capital of the state of Massachusetts, in U.S. Boston city, had a population of 684,379 inhabitants in 2020. Considering the greater area with surrounding towns, the population has increased to 4.315,000, and 5% of the Brazilian immigrants of Massachussets have lived there [16]. Parents or guardians of children between 2 and 5 years old were selected to participate in the survey. Brazilian parents or guardians of Brazilian children residing in Curitiba, American parents or guardians of American children residing in Boston, and Brazilian parents or guardians of American children residing in Boston were eligible for the survey. Children who had any food restriction or allergy that required a special diet were excluded from the survey. 1.1.2 Data collection To recruit participants for the Brazilian survey, parents or guardians of children enrolled in the municipal education system were invited to participate. Parents from all 40 selected preschools were invited to participate. All 10 regions of the city. The first contact was with the main chair from the school. After agreeing to participate, each teacher from each class helped by sending a short text explaining the goal of the survey to parents. Those who agreed to participate in the survey had access facilitated by a shared link. For the data collection of American data, an approach script was used to invite potential participants to the Tufts University School of Dental Medicine clinic waiting rooms. Flyers were posted throughout the TUSDM and given to organizational leaders, such as community centers, head start programs, day care centers and pre-kindergartens. To maximize participation, a request to email participants was sent to the leaders of the organizations. Upon their approval to contact their populations, the leaders were asked to email potential participants with the link to the survey. Flyers were also given to the organization leaders to be distributed to their populations. Parents or guardians were also approached personally when allowed by the organization. For data collection, parents or guardians received self-administered questionnaires that were distributed on paper or electronically via Google Forms and Qualtrics via an iPad or via an electronic Qualtrics link sent to potential participants. The Brazilian data were collected between October 2020 and February 2021, and the American data were collected between October and December 2021. 1.1.3 Measures Socioeconomic and demographic aspects and children’s oral health The socioeconomic and demographic aspects of the questionnaire, such as age, educational level, marital status, work or training in a health-related area, and child’s age, were collected from parents or guardians. The food practices of preschools and the food behavior of parents or guardians were evaluated, as was the cariogenic food consumption of preschoolers using a specific questionnaire. In the construction of the questions about the frequency of consumption of food items, the five main ultra-processed foods with cariogenic potential included were considered sources of free sugars according to the report of the Pan American Health (PAHO – WHO) on food consumption and ultra-processed and cariogenic beverages in Latin America [17]: soft drinks or carbonated beverages; artificial juices, powdered refreshments or concentrated juices; sweets such as candy, caramel, lollipop, ice cream, and chocolate; cakes made from cake mix or purchased ready-made; and biscuits or sweet biscuits/cookies. It was decided to keep the same list of foods for data collection in the U.S., knowing that these are also foods with high consumption in this population. Parents or guardians were instructed to report the frequency of intake of each type of food in the last 3 months, marking the cell corresponding to the option that was closest to the child’s food consumption practice. The categories used to report the frequency of consumption items were never or rarely, 1 or 2 times a week, 3 to 6 times a week, 1 or 2 times a day, and 3 or more times a day. To define the number of daily contacts with each food, the categories were weighted as follows: never or rarely = zero; 1 or 2 times a week = 0.214 (1.5 times/7 days a week); 3 to 6 times a week = 0.643 (4.5 times/7 days a week); 1 or 2 times a day = 1 (1.5 times/1 day); and 3 or more times a day = 3 (3 times/1 day) [18, 19]. Finally, the daily consumption frequency of cariogenic foods was obtained by the average of the daily frequency values of the set of food items evaluated. To assess the behavior of parents in their children’s nutritional education, the PMAS (Parental Mealtime Action Scale) instrument in the English language version and Brazilian Portuguese version were used [20]. The domains used were “Daily availability of fruits and vegetables”, which indicates the consumption of these food items by parents and their offer to children; “Snacks consumption model”, which reflects the consumption of sweets, soft drinks and snacks by parents, serving as a model for children; and “Snacks limit”, which reports the limits established by parents when consuming daily sweets. Each of the three domains had three questions, and for each question, a scoring scale from one to three points (never = 1; sometimes = 2; always = 3) was used to obtain the parent’s or guardian’s reports on how often they adopted each behavior in a typical week. The domain value was obtained from the average of the answers for each question and was used as a numerical variable. For the first and third domains, higher averages represented a greater frequency of behavior by those responsible for their children’s nutritional education. For the second domain, higher averages represented less favorable behavior for the child’s oral health [21]. To assess parental reports on the child’s oral health, a question in the questionnaire was used, which classified the child’s health as 'very good or good', 'fair', or 'poor or very poor'. Parents’ or guardians’ Oral Health Literacy To assess the parental OHL level, the original version of the Oral Health Literacy Adult Questionnaire (OHL-AQ) in English and the translated into Brazilian Portuguese [22-24] were used. The instrument consists of 17 questions, including four sessions covering different abilities. The “reading comprehension” session included three incomplete multiple-choice questions. The parent should select one of the five possible choices to fill the blank space with the alternative that he/she believes to be the best compliment for the gap. The “numeracy” session included four questions about a written box. The parent was asked to read an amoxicillin prescription and then answer a free-text question and a multiple-choice question about the drug prescription. The “listening session” included two questions given by a new written box about instructions for a sodium fluoride mouth rinse. The parent should use listening skills to understand the instructions and then answer a free-text and multiple-choice question. However, considering the new conditions imposed by the COVID-19 pandemic, in this study, the listening session was converted into reading questions. The last session, “decision-making”, included five multiple-choice questions related to common oral health problems and medical history forms. One of the answer alternatives for all questions was the right one, and another was “I don’t know”. The parent was instructed to select this answer instead of guessing when he/she did not know the answer. Correct answers were scored with 1 point, while incorrect answers or “I don’t know” were scored as zero. The total score was obtained from the sum of individual scores for each question, ranging from 0 to 17 points. 1.1.4 Analysis The collected data were analyzed by SPSS software (SPSS Statistical). Descriptive analysis was performed to compare the three different groups: Brazilian parents residing in Brazil, American parents residing in the U.S., and Brazilian parents residing in the U.S. The independent variables were categorized as follows: child’s gender (“female” or “male”); relationship with the child (“mother”, “father” or “other”); parental training in health care (“yes” or “no”); parental work in health-related areas (“yes” or “no); parental educational level (“primary education”, “secondary education” or “higher education”); parental marital status (marriage or stable union “yes” or “no”); parental report of a child’s oral health (“very good or good”, “regular” or “bad or very bad”). The remaining variables were analyzed as numerical variables: parent’s age, child’s age, cariogenic food consumption, parent`s behavior with children’s nutritional education, and parental oral health literacy level. For numerical variables, a normality test was performed. All variables had a nonnormal variation. The multiple comparison test used to verify the difference between groups was the Kruskal‒Wallis test post hoc with Bonferroni correction. For categorical variables, the chi2 test was performed. A 5% significance level was considered for the analysis. RESULTS Among the parents invited to participate in the survey, 672 were Brazilian parents residing in Brazil, 203 were American parents residing in the U.S., and 61 were Brazilian parents residing in the U.S. Of those who were residing in the U.S., 68.9% had resided there for less than or equal to 10 years, 14.7% for more than 10 years, and 16.4% did not answer this question. Overall, 936 parents or guardians agreed to participate in the survey by signing the consent form. The average age of the guardians and the children were 33.4 [Standard Deviation (SD) = 7.3] years and 3.7 (SD = 1.1) years, respectively. According to socioeconomic and demographic variables (Table 1 ), parents residing in the U.S. have more training in health care than parents residing in Brazil. Thus, parents residing in the U.S. also have more work in health-related areas than parents residing in Brazil. Parents with a stable marital status are more likely to be in a stable union for parents residing in the U.S. Parents residing in Brazil report their child’s oral health as very good or good more than do parents residing in the U.S. Table 1 – COMPARISON OF SOCIOECONOMIC AND DEMOGRAPHIC VARIABLES ACCORDING TO THE EVALUATED GROUP BRAZILIAN PARENT’S CURITIBA AMERICAN PARENT’S MASSACHUSSETS BRAZILIAN PARENT’S MASSACHUSSETS VARIABLE n(%) n(%) n(%) p-value* Relationship with the child Mother or Father 653 (97.6) 192 (95.5) 60 (100) 0.114 Other 16 (2.4) 9 (4.5) 0 (0) Child’s sex Female 327 (48.7) 106 (53.3) 32 (54.2) 0.416 Male 345 (51.3) 93 (46.7) 27 (45.8) Training in health care No 624 (92.9) 177 (90.8) 51 (83.6) 0.035 Yes 48 (7.1) 18 (9.2) 10 (16.4) Work in health-related area No 641 (95.8) 139 (89.7) 47 (83.9) <0.001 Yes 28 (4.2) 16 (10.3) 9 (16.1) Parental marital status (marriage or stable union) No 262 (39.4) 38 (20.5) 4 (7.3) <0.001 Yes 403 (60.6) 147 (79.5) 51 (92.7) Parental Educational level PE 84 (12.6) 7 (3.6) 6 (9.8) SE 318 (47.5) 23 (11.7) 12 (19.7) <0.001 HI 267 (39.9) 167 (84.8) 43 (70.5) Oral health Very good or good 552 (82,8) 133 (68,6) 42 (68,9) <0.001 Regular, bad or very bad 115 (17.2) 61 (31.4) 19 (31.1) NOTE: PE (Primary Education); SE (Secondary Education); HE (Higher Education); *Chi2 test. Table 2 shows that children with American and Brazilian parents residing in the U.S. have a greater consumption of carbonated soft drinks, sweetened juices, sweets, cookies, cakes, pastries and deserts. Considering all cariogenic food consumption, an American child with American parents has a similar consumption as an American child with Brazilian parents, both residing in the U.S., and this consumption is greater than that of a Brazilian child residing in Brazil. Table 2 – CARIOGENIC FOOD CONSUMPTION AND PARENTAL ORAL HEALTH LITERACY LEVELS BRAZILIAN PARENT’S CURITIBA AMERICAN PARENT’S MASSACHUSSETS BRAZILIAN PARENT’S MASSACHUSSETS VARIABLE Median (Q1-Q3) Median (Q1-Q3) Median (Q1-Q3) p-value* Carbonated soft drinks 0.21 (0.0-0.21) a 0.21 (0.0-0.64) b 0.21 (0.0-0.42) ab 0.003 Sweetened juices 0.21 (0.0-0.64)a 0.64 (0.21–1.50)b 0.64 (0.21–1.50)b < 0,001 Sweets 0.21 (0.21–0.21)a 0.64 (0.21–0.64)b 0.64 (0.21–0.64)b < 0,001 Cookies 0.21 (0.21–0.64)a 0.64 (0.21–1.50)b 0.64 (0.21–1.50)b < 0,001 Cake, pastries or deserts 0.0 (0.0-0.21)a 0.21 (0.21–1.28)b 0.64 (0.21–0.64)b < 0,001 Cariogenic food consumption 1.05 (0.63–2.13)a 2.77 (1.27–5.30)b 2.99 (0.84–5.61)b < 0.001 PMAS domain Daily fruits and vegetables availability 2.33(2.33-3)a 2.33 (2–3)b 2.00 (2–3)b < 0.001 PMAS domain Snack Modeling 1.67 (1.33-2)a 2.00(2–2)b 2.00 (1.67-2)b < 0.001 PMAIS domain Snack Limits 3.00 (2.33-3)a 2.33 (2–3)b 3.00 (2–3)ab < 0.001 OHL-AQ 14 (11–15)a 16 (14–17)b 15 (14–16)b < 0.001 NOTE: *Kruskall-Wallis test post hoc with Bonferroni correction; Q1 = first quartile; Q3 = third quartile. Different letters denote statistical significance. The daily fruit and vegetable availability was greater for American families than for the other groups. The snake modeling domain and snack limits were greater for American and Brazilian parents residing in the U.S. than for Brazilian parents residing in Brazil. In addition, the OHL level of Brazilian parents residing in the U.S. was greater than that of Brazilian parents residing in Brazil and was more similar to that of American parents. Figure 1 shows the distribution of OHL-AQ values in each group. DISCUSSION An important finding of this study is the observation of a pattern for the consumption of cariogenic food. Children of Brazilian parents residing in Massachussets are more homogeneous to children of American parents also residing in Massachussets, and their consumption of cariogenic food was greater than that of children of Brazilian parents residing in Curitiba. In addition, parents’ behavior regarding the dietary education of their children followed the same logic when evaluating the three PMAS domains. This approximation of the consumption patterns and behaviors of Brazilians residing in the USA and of Americans is probably because children of immigrants can be vulnerable to the food culture in host countries, where unhealthy food is more accessible and favored [ 25 , 26 ]. Consequently, with the increased consumption of sugar, refined carbohydrates, and soda, U.S. immigrants have increased chances of having chronic diseases, such as obesity [ 27 , 28 ], cardiovascular diseases [ 29 ] and dental caries [ 30 ]. Because young children are exposed to the host culture indirectly through their parents and other caregivers [ 31 , 32 ], it is presumed that being a first-generation child with at least one foreign-born parent increases a cariogenic diet. Additionally, probably because of acculturation effects, children of Brazilian parents residing in Massachussets have a similar cariogenic diet to children of American parents residing in Massachussets. This result is the same as that of Batis et al. (2011), who compared the effects of food acculturation on Mexican children, adolescents and adults residing in the U.S. They indicated that within one generation in the U.S., the influence of the Mexican diet is almost lost [ 29 ]. Other studies that compared the diet of U.S. immigrants with that of Americans also reported the influence of the acculturation process [ 27 , 29 ]. Similarly, parental educational level, parental perception of the child’s oral health condition and parental OHL level were greater for Brazilian and American parents residing in Massachussets than for Brazilian parents residing in Curitiba. This difference probably occurred because there was a greater prevalence of Brazilian and American parents who resided in Massachussets and worked in health-related areas. Compared with general migrants, health workers who are immigrants are more likely to have higher health literacy scores [ 33 ]. Those families had at least one respondent with a higher educational level, and studies have shown that a higher education level is associated with a greater health literacy score for the immigrant population [ 33 ]. The same logic applies to OHL; a higher OHL is associated with a higher educational level [ 34 , 35 ]. Income is considered an indicator of material living standards in health research [ 36 ], complemented by parental educational level [ 37 ], which is likely why Brazilian families residing in Massachussets, which have a higher family income, also have parents with a higher educational level than do Brazilian families residing in Brazil. Some studies show that a migration background can be a risk factor for poor oral health [ 38 – 40 ], just as migration is related to socioeconomic status and educational level [ 13 , 39 , 41 , 42 ]. This means that people who do not live in their own country of birth generally have significantly worse oral health than those who live in their own country of birth in the target population [ 40 ]. Therefore, individuals with a migration background are likely to have poor oral health, and they are likely to have the same perceptions of their children’s oral health. According to the results presented in this survey, Brazilian parents residing in Massachussets reported their child’s oral health as regular, bad, and very bad more frequently than did Brazilian parents residing in Curitiba. Migrant populations usually represent a heterogeneous group of people with variable oral health knowledge and diverse beliefs and attitudes shaped by their culture and past experiences with the respective health care system in their home countries [ 40 ]. Most studies report inequity among migrants or ethnic minorities [ 11 , 38 , 40 ]. However, social, economic, cultural, and environmental conditions can influence improving or worsening individuals’ health [ 43 ]. Although there is a greater risk to oral health outcomes for families with socioeconomic mobility [ 41 , 43 ] and those who have a migration background, the results show that Brazilian and American parents who live with their child in Massachussets, regardless of the time of immigration, have an improvement in their OHL status. This is likely the result of the higher family income, higher parental educational level, and higher OHL level of this group. The OHL level of Brazilian parents residing in the U.S. is close to the OHL level of American parents residing in the U.S. and greater than that of Brazilian parents residing in Brazil. This result is associated with the higher parental educational level of Brazilian parents who migrate to the U.S., once the OHL level and educational level are directly associated [ 35 , 40 ]. Low health literacy is associated with poor health status and poor outcomes [ 44 ]. Individuals with low OHL have poorer oral health [ 45 ] and poorer periodontal health [ 2 ], and children have more dental caries [ 46 ]. Compared with Brazilian nonimmigrants, Brazilian immigrants enrolled in our survey had a greater average level of OHL. Parthasarathy, 2014, states that for selecting relevant instruments, one must consider the impact of language and culture [ 47 ]. For this reason, this study used a validated and translated instrument to assess OHL in both English and Brazilian Portuguese [ 22 , 24 ]. The whole questionnaire, as well as the OHL-AQ instrument, was available in English and in Portuguese. Participants could choose in which language to answer the questionnaire. The choice to provide the instrument in both languages did not influence the OHL level if any parent did not have proficiency in the language of the host country. The sampling of data from Massachussets resulted in a convenience sample, distinct from the data from Brazil, which was a representative sample from the city collected just from municipal preschools. Another limitation is that this cross-sectional observational design cannot establish a causal effect between immigration and other variables. Further studies with a longitudinal design must consider migrant backgrounds when analyzing the association between OHL and food consumption. Current literature indicates that parental OHL plays an important role in ensuring good practices for oral health in children [ 48 , 49 ]. Individuals’ cultural background has a significant influence on how migrants promote and maintain good oral health [ 40 ]. It is possible that children’s oral health can be improved by improving parental OHL levels. It is also important to establish actions to improve the population’s OHL according to the countries’ local contexts, as the OHL level can vary between populations. Oral health-promoting behavior, attitudes, capabilities, and beliefs, as well as cultural and ethnic backgrounds, should be considered in oral health prevention programs. In conclusion, the food consumption patterns and OHL of Brazilian parents and children residing in the U.S. are similar to those of American parents and children than are those of Brazilian parents and children residing in Brazil. Abbreviations AA American and Brazilian families. Brazilian parents of Brazilian children BB American parents of American children BA Brazilian parents of American children Declarations Human Ethics and consent to participate Prior to data collection, the Institutional Review Board of the Tufts University School of Dental Medicine (TUSDM) and the Human Research Ethics Committee of the Health Sciences Center of the Federal University of Parana (UFPR) approved this survey (#29188620.3.0000.0102 and #00002056, respectively). Consent for publication Parents or caregivers received informed consent previously of the questionnaire. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests Funding This study was financed in part by the Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior – Brazil (Capes) – Finance 001. Acknowledgements Not applicable Authors contributions Conception: Andrea Ferreira Zandoná, Fabian Calixto Fraiz. Fernanda Moraes Ferreira Design of the work: Andrea Ferreira Zandoná, Fabian Calixto Fraiz, Jose Vitor Nogara Borges de Menezes, Sandra Patrícia Crispim Acquisition: Bruna Leticia Vessoni Menoncin AND Aline Fabris de Araújo Crema Analysis: Fabian Calixto Fraiz Interpretation of data: Fabian Calixto Fraiz AND Bruna Leticia Vessoni Menoncin References National Center for Health Statistics and Health People. Final Review 2010. 2nd ed. Washington, DC: US Government Printing Office; 2010. p. 560. Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health. 2018;18(1):172. Khodadadi E, Niknahad A, Sistani MM, Motallebnejad M. Parents' Oral Health Literacy and its Impact on their Children's Dental Health Status. Electron Physician. 2016;8(12):3421–5. Alzahrani AY, El Meligy O, Bahdila D, Aljawi R, Bamashmous NO, Almushayt A. The influence of parental oral health literacy on children's oral health: a scoping review. J Clin Pediatr Dent. 2024;48(4):16–25. Montes GR, Bonotto DV, Ferreira FM, Menezes JVNB, Fraiz FC. Caregiver's oral health literacy is associated with prevalence of untreated dental caries in preschool children. Cien Saude Colet. 2019;24(7):2737–44. Samaddar A, Shrikrishna SB, Moza A, Shenoy R. Association of parental food choice motives, attitudes, and sugar exposure in the diet with early childhood caries: Case–control study. J Indian Soc Pedod Prev Dent. 2021;39(2):171–7. Wang Y, Inglehart MR, Yuan C. Impact of Parents' Oral Health Literacy on Their Own and Their Children's Oral Health in Chinese Population. Front Public Health. 2022;10:809568. Russell CG, Worsley A, Liem DG. Parents' food choice motives and their associations with children's food preferences. Public Health Nutr. 2015;18(6):1018–27. Scaglioni S, De Cosmi V, Ciappolino V, Parazzini F, Brambilla P, Agostoni C. Factors Influencing Children's Eating Behaviors. Nutrients. 2018;10(6). Yee AZ, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2017;14(1):47. National Research Concil. Improving access to oral health care for vulnerable and underserved populations. Washington (DC): National Academies; 2012. Vatanparast H, Islam N, Masoodi H, Shafiee M, Patil RP, Smith J, et al. Time, location and frequency of snack consumption in different age groups of Canadians. Nutr J. 2020;19(1):85. Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, Regional, and National Prevalence, Incidence, and Disability- Adjusted Life Years for Oral Conditions for 195 Countries, 1990–2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors. J Dent Res. 2017;96(4):380–7. Spinler K, Weil MT, Valdez R, Walther C, Dingoyan D, Seedorf U, et al. [Oral health literacy of persons with migration background-first results of the MuMi study]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2021;64(8):977–85. Parana Institute for Economic and Social Development (IPARDES). [Caderno estatístico município de Curitiba]: Available in: http://www.ipardes.gov.br/cadernos/MontaCadPdf1.php?Municipio=80000 Boston Planing & Development Agency Research Divison. April 2017. Available in: https://www.bostonplans.org/ Panamerican Health Organization (PAHO). Ultra-processed food and drink products in Latin America: Sales, sources, nutrient profiles, and policy implications. Washington, D.C.: PAHO; 2019. https://iris.paho.org/handle/10665.2/51094 . Sauvageot N, Alkerwi A, Albert A, Guillaume M. Use of food frequency questionnaire to assess relationships between dietary habits and cardiovascular risk factors in NESCAV study: validation with biomarkers. Nutr J. 2013;12(1):143. Daly AM, Parsons JE, Wood NA, Gill TK, Taylor AW. Food consumption habits in two states of Australia, as measured by a Food Frequency Questionnaire. BMC Res Notes. 2011;23(4):507. Hendy HM, Williams KE, Camise TS, Eckman N, Hedemann A. The Parent Mealtime Action Scale (PMAS). Development and association with children's diet and weight. Appetite. 2009;52(2):328–39. Petty ML, Escrivão MA, Souza AA. Preliminary validation of the Parent Mealtime Action Scale and its association with food intake in children from São Paulo, Brazil. Appetite. 2013;62:166–72. Flynn PM, John MT, Naik A, Kohli N, VanWormer JJ, Self K. Psychometric properties of the English version of the Oral Health Literacy Adults Questionnaire - OHL-AQ. Community Dent Health. 2016;33(4):274–80. Sistani MMN, Montazeri A, Yasdani R, Murtomaa H. New oral health literacy instrument for public health: development and pilot testing. J Investig Clin Dent. 2014;5(4):313–21. Almeida ER, Sistani MMN, Bendo CB, Pordeus IA, Firmino RT, Paiva SM, Ferreira FM. Validation of the Brazilian Oral Health Literacy-Adults Questionnaire. Health Lit Res Pract. 2022;6(3):e224–31. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378(9793):804–14. Dave JM, Evans AE, Saunders RP, Watkins KW, Pfeiffer KA. Associations among food insecurity, acculturation, demographic factors, and fruit and vegetable intake at home in Hispanic children. J Am Diet Assoc. 2009;109(4):697–701. Zhang Q, Liu R, Diggs LA, Wang Y, Ling L. Does acculturation affect the dietary intakes and body weight status of children of immigrants in the U.S. and other developed countries? A systematic review. Ethn Health. 2019;24(1):73–93. Lindsay AC, Wallington SF, Greaney ML, Hasselman MH, Machado MM, Mezzavilla RS, et al. Sociocultural and Environmental Influences on Brazilian Immigrant Mothers' Beliefs and Practices Related to Child Feeding and Weight Status. Matern Child Health J. 2017;21(5):1085–94. Batis C, Hernandez-Barrera L, Barquera S, Rivera JA, Popkin BM. Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. J Nutr. 2011;141(10):1898–906. Manohar N, Hayen A, Fahey P, Arora A. Obesity and dental caries in early childhood: A systematic review and meta-analyses. Obes Rev. 2020;21(3):e12960. Dancel LD, Perrin E, Yin SH, Sanders L, Delamater A, Perreira KM, et al. The relationship between acculturation and infant feeding styles in a Latino population. Obes (Silver Spring). 2015;23(4):840–6. Lindsay AC, Vianna GVB, Arruda CAM, Alves ASM, Hasselmann MH, Machado MM, et al. Brazilian immigrant fathers' perspectives on child's eating and feeding practices: a qualitative study conducted in the United States. Public Health Nutr. 2020;23(17):3211–25. Kosiyaporn H, Julchoo S, Sinam P, Phaiyarom M, Kunpeuk W, Pudpong N, et al. Health Literacy and Its Related Determinants in Migrant Health Workers and Migrant Health Volunteers: A Case Study of Thailand, 2019. Int J Environ Res Public Health. 2020;22(6):2105. Bado FMR, De Checchi MHR, Cortellazzi KL, Ju X, Jamieson L, Mialhe FL. Oral health literacy, self-rated oral health, and oral health-related quality of life in Brazilian adults. Eur J Oral Sci. 2020;128(3):218–25. Márquez-Arrico CF, Almerich-Silla JM, Montiel-Company JM. Oral health knowledge in relation to educational level in an adult population in Spain. J Clin Exp Dent. 2019;11(12):e1143–50. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health. 2006;60(1):7–12. Shao LF. Robust determinants of income distribution across and within countries. PLoS ONE. 2021;16(7):e0253291. Arora G, Mackay DF, Conway DI, Pell JP. Ethnic differences in oral health and use of dental services: cross-sectional study using the 2009 Adult Dental Health Survey. BMC Oral Health. 2016;17(1):1. Batra M, Gupta S, Erbas B. Oral Health Beliefs, Attitudes, and Practices of South Asian Migrants: A Systematic Review. Int J Environ Res Public Health. 2019;1(11):1952. Valdez R, Spinler K, Kofahl C, Seedorf U, Heydecke G, Reissmann DR, et al. Oral Health Literacy in Migrant and Ethnic Minority Populations: A Systematic Review. J Immigr Minor Health. 2021;24(4):1061–80. Lauritano D, Moreo G, Carinci F, Campanella V, Della Vella F, Petruzzi M. Oral Health Status among Migrants from Middle- and Low-Income Countries to Europe: A Systematic Review. Int J Environ Res Public Health. 2021;18(22):12203. Calvasina P, Lawrence HP, Hoffman-Goetz L, Norman CD. Brazilian immigrants' oral health literacy and participation in oral health care in Canada. BMC Oral Health. 2016;16:18. Teixeira AKM, Roncalli AG, Noro LRA. Income Trajectories and Oral Health of Young People in a Life Course Study. Caries Res. 2019;53(3):347–56. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107. Batista MJ, Lawrence HP, Sousa MDLR. Oral health literacy and oral health outcomes in an adult population in Brazil. BMC Public Health. 2017;18(1):60. Firmino RT, Ferreira FM, Martins CC, Granville-Garcia AF, Fraiz FC, Paiva SM. Is parental oral health literacy a predictor of children's oral health outcomes? Systematic review of the literature. Int J Paediatr Dent. 2018:8. Parthasarathy DS, McGrath CP, Bridges SM, Wong HM, Yiu CK, Au TK. Efficacy of instruments measuring oral health literacy: a systematic review. Oral Health Prev Dent. 2014;12(3):201–7. Miller E, Lee JY, DeWalt DA, Vann WF. Impact of caregiver literacy on children's oral health outcomes. Pediatrics. 2010;126(1):107–14. Bridges SM, Parthasarathy DS, Wong HM, Yiu CK, Au TK, McGrath CP. The relationship between caregiver functional oral health literacy and child oral health status. Patient Educ Couns. 2014;94(3):411–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5339307","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374202621,"identity":"de0d7e15-36e2-4ba9-85e9-5f42a1582bd7","order_by":0,"name":"Bruna Leticia Vessoni Menoncin","email":"","orcid":"","institution":"Federal University of Paraná","correspondingAuthor":false,"prefix":"","firstName":"Bruna","middleName":"Leticia Vessoni","lastName":"Menoncin","suffix":""},{"id":374202624,"identity":"512b9f9e-f722-4cd2-a0f8-6d803bb915fd","order_by":1,"name":"Aline Fabris de Araújo Crema","email":"","orcid":"","institution":"Federal University of Paraná","correspondingAuthor":false,"prefix":"","firstName":"Aline","middleName":"Fabris de Araújo","lastName":"Crema","suffix":""},{"id":374202625,"identity":"6e6c433e-72ae-457c-84a8-5238f1239404","order_by":2,"name":"José Vitor Nogara Borges de Menezes","email":"","orcid":"","institution":"Federal University of Paraná","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Vitor Nogara Borges","lastName":"de Menezes","suffix":""},{"id":374202631,"identity":"5c29e808-c983-48fc-9b7a-709b12bd217e","order_by":3,"name":"Sandra Patrícia Crispim","email":"","orcid":"","institution":"Federal University of Paraná","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"Patrícia","lastName":"Crispim","suffix":""},{"id":374202633,"identity":"ae90477a-7e46-4114-9752-93be8f932225","order_by":4,"name":"Fernanda de Morais Ferreira","email":"","orcid":"","institution":"Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Fernanda","middleName":"de Morais","lastName":"Ferreira","suffix":""},{"id":374202634,"identity":"45537328-9751-4349-9ce3-f2b9a9165b1a","order_by":5,"name":"Andrea Ferreira Zandoná","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"Ferreira","lastName":"Zandoná","suffix":""},{"id":374202635,"identity":"15fbdecd-42fc-4ad5-8094-22dd5bbbbab0","order_by":6,"name":"Fabian Calixto Fraiz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBAC9gYehgMMDHIMDMwMjA+AAjx8hLTwHABrMQZpYTYACbARo4UBrIWBgU0CTBLUwn724IGfOwzy+dvZn1V+zbGTYWNgfvjoBj4tPHkJB3vPGFjOOMyQdlt2WzLQYWzGxjl4tNgz5Bgc4G37Y8BwmOHYbcltzEAtPGzS+LTw8L8xOPi3zcBA/jBjW7HktnoitEjkGBzmBWoxOMzMxvhx22FitLxLOCwL1GJ4mI1ZmnHbcR42ZgJ+4eHPPfzxLVCL3PnjDz/+3FZtz8/e/PAxPi0ogBkcR8zEKgcBxh+kqB4Fo2AUjIIRAwCHJkLjUFKligAAAABJRU5ErkJggg==","orcid":"","institution":"Federal University of Paraná","correspondingAuthor":true,"prefix":"","firstName":"Fabian","middleName":"Calixto","lastName":"Fraiz","suffix":""}],"badges":[],"createdAt":"2024-10-27 01:23:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5339307/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5339307/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69460715,"identity":"aeed372c-7528-4c46-b0a9-a1d60f48f444","added_by":"auto","created_at":"2024-11-20 14:51:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76896,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of OHL-AQ values in each group.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQ1= first quartile; Q3= third quartile SD= Standard Deviation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5339307/v1/a37dd45c17095c9a776c4207.png"},{"id":86768494,"identity":"c89fddbe-f7a6-47f4-a3f5-1b6dc21b59b0","added_by":"auto","created_at":"2025-07-15 11:24:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":671969,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5339307/v1/7d9b26d7-4a11-44eb-b426-998ce0766894.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e Child Cariogenic Diet and Parental Oral Health Literacy Level Between American and Brazilian Families\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOral health literacy (OHL) is defined as an individual\u0026rsquo;s ability to obtain, process, and understand information essential for making appropriate decisions regarding oral health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Individuals\u0026rsquo; OHL levels impact their ability to read and understand written texts, efficiently communicate information related to oral health, use health systems, and maintain their own health [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Considering parental OHL, this ability also includes maintaining children\u0026rsquo;s oral health. Inadequate parental OHL is associated with a greater incidence of dental caries in children [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFood choices are strongly associated with oral health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and can be influenced by OHL levels [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition, it is between 2 and 5 years of age that the child learns about food choices and starts to have food preferences based on food items that were exposed during this period [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this way, it is understandable that parental eating habits are a model of eating behavior for their children [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current understanding of OHL includes cultural factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Cariogenic diet is also influenced by culture and location and social and economic development. In regard to children\u0026rsquo;s eating practices, parents can affect their children\u0026rsquo;s diet by making some food items more accessible than others [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, snack consumption may vary by nutrient content and portion size [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKnowing that children\u0026rsquo;s oral conditions are affected among disadvantaged individuals and populations, such as parents, where parents are born, who grow, who live and who work [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and considering that OHL levels and food consumption probably vary according to the country in which a family lives and that migration background is a discrete risk factor for lower oral health and OHL [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This study aimed to compare the cariogenic diet and parental oral health literacy levels of children between American and Brazilian families.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e1.1.1 Participants\u003c/p\u003e\n\u003cp\u003eThe cross-sectional observational survey was conducted in Curitiba, Brazil, and in Boston, USA. Curitiba is the capital city of the state of Paran\u0026aacute;. There were an estimated 1,948,626 inhabitants in 2020. The city has a very high human development index (HDI) of 0.823 and a Gini index of household income per capita of 0.05752, with a yearly per capita income of R$18.972,48 [15]. Boston, the most populous capital of the state of Massachusetts, in U.S. Boston city, had a population of 684,379 inhabitants in 2020. Considering the greater area with surrounding towns, the population has increased to 4.315,000, and 5% of the Brazilian immigrants of Massachussets have lived there [16].\u003c/p\u003e\n\u003cp\u003eParents or guardians of children between 2 and 5 years old were selected to participate in the survey. Brazilian parents or guardians of Brazilian children residing in Curitiba, American parents or guardians of American children residing in Boston, and Brazilian parents or guardians of American children residing in Boston were eligible for the survey. Children who had any food restriction or allergy that required a special diet were excluded from the survey.\u003c/p\u003e\n\u003cp\u003e1.1.2 Data collection\u003c/p\u003e\n\u003cp\u003eTo recruit participants for the Brazilian survey, parents or guardians of children enrolled in the municipal education system were invited to participate. Parents from all 40 selected preschools were invited to participate.\u003c/p\u003e\n\u003cp\u003eAll 10 regions of the city. The first contact was with the main chair from the school. After agreeing to participate, each teacher from each class helped by sending a short text explaining the goal of the survey to parents. Those who agreed to participate in the survey had access facilitated by a shared link.\u003c/p\u003e\n\u003cp\u003eFor the data collection of American data, an approach script was used to invite potential participants to the Tufts University School of Dental Medicine clinic waiting rooms. Flyers were posted throughout the TUSDM and given to organizational leaders, such as community centers, head start programs, day care centers and pre-kindergartens. To maximize participation, a request to email participants was sent to the leaders of the organizations. Upon their approval to contact their populations, the leaders were asked to email potential participants with the link to the survey. Flyers were also given to the organization leaders to be distributed to their populations. Parents or guardians were also approached personally when allowed by the organization.\u003c/p\u003e\n\u003cp\u003eFor data collection, parents or guardians received self-administered questionnaires that were distributed on paper or electronically via Google Forms and Qualtrics via an iPad or via an electronic Qualtrics link sent to potential participants. The Brazilian data were collected between October 2020 and February 2021, and the American data were collected between October and December 2021.\u003c/p\u003e\n\u003cp\u003e1.1.3 Measures\u003c/p\u003e\n\u003cp\u003eSocioeconomic and demographic aspects and children\u0026rsquo;s oral health\u003c/p\u003e\n\u003cp\u003eThe socioeconomic and demographic aspects of the questionnaire, such as age, educational level, marital status, work or training in a health-related area, and child\u0026rsquo;s age, were collected from parents or guardians.\u003c/p\u003e\n\u003cp\u003e The food practices of preschools and the food behavior of parents or guardians were evaluated, as was the cariogenic food consumption of preschoolers using a specific questionnaire. In the construction of the questions about the frequency of consumption of food items, the five main ultra-processed foods with cariogenic potential included were considered sources of free sugars according to the report of the Pan American Health (PAHO \u0026ndash; WHO) on food consumption and ultra-processed and cariogenic beverages in Latin America [17]: soft drinks or carbonated beverages; artificial juices, powdered refreshments or concentrated juices; sweets such as candy, caramel, lollipop, ice cream, and chocolate; cakes made from cake mix or purchased ready-made; and biscuits or sweet biscuits/cookies. It was decided to keep the same list of foods for data collection in the U.S., knowing that these are also foods with high consumption in this population. Parents or guardians were instructed to report the frequency of intake of each type of food in the last 3 months, marking the cell corresponding to the option that was closest to the child\u0026rsquo;s food consumption practice. The categories used to report the frequency of consumption items were never or rarely, 1 or 2 times a week, 3 to 6 times a week, 1 or 2 times a day, and 3 or more times a day. To define the number of daily contacts with each food, the categories were weighted as follows: never or rarely = zero; 1 or 2 times a week = 0.214 (1.5 times/7 days a week); 3 to 6 times a week = 0.643 (4.5 times/7 days a week); 1 or 2 times a day = 1 (1.5 times/1 day); and 3 or more times a day = 3 (3 times/1 day) [18, 19]. Finally, the daily consumption frequency of cariogenic foods was obtained by the average of the daily frequency values of the set of food items evaluated.\u003c/p\u003e\n\u003cp\u003eTo assess the behavior of parents in their children\u0026rsquo;s nutritional education, the PMAS (Parental Mealtime Action Scale) instrument in the English language version and Brazilian Portuguese version were used [20]. The domains used were \u0026ldquo;Daily availability of fruits and vegetables\u0026rdquo;, which indicates the consumption of these food items by parents and their offer to children; \u0026ldquo;Snacks consumption model\u0026rdquo;, which reflects the consumption of sweets, soft drinks and snacks by parents, serving as a model for children; and \u0026ldquo;Snacks limit\u0026rdquo;, which reports the limits established by parents when consuming daily sweets. Each of the three domains had three questions, and for each question, a scoring scale from one to three points (never = 1; sometimes = 2; always = 3) was used to obtain the parent\u0026rsquo;s or guardian\u0026rsquo;s reports on how often they adopted each behavior in a typical week. The domain value was obtained from the average of the answers for each question and was used as a numerical variable. For the first and third domains, higher averages represented a greater frequency of behavior by those responsible for their children\u0026rsquo;s nutritional education. For the second domain, higher averages represented less favorable behavior for the child\u0026rsquo;s oral health [21].\u003c/p\u003e\n\u003cp\u003eTo assess parental reports on the child\u0026rsquo;s oral health, a question in the questionnaire was used, which classified the child\u0026rsquo;s health as \u0026apos;very good or good\u0026apos;, \u0026apos;fair\u0026apos;, or \u0026apos;poor or very poor\u0026apos;. \u003c/p\u003e\n\u003cp\u003eParents\u0026rsquo; or guardians\u0026rsquo; Oral Health Literacy\u003c/p\u003e\n\u003cp\u003eTo assess the parental OHL level, the original version of the \u003cem\u003eOral Health Literacy Adult Questionnaire \u003c/em\u003e(OHL-AQ) in English and the translated into Brazilian Portuguese [22-24] were used. The instrument consists of 17 questions, including four sessions covering different abilities. The \u0026ldquo;reading comprehension\u0026rdquo; session included three incomplete multiple-choice questions. The parent should select one of the five possible choices to fill the blank space with the alternative that he/she believes to be the best compliment for the gap. The \u0026ldquo;numeracy\u0026rdquo; session included four questions about a written box. The parent was asked to read an amoxicillin prescription and then answer a free-text question and a multiple-choice question about the drug prescription. The \u0026ldquo;listening session\u0026rdquo; included two questions given by a new written box about instructions for a sodium fluoride mouth rinse. The parent should use listening skills to understand the instructions and then answer a free-text and multiple-choice question. However, considering the new conditions imposed by the COVID-19 pandemic, in this study, the listening session was converted into reading questions. The last session, \u0026ldquo;decision-making\u0026rdquo;, included five multiple-choice questions related to common oral health problems and medical history forms. One of the answer alternatives for all questions was the right one, and another was \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;. The parent was instructed to select this answer instead of guessing when he/she did not know the answer. Correct answers were scored with 1 point, while incorrect answers or \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; were scored as zero. The total score was obtained from the sum of individual scores for each question, ranging from 0 to 17 points.\u003c/p\u003e\n\u003cp\u003e1.1.4 Analysis\u003c/p\u003e\n\u003cp\u003eThe collected data were analyzed by SPSS software (SPSS Statistical). Descriptive analysis was performed to compare the three different groups: Brazilian parents residing in Brazil, American parents residing in the U.S., and Brazilian parents residing in the U.S.\u003c/p\u003e\n\u003cp\u003eThe independent variables were categorized as follows: child\u0026rsquo;s gender (\u0026ldquo;female\u0026rdquo; or \u0026ldquo;male\u0026rdquo;); relationship with the child (\u0026ldquo;mother\u0026rdquo;, \u0026ldquo;father\u0026rdquo; or \u0026ldquo;other\u0026rdquo;); parental training in health care (\u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;); parental work in health-related areas (\u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no); parental educational level (\u0026ldquo;primary education\u0026rdquo;, \u0026ldquo;secondary education\u0026rdquo; or \u0026ldquo;higher education\u0026rdquo;); parental marital status (marriage or stable union \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;); parental report of a child\u0026rsquo;s oral health (\u0026ldquo;very good or good\u0026rdquo;, \u0026ldquo;regular\u0026rdquo; or \u0026ldquo;bad or very bad\u0026rdquo;). The remaining variables were analyzed as numerical variables: parent\u0026rsquo;s age, child\u0026rsquo;s age, cariogenic food consumption, parent`s behavior with children\u0026rsquo;s nutritional education, and parental oral health literacy level.\u003c/p\u003e\n\u003cp\u003eFor numerical variables, a normality test was performed. All variables had a nonnormal variation. The multiple comparison test used to verify the difference between groups was the Kruskal‒Wallis test post hoc with Bonferroni correction. For categorical variables, the chi2 test was performed. A 5% significance level was considered for the analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAmong the parents invited to participate in the survey, 672 were Brazilian parents residing in Brazil, 203 were American parents residing in the U.S., and 61 were Brazilian parents residing in the U.S. Of those who were residing in the U.S., 68.9% had resided there for less than or equal to 10 years, 14.7% for more than 10 years, and 16.4% did not answer this question. Overall, 936 parents or guardians agreed to participate in the survey by signing the consent form. The average age of the guardians and the children were 33.4 [Standard Deviation (SD)\u0026thinsp;=\u0026thinsp;7.3] years and 3.7 (SD\u0026thinsp;=\u0026thinsp;1.1) years, respectively.\u003c/p\u003e\n\u003cp\u003eAccording to socioeconomic and demographic variables (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), parents residing in the U.S. have more training in health care than parents residing in Brazil. Thus, parents residing in the U.S. also have more work in health-related areas than parents residing in Brazil. Parents with a stable marital status are more likely to be in a stable union for parents residing in the U.S. Parents residing in Brazil report their child\u0026rsquo;s oral health as very good or good more than do parents residing in the U.S.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; COMPARISON OF SOCIOECONOMIC AND DEMOGRAPHIC VARIABLES ACCORDING TO THE EVALUATED GROUP\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRAZILIAN PARENT\u0026rsquo;S CURITIBA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMERICAN PARENT\u0026rsquo;S MASSACHUSSETS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRAZILIAN PARENT\u0026rsquo;S MASSACHUSSETS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVARIABLE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eRelationship with the child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMother or Father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e653 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e192 (95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e60 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eChild\u0026rsquo;s sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e327 (48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e106 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e32 (54.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e345 (51.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e93 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e27 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTraining in health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e624 (92.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e177 (90.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e51 (83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e48 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e18 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eWork in health-related area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e641 (95.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e139 (89.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e47 (83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e28 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eParental marital status (marriage or stable union)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e262 (39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e38 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e403 (60.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e147 (79.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e51 (92.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eParental Educational level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e84 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e318 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e23 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e267 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e167 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e43 (70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eOral health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVery good or good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e552 (82,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e133 (68,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e42 (68,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRegular, bad or very bad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e115 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e61 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e19 (31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eNOTE: PE (Primary Education); SE (Secondary Education); HE (Higher Education); *Chi2 test.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows that children with American and Brazilian parents residing in the U.S. have a greater consumption of carbonated soft drinks, sweetened juices, sweets, cookies, cakes, pastries and deserts. Considering all cariogenic food consumption, an American child with American parents has a similar consumption as an American child with Brazilian parents, both residing in the U.S., and this consumption is greater than that of a Brazilian child residing in Brazil.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; CARIOGENIC FOOD CONSUMPTION AND PARENTAL ORAL HEALTH LITERACY LEVELS\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBRAZILIAN PARENT\u0026rsquo;S CURITIBA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAMERICAN PARENT\u0026rsquo;S MASSACHUSSETS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBRAZILIAN PARENT\u0026rsquo;S MASSACHUSSETS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVARIABLE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (Q1-Q3)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (Q1-Q3)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (Q1-Q3)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCarbonated soft drinks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.0-0.21)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.0-0.64) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.0-0.42)\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSweetened juices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.0-0.64)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;1.50)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;1.50)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSweets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.21\u0026ndash;0.21)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;0.64)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;0.64)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCookies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.21\u0026ndash;0.64)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;1.50)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;1.50)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCake, pastries or deserts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0 (0.0-0.21)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21 (0.21\u0026ndash;1.28)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64 (0.21\u0026ndash;0.64)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCariogenic food consumption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.05 (0.63\u0026ndash;2.13)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.77 (1.27\u0026ndash;5.30)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.99 (0.84\u0026ndash;5.61)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePMAS domain Daily fruits and vegetables availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.33(2.33-3)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.33 (2\u0026ndash;3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00 (2\u0026ndash;3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePMAS domain Snack Modeling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.67 (1.33-2)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00(2\u0026ndash;2)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00 (1.67-2)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePMAIS domain Snack Limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00 (2.33-3)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.33 (2\u0026ndash;3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00 (2\u0026ndash;3)ab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOHL-AQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (11\u0026ndash;15)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (14\u0026ndash;17)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (14\u0026ndash;16)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eNOTE: *Kruskall-Wallis test post hoc with Bonferroni correction; Q1\u0026thinsp;=\u0026thinsp;first quartile; Q3\u0026thinsp;=\u0026thinsp;third quartile. Different letters denote statistical significance.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe daily fruit and vegetable availability was greater for American families than for the other groups. The snake modeling domain and snack limits were greater for American and Brazilian parents residing in the U.S. than for Brazilian parents residing in Brazil. In addition, the OHL level of Brazilian parents residing in the U.S. was greater than that of Brazilian parents residing in Brazil and was more similar to that of American parents. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the distribution of OHL-AQ values in each group.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAn important finding of this study is the observation of a pattern for the consumption of cariogenic food. Children of Brazilian parents residing in Massachussets are more homogeneous to children of American parents also residing in Massachussets, and their consumption of cariogenic food was greater than that of children of Brazilian parents residing in Curitiba. In addition, parents\u0026rsquo; behavior regarding the dietary education of their children followed the same logic when evaluating the three PMAS domains. This approximation of the consumption patterns and behaviors of Brazilians residing in the USA and of Americans is probably because children of immigrants can be vulnerable to the food culture in host countries, where unhealthy food is more accessible and favored [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Consequently, with the increased consumption of sugar, refined carbohydrates, and soda, U.S. immigrants have increased chances of having chronic diseases, such as obesity [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], cardiovascular diseases [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and dental caries [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Because young children are exposed to the host culture indirectly through their parents and other caregivers [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], it is presumed that being a first-generation child with at least one foreign-born parent increases a cariogenic diet.\u003c/p\u003e \u003cp\u003eAdditionally, probably because of acculturation effects, children of Brazilian parents residing in Massachussets have a similar cariogenic diet to children of American parents residing in Massachussets. This result is the same as that of Batis et al. (2011), who compared the effects of food acculturation on Mexican children, adolescents and adults residing in the U.S. They indicated that within one generation in the U.S., the influence of the Mexican diet is almost lost [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Other studies that compared the diet of U.S. immigrants with that of Americans also reported the influence of the acculturation process [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, parental educational level, parental perception of the child\u0026rsquo;s oral health condition and parental OHL level were greater for Brazilian and American parents residing in Massachussets than for Brazilian parents residing in Curitiba. This difference probably occurred because there was a greater prevalence of Brazilian and American parents who resided in Massachussets and worked in health-related areas. Compared with general migrants, health workers who are immigrants are more likely to have higher health literacy scores [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Those families had at least one respondent with a higher educational level, and studies have shown that a higher education level is associated with a greater health literacy score for the immigrant population [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The same logic applies to OHL; a higher OHL is associated with a higher educational level [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Income is considered an indicator of material living standards in health research [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], complemented by parental educational level [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which is likely why Brazilian families residing in Massachussets, which have a higher family income, also have parents with a higher educational level than do Brazilian families residing in Brazil.\u003c/p\u003e \u003cp\u003eSome studies show that a migration background can be a risk factor for poor oral health [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], just as migration is related to socioeconomic status and educational level [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This means that people who do not live in their own country of birth generally have significantly worse oral health than those who live in their own country of birth in the target population [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Therefore, individuals with a migration background are likely to have poor oral health, and they are likely to have the same perceptions of their children\u0026rsquo;s oral health. According to the results presented in this survey, Brazilian parents residing in Massachussets reported their child\u0026rsquo;s oral health as regular, bad, and very bad more frequently than did Brazilian parents residing in Curitiba.\u003c/p\u003e \u003cp\u003eMigrant populations usually represent a heterogeneous group of people with variable oral health knowledge and diverse beliefs and attitudes shaped by their culture and past experiences with the respective health care system in their home countries [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Most studies report inequity among migrants or ethnic minorities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, social, economic, cultural, and environmental conditions can influence improving or worsening individuals\u0026rsquo; health [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Although there is a greater risk to oral health outcomes for families with socioeconomic mobility [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] and those who have a migration background, the results show that Brazilian and American parents who live with their child in Massachussets, regardless of the time of immigration, have an improvement in their OHL status. This is likely the result of the higher family income, higher parental educational level, and higher OHL level of this group. The OHL level of Brazilian parents residing in the U.S. is close to the OHL level of American parents residing in the U.S. and greater than that of Brazilian parents residing in Brazil. This result is associated with the higher parental educational level of Brazilian parents who migrate to the U.S., once the OHL level and educational level are directly associated [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLow health literacy is associated with poor health status and poor outcomes [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Individuals with low OHL have poorer oral health [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and poorer periodontal health [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and children have more dental caries [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Compared with Brazilian nonimmigrants, Brazilian immigrants enrolled in our survey had a greater average level of OHL. Parthasarathy, 2014, states that for selecting relevant instruments, one must consider the impact of language and culture [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. For this reason, this study used a validated and translated instrument to assess OHL in both English and Brazilian Portuguese [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The whole questionnaire, as well as the OHL-AQ instrument, was available in English and in Portuguese. Participants could choose in which language to answer the questionnaire. The choice to provide the instrument in both languages did not influence the OHL level if any parent did not have proficiency in the language of the host country.\u003c/p\u003e \u003cp\u003eThe sampling of data from Massachussets resulted in a convenience sample, distinct from the data from Brazil, which was a representative sample from the city collected just from municipal preschools. Another limitation is that this cross-sectional observational design cannot establish a causal effect between immigration and other variables. Further studies with a longitudinal design must consider migrant backgrounds when analyzing the association between OHL and food consumption.\u003c/p\u003e \u003cp\u003eCurrent literature indicates that parental OHL plays an important role in ensuring good practices for oral health in children [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Individuals\u0026rsquo; cultural background has a significant influence on how migrants promote and maintain good oral health [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. It is possible that children\u0026rsquo;s oral health can be improved by improving parental OHL levels. It is also important to establish actions to improve the population\u0026rsquo;s OHL according to the countries\u0026rsquo; local contexts, as the OHL level can vary between populations. Oral health-promoting behavior, attitudes, capabilities, and beliefs, as well as cultural and ethnic backgrounds, should be considered in oral health prevention programs.\u003c/p\u003e \u003cp\u003eIn conclusion, the food consumption patterns and OHL of Brazilian parents and children residing in the U.S. are similar to those of American parents and children than are those of Brazilian parents and children residing in Brazil.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican and Brazilian families. Brazilian parents of Brazilian children\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican parents of American children\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrazilian parents of American children\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eHuman Ethics and consent to participate\u003c/p\u003e\n\u003cp\u003ePrior to data collection, the Institutional Review Board of the Tufts\u0026nbsp;University\u0026nbsp;School\u0026nbsp;of\u0026nbsp;Dental\u0026nbsp;Medicine\u0026nbsp;(TUSDM)\u0026nbsp;and\u0026nbsp;the\u0026nbsp;Human\u0026nbsp;Research\u0026nbsp;Ethics\u0026nbsp;Committee of the Health Sciences Center of the Federal University of Parana\u0026nbsp;(UFPR)\u0026nbsp;approved\u0026nbsp;this\u0026nbsp;survey\u0026nbsp;(#29188620.3.0000.0102\u0026nbsp;and\u0026nbsp;#00002056,\u0026nbsp;respectively).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eParents or caregivers received informed consent previously of the questionnaire. Availability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;study\u0026nbsp;was\u0026nbsp;financed\u0026nbsp;in\u0026nbsp;part\u0026nbsp;by\u0026nbsp;the\u0026nbsp;Coordenacao\u0026nbsp;de\u0026nbsp;Aperfeicoamento\u0026nbsp; \u0026nbsp; \u0026nbsp;de\u0026nbsp;Pessoal\u0026nbsp;de\u0026nbsp;Nivel\u0026nbsp;Superior\u0026nbsp;\u0026ndash;\u0026nbsp;Brazil\u0026nbsp;(Capes) \u0026ndash;\u0026nbsp;Finance\u0026nbsp;001.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConception:\u0026nbsp;Andrea Ferreira Zandon\u0026aacute;, Fabian Calixto Fraiz.\u0026nbsp;Fernanda Moraes Ferreira\u003c/p\u003e\n\u003cp\u003eDesign of the work:\u0026nbsp;Andrea Ferreira Zandon\u0026aacute;, Fabian Calixto Fraiz, Jose Vitor Nogara Borges de Menezes, Sandra Patr\u0026iacute;cia Crispim\u003c/p\u003e\n\u003cp\u003eAcquisition: Bruna Leticia Vessoni Menoncin AND\u0026nbsp;Aline Fabris de Ara\u0026uacute;jo Crema\u003c/p\u003e\n\u003cp\u003eAnalysis: \u0026nbsp;Fabian Calixto Fraiz\u003c/p\u003e\n\u003cp\u003eInterpretation of data: \u0026nbsp;Fabian Calixto Fraiz AND \u0026nbsp;Bruna Leticia Vessoni Menoncin\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Center for Health Statistics and Health People. Final Review 2010. 2nd ed. Washington, DC: US Government Printing Office; 2010. p. 560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health. 2018;18(1):172.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhodadadi E, Niknahad A, Sistani MM, Motallebnejad M. Parents' Oral Health Literacy and its Impact on their Children's Dental Health Status. Electron Physician. 2016;8(12):3421\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlzahrani AY, El Meligy O, Bahdila D, Aljawi R, Bamashmous NO, Almushayt A. The influence of parental oral health literacy on children's oral health: a scoping review. J Clin Pediatr Dent. 2024;48(4):16\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontes GR, Bonotto DV, Ferreira FM, Menezes JVNB, Fraiz FC. Caregiver's oral health literacy is associated with prevalence of untreated dental caries in preschool children. Cien Saude Colet. 2019;24(7):2737\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamaddar A, Shrikrishna SB, Moza A, Shenoy R. Association of parental food choice motives, attitudes, and sugar exposure in the diet with early childhood caries: Case\u0026ndash;control study. J Indian Soc Pedod Prev Dent. 2021;39(2):171\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Inglehart MR, Yuan C. Impact of Parents' Oral Health Literacy on Their Own and Their Children's Oral Health in Chinese Population. Front Public Health. 2022;10:809568.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell CG, Worsley A, Liem DG. Parents' food choice motives and their associations with children's food preferences. Public Health Nutr. 2015;18(6):1018\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScaglioni S, De Cosmi V, Ciappolino V, Parazzini F, Brambilla P, Agostoni C. Factors Influencing Children's Eating Behaviors. Nutrients. 2018;10(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYee AZ, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2017;14(1):47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Research Concil. Improving access to oral health care for vulnerable and underserved populations. Washington (DC): National Academies; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVatanparast H, Islam N, Masoodi H, Shafiee M, Patil RP, Smith J, et al. Time, location and frequency of snack consumption in different age groups of Canadians. Nutr J. 2020;19(1):85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKassebaum NJ, Smith AGC, Bernab\u0026eacute; E, Fleming TD, Reynolds AE, Vos T, et al. Global, Regional, and National Prevalence, Incidence, and Disability- Adjusted Life Years for Oral Conditions for 195 Countries, 1990\u0026ndash;2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors. J Dent Res. 2017;96(4):380\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpinler K, Weil MT, Valdez R, Walther C, Dingoyan D, Seedorf U, et al. [Oral health literacy of persons with migration background-first results of the MuMi study]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2021;64(8):977\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParana Institute for Economic and Social Development (IPARDES). [Caderno estat\u0026iacute;stico munic\u0026iacute;pio de Curitiba]: Available in: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ipardes.gov.br/cadernos/MontaCadPdf1.php?Municipio=80000\u003c/span\u003e\u003cspan address=\"http://www.ipardes.gov.br/cadernos/MontaCadPdf1.php?Municipio=80000\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoston Planing \u0026amp; Development Agency Research Divison. April 2017. Available in: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bostonplans.org/\u003c/span\u003e\u003cspan address=\"https://www.bostonplans.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanamerican Health Organization (PAHO). Ultra-processed food and drink products in Latin America: Sales, sources, nutrient profiles, and policy implications. Washington, D.C.: PAHO; 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.paho.org/handle/10665.2/51094\u003c/span\u003e\u003cspan address=\"https://iris.paho.org/handle/10665.2/51094\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSauvageot N, Alkerwi A, Albert A, Guillaume M. Use of food frequency questionnaire to assess relationships between dietary habits and cardiovascular risk factors in NESCAV study: validation with biomarkers. Nutr J. 2013;12(1):143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaly AM, Parsons JE, Wood NA, Gill TK, Taylor AW. Food consumption habits in two states of Australia, as measured by a Food Frequency Questionnaire. BMC Res Notes. 2011;23(4):507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHendy HM, Williams KE, Camise TS, Eckman N, Hedemann A. The Parent Mealtime Action Scale (PMAS). Development and association with children's diet and weight. Appetite. 2009;52(2):328\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetty ML, Escriv\u0026atilde;o MA, Souza AA. Preliminary validation of the Parent Mealtime Action Scale and its association with food intake in children from S\u0026atilde;o Paulo, Brazil. Appetite. 2013;62:166\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlynn PM, John MT, Naik A, Kohli N, VanWormer JJ, Self K. Psychometric properties of the English version of the Oral Health Literacy Adults Questionnaire - OHL-AQ. Community Dent Health. 2016;33(4):274\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSistani MMN, Montazeri A, Yasdani R, Murtomaa H. New oral health literacy instrument for public health: development and pilot testing. J Investig Clin Dent. 2014;5(4):313\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlmeida ER, Sistani MMN, Bendo CB, Pordeus IA, Firmino RT, Paiva SM, Ferreira FM. Validation of the Brazilian Oral Health Literacy-Adults Questionnaire. Health Lit Res Pract. 2022;6(3):e224\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378(9793):804\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDave JM, Evans AE, Saunders RP, Watkins KW, Pfeiffer KA. Associations among food insecurity, acculturation, demographic factors, and fruit and vegetable intake at home in Hispanic children. J Am Diet Assoc. 2009;109(4):697\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Q, Liu R, Diggs LA, Wang Y, Ling L. Does acculturation affect the dietary intakes and body weight status of children of immigrants in the U.S. and other developed countries? A systematic review. Ethn Health. 2019;24(1):73\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindsay AC, Wallington SF, Greaney ML, Hasselman MH, Machado MM, Mezzavilla RS, et al. Sociocultural and Environmental Influences on Brazilian Immigrant Mothers' Beliefs and Practices Related to Child Feeding and Weight Status. Matern Child Health J. 2017;21(5):1085\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatis C, Hernandez-Barrera L, Barquera S, Rivera JA, Popkin BM. Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. J Nutr. 2011;141(10):1898\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManohar N, Hayen A, Fahey P, Arora A. Obesity and dental caries in early childhood: A systematic review and meta-analyses. Obes Rev. 2020;21(3):e12960.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDancel LD, Perrin E, Yin SH, Sanders L, Delamater A, Perreira KM, et al. The relationship between acculturation and infant feeding styles in a Latino population. Obes (Silver Spring). 2015;23(4):840\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindsay AC, Vianna GVB, Arruda CAM, Alves ASM, Hasselmann MH, Machado MM, et al. Brazilian immigrant fathers' perspectives on child's eating and feeding practices: a qualitative study conducted in the United States. Public Health Nutr. 2020;23(17):3211\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKosiyaporn H, Julchoo S, Sinam P, Phaiyarom M, Kunpeuk W, Pudpong N, et al. Health Literacy and Its Related Determinants in Migrant Health Workers and Migrant Health Volunteers: A Case Study of Thailand, 2019. Int J Environ Res Public Health. 2020;22(6):2105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBado FMR, De Checchi MHR, Cortellazzi KL, Ju X, Jamieson L, Mialhe FL. Oral health literacy, self-rated oral health, and oral health-related quality of life in Brazilian adults. Eur J Oral Sci. 2020;128(3):218\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026aacute;rquez-Arrico CF, Almerich-Silla JM, Montiel-Company JM. Oral health knowledge in relation to educational level in an adult population in Spain. J Clin Exp Dent. 2019;11(12):e1143\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health. 2006;60(1):7\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShao LF. Robust determinants of income distribution across and within countries. PLoS ONE. 2021;16(7):e0253291.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora G, Mackay DF, Conway DI, Pell JP. Ethnic differences in oral health and use of dental services: cross-sectional study using the 2009 Adult Dental Health Survey. BMC Oral Health. 2016;17(1):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatra M, Gupta S, Erbas B. Oral Health Beliefs, Attitudes, and Practices of South Asian Migrants: A Systematic Review. Int J Environ Res Public Health. 2019;1(11):1952.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValdez R, Spinler K, Kofahl C, Seedorf U, Heydecke G, Reissmann DR, et al. Oral Health Literacy in Migrant and Ethnic Minority Populations: A Systematic Review. J Immigr Minor Health. 2021;24(4):1061\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLauritano D, Moreo G, Carinci F, Campanella V, Della Vella F, Petruzzi M. Oral Health Status among Migrants from Middle- and Low-Income Countries to Europe: A Systematic Review. Int J Environ Res Public Health. 2021;18(22):12203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalvasina P, Lawrence HP, Hoffman-Goetz L, Norman CD. Brazilian immigrants' oral health literacy and participation in oral health care in Canada. BMC Oral Health. 2016;16:18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeixeira AKM, Roncalli AG, Noro LRA. Income Trajectories and Oral Health of Young People in a Life Course Study. Caries Res. 2019;53(3):347\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatista MJ, Lawrence HP, Sousa MDLR. Oral health literacy and oral health outcomes in an adult population in Brazil. BMC Public Health. 2017;18(1):60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFirmino RT, Ferreira FM, Martins CC, Granville-Garcia AF, Fraiz FC, Paiva SM. Is parental oral health literacy a predictor of children's oral health outcomes? Systematic review of the literature. Int J Paediatr Dent. 2018:8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParthasarathy DS, McGrath CP, Bridges SM, Wong HM, Yiu CK, Au TK. Efficacy of instruments measuring oral health literacy: a systematic review. Oral Health Prev Dent. 2014;12(3):201\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller E, Lee JY, DeWalt DA, Vann WF. Impact of caregiver literacy on children's oral health outcomes. Pediatrics. 2010;126(1):107\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBridges SM, Parthasarathy DS, Wong HM, Yiu CK, Au TK, McGrath CP. The relationship between caregiver functional oral health literacy and child oral health status. Patient Educ Couns. 2014;94(3):411\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health literacy, Eating behavior, Population characteristics, Preschool children, Immigrant parents","lastPublishedDoi":"10.21203/rs.3.rs-5339307/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5339307/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e To comparethe cariogenic diets of children and parental OHL levels between American and Brazilian families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Participating in this cross-sectional study were the parents/guardians of 946 children aged 2 to 5, Brazilian parents of children. There were 672 Brazilian parents of Brazilian children (BB), 203 American parents of American children (AA) and 61 Brazilian parents of American children (BA). A self-administered questionnaire about sociodemographic aspects and children’s oral health conditions was administered. Food practices were analyzed using a specific questionnaire. The parental mealtime action scale (PMAS) scores for daily fruit and vegetable availability, the snacks consumption model, and the snacks limit were collected. Parental OHL levels were assessed by the \u003cem\u003eOral Health Literacy Adult Questionnaire \u003c/em\u003e(OHL-AQ). Multiple comparison tests with the Kruskal‒Wallis post hoc test and Bonferroni correction were used for numerical variable analysis. For categorical variables, chi-square tests were performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The AA and BA groups had more training in healthcare, more work in health-related areas and were more likely to be in a stable union when married than the BB group. \u0026nbsp;Children of group AA or BA consumed more cariogenic food than those of BB group. The daily fruit and vegetable availability was greater in the AA group than in the other groups. Compared with those of BB, the snake modeling domain and snack limits of AA and BA were greater. The OHL of BA was greater than that of BB and was more similar to that of AA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e American children of Brazilian parents are closer to the eating habits of American children of American parents than to Brazilian children of Brazilian parents.\u003c/p\u003e","manuscriptTitle":"Child Cariogenic Diet and Parental Oral Health Literacy Level Between American and Brazilian Families","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-20 14:51:16","doi":"10.21203/rs.3.rs-5339307/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ecbf69fd-7b7d-4347-9d1c-5741e3d3cc00","owner":[],"postedDate":"November 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-15T11:23:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-20 14:51:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5339307","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5339307","identity":"rs-5339307","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}