Indonesian parental knowledge, attitudes, and sources of information regarding pediatric space maintainers: a cross-sectional questionnaire-based study

Ethics approval

This study was conducted following ethical guidelines and was approved by the Universitas Airlangga Faculty of Dental Medicine Health Research Ethical Clearance Commission. The approval reference number is 723/HRECC.FODM/VII/2023, dated July 10, 2023. Participants’ participation was entirely voluntary, and they were free to leave the research at any moment. The respondents gave their consent before the commencement of their responses to the survey to use them in the current study without any personal identification.

Study design

This research employed a descriptive cross-sectional study to evaluate the awareness, attitudes, and information sources among Indonesian parents on the use of space maintainers in paediatric dentistry. The cross-sectional design allowed a snapshot evaluation of parental views, facilitating an assessment of current levels of parental awareness and perception at a point in time.

Study population and sampling

The study population was made up of Indonesian parents and caregivers of children ages 3–12 years, living in urban, semi-urban, and rural areas in Indonesia. Participants were recruited from public and private dental clinics, schools, and social media accounts so that they would be representative of various geographic and socio-economic contexts while also accounting for differences in case management due to factors including culture and accessibility to healthcare services. A stratified positional multi-stage cluster sampling approach was followed so that participants were representative of these contexts. The minimum required sample size was calculated using Cochran’s formula for proportions under the conservative assumption of a population of 1 million, a predicted proportion of 74% from previous studies, an estimated margin of error of 5% and a 95% confidence level. Based on a stratified group, this led to a sample size of 296 that was adjusted to take into consideration the design impact of 1.

Inclusion and exclusion criteria

Section 1: demographic details of parents

In this section, we collected demographic data, such as the participant’s age and gender, as well as information on the parents’ educational backgrounds. Data on family size, including the number of children and their ages, was also acquired. One question revealed information about how frequently parents arranged dental checkups for their children.

Section 2: parental knowledge about space maintainers

This section constituted a pivotal aspect of our questionnaire, focusing on gathering data regarding the number of parents who were aware of paediatric space maintainers. Parents who indicated awareness were subsequently directed to proceed with the survey, allowing us to gather insights into their knowledge of space maintainers. Questions about utilization and various types pf space maintainers were included in the survey. Additionally, parents were enquired whether they thought space maintainers were a common treatment.

Section 3: parental attitudes toward space maintainers

This particular section focused on gathering information about parental attitude towards space maintainers. Participants were asked to rate their comfort level, which ranged from ‘very comfortable’ to ‘very uncomfortable’. They also cited reasons for their comfort and discomfort levels, such as cost, discomfort to children, belief in the dentist, and fear of complications. Also, parents were asked whether they considered alternatives like braces or other treatments instead of space maintainers.

Section 4: sources of information for parents on space maintainers

This section provided input on the sources parents utilize to acquire knowledge about their child’s dental health, such as whether they discussed space maintainers with their dentists or actively sought information from online parenting forums or platforms. One question explored the impact of advice and experiences shared by other parents on their decision-making process.

This cross-sectional study targeted the population of either current parents or prospective parents residing in who were recruited from social media platforms. The questionnaire was designed using Google Forms and widely distributed among parents through social networking sites, primarily WhatsApp, Telegram, and Instagram. Although this method enabled broad and rapid dissemination, there also existed the possibility of selection bias since some parents who are not digitally literate or do not have reliable internet access may have not be adequately represented. This is a particular limitation for lower income and rural populations as they tend to use community channels to gain health knowledge compared to digital channels.

Validation of the questionnaire

A thorough examination of the literature and professional advice from two researchers with experience in survey methodology and two paediatric dentists served as the foundation for the questionnaire’s creation. The knowledge items were adapted from Visanth et al. (2024) and Linjawi et al. (2016) while the attitudinal constructs were adapted from frameworks by Alduraihim et al. (2020) and Ali et al. (2022). The sources of information were guided by Doğan, Polat & Özüdoğru (2025). Furthermore, the demographic items and questions related to culturally specific matters were newly developed to reference the Indonesian context.

Each item was examined by a panel of experts to ensure that it was relevant and in line with the desired constructions in order to establish content validity. In a pilot study, 30 parents rated the questions’ comprehensibility and clarity in order to determine face validity. The appropriate changes were made to improve clarity and reduce ambiguity in response to their input. Factor analysis was used to confirm that the items were logically grouped within the predetermined categories of knowledge, attitudes, and information sources in order to assure construct validity. Questions with factor loadings below 0.4 were either revised or excluded to strengthen the overall validity of the instrument.

Reliability of the questionnaire

Cronbach’s alpha was used to assess the questionnaire’s internal consistency; the result was 0.82, suggesting a high degree of reliability. By giving the questionnaire to 30 participants twice over a two-week period, test-retest reliability was evaluated. The results showed strong stability over time, with an intraclass correlation coefficient (ICC) of 0.89. With a 92% agreement rate between two independent reviewers, inter-rater reliability was also assessed. These metrics attest to the questionnaire’s ability to deliver consistent and trustworthy data for evaluating parents’ attitudes, knowledge, and information sources on space maintainers.

Statistical analysis

The authors entered data into Microsoft Excel and examined it using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). The study relied on descriptive statistics (frequency, percentages, mean, and standard deviation) to summarize participants’ demographic characteristics and responses regarding knowledge, attitudes, and sources of information about space maintainers and used inferential statistics to test for associations and predictors. For categorical variables (e.g., place of residence, education level, prior dental visits), Chi-square (χ²) tests were used to check for relationships with key outcomes (knowledge and attitude levels). For comparing means across continuous or ordinal variables, independent-sample t-tests and one-way analysis of variance (ANOVA) were used when appropriate. Binary logistic regression analyses were performed to test possible predictors of significant parental awareness and attitude towards space maintainers. The authors conducted post hoc interaction analysis (Knowledge × Residence) to test for moderation effects. All models were controlled for relevant covariates (including education, income, and frequency of dental visits). Prior to regression analysis, the authors ran multicollinearity diagnostics. Variance Inflation Factor (VIF) scores for all predictors were under 2.0, and tolerance levels were higher than 0.1, indicating acceptable levels of multicollinearity. To assess the model fit, the authors looked at the Hosmer–Lemeshow goodness-of-fit test. All models had non-significant results indicating acceptable fit to the observed data. A p-value of less than or equal to 0.05 was considered statistically significant.

Demographic profile of respondents

The final sample consisted of 400 Indonesian parents, overwhelmingly distributed in urban locations (n = 240; 60%) over rural ones (n = 160; 40%). The majority of respondents identified as female (73%), in line with current demographic patterns of child health research, which indicates that mothers are still more commonly the primary caregivers and decision-makers, specifically in paediatric health. The age distribution was as follows: <25 years (26.0%), 25 to 34 years (33.0%), 35 to 44 years (18.0%), and 45 to 54 years (23.0%) (Fig. 1). The composition of participants’ families varied, with 33.75% reporting no children, 31.75% having one child, 30.75% having two children, and only 3.75% reporting three or more children. Education had a marked cross-tabular difference by location among respondents (χ² = 35.2, p < 0.001) (Fig. 2). Metropolitan parents tended to have undergraduate degrees or higher, suggesting differing access to education which may have impacted access to health literacy.

Dental visit patterns by residential location

A significant disparity in access to paediatric dental care is evident when comparing urban and rural populations, highlighting a critical public health issue. Specifically, only 21% of urban children have ever received preventative dental care, whereas a mere 2.5% of rural children have had the same experience. This difference is statistically significant (χ² = 38.9, p < 0.001) and is nearly ten times different and indicative of structural inequities in the delivery of oral health services. A further look at the parental reports of the types of visits indicate more blatant differences; medically-motivated visits (i.e., visits related to pain, infection, or visual decay) occurred at a higher rate for rural children (52.5%) than urban children (33.3%) in part because of a primarily reactive and not preventative strategy to oral health for rural visits in conjunction with the sad fact that 27.5% of rural children have never been to the dentist (that’s more than twice as many urban children (13%) (Fig. 3). The result points to a disparity between rural-urban access of preventative dental care for Indonesian children as being a structural inequity in the health care system in Indonesia.

Preventative dental visit disparity

A notable disparity in preventative dental visits was identified between urban and rural children. Specifically, 21% (50 out of 240) of urban children had received a preventative dental visit, in contrast to a mere 2.5% (four out of 160) of rural children. This difference was statistically significant, as demonstrated by a chi-square test (χ² = 26.08, p < 0.001) and Fisher’s exact test (p < 0.001). The association between residential location and the receipt of preventative care was moderate, as indicated by Cramér’s V of 0.255. Urban children were 8.33 times more likely to have received preventative care than their rural counterparts (Relative Risk = 8.33, 95% CI [3.07–22.62]). The odds of receiving preventative care were over tenfold higher in urban settings (Odds Ratio = 10.26). Furthermore, the prevalence confidence intervals—21.0% (95% CI [16.2%–26.4%]) for urban children and 2.5% (95% CI [1.0%–6.3%]) (Fig. 4) for rural children—do not overlap, underscoring the strength and robustness of the observed disparity.

Knowledge assessment

Of the participants, 25% (n = 100/400) indicated that they were aware of space maintainers. There was a statistically significant difference in awareness by location, as urban parents showed a much higher awareness (37.5%; 90/240) compared to rural parents (6.3%; 10/160). χ² = 48.35, p < 0.001. The odds ratio was calculated at 10.26, and the relative risk was 8.33 (95% CI [3.07–22.62]), indicating that urban parents were over eight times more likely to be aware than their rural counterparts (Fig. 5A).

Of those who were aware, 65% correctly identified the functional aspect of space maintainers; that is, it mainly preserves space in regards to teeth that erupt permanently and that it does not promote malocclusion. However, it was clear that the quality of knowledge was inconsistent, as 46.4% of the rural parents who were aware offered vague or incorrect descriptions, suggesting a gap in functional understanding. Furthermore, there were notable deficits in device-specific knowledge: 38.2% of aware urban parents could name appliances such as the band and loop, compared to only 9.3% of rural aware parents; 58% of the latter could not name any device (Fig. 5B). Parents’ level of comfort with space maintainers was significantly impacted by their level of awareness. Parents who were aware of space maintainers reported a higher level of comfort (M = 4.21, SD = 0.91) than parents who were unaware of space maintainers (M = 3.76, SD = 1.12) and this difference in comfort level was statistically significant (t(283) = 3.26, p = 0.0013). The distribution of comfort scores based on awareness was shown in Fig. 5C, which consistently demonstrated a positive relation between knowledge and comfort.

Attitude assessment

Parental attitudes toward space maintainers exhibited significant variation based on geographic location. Among urban parents, 91.3% demonstrated positive attitudes, in contrast to 53.8% of rural parents. Rural respondents were more frequently neutral (42.5%), with only a small minority (3.7%) expressing negative attitudes. In contrast, only 7.9% of urban parents expressed neutrality, and less than 1% expressed a negative attitude (Fig. 6A). This difference was statistically significant (χ² = 74.58, p < 0.001). Being aware of space maintainers also showed to be an important predictor of positive attitude: while 88% of parents who were aware expressed a positive attitude toward space maintainers, only 72.3% parents who were not aware expressed a positive attitude. Urban parents among the aware parents were very favourable (92.2%), while aware parents residing in rural regions were less favourable (50%). Likewise, the association between awareness and attitude was statistically significant (χ² = 10.88, p = 0.0043). Figure 6B presents a detailed cross-tabulation of awareness and attitude responses showing that the unaware group had a higher rate of neutral and negative responses. These findings provide insight into the importance of front-end education and awareness of preventive dental treatment to develop positively enhanced attitudes.

Interaction between knowledge and residence

A logistic regression analysis was performed to examine the interaction effect between knowledge (awareness) and residential area on parents’ positive attitudes. The results indicated that urban residence significantly predicted a higher likelihood of a positive attitude (adjusted odds ratio (AOR) ≈ 8.27, p < 0.001). However, neither knowledge alone nor its interaction with residence was statistically significant (p = 0.806 and p = 0.658, respectively) (Table 1). These findings suggest that geographic location exerted a stronger influence than awareness alone, and that awareness did not significantly moderate the effect of residence on attitude within this model.

Information sources

The primary source of information for urban parents was the dentist, as reported by 68.75% of respondents. In contrast, only 41.88% of rural parents identified dentists as their source of information, a difference that is statistically significant (χ² = 27.37, p < 0.001). Importantly, 25% of rural parents identified community sources as the source in which they heard about space maintainers, whereas no urban parents did (χ² = 63.92, p < 0.001). Plus, 26.25% of rural respondents and 29.17% of urban respondents identified the internet or social media as potential sources (Table 2). These findings highlighted differences in sources of information, such that rural parents tended to rely on community-based sources, whereas urban parents primarily relied on the professional healthcare system (dentists).

Associations and predictive analysis

Multivariate logistic regression analysis yielded urban residence as the sole significant predictor of awareness of space maintainers (AOR = 8.92; 95% CI [4.31–18.45]; p < 0.001). Higher education (AOR = 0.96; p = 0.897) and prior dental visits (AOR = 1.19; p = 0.632) did not reach statistical significance (Fig. 7). As a result, residential location is the best predictor for parental awareness, and urban parents are approximately nine times more likely to be aware than rural parents.

Model diagnostics and assumptions

Prior to the multivariate logistic regression, we assessed for multicollinearity among the predictors by using Variance Inflation Factor (VIF). All the VIFs were less than 2.0 indicating that multicollinearity is not a problem, and all tolerance statistics were above the suggested cutoff value of 0.1 indicating acceptable levels of independence between all predictors.

The fit of each model was assessed using the Hosmer–Lemeshow goodness-of-fit test. The model quantifying predictors of awareness of space maintainers was not significant (χ² = 5.21, df = 8, p = 0.736) and indicated a good fit to the observed data. The attitude model produced similar findings (χ² = 6.84, df = 8, p = 0.552) which suggest that both logistic models successfully captured the observed or latent patterns in these underlying data.