DOI: https://doi.org/10.21203/rs.3.rs-21071/v1
Background: In order to prevent oral diseases, the use of appropriate educational methods at childhood is one of the most important determinants of the public health. Therefore, the aim of this study was to investigate the effect of training through animations and games on oral health self-efficacy and self-care behaviors in students aged 6-12 years old.
Methods: In this interventional study, 82 students were selected using cluster random sampling (38 subjects in the case group and 44 in the control group). The case group received 4 sessions of blended learning per week including animations and games while the control group received routine school education. Data were collected in six domains, including demographics, self-care, knowledge, attitude, behavior and self-efficacy before and 5 months after the intervention using a questionnaire. SPSS version 20 was used for data analysis.
Results: Five months after the intervention, the mean score of self-care increased from 3.8 to 4.8 of 5, the mean score of self-efficacy increased from 36.8 to 48.9 of 70, and the mean score of behavior increased from 17.07 to 18.29 of 32, indicating significant changes (p < 0.05). There were no significant changes in these variables in the control group (p >0.05)
Conclusion: Use of combined methods for oral health self-care education has positive effects on the students' performance and self-efficacy.
IRCT registration number: This trial has been registered at IRCT. IRCT2017042133565N1
Registration date: 2017-05-17 https://en.irct.ir/trial/25851
Despite major advances in oral and dental health in many countries, oral and dental health problems are still a global challenge with a larger magnitude in populations with a weak socioeconomic status (1). Early loss of teeth, in addition to undesirable effects on facial aesthetics and pronunciation, may result in inadequate growth and nutritional problems due to chewing difficulties. Moreover, untreated oral and dental infections can cause valvular heart disease, digestive problems, and rheumatic heart disease (2).
According to a national survey in 2015, the dmft index of 6-year-old children was 5.84 in a national level(1) DMFT was also determined (5.4 ± 2.83) in Arak city (2)the DMFT index of children aged 12 years was 2.09 in a national level(3). This is while the WHO emphasized that the DMFT index of 12-year-old children should be less than 1 and 90% of the 6-year-old children should have completely healthy teeth by 2010 (3).
Due to the high prevalence of caries and the importance of permanent growth of teeth in children aged 6 to 12 years, this group is a priority in terms of oral health programs. Any change or improvement in the behavior of this group can have long-term and significant effects on their future.Some researchers believe that raising awareness in this age group is the only way to improve oral health in society(4). To prevent oral and dental diseases, implementation of health interventions at schools, due to their roles in structuring and forming habits, beliefs, and insight in students, may have significant long-standing effects on the health behaviors of future generations(5); moreover, it is an effective and efficient method for communicating health messages to the students’ families and the society to promote a healthy lifestyle(6). The use of conventional health education methods in a traditional way may cause anxiety in children; therefore, providing a happy and child-friendly environment usually facilitates achieving this objective(7). Compared to traditional methods in which texts and static graphics are used for training, the students are exposed to dynamic images and motion pictures in the animation method, which gives a new meaning and concept to literacy and education(8). Games, as a means of entertainment, can also be used for education. During games, the children achieve valuable experiences and learn new things willingly without pressure(9) .
It has been recommended that health experts emphasize self-efficacy as the most important predictor of oral and dental health behaviors ((10),(11). Self-efficacy refers to a person’s belief that they can do successfully the behavior necessary to produce the desired outcomes. It is the belief in her or his ability to do and succeed in a particular task. Efficacy ,
In turn, it has four sources: mastery experiences, observing learning, verbal persuasion, and Physiological and emotional states during behavioral opportunities .Thus, in the theory of self-efficacy, there are both sources of self-efficacy and mechanisms through it It has been shown to affect behavior and can be used for behavioral design (12)
Studies have shown that Motivating Factors are not merely enough for behavior change and it has been suggested to use self-regulating strategies like Planning as a complement for educational programs(1). In self-care programs, the person is supposed to know his/her own unfavorable condition, set objectives and make plans to reach the favorable condition, become committed to execute the plan, be aware of the consequences of executing the self-care program, and learn the required skills for behavior change. In this study, a combination of training methods was used to promote Knowledge, motivation, and self-efficacy and behavior of the students and a self-care program was used as a complement for ensuring order and stability in the behavior. The aim of this study was to use a combined training package for promoting oral and dental health in students, apply a self-care program to ensure the continuity of oral and dental health behaviors, and to teach oral and dental self-care skills in a practical manner.
This interventional study was conducted in 82 primary school students .Multi-stage cluster sampling was applied to select the participants. After receiving the required clearance for conducting the research and coordination with local authorities, two girls’ schools and two boys’ schools were randomly selected from governmental schools. Each grade was considered a cluster and 4 subjects were randomly selected from each grade using class rosters. In the next stage, using simple randomization, one boys’ school was selected as the case school and the other school was considered as the control school. The same process was applied to girls’ schools. The sample size, with regards to previous studies, α = 0.01, β = 0.1, and attrition of 20% was 48 subjects in the case group and 48 participants in the control group(13) .
Fourteen students did not complete the study; therefore, the data of 82 students, 38 in the case group and 44 in the control group, were analyzed. The inclusion criteria were willingness to participate in the study, having the consent form signed by parents, and studying in the primary schools of X city. The exclusion criteria were withdrawal from the study, missing more than one educational session, and immigration from X city.
The data collection tool was a researcher-made questionnaire containing questions on self-care, knowledge, attitude, behavior, and self-efficacy that was developed using the questionnaires applied by Mohammadi Zeidi et al (14)and Samiee Roudi et al(15). To determine the content validity of the questionnaire (CVI and CVR), a panel of experts including 10 experts in health education, school health, oral and dental health, and dentists evaluated its validity qualitatively and qualitatively. A CVR of above 0.62 was considered acceptable. For CVI, the experts evaluated each item in terms of relevance, clarity, and simplicity, and since all values were above 0.79, they were considered acceptable(16). The reliability of the questionnaire was measured through the Cronbach’s alpha coefficient in 30 students aged 6–12 years whose demographic characteristics were similar to those of the study population using the Stata 14 software(17) .
The questionnaire was designed in six sections. The variables like age, grade, sex, height, weight, etc. were collected in the demographics section. Private and personal questions were avoided in this part. The self-care section contained 5 questions with “yes”, “no”, and “I don’t know” as answers. Each correct answer received a score of 1 and a score of 0 was given to wrong and “I don’t know” answers. The total score of this section was 5. The knowledge section contained 10 questions with three-choice answers. A score of 1 was given to correct answers, totaling a score of 10. The attitude section had 13 questions in a 5-point Likert scale from 1 to 5 with a total score of 65. Behavior was assessed with 8 questions in a 5-poinyt Likert scale from 0 to 4 with a total score of 32. Fourteen questions were used to assess self-efficacy in a 5-point Likert scale from 1 to 5, scoring a total of 70 points. After coordination with schools principals and conducting a pretest, two schools were randomly selected as cases and received training in 4 sessions of 45–60 minutes according to Table 1. The control schools received routine school training. This study caused no conflicts of interest for any persons or organizations.
In this study, watching animations was used as a substitute for traditional training techniques. Exercising and recalling the learned material during games in a simple and child-friendly atmosphere causes an emotional arousal in children. Children’s involvement in practical education of oral and dental health behaviors, their success in correct performance, and regular display of the behavior based on a plan can be source of self-efficacy. Moreover, positive feedback and encouragement of the instructors and parents provide a Source of verbal persuasion for children
| Session | Topic | Training method |
|---|---|---|
| One | Primary information about dental and oral health and attitude | Film, photographic slides, educational booklet, question and answer |
| Two | Self-care: assessing oral and dental health, determining the objectives, setting a timetable, learning necessary skills | Group discussion, lecture, animation |
| Three | Behavior: Brushing technique, use of dental floss and mouthwash, etc. | Practical education, game, animation |
| Four | Self-efficacy: in addition to educational animation, games were used to practice oral and dental health skills in different situations like tiredness, disease, party, etc. | Animation, game, group discussion |
Pre and post-intervention data were collected using a questionnaire and entered into SPSS version 20. The Kolmogorov-Smirnov test was applied to check normal data distribution and proper statistics were used accordingly. Chi square test, paired and independent t test, Mann-Whitney U test, and Wilcoxon signed-rank test were used for statistical analysis.
The results showed that the variables of sex, father’s education, mother’s education, and number of family members had a similar distribution between the two groups (Table 2). The mean age of the subjects was 9.6 ± 1.9 years in the control group and 9.4 ± 1.8 years in the case group (Table 3). After the intervention in the case group, the mean scores of self-care, knowledge, attitude, behavior, and self-efficacy increased from 3.8 ± 0.96 to 4.8 ± 0.3, 6.7 ± 2.5 to 9.4 ± 0.9, 55.1 ± 12.5 to 61.5 ± 4.8, 17.07 ± 5.61 to 21.21 ± 5.07, and 36.8 ± 11.6 to 48.9 ± 10.8 respectively, which were all significant.
| Group Variable | Case | Control | p-v | |||
| Number | Percentage | Number | Percentage | |||
| Father’s education | Primary school and Junior high school | 7 | 18/4 | 9 | 20/5 | 0/965 |
| High school diploma and associate degree | 19 | 50/00 | 22 | 50/00 | ||
| Bachelor’s degree and higher | 12 | 31/6 | 13 | 19/5 | ||
| Mother’s education | Primary school and Junior high school | 6 | 15/8 | 11 | 23/3 | 0/458 |
| High school diploma and associate degree | 22 | 57/9 | 26 | 60/5 | ||
| Bachelor’s degree and higher | 10 | 26/3 | 7 | 16/3 | ||
| Birth Rank | First | 15 | 39/5 | 26 | 59/1 | 0/207 |
| Second | 15 | 39/5 | 12 | 17/3 | ||
| Third or higher | 8 | 21/05 | 6 | 13/6 | ||
| Sex | Girl | 22 | 57/9 | 20 | 45/5 | 0/184 |
| Boy | 16 | 42/1 | 24 | 54/5 | ||
| group | Number | Percentage | Standard deviation | p-v** | |
|---|---|---|---|---|---|
| Number of family members | Control | 44 | 3/93 | 0/9 | 0/533 |
| Case | 38 | 4/05 | 0/8 | ||
| Age | Control | 44 | 9/64 | 1/9 | 0/424 |
| Case | 38 | 9/39 | 1/8 |
| Variable | Time group | Before intervention | Five months after intervention | p-value Wilcoxon | ||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | |||
| Self-care | Case | 3/8 | 0/96 | 4/8 | 0/3 | < 0/001 |
| Control | 4/2 | 1/1 | 4/2 | 0/89 | 0/527 | |
| p-value Mann Whitney | 0/057 | 0/002 | ||||
| Knowledge | Case | 6/7 | 2/5 | 9/4 | 0/9 | 0/001 |
| Control | 6/2 | 2/3 | 6/7 | 2/1 | 0/004 | |
| p-value Mann Whitney | 0/253 | < 0/001 | ||||
| Attitude | Case | 55/1 | 12/5 | 61/5 | 4/8 | < 0/001 |
| Control | 54/02 | 14/7 | 55/06 | 11/4 | 0/897 | |
| p-value Mann Whitney | 0/627 | < 0/001 | ||||
| p-value paired t- test | ||||||
| Behavior | Case | 17/07 | 5/61 | 21/21 | 5/07 | < 0/001 |
| Control | 18/2 | 5/87 | 17/97 | 5/55 | 0/142 | |
| p-value t- test | 0/343 | 0/008 | ||||
| Self-efficacy | Case | 36/8 | 11/6 | 48/9 | 10/8 | < 0/001 |
| Control | 42/11 | 15 | 41/93 | 14/9 | 0/543 | |
| p-value t- test | 0/089 | 0/019 | ||||
The results of this study showed a significant increase in the mean score of self-care in the case group after the educational intervention compared to baseline, indicating the positive effect of Planning on improving self-care. The results of a study by Mohammad-Zeidi et al (14) on the effectiveness of an educational intervention based on the stages-of-change model in improving oral health self-care behaviors of 160 male and female elementary students of Qazvin were consistent with our findings. Moreover, Mohammadi Zeidi et al. (18)studied the effectiveness of motivational interviewing of oral self-care behaviors among high school students ion Qazvin and found a significant change in the mean score of behavioral intention in the case group after the intervention.
Health education is a widely accepted and practiced approach to prevention of oral and dental diseases and is process that transfers the knowledge and skills required for quality of life improvement(19). In this study, the variable of knowledge increased significantly after the intervention in the case group, which was consistent with the results of studies by conducted Goudarzi (20)and Samiee Roudi(15). The mean score of knowledge increased after the intervention in the control group although this difference was smaller compared to the case group. The reason for this difference could be the routine education provided by school health instructors according to the educational curriculum. Mamata Hebbal (21)found a significant change in knowledge in the control group after the intervention and attributed it to the Hawthorne effect.
There was a significant change in the score of knowledge between the case and control groups after the educational intervention, which could indicate the greater effect of educational interventions delivered through animation and game. Moreover, studies have shown that having knowledge about a particular subject affects the person’s behavior in that regard(22) .
To have a healthy lifestyle, early training of children forms their attitude and promotes healthy behaviors in them(23). This study assessed the students’ attitude, i.e. their positive or negative thoughts about oral health behaviors. One of the assumptions of this study was a significant change in the mean score of attitude in the case group after the intervention, which was confirmed by the results. The results of studies by Goudarzi et al (20)and Mohd Zulkarnain Sinor et al (24)were in line with our findings in this regard.
The learner’s practical engagement in the subject and Interact too help the learner to recall 60% of the learned behavior(12). In this study, after educational intervention using a combination of games and animation and conducting the self-care program, the mean score of behavior increased significantly compared to baseline in the intervention group, which was consistent with the results of studies by Mohamadkhah et al in Chabahar elementary students(18), Neha Singh et al(25), and Goudarzi et al (20)that reported significant changes in the score of behavior after the intervention.
Bandora considers self-efficacy as an essential factor in behavior change that improves through mastery over the behavior. Therefore, self-efficacy improves following active and successful participation in a behavior(12). In this study, the mean score of self-efficacy increased significantly in the case group after the intervention that was in line with the study conducted by Mohammad-Zeidi et al(18).
Due to the very high cost of making the animation, it was not possible for the researcher to prepare the animation, and the available and available animations that were in accordance with the needs of the study group were used for educational intervention.
Considering the results of this study, use of combined training and age-appropriate methods, including animation and game that were used to promote self-efficacy in this study, in addition to improving the students’ knowledge and changing their attitude towards the importance of oral health, has important effects on improving the oral health behaviors and self-efficacy in students. The school environment, with its unique time and place structure, has a great potential for educational interventions .
It should be noted that this study had some limitations; for example, conducting the educational intervention in all 6 primary grades, in addition to difficulties in coordination for participation of all students, interfered with their routine classes, especially in grades five and six, due to an overcrowded curriculum. Due to high costs, it was not possible for the researcher to produce an animation and the available animations were used. It is suggested that qualitative studies be conducted to evaluate oral health behaviors of students.
Decayed, Missing, and Filled Teeth
Content Validity Ratio
Content validity Index
World health organization
Ethics approval and consent to participate:
Ethical approval received from Arak University of Medical Sciences (ethical code: IR.ARAKMU.REC.1395.446). This study was also registered in the Iranian Registry of Clinical Trials (IRCT2017042133565N1). Informed consent was obtained in writing from all participants in this study.
Consent for publih: The manuscript does not contain any individual personal data in any form.
Availability of data and material: The datasets used and/or analyzed during the current study are available upon reasonable request from the corresponding author.
Competing interests: The authors declare that they have no competing interests.
Funding: the vice chancellor for Research in the University for supported this project.
Authors' contributions: H z and K M and SH M and M R designed the study. H z performed the intervention. M R analyzed the data. H z and K M and SH M and M R wrote the paper with input.All authors read and approved the manuscript.
Acknowledgement
The authors would like to thank the authorities of the Department of Education in Markazi Province and XCounty as well as the teachers, parents, and students who participated in this study for their sincere cooperation.
This study adheres to Consort guidelines. See attached checklist.