In the present interventional study, 82 primary school students were selected based on multi-stage cluster sampling. After receiving the required clearance for conducting the research and coordination with local authorities, two girl schools and two boy schools were randomly selected from governmental schools. Each grade was considered a cluster and 4 participants were randomly selected from each grade using class rosters. In the next stage, using simple randomization, one boy school was selected as the case school and another school was considered as the control school. The same process was applied to girl schools. The sample size, based on the results of the previous studies, was α=0.01 and β=0.1, and the attrition of 20% was 48 participants in the case group and 48 in the control group (18) . However, 14students did not complete the study. Thus, the data for 82 students including 38 in the case group and 44 in the control group were considered for analysis. 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, which was developed based on the questionnaires designed by Mohammadi Zeidi et al. (19) and Samiee Roudi et al. (20). The content validity Index and ratio of the questionnaires (CVI and CVR) was evaluated by asking a panel of experts including 10 experts in health education, school health, oral and dental health, and dentists. A CVR of above 0.62 was considered as acceptable. Regarding CVI, the experts evaluated each item in terms of relevance, clarity, and simplicity Based on the results, all were considered as acceptable since all values were above 0.79 (21) . 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 (22) .
The questionnaire was designed in six sections. The variables like age, grade, sex, height, weight, etc. were collected in the demographics section. The self-care section included 5 yes-no questions, 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. For example, I clean my mouth and teeth myself (Yes, No, I don't know). The knowledge section contained 10 questions with three-choice answers For example, what is the best way to clean the space between your teeth? (Toothbrush, Dental floss, Mouthwash). 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. For example,I think eating milk is very important for dental health (I totally agree, I agree, It doesn't matter, I disagree, I completely disagree) Behavior was assessed with 8 questions in a 5-point Likert scale with a total score of 32. For example, I wash my mouth after eating sweets and food (Always, Most of the time, Sometimes, Rarely, Never). In adition, fourteen questions were used to assess self-efficacy in a 5-point Likert scale, scoring a total of 70 points. In each of the following situations, how sure are you that you can clean your teeth? ( I'm not at all sure, I'm a little confident, I'm pretty sure, I'm pretty sure, I'm pretty sure). The questionnaires were completed in the form of interviews to explain more details to the students and provide appropriate answers. After coordination with school principals and conducting a pretest, two schools were randomly selected as the cases and received training in 4 45-60-min sessions (Table 1). The schools considered for control received routine school training (Educating by health Instrutor). This study caused no conflicts of interest for any person or organization.
We used the animations related to oral health that are available in Aparat.com.
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 considered as the sources for self-efficacy. Moreover, positive feedback and encouragement of the instructors and parents provide a source of verbal persuasion for children. In this study, the students were taught about nutrition and its effect on oral health.
Written parental informed consent, as well as written child assent, was obtained from all students participating in this study. In addition, the training materials such as the booklets and CD (Animation ) were given to the control group. This study was registered under the ethics code of IR.ARAKMU.REC.1395.446.
Table 1. Educational content and methods of training sessions in the case group of schoolchildren
Session
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Topic
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Training method
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One
Knowledge
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Poviding Primary information about dental and oral health to students : The importance of oral hygiene, the role and use of teeth, tooth structure, number and types of teeth, how tooth decay, factors affecting dental health, ways to prevent tooth decay, how to use toothbrushes , how to use dental floss and mouthwash, time to see a dentist
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Film, photographic slides, educational booklet, question and answer
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Two (Self care)
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Assessing oral and dental health, self-care of students: determining the objectives, setting a timetable, learning necessary skills,
the importance of brushing to remove dental plaque, the definition of plaque and how tooth decay, the frequency of brushing, the duration of brushing, choosing the right toothbrush and toothpaste, how to use floss, useful and harmful foods to teeth in the form of an animation
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Group discussion, lecture, animation
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Three
Behavior:
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Telling students: how to Brushing, use of dental floss and mouthwash, diet, healthy life style, etc
In order to assess the level of performance of students and identify their weaknesses, three students were asked to show how to brush and use dental floss. Then, the correct use of toothbrush was taught on the model. Based on the students' learning, toothbrushes and toothpaste were distributed among the students. To keep the behavior going, students were asked to check each time they brushed their teeth in the behavior chart. In the next step, how to use dental floss was taught, and virtually every student was taught with the distribution of floss.
After the reception, a group game "Saying on the phone" was held to draw the students' attention and remind them of the contents of the previous session. In this way, the set goals of oral care and the desired activities were repeated in the form of sentences and in the form of games. In this way, the students were divided into two groups and placed in two rows. The first person in each group was called a sentence, and this sentence had to be repeated slowly in the next person's ear, respectively, and the last person had to say the sentence completely and correctly to the instructor. Each group did this faster and won the game. In the next step, the use of mouthwash was explained and the mouthwash was practically used and the animation was displayed. Proper use of toothbrushes, floss and mouthwash was shown in 5 minutes with animation.
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Practical education, game, animation
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Four
Self-efficacy
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In addition to educational animation, games were used to practice oral and dental health skills in different situations like tiredness, disease, party, etc.
Skills were learned in a variety of situations including time of fatigue, illness, lack of toothbrushes, and playing and attending a party were performed by the students themselves in a pantomime format so that the activity was performed by one student. And the other students guessed what the situation was and expressed their views on the situation. Also, the student behavior chart was reviewed a week ago, and the importance of behavior behavior was recalled, and students were asked to find ways to recall behavior by conducting group discussions, and at the end of the discussion, repetitive topics were removed and final comments such as "Let's ask Dad and Mom to remind us" or "Put a toothbrush picture on the wall of the room." The animation was then displayed. The animation showed the importance of permanent teeth, the important of six teeth, fluoride therapy and fissure sealant, seeing a dentist and emphasizing the regular use of toothbrushes and toothpaste in 3 minutes. Also, it was handed over to the students to see with the family in order to repeat the lessons at home and the family's access to the educational materials of the CD animation.
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Animation, game, group discussion
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