At the social assessment stage, the impact of oral and dental health on the quality of life in children and their families was assessed in different aspects based on the study of 13 theses, 26 Persian articles, 54 English articles, 12 books, other scientific resources, and a group discussion with 9 stakeholders (mothers with children aged 6-12 and dentists). It was found out that poor oral and dental health affects people's physical, mental, social, and economic quality of life [Table 2]. In the epidemiological, behavioral, and environmental assessment (phase 2), the major index related to the quality of life, in terms of oral and dental health, was the number of decayed, missing (extracted), and filled teeth (DMFT), and the most important of which was dental caries. Next, behavioral and non-behavioral factors were identified [Table 3] based on the review of 9 theses, 36 Persian articles, 39 English articles, 8 books, other scientific resources, such as the World Health Organization, and a group discussion with 9 stakeholders (mothers with children aged 6-12 and dentists). In addition, the major influential behavioral factor was determined to be brushing behavior based on the opinions of a 14 health education professionals and dentists on the basis of decision-making matrix, with two criteria of importance and variability.
In phase three (educational and ecological assessment), predisposing, enabling, and reinforcing factors associated with brushing behavior were identified based on the study of 7 theses, 26 Persian articles, 21 English articles, books, scientific sites and documentations, and a group discussion with 9 stakeholders (mothers with children aged 6-12 and dentists). Next, a qualitative study was designed aimed at better explaining the data, and semi-structured interviews were conducted with 39 stakeholders, including dentists, health education and promotion specialists, parents, teachers, and school health educators. Accordingly, the major factors affecting tooth-brushing behavior were identified, and after adjusting them to the findings of the first part of this phase, the major predisposing, enabling, and reinforcing factors associated with brushing behavior were identified.
After adjusting the findings of the qualitative section to those of the quantitative one, the research tool was formulated, face and content validity was assessed by 10 experts, and reliability was assessed by a test-retest estimate in 57 persons at a 14-day interval, and the final tool was designed [Table 1].
In the fourth phase, a session was held at the office of the head of Rafsanjan Administration of Education, and the program was explained to the principals of the selected schools. Then, a coordination session was held separately at each school, all resources and facilities were reviewed, and pre-test was done. The results of the pre-test were analyzed, an intervention program was formulated, a coordination session with school administrators was re-arranged, and the method of implementing the intervention program was explained.
An intervention program was run based on the findings from previous steps among students (6 training sessions and one session for brushing) aimed at promoting students' knowledge, attitude, and practice in terms of brushing. The program included lectures, questions and answers, the explaining of related experiences, practical demonstration, and role playing in learning areas and educational goals, the use of educational media, such as short videos, posters, and educational folders. Three sessions for parents and two sessions for teachers and school health educators were held aimed at enhancing their collaboration and gaining their support for sustaining students’ behavior. Then, impact assessments were carried out, based on the designed method, among the students three months after the intervention. In addition, leaflets, CDs, educational folders, toothbrushes, and toothpastes were distributed among the students as gifts.
In the brushing session, according to the correct brushing method at the last session using practical demonstration, the role-playing method, and the use of moulage, the school water supply was used, and brushing was performed in groups of 5 to 7 individuals, with the brushing behavior of each student evaluated and necessary trainings provided. The purpose of this session was to remove some barriers, such as embarrassment and low self-efficacy in some students. In this session, the school's health educator brushed with the students, thereby encouraging them to grow enthusiasm.
In the beginning of the study (phase 1) until the completion of the intervention program (the implementation phase), all activities were planned in the Gantt chart. This program was scheduled for a 12-month period, and process evaluation was carried out and reported for each activity. To do so, activities carried out at each stage were reviewed by the type of activity, its scheduling, and its implementation method, with necessary corrections made. The important point in the evaluation was the increase in the time assigned to the interviews, which were planned over two months, but they took three months due to the sampling problems. In the end, it took 12 months for this study to complete the intervention and 3 months to evaluate the effect.
According to the impact assessment results, the mean age of the intervention group and that of the control group was 10.77±1.01 and 10.98±0.88, respectively. About 49% and 47% of the students in the intervention and control groups were girls, respectively. The results of the independent t-test and the chi-square test showed no significant difference in the variables of age, gender, parental education, parental occupation, family income, as well as oral and dental health status between the two groups (P>0.05). After implementing the intervention program, a significant difference was observed (P <0.001) in the mean score and standard deviation of knowledge, attitude, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, perceived behavioral control, subjective norms, motivation to comply, observational learning, brushing skills, social support and reinforcement, as well as the behavioral intention of brushing in the intervention group members. In addition, the results indicated the impact of the intervention program on all predisposing, enabling, and reinforcing factors as well as proper brushing behavior [Tables 4 and 5].
In this study, due to the time constraints of the thesis, changes made to oral and dental health indices, such as DMFT, as well as the related outcomes were not evaluated. In addition, according to the experts in the qualitative research, behavioral preferences of children, such as brushing outside the toilet, having a colorful and attractive toothbrush, being able to choose toothbrushes and toothpastes, and brushing with parents must be taken into consideration.