ORIGINAL ARTICLE
Impact of Education on Interdental Cleaning Behaviour Based on the Transtheoretical Model Masomeh Hashemiana/Arezoo Fallahib/Golaleh Tavakolic/Yadolah Zarezadehd/ B. Nemat Shahr Babakie/Zohreh Rahaeif Purpose: To determine the impact of education on stages of change of behaviour in Iranian senior high school students for interdental cleaning based on the transtheoretical model. Materials and Methods: This experimental study took place from April to November 2010. 306 students were selected by multistage cluster sampling and placed into two groups: control (153 students) and intervention (153 students). Appropriate instruments and the intervention programme were designed with the purpose of improving stages of interdental cleaning behaviour, perceived benefits and self-efficacy, as well as reducing perceived barriers and gingival index (GI). The impact of the intervention programme was assessed after 24 weeks and the GI of each student was recorded for both groups before and after intervention. The data were analysed using SPSS software and the chi-square, t test, ANOVA, paired t test, Mann-Whitney U-test and sign test. Results: The intervention had a significant, positive impact on improvement of the stages of interdental cleaning behaviour, increase in self-efficacy, perceived benefits, decrease in perceived barriers and improvement of GI (P < 0.001). After the intervention, the average grades of self-efficacy, perceived barriers and perceived benefits in the control group vs the intervention group were significantly different (P < 0.001 to 0.01). Conclusion: The programme was found to positively influence the stages of change and potential indicators of interdental cleaning behaviour and GI. It is suggested that this model be used for interventions in the other population groups. Key words: gingival index, oral and dental self-care behaviour, transtheoretical model Oral Health Prev Dent 2012; 10: 37-46
O
ral and dental health plays an important role in general health, and its absence adversely
a
Faculty Member, Department of Public Health, Sabzevar University of Medical Science, Sabzevar, Iran. PhD Student in Health Education, School of Medicine, Tarbiat Modares University, Tehran, Iran.
b
Instructor, Department of Public Health, School of Health, Kurdistan University of Medical Sciences, Sanandaj Iran; PhD Student in Health Education, School of Medicine, Tarbiat Modares University, Tehran, Iran.
c
Visiting Assistant Professor, Health Services Management, School of Environmental and Health Sciences, Canadian University of Dubai, UAE.
d
Associate Professor, Medical Sciences Education Development Centre, Kurdistan University of Medical Sciences, Sanandaj, Iran.
e
MS Student in Health Services Management, Azad University, Tehran, Iran; Public Health Expert, Giroft University of Medical Sciences, Giroft, Iran.
f
PhD Student in Health Education, School of Medicine, Tarbiat Modares University, Tehran, Iran.
Correspondence: Arezoo Fallahi, Department of Public Health, School of Health, Kurdistan University of Medical Sciences, Sanandaj, Kurdistan, Iran, Postal code 6617713391. Mobile phone:+98-918-373-7591, Fax: +98-871-662-5131. Email:
[email protected]
Vol 10, No 1, 2012
Submitted for publication: 24.01.11; accepted for publication: 07.05.11
affects the quality of life. Mouth infections, toothaches and loss of teeth can affect the person’s welfare, mind, body, food chewing process, talking and public relations. Therefore, like any other disease, it needs treatment (Canadian Dental Association, 2010). Research has shown that oral and dental diseases are related to other diseases, such as diabetes, cardiac disorders, premature birth and low birthweight. Healthcare behaviours such as regular checkups, tooth- and tongue-brushing twice a day and daily use of cleaning instruments (dental floss and toothpicks) for interdental cleaning will help reduce oral and dental diseases (American Dental Association, 2010). These instruments remove dental plaque and bacteria which are not accessible and removable by toothbrushes. When these instruments are not used, one third of the interdental surfaces will remain uncleaned and plaque – which is the main cause of gum disease – will be formed (Canadian Dental Association, 2010). The dental
37
Hashemian et al
plaque hardens into a mass which is removable only by interdental cleaning (Philippot et al, 2005; Hugoson and Norderyd, 2008). According to the report by the Center for Preventing Chronic Diseases, dental caries in 6- to 11-year-old children is 25%, in 12- to 19-year-olds 59% and in 14- to 18-year-olds it is four times more common than asthma (59% compared to 15%). 28% of persons in the age range of 35 to 44 years and 18% of 65-year-olds do not seek any treatment for their decayed teeth (Preventing Chronic Diseases, 2009). In spite of obvious advantages of toothbrushing and regular flossing, the prevalence of this behaviour is low (Philippot et al, 2005; Hugoson and Norderyd, 2008) and many people believe that missing teeth is something natural (Petersen, 2003; Astrøm, 2004). The results of a study in the Islamic Republic of Iran showed the DMFT index (permanent decayed, missing and filled teeth) for 12-year-olds is 2.46 (Pakshir, 2004) and for 15- and16-year-olds, it was 2.66 and 2.77, resp (Hamissi et al, 2008). Other authors stated that only 0.05% of 6- to 12-year-old Iranian students used dental floss (Ghandehari Motlagh et al, 2007), but 37.5% of high school girls did so (Mazloomi Mahmoodabad and Roohani Tanekaboni, 2009). It is believed that recognition of factors such as perceived benefits and barriers in using dental floss and toothpicks can be helpful in determining some of the indicators for the use of these instruments (Tillis et al, 2003). In behavioural science studies, it is important to recognise the health behaviour indicators in the framework of models and theories of recognition and change of behaviour. Positive attitudes about self-care behaviour will result in an increase of such behaviour, and putting such beliefs into action will facilitate promotion of self-care behaviour. One of the most effective models for determining healthrelated behaviours in social psychology is the transtheoretical model, which is applied by many researchers as an efficient model for increasing preventive health behaviour. The psychological principals of this model can supplement the logical understanding of behaviour and its strengths and weaknesses (Prochaska et al, 1997). This model comprises four structures: stages of change, decisional balance, self-efficacy and processes of change, and is used as a successful framework for studying behavioural changes, including oral and dental self-care behaviour (Tillis et al, 2003), and also regular dental checkups for teenagers based on decisional balance and stages of change (Coulson and Buchanan, 2002).
38
Self-efficacy is a personal assessment or internal belief in one’s own capabilities. It is important because it anticipates the changes resulting from the interventional methods – here, interdental cleaning – and is the best strategy for encouraging persons in following their oral and dental self-care behaviour (Buglar et al, 2009). Decisional balance reflects the interdental cleaning behaviour and the person’s assessment of the benefits and barriers to behavioural change; as behavioural change progresses from stage to stage, the benefits increase and barriers decrease. The person will not change his/her behaviour unless the benefits are greater than the barriers (Prochaska, 1994; Herrick et al, 1997). The stages of change show that when the person decides to change his/her behaviour, he/ she will move through the following five stages: 1) Pre-contemplation: the person does not intend to change his/her behaviour; 2) Contemplation: the person intends to change his/her behaviour in the next six months; 3) Preparation: the person has the intention to implement the healthcare practice within one month; 4) Action: in this stage, the person has practiced the interdental cleaning behaviour for less than six months. 5) Maintenance: in this stage, the person has been practicing the interdental cleaning behaviour regularly for more than six months (Tillis et al, 2003). Several authors who applied the transtheoretical model for determining indicators of oral and dental self-care behaviour have found it to be successful (Hollister and Anema, 2004; Kasila et al, 2006) and suitable for oral and dental self-care behaviours (Tillis et al, 2003; Morowatisharifabad et al, 2011). However, research on oral and dental health self-care behaviour in Iran has been limited (Mazloomi Mahmoodabad and Roohani Tanekaboni, 2009); hence, many unanswered questions remain. Bearing in mind the importance of healthcare promotion programs (Coulson and Buchanan, 2002), the effectiveness of use of interdental cleaning instruments to reduce periodontal disease and caries (Egelberg and Claffey, 1998), the high prevalence of caries (Pakshir, 2004), the lack of application of suitable models for interdental cleaning (Birang et al, 2005) and the applicability of the TTM in this context, the present study was done to determine the impact of education on stages of change of behaviour for interdental cleaning and its relation to self-efficacy, perceived benefits and barriers and the gingival index (GI) in senior high school students in the city of Sanandaj, Iran.
Oral Health & Preventive Dentistry
Hashemian et al Table 1 Determination of stages of change of interdental cleaning behavior based on the students’ answers to the stages of change questions prior to intervention Questions
1. How frequently do you clean between your teeth?
2. How long have you been cleaning between your teeth at your current frequency?
5 Maintenance
3 or more times/week
6 months or more
4 Action
3 or more times/week
