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ORIGINAL ARTICLE Comparison of Methods in Oral Health Education from the Perspective of Adolescents Cléa Adas Saliba Ga...

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Comparison of Methods in Oral Health Education from the Perspective of Adolescents Cléa Adas Saliba Garbina/Ana Paula Dossi de Guimarães e Queirozb/Artênio José Ísper Garbinc/Suzely Adas Saliba Moimazd/Gabriella Barreto Soarese Purpose: To investigate whether teenagers’ knowledge about oral health is influenced by educational methods and to verify the most effective method according to their perception. Methods: The study was performed in Araçatuba, São Paulo State, Brazil, with 127 teenagers from a vocational school. It was realised in 3 steps: 1. An evaluation of knowledge about oral health using a self-applied questionnaire. 2. An application of educational methods, where the students were divided into two groups (A and B). Group A participated in three educational activities that involved lectures, individual demonstration, and participatory activity. Group B was divided into three subgroups (B1, B2, B3) and each of them participated in only one of the methods. 3. The acquired knowledge was evaluated. Group A created a focus group to give their opinion about strategies. Results: With regards to knowledge after the application of the different methods in all groups, there was a statistically significant difference concerning periodontitis, gingivitis and herpes. In group A, after the three activities, and in group B2 after the individual demonstration, an association was found between ‘healthy teeth’ and ‘general health’ (P = 0.004 and P = 0.022, respectively). After the individual demonstration, an association was shown between variables of acquired knowledge about ‘harmful diet’ and ‘dental caries’ (P = 0.002) as well as ‘good diet’ and ‘prevention of oral diseases’ (P = 0.032). The favourite method was individual demonstration, due to the contact with educational materials, followed by participatory activity because it encouraged learning in a more dynamic way. Conclusion: Educational methods influenced knowledge about oral health, with individual demonstration proving to be the most effective method for acquiring knowledge. In the adolescents’ view, the participatory activity was the preferred method. Oral Health Prev Dent 2013; 11: 39-47


he different strategies of health education constitute an essential tool in promotion and prevention, because they encourage and motivate individuals to take responsibility for their own health. a

Coordinator of Postgraduate Programme in Preventive and Social Dentistry, Araçatuba Dental School, Paulista State University, São Paulo, Brazil.


Assistant Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Paulista State University, São Paulo, Brazil.


Associate Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Paulista State University, São Paulo, Brazil.


Full Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School Paulista State University, São Paulo, Brazil.


Master’s Student, Preventive and Social Dentistry, Araçatuba Dental School Paulista State University, São Paulo, Brazil.

Correspondence: Gabriella Barreto Soares, 1193 José Bonifácio Street, Vila Mendonça, Araçatuba, São Paulo, Brazil. Tel: +55-18-36363249/ +55-18-8120-3999. Email: [email protected]

Vol 11, No 1, 2013

Submitted for publication: 12.04.12; accepted for publication: 16.05.12

‘To educate’ means to improve the level of an individual’s learning and the ability to change; this development should be based on the knowledge of reality and the thought processes of each subject (Aranha, 1998; Campos and Zuanon, 2004). When approaching the topic of health education, it should be borne in mind that the more health knowledge the population acquires, the healthier it becomes. Thus, two aspects of the educational process should be considered: the perception and the motivation of the person receiving the education. The association of these aspects encourages the change of individuals’ behaviour and makes them responsible for their own health (Bastos et al, 2003). The search for the relation between the binomial perception-motivation and the methods of health education should follow the different stages of life and be attentive to the different needs of each age group: children, adolescents, adults and the elder-


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ly. However, even with established methods, changes occurring in society require frequent re-evaluation of the strategies used to obtain the desired effects. When a method is applied, it is necessary to consider the values, customs, rules, language, emotional and social needs and the expectations of the studied population. Oral health education for adolescents should provide information about physical and psychological changes that occur in this phase. Adolescence is a psychological and social phenomenon possessing some features and dynamic processes that can cause severe mental and physical disturbances for the adolescent (Outeiral, 1994). Teenagers between 12 and 15 years old gain considerable motor control and physical strength; they behave according to a peer-group standard which suffers frequent changes; they identify strongly with peers of the same gender and use language to express and clarify the most complex concepts (Bastos et al, 2003). The literature emphasises that adolescence is the crucial period for health services because during this time, anything learned becomes established and linked to future conduct and behaviour. This is the ideal phase for developing a healthy lifestyle that will consolidate into a longer-term selfcare mentality (Tomita et al, 2001; Broadbent et al, 2006; Källestål et al, 2006; Freddo et al, 2008). In terms of dental health, this phase represents the moment of higher caries risk due to poor control of biofilm and decreasing oral hygiene (Thomsen et al, 2002). Considering this age group’s risk for developing oral diseases and greater receptivity for acquiring good habits, it makes sense to give priority to educating adolescents. Educational programmes or methods should be planned by health professionals with the aim of promoting behavioural change and acquiring participatory practices (Oliveira et al, 2009). The first step for the success of oral health education is to determine what motivates adolescents (De Biase, 1991). The constant changes that characterise adolescence require constant adaptations of methods used to involve this age group. The presence of attractive materials that are easy to understand and interesting can increase their interest and consequently improve the teaching/learning process (Mialhe et al, 2008). It is recommended to work with self-esteem, teach hygiene and mainly challenge them to become responsible for their own health (Rangel et al, 2004). Although the


subjective means of evaluating the oral health perception of adolescents have not been explored in depth, they are important. Effective health education can help this age group to become aware of their own condition, and this can cause behavioural changes and consequently an improvement in their quality of life (Mathias et al, 1995; Martins et al, 2009). The school was chosen as the location to perform oral health education for adolescents, due its favorable environment and its influence on forming opinions (Burghardt etal, 1995; Campos and Zuanon, 2004; Yalcinkaya and Atalay, 2006). The aims of this study were to understand the oral health perception of adolescents, investigate whether knowledge was influenced by the educational methods applied and verify which tools used in the health educational process were the most effective for adolescents.

METHODS This was an exploratory cross-sectional study, with an analytic, qualitative and quantitative profile that was realised in Araçatuba City, São Paulo State. The study followed the regulations for research with humans and received the approval of the Ethics Committee in Research with Humans of the School of Dentistry of Universidade Estadual Paulista (UNESP), Araçatuba Campus (process: FOA00449/2011). The sample was composed of 127 male and female adolescents aged between 14 and 17 years old who were enrolled in a public school in Araçatuba City, São Paulo State. The sample selection also followed the school’s system which admits 4 adolescent classes annually, in other words, new students are enrolled and begin their activities every three months. Students admitted in April and August 2011 and who accepted our invitation were included in this research (n = 188). However, over the 3 months of this study, the number of adolescents decreased because 61 stopped attending this school. The research was performed in three steps. The first was the initial evaluation of adolescents’ knowledge about oral health using self-applied questionnaires relating to the main oral diseases, hygiene methods and the importance of dental care. This method was adopted based on the study of Souza et al (2007). In the second step, educational methods were performed. The students were divided

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1st step

2nd step

3rd step


Use of questionnaire to verify the initial knowledge

Lecture, individual demonstration, participatory activity

Use of questionnaire to verify acquired knowledge, focal group


Use of questionnaire to verify initial knowledge


Use of questionnaire to verify acquired knowledge


Use of questionnaire to verify initial knowledge

Individual demonstration

Use of questionnaire to verify acquired knowledge


Use of questionnaire to verify initial knowledge

Participatory activity

Use of questionnaire to verify acquired knowledge

Fig 1  Method used for development of educational activities in oral health, Araçatuba, 2011.

into two groups (A and B) and members of group A participated in all of the educational activities and compared them at the end of the study. Group B was subdivided into 3 parts (B1: lectures; B2: individual demonstration; B3: participatory activity). Each subgroup participated in only one educational method, as shown in Fig 1. The performed activities included an educational lecture that covered the importance of oral health, oral diseases and prevention methods, using illustrative and interactive slideshows as support material. Individual demonstration was another applied method that addressed the topic of oral health. It used acrylic models, macromodels of hygiene, an illustrated guide and also the disclosure of dental biofilm and supervised tooth brushing. Participation was the third step, where the groups had to deal with themes such as the importance of oral health, prevention methods and oral diseases. This was achieved by plays, videos, games and designing posters. The intention was to use methods and language that were compatible with this age group. Educational activities were performed during the class period, respecting the school’s schedule. The third step was performed after collection of the initial data and application of educational methods to verify acquired knowledge and the adolescents’ perception of the methods applied. Therefore, the questionnaire was given to the students again. The adolescents that did part of the three activities (group A) were invited to participate in a focus group where they could give their opinion about applied educational methods. The focus group method is a way of data collection directly from the conversations of a group which report their experiences and perceptions around some themes they all collectively thought were interesting (Gomes et al, 2009).

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Each focus group was composed of 6 adolescents, one moderator (the person who facilitates the conversation among the group members) and one writer (the person who is responsible for the written and audio recordings of the conversations). It is important to know that the moderator and the writer were the same people during the two meetings; both researchers performed this task in the morning and in the afternoon. The obtained data were recorded (both written and audio) to register what each participant said and to reflect about the content of discussion. After the researchers had analysed the audio recordings and had carefully read the notes, all content was evaluated to determine the adolescents’ perception of the educational methods applied concerning oral health. All collected data were entered into a PC using the software Epi-Info version 5.0.3 (Centers for Disease Control and Prevention; Atlanta, GA, USA). Results were discussed among members of groups themselves and were statistically analysed using the chi-square and Fisher’s tests at the 5% significance level.

RESULTS The adolescents composed a homogeneous sample with similar social and demographic features. Among 127 participants, 55.9% were 15 years old and the predominant gender was female (55.1%). Of the total, 8.7% said that they had smoked once in their life and 59.0% had drunk an alcoholic beverage. In relation to adolescents’ perceptions of their health, it was verified that oral health influences the majority of participants’ lives (57.5%) (Table 1).


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53.6% of adolescents considered their oral health ‘good’ or ‘excellent’. More than half (64.6%) of teenagers cited that something about their appearance bothered them, showing the concern adolescents generally have with their appearance. The results of the knowledge about oral health are showed in Table 2. There was a statistically significant difference in group A before and after educational intervention, and between group B (baseline group before intervention) and B1, B2, B3, where there was some improvement in knowledge of oral diseases – periodontal disease, gingivitis and oral herpes – after applying the educational methods. In relation to the importance of having good teeth, group A (after activities) and group B2 (after individual demonstration) showed they realised there was an important association with systemic health. The results obtained for group B2 in relation to the importance of a good diet showed that these teenagers saw an association between a harmful diet and the causes of dental caries. A good diet was indicated as preventing oral diseases. Table 3 shows the main themes spoken about by the participants regarding the three activities, highlighting the strengths of each.

Table 1 Numeric and percent distribution of adolescents’ perception about oral health Questions

N (%)*

Does oral health influence your life? Yes

73 (57.5)


47 (37.0)

Is there something that bothers you about your appearance? Yes

82 (64.6)


43 (33.8)

If yes, what bothers you? Teeth/smile

23 (18.1)


44 (34.6)


21 (16.5)


27 (21.2)


22 (17.3)

Are you satisfied with your oral health? Yes

65 (51.2)


52 (40.9)

How would you classify your oral health?

DISCUSSION The knowledge about the needs and behaviours of adolescents in relation to oral health contributed to optimising dental attendance and creating effective programmes with the aim of promoting health and improving the quality of life of this part of population (Granville-Garcia et al, 2009). The present study showed that it was possible to analyse the students’ knowledge about oral health, while demonstrating the importance of developing health education methods and what the most attractive methods were for this age group. The data obtained from this investigation of adolescents’ perception about oral health confirmed the results of the Brazilian Oral Health Project 2010 (Brazil, 2011), where 45.7% of Brazilian teenagers cited satisfaction with oral health, as did the study of Garbin et al (2009) with adolescents from the same school, where 53.6% classified their oral health as ‘good’. Regarding their appearance, teeth/smile were cited as one of the causes of dissatisfaction of the participating adolescents. This point is important



11 (8.7)


57 (44.9)


52 (40.9)


7 (5.5)

* Response rate was not 100%.

and should be considered when dealing with development of oral health educational programmes, because aesthetics is the main reason for oral care among this age group (Flores and Drehmer, 2003). In relation to oral health knowledge, almost all adolescents cited dental caries as the most wellknown oral disease, probably due to the emphasis it receives in media and in educational and preventive campaigns (Granville-Garcia et al, 2010). Other important information in relation to the knowledge about oral diseases before the educational methods were taught is that the majority of adolescents did not know about periodontal disease and gingivitis; however, once the educational methods had been performed, all of the students were aware of them. An assimilation of information

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Table 2 Knowledge about oral health among the studied groups Questions

Group A – before (n = 71)

Group A − After (n = 71)

A before x A after P -value

Group Bbefore (n = 56)

Group B1 (n = 16)

B x B1 P-value

Group B2 (n = 23)

B x B2 P-value

Group B3 (n = 17)

B x B3 P-value

70 (98.6)

70 (98.6)


54 (96.4)

16 (100)


23 (100)


16 (94.1)



7 (9.9)

26 (36.6)


2 (5.6)

4 ( 25.0)


17 (73.9)


5 (29.4)



29 (40.8)

55 (77.5)