Saied-Moallemi ORIGINAL ARTICLE et al
Change in Conceptions of Iranian Pre-adolescents’ Oral Health After a School-based Programme: Challenge for Boys Zahra Saied-Moallemia/Heikki Murtomaab/Jorma I. Virtanenc Purpose: To determine the role of pre-adolescents’ conceptions in improving their oral health in a school-based health education programme. Materials and Methods: A school-based programme was designed as a 3-month intervention study for a representative sample of 9-year-olds (n = 338) in 12 schools in Tehran, Iran. The schools were randomly assigned to the intervention groups and controls, separately for boys’ and girls’ schools. Children (n = 222) underwent two kinds of oral health education programmes. The control group (n = 116) had no intervention. Positive changes in the child’s oral health conceptions were evaluated after the programme as determinants of each child’s oral health. Final effects of the intervention were assessed as improvements in gingival health when all index teeth with bleeding at baseline became healthy (healthy gingiva). Statistical analysis included chi-square, independent samples t-test and logistic regression models. Factor analyses were applied to the child’s oral health conceptions. Results: Three factors regarding the children’s oral health conceptions emerged. After the programme, boys and girls in the intervention group experienced fewer barriers to dental care than did the controls. Healthy gingiva was apparent among the boys (OR = 2.0) and the girls (OR = 4.1) in the intervention group. Girls experienced fewer barriers to dental care after the programme (OR = 1.5) and achieved more healthy gingiva, but boys’ oral health conceptions showed no effect on the health of their gingiva. Conclusion: In designing health education programmes, in addition to other determinants, pre-adolescents’ oral health conceptions deserve consideration. Intervention planning necessitates awareness of gender differences. Key words: gender differences, health promotion, oral health, random allocation, school health Oral Health Prev Dent 2014;1:21-28
Submitted for publication: 29.07.12; accepted for publication: 02.01.13
doi: 10.3290/j.ohpd.a31214
T
he school years have a strong influence on children’s accepting and maintaining positive health and oral health behaviours. In addition, the preadolescent period is also a critical time for developing lifelong beliefs and attitudes (Kwan et al, 2005). a
Assistant Professor, Torabinejad Dental Research Center, Department of Oral Public Health and Community Dentistry, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland.
b
Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland.
c
Professor, Institute of Dentistry, University of Oulu, Oulu University Hospital, Oulu, Finland; Department of Public Health, University of Helsinki, Helsinki, Finland.
Correspondence: Dr. Zahra Saied-Moallemi, Torabinejad Dental Research Center, Department of Oral Public Health and Community Dentistry, Institute of Dentistry, Isfahan University of Medical Sciences, Hezarjerib Ave, Isfahan, 8174673461, Iran. Tel: +98-311792-2894, Fax: +98-311-668-7080. Email:
[email protected]
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Amongst a set of suitable settings, school has been defined as the main setting for oral health promotion programmes to reach over 1 billion children, and through them, their families and community members (Watt, 2005). The existing school system in many countries has been shown to be a suitable system in place to implement oral health promotion programmes (Vanobbergen et al, 2004). Especially in countries with a developing oral health care system, benefits of the school system have been emphasised (Saied-Moallemi et al, 2009; Yazdani et al, 2009). To prevent and control oral diseases, research should focus on determinants of oral health. It is known that the parents play a crucial role in children’s general health and oral health (Poutanen et al, 2006). Our previous studies among Iranian children showed that especially mothers play a crucial
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role in their children’s oral health and behaviour (Saied-Moallemi et al, 2007, 2008a). The central role of the mothers sustained their children’s oral health throughout a school-based intervention programme (Saied-Moallemi et al, 2009). Gender differences in oral health and behaviour are found in the literature (Maes et al, 2006; Dorri et al, 2009). Gender differences are observable for dental-service utilisation as well; boys experience more barriers to dental visit than do girls (Villalobos-Rodelo et al, 2010). The person’s own knowledge, attitudes and beliefs are factors that exert their effects prior to a behaviour’s occurrence (Green and Kreuter, 1991); dental health beliefs can influence a person’s oral health care (Inglehart and Tedesco, 1995). In terms of primary school children, however, the literature lacks information on how influential the children’s own dental health beliefs are in improving their oral health. The general aim of this study was to determine the role of pre-adolescents’ conceptions regarding improving their oral health in a schoolbased health education programme.
A similar clinical dental examination was carried out at baseline and at the end of the study for all children (Saied-Moallemi et al, 2009). A bleeding index (BI) concerning the presence or absence of bleeding was used for each child’s clinical examination (WHO, 1997), which was recorded for each of the six index teeth (dd 16, 11, 26, 36, 31 and 46) and was scored as healthy (0) or bleeding (1). For evaluating the programme, the outcome ‘healthy gingiva’ was defined as an improvement in all the index teeth which showed bleeding at baseline. Further details have been described elsewhere (SaiedMoallemi et al, 2009). The baseline clinical examinations were conducted by the first author (Z. S-M.) and a trained dentist blind to group assignment carried out all the outcome clinical examinations. To achieve acceptable agreement among the examiners, training and subsequently calibration was carried out on a separate group of 27 children, yielding a kappa value of 0.63 for interexaminer reliability.
MATERIALS AND METHODS
Children’s questionnaire
Study design and sampling
The questionnaire utilised oral health-related belief statements from previous studies (Chen et al, 1997; Watson et al, 1999); originally written in English, it was translated into Persian. After a pilot study in a separate group of children, the questionnaire was modified. Ten statements about the importance of oral health, the seriousness of oral diseases, causes and prevention of oral diseases and barriers to dental care assessed each child’s oral health conceptions on a five-point Likert scale from ‘fully agree’ to ‘fully disagree’ before and after the programme. Responses were scored from 1 to 5, with the higher scores indicating more positive conceptions (statements were rescored when relevant). To determine the reliability of the questionnaire, a separate group of children (n = 27) answered the questionnaire twice, and kappa values of 0.8 to 1.0 for different questions were calculated. Children were asked to answer the question ‘Have you learned about your teeth and how to take care of them from any of the following sources?’ with alternatives to choose among. Two questions about the time and the reasons of the last dental visit provided data on the child’s dental-service utilisation.
A 3-month school-based intervention study was designed for a representative sample of 9-year-olds in Tehran, Iran. The data included the children’s clinical dental examinations and self-administered questionnaires at baseline and at the end of the study. Multi-stage sampling was applied. As explained in detail elsewhere (Saied-Moallemi et al, 2007, 2008b), from a list of all public primary schools and taking children’s gender into account, 12 schools (6 for boys, 6 for girls) were randomly selected. Randomisation was performed separately for boys’ and girls’ schools through systematic random allocation. Then, from each school, one third-grade class including all its children was randomly chosen. After separate baseline data collection for boys’ and girls’ schools, the schools were randomly assigned to the intervention (4 boys’ and 4 girls’ schools) or control (2 boys’ and 2 girls’ schools) groups. From a total number of 346 subjects, eight children who were absent on the day of follow-up examination were excluded from the analyses. In total, 338 children (163 boys and 175 girls) from 12 schools were enrolled in the study.
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Clinical examination
Oral Health & Preventive Dentistry
Saied-Moallemi et al
School-based interventions Among the intervention group, two kinds of intervention – one through the class and one through the parents – were implemented and compared with findings for the controls, who had no intervention. The intervention was applied to the boys’ and girls’ schools similarly. The follow-up examinations were performed three months after the interventions. Classwork group (n = 110)
This intervention was applied during class hours by use of seven different illustrative puzzles as learning tools, all including oral health messages about twice-daily toothbrushing and use of fluoride toothpaste. A health counsellor at each school, previously advised about the puzzles by the first author, supervised the children in solving the puzzles, and after the completion of each puzzle, she explained its oral health message regarding toothbrushing or use of fluoride toothpaste. Parental-aid group (n = 112)
This intervention was applied by the parents at home. The health counsellors gave one oral health education leaflet and a brushing diary, both prepared for the programme, to each of the children to take home. This leaflet, in simple, clear language, explained basic oral health information on gingival disease and dental caries and recommended twice-daily toothbrushing, use of fluoride toothpaste and restriction of sugary snacks, highlighting the modelling role of parents in their children’s good oral health behaviours. Parents were also recommended to encourage the child and to keep a diary on the child’s toothbrushing, to supervise and aid in toothbrushing and to provide the child with non-sugary snacks.
emerged after the programme. To determine the overall effect of the programme, the results of the intervention groups were pooled and compared with the controls. To identify the latent dimensions of the child’s oral health conceptions and to discover the synergic effect of the statements, factor analysis with a principle component method and varimax rotation was applied before and after the programme. Each item that loaded at 0.50 or greater on only one factor was included as an item for a given factor. Three factors on the children’s oral health conceptions were obtained from similar statements made before and after the programme, except for the statement ‘When I eat sweet foods, my teeth become decayed’, which was included in the factor called ‘Prevention’ before the programme and in the factor ‘Importance of disease’ after the programme. Based on the factor analysis, the sum of the value of the original variables with the highest loading in that factor was calculated to create a new variable vis-à-vis each factor. Each sum was then standardised by dividing that sum by the number of variables included. Evaluation of the statistical significance between the computed sum variables was examined using the independent samples ttest. Comparisons of dental service utilisation were made with the chi-square test. Binary logistic regression models were applied to explain the clinical outcome achieved after the programme with the intervention groups and the computed sum of the oral health-related conceptions after the programme. The sums of two oral health conceptions which differed between the intervention group and controls after the programme were entered into the logistic regression models, but the oral health conception which was similar among the groups was excluded from the models. Corresponding odds ratios (OR) and 95% confidence intervals (95% CI) were determined.
Control group (n = 116)
This group received no intervention at all, but the same data collection was performed for all the children.
RESULTS Sources for oral health information
Statistical methods The mean values of the responses to the statements on oral health conceptions were calculated by comparing the intervention group with controls at baseline and at study’s end. Overall positive changes in the child’s oral health conceptions
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A majority of the children (90%) reported that their parents and almost one-third (30%) reported that their school health counsellors were one of the main sources of oral health information. These were followed by sisters and brothers (19%), teachers (15%) and dentists (12%), as ranked by the children. Friends, physicians, school books and mass media
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were sources as well. Parents were the single source of oral health information for 17% of the children.
Dental service utilisation Two-thirds (68%) of the children reported visiting a dentist within the previous year and almost a quarter of them (25%) attended regular dental checkups. Girls more frequently reported visiting a dentist within the previous year and undergoing dental check-ups and receiving treatment procedures than did boys. This, however, was not statistically significant (Table 1). The children who visited a dentist within the previous year reported feeling less fear of the dental visit (P = 0.01).
Follow-up findings on the children’s oral health conceptions and clinical outcome All children except two boys had index teeth with bleeding at baseline. As shown in Table 2, during the 3-month school-based intervention, 60% of the
children in the intervention group and 32% of controls achieved a more ‘healthy gingiva’ (P = 0.02). Three factors were revealed as related to the children’s oral health conceptions and explained 55% of the common variance: ‘Prevention’, ‘Barrier to care’, and ‘Importance of disease’ (Table 3). The mean values of the computed sums of the children’s oral health conceptions in different trial groups are shown in Table 4. After the programme, boys and girls in the intervention group showed fewer barriers to dental care than did the controls. In addition, the boys in the intervention group placed more importance on oral diseases than did their counterparts in the control group. Two separate binary logistic regression models for boys and girls showed the effect of the programme and showed the child’s oral health conceptions after the programme concerning achieving a healthy gingiva (Table 5). The outcome of achieving a healthy gingiva was apparent amongst the boys (OR = 2.0; 95% CI: 1.0–4.6) and the girls (OR = 4.1; 95% CI: 2.0–8.3) participating in the intervention group. In addition, girls – who felt fewer barriers to dental care after the programme (OR = 1.5; 95%
Table 1 Dental service utilisation among Iranian boys (n = 163) and girls (n = 175) at baseline Dental service utilisation
Total n (%)
Boys n (%)
Girls n (%)
Dental visit timepoint Within one year More than one year ago Never been to the dentist
227 (68) 55 (16) 54 (16)
106 (65) 30 (19) 26 (16)
121 (70) 25 (14) 28 (16)
Reason for the last dental visit Pain Regular check-up Any kind of dental treatment Do not remember
72 (26) 66 (23) 126 (45) 16 (6)
41 (31) 29 (22) 55 (41) 8 (6)
31 (21) 37 (25) 71 (48) 8 (6)
P
0.58
0.30
Statistical analyses by chi-square.
Table 2 Percentages of children achieving healthy gingiva during the school-based intervention Boys
Girls
Total
n = 163 (%)
n = 175 (%)
n = 338 (%)
Intervention group
61
59
60
Controls
42
23
32
P
0.02
