Evaluation of an Oral Health Intervention Questionnaire amongst Parents of Pre-School Children from Bangalore North: A Comparative Study

Original Article Int J Clin Prev Dent 2015;11(1):1-6 ㆍ http://dx.doi.org/10.15236/ijcpd.2015.11.1.1 ISSN (Print) 1738-8546 ㆍ ISSN (Online) 2287-6197 Evaluation of an Oral Health Intervention Questionnaire amongst Parents of Pre-School Children from Bangalore North: A Comparative Study Deepak Viswanath, Anindita Sarma Department of Pedodontics and Preventive Dentistry, Krishnadevaraya College of Dental Sciences, Bangalore, India Objective: The aim of the study was to assess the impact of different and newer health education methods amongst the parents of pre-schoolers from Bangalore-North. Methods: The study comprised of 180 parents along with their respective children from the same socio-economic status from three different play schools having strength of 60 children each. Further, in each school, the children were randomly divided into three groups and questionnaires were distributed on three consecutive days; the filled questionnaires were collected half an hour later on all the three consecutive days. Results: Comparison of the statistical data showed that there was a significant statistical improvement in all groups except the control group. In our study, the respective subgroup III (involving 20 parents each) from all the groups A, B, and C showed significant improvement when compared with other subgroups (I and II). Conclusion: A motion media presentation, as a method of health education and promotion indeed had a big impact on the oral health attitude and knowledge of the parents so that these parents can act as reinforces in improving the oral health among their children. Keywords: intervention, care givers, dental caries, knowledge, questionnaires Introduction It is a well-known fact that good oral hygiene practices are Corresponding author Deepak Viswanath Department of Pedodontics and Preventive Dentistry, Krishandevaraya College of Dental Sciences, Int. Airport Road, Hunasamaranahalli, Bangalore, Karnataka 562157, India. Tel: +91-9480226226, Fax: +91-8028467084, E-mail: pedodons@gmail.com Received September 11, 2014, Revised September 17, 2014, Accepted March 14, 2015 necessary from a young age so as to ensure positive long term dental health and hygiene [1]. Frequent consumption of food stuffs containing non milk extrinsic sugars coupled with lack of fluoride have been clearly identified as the main contributor leading to the development of dental caries [2]. Positively influencing the knowledge, attitude and behavior of children towards sustaining a good oral health requires an integrated health education as well as a proper health promotion. Behavior change theories such as the Social Learning Theory [3] and the Health Belief Model [4] suggests that changes in knowledge, attitudes and behavior may be brought about using a concerted approach involving mass media, community; further the effectiveness of media campaigns is enhanced when re- Copyright c 2015. Korean Academy of Preventive Dentistry. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1

International Journal of Clinical Preventive Dentistry Figure 1. Showing distribution of samples. inforced by individual interaction [5]. Coupled with this, the combined approach of media supported by health professional input has been shown to affect sustained behavioral change [6]. Mass media has been identified and accepted as a possible vehicle for dental health education [7]. Further, to ensure a long-term good dental health, oral hygiene practices are critical from a very young age where an integrated health education and health promotion is necessary to positively influence the knowledge, attitude and behavior of children towards good oral health. For a successful oral health program, one of the positive mediators is through school based programs which aim at improving the overall oral health status of children. The present generation of pre-schoolers is not only influenced by social environment and teachers, but also by media and television. The methods of health education provided to these pre-schoolers vary according to their age groups. It is hypothesized that the effects on a child s oral health will be mediated through the primary care-giver (parent). Therefore the present study was aimed at evaluating the intervention (through a questionnaire) primarily amongst the parents of pre-school children from Bangalore North. Hence our study was planned to assess the impact of two different modes of health education among parents of pre-schoolers and to determine the most effective mode among them. Materials and Methods The study protocol was assessed and approved by the institutional review board of Krishnadevaraya College of Dental Sciences, Bangalore, India. Parental consent was obtained to carry out the study and the sample was selected in such a way that all participants belonged to the same socio-economic status and had a full complement of primary dentition. The study group included 180 parents of 180 pre-schoolers. The aim of the intervention program/the present study was to increase awareness and knowledge of the importance of oral health maintenance among the care-givers of the pre-schooler children so that they act as role models/peers in incorporating a positive behavioral change in their children. Three play schools from same socio-economic strata were included in the study and were divided into three sub-groups (A1, A2, A3, B1, B2, B3 & C1, C2, C3; Figure 1). On day 1 (of first week), the questionnaires were distributed among 20 parents from school A selected randomly without any prior notice. This was to ensure and check the pre-existing knowledge of the parents/care givers and their attitude towards dental awareness. The filled questionnaires were collected within 30 minutes. Similar protocol was adopted in school B and C in the succeeding weeks. On day 2 (of first week), 20 parents were selected randomly and were subjected to a pictographic presentation, highlighting the important aspects of the oral health education and preventive aids for children. The parents were given questionnaires and the filled questionnaires were collected within 30 minutes. Similar protocol was adopted in school B and C in the succeeding weeks. On day 3 (of first week), 20 parents were randomly selected and were shown a motion media presentation highlighting the important aspects of oral health education and preventive aids for children and were subsequently given a questionnaire. The filled questionnaires were collected within 30 minutes. Similar protocol was adopted in school B and C in succeeding weeks. The statistical analyses were performed with the SPSS ver.17 software (SPSS Inc., Chicago, IL, USA) and p<0.05 accepted as the level for statistical significance. Results Table 1 shows that the gender distribution in all the groups was not statistically significant (p=0.817); Table 2 shows that 2 Vol. 11, No. 1, March 2015

Deepak Viswanath and Anindita Sarma:Oral Health Intervention Table 1. Gender distribution of students studied Gender School A School B School C Total Female 34 (56.7) 31 (51.7) 34 (56.7) 99 (55.0) Values are presented as number (%). Chi-square test, p=0.187. Table 2. Age distribution of students studied Age (yr) School A School B School C Total 1.0-2.0 0 (0) 1 (1.7) 0 (0) 1 (0.6) 2.1-4.0 49 (81.7) 44 (73.3) 43 (71.7) 136 (75.6) 4.1-6.0 11 (18.3) 15 (25.0) 17 (28.3) 43 (23.9) Values are presented as range or number (%). Fisher exact test, p=0.371. Table 3. Questionnaire analysis Questionnaire Group I (n=60) Group II (n=60) Group III (n=60) Total (n=180) p-value Q1. Knowledge about pedodontist No 46 (76.7) 32 (53.3) 11 (18.3) 89 (49.4) Yes 14 (23.3) 28 (46.7) 49 (81.7) 91 (50.6) Q2. Methods of brushing Circular 41 (68.3) 34 (56.7) 52 (86.7) 127 (70.6) Horizontal 1 (1.7) 0 (0) 0 (0) 1 (0.6) Vertical 1 (1.7) 0 (0) 0 (0) 1 (0.6) Q3. Type of bristle Medium 28 (46.7) 35 (58.3) 19 (31.7) 82 (45.6) Soft 32 (53.3) 25 (41.7) 41 (68.3) 98 (54.4) Q4. Frequency of brushing Once 37 (61.7) 14 (23.3) 8 (13.3) 59 (32.8) Twice 23 (38.3) 46 (76.7) 52 (86.7) 121 (67.2) Q5. Duration of brushing (min) 1 3 (5.0) 0 (0) 0 (0) 3 (1.7) 2 39 (65.0) 6 (10.0) 7 (11.7) 52 (28.9) 3 18 (30.0) 54 (90.0) 53 (88.3) 125 (69.4) Q6. Frequency of changing toothbrush Monthly 18 (30.0) 25 (41.7) 4 (6.7) 47 (26.1) 3 Monthly 36 (60.0) 35 (58.3) 54 (90.0) 125 (69.4) Bristles 6 (10.0) 0 (0) 2 (3.3) 8 (4.4) Q7. Use of fluoridated toothpaste Fluoridated 49 (81.7) 39 (65.0) 27 (45.0) 115 (63.9) Nonfluoridated 11 (18.3) 21 (35.0) 32 (53.3) 64 (35.6) Q8. Initiation of fluoride toothpaste (yr) 2-3 6 (10.0) 0 (0) 3 (5.0) 9 (5.0) 3-4 37 (61.7) 27 (45.0) 10 (16.7) 74 (41.1) 5-6 17 (28.3) 33 (55.0) 47 (78.3) 97 (53.9) Q9. Use of oral hygiene aids No 52 (86.7) 58 (96.7) 27 (45.0) 137 (76.1) Yes 8 (13.3) 2 (3.3) 33 (55.0) 43 (23.9) Q10. Aid used NA 50 (83.3) 58 (96.7) 27 (45.0) 135 (75.0) Plastic 7 (11.7) 1 (1.7) 28 (46.7) 36 (20.0) Steel 3 (5.0) 1 (1.7) 5 (8.3) 9 (5.0) 0.569 0.013 Values are presented as number (%). Chi-square/Fisher exact test. NA: not available. there was no statistically significant difference among the groups based on age (p=0.371). When enquired about the knowledge regarding the services of a pedodontist, the highest positive response rate was obtained from subgroup III (81.7%) when compared with subgroup II (46.7%) whereas subgroup I yielded the least positive response (14%). Thus we can conclude from our study that motion media played a major role in education and motivation of parents; significantly a better response was elicited through this question (Table 3, Figure 2). Regarding the methods of tooth brushing, subgroup III showed better response of (86.7%) than subgroup II but subgroup I showed better response than subgroup II. When asked about the usage of the type of bristles for children, subgroup III gave the highest positive response (68.3%) compared to subgroup II (41.7%). Subgroup III showed highest response (86.7%) for brushing twice per day while subgroup II (76.7%) showed moderate response while subgroup I showed least response (38.3%) (Table 3, Figure 3). For duration of brushing, there was not much statistical difference between subgroup III and II while subgroup I showed poor response (Table 3). When asked about the frequency of changing toothbrush, subgroup III gave the highest positive response (90.0%) compared to subgroup II (58.3%) and subgroup I (60.0%). When asked about the usage of fluoridated toothpaste, subgroup III showed lower response than subgroup II and I. Subgroup III gave highest response (78.3%) in starting fluoridated toothpaste from the age of 5 to 6 years in comparison to subgroup II (55.0%) while subgroup I showed the least positive response www.ijcpd.org 3

International Journal of Clinical Preventive Dentistry Figure 2. Showing response knowledge regarding the services of a pedodontist. Figure 3. Showing responses regarding the usage of the type of bristles for children. (28.3%). About tongue cleaner usage, subgroup III responded highest (55.0%) than subgroup II (3.3%) and subgroup I (13.3%). It was also seen that parents of each groups used to watch and advice their children on oral hygiene, hence adequate oral health education will incur better oral hygiene in the children. It was found that there was a significant difference (positive response) in the knowledge and attitude of the parents/care givers of the pre-schoolers who were shown motion media presentation than the other intervention group (poster) while the control group showed that the pre-existing knowledge about oral health awareness. Discussion Oral health education can bring about positive changes in the attitude and behavior of an individual. More recently, several initiatives have been taken to implement preventive oral health-care programs especially among school children [1,6,7]. Some of the school based programs which have been conducted in Brazil [8], Madagascar [9], and Indonesia [10] have shown encouraging results. As a routine practice, oral health education is given by the concerned dental health professional or the designated teachers of the school. Scant literature exists on the impact of the various modes delivered by these health education programs. Therefore, a cross-sectional study was planned to investigate the impact of Evaluation of an Oral Health Intervention Questionnaire amongst Parents of Pre-School Children from Bangalore North: A Comparative Study. Our study comprised of children and parents from 3 different schools and the sample was 60 in each. The sample was further divided into 3 subgroups corresponding to control group, poster group, and motion media group. From the study, children from all groups had no significant difference in the percentage of gender distribution and the average age (Table 1, 2). The results of these two are in accordance with a study done by John et al. [11] who have reported similar findings in their study. In the present study, subgroup III that received health education through the motion media presentation showed improvement, which was a newer trend incorporated in our study unlike other studies [11]. This substantiates the fact that dentists have a vital role to play in influencing the oral health knowledge and practices of school children [11]. The subgroup II, which received oral health education through posters also showed an improvement probably due to the visual impact of the poster. The subgroup I showed poor existing knowledge about oral hygiene. Parents liked the motion media presentation as it illustrated the oral hygiene methods more vibrantly than poster. The impact of audio visual presentation helped the parents to register the information more aptly in their minds. The current generation of children is attracted by the cartoon characters as they spend more time watching television and cartoon serials [11], hence incorporation of cartoon characters in the motion media presentation made it more impactful for the children as well. Not only is the content of the message important but the way it is conveyed to the target population, so as to retain the information also is more important. This was the probable reason for subgroup III to have better results than the other groups. About the methods of tooth brushing, subgroup III showed better response (86.7%) than subgroup II but subgroup I showed better response than subgroup II which was in accordance with study done by Blinkhorn et al. [12]. When asked about the usage of the type of bristles for children, subgroup III gave the highest positive response (68.3%) compared to subgroup II (41.7%). This was included in our study as the type of bristles also matters in plaque removal [13]. Subgroup III showed highest response 4 Vol. 11, No. 1, March 2015

Deepak Viswanath and Anindita Sarma:Oral Health Intervention (86.7%) for brushing twice per day while subgroup II (76.7%) showed moderate response while subgroup I showed least response (38.3%) (Table 3, Figure 3) which was in accordance with the study done by Blinkhorn et al. [12]. For duration of brushing, there was not much statistical difference between subgroup III and II and subgroup I showed poor response (Table 3). We have incorporated this in our study for the reason that an effective method of tooth brushing is time dependent and significant in the reduction of oral health diseases [14]. When asked about the usage of fluoridated toothpaste, it was not statistically significant which was in accordance with an earlier study done by Blinkhorn et al. [12]. Subgroup III gave highest response (78.3%) in starting fluoridated toothpaste from the age of 5 to 6 years in comparison to subgroup II (55%) while subgroup I showed the least positive response (28.3%). The control group results were in accordance with study done by Blinkhorn et al. [12]. In the study done by Blinkhorn et al. [12] as well as in our study, it was clear from the results of the questionnaire that many parents knew what should be done but were either unable to do it for other reasons, not specified. The parents need more than information or simple encouragement which might require help by demonstration and practical assistance so that they can impart this knowledge into everyday practice [12]. Hence the motion media presentation catered to this need. Therefore the present study was conducted to find out which is a better mode of intervention for easier adaptation, feasibility and repeatability. In an earlier study, drama mode [12] was found effective but conducting it simultaneously in many schools was difficult. On the other hand, motion media presentation which, once, recorded can be replayed again and again and is a major advantage in not only saving time and expenses, but also at the same time equivalent amount of positive response could be obtained like that from drama. Therefore, it is for this reason, we have incorporated the use of motion media presentation as an effective adjunct/educative tool for the benefit of the parent population and we can conclude from our study that motion media is a more feasible method but there were a few limitations in the study like the pre-existing knowledge about oral hygiene of some keen parent could have influenced the questionnaire score and at the same time, some of the unenthusiastic parents might have not paid attention to either the poster or the motion media and lead to bias in the results. Within the limitations of our study, we can conclude that the motion media mode of providing oral health education to parents of pre-schoolers was effective. Conclusion Oral health education plays a major role in oral health promotion among school children. This method of using motion media presentation incorporating cartoon characters had a major advantage in making the children understand the positivity of health education. Further motion media had a much greater impact on the oral health knowledge, attitude and practices. Acknowledegements We sincerely acknowledge all the participant parents and also the school authorities for giving us necessary permission to conduct the questionnaire based study. References 1. Friel S, Hope A, Kelleher C, Comer S, Sadlier D. Impact evaluation of an oral health intervention amongst primary school children in Ireland. Health Promot Int 2002;17:119-26. 2. Arrens U. British Nutrition Foundation Task Force report. Oral health: diet and other factors. New York; Oxford: Elsevier; 1999. 3. Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice- Hall; 1977. 4. Becker MH. The health belief model and personal health behaviour. Thorofare, NJ: Slack; 1974. 5. Bakdash MB, Lange AL, McMillan DG. The effect of a televised periodontal campaign on public periodontal awareness. J Periodontol 1983;54:666-70. 6. Flay BR. Evaluation of the development, dissemination and effectiveness of mass media health programming. Health Education Research 1987;2:123-30. 7. Pine CM, McGoldrick PM, Burnside G, Curnow MM, Chesters RK, Nicholson J, et al. An intervention programme to establish regular toothbrushing: understanding parents' beliefs and motivating children. Int Dent J 2000;Suppl Creating A Successful: 312-23. 8. Buischi YA, Axelsson P, Oliveira LB, Mayer MP, Gjermo P. Effect of two preventive programs on oral health knowledge and habits among Brazilian schoolchildren. Community Dent Oral Epidemiol 1994;22:41-6. 9. Petersen PE, Razanamihaja N. Carbamide-containing polyol chewing gum and prevention of dental caries in schoolchildren in Madagascar. Int Dent J 1999;49:226-30. 10. Hartono SW, Lambri SE, van Palenstein Helderman WH. Effectiveness of primary school-based oral health education in West Java, Indonesia. Int Dent J 2002;52:137-43. 11. John BJ, Asokan S, Shankar S. Evaluation of different health education interventions among preschoolers: a randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 2013;31:96-9. 12. Blinkhorn AS, Wainwright-Stringer YM, Holloway PJ. Dental health knowledge and attitudes of regularly attending mothers of high-risk, pre-school children. Int Dent J 2001;51:435-8. www.ijcpd.org 5

International Journal of Clinical Preventive Dentistry 13. Sripriya N, Shaik Hyder Ali KH. A comparative study of the efficacy of four different bristle designs of tooth brushes in plaque removal. J Indian Soc Pedod Prev Dent 2007;25:76-81. 14. Terézhalmy GT, Biesbrock AR, Walters PA, Grender JM, Bartizek RD. Clinical evaluation of brushing time and plaque removal potential of two manual toothbrushes. Int J Dent Hyg 2008;6:321-7. 6 Vol. 11, No. 1, March 2015