Introduction

Oral health is defined “as being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity” [ 1 ].

According to the World Health Organization (WHO), dental caries is still a major oral health problem, and about 60-90% of schoolchildren and the vast majority of adults are affected by dental caries [ 2 ]. According to the national oral health survey, 89% of the 6-year-old children have had dental caries experience [ 3 ]. In addition, the prevalence of dental caries among preschool children was reported 70% in the study of Shaghaghian et al. in Shiraz [ 4 ]. In a study by Gharlipour et al. [ 5 ] decayed, missing, and filled teeth (dmft) scores were 5.49±3.6 in Iranian preschool children.

Oral self-care behaviors are necessary for the oral health promotion [ 6 ]; oral self-care habits such as tooth brushing, dental flossing, and regular dental visits are recommended for good oral health and prudential health [ 7 - 8 ]. The recent study in Iran showed that 25.0% of children never brushed their teeth, which indicates a poor oral self –care in children [ 9 ].

Studies reported the positive effect of mothers’ oral health behaviors on their children’s oral health, and mothers’ tooth brushing was a significant indicator for the tooth brushing behavior of their children [ 9 - 10 ].

Based on previous studies, a serious need for planning and performing appropriate programs to improve children’s oral health behavior is highly suggested [ 5 , 11 - 12 ]. Health education is a vital component in promotion of oral health [ 13 ]. Therefore, theory-based educational interventions are recommended to promote oral health habits [ 14 - 16 ]; they are more successful for changing and maintaining healthy behavior [ 17 - 18 ]. The theory of planned behavior (TPB) describes the main elements of healthy behavior and consists of five constructs including intention, attitude, subjective norm, and perceived behavioral control. The intention is formed by an individual’s attitude towards the behavior, subjective norm, and perceived behavioral control. Attitude includes beliefs about the positive or negative outcomes of the engaging behavior. Subjective norm can be defined as the beliefs of whether important others (e.g. family, dentist, health nurses) think one should engage in a behavior. Perceived behavioral control refers to the degree to which a person believes the engaging behavior is under his/her control [ 19 ].

Based on our knowledge, there are very few theory-based interventions on oral self-care behaviors among both mothers and their children. Therefore, the aim of this study was to evaluate the effect of an educational program based on the theory of planned behavior on maternal and their children oral self-care behavior.

Materials and Method

Study design and population

This quasi-experimental intervention study was conducted on 148 mothers and their children aged 1–6 years who referred to the health centers of Tabriz, Iran from December 2015 to January 2016. Tabriz is located in the North-west of Iran and is the center of East Azerbaijan province.

Methods

Among the urban health centers of Tabriz, four centers were randomly selected from the same socio-economic areas. Then, these four centers were randomly allocated to the experimental and control groups. The random sampling method was done among the mothers who referred to the health center to receive health care. The randomization was performed using the file number of their documented health records. The required sample size was determined to be 148 using the following formula. The samples were divided into two groups of experimental (n=74) and control (n=74).

$n=\frac{2{(Z_{\mathrm{1-\alpha /2}}+Z_{\mathrm{1-\beta }})}^2}{{\mathrm{ES}}^2}$

In this formula, Z₁ and Z₂ were extracted from standard normal distribution based on confidence level and power of 0.95 and 0.84, respectively and ES was the effect size of the test that was considered 0.5.

Measuring tools: validity and reliability

Data were measured through a self-administered questionnaire, which was completed immediately after the intervention and at 3 and 6 months of follow-ups by participants in experimental and control groups. Data were collected through researcher-made questionnaires, which composed of three parts including socio-demographic data, oral health self-care behaviors, and structures of TPB.

In part one, we evaluated the demographic characteristics of the participants including age, educational level of the participants (primary school, secondary school, high school, diploma, and academic education), employment and marital status, self- rated economic status(poor, average, good), and number of members in family.

In part two, the oral health self-care behaviors of the mothers and their children were measured with 5 questions (3 items for mothers and 2 items for children) derived from the available literature [ 12 , 20 ]. For instance, the frequency of tooth brushing were asked, and the given score ranged from 0(Irregularly or never) to 4(twice daily or more). The possible score range was 0–11 and the higher score indicated the higher oral health self-care behaviors.

In part three, the constructs of TPB related to oral health was assessed through 18 questions [ 20 ]. The items are presented in Table 1. The TPB- based questions included attitude (6items), subjective norms (6items), perceived behavioral control (3items), and intention (3items). Responses for all the TPB constructs were scored from 1(strongly disagree) to 5(strongly agree). The expert panel of ten academicians (four dental public health professionals, four professionals in health education and health promotion professionals, and two health care providers) confirmed the content validity. The mean content validity ratio (CVR) and content validity index (CVI) were calculated at 0.79 and 0.87, respectively. The total reliability (Cronbach’s alpha) for the scale was 0.89.

Intervention

Mothers in the experimental group participated in three educational sessions, each session was held for 120 minutes. The employed educational method included interactive lectures, group discussions, demonstrations, and question-answers sessions. The educational interventions team included a dentist, a nutritionist, and a health care provider with the background in health education. The educational media such as video projectors, PowerPoint, and posters were used in educational sessions. All participants in the intervention group received a pamphlet containing information on oral health, the importance of oral self- care behaviors, the recommended oral health self –care behavior, and the correct technique for tooth- brushing, and dental flossing. The details of the intervention are presented in Table 2.

Ethical consideration

The Ethical Committee of Isfahan University of Medical Science, Iran, approved the study protocol (ID number- 93-393296). The purpose of the study was explained to the participants, and a written consent was then obtained from participating mothers who volunteered to enter this study.

Inclusion and exclusion criteria

The eligibility criteria for inclusion was having profile in health centers, willing to participate in the study, not suffering from special mental and emotional diseases (concerning their medical profiles). Exclusion criteria were the failure to complete three educational sessions and the lack of desire for participation.

Data Analyses

SPSS version 16 (SPSS, Inc., Chicago, IL, USA) statistical software was used to analyze the data. Descriptive statistics were performed to assess the means and standard deviation for quantitative variables and frequencies for categorical variables. Independent samples t-test for continuous variables and chi-square test for categorical variables were used to compare the demographic characteristics between the two groups. Independent samples t-test was used to compare the constructs of TPB and oral self –care behaviors score between two groups at baseline and follow- up (immediately, 3 months, and 6 months after the intervention). Repeated measure ANOVA was used to compare the constructs of TPB and oral health self-care behaviors in four measurements. For all tests, the significance level of α was considered as 0.05.

Results

The mean (SD) age of the participants was 29.4 (7.1) and 28.7 (6.4) years in the experimental and control groups, respectively. According to the independent samples t-test, the mean age of the participants was not significantly different between the two groups (t=0.44, p= 0.65). Socio-demographic characteristics of the participants are presented in Table 3. This finding showed that there was no significant difference between both groups in the terms of marital status (p= 0.49), occupation (p=0.6), education level (p= 0.97), economic status (p= 0.62),and number of family (p= 0.56).

As shown in Table 3, at the baseline, there was no significant difference in the mean scores of mothers’ attitude, subjective norm, perceived behavioural control, and intention regarding children oral health between two groups (p> 0.05). However after intervention, there was a significant difference in the mean scores of mothers’attitude, subjective norm, perceived behavioural control, and intention regarding children oral health between two groups (p< 0.001). The mean and standard deviations of TPB constructs and oral self- care behaviors at the baseline and after intervention are shown in Table 4. The results of the R.M.ANOVA showed a significant increase in TPB constructs, oral self- care behaviors scores of the participants (both mother and child) in the experimental group after the intervention (p< 0.001). But, the TPB constructs and oral self- care behaviors scores of the participants (both mother and child) in the control group was not signifi-cantly different at the baseline and after intervention (p> 0.05). Children tooth brushing behavior at the baseline and 6 months after intervention are shown in Table 5.

The results of the chi-square test showed a significant increase in the frequency of children tooth brushing in the experimental group after the intervention (p< 0.001). In the experimental group, the children brushing twice-daily was 8.1 %( 6/74) which increased to 55.4% (41/74) after the intervention (p< 0.001).

Discussion

Based on our knowledge, this study is one of the few theory-based interventions on oral self-care behaviors among both mothers and their children. According to our results, after the intervention, mothers 'attitude, subjective norm, perceived behavioral control, intention regarding oral health, and oral self-care behaviors (mother and child) of the experimental group was found to be significantly increased as compared to those who were in control group. Hence, it can be verified that theory-based intervention was effective in improving and maintaining the oral self-care behavior of both mothers and their children. This study showed the score of the children’s oral self-care significantly increased in the experimental group after immediately, 3 and 6 months of follow-up. This finding is consistent with some studies that reported the positive impact of the education intervention for mothers and caregivers in improving the children’s oral health behavior [ 21 - 22 ]. A study conducted by Naidu et al. [ 23 ] indicated that the children’s oral health behavior increased after parents and caregivers participating in educational intervention program. The investigation of Soussou et al. [ 24 ] showed that children's tooth brushing improved from 54% to 85% after oral health education for their mothers. The study of Huebner and Milgrom [ 25 ] evaluated a parent‐designed program to support tooth brushing of infants and young children and showed that children's brushing twice daily increased from 59% to 89% after intervention.

Tooth brushing is an important aspect of child oral self-care; tooth brushing twice daily is recommended for children’s oral health self-care [ 24 - 25 ]. On the other hand, parents are responsible for their children’s oral hygiene and the mother’s role is significant in this regard [ 12 ]. The results of this study showed that the score of the mothers’ oral self-care behaviors has significantly increased in the experimental group after immediately, 3and 6 months of follow-up. This finding is consistent with several previous studies in this field that found a significant improvement on oral health self-care after intervention [ 26 - 27 ]. In another study, it was found that oral self-care skills scores were increased significantly after intervention among adolescents [ 28 ].

This study revealed that the experimental group had higher attitude toward oral self-care behaviors compared to the control group after the intervention. This finding is consistent with several previous studies [ 29 - 30 ]. Amin et al. [ 31 ] reported the positive effect of the intervention considering TPB on participants’ attitude toward oral health behavior. One of the predisposing factors to achieve health-promoting behaviors is the attitude [ 8 ]. Some previous studies emphasized the role of mothers’ attitude on their children’s oral self-care behaviors, and subsequently on their children’s oral health [ 20 , 32 ].

Similar to the findings of previous studies [ 27 , 30 - 31 ], in the current study, after intervention, the mean score of perceived behavioral control towards children's oral health was increased significantly in the experimental group compared to control group. This finding is also consistent with a similar previous study by Hatefnia et al. [ 33 ] that found the positive impacts of theory- based interventions on maternal perceived behavioral control toward children's oral self- care.

 The results of current study showed that mothers’ intention towards children's oral health increased in experimental group significantly compared to the control group. This finding is consistent with Jafari Baghkheirati et al. [ 30 ], Amin et al. [ 31 ], which reported positive effects of educational intervention on intention toward oral self- care. In addition, this finding is in line with another study that showed the positive impacts of interventions on maternal intention toward children's oral self- care [ 33 ]. There were some limitations to this study. Firstly, the questionnaire was self-reported that could be subjected to recall and social desirability biases. Secondly, there was no clinical examination for the outcome variable (oral self- care behaviors).

Conclusion

In conclusion, the results of this study showed that TPB-based education intervention program for mothers can increase their attitude, intention, perceived behavioral control towards children oral health and oral self-care of mothers and their children. Therefore, TPB-based interventions need to be considered in the preventive oral health program at health centers.

References

1. Petersen PE, Bourgeois D, Bratthall D, Ogawa H. Oral health information systems--towards measuring progress in oral health promotion and disease prevention. Bull World Health Organ. 2005; 83: 686-693.
2. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme. Community Dentistry Oral Epidemiology. 2003; 31: 3-24.
3. Bayat Movahed S, Samadzadeh H, Ziyarati L, Memory N, Khosravi R, Sadr Eshkevari P. Oral health of Iranian children in 2004: a national pathfinder survey of dental caries and treatment needs. EMHJ. 2011; 17: 243-249.
4. Shaghaghian S, Zeraatkar M, Sabokseir A, Amin M. Factors associated with parental awareness of dental caries in preschool children in Shiraz, Iran, in 2014. Journal of Oral Health and Oral Epidemiology. 2017; 6: 92-101.
5. Gharlipour Z, Sharifirad G, Kazazloo Z, Khoshdani Farahani P, Mohebi S. Factors Affecting Oral-Dental Health in Children in the Viewpoints of Mothers Referred to the Health Centers in Qom City: Using the Health Belief Model. International Journal of Pediatrics. 2016; 4: 3449-3460.
6. Buunk‐Werkhoven YA, Dijkstra A, van der Schans CP. Determinants of oral hygiene behavior: a study based on the theory of planned behavior. Community Dentistry and Oral Epidemiology. 2011; 39: 250-259.
7. Honkala S, Vereecken C, Niclasen B, Honkala E. Trends in toothbrushing in 20 countries/regions from 1994 to 2010. Eur J Public Health. 2015; 2: 20-23.
8. Iwuala SO, Umeizudike KA, Ozoh OB, Fasanmade OA. Oral self-care practices, dental attendance and self-perceived oral health status among internal medicine residents in Nigeria. European Journal of General Dentistry. 2015; 4: 79-86.
9. Soltani R, Eslami AA, Akhlaghi N, Sharifirad G, Alipoor M, Mahaki B. Toothbrushing frequency among 4–6-year-old Iranian children and associated maternal attitude and sociobehavioral factors. Dent Res J. 2017; 14: 50-56.
10. Folayan MO, Kolawole KA, Oyedele T, Chukwumah NM, Onyejaka N, Agbaje H, et al. Association between knowledge of caries preventive practices, preventive oral health habits of parents and children and caries experience in children resident in sub-urban Nigeria. BMC Oral Health. 2014; 14: 156.
11. Charkazi A, Berdi Ozouni- Davaji R, Bagheri D, Mansourian M, Qorbani M, Safari O, et al. Predicting Oral Health Behavior using the Health Promotion Model among School Students: a Cross-sectional Survey. International Journal of Pediatrics. 2016; 4: 2069-2077.
12. Soltani R, Ali Eslami A, Mahaki B, Alipoor M, Sharifirad G. Do Maternal Oral Health-Related Self-Efficacy and Knowledge Influence Oral Hygiene Behavior of their Children?. International Journal of Pediatrics. 2016; 4:2035-2042.
13. Ueno M, Takeuchi S, Oshiro A, Kawaguchi Y. Relationship between oral health literacy and oral health behaviors and clinical status in Japanese adults. Journal of Dental Sciences. 2013; 8: 170-176.
14. Adair PM, Burnside G, Pine CM. Analysis of health behaviour change interventions for preventing dental caries delivered in primary schools. Caries Res. 2013; 1: 2-12.
15. Simpriano DCAB, São-João TM, Mialhe FL. Use of the Theory of Planned Behavior and Implementation Intentions in Dentistry: Evidence of Literature. Brazilian Research in Pediatric Dentistry and Integrated Clinic. 2015; 15: 345-360.
16. Ghaffari M, Nasirzadeh M, Rakhshanderou S, Ramezankhani A. Some of the Strongest Predisposing Factors on the Behavior of Tooth Brushing among Iranian School Age Children. International Journal of Pediatrics. 2017; 5: 4783-4791.
17. Aleksejuniene J, Brukiene V, Dziaugyte L, Peciuliene V, Bendinskaite R. A theory-guided school-based intervention in order to improve adolescents&#039; oral self-care: a cluster randomized trial. International journal of paediatric dentistry/ the British Paedodontic Society [and] the International Association of Dentistry for Children. 2016; 26: 100-109.
18. Ebadi Fardazar F, Solhi M, Mansori K, Mansouri Hanis S, Hashemi SS. Assessment the Effect of Educational Intervention on Preventive Behaviors of Home Accidents in Mothers with Children Less than 5- Year Based on Protection Motivation Theory (PMT). International Journal of Pediatrics. 2016; 4: 2051-2059.
19. Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991; 50: 179-211.
20. Soltani R, Sharifirad G, Mahaki B, Eslami AA. Determinants of Oral Health Behavior among Preschool Children: Application of the Theory of Planned Behavior. J Dent Shiraz Univ Med Sci. 2018; 19: 273-279.
21. Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM. A cluster randomised trial of effectiveness of educational intervention in primary health care on early childhood caries. Caries Res. 2009; 43: 110-118.
22. Van den Branden S, Van den Broucke S, Leroy R, Declerck D, Bogaerts K, Hoppenbrouwers K. Effect evaluation of an oral health promotion intervention in preschool children. The European Journal of Public Health. 2014; 24: 893-898.
23. Naidu R, Nunn J, Irwin JD. The effect of motivational interviewing on oral healthcare knowledge, attitudes and behaviour of parents and caregivers of preschool children: an exploratory cluster randomised controlled study. BMC Oral Health. 2015; 15: 101.
24. Soussou R, Jolanta Aleksejuniene D, Rosamund Harrison D. Waiting room time: An opportunity for parental oral health education. Canadian Journal of Public Health. 2017; 108: E251.
25. Huebner C, Milgrom P. Evaluation of a parent‐designed programme to support tooth brushing of infants and young children. International Journal of Dental Hygiene. 2015; 13: 65-73.
26. Schwarzer R, Antoniuk A, Gholami M. A brief intervention changing oral self-care, self-efficacy, and self-monitoring. British Journal of Health Psychology. 2015; 20: 56-67.
27. Pakpour AH, Gholami M, Gellert P, Yekaninejad MS, Dombrowski SU, Webb TL. The Effects of Two Planning Interventions on the Oral Health Behavior of Iranian Adolescents: A Cluster Randomized Controlled Trial. Ann Behav Med. 2016; 50: 409-418.
28. Džiaugytė L, Aleksejūnienė J, Brukienė V, Pečiulienė V. Self‐efficacy theory‐based intervention in adolescents: a cluster randomized trial- focus on oral self‐care practice and oral self‐care skills. Int J Paediatr Dent. 2017; 27:37- 46.
29. Pakpour AH, Yekaninejad MS, Sniehotta FF, Updegraff JA, Dombrowski SU. The effectiveness of gain-versus loss-framed health messages in improving oral health in Iranian secondary schools: a cluster-randomized controlled trial. Annals of Behavioral Medicine. 2014; 47: 376-387.
30. Jafari Baghkheirati A, Ghahremani L, Kaveh MH. The Effect of Educational Intervention Based on the Theory of Planned Behavior on Degree of Optimism among Male High School Students. Journal of Health Sciences and Surveillance System. 2015; 3: 27-35.
31. Amin M, Nyachhyon P, Elyasi M, Al-Nuaimi M. Impact of an oral health education workshop on parents’ oral health knowledge, attitude and perceived behavioral control among African immigrants. Journal of Oral Diseases. 2014; 2014: 1-7.
32. Vichayanrat T, Sudha K, Kumthanom K, Apisuttisin J, Uawatanasakul N, Ariyakieatsakul Y. What factors influence mothers&#039; behavior regarding control of their children&#039;s sugary snack intake? An application of the Theory of Planned Behavior. Int Dent J. 2018; 68: 336-343.
33. Hatefnia E, Alinasab A, Ghorbani M. Impact of theory-based educational intervention on promotion of cariesprevention behaviors in Iranian mothers with 3-6-year-old children. Biomedical Research. 2017; 28: 1969-1974.