search for




 

Development of a Motivational Interviewing Oral Health Education Program for Elementary School Students
J Dent Hyg Sci 2024;24:274-88
Published online December 31, 2024;  https://doi.org/10.17135/jdhs.2024.24.4.274
© 2024 Korean Society of Dental Hygiene Science.

Yi-Seul Kim1 and Soon-Ryun Lim2,†

1Department of Dental Hygiene, Graduate School Namseoul University, Cheonan 31020, 2Department of Dental Hygiene, Namseoul University, Cheonan 31020, Korea
Correspondence to: Soon-Ryun Lim, https://orcid.org/0000-0002-5654-1995
Department of Dental Hygiene, Namseoul University, 91 Daehak-ro, Seonghwan-eup, Seobuk-gu, Cheonan 31020, Korea
Tel: +82-41-580-2560, Fax: +82-41-580-2926, E-mail: dittochun4@hanmail.net
Received September 3, 2024; Revised September 13, 2024; Accepted October 2, 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Motivational interviewing (MI) is effective in promoting sustained behavioral changes across various fields. However, there is a lack of research on the application of MI in oral health education, targeting elementary school students in South Korea. This study aimed to develop an MI-based oral health education program to positively influence oral health behaviors and improve the oral health of elementary school students.
Methods: The program was developed using Sussman’s curriculum development model in four stages: theoretical research and needs assessment; collection of program activity strategies; evaluation and review of activities; and final production of the program. The program was refined based on feedback from four experts to enhance its validity and effectiveness.
Results: The final program consisted of five one-hour sessions. Fifteen activity sheets were created to align the contents of each session. The sessions incorporated key MI techniques, including open questions, affirmations, reflections, summaries and information provision, with the goals of building rapport, assessing readiness for behavior change, exploring ambivalence, creating discrepancies, motivating change, and planning for action. The oral health education content was tailored to the level of upper elementary students, covering topics such as tooth structure and function, causes and progression of dental caries, Bass method of tooth brushing, use of dental floss and tongue cleaners, and identification of cariogenic foods.
Conclusion: This study is significant because it developed an MI-based program capable of promoting self-driven behavioral change that moves beyond traditional lecture-based oral health education. Future research should focus on evaluating the effectiveness of the program and exploring its applicability to other age groups.
Keywords : Dental health education, Motivational interviewing, Program development
Introduction

1. Background

According to the 2021∼2022 Korean National Children’s Oral Health Survey conducted by the Korea Disease Control and Prevention Agency to ascertain the current state of children’s oral health and management methods in South Korea, the percentage of 12-year-olds with experience of dental caries in the permanent teeth was 58.5%, representing a small increase of 2.0% compared to the rate of 56.4% in 20181). These results show that the prevalence of dental caries has increased despite preventive efforts, including fluoride use, dental sealants, regular examinations, and oral healthcare education.

The main risk factors for dental caries are closely related to oral care attitudes and behaviors2). In particular, proper oral health habits in elementary school can continue into adulthood, meaning that systematic oral healthcare education is important to help maintain behavioral changes3). Current oral healthcare education, however, is mostly delivered in the form of lectures, and though this helps to improve oral health knowledge, it has limited ability to induce persistent behavioral changes4).

Recently, there has been research into psychological approaches to effectively promote and sustain health-related behavioral changes. Motivational interviewing (MI) is a client-centered psychological approach developed by Miller5) in 1983 for the treatment of alcohol addiction. Through strategic utilization of the core conversation techniques of open questions, affirmations, reflections, and summarizing, the client’s internal motivations are reinforced and their ambivalence is explored to promote behavioral changes6). MI has been used in diverse fields, including medicine7), dentistry8), and psychology9).

In the field of dentistry, overseas studies have shown that MI-based behavioral changes related to oral health improvement10), smoking abstinence11), and oral care in implant patients8) persisted over time. In one study of adolescents, the incidence of new carious teeth decreased. In a study on the gingival and plaque indices of orthodontic patients, the plaque index decreased from 1.05 to 0.53 and remained at this level even after 6 months. The gingival index also decreased from 0.72 to 0.39 and this decrease was maintained after 6 months, whereas the control group, who received conventional oral healthcare education, showed no significant changes in either plaque index or gingival index following the intervention4,12). In South Korea, studies on MI in mental health management have been conducted in nursing, but there has been a shortage of MI studies on dental hygiene, with only a single study of university students13). In particular, there have been no studies on elementary school students, who have a high prevalence of dental caries.

2. Objectives

The purpose of this study was to develop an MI-based oral healthcare education program to induce positive changes in oral health behaviors and improve oral health in elementary school students.

Materials and Methods

1. Methods

This study was improved by the institutional review board at Namseoul University. To develop the program, we used the curriculum development model for school-based prevention suggested by Sussman14). This model uses a four-step development process, as shown in Fig. 1. Written informed consent was obtained from all participants.

Fig. 1. Program development process.

1) Step 1: Theory and needs identification

In the first step of theory and needs identification, we reviewed international literature published in the last 10 years on MI in the field of dentistry. For the international literature search, we used PubMed and Medline and searched for combinations of the keywords ‘motivational interviewing’, ‘oral’, and ‘oral health’. When selecting studies, we reviewed the titles and abstracts and excluded studies that were no MI studies on oral health, or where the manuscript could not be accessed. Through the literature review, we examined trends in MI research and identified the purpose of needs of the study.

2) Step 2: Collection of strategies for program activities

In the second step of collecting strategies for program activities, in order to develop a program with the required content for oral healthcare in elementary school students, we set MI courses, and goals and oral healthcare education content for each course. The MI process consists of four stages—engaging, focusing, evoking, and planning—and we set goals for behavioral changes at each stage, focusing on oral healthcare behaviors. Oral healthcare education content was set to meet the levels of mid-to-late elementary school students, consisting of the structure and function of teeth, the causes and course of dental caries, rotary toothbrushing technique, use of floss and tongue cleaners, and cariogenic foods.

3) Step 3: Activity assessment and review

In the third step of activity assessment and review, we conducted an expert assessment to determine the suitability of the program. The expert assessment was conducted from April 15th to 29th, 2024. The experts consisted of a counseling professor, an active international MI trainer and the first person in South Korea to be educated as an MI trainer, an elementary school teacher with experience of developing and researching an MI program for elementary school students, a person with experience of developing and researching two MI programs in the field of dental hygiene, and a dental hygienist with experience of providing oral healthcare education to elementary school students more than 10 times. The experts rated the validity of the goals, intervention methods, introduction, development, ending, and MI-related activity sheet for each stage of the program on a 5-point Liekrt scale from 1 point (very invalid) to 5 points (very valid), and provided their opinions openly about specific revisions and additions to the program.

4) Step 4: Program production

In the fourth step of program production, we revised and supplemented the content of the program based on the expert assessment, and ultimately developed an MI-based oral healthcare education program for elementary school students.

Results

1. Theory and needs identification

In the literature review, we retrieved 16 studies, with 7 studies on parents and children, 3 studies on 12∼13-year-olds, 2 studies on pregnant women, 2 studies on the elderly, 1 study on general adults, and 1 study on periodontitis patients with implant prostheses. In terms of the number of MI sessions, the most common were single-session studies (9 studies), and the session durations were ≤45 minutes. All 3 studies on 12∼13-year-olds were single-session studies. The session durations were 15∼30 minutes in 2 studies, and in 1 study were 20∼30 minutes for an in-person MI group and 30∼45 minutes for an online MI group. The common dependent variables were toothbrushing frequency, snacking frequency, and oral care self-efficacy, with the MI groups showing increased toothbrushing frequency and decreased snacking frequency (Table 1)4,8,15-28).

Characteristics of Included Studies

No Author Year Sample Design Session Time (min) Dependent variable Main result Research objective
1 Mohammadi et al.15) 2015

222

Parent-childdyads

RCT 1 Session 45 PI, GI, DMFT Significant improvement in PI and GI in the MI group compared to the traditional group. No significant difference in DMFT To evaluate the effectiveness of MI versus traditional oral health education methods on the oral health status of preschool children
2 Naidu et al.16) 2015

79

Parent-child dyads

RCT 1 Session 30 Oral health knowledge, attitudes, beliefs, behaviors, self-efficacy MI group showed improvements in tooth brushing frequency, reduction in oral health fatalism, and positive acceptance of MI intervention To assess the effect of MI on oral health knowledge, attitudes, beliefs, and behaviors among parents and caregivers of preschool children
3 Gao et al.17) 2015

495

12∼13 years old

RCT 1 Session 20∼30 or 30∼45 Oral health behaviors (toothbrushing, snacking), number of new caries surfaces, gingival bleeding score, oral health self-efficacy Since online group MI is expected to be more convenient, accessible, and time efficient, it might address the practicality issues and pave the way for the application of MI in dental practice To compare the effectiveness of health education, face-to-face individual MI, and online group MI in improving adolescents’ oral health behaviors
4 Wu et al.4) 2017

512

12∼13 years old

RCT 1 Session 15∼30 Oral hygiene, dental caries, oral health self-efficacy, toothbrushing frequency, snacking frequency

Groups II and III showed greater reduction in snacking frequency and increase in toothbrushing frequency compared to group I

Groups II and III had fewer new carious teeth compared to group I

To evaluate the effectiveness of MI in improving adolescents’ oral health behaviors and preventing dental caries
5 Henshaw et al.18) 2018

1,065

Parent-child dyads

RCT 9 Session 30 DMFS, caregiver oral health knowledge, child oral health behaviors Significant increase in caregiver oral health knowledge in the intervention group compared to control To evaluate whether MI intervention reduces caries increment over 2 years among children aged 0 to 5 years living in public housing compared to controls
6 Tellez et al.19) 2019

60

Elderly

One group pre-post 1 Session 45 Self-efficacy, oral health-related quality of life, oral health knowledge MI intervention had a positive impact on self-efficacy and oral health-related quality of life To evaluate the treatment fidelity of an individual-based MI intervention and assess factors like self-efficacy, oral health-related quality of life, and oral health knowledge among the elderly
7 Faustino-Silva et al.20) 2019

414

Parent-child dyads

RCT 4 Session - Caries incidence rate MI had a greater preventive effect against caries in lower-income groups, preventing 57% of carious lesions To investigate the differential preventive effect of MI on ECC according to socioeconomic variables
8 Tellez et al.21) 2020

180

Older adults

RCT 1 Session 45 Self-efficacy, oral health-related quality of life, oral health knowledge Significant improvement in SE and oral health-related quality of life scores over 12 months in the MI group To assess the treatment fidelity and non-clinical outcomes of an oral health education intervention using MI among older adults in Philadelphia
9 Saffari et al.22) 2020

112

Pregnant women

RCT 2 Session 45 Oral health self-efficacy, oral health behaviors Significant improvements in oral health self-efficacy, general self-efficacy, and healthy oral behaviorsin the MI group To investigate the effect of a health education program using MI on oral health behavior and self-efficacy in pregnant women
10 Jiang et al.23) 2020

692

Parent-child dyads

RCT 1 Session 15∼20 Parental efficacy, children’s oral health behaviors, PI, DMFS The PE+MI and PE+MI+RA groups showed significantly lower caries incidence and plaque scores, with improvements in parental efficacy and children’s oral health behaviors compared to the PE group To evaluate the effectiveness of integrating MI and a caries RA tool into PE on preventing ECCaries and improving oral health behaviors
11 Wu et al.24) 2022

512

12∼13 years old

RCT 1 Session 15∼30 Oral health self-efficacy, snacking frequency, toothbrushing frequency, plaque score, caries increment MI groups showed significant improvements in oral health behaviors and self-efficacy, with group III showing greater reductions in snacking frequency and increases in toothbrushing frequency To evaluate the effectiveness of MI and the cariogram tool in changing oral health behaviors and preventing dental caries in adolescents
12 Arnett et al.25) 2022

60

Adult

RCT 4 Session 5∼10 Perceived importance, interest, and self-efficacy regarding oral health behaviors The MI group showed significant increases in perceived importance, interest, and self-efficacy regarding oral health behaviors compared to the control group, with statistically significant results in long-term behavior change maintenance To investigate the effect of MI on periodontal patients’ perceived importance, interest, and self-efficacy of oral health behaviors, and to evaluate the impact of MI fidelity on these outcomes
13 Ramírez-Trujillo et al.26) 2022

135

Pregnant women

RCT 1 Session 20 COHKAP, MOHKAP, COHMSE The experimental group showed significant improvements in COHKAP, MOHKAP, and COHMSE compared to the control group To evaluate the effect of MI on maternal and child oral health behaviors, self-efficacy, and oral health knowledge, attitudes, and practices
14 Falahinia et al.27) 2023

61

Parent-leukemic child dyads

RCT 3 Session 45 Mother’s knowledge, attitude, motivation, and practices regarding oral health (for both child and personal care), child’s PI The MI group showed significant improvements in mother’s knowledge, attitude, motivation, and practices, as well as a significant reduction in child’s PI compared to the CI group To evaluate the effect of MI on the oral health of leukemic children and their mothers’ oral health knowledge, attitude, motivation, and practices
15 He et al.8) 2023

70

Implant-restored patients with periodontitis

RCT - 15∼20 Oral cleaning behavior, periodontal health status (modified Plaque Index mPLI, modified Bleeding Index mSBI) The MI group showed significant improvements in oral cleaning behavior and periodontal health status compared to the control group To evaluate the effect of MI based on the transtheoretical model on the oral cleaning behavior of patients with periodontitis who have undergone implant restoration
16 Arrow et al.28) 2023

917

Parent-child dyads

RCT 3 Session - ECC, parental attitudes toward oral health, parental self-efficacy The experimental group showed improved parental attitudes toward oral health, but there was no significant difference in ECC incidence To evaluate the effectiveness of MI combined with anticipatory guidance in preventing ECC and improving parental attitudes and self-efficacy

RCT: randomized controlled trial, MI: motivational interviewing, PI: plaque index, GI: gingival index, DMFT: decayed, missing, and filled teeth, DMFS: decayed, missing, and filled surfaces, ECC: early childhood caries, PE: prevailing health education, RA: risk assessment, COHKAP: child oral health knowledge and practices, MOHKAP: maternal oral health knowledge and practices, COHMSE: child oral health-related self-efficacy, CI: common instruction.



2. Collection of strategies for program activities

Table 2 shows the results of constructing the MI courses, and the goals and oral healthcare education content for each course. Session 1 was the ‘engaging’ course, and consisted of self-introductions through identification of one’s strengths, signing the program pledge, observing and drawing the inside of one’s mouth, and activities related to recognizing the current importance of oral care and finding self-confidence. The goals of these activities were to form a trust relationship between the researchers and participants, and to provide motivation to participate in the oral healthcare education program. Session 2 was the ‘focusing’ course and part of the ‘evoking’ course, and consisted of education in toothbrushing methods and activities for thinking about the timing, methods, and frequency of one’s own toothbrushing, and likes and dislikes related to toothbrushing. The goals of these activities were for participants to recognize their changed intentions towards oral care, to explore their ambivalence towards oral care, and to develop discrepancy. Sessions 3 and 4 were part of the ‘evoking course’, and consisted of sharing experiences of toothbrushing failures and successes after toothbrushing education, imaging the future appearance of one’s mouth, recognizing the importance of and finding self-confidence for the use of oral hygiene aids and finding self-confidence, identifying one’s liked and disliked foods, and recognizing the importance of and finding self-confidence for controlling one’s diet. The goals of these activities were to provide and strengthen motivation for oral care. Session 5 was the ‘planning’ course, and the goals were to make a plan for practicing oral care, and to finally test one’s self-confidence towards alternative behaviors and change.

Strategies for Collecting Motivational Interviewing (MI) Program Process

Stage 1 2 3 4
MI process Engaging Focusing Evoking Panning
Session 1 2 2, 3, 4 5
MI goal

Building rapport

Motivating participation

Identifying willingness to change

Exploring ambivalence

Develop

Discrepancy

Elicit motivation

Explore alternative behaviors

Develop a change plan

Final review of change confidence

Oral health education Structure and function of teeth, causes and process of dental caries Rolling method of toothbrushing Dental floss, tongue cleaner, cariogenic diet Developing an oral health action plan


3. Activity assessment and review

1) Results of expert assessment for Session 1

The mean and standard deviation of the validity scores for Session 1 of the program are described below (Table 3). The mean validity scores were all ≥4.00 points for goals (4.75±0.50), intervention methods (4.25±0.95), introduction (4.25±1.50), development (4.00±0.50), ending (4.25±1.50), and activity sheets (4.25±0.95).

Expert Assessment Validity for Session 1 (n=4)

Category Mean SD Min Max
Objective 4.75 0.50 4 5
Intervention method 4.25 0.95 3 5
Introduction 4.25 1.50 2 5
Development 4.00 0.50 3 5
Conclusion 4.25 1.50 2 5
Activity sheet 4.25 0.95 4 5

SD: standard deviation.



(1) Reflecting the results of expert assessment for Session 1

In the expert assessment for Session 1, we received opinions stating the need for setting goals at the level of change desired by the individual participant. Specific opinions included, “You need to have a section for discussion of personal intentions or goals,” “The participants need to set their own goals for change at their desired level,” and “One goal [of this session] should be to set targets that account for the stage of change.” Thus, in addition to recognizing the importance of and finding self-confidence for oral care, we added activities for setting personal goals for change. We also hear opinions that there was a large amount of content for activities and that these could be difficult for elementary school students. Specific opinions included, “You need to have a section for discussion of personal intentions or goals,” “It might be difficult for elementary school students, during the first session, to discuss their strengths in relation to practice,” “Rather than discussing strengths, I would suggest discussing past experiences at the dentist,” “Since there are so many activities for developing content, I recommend reducing the time of the introduction,” “On the activity sheet, you need to indicate the meaning of each score from 0 to 10 points (e.g., strongly disagree, strongly agree, etc.),” “I expect it will be difficult for mid-to-late elementary school students to write specific explanations of their scores for importance and self-confidence, and providing examples would make the activity easier,” and “There seem to be a lot of activities, and I think it would be better to conduct the first session at a more leisurely pace.” Thus considering the duration and difficulty, we omitted the activity for identifying strengths. On the activity sheets, we categorized the meanings of scores (0∼10 points) for oral care importance and self-confidence as “not at all important”, “not sure”, and “important”, and presented examples of explanations for why each score might be given. To use the time appropriately, the introduction and ending times were reduced from 10 minutes each to 5 minutes each, and the development time, mostly consisting of program activities and education, was extended from 40 minutes to 50 minutes. Considering that the typical class duration in elementary school is 40 minutes, and that students’ concentration might drop during a 1-hour program session, we also included a 5-minute break in the middle of the session.

2) Results of expert assessment for Session 2

The mean and standard deviation of the validity scores for Session 2 are presented below (Table 4). The mean validity scores were all ≥4.00 points for goals (4.25±1.50), intervention methods (4.25±0.95), introduction (4.75±0.50), development (4.00±1.15), ending (4.75±0.50), and activity sheets (4.50±1.00).

Expert Assessment Validity for Session 2 (n=4)

Category Mean SD Min Max
Objective 4.25 1.50 2 5
Intervention method 4.25 0.95 3 5
Introduction 4.75 0.50 4 5
Development 4.00 1.15 3 5
Conclusion 4.75 0.50 4 5
Activity sheet 4.50 1.00 3 5

SD: standard deviation.



(1) Reflecting the results of expert assessment for Session 2

For Session 2, we received opinions on the need to make questions on ambivalence towards toothbrushing more specific. Detailed opinions included, “You need to specifically verify what participants think about toothbrushing,” “You have to identify both negative and positive emotions,” and “How about expanding the breadth of the questions to obtain diverse responses, such as positive and troubled memories relating to toothbrushing?” Thus, to the activity sheet on which participants wrote about their likes and dislikes relating to toothbrushing, we added a question asking participants about the positive and troubled memories that come to mind when they hear the word “toothbrushing”.

3) Results of expert assessment for Session 3

The mean and standard deviation of the validity scores for Session 3 are presented below (Table 5). The mean validity scores were all ≥4.00 points for goals (4.75±0.50), intervention methods (4.50±0.57), introduction (5.00±0.00), development (4.50±0.57), ending (4.25±1.50), and activity sheets (4.00±1.15).

Expert Assessment Validity for Session 3 (n=4)

Category Mean SD Min Max
Objective 4.75 0.50 4 5
Intervention method 4.50 0.57 4 5
Introduction 5.00 0.00 5 5
Development 4.50 0.57 4 5
Conclusion 4.25 1.50 2 5
Activity sheet 4.00 1.15 3 5

SD: standard deviation.



(1) Reflecting the results of expert assessment for Session 3

For Session 3, we received opinions on the need to make questions about experiences of practicing toothbrushing more specific. Detailed opinions included, “The questions on experiences of practicing toothbrushing feel like they’re not specific. You need to be more specific, such as the frequency of performing toothbrushing properly or not, and what aspects were successful” and “It could be difficult for elementary school students to complete the activity sheet, so you need to present suitable examples.” As such, we added more detail to questions on the activity sheet, such as questions on experiences of failures in practicing toothbrushing, difficulties, experiences of successes, positive aspects, and on the weekly frequency of performing toothbrushing properly or not, the reasons for this, and what aspects were difficult.

4) Results of expert assessment for Session 4

The mean and standard deviation of the validity scores for Session 4 are presented below (Table 6). The mean validity scores were all ≥4.50 points for goals (4.75±0.50), intervention methods (4.75±0.50), introduction (5.00±0.00), development (4.50±0.57), ending (4.75±0.50), and activity sheets (4.75±0.50).

Expert Assessment Validity for Session 4 (n=4)

Category Mean SD Min Max
Objective 4.75 0.50 4 5
Intervention method 4.75 0.50 4 5
Introduction 5.00 0.00 5 5
Development 4.50 0.57 4 5
Conclusion 4.75 0.50 4 5
Activity sheet 4.75 0.50 4 5

SD: standard deviation.



(1) Reflecting the results of expert assessment for Session 4

In the expert assessment for Session 4, we received opinions on the need for activities for thinking about lists of alternative foods. Specific opinions included, “I think it would be good to add content for identifying cariogenic foods and discussing alternative foods that could be eaten instead,” “I think it would be good to include activities to think about lists of possible alternative foods,” and “Because it is difficult to achieve behaviors change by simply stopping a behavior, making a list of alternative behaviors could help with performing the desired behaviors.” Thus, on the activity sheet, to the question about liked and disliked foods, we added a section where participants could write about alternative foods and snacks.

5) Results of expert assessment for Session 5

The mean and standard deviation of the validity scores for Session 5 are presented below (Table 7). The mean validity scores were all ≥4.25 points for goals (4.75±0.50), intervention methods (4.50±1.00), introduction (4.50±1.00), development (4.25±0.95), ending (4.75±0.50), and activity sheets (4.25±0.95).

Expert Assessment Validity for Session 5 (n=4)

Category Mean SD Min Max
Objective 4.75 0.50 2 5
Intervention method 4.50 1.00 3 5
Introduction 4.50 1.00 3 5
Development 4.25 0.95 2 5
Conclusion 4.75 0.50 4 5
Activity sheet 4.25 0.95 3 5

SD: standard deviation.



(1) Reflecting the results of expert assessment for Session 5

In the expert assessment for Session 5, we received opinions such as, “You need to unify questions on SMART and make them more specific,” and “I think the students will find it difficult to write [the answers], so you need to provide examples to help them.” Therefore, we revised these questions to, “S: What can I do in the future for healthy oral care?”, “M: What methods can I use for oral care?”, “A: What are my advantages?”, “R: How can my advantages help me to perform oral care?”, and “T: How long can I perform healthy oral care for?”

4. Program production

Table 8 shows the learning goals and main content of the final program. The program consisted of five sessions in total, with one hour per session. There were a total of 15 activity sheets constructed to fit the contents of each session. We included the core MI techniques of open questions, affirmations, reflections, summaries (OARS) and information provision in each session. Table 9 and Fig. 2 show the goals, intervention methods, introduction, development, and ending of each session, as well as some detailed contents from the activity sheets.

Fig. 2. Final program activity sheet.

Final Program Learning Objectives and Key Content

Session Subject Goal Content MI skill Time
1 Structure and function of teeth, causes and process of dental caries

Building rapport

Understanding the structure and function of teeth

Comprehending the causes and processes of dental caries and setting personal oral hygiene goals to motivate participation in the program

Self-introduction

Introduction of personal experiences related to dentistry

Explanation of the structure and function of teeth

Personal oral observation

Understanding the importance of oral care and assessing confidence

Setting goals for oral care improvement

Signing a participation pledge

Open question

Affirmation

Simple reflection

Summary

1 h
2 Rolling method of toothbrushing

Exploring ambivalence towards oral care

Performing the toothbrushing technique using the bass method

Assessing readiness for change in oral care

Understanding current oral care practices

Exploring ambivalence towards toothbrushing

Learning proper toothbrushing techniques

Assessing readiness for change

Open question

Affirmation

Double-sided reflection

Summary

1 h
3 Dental floss, tongue cleaner

Creating a sense of discrepancy regarding oral care to motivate change

Motivating the use of toothbrushing and oral care adjuncts

Performing the use of handled floss and tongue cleaner

Sharing experiences of toothbrushing over the past week

Imagining the desired future oral appearance

Learning the necessity and usage of floss and tongue cleaner

Understanding the importance of using floss and tongue cleaner and assessing confidence

Open question

Affirmation

Complex reflection

Summary

1 h
4 Cariogenic diet

Strengthening motivation for oral care

Identifying cariogenic foods

Sharing experiences with toothbrushing, flossing, and using a tongue cleaner

Identifying the liked foods

Learning about cariogenic foods, protective foods, and cleansing foods

Understanding the importance of not consuming cariogenic foods and assessing confidence

Open question

Affirmation

Simple reflection

Summary

1 h
5 Developing an oral health action plan

Assessing future readiness for change

Writing a change plan

Final review of the importance of change and confidence

Sharing oral care experiences during the program

Importance of and confidence in oral care

Writing a SMART action plan

Open question

Affirmation

Summary

1 h

MI: motivational interviewing.



Detailed Content by Session for the Final Program

Session 3 Subject (dental floss, tongue cleaner)
Goal
  • Create a sense of discrepancy regarding oral care

  • Build motivation for toothbrushing and the use of oral care adjuncts

  • Perform the use of handled floss and tongue cleaner

Intervention methods
  • Write about the successes and failures, positive aspects, and challenges related to toothbrushing practice over the past week. Reflect and summarize participants’ responses during the conversation

  • Encourage participants to think about their desired oral appearance and classify it on the activity sheet Create a sense of discrepancy in oral care by comparing the participant’s current oral care habits, past failures, challenges during practice, and the desired future oral appearance

  • Seek permission to provide information on the use of floss and tongue cleaner, then provide the information

  • Check the importance and confidence in using floss and tongue cleaner on the activity sheet and write down the reasons

  • Ask open-ended questions about the reasons for considering something important or not, and the reasons for high or low confidence. Reflect and summarize these responses

  • Discuss participants’ thoughts on their educational experience, assess their readiness for change, and offer acknowledgment

Activity process Content Time
Introduction
  • Greetings

  • Introduction of the conversation topic

5 min
Development

[Sharing toothbrushing experiences]

  • Write about successes, failures, positive aspects, and challenges of toothbrushing over the past week on the activity sheet

  • Discuss experiences and reflections

[Imagining the desired future oral appearance]

  • Write on the activity sheet

[Learning how to use floss and tongue cleaner]

  • Provide information on the necessity and usage of floss and tongue cleaner using a PPT

  • Practice using handled floss and a tongue cleaner in front of a mirror

[Assessing the importance of and confidence in using floss and tongue cleaner]

  • Mark the importance and confidence scale on the activity sheet

50 min
Conclusion
  • Sharing reflections

  • Announcing the topic for the next session

5 min
Materials Activity sheets, pen, mirror, floss, tongue cleaner, PPT

PPT: power point presentation.


Discussion

1. Interpretation

The aim of this study was to develop an MI-based oral healthcare education program for elementary school students. To this end, we applied the curriculum development model for school-based prevention suggested by Sussman14), collected program activity strategies based on theoretical evidence and investigation of needs, and finally developed a program via a process of activity assessment and review.

2. Comparison with previous studies

In the theory and needs identification stage, we reviewed international MI papers on dentistry from the last 10 years. Of these, there were 3 studies on 12∼13-year-olds. Compared to groups receiving general oral healthcare education, groups receiving MI-based oral healthcare education showed increased toothbrushing frequency and oral care self-efficacy, and reduced snacking frequency. In South Korea, although there have been studies on MI in various fields, including nursing, psychology, and education, there has only been on study of MI in dental hygiene, in which Han et al.13) analyzed the effects of an oral care program using MI in university students. There have also been studies of MI in elementary school students, such as reports by Lee and Shin29) and Kim30), who developed and assessed programs to prevent internet addiction and smartphone overdependence, respectively. However, there is a severe shortage of research on MI-based oral healthcare education in the fields of dentistry and dental hygiene in South Korea, and there have been no such studies on elementary school students.

We reviewed the number of sessions and session duration in studies developing MI-based programs for smoking abstinence. Ha and Choi31) constructed an MI-based program for smoking abstinence with one 30-minute session per week for a total of four sessions, but did not perform expert assessment. Shin and Kim32) constructed a program with one 45-minute session per week for a total of six sessions, and the program was assessed by a panel of four experts. Chang and Kang33) also constructed a program with one 45-minute session per week for a total of six sessions, and the program was assessed by a panel of three experts. The expert panels included nursing professors, addiction treatment experts, and smoking abstinence counselors, but did not include domestic MI trainers or persons with experience of receiving MI training from the Korean Association of Motivational Interviewing. In our study, we constructed an MI-based oral healthcare education program with a total of five 60-minute sessions. As part of the program development, we subjected the program to expert assessment by a panel of four experts, one of whom was an international MI trainer. Thus, we appropriately revised and supplemented the program based on a reliable expert assessment of the number and duration of MI sessions, the steps, basic mindset, core techniques, and program composition.

Elementary school students are at an age when oral health-related habits can be formed. Oral healthcare education using the core techniques of MI at this time can promote positive oral health-related behaviors that persist to adulthood, effectively promoting improvement and maintenance of oral health. As such, there is a need to validate whether the principles and core techniques of MI are suitable as a method to improve the oral health of elementary school students in South Korea.

In the step for collecting activity strategies, including the core OARS techniques of MI and the stage of behavioral change, we identified essential oral healthcare education content for elementary school students and set goals for each session. We supplemented the program through expert assessment, and reinforced elements such as ‘goal setting’, ‘exploring ambivalence’, and ‘identifying alternative foods’. In addition, we made revisions to improve understanding, such as adjusting the language of the program to suit the level of elementary school students, and adding examples to the open-ended questions.

The final developed program consisted of 5 sessions in total. The main content included the structure and functions of teeth, rotary toothbrushing, the use of floss and tongue cleaners, and alternatives to cariogenic foods. Each session was focused on promoting changes in oral health behaviors, through the formation of trust relationships, setting goals for change, providing motivation to participate, exploring ambivalence, identifying one’s changed intentions, and strengthening motivation.

We anticipate that the MI-based oral healthcare education program developed in our study will help to improve oral care knowledge and behaviors and maintain behavioral changes in mid-to-late elementary school students.

3. Limitations

Although we conducted an expert assessment as part of the development of our MI-based oral healthcare education program, one limitation is that there were only four persons on the expert panel. Another limitation of the program is that some of the activities intended to promote intrinsic motivation and behavioral change, such as rotary toothbrushing and the use of floss picks, require the participants to perform activities themselves, meaning that the program could only be developed for mid-to-late elementary school students, and no early elementary school students.

4. Suggestion

This study is valuable because we developed an MI-based program that goes beyond current lecture-based oral healthcare education in the field of dentistry in South Korea, and can encourage participants to achieve behavioral changes. In future studies, it will be necessary to evaluate the efficacy of this program in mid-to-late elementary school students, and to develop programs that can be applied to other age groups.

Acknowledgements

None.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

This study was approved by the institutional review board of Namseoul University (IRB No. NSU-202402-001).

Author contributions

Conceptualization: Yi-Seul Kim and Soon-Ryun Lim. Data acquisition: Yi-Seul Kim. Formal analysis: Yi-Seul Kim. Supervision: Soon-Ryun Lim. Writing-original draft: Yi-Seul Kim. Writing-review & editing: Soon-Ryun Lim.

Funding

None.

Data availability

Raw data is provided at the request of the corresponding author for reasonable reason.

References
  1. Korean Statistical Information Service: 2021-2022 Survey on children's oral health. Retrieved August 24, 2024, from https://kosis.kr/statHtml/statHtml.do?orgId=177&tblId=DT_117051_AD1224&conn_path=I2(September 11, 2023)
  2. Sandström A, Cressey J, Stecksén-Blicks C: Tooth-brushing behaviour in 6-12 year olds. Int J Paediatr Dent 21: 43-49, 2011. https://doi.org/10.1111/j.1365-263X.2010.01080.x
    Pubmed CrossRef
  3. Bartley M, Blane D, Montgomery S: Health and the life course: why safety nets matter. BMJ 314: 1194-1196, 1997. https://doi.org/10.1136/bmj.314.7088.1194
    Pubmed KoreaMed CrossRef
  4. Wu L, Gao X, Lo ECM, Ho SMY, McGrath C, Wong MCM: Motivational interviewing to promote oral health in adolescents. J Adolesc Health 61: 378-384, 2017. https://doi.org/10.1016/j.jadohealth.2017.03.010
    Pubmed CrossRef
  5. Miller WR: Motivational interviewing with problem drinkers. Behav Cogn Psychother 11: 147-172, 1983. https://doi.org/10.1017/S0141347300006583
    CrossRef
  6. Miller WR, Rollnick S: Motivational interviewing: helping people change. 3rd ed. Guilford Press, New York, pp. 1-211, 2013.
    CrossRef
  7. Li X, Yang S, Wang Y, Yang B, Zhang J: Effects of a transtheoretical model - based intervention and motivational interviewing on the management of depression in hospitalized patients with coronary heart disease: a randomized controlled trial. BMC Public Health 20: 420, 2020. https://doi.org/10.1186/s12889-020-08568-x
    Pubmed KoreaMed CrossRef
  8. He G, Wang Z, Hu C, et al: The effect of motivational interviewing based on the transtheoretical model on oral cleaning behavior of patients with periodontitis who have undergone implant restoration. Technol Health Care 31(S1): 541-549, 2023. https://doi.org/10.3233/thc-236048
    Pubmed KoreaMed CrossRef
  9. Kang HY, Lee HJ: The effect of motivational interviewing program on self-efficacy and suicidal ideation of suicide attempters. Ment Health Soc Work 45: 116-143, 2017. https://doi.org/10.24301/MHSW.2017.03.45.1.116
    CrossRef
  10. Hawrot H: Does motivational interviewing promote oral health in adolescents?. Evid Based Dent 22: 134-135, 2021. https://doi.org/10.1038/s41432-021-0219-6
    Pubmed CrossRef
  11. Melnick R, Mendonça CS, Meyer E, Faustino-Silva DD: Effectiveness of motivational interviewing in smoking groups in primary healthcare: a community-based randomized cluster trial. Cad Saude Publica 37: e00038820, 2021. https://doi.org/10.1590/0102-311x00038820
    Pubmed CrossRef
  12. Rigau-Gay MM, Claver-Garrido E, Benet M, Lusilla-Palacios P, Ustrell-Torrent JM: Effectiveness of motivational interviewing to improve oral hygiene in orthodontic patients: a randomized controlled trial. J Health Psychol 25: 2362-2373, 2020. https://doi.org/10.1177/1359105318793719
    Pubmed CrossRef
  13. Han YS, Bae HS, Cho YS: The effect of oral health care program based on motivational interviewing. J Dent Hyg Sci 14: 287-294, 2014. https://doi.org/10.17135/jdhs.2014.14.3.287
    CrossRef
  14. Sussman S: Curriculum development in school-based prevention research. Health Educ Res 6: 339-351, 1991. https://doi.org/10.1093/her/6.3.339
    CrossRef
  15. Mohammadi TM, Hajizamani A, Bozorgmehr E: Improving oral health status of preschool children using motivational interviewing method. Dent Res J (Isfahan) 12: 476-481, 2015. https://doi.org/10.4103/1735-3327.166231
    Pubmed KoreaMed CrossRef
  16. 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 15: 101, 2015. https://doi.org/10.1186/s12903-015-0068-9
    Pubmed KoreaMed CrossRef
  17. Gao X, Lo EC, McGrath C, Ho SM: Face-to-face individual counseling and online group motivational interviewing in improving oral health: study protocol for a randomized controlled trial. Trials 16: 416, 2015. https://doi.org/10.1186/s13063-015-0946-0
    Pubmed KoreaMed CrossRef
  18. Henshaw MM, Borrelli B, Gregorich SE, et al: Randomized trial of motivational interviewing to prevent early childhood caries in public housing. JDR Clin Trans Res 3: 353-365, 2018. https://doi.org/10.1177/2380084418794377
    Pubmed KoreaMed CrossRef
  19. Tellez M, Myers Virtue S, Neckritz S, Bhoopathi V, Hernández M, Shearer B: Motivational interviewing and oral health education: experiences from a sample of elderly individuals in North and Northeast Philadelphia. Spec Care Dentist 39: 201-207, 2019. https://doi.org/10.1111/scd.12366
    Pubmed CrossRef
  20. Faustino-Silva DD, Colvara BC, Meyer E, Hugo FN, Celeste RK, Hilgert JB: Motivational interviewing effects on caries prevention in children differ by income: a randomized cluster trial. Community Dent Oral Epidemiol 47: 477-484, 2019. https://doi.org/10.1111/cdoe.12488
    Pubmed CrossRef
  21. Tellez M, Myers Virtue S, Neckritz S, et al: Randomised clinical trial of a motivational interviewing intervention to improve oral health education amongst older adults in Philadelphia: 12-month evaluation of non-clinical outcomes. Gerodontology 37: 279-287, 2020. https://doi.org/10.1111/ger.12488
    Pubmed CrossRef
  22. Saffari M, Sanaeinasab H, Mobini M, et al: Effect of a health-education program using motivational interviewing on oral health behavior and self-efficacy in pregnant women: a randomized controlled trial. Eur J Oral Sci 128: 308-316, 2020. https://doi.org/10.1111/eos.12704
    Pubmed CrossRef
  23. Jiang S, McGrath C, Lo EC, Ho SM, Gao X: Motivational interviewing to prevent early childhood caries: a randomized controlled trial. J Dent 97: 103349, 2020. https://doi.org/10.1016/j.jdent.2020.103349
    Pubmed CrossRef
  24. Wu L, Lo ECM, McGrath C, Wong MCM, Ho SMY, Gao X: Motivational interviewing for caries prevention in adolescents: a randomized controlled trial. Clin Oral Investig 26: 585-594, 2022. https://doi.org/10.1007/s00784-021-04037-w
    Pubmed CrossRef
  25. Arnett MC, Evans MD, Stull CL: Brief motivational interviewing: evaluation of a skills-based education program. J Dent Hyg 96: 46-56, 2022.
  26. Ramírez-Trujillo M, Villanueva-Vilchis MC, Gaitán-Cepeda LA, Aguilar-Díaz FC, Rojas-Russell ME, Fuente-Hernández J: Impact of a maternal motivational interviewing on oral health in the mother-child dyad. Healthcare (Basel) 10: 1044, 2022. https://doi.org/10.3390/healthcare10061044
    Pubmed KoreaMed CrossRef
  27. Falahinia N, Razeghi S, Shamshiri AR, Firoozi M, Mohebbi SZ: The effectiveness of motivational interviewing on the oral health of leukemic children and oral health care knowledge, attitude and practice of their mothers: a hospital- based intervention. BMC Pediatr 23: 261, 2023. https://doi.org/10.1186/s12887-023-04078-y
    Pubmed KoreaMed CrossRef
  28. Arrow P, Raheb J, McInnes R: Motivational interviewing and childhood caries: a randomised controlled trial. Int J Environ Res Public Health 20: 4239, 2023. https://doi.org/10.3390/ijerph20054239
    Pubmed KoreaMed CrossRef
  29. Lee JN, Shin JH: The effects of motivational group art therapy on symptoms of internet addiction and self-control of internet-addicted children. Korean J Art Ther 27: 259-281, 2020. https://doi.org/10.35594/kata.2020.27.2.004
  30. Kim H: The development and effectiveness of motivational interviewing smartphone addiction prevention program for the middle grades of elementary school. J Educ Cult 28: 573-597, 2022. https://doi.org/10.24159/joec.2022.28.5.573
    CrossRef
  31. Ha YS, Choi YH: Effectiveness of a motivational interviewing smoking cessation program on cessation change in adolescents. J Korean Acad Nurs 42: 19-27, 2012. https://doi.org/10.4040/jkan.2012.42.1.19
    Pubmed CrossRef
  32. Shin ES, Kim SJ: The effect of motivational counseling program on the knowledge and attitude of smoking cessation and smoking cessation behaviors of middle school students. J Korea Contents Association 16: 444-455, 2016. https://doi.org/10.5392/JKCA.2016.16.11.444
    CrossRef
  33. Chang KO, Kang JH: The effects of motivation enhancement for smoking cessation program on middle school students' knowledge on smoking, self-efficacy, and daily amount of smoking. J Korea Acad Ind Coop Soc 19: 393-403, 2018. https://doi.org/10.5762/KAIS.2018.19.12.393


December 2024, 24 (4)
Full Text(PDF) Free

Social Network Service

Cited By Articles
  • CrossRef (0)
  • Download (61)

Author ORCID Information