|Year : 2014 | Volume
| Issue : 3 | Page : 225-230
Infant motivation in dental health: Attitude without constant reinforcement
Fabiana Bucholdz Teixeira Alves1, Eunice Kuhn1, Danielle Bordin1, Vitoldo Antonio Kozlowski1, Daniela Procida Raggio2, Cristina Berger Fadel1
1 Department of Dentistry, Ponta Grossa State University, Ponta Grossa, Brazil
2 Department of Pediatric Dentistry and Orthodontics, Dental School, University of Sao Paulo-USP, Sao Paulo, Brazil
|Date of Web Publication||2-Jul-2014|
Fabiana Bucholdz Teixeira Alves
Department of Dentistry, Ponta Grossa State University, General Carlos Cavalacanti Av., 4748 - Campus Uvaranas, CEP: 84030-900, Ponta Grossa, PR
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Social factors determine the child's behavior and motivation is an important task in the teaching-learning process. This longitudinal and cross-sectional study aimed to analyze the effectiveness of a motivational activity program for oral hygiene habits formation after motivation and without constant reinforcement. Materials and Methods: The sample was constituted of 26 children (mean 6 years old) from a Public Kindergarten School in Ponta Grossa, PR, Brazil. Data were collected applying a test-chart, with figures reporting the process of dental health/illness. Some figures were considered positive to dental health (dentist/Cod 1, toothbrush/Cod 3, dentifrice/dental floss/Cod 6, fruits/vegetables/Cod 7 and tooth without caries lesion/Cod 8) and negative on dental health (sweets/Cod 2, bacteria/Cod 4, tooth with caries lesion/Cod 5). The figures presentation occurred in three different stages: First stage - figures were presented to children without previous knowledge; second stage - following the motivational presentation, and third stage - 30 days after the first contact. Results: On the first stage, most children select good for the figures considered harmful to their teeth (Cod 2-88%; Cod 4-77% and Cod 5-65%). On the second stage, there was a lower percentage: 23% (P < 0.0001), 8% (P < 0.0001), and 23% (P = 0.0068) related to the Cod 2, 4, and 5. On the third stage, the results showed again an association with the good choice to these figures considered harmful (Cod 2-85%, Cod 4-65% and Cod 5-54%) similar the results obtained on the first stage. Conclusion: The motivational programs performed without constant reinforcement does not have a positive influence in changing the child's behavior related to a better dental care.
Keywords: Child, dental health education, motivation
|How to cite this article:|
Teixeira Alves FB, Kuhn E, Bordin D, Kozlowski VA, Raggio DP, Fadel CB. Infant motivation in dental health: Attitude without constant reinforcement. J Indian Soc Pedod Prev Dent 2014;32:225-30
|How to cite this URL:|
Teixeira Alves FB, Kuhn E, Bordin D, Kozlowski VA, Raggio DP, Fadel CB. Infant motivation in dental health: Attitude without constant reinforcement. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2018 Jul 19];32:225-30. Available from: http://www.jisppd.com/text.asp?2014/32/3/225/135829
| Introduction|| |
Studies show that to obtain and keep oral health it is necessary to use certain resources, especially when we face children's oral hygiene. When the target is infant public, the simple contact with the information it is not always enough to guarantee a satisfactory and lasting behavior about hygiene habits. In addition, daily bases procedures, apparently seems to be easy, but demand time, ability, determination and above all, motivation. The motivation has been pointed as responsible for obtaining positive results in educational health with patients, whether in individual or groups. , All the work team must be together to the action and the patient has to be seen as whole, biologically, socially and emotionally and hence that it will motivate him/her to acquire new healthy habits (attitudinal competence).  Several studies have been carried out in order to evaluate the efficiency of educational/motivational programs, using different methods and observing if they are able in helping to change individual behavior. ,,, Yet, with the same purpose and considering the necessity to prove the importance and efficiency of a preventive/educational program, other researchers concluded that motivation programs must be carried out continuously, for a long period and with a constant effort; only then it is possible to offer effective learning and possible changes of behavior in children in relation to their hygiene habits. ,
Sgan-Cohen  had reported that the basis for any intervention on health, including oral hygiene instruction, must be firmly based on scientific evidence. This must include two components: The identification of risk and level of motivation of patients and their communities. The patients to acquire and keep oral health it is not enough to explain repeatedly the causes of the diseases, neither to show several ways to avoid and finally to oblige them to assimilate the new information. Although, it is necessary to pay attention to the teaching/learning process, that must be conscious and pleasant, aiming to develop their will to learn and also acquire new hygiene habits. These will help them to create and develop favorable conditions to their learning, what will lead them to reach an effective change in their hygiene habits. 
The process that allows the building of learning by children requires from them an intense and internal activity. In these activities they are able to establish relations between new and previous knowledge using the resources they have. This process will help them to change the knowledge they have already acquired, diversifying, enriching or differentiating it due to new information received, what will make them capable to carry out new learning, leading to a more expressive process. The method to achieve training and behavioral changes in the prevention of dental caries is a motivational program to promote dental health education. In this way, the aim of this study was to analyze the effectiveness of a motivational activity program as an aid in oral hygiene habits formation after motivation and without constant reinforcement, applied in preschool children.
| Materials and Methods|| |
This research protocol no. 03436/01 was conducted after Ponta Grossa State University, Institutional Ethical Review Board approval and the information and permission was obtained after consent form signed by a legal guardian.
It was selected a sample of 29 preschool children from 5 to 6 years old, both sex, attending Caritas Municipal Public School, Ponta Grossa, PR, Brazil. The selection of this institution followed an essential criterion for this study: This institution has not been visited before by dentists, or dental students, whether to treatment practices or preventive-motivational reasons. This fact assured a condition of complete lack of technical information from the preschool children about harmful habits concerning to dental health.
It was used a test-chart, especially developed for this study, as an instrument for data collection. It has some figures (Cod) that show a positive and negative relation to dental health, with the aim to collect information about knowledge related to this area. This test-chart followed some criteria in order to be able to recover the children's knowledge:
- To apply a test of perception visual-motor coordination, that is a fast, objective, practical, and efficient way to evaluate or measure some aspects of children's development in relation to the subject discussed.
- To elaborate the test-chart according to age, level of visual and emotional development and motor perception.
- The elaboration of this test, in spite of being original, was based on technical and scientific fields of infant psychology and pedagogy, ,, what gave reliability to the applied methodology. In addition, it is important to point that the test-chart was elaborated respecting the age group by an exercise of visual perception, what made reliable the data collected in the research. A pilot study was carried out with eight children of the same age group from another school, in order to test and improve the test-chart; it was observed the ability of children's interpretation against the proposed figures, where the changes were carried out before applying it in the experimental group.
- The test-chart [Figure 1] is composed of eight figures referring to process of oral health/illness: Five of these figures are considered healthy (positive status) and three harmful (negative status). Each figure was assigned a code (Cod). The healthy figures were represented by the figure of a dentist (Cod 1), illustrated with a professional holding a clinical mirror and wearing an overall; the figure of a toothbrush (Cod 3); the figure illustrated by a dental floss and toothpaste (Cod 6); the figure of fruits, vegetables and healthy food illustrated by a carrot, apple and cheese (Cod 7); and the figure of a tooth without a caries lesion, totally white (Cod 8). Three figures considered harmful represented by candies and sweets, illustrated by chocolate, lollypop and candies (Cod 2); bacteria illustrated by an angry animal with an arrow as if it was ready to attack (Cod 4); and the last one a tooth with caries lesion, with a part colored in black (Cod 5). Next to each figure, the children had two options to choose: Good and bad, represented through the symbol recognized by the children (sad/happy smile).
|Figure 1: Test-chart composed for eight fi gures referring to process of dental health/illness|
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A teacher applied this test with her own students that were involved in the research. She was trained just to remind them that the figure with a happy smile represented something positive and the sad smile something negative. The children should look at each figure carefully, interpret it and put an "X" if it represented something good or bad, avoiding inducing the answer or even to explain the figure. Each child received a test-chart to analyze and interpret in three different stages: On the first stage, the chart was delivered to the children without any intervention from the researchers. The teacher guided them to answer, only explaining that they should look at the figure and put a check if the figure symbolized something good or bad, just pointing to the related symbols. Soon after the children have filled in the chart, they were exposed to a second stage. At this moment, the motivational program showed a video of Doctor Rabbit (around 15 min), who took a trip to several places giving information of how to keep dental health. After the video presentation, it was carried out a puppet play, whose story was about a boy who did not care of his teeth and when his tooth hurt, he went to the dentist where he learned how important it is to take care of teeth. Finally, the students attended a lecture with information about the dental caries process, hygiene care, how to brush their teeth, how they have to use dental floss and about food habits. After this motivational program, the children answered the same test that had been applied before. The whole activity lasted for 4 h.
Thirty days after the first contact, it was carried out the third stage of the research, that was when the children answered the test-chart, conducted by the same teacher, who was asked not to make any comment about the motivational program.
The Chi-square test was applied using GraphPad Prism, versγo 5.0 (GraphPad Software Inc., San Diego, CA, EUA) with the results grouped for each figure on the first, second and third stages; when only two stages were compared, Fisher's exact test was applied. The GraphPad StatMate software (San Diego, CA, USA) was applied to calculate an anticipated proportion between stages = 0.2727 (95% confidence interval = 0.1074-0.5025), indicating a relationship between sample size = 25 children, with 80% power and detectable difference = 0.3849.
| Results|| |
From the total sample, three charts were discharged because those three children were not present in every step of the study, having a final sample of 26 children. Results were obtained and expressed in percentage of the category frequency distribution (good/bad) to each Cod previously defined in the materials and methods section [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]. The Chi-square test indicated a significant difference between figures and stages (P < 0.0001).
|Figure 2: Category (good/bad) frequency distribution for dentist figure (Cod 1)|
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|Figure 3: Category (good/bad) frequency distribution for candies/sweets figure (Cod 2)|
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|Figure 4: Category (good/bad) frequency distribution for toothbrush figure (Cod 3)|
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|Figure 5: Category (good/bad) frequency distribution for bacteria figure (Cod 4)|
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|Figure 6: Category (good/bad) frequency distribution for tooth decay figure (Cod 5)|
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|Figure 7: Category (good/bad) frequency distribution for dentifrice/ dental floss figure (Cod 6)|
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|Figure 8: Category (good/bad) frequency distribution for fruits/ vegetables figure (Cod 7)|
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|Figure 9: Category (good/bad) frequency distribution for health tooth figure (Cod 8)|
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| Discussion|| |
The evaluated children referred to the dentist [Figure 2] and health tooth [Figure 9] as a positive image, with no statistical difference in the three stages to dentist figure (P = 0.7683) and health tooth figure (P = 0.5986) respectively. It is interesting to observe that children showed a positive perception of the dentist, which reflects a higher possibility of the success of the motivational program, because they know that oral health is associated to the dentist. The figure of the tooth with no caries lesion, children referred to it as something good to their health. According to Frostig et al.,  the perceptual functions are the key point to an educative program, more specifically the visual perception, seeing it as the function that is able to recognize and discriminate between the visual stimulus, interpreting and associating them to previous experiences.
Concerning to the candies and sweets (Cod 2), there was a statistically significant difference between three stages (P < 0.0001), demonstrated in Figure 3. When these data were analyzed, it was possible to suggest that the sweets are something related to pleasuring; explaining the difficulty that the children have to understand that from a determined stage the sweets could represent something bad. It is known that in daily practice it is very difficult not allow them to eat sweets, especially those children that have received this type of food since of early age. Furthermore, it is noticeable to see how important it is to include an educational/preventive program at this moment of life; hence the 1 st year represent an initial phase in the process of understanding things, and they are seen as an important moment in their lives as they determine the conditions of keeping oral health. It is in infancy that human development and growing starts an intense rhythm, and it is a continuous process, where each stage is a decisive phase for the next one. Habits are inserted in biological, psychosocial and emotional areas. 
When the Cod 7 (fruits and vegetables) was analyzed, it was possible to observe that on the first stage the children chose partially the option good (54%) and 46% the option bad; however, on a second stage, 85% chose the option good and on a third stage 46% good and 54% bad [Figure 8]. From this last result, similar to the first stage, it means that from the 14 children who reported, on a first stage, as something good, after the motivational program, two identified the figure of vegetables and fruits as something bad (P = 0.0106). This leads us to believe that since the first stage there is some doubt about the figure of vegetables and fruits, they may understand that they are figures that bring benefits to a healthy life (second stage), however, this type of food may not be a part of their daily diet.
Regarding the toothbrush [Figure 4], Cod 3] it is possible to see that they were seen by the children in a positive way, there was no statistical difference between the three stages (P = 0.1581). The good perception to dentifrice and dental floss demonstrated in [Figure 7] [Cod 4] statistical difference (P = 0.0226) between the stages. Belloso et al.  have reported that behavioral patterns are input by innate characteristics of the children, receiving a direct influence by the environment where they live. Nevertheless, to wake up in the parents the necessity to acquire positive habits, and also in oral health of their children, it will facilitate children to accept the practices that constitute most of the preventive measures; and this could only be achieved with education, by educational/preventive programs that are adequate to their reality and social level (cultural, educational, end economical) of each family. ,
About the bacteria [Figure 5], Cod 4], 77% of the children on the first moment chose the option good; after that on a second stage, only 8% chose the option good, this demonstrated the positive effect of the program. Although on a third stage (30 days later), the percentage obtained had almost the same result from the beginning with 65% of the children chose the option good, with statistically significance (P < 0.0001). There is a consensus that motivation and infant behavior are important elements in the development of educational programs, and they are also considered fundamental parts in the process of teaching/learning.  It may also infer that because the representations remind some heroes from animations, it is no longer a symbol that makes the difference between what it is good and what is bad. The graphic representations in these conditions must show symbolic characteristics that are really representative of a show the real meaning of good or bad.
The Cod 5 [Figure 6] that shows the tooth with a lesion, on the first stage the children identified it as something good (65%). It means that they were not able to understand the representation of the lesion. After the second stage, 23% select the option good [Figure 6]; it explains that after they had seen the program, they could identify the graphic representation better. There was a statistically significant difference in relation to the three stages (P = 0.0068).
In literature, there is a concern about how to motivate the patient in an effective way whether by direct or indirect means. , However, the effectiveness of programs and health education interventions are sufficient for temporary effect on plaque accumulation, assessed by a systematic review.  The ability of oral health knowledge to change behavior is a matter of discussion, motivational programs performed without constant reinforcement does not have a positive influence in changing the child's behavior related to a better oral care. Regarding the age of the children evaluated, whether they have enough maturity to understand the test-chart, according to Harris et al.,  children rarely express in words what they feel, but they reveal their feelings by the tone of their voices, facial expression or other nonverbal ways (figures, symbols). Children from 1 to 6 years old, undergo a training of their emotions, in other words, emotional teaching where they express their emotions drawing little faces that can be identified as happy and sad or good and bad.
The knowledge about oral health can be improved through oral health promotion activities and programs that increase knowledge may also change behaviors, although the causal relationship between knowledge and behavior is weak. The evidence of effectiveness for clinic based health promotion and educational activities on dental caries of patients are rated as insufficient.  However, it was concluded that the inclusion of motivation programs, when it is not frequent or does not have constant reinforcements; it does not bring any changes in behavior or positive alteration in infant behavior concerning to oral health aspects. The use of the test-chart may be a useful resource to evaluate the acquisition of new hygiene habits of oral health.
| References|| |
|1.||Alsada LH, Sigal MJ, Limeback H, Fiege J, Kulkarni GV. Development and testing of an audio-visual aid for improving infant oral health through primary caregiver education. J Can Dent Assoc 2005;71:241, 241a-241h. |
|2.||Ferrazzano GF, Cantile T, Sangianantoni G, Ingenito A. Effectiveness of a motivation method on the oral hygiene of children. Eur J Paediatr Dent 2008;9:183-7. |
|3.||Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: A randomized trial. Pediatr Dent 2007;29:16-22. |
|4.||Bennett GA, Roberts HA, Vaughan TE, Gibbins JA, Rouse L. Evaluating a method of assessing competence in motivational interviewing: A study using simulated patients in the United Kingdom. Addict Behav 2007;32:69-79. |
|5.||Belloso N, Hernández N, Rivera L, Morón A. Effectiveness educational programs for school dental health. Experimental trial. Acta Cient Venez 1999;50:42-7. |
|6.||Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health 1998;15:132-44. |
|7.||Hawkins RJ, Zanetti DL, Main PA, Jokovic A, Dwyer JJ, Otchere DF, et al. Oral hygiene knowledge of high-risk grade one children: An evaluation of two methods of dental health education. Community Dent Oral Epidemiol 2000;28:336-43. |
|8.||Schou L. Active-involvement principle in dental health education. Community Dent Oral Epidemiol 1985;13:128-32. |
|9.||Sgan-Cohen HD. Oral hygiene improvement: A pragmatic approach based upon risk and motivation levels. BMC Oral Health 2008;8:31. |
|10.||Delitala G. Incorporating Piaget's theories into behavior management techniques for the child dental patient. Gen Dent 2000;48:74-6. |
|11.||Flavell JH. Cognitive development: Past, present, and future. Dev Psychol 1992;28:998-1005. |
|12.||Frostig M, Maslow P, Lefever DW, Wittlesey JR. Developmental Test of Visual Perception. Palo Alto, Calif: Consulting Psychologists; 1964. |
|13.||Moriguchi Y, Hiraki K. Neural origin of cognitive shifting in young children. Proc Natl Acad Sci U S A 2009;106:6017-21. |
|14.||Rozier RG. Effectiveness of methods used by dental professionals for the primary prevention of dental caries. J Dent Educ 2001;65:1063-72. |
|15.||Livny A, Vered Y, Slouk L, Sgan-Cohen HD. Oral health promotion for schoolchildren - Evaluation of a pragmatic approach with emphasis on improving brushing skills. BMC Oral Health 2008;8:4. |
|16.||Harris PL, Olthof T, Terwogt MM. Children's knowledge of emotion. J Child Psychol Psychiatry 1981;22:247-61. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]