Background
Early childhood caries (ECC) is the presence of a primary tooth that is carious (non-cavitated or cavitated), missing due to caries, or filled in a child under the age of six years [
1]. ECC can be prevented by behavior change interventions targeting regular tooth brushing using fluoridated toothpaste [
2]. However, children are dependent on their parents, and through primary socialization, learn the norms, beliefs, and health behaviors of their families [
3]. Thus, it is important to develop interventions targeting parents to adopt positive oral heath behaviours for their children to prevent ECC.
Printed materials such as posters, flyers, leaflets, and mass media have been traditionally used for oral health promotion [
4]. Also, motivational interviewing (MI) can change oral health knowledge, attitudes, and behaviors of parents of preschool children [
5], thus, preventing ECC [
6].
Dental health education messages delivered via mobile phones are useful with parents of young children [
7], improving knowledge of children’s oral health [
8]. Text messaging has multiple attractive features. They require less resources than interventions based on in-person delivery, can be automated for delivery to targeted populations at pre-specified times, reach a broad audience at reduced cost and their frequencies can be tailored according to the complexity of targeted behaviors and interventions. They can also be sent through social media platforms and serve as reminders for behaviours.
Video consumption is rapidly growing and online videos constitute over 75% of all global internet traffic [
9]. Storytelling in videos can positively impact patients’ education and influence behavior, providing a simulation to real life that immerses viewers in experiences, exposes them to new places and situations, and makes viewers care more about the issue [
9]. Videos were also effective in improving oral health knowledge [
10].
With the increased use of mobile phones, mobile health (mHealth) applications were developed. mHealth includes medical and public health practices supported by mobile devices, such as mobile phones, personal digital assistants, wireless devices, and patient monitoring devices [
11]. However, mHealth products, including videos and messages, are rapidly evolving at the expense of being based on sound theoretical frameworks or tailored to participants’ needs [
12]. Solid theoretical frameworks can support the production of mHealth interventions but are often overlooked and seldom reported [
13].
It is estimated that 67% of Egyptian preschool children suffer from untreated ECC [
14]. In addition, Egyptian school children aged 11–15 years old rank the second lowest worldwide in the percentage of children with regular toothbrushing (32.1%) [
15]. The large number of Egyptian preschool children affected by ECC, and the prevalent suboptimal level of oral hygiene call for interventions to affect behavior change and instill proper oral hygiene practices. In addition, the high level of internet penetration in Egypt [
16] makes it possible to use m-oral health applications to promote oral health.
The Multi-Phase Optimization Strategy (MOST) is an engineering framework to develop and assess the efficacy of separate components of an intervention package. The MOST framework consists of three phases:
preparation, optimization, and evaluation; in which an intervention is developed then optimized in a subsequent optimization factorial trial before it can be tested as a package in a randomized clinical trial (RCT) in the evaluation phase [
17]. An optimization objective is also specified in the preparation phase to ensure that the resulting package is affordable, scalable, and efficient. The preparation phase in this study includes: (1) developing a conceptual framework to guide the design of the intervention components, (2) developing the intervention components, (3) conducting a feasibility pilot study to determine the acceptability of the intervention components and the preferred frequency and timing of receiving the intervention components and (4) setting an optimization objective [
18].
In this preparation phase study, two m-oral health components (oral health promotion messages (OHPMs) and STVs) and MI sessions were developed and their acceptability to mothers of preschool children was assessed. The current study is the first to apply the MOST framework in the field of dentistry and will be followed later by a subsequent optimization factorial trial.
Results
Most (68.8%) mothers were between 25 and 34 years of age, married (93.8%), with college/ university degree or higher (50.0%) and housewives (62.5%, Table
2).
Table 2
Demographic characteristics of the participating mothers (n = 16)
25–34 years | 11 (68.8) |
35–44 years | 5 (31.2) |
Marital status |
Married | 15 (93.8) |
Divorced | 1 (6.2) |
Number of children: Mean (SD) | 2.2 (1.0) |
Father’s Education |
High school | 7 (43.7) |
College/University and higher | 9 (56.3) |
Mother’s Education | |
Middle school | 3 (18.8) |
High school | 5 (31.2) |
College/University and higher | 8 (50.0) |
Mother’s Job |
Housewife | 10 (62.5) |
Works outside home | 6 (37.5) |
We identified two main themes with underlying sub-themes related to how mothers perceived the intervention components:
Theme 1. Features of the components related to perceived impact
Theme 1.1 support for mothers to brush their children’s teeth
The mothers had positive perception of the components, expressing that they were satisfied with them, and that the interventions motivated them to brush their children’s teeth “When you send me something occasionally, and I see it, it makes a difference and encourages me to brush their teeth (participant 2)”, and acted as reminders “It is something that makes me remember and reminds me when I forget (participant 1)”. The interventions also provided confirmation supporting them to take care of their children’s health. “I feel like I know this information, but I feel you gave me a push to take care of their teeth and honestly, I am happy (participant 6).” Some mothers emphasized the importance of face-to-face MI sessions for motivation, “the interview is very nice (participant 5)”, “the interview is the best (participant 7).”
Theme 1.2 explaining harmful effects of caries had great impact
The participants emphasized that interventions explaining how the lack of toothbrushing negatively impacted a child’s health are convincing. The mothers stated that understanding the potential harm resulting from poor oral health had a stronger motivational effect compared to simply hearing a story. “The harm, if it is more, is more motivating than having one tell a story, because the harm is what makes mothers more motivated”. The mothers also highlighted the importance of focusing on the negative consequences of caries on various aspects of their child’s life. “The impact on eating, school, and concentration because of cavities, …. [should be highlighted] … because school is very important (participant 1)”.
Theme 1.3 relatable and real storytelling videos
The mothers commented on how the STVs were relatable and similar to real life experiences. “My son Mohamed, for example, is exactly like the boy in the video (participant 7)”. The mothers felt that the stories depicted in the videos were authentic and genuine, and some shared personal experiences. One mother recounted an experience she had with a child who suffered from stuttering. She felt that witnessing such tangible stories would convince many mothers to take immediate action and take care of their children’s teeth. “By the way, the story of the stuttering that I saw in this video… I had a personal experience with a child who was the same way, and his front teeth were all decayed like that, and the way he spoke, even though he was somewhat older…… It was very clear to us that he was embarrassed. This is tangible and is something that would make any mother take care of her child’s teeth immediately (participant 8).”
Theme 1.4 advantages of electronic interventions
The mothers explained that mHealth interventions were easily accessible and no effort would be exerted to participate in the interventions using them. “I hold my mobile phone all day, so there is no effort (participant 13)”. The mothers highlighted that almost all people nowadays have internet connection at home, and there was no additional cost associated with the mHealth interventions. “There is no [additional] cost. We hold the mobile phone in our hands all day long. Instead of playing games, it is better to see something useful for a change (participant 4)”. Participants also felt the importance and usefulness of sharing dental health information on social media platforms, since technology is the main method of communication between people nowadays, regardless of their social and educational level. “I want you to upload a video with the information you just told me (participant 8)”, “I wish you would upload the videos on the internet so that mothers could learn how to deal with their daughters and brush their teeth. Encourage the mothers; there are mothers who do not know [how to take care of their children’s teeth] (participant 9)”.
Theme 2. Time and commuting as problems with the intervention components
Time and commuting were the main problems against getting involved with the intervention components, especially face-to-face MI sessions and MI follow-up calls. “It is very difficult for me to come here; I have to wake up early, and so does the child (participant 6).” Others tried to find a solution, “[Coming to the] interviews is a bit of a problem, but this may be solved when the vacation comes (participant 1),” and “I have two days off per month and can use these to come here to gain experience (participant 4).” Working mothers felt that the only free time they have was at night, when they had no work and their spouses were not home. Others felt that their free time was “precious” and “sacred” and spending it answering follow-up MI phone calls would be a commitment and a burden, unlike viewing videos and messages on their mobile phones whenever they were free. On the other hand, some stay-at-home moms felt they could allocate some free time to receiving the interventions “I am a housewife and I have a lot of free time, so I don’t feel like it troubles me (participant 5)”, “I am a housewife, and I do not have meetings, nor do I have interviews with someone, only my home, my husband, and my children. My connections and trips are very few. I feel that I can devote time to the things I hear or read (participant 8).”
The mothers’ responses to the acceptability questionnaire are tabulated in Table
3. The analysis showed high median scores for
affective attitude, intervention coherence and perceived effectiveness, indicating high acceptability of the three components.
Perceived burden,
ethicality, and opportunity cost had low median scores, indicating minor perceived problems in these areas with the three components.
Table 3
Mother’s acceptance of the intervention components
Affective attitude | 1. Enjoyed receiving it | 5 (0.0) | 4 (1.0) | 5 (1.0) |
Perceived burden | 2. Exerted effort to receive it | 1(1.7) | 1 (1.0) | 1 (1.0) |
Intervention Coherence | 3. Easy to understand and follow content | 5 (0.7) | 5 (1.0) | 5 (0.0) |
Ethicality | 4. Inappropriate for my values and the way I live | 1(0.0) | 1 (0.2) | 1 (0.0) |
Opportunity Cost | 5. Gave up important things to receive it | 1(0.0) | 1(0.0) | 1 (0.0) |
Perceived effectiveness | 6. Acts as motivation for other mothers | 5 (0.0) | 5 (1.0) | 5 (0.0) |
Most mothers preferred receiving the m-oral health components once per week (80.0%). Half the mothers preferred receiving the interventions from 8pm to 2am emphasizing that they have busy schedules, and late evenings provided them with an opportunity to check their phones and engage better with the messages and videos sent.
Setting the optimization objective
60.0% of the mothers indicated that 15–30 min is the maximum time they were willing to spend receiving the components (Table 4). Therefore, the optimization objective was set to be the lowest plaque index score that can be obtained provided that the mother does not spend more than 15 min receiving the intervention components.
Table 4
Optimization Objective
Preferred maximum frequency of receiving the videos and messages | Once per week | 12 (80.0%) |
3 times per month | 2 (13.3%) |
2 times per month | 1 (6.7%) |
Preferred time of receiving the videos and messages | 8am to 2pm | 3 (21.4%) |
2pm to 8pm | 3 (21.4%) |
8pm to 2am | 7 (50.0%) |
2am to 8am | 1 (7.2%) |
Maximum total time to spend receiving intervention components | > 1.5–2.5 | 5 (33.3%) |
> 15–30 | 9 (60.0%) |
> 30–45 | 1 (6.7%) |
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.