Reminder-based Educational Mobile Intervention for for Maternal Oral Health Literacy and Preschoolers' Dental Health

Study Design and Setting:

This study employed a quasi-experimental design with a pretest-posttest non-equivalent control group approach and was conducted in parallel between the intervention and control groups in seven preschool in Pancoran Mas , Depok City, Indonesia, between July and December 2024. Participant allocation was non-randomized. The sample size was calculated using the analytical formula for comparing numerical between two independent groups. The final sample size was determined to be 100 participants in each group, yielding a total analytical sample of 200 mother-child pairs. Participants were recruited through a non-probability purposive sampling method at the village and school levels.

Intervention:

The study compared two educational media containing identical content on tooth anatomy, oral hygiene practices, oral diseases, and the development of dental caries (four chapters):

• Application (Peri Bugi): An interactive mHealth application featuring daily notifications and reminders, supplemented with a rule-based AI system that personalizes the frequency of educational messages according to quiz performance and compliance with the toothbrushing checklist.
• Booklet: A printed text-based educational material designed for self-directed learning.

Study Protocol:

• Application Development. The development process included conceptual planning (objectives, target users, framework, and REALD-30-based content), UI/UX wireframe design, development of the four educational chapters, and prototype creation.
• Expert Evaluation. Four experts (two computer science experts and two experts/master's students in community dentistry) evaluated the feasibility and usability of the prototype online via Zoom using the System Usability Scale (SUS) questionnaire. The evaluation results were used to revise and improve the application.
• Pilot Study. Twenty end users (10 in the application group and 10 in the booklet group) tested the intervention over a two-week period. Baseline assessments included the REALD-30 questionnaire for mothers and the Oral Hygiene Index-Simplified (OHI-S) for children.
• Main Effectiveness Trial

• Baseline Assessment: All participants completed a pretest to assess baseline conditions. Mothers completed the REALD-30 questionnaire, while children underwent DI-S and mGI examinations performed by calibrated dentists.
• Intervention Period: Participants in the intervention group used the Peri Bugi application, whereas those in the control group used the printed booklet. Educational materials were delivered progressively, with one chapter released each week over a four-week period. Participants were also required to complete morning and evening toothbrushing checklists. Coordination regarding chapter release schedules was conducted through WhatsApp groups.
• Post-Intervention Assessment: One month after baseline, all participants completed a posttest involving the same assessments administered at baseline. In addition, participants in the intervention group completed an application usability assessment.

Assessment Tools:

Oral Health Literacy: The REALD-30 questionnaire (Lee et al., 2007) was used to assess mothers' oral health literacy through recognition of dental terminology. Scores were converted to a 0-100 scale, with higher scores indicating better oral health literacy. The questionnaire was administered at both pretest and posttest.

Children's Oral Health Status: The Debris Index-Simplified (DI-S) was used to assess oral hygiene status, while the Modified Gingival Index (mGI) was used to evaluate gingival health. Both measurements were conducted at pretest and posttest by calibrated dentists.

Application Usability: The Mobile Health App Usability Questionnaire (MAUQ) (Zhou et al., 2019), consisting of three subscales and a 7-point Likert scale, was administered to participants in the intervention group at posttest. Lower scores indicated better usability according to the scoring system applied in this study.

Assessment Tools:

• Oral Health Literacy: The REALD-30 questionnaire (Lee et al., 2007) was used to assess mothers' oral health literacy through recognition of dental terminology. Scores were converted to a 0-100 scale, with higher scores indicating better oral health literacy. The questionnaire was administered at both pretest and posttest.
• Children's Oral Health Status: The Debris Index-Simplified (DI-S) was used to assess oral hygiene status, while the Modified Gingival Index (mGI) was used to evaluate gingival health. Both measurements were conducted at pretest and posttest by calibrated dentists.
• Application Usability: The Mobile Health App Usability Questionnaire (MAUQ) (Zhou et al., 2019), consisting of three subscales and a 7-point Likert scale, was administered to participants in the intervention group at posttest. Higher scores indicated better usability according to the scoring system applied in this study.

Inclusion criteria

• Mothers with a child aged 3-7 years (preschool-aged child).
• Mothers who own a smartphone and are able to download and install applications.
• Mothers who have internet access and actively use the internet.
• Mothers who are willing and cooperative to participate in the study from enrollment until study completion.
• Preschool children aged 3-7 years.
• Children enrolled in a preschool located in Pancoran Mas, Depok City.

Exclusion criteria

• Mothers who were unwilling to sign the informed consent form.
• Mothers or children with physical or mental disabilities (e.g., Down syndrome, hearing impairment, visual impairment, cerebral palsy, or other developmental or physical disabilities).
• Children with congenital diseases or congenital anomalies.
• Children with systemic diseases, such as congenital heart disease, epilepsy, thalassemia, hemophilia, or other systemic medical conditions.