‫املجلد السابع عرش‬ ‫املجلة الصحية لرشق املتوسط‬

‫العدد الثاين‬

Impact of an educational leaflet on parents’

‫أثر النرشات التثقيفية عىل معارف األباء وإدراكهم ملشكالت تقويم األسنان يف أطفاهلم يف شرياز‬
‫ سحر قديس بوشهري‬،‫ ندا بزوهي‬،‫ ياسمني قهرماين‬،‫ شهالمومني دانايي‬،‫مرتىض ُع َّشاق‬
‫ واهلدف من الدراسة‬.‫ ت َُعدُّ توعية اآلباء بسوء اإلطباق السني الوجهي أمر ًا عىل درجة كبرية من األمهية لتجنب التأخري يف التامس املعاجلة‬:‫اخلالصة‬
‫ من آباء تالميذ‬533 ‫ وقد قام الباحثون بتقسيم‬.‫احلالية هو تقييم أثر النرشات التثقيفية عىل معارف اآلباء وإدراكهم لسوء اإلطباق السني يف األطفال‬
‫ واألخرى كانت جمموعة‬،‫ تل ّقت إحداها نرشة تثقيفية‬،‫ إىل جمموعتني‬،‫ بصورة عشوائية‬،‫املدارس الذين تـراوحت أعامرهم ما بني سبع وتسع سنوات‬
‫ ثم أجر َيت مقارنة بني درجات االختبار الذي أجري قبل املداخلة وبعدها من خالل استبيان حول مشكالت تقويم‬.‫شاهدة مل تتلق أية نرشات‬
‫ من‬.‫ وكانت االختالفات كبرية بدرجة ُي ْعتَدُّ هبا إحصائي ًا بني االختبارين بني املجموعة التي تل ّقت النرشة التثقيفية عنها يف املجموعة الشاهدة‬،‫األسنان‬
‫ واستنتج الباحثون أن‬.‫تسجل فروق ًا ُي ْعتَدُّ هبا‬
ِّ ‫ أما الدرجات اخلاصة باملعارف حول فتـرات اإلحالة فلم‬.‫حيث الوعي العام بمشكالت تقويم األسنان‬
.‫املعلومات التي تقدمها النرشات التثقيفية يمكن أن تفيد يف االرتقاء بمستوى وعي اآلباء بمشكالت التقويم يف أطفاهلم‬

ABSTRACT Raising parents’ awareness about dentofacial malocclusions is important for avoiding delays in
seeking treatment. The aim of the present research was to assess the impact of an educational leaflet on parent’s
knowledge and awareness of orthodontic malocclusion in children. Parents of 533 7–9-year-old schoolchildren
were randomized into a leaflet group who received an educational leaflet and a control group with no leaflet. Pre-
and post-intervention test scores on a questionnaire about orthodontic problems were compared. Differences
between post- and pre-test scores were significantly higher in the leaflet group than the control group for the total
score and the domain on general awareness of orthodontic problems. Scores on the domain of knowledge of
referral intervals did not differ significantly. Information leaflets may be useful for increasing parents’ awareness
of orthodontic problems in children.

Impact d’un dépliant éducatif sur les connaissances des parents concernant les problèmes orthodontiques
de l’enfant et sur leur sensibilisation en la matière à Chiraz

RÉSUMÉ Sensibiliser les parents aux malocclusions dentaires est important pour éviter des retards dans le
recours aux soins. La présente recherche visait à évaluer l’impact d’un dépliant éducatif sur les connaissances
des parents concernant la malocclusion dentaire de l’enfant et sur leur sensibilisation en la matière. Les parents
de 533 écoliers âgés de sept à neuf ans ont été randomisés, soit dans un groupe recevant un dépliant éducatif,
soit dans un groupe ne recevant pas de dépliant. Les scores précédant et suivant l’intervention issus des
questionnaires sur les problèmes orthodontiques ont été comparés. Les différences entre les scores précédant
et suivant l’intervention étaient significativement plus marquées dans le groupe ayant reçu un dépliant éducatif
par rapport au groupe témoin, pour le score total et pour la sensibilisation aux problèmes orthodontiques en
général. Les scores pour les connaissances portant sur les intervalles jusqu’à l’orientation-recours n’étaient pas
très différents. Les dépliants d’information peuvent être utiles pour renforcer la sensibilisation des parents aux
problèmes orthodontiques de l’enfant.

1
Shiraz Orthodontic and Educational Research Centre, Department of Orthodontics, Faculty of Dentistry, Shiraz University of Medical Sciences,
Shiraz, Islamic Republic of Iran (Correspondence to S. Momeni Danaei: momenish@sums.ac.ir).
Received: 03/03/09; accepted: 02/08/09

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La Revue de Santé de la Méditerranée orientale

Introduction the effects of an educational leaflet on problems and knowledge about referral
general knowledge of children’s par- to the orthodontist. The orthodontic
In recent years, the main emphasis in ents about +diagnosis of orthodontic awareness section included questions
dentistry has shifted from treatment malocclusions. covering topics such as whether den-
and repair of damage to prevention of tofacial malocclusion can be prevented
disease, and the public’s role is changing by taking care of primary teeth; the time
from passive recipient to participant Methods of exfoliation of primary teeth; how to
in prevention. Helping individuals to recognize decayed teeth and when to
Subjects take the child to a dentist; oral habits that
assume responsibility for preserving
their oral health is an important goal In 2008, a prospective study was per- cause malocclusion; how to recognize
which cannot be attained without pub- formed on a random selection of parents problems with malocclusion; who to
lic education and motivation [1–4]. of 533 children aged 7–9 years old (226 refer to for checkups for orthodontic
The importance of information pro- girls and 307 boys) in primary schools problems; and complications of untreat-
vision in orthodontic treatment and in the city of Shiraz, Islamic Republic ed malocclusion. The referral intervals
its effect on patients’ cooperation has of Iran. In Shiraz, primary education is section assessed their knowledge about
been identified by Brattstrom et al. They divided into 4 districts. Using random what age a child should first be examined
reported that 4% of patients terminated cluster sampling 1 boys’ and 1 girls’ for dentofacial malocclusions.
treatment prematurely and that the primary school was selected in each dis- After the pre-intervention test ques-
reasons for not completing treatment trict and classes were selected randomly tionnaires were completed, the parents
included insufficient information about within each school. In the selected were randomly divided into 2 groups:
the exact nature of treatment, lack of classes, all students who were 7–9 years control and leaflet. The leaflet group
motivation and lack of communication of age, had Farsi as the first language received an educational leaflet in Farsi
between orthodontist and patient [5]. and had no experience of orthodontic language comprising basic information
Although a dentist may suggest that a treatment were included [9]. A letter about definitions, malocclusion types,
child needs orthodontic treatment, the explaining the aims of project and a normal occlusion, prevention, eruption
perception by the parent that the child consent form were sent to each parent and exfoliation of teeth and problems
has an orthodontic problem will play a and those who agreed to participate of non-treatment of malocclusions. The
part in whether or not the child receives were included. Then the questionnaires leaflet was delivered to parents via the
treatment [6]. were delivered to the parents with the children. The parents were instructed to
There is evidence that patients only help of their children. read the leaflet over a 2-week period. The
retain about 20% of verbal informa- control group were not sent the leaflet.
Data collection After 2 weeks parents in both the control
tion from physicians, but that recall
may increase by up to 50% if there is Ethical approval for the study was ob- and leaflet groups repeated the question-
additional visual or written input [7]. tained from the ethics committee of naire as a post-intervention test.
George et al. demonstrated that patients Shiraz University of Medical Sciences. The reliability of the questionnaire
favoured written information and that Parents who agreed to participate were was assessed by asking 20 subjects to
those who were given leaflets were more sent a questionnaire to complete, ac- complete it twice with a 2-week interval.
satisfied with their treatment as a whole companied by a letter outlining the Cronbach alpha was used as a measure
[8]. Studies have shown that written objective and the methods of the study. of reliability (α = 0.75).
information can help patients to under- The questionnaires could be completed
stand and comply with their dentist’s by either of the parents or a guardian Analysis
or doctor’s advice [9–11]. Leaflets are with the help of their children but most Each orthodontic awareness item was
cheap to produce and can save patients of the questionnaires were completed given a score. The total score for each
the embarrassment of asking questions by mothers. participant and the mean score for the
directly of a professional [12]. The questionnaire asked for de- 2 groups were calculated. The pre- and
Mortensen et al. concluded that mographic data about name, age, sex, post-test scores were compared using
future research should focus on meth- family size, ethnicity, family income and the Mann–Whitney U-test. Parents’
ods of improving communication parents’ occupation and education level education level and occupation were
with children undergoing orthodontic (as a proxy measure for social class). The compared between the control and
treatment so that they understand their knowledge parts of the questionnaire leaflet groups using the chi-squared test.
treatment [13]. This study the Islamic included 13 questions in 2 domains: The number of people per family and
Republic of Iran aimed to determine general awareness about orthodontic the family income for both groups were

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‫العدد الثاين‬

compared using Student t-test. The for the domain of general awareness city in pre-test scores (P < 0.001) and
correlation between parents’ occupa- about orthodontic problems; scores post-test scores (P < 0.001). Higher
tion and income and family population in both groups significantly improved pre- and post-test scores were found in
and place of birth were examined using post-intervention but the difference in the higher socioeconomic status areas
Spearman rank correlation. mean score was significantly higher in (districts 1 and 2) than the lower socio-
the leaflet group [3.4 (SD 4.9)] than the economic status areas (districts 3 and
controls [1.7 (SD 4.0)] (P < 0.001). For 4). However, there was no significant
Results the domain of knowledge of referral in- difference between the 4 areas in the
tervals there was no significant improve- mean difference of pre- and post-test
Results were obtained from the parents ment in mean score post-test for either scores (P = 0.39).
of the control group of 253 children the leaflet or control group [0.04 (SD Mean differences in pre- and post-
(119 girls and 134 boys) who received 1.8) and –0.07 (SD 1.8) respectively] test scores in both groups according
no leaflet and the intervention group of (P = 0.497). to parents’ education level are shown
280 children (107 girls and 173 boys) The pre- and post-intervention test in Table 3. Significantly higher mean
who received the educational leaflet. scores of the total sample in the differ- differences were found between the
Although 7 parents (< 1.5%) failed to ent educational districts of Shiraz are leaflet and control groups for parents
answer single items in the questionnaire shown in Table 2 There were significant with diploma or above diploma level of
their data were included. differences between the 4 areas of the education (P < 0.001).
Demographic data
The age and sex distribution of the 2 Table 1 Background characteristics of the leaflet and control groups of parents
groups were similar. The age range of Variable Control group Leaflet group
students was 7–9 years. The propor- (n = 253) (n = 280)
tion of highly educated mothers in the No. % No. %
control group was greater than in the Father’s education level
leaflet group (P = 0.008) (Table 1). High school 74 29.2 115 41.1
However, there were no significant dif- Diploma 86 33.9 82 29.2
ferences between the groups in terms Above diploma 91 35.9 82 29.2
of family income (P = 0.16), father’s Mother’s education level
occupation (P = 0.66) or father’s educa- High school 77 30.4 119 42.5
tion (P = 0.078). Diploma 85 33.5 96 34.2
Above diploma 90 35.5 63 22.5
Pre- and post-intervention test
Father’s occupation (n = 235) (n = 269)
scores
Unemployed 1 0.4 5 1.8
The mean pre- and post-test scores of
Public employee 98 41.7 95 35.3
general awareness about orthodontic
Manual worker 22 9.3 35 13.0
problems, knowledge of referral inter-
Private sector 111 47.2 128 47.6
vals to the dentist/orthodontist and
Retired 3 1.3 6 2.2
total scores of the 2 groups are shown
Mother’s occupation (n = 239) (n = 269)
in Table 2. The initial score of the con-
Unemployed status 200 83.7 233 86.6
trol group was significantly higher than
Public employee 33 13.8 36 13.4
that of the leaflet group; at the post-test
Private sector 6 2.5 0 0
the leaflet group had higher scores on
knowledge but not significantly so. Family income per month
(euro) (n = 241) (n = 270)
Although the mean total score im-
< 200 61 25.3 79 29.2
proved significantly in both the leaflet
200–350 62 25.7 96 35.5
and controls groups, the difference be-
350–500 56 23.2 40 14.8
tween pre- and post-test total score was
> 500 62 25.7 55 20.3
significantly higher for the leaflet group
Family size (n = 236) (n = 259)
[3.5 (standard deviation (SD) 5.7)]
< 4 persons 199 84.3 199 76.8
than the control group [1.6 (SD 4.6)]
≥ 4 persons 37 15.6 60 23.1
(P < 0.001). Similar results were found

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La Revue de Santé de la Méditerranée orientale

Table 2 Differences between pre- and post-intervention test scores of parents’ in Shiraz according to knowledge and
education district
Knowledge item/ No. Pre-test score Post-test score Difference between
education district/ pre- and post-scores
group
Mean (SD) Mean (SD Mean (SD)
Awareness about orthodontic problems
Control group 253 12.4 (4.7) 14.1 (5.0)a 1.7 (4.0)
Leaflet group 280 11.4 (4.5) 14.8 (5.9) a
3.4 (4.9)
Knowledge about referral to orthodontist
Control group 253 4.1 (1.6) 4.1 (1.5) < 0.1 (1.8)
Leaflet group 280 4.0 (1.6) 4.1 1.5) < 0.1 (1.8)
Total knowledge
Control group 253 16.6 (5.4) 18.2 (5.4)a 1.6 (4.6)
Leaflet group 280 15.5 (5.1) a
18.9 (6.6)a 3.5 (5.7)
District 1
Control group 80 17.4 (5.3) 19.3 (5.4)a 1.9 (5.4)
Leaflet group 70 16.4 (4.9) 19.4 (6.7) a
3.0 (5.6)
District 2
Control group 80 18.9 (5.3) 20.6 (4.7)a 1.7 (3.9)
Leaflet group 72 18.5 (5.2) 22.5 (6.4)a 4.0 (4.7)
District 3
Control group 27 12.6 (3.8) 14.5 (4.3)a 1.9 (4.8)
Leaflet group 43 13.6 (4.9) 17.9 (6.1) a
4.3 (6.6)
District 4
Control group 66 14.3 (4.5) 15.4 (4.8)a 1.0 (4.3)
Leaflet group 95 13.3 (3.8) 16.4 (5.7) a
3.0 (5.9)
a
P < 0.001 versus pre-test score; SD = standard deviation.

Discussion treatment and outcomes may produce a the leaflet group had higher scores on
shift in their attitudes [15]. knowledge. This contrasts with Ley and
The current study showed that an edu- In our study, the initial knowledge of Spelman’s study, which reported that
cation leaflet was effective in increasing the control group was higher than that initial knowledge is a good predictor of
the level of parents’ knowledge about of the leaflet group, but at the post-test knowledge at follow-up [17,18].
orthodontic problems. Differences be-
tween pre- and post-intervention tests
of parents’ general awareness score and Table 3 Differences between parents’ pre and post-intervention scores in the
control and leaflet groups by father’s and mother’s educational level
total score were significantly higher than
those of the control group but there was Education level/group Difference between pre- and post-test scores
Fathers Mothers
no significant difference in scores on
Mean (SD) Mean (SD)
knowledge of referral intervals between
High school
the 2 groups. Our leaflet was targeted
Control group 1.4 (4.3) 1.6 (5.2)
on parents, as apart from the dentist, it
Leaflet group 2.7 (6.2) 2.0 (5.9)
is parents who make the final decision
about treatment, and as parents may Diploma

have different motives for treatment Control group 2.6 (4.9) 1.9 (4.5)

than the children [14,15]. It has been Leaflet group 4.4 (5.2) a
4.6 (5.6)a
reported that parents are the most Above diploma
powerful single factor in the motivation Control group 0.9 (4.5) 1.4 (4.1)
for treatment [16]. Information to the Leaflet group 3.5 (5.2)a 4.3 (4.6)a
patient and the parents about aspects of a
P < 0.001 versus control group; SD = standard deviation.

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‫املجلد السابع عرش‬ ‫املجلة الصحية لرشق املتوسط‬
‫العدد الثاين‬

The effectiveness of the leaflet may patient information leaflets have been It should be kept in mind that pos-
have resulted from its content and at- shown to be effective in increasing sessing the appropriate orthodontic in-
tractive format. Colour photographs knowledge, they need to be written at a formation and knowing the appropriate
of malocclusions and facial forms were suitable level to be understood [21,22]. attitudes and behaviours are only medi-
shown but not photographs about treat- This effectiveness of suitable leaflets is ating factors and may not in themselves
ment effects or appliances. The British confirmed by our study. lead to improved orthodontic health.
Dental Health Foundation (BDHF) There were some limitations to our Measuring actual success of preventive
leaflet Tell me about orthodontic treatment study. For example, we did not request treatments is the ultimate proof of a
was reported to be plain and unexciting that students return the leaflets before successful programme [1]. Neverthe-
[19]. It was judged to be a good guide completion of the post-test question- less, the present study indicates that
for patients coming from general dental naire and parents may have been able to information leaflets could be useful to
practice but not comprehensive enough refer to the leaflet. Also long-term reten- increase parents’ awareness of ortho-
for an orthodontic practice to send out. tion of information was not assessed. It dontic problems in their children.
Although our leaflet was more attractive, was hoped that these factors would not
due to its design and colours, its use can have a major effect on the findings. The
be compared with the BDHF leaflet. strengths of the study were that we used Acknowledgments
Other studies have shown that written simple language in the leaflets and the
information can help patients to under- questionnaire was formulated to be un- This study was supported by the Office
stand and comply with the advice of their derstood by a range of education abili- of the Vice Chancellor for Research of
dentist or doctor [9–11]. Fleckenstein’s ties. To reduce bias, our researchers were Shiraz University of Medical Sciences.
brochure, given to every patient, had instructed not to give verbal information We thank the Center for Development
virtually 100% acceptance and coopera- about orthodontic treatment before and of Clinical Research of Nemazee Hos-
tion [12]. Weinman confirmed the value while the student and/or family partici- pital in Shiraz for editorial assistance,
of leaflets for patients, showing that 75% pated in the study. This ensured that, as Dr. Heidari for statistical support and
wanted written information and that far as possible, information came from Dr. Shokrpoor for improving the use of
80% read the leaflets [20]. Although only one source (the leaflet). English in the manuscript.

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