Development and randomized controlled trial evaluation of “Safeguard Your Smile” an oral health literacy intervention promoting oral hygiene self-care behavior among Punjabi immigrants

Background: Research shows that immigrants have higher rates of oral diseases, poorer access to dental care services and lower levels of health literacy than their Canadian-born peers. Recently, oral health literacy has emerged as a potential pathway to reduce oral health disparities. Existent scarcity and methodological shortcomings of studies on oral health literacy interventions particularly among immigrants lent urgency to our present research study. Objectives: The overarching goal of present research study was to develop and evaluate the effectiveness of an oral health literacy intervention aimed to promote positive oral hygiene self-care behavior among Punjabi immigrants. To achieve this goal, we conducted four separate studies having following objectives: i) To conduct a scoping review to identify and synthesize the current evidence and knowledge gaps on the topic of oral health literacy. ii) To develop a culturally and linguistically appropriate educational material (photonovel) for Punjabi immigrants using a community based participatory approach. iii) To develop a theoretically grounded oral health literacy intervention aimed to improve oral hygiene self-care behavior among Punjabi immigrants. iv) To evaluate the effectiveness of the developed oral health literacy intervention aimed to promote positive oral hygiene self-care behavior among Punjabi immigrants. Results: The main findings of our four investigations were: 1) Findings of the first study affirmed a need to develop new assessment tools to capture all dimensions of oral health literacy and highlighted scarcity of oral health literacy interventions among vulnerable populations particularly among immigrants. Also, it affirmed that low oral health literacy is positively and significantly related to poor oral health knowledge, poor oral health behaviour and poor oral health outcomes. 2) In the second study, the focus group meetings revealed four themes identifying following perceptions held by Punjabi immigrants regarding oral hygiene self-care: i) lack of understanding about oral hygiene self-care related knowledge and risk factors; ii) lack of oral hygiene self-care related adequate skills and routine; iii) lack of emphasis on prevention by oral health care providers; and iv) perceived barriers to access dental health. Findings of the focus group discussions were used to develop an educational material (photonovel) for Punjabi immigrants. 3) The third study developed a theoretically grounded oral health literacy intervention aimed to improve oral hygiene self-care behavior by employing “Behaviour Change Wheel” (BCW) method. Using the BCW method, we first identified various barriers and enablers and linked those with specific intervention functions, policy categories and behavior change techniques identified from the range of options provided by the BCW. Six intervention functions (education, training, modeling, restriction, environmental restructuring and enablement) were subsequently mapped to two policy categories (communication and service provision) since they met the APEASE criteria. 4) In the fourth study, linear mixed model analysis for repeated measures comparing the intervention and control groups at pre-and post-intervention reported that participants who received “Safeguard Your Smile” intervention showed significant improvement in their adequately brushing and flossing routine and in their plaque and gingival indices and oral health literacy than control group participants. Conclusions: The novel attempt of the present research study of developing and evaluating a theoretically grounded and community based oral health literacy intervention among Punjabi immigrants has addressed a deficit in this field and proposed a model of oral health literacy intervention that could be adapted among other low oral health literate communities to reduce the oral health disparities.

Keyphrases: Oral health literacy, Oral hygiene self-care behavior, Intervention, Punjabi immigrants