How can children be involved in developing oral health education interventions?

This review examined the oral health interventions that have been developed for elementary school age children and the involvement of children in these intervention studies. Eight randomised controlled trials involving 3,232 children were analysed using deductive content analysis by two authors. Child involvement was categorised using the Typology of Youth Participation and Empowerment TYPE model. In all eight studies, the interventions were designed by the researchers and adult-led without involvement of children. Further studies with participatory research methodology are recommended to better understand the role of involvement of children in oral health education.Data sources The data search was carried out in April 2018 using PubMed, CINAHL, Embase and Scopus databases. The search focused on elementary age school children (6-12 years) who were involved in oral health education intervention studies. Exclusion criteria were studies involving children with mental or physical impairment, undergoing hospital or orthodontic treatment, preventative treatments or solely targeted towards parents/caregivers or teachers.Study selection A systematic review method of randomised controlled trials (RCTs) was selected. Titles and abstracts were included or excluded before full text analysis for eligibility was carried out. Studies were assessed by two authors with a third author to be consulted in cases of disagreement.Data extraction and synthesis Study sample, intervention duration and content, selection, use of educational methods including use of a theoretical framework and outcomes were extracted from the data. Child involvement was categorised using the Typology of Youth Participation and Empowerment (TYPE) pyramid (Wong et al., 2010).¹ The quality of studies was assessed using the CONSORT checklist and the Cochrane risk of bias tool. The methodological quality of the studies was relatively low with a score of 14-22 out of 36. Three studies were rated as being fair quality in terms of risk of bias. The remaining five were rated as either unclear or high risk of bias.Results Eight RCTs were selected for review. Sixty-five articles were assessed for eligibility and 57 articles were excluded due to non-RCT design, excluded/unreported ages and full text unavailability. Nine different methods of oral health education were identified: lecture; printed material; demonstration; toothbrushing diary; game; video; workshop; discussion; and oral hygiene training. None of the reported studies demonstrated a rationale for selecting their educational method. Four reports described a theoretical framework for development their intervention: social learning theory (Parcel and Baranowski, 1981) was used by Haleem et al. (2012); Health Belief Model (Becker, 1974) by Yekaninejad et al. (2012), Wolf's health learning capacity (2009) by Freeman et al. (2016) and Ajzen's theory of planned behaviour (1991) by Simpriano and Mialhe (2017). However, the use of these theories was limited and no attempts to introduce children's perspectives into the theoretical framework was identified.Five outcomes to measure effectiveness were found: clinical oral health status; oral health-related behaviour; oral health knowledge; attitudes towards oral health; and oral health related quality of life. Clinical oral health status was the most commonly used outcome (seven of the eight studies). Positive outcomes were found in all eight studies. None of the reports considered the potential for enhancing intervention effects by involving children more actively. The children's role in the interventions was mostly the Vessel type of participation from the TYPE pyramid model. Partially symbolic participation was detected in two studies - Haleem et al. (2012) trained children to conduct oral health education in the role of peer educators and Simpriano and Mialhe (2017) trained children to create their own plans for daily toothbrushing and how to overcome situations preventing that task. There were no reports of consultation or collaboration with children for their perspectives before or after the interventions. Interventions appear to have been created by the researchers alone.Conclusions In all of the included studies, children were only involved during the intervention implementation phase. The interventions were all adult designed and adult led. Lack of detail in the reports meant that reported positive outcomes could not be clearly attributed to the activities carried out by the children. Further studies with participatory research methodology are recommended to better understand the potential role of children in oral health education and research.