An oral health education video game for high caries risk children: study protocol for a randomized controlled trial

Tooth decay is the most common childhood illness in the world [1]. Early childhood caries is commonly defined as the occurrence of any sign of dental caries on any tooth surface before the age of 6 years [2]. In England, 12 % of children aged three [3], and 28 % of children aged five, have dental caries [4]. The disease can gravely affect the quality of life of these children and their families [5]; furthermore, contracting the disease at an early age puts these children at greater risk of developing caries and sepsis in the future [6, 7]. For a significant proportion, the end result is dental extraction under general anaesthesia, which nowadays is the most common reason for hospital admission in children aged five to nine years in England [8]. Reported general anaesthesia repeat rates are fairly high (25 %), despite rigorous examination and radical treatment [9]. Moreover, many of these children have siblings who have had similar treatment [10]. These findings suggest that there is failure in improving caries prevention in those children and their families postoperatively. Indeed, almost 80 % of parents of these children requested more support in preventing dental caries in their children. Furthermore, 55 % requested that more help with caries prevention be included in subsequent hospital visits [10].

Previous studies suggested that these families display poor oral health knowledge as well as face difficulties in implementing healthy oral habits at home [11]. Given the suggested deficiency in oral health knowledge in these families, provision of oral health advice can be an important part of promoting oral health, and exploration of methods of advice delivery that are effective and acceptable to them is necessary. In a previous study, parents of children referred for extractions under general anaesthesia suggested that different methods for delivering oral health advice can be acceptable, including: websites (64 %), leaflets (63 %), and DVDs (49 %) [10]. In another study, similar findings were reported: (89 %) found leaflets and (67 %) found the internet acceptable methods for oral health advice delivery [12].

The use of video games is a less traditional method of oral health advice that should be considered and explored, as these games might have great potential. Evidence suggests that such games have several advantages over other methods of learning, including: multisensory support, problem-based learning, activation of prior knowledge, immediate feedback, and provision of a social environment involving communities of players [13]. Moreover, video gaming is widely practised nowadays, especially by children. Almost 90 % of American children and teens were reported to play such games on various platforms [14], with the average child aged eight to ten years spending an hour per day playing [15]. In the UK, more than 90 % of six- to nine-year old boys and girls are reported to play such games [16].

Health researchers have realised the potential games may have in delivering health advice. Previous research suggests that using such games to promote a healthy diet carries potential. For example, a study that used a game to promote intake of fruits and vegetables has reported that children had one more serving of fruit or vegetable per day after the intervention and that those with the lowest intake at the baseline benefited the most [17]. Another study assessed the effectiveness of a nutritional education computer package [18] in 8- to 11-year olds in schools compared with traditional methods and suggested that both methods increased the children’s knowledge and that knowledge was retained three months later [19]. A review in 2008 that included 25 studies utilizing such games concluded that they can induce positive health-related outcomes [20]. A more recent review has suggested that amongst 38 studies and a total of 195 health outcomes, video games improved 69 % of psychological therapy outcomes, 59 % of physical therapy outcomes, 50 % of physical activity outcomes, 42 % of health education outcomes, 42 % of pain distraction outcomes, and 37 % of disease self-management outcomes [21]. The reviews also revealed that although these games show the potential to improve health outcomes, most studies are of poor quality and more rigorous randomized controlled trials are needed.

Evidence of the use of video games in oral health education in particular is scarce. A pilot study involving 26 four-year-old nursery children tested a prototype oral health education video game developed by one of the investigators (MTH) and an MSc computer science student [22]. The results suggested no difference in healthy food identification after using the video game, although the sample size was too small to reach significance. Teachers involved in the study viewed the game positively but recommended that it involve more interaction and additional material [23].

In 2008, two of the authors (CR) and (MTH) developed a new prototype oral health education video game. The development process comprised of three steps: first, collection of opinion from experts in the fields of paediatric dentistry, dental public health, nutrition and child education to inform the game’s design. Second, designing the game using the aforementioned input and using Microsoft PowerPoint, and finally, assessment by six six-year-old children to test functionality, child engagement and navigation. The game was named ‘Barney’s healthy foods’, and included an avatar to guide the child through it, as this has been suggested to improve the learning experience [24]. The game was also developed in line with the Scottish National Curriculum, as oral health education programmes that are well integrated into the National Curriculum have been suggested to lead to improvements in children’s oral health knowledge [25]. The game was assessed in a phase-I randomized controlled trial (RCT) that included four- to seven-year-old children in two primary schools in Stornoway, Scotland. The results suggested that this method of oral health education delivery can be as effective as regular paper-based methods in improving children’s recognition of healthy foods [26].

In light of those findings, the current study is a phase-II blind RCT that aims to assess an oral health education video game in comparison with verbal oral health education in terms of family satisfaction, effect on oral health knowledge, and effect on dietary and oral hygiene habits in high caries risk families.

This is the first RCT designed to investigate the use of video games in providing oral health education focused on diet and oral hygiene to this cohort. This study will explore this novel intervention’s acceptability, effectiveness in increasing knowledge, and effectiveness in improving dietary and oral hygiene habits in the short term. This complies with the guidance of the UK Medical Research Council, which recommends that newly developed interventions are not only assessed for effectiveness but also acceptability, as this point is frequently overlooked [32]. Further studies will be necessary, to assess whether such an intervention can lead to sustained changes in dietary and oral hygiene habits and, eventually, positive clinical outcomes. As Nutbeam suggested, evaluating oral health promotion interventions includes four levels: health promotion action (e.g., education), health promotion outcomes (e.g., health literacy), intermediate health outcomes (e.g., health behaviour), and finally, health and social outcomes (e.g., plaque score.) [33].

In our earlier research, parents of children with high caries risk displayed lack of knowledge on the prevention of dental caries [11]. Providing these families with information is important, as knowledge is a vital component in working towards behaviour change, as indicated by social cognitive theory [34]. However, previous evidence suggests that oral health education alone is not enough to achieve clinically significant outcomes [35]. Promoting oral health in such families will require ‘upstream’ action that tackles the social and cultural determinants of the disease supplemented by ‘downstream’ action, focusing on oral health determinants. Nevertheless, delivering oral health advice remains an important part of oral health promotion [36]; the Ottawa charter for health promotion stressed the importance of helping individuals improve personal skills as part of health promotion, and this can be achieved through provision of information, health education and enhancement of life skills in an appropriate manner [37].

Providing oral health education directly to the child might be questioned, since it is assumed that parents are responsible for the families’ oral health practices. However, there is some evidence that children play a role in shaping their oral health practices from a young age; Roberts et al. [38] suggested that children aged seven and older possess some control over their dietary selections in what is commonly known as ‘pester power’. It is important to note that Roberts et al. did not include children younger than 7, but other authors have suggested that children as young as 4 years old have a ‘pester’ or ‘nag’ power over their family’s food shopping [39]. Moreover, Birch and Fisher [40] suggested that even though young children have an innate preference for sugary foods, their dietary preferences are influenced by social and cultural norms, advertising and modelling. Providing children with oral health education through a potentially interesting method, such as video games, might provide them with a positive media influence. In addition, parents are indeed going to be part of the intervention in this study, as they will be required to guide the child through the game. Moreover, parents might learn indirectly, as some evidence suggests that children can transmit knowledge to their parents [41].

Selecting the measures used in this study has been difficult; considering the population targeted. This population is notoriously poor in attending dental clinics regularly [42, 43]. With that in mind, the phase-II RCT is designed to engage families in a positive way about oral health whilst simplifying data collection and reducing the time needed to complete the assessments. Despite this, we anticipate that following participants up at three months might be difficult; hence, we will offer telephone follow-up as an alternative.

The visual analogue scale is a low-burden measure that can be completed quickly and has been validated for use in measuring participant’s satisfaction [29, 30]. There is a risk that participants will feel inclined to give better scores for the nurse providing the control intervention. For this reason, qualitative data will also be collected. Nonetheless, it is recognized that parents might still give socially acceptable answers; thus, the interview approach is important, to ensure that participants feel comfortable in giving their responses.

Measuring the dietary knowledge of children is challenging. A comprehensive review of studies across different health fields reveals how diverse these measures are, with many being designed to measure specific aspects of nutrition knowledge [44]. There is a lack of nutrition knowledge questionnaires for children when oral health is in question. We have chosen to construct a pictorial quiz as this form of questionnaires was suggested as suitable for young children [44], is less likely to be affected by differences in literacy and was also piloted in the phase-I trial. A drawback might be that the quiz will only report recognition of unhealthy items and not knowledge of frequency. It might also be too easy for older children and too difficult for younger ones.

The children’s dietary questionnaire will record changes in dietary practices [31]. This is a 7-day recall dietary questionnaire that is validated and both easy to use and analyse. It contains items measuring consumption of sugary foods and drinks, fits our study design and participant age, and is recommended by the UK National Obesity Observatory [45]. However, it might have poor correlation for some items and has not been yet validated in the UK. Therefore, some of the food items have been altered to UK English to suit the population studied. Children’s snacking and toothbrushing practices will be measured using diaries. Diaries can keep the child involved but these self-reported measures might not be reliable and families might just record the ‘correct’ rather than the real answer [46]. We also anticipate that completion and return rates might not be ideal. Therefore, in this study, story books will be given as prizes to motivate the children, and text messages will be used as reminders for parents. Prepaid envelopes will be provided to those who do not bring the diary back in person, so that they can mail it.

We will not be able to approach all children attending for dental extraction of decayed teeth under general anaesthesia, as many might attend and leave the pre-assessment clinic while the researcher is in the process of applying the intervention to another child. However, the total numbers of those attending, approached and providing consent will be recorded, to reduce bias. Also, it is worth noting that the area served by King’s College Hospital is highly culturally diverse, with many immigrant families [47]. Families without sufficient English language skills will be excluded. These families’ usual languages will be recorded for future reference and can be considered in future versions of the video game.

The phase-II trial commenced in October 2013 and the process of recruitment is still ongoing.