Applied Research

International Quarterly of
Community Health Education
Self-Assessment of Psychological and 0(0) 1–9
! The Author(s) 2019
Mechanical Factors Affecting Oral Hygiene Article reuse guidelines:
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Among Indian College-Going Students: DOI: 10.1177/0272684X19885496
journals.sagepub.com/home/qch

A Model-Guided Study

Kailash Asawa1, Tulip Chakravarty1 , Mridula Tak1, Dev Rathod1, and

Nandini Sen1

Abstract
Good oral hygiene is the foundation for a healthy mouth. This study was aimed to determine the efficacy of oral health education
based on an integrated model on oral hygiene attitude and behavior among the college students of Udaipur city. An intervention study
was conducted among 156 college students in Udaipur city. The questionnaire based on the new integrated model was tested for
validity and reliability. Paired t test and multinomial regression analysis were employed for statistical analysis. Significant differences
were observed regarding all the indicators of oral hygiene practices, perceived susceptibility, seriousness, benefits, barriers, self-
efficacy, and external locus of control. Odds ratio was significantly greater among undergraduate regarding oral hygiene practices. Also
odds ratio of perceived susceptibility and seriousness was more among male population. The educational intervention was successful
in conveying the message regarding the importance of oral hygiene practices.

Keywords
oral hygiene, psychological, mechanical, behavior, health education, dental

Introduction
Oral health is a key indicator of overall health, well-being,
and quality of life. World Health Organization defines oral
health as a state of being free from chronic mouth and facial
pain, oral and throat cancer, oral infection and sores, peri-
odontal (gum) disease, tooth decay, tooth loss, and other
diseases and disorders that limit an individual’s capacity
in biting, chewing, smiling, speaking, and psychosocial
well-being.1 A healthy mouth enables people to eat, speak,
and socialize without pain, discomfort, or embarrassment.
The impact of oral disease on people’s everyday lives is
subtle and pervasive, influencing eating, sleep work, and
social roles. The prevalence and recurrences of these impacts
constitutes a silent epidemic.2
Hygiene is a science concerned with the investigations of
environmental factors that affect human health. It shows
how the human body responds to them. Dental hygiene is
the science and practice of the recognition, treatment, and
prevention of oral diseases. Good oral hygiene is the foun-
dation for a healthy mouth and prevents majority of all
dental problems. Obeying the rules of proper oral hygiene
is of primary importance in the prevention of dental caries
and periodontal diseases. Unfortunately, oral hygiene prac-
tice is very low in our society. A survey conducted by
Gopikrishna et al.3 suggested that there was an insufficient
degree of education about oral health and that many children
in the country did not even use a toothbrush, instead relied
on traditional methods to keep their teeth clean.
Despite many recent technical breakthroughs in health
care, human behavior remains the largest source of variance
in health-related outcomes. Changing and promoting health
behaviors involve specifying and targeting beliefs, attitudes,
intentions, and context-related barriers that prevents behav-
ior change.4 Educational theory has identified that there are
1
Department of Public Health Dentistry, Pacific Dental College and Hospital,
Udaipur, India
Corresponding Author:
Kailash Asawa, Department of Public Health Dentistry, Pacific Dental College and
Hospital, Udaipur, Rajasthan 313024, India.
Email: kailashasawaudr@yahoo.com
2 International Quarterly of Community Health Education 0(0)
three domains of learning: cognitive, affective, and
behavioral.
Traditional dental health education was based on the
theory that acquiring new knowledge would alter attitudes
and lead to a change in behavior. But in reality, a very com-
plex and dynamic relationship operates between the three
domains of learning. Behavior is largely determined by the
opportunities and conditions in which individuals are placed.
An extensive range of models and theories have been
proposed to explain behavior change.5 It has been found
that health education interventions based on psychological
theory are the most effective. Health behavior theories and
models suggest effective components of promoting health.
These theories also provide information about how interven-
tions work and allow for replication of studies, an important
aspect of determining effectiveness.
The Health Belief Model (HBM) is one of the best-known
frameworks that refer to the key role of people’s beliefs as a
stimulus for behavior change implementation. Based on this
model, when people understand the level of risk that an
unhealthy behavior poses, and their susceptibility to the
adverse consequences of their feelings, as well as understand-
ing their behaviors, they become interested in methods to
reduce their risks. By using learning methods to counteract
and reduce existing barriers, they are able to mitigate these
adverse effects; moreover, they can change their attitudes and
the range of positive behaviors will increase.6
Self-efficacy is advocated within the framework of social
learning theory and is defined as an individual’s confidence in
determining how well he or she can take the actions necessary
for producing certain results. In the field of dentistry, corre-
lations have been reported between self-efficacy and frequen-
cies of brushing, flossing, and dental visits. Higher self-
efficacy in periodontal patients correlates with better adher-
ence to oral hygiene instruction and periodontal treatment.
Whether people with periodontal disease can properly adhere
or not to these health regimens is the key to success in pre-
venting periodontal diseases. Therefore, people with relative-
ly greater self-efficacy may exhibit overall better self-care
behaviors and periodontal health than those with relatively
lower self-efficacy.7
Locus of control refers to an individual’s generalized
expectations concerning where control over subsequent
events resides—in other words, who or what is responsible
for what happens. The notion of perceived locus of control is
perhaps the most widely known of the psychological con-
structs associated with beliefs about control. Although this
trait is no doubt distributed normally among people, those
who believe that they are influenced by external forces are
considered to have an external locus of control (ELOC).
However, those who have confidence that whatever happens
to them, pleasant or unpleasant, is substantially within their
domain of influence are said to have a predominantly inter-
nal locus of control. Rotter’s concept viewed locus of control
as unidimensional (internal to external). Levenson’s model
asserts that there are three independent dimensions: internal-
ity, chance, and powerful others. According to Levenson’s
model, one can endorse each of these dimensions of locus
of control independently and at the same time. For example,
a person might simultaneously believe that both oneself
and powerful others influence outcomes, but that chance
does not.8
Based on this behavioral theory, a new integrated model
was constructed to determine the efficacy of oral health inter-
vention on the mechanical factors and psychological factors
of oral hygiene behavior among the college students in
Udaipur city. Keeping this new model in mind, a 53 self-
administered structured questionnaire was developed to
assess the oral hygiene habits and behavior.
Materials
Study Design, Study Population, and Study Area
An intervention study was conducted in 156 college students
in Udaipur, India for a duration of 1 month.
Ethical Approval
The study protocol was received by the ethical committee of
Pacific Dental College and Hospital and was granted ethical
clearance. Before conducting the study, an official permission
was taken from the principal of the college and concerned
authorities of Pacific Academy of Higher Education and
Research University.
Informed Consent
All the subjects who agreed to participate in the study was
requested to give written consent prior to the beginning of
the study.
Inclusion criteria are the following:
• Participant who were willing to participate in the study.
• Students aged between 18 and 30 years.
Exclusion criteria are the following:
• Participants who were pursuing dentistry course.
• Students who were planning to migrate or leave the city in
the next 4 months.
Questionnaire
A 53 self-administered structured questionnaire was devel-
oped. The questionnaire consisted of three sections—the
first section solicited general demographic details including
age, gender, family income, and level of education.
Socioeconomic status was classified according to Prasad’s
Classification of socioeconomic status scale.9
Asawa et al.
The second section consisted of seven closed-ended
questions on oral hygiene behavior: frequency of brushing,
duration of brushing, method of cleaning, types of bristle,
frequency of replacing toothbrush, frequency of dental
checkup, and other hygiene aids.
The third section consisted of 38 closed-ended model-
guided questions with response ranging from strongly agree
to strongly disagree. Perceived susceptibility (2Q), perceived
seriousness (6Q), perceived benefits (8Q), perceived barriers
(6Q), self-efficacy (8Q), and external locus of health (8Q).
Pretesting Survey
The assessment of content validity in the questionnaire was
related to the opinions expressed by a group of six panelists
(a panel of academician and postgraduate). Mean content
validity ratio was calculated as 0.8. Content validity identifies
whether the measures represent all the facets of a given
construct.
Face validity, which describes whether the test “looks
valid” to the examinees who take it, the administrative per-
sonnel who decide on its use, and other technically untrained
observers was assessed by administering the questionnaire to
12 subjects who were asked to rate the questionnaire on a
scale of very easy, somewhat easy, very difficult, and some-
what difficult was taken in the category of difficult. Chi-
square test was applied, and it was observed that 90% of
the participants found the questionnaire to be easy
(p < .05). Criterion validity was also assessable and found
to be satisfactory (Cronbach’s a: .88)
The questionnaire was further pretested to assess its fea-
sibility and reliability which were found to be satisfactory.
Test of reliability comprised two components: question–
question reliability that was assessed by the percentage of
agreement (90%) and internal reliability for the responses
to questions, which was assessed using Cronbach’s a (.84).
All necessary changes were introduced in the main study.
Methodology
A list was prepared regarding all the universities in Udaipur
city. Out of those, one was randomly selected (i.e., Pacific
Academy of Higher Education and Research). Then at
second stage, a list of all constituent colleges of Pacific
Academy of Higher Education and Research University
was prepared and out of which one college was selected ran-
domly (Pacific College of Management). All the students
studying in that college were included in the study. The
final sample size consisted of 156 students based on inclusion
and exclusion criteria.
Baseline Data
On the predecided day, the investigator visited the selected
college and distributed the questionnaire to the subjects.
The participants were asked to place a right mark beside
3
the selected answers. The investigator was consistently avail-
able at the venue in order to clear any query in understanding
the question.
The intervention consists of lecture along with power
point presentation about the anatomy of oral cavity, healthy
oral cavity, poor oral hygiene, factors affecting oral hygiene,
consequences of poor oral hygiene, and maintenances of oral
hygiene.
Follow-Up
After 1 month of intervention, study subjects were again
made to fill the same questionnaire.
Statistical Analysis
The data were coded and entered into Microsoft Excel
spreadsheet. Analysis was done using SPSS version 20
(IBM SPSS statistic Inc, Chicago, IL) windows software pro-
gram. Descriptive analyses were conducted to determine the
sociodemographic characteristics, distribution of oral
hygiene habits, and subscales of the model. Paired t test
was used to compare the values before and after the inter-
vention. Multinomial regression analysis was employed to
determine the odds ratio.
Results
In a total population of 156 subjects, majority were males
(n ¼ 107[68.6%]) in the age-group from 18 to 20 years
(n ¼ 107[68.6%]). Majority of the study population were
from rural areas (n ¼ 92[59%]), from upper middle class
(n ¼ 54[34.6%]), and were undergraduate students (n ¼ 92
[59%], Table 1).
Significant differences were observed in almost all the indi-
cators of oral hygiene practices except the frequency of
replacing toothbrush (p ¼ .75) after intervention (Table 2).
A significant difference regarding perceived susceptibility
was observed between mean score obtained before
(4.05  2.91) and after intervention (6.21  2.00). Maximum
difference was observed regarding the frequency of dental
checkup before and after interventions (0.12 vs. 0.88; Table
3).
Before intervention, the total mean score regarding per-
ceived susceptibility was 5.37, whereas after intervention, the
score increased to 8.66, and this difference was found to be
statistically significant (p ¼ .03; Table 4).
Before intervention, the total mean score regarding per-
ceived seriousness of poor oral hygiene was 24.43  5.38,
whereas after intervention, it was found to be 25.4  3.4,
which was statistically significant. Overall, all the indicators
of perceived seriousness showed significant improvement
(Table 5).
An overall improvement has been shown in the total mean
score of perceived benefits (i.e., 32.64 vs. 34.59), which was
statistically significant (p ¼ .004). After intervention,
4 International Quarterly of Community Health Education 0(0)

Table 1. Distribution of Study Population According to Various Table 2. Distribution of Oral Hygiene Practices Before and After
Independent Variables. Intervention.

Number Percentage Before After

Variables (n) (%) Oral hygiene practices n (%) n (%) p

Age, years Frequency of brushing teeth

18–20 107 68.6 Once 56 (35.9) 27 (17.4) .000039
>20 49 31.4 Twice 97 (62.2%) 119 (76.3)
Gender Thrice 3 (1.9%) 10 (6.4)
Male 107 68.6 Duration of brushing teeth
Female 49 31.4 30–60 seconds 28 (17.9) 3 (1.9) .000007
Place of residence 1–2 minutes 68 (43.6) 69 (44.2)
Rural 92 59 2–5 minutes 60 (38.5) 84 (53.8)
Urban 64 41 Method of brushing teeth
Percapita income Horizontal 44 (28) 29 (18.6) .000032
Lower class 0 0 Vertical 39 (25) 13 (8.3)
Lower middle class 21 13.5 Circular 73 (46.8) 114 (73.1)
Middle class 33 21.2 Types of bristles
Upper middle class 54 34.6 Soft 61 (39.1) 138 (88.5) <.05
Upper class 48 30.8 Medium 86 (55.1) 17 (10.9)
Education Hard 9 (5.8) 1 (0.6)
Undergraduate 92 59 Frequency of replacing tooth brush
Postgraduate 64 41 3–4 months 89 (57) 92 (59) .75
Total 156 100 6–8months 16 (10.3) 5 (3.2)
As soon as bristles fray out 51 (32.7) 59 (37.8)
Frequency of dental checkup
Once in every 6 months 18 (11.5) 136 (87.2) .001
maximum changes were observed regarding benefits related
Once in a year 26 (16.7) 10 (6.4)
to avoidance of wastage of money and time on every dental Once when any dental 112 (71.8) 10 (6.4)
visits (4.17; p ¼ .000009) and benefits of preventing of tooth problem is there
decay (4.38; p ¼ .000009; Table 6). Other oral hygiene aids
Overall, a significant decrease in the score was observed No aids 48 (30.8) 10 (6.4) 005
regarding participants’ barrier in oral hygiene practices at Mouth rinse 29 (18.6) 54 (34.6)
follow-up compared with baseline (17.11 vs. 10.92; Flossing 5 (3.2) 12 (7.7)
Tongue cleaner 66 (42.3) 61 (39.1)
p ¼ .000273; Table 7).
Other hygiene aids 8 (5.1) 19 (12.1)
A comparative assessment of mean of self-efficacy among
study population before and after interventions has showed Note. Paired sample t test has been applied.
an overall improvement regarding participants self-efficacy *p  .05 statistically significant.
of maintaining oral hygiene practices at follow-up which
was at statistically significant (30.02 vs. 36.63; p ¼ .001; Table 3. Comparative Assessment of Mean of Correct Responses on
Table 8). Oral Hygiene Practices Among Study Population Before and After
After intervention, an overall decrease in the total mean Intervention.
score regarding ELOC has been observed, which was statis-
Before After
tically significant (21.06 vs. 16.08; p ¼ .005; Table 9). intervention intervention
A significant greater odds ratio of 3.62 was seen among Oral hygiene practices Mean  SD Mean  SD p
undergraduate students regarding oral hygiene practices after
intervention. Perceived susceptibility’s odds ratio was more Frequency of brushing 0.63  0.48 0.83  0.38 .000042
Duration of brushing 0.82  0.38 0.98  0.13 .000001
significant among males (0.366) and those who residing
Method of cleaning 0.47  0.5. 0.73  0.44 .000001
from rural area (0.327). Similarly perceived seriousness’s Types of bristles 0.39  0.49 0.88  0.32 .000000
odds ratio (0.283) was more among males than in females Frequency of replacing 0.90  0.30 0.97  0.17 .007
(Table 10). toothbrush
Frequency of dental checkup 0.12  0.32 0.88  0.32 .000000
Other oral hygiene aids 0.72  0.44 0.94  0.24 .000000
Discussion Total 4.05  2.91 6.21  2.00 .014
People’s readiness to recognize and practice the appropriate Abbreviation: SD, standard deviation.
ways of living in order to maintain health and avoid diseases Note. Paired sample t test has been Test applied.
requires the modification of their behaviors. Failure to *p  .05 statistically significant.
Asawa et al. 5

Table 4. Comparative Assessment of Perceived Susceptibility Among Table 6. Comparative Assessment of Perceived Benefits Among Study
Study Population Before and After Intervention. Population Before and After Intervention.

Before After Before After

intervention intervention intervention intervention
Perceived susceptibility Mean  SD Mean  SD p Perceived benefits Mean  SD Mean  SD p

I think my oral hygiene is poor 2.68  0.98 4.42  0.86 <.05 If I maintain oral hygiene——————
I think I am susceptible to 2.69  0.99 4.24  0.83 <.05 My teeth will not be painful. 4.13  0.95 4.23  0.67 .315
poor oral hygiene My teeth will not be yellow 4.15  0.87 4.22  1.08 .41
Total 5.37  1.97 8.66  1.69 .03 in appearance.
I won’t have bad breath. 3.96  1.04 4.49  0.50 <.05
Abbreviation: SD, standard deviation.
There won’t be wastage of 3.64  1.27 4.17  0.80 .000009
Note. Paired sample t test has been applied.
*p  .05 statistically significant.
time and money on every
dental visits.
I won’t have tooth decay. 4.05  0.98 4.38  0.48 .000009
Table 5. Comparative Assessment of Perceived Seriousness Among My gums wont bleed. 4.27  3.38 4.44  0.49 .54
Study Population Before and After Intervention. My teeth will survive for 4.10  0.94 4.45  0.66 .000116
longer period.
Before After I will look good. 4.06  1.24 4.21  1.05 .25
intervention intervention Total 32.36  10.67 34.59  5.73 .004
Perceived seriousness Mean  SD Mean  SD p
Note. Paired sample t test has been applied.
I think poor oral hygiene leads to 3.91  1.06 4.31  0.69 .000136 *p  .05 statistically significant.
tooth decay
I believe poor oral hygiene leads 3.91  0.96 4.15  0.59 .010042
to swelling of gingival
Table 7. Comparative Assessment of Perceived Barriers Among Study
I believe poor oral hygiene can 3.93  0.79 4.17  0.38 .000338
Population Before and After Intervention.
cause tooth mobility
I believe poor oral hygiene can 4.01  0.80 4.22  0.64 .016587 Before After
seriously affect general health intervention intervention
I believe that poor oral hygiene 4.24  0.89 4.40  0.49 .041519 Perceived barriers Mean  SD Mean  SD p
produces bad breath and will
affect people at work or I believe I skip brushing when I 3.09  1.33 1.89  1.03 .001
others aspect of everyday life am in a rush
I believe poor oral hygiene can 4.43  0.88 4.67  0.61 .002 I feel too lazy to brush regularly 2.56  1.35 1.62  0.90 .001
cause yellowness of teeth that Maintenance of oral hygiene on a 2.76  1.26 2.20  1.07 .0002
makes people look bad in daily basis is a tiresome,
appearance boring and exhausting habit
Total 24.43  5.38 25.4  3.4 .001 My unfamiliarity with proper 3.09  1.93 1.93  1.05 .001
brushing technique is the sole
Abbreviation: SD, standard deviation. reason of poor oral hygiene
Note. Paired sample t test has been applied. I believe that lack of dentists in 2.78  1.19 1.63  0.66 .001
*p  .05 statistically significant.
my neighborhood is the sole
reason of poor oral hygiene
I am less likely to maintain oral 2.83  1.57 1.65  0.58 .001
comply with good health behavior can be seen in all societies,
hygiene because it is wastage
illiterate or literate, rich or poor. Students community all of money and expensive
together play a vital role in bringing about a behavioral Total 17.11  8.63 10.92  5.3 .001
change in the society. With this in view, this study was con-
ducted to assess the efficacy of oral health education based Abbreviation: SD, standard deviation.
Note. Paired sample t test has been applied.
on an integrated model on oral hygiene practices, attitude, *p  .05 statistically significant.
and behavior among the college-going students.
College students are no different than others in their age-
group. They are risk takers. They no longer have parents in for the future. College students often abandon healthy life-
their immediate presence to remind them to brush their teeth. style habits when going off to college and this could include
College students may forget to floss daily, brush their teeth dental health habit.10 Therefore, it is very important to create
multiple times per day, or they may even go days without an awareness regarding the importance of oral hygiene.
brushing their teeth. The combination of busy college stu- Moreover, it has been noted that oral health education
dents, risk taking, and lack of campus dental health-care based on psychological theories has immensefully helped in
services is a dangerous triad both for the present and also promoting the knowledge, attitude, perceptions, and
6 International Quarterly of Community Health Education 0(0)

Table 8. Comparative Assessment of Self-efficacy Among Study Population Before and After Intervention.

Before After
intervention intervention
Self-efficacy Mean  SD Mean  SD p

I am confident that I can brush my teeth regularly even when I am busy with work 4.14  1.04 4.59  0.74 .000018
I place a great value on my oral hygiene 3.98  0.97 4.44  0.49 .000003
I am confident that I can manage to brush my teeth twice a day 3.83  1.17 4.54  0.82 .001
I am confident that I can brush my teeth more than twice a day, if I think that 3.56  1.17 4.69  0.46 .001
there is good reason for doing so (e.g., I have eaten sweets)
If I were given oral health-care training, I would be able to practice better oral health care 3.81  1.09 4.50  0.82 .001
I believe I know how to floss correctly 2.96  1.22 4.69  0.4 .001
I am confident that I can manage to clean my tongue daily along with brushing 4.02  0.96 4.50  0.82 .000020
I believe I can successfully remove the majority of plaque to prevent cavities and gum disease 3.72  1.23 4.68  0.46 .001
Total 30.02  8.85 36.63  5.01 .001
Abbreviation: SD, standard deviation.
Note. Paired sample t test has been applied.
*p  .05 statistically significant.

Table 9. Comparative assessment of ELOC Among Study Population Before and After Intervention.

Before After
intervention intervention
ELOC Mean  SD Mean  SD p

If I don’t visit my dentist regularly, I am more likely to have poor oral hygiene 2.87  1.97 1.67  0.70 .001
Other people play a big role in whether my oral hygiene improves, stays the same, or gets worse 2.53  1.22 1.36  0.66 .001
Luck plays a big part in determining how my oral hygiene improves 2.24  1.17 1.58  0.99 .001
The type of help I receive from my family members determines how soon my oral hygiene improves 3.03  1.13 1.51  0.72 .001
I believe poor oral hygiene is normal part of getting older 2.97  1.17 1.62  1.02 .001
Money plays a big role in whether my oral hygiene improves, stays the same, or get worse 2.92  1.4 1.96  1.4 .001
Education plays a big role in determining how my oral hygiene improves 3.78  1.19 4.24  1.21 .001
Hereditary plays a big role in whether my oral hygiene improves, stays the same, or gets worse 2.96  1.29 2.14  1.54 .001
Total 21.06  10.54 16.08  8.24 .005
Abbreviation: ELOC, external locus of control.
Note. Paired sample t test has been applied.
*p  .05 statistically significant.

ultimately altering the behavior. Henceforth, a new integrat-
ed model was constructed for this awareness program.
The results of oral hygiene practices showed that the sub-
jects were not aware of the importance of correct oral
hygiene practices before intervention. But a significant
improvement has been observed after the model-guided inter-
vention (i.e., 4.05 vs. 6.21) which is in accordance with the
results of study conducted by Bakhtiar et al.11 on 164 Iranian
pregnant women and Wickremasinghe et al.12 on 15-year-old
students attending public school in Srilanka. Similarly, find-
ings related to oral hygiene practices were observed by Haque
et al.13 among adolescents in Bangladesh. This increase in
mean scores can be attributed to factors such as oral health
education based on new integrated model, well performance
of the principal investigator, lectures were provided with
power point presentation, and video demonstration of brush-
ing and flossing along with demonstration showed on
models.
The results of this study following intervention showed a
significant increment in all the constructs of HBM. Before
intervention, the study population neither consider them-
selves susceptible to poor oral hygiene nor do they were
aware regarding the consequences of poor oral hygiene.
After intervention, improvement in the mean score of per-
ceived susceptibility (5.37 vs. 8.66) and perceived seriousness
(24.43 vs. 25.4) were observed, which is in accordance with
the findings of study conducted by Bakhtiar et al.11 on
pregnant women, where the authors found a significant
improvement in the scores of perceived susceptibility and
perceived seriousness after intervention. This improvement
of the present study could be attributed to increase in the
knowledge regarding ill effects of not maintaining oral
hygiene that was provided to them in educational interven-
tion. The study by Jeihooni et al.14 also confirmed the
above-mentioned results favoring the health promotion
through HBM model.
 Table 10. Multinomial Logistic Regression Odds Ratio (95% CI) for Oral Hygiene Practices, Perceived Susceptibility, Perceived Seriousness, Perceived Benefits, Perceived Barriers,
Self-efficacy, and External Locus of Control as Dependent Variable.

Odds ratio (95% CI)

Variable
Oral hygiene Perceived Perceived Perceived Perceived
practices susceptibility seriousness benefits barriers Self-efficacy ELOC

Age
18–20 2.51 (0.667–9.835) 0.5 (0.120––2.087) 1.172 (0.424–3.243) 0.694 (0.264–1.824) 0.487 (0.118–2.012) 0.566 (0.178–1.807) 1.27 (0.340–4.74)
>20 1 1 1 1 1 1 1
Gender
Male 2.629 (0.79–8.732) 0.336 (0.116–0.974)* 0.283 (0.126–0.635)* 0.967 (0.434–2.154) 1.150 (0.356–3.718) 0.550 (0.199–1.519) 2.045 (0.770–5.428)
Female 1 1 1 1 1 1 1
Location
Rural 1.607 (0.503–5.134) 0.327 (0.113–0.947)* 0.548 (0.252–1.189) 0.808 (0.383–1.703) 0.655 (0.215–1.995) 0.78 (0.286–2.129) 1.017 (0.395–2.623)
Urban 1 1 1 1 1 1 1
Percapita income
Lower middle 0.334 (0.051–2.203) 1.741 (0.389–7.781) 1.110 (0.348–3.535) 0.652 (0.211–2.013) 2.696 (0.486–14.94) 0.483 (0.088–2.666) 2.014 (0.430–9.443)
class
Middle class 1.384 (0.354–5.404) 0.685 (0.146–3.202) 1.494 (0.552–4.048) 0.732 (0.275–1.949) 2.253 (0.486–8.293) 1.150 (0.358–3.693) 0.394 (0.119–1.311)
Upper middle 0.669 (0.2–2.236) 0.955 (0.285–3.198) 0.996 (0.416–2.386) 1.68 (0.508–2.684) 3.196 (0.902–11.327) 0.596 (0.193–1.841) 0.779 (0.271–2.237)
class
Upper class 1 1 1 1 1 1 1
Education
Undergraduate 3.622 (1.102–11.902)* 1.386 (0.439–4.379) 0.915 (0.38–2.166) 0.699 (0.301–1.623) 0.049 (0.337–3.265) 0.581 (0.212–1.590) 0.542 (0.175–1.678)
Postgraduate 1 1 1 1 1 1 1
Abbreviations: CI, confidence interval; ELOC, external locus of control.
Note. Multinomial logistic regression has been applied.
*p  .05 statistically significant.

7
8 International Quarterly of Community Health Education 0(0)
It is evident from our study result that there is significant
increase in the mean score of perceived benefits after inter-
vention. The result (32.36 vs. 34.59) certified the efficacy of
the intervention in conveying the message regarding the ben-
efits of maintaining oral hygiene. The result of this variable is
in consistent with the findings of the study conducted by
Bakhtiar et al.11 and Shahnazi et al.15 This change could be
attributed to increase in the knowledge of oral hygiene
behavior after intervention.
In line with these results, following the training interven-
tion, an increase in the mean score of self-efficacy has been
observed in our findings (30.02 vs. 36.63). A similar result has
been reported by Bakhtiar et al.,11 Jeihooni et al.14 and
Shahnazi et al.15 A study conducted by Buglar et al.7 esti-
mated that self-efficacy has the vital role in practicing daily
oral hygiene practices including flossing and tooth brushing.
Self-efficacy is the most important motivating factor for
implementing new healthy behavior. The increase in the
score after intervention was the evidence of amplification of
self-confidence of the participants. However, the video and
model demonstration of flossing, tooth brushing along with
oral health promotion through new integrated model-guided
intervention have outstandingly helped in making them self-
competent and self-conscious enough regarding their oral
hygiene practices.
Perceived barrier is a very important component in the
model, which helped us in scrutinizing the real obstacles in
the acquirement of maximum oral hygiene. Accordingly, it
helped us to plan the intervention where more emphasis has
been given on obstacles, ultimately overcoming the barrier.
However, the decline in the mean score is in accordance with
the study findings of Bakhtiar et al.,11 Jeihooni et al.14 and
Hosseini et al.16 On the contrary, the study findings of
Wickremasinghe et al.12 and Shahnazi et al.15 were in con-
trast with our findings.
This study showed an overall decrease in ELOC after
intervention which is in consistent with the findings of the
study conducted by Top et al.17 The decline in the score
verified the energetic influence the intervention has on the
study participants, enhancing the self-confidence of the par-
ticipants. Moreover, the intervention was successful enough
to remove the myth regarding oral hygiene and helped them
to be self-competent.
A new insight has been provided by the new integrated
behavioral model in relation to the individual demographic
variables for the oral health discrepancies in the college-going
students. Study outcomes reflected that males were less sus-
ceptible to poor oral hygiene and less serious regarding their
oral hygiene practices when compared with females as males
were less disciplined or still immature to follow any sugges-
tion. In addition, they were more vulnerable to peer-related
pressure or stress-related environment. In relation to new
integrated model, education was considered as the strongest
predictor for optimal oral hygiene practices. Adherence of
the optimal oral hygiene practices was more among the
undergraduate students rather than that of the postgraduate
students who suggested lack of time and busy schedule that
restrict them from implementing optimal oral hygiene prac-
tices. Another significant association was geographic location
and perceived susceptibility. As anticipated, subjects residing
from the rural areas were more adhere to their cultural beliefs
and practices creating a conflict between the new knowledge
and attitude.
Conclusion
The findings of our study concluded that an educational
intervention based on the integrated model has benefit the
study population by increasing the score of perceived suscep-
tible, perceived seriousness, perceived benefits, self-efficacy,
and decrease the score of perceived barriers and ELOC. In
addition, the oral health educational intervention was suc-
cessful in accomplishing the study objectives in conveying
the message regarding the importance of optimal oral
hygiene practices. Each of the components has its own role
and interlinked with each other. Moreover, the model has
successfully helped the study population in self-analyzing
the knowledge regarding oral hygiene, its benefits and bar-
riers and myths and in the same model intervention was pro-
vided to increase the self-confident and self-efficiency in
implementing healthy oral hygiene practices.
Limitations
The limitation of this study is that it was conducted among
students from only one specialty, that is, Pacific College of
Management. Therefore, it is recommended that further
studies should be conducted among students from different
specialties.
Acknowledgments
The authors would like to thank the study participants for their
participation and kind cooperation throughout the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Tulip Chakravarty https://orcid.org/0000-0002-5687-6349
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Author Biographies
Kailash Asawa is an associate professor in the Department of
Public Health Dentistry at Pacific Dental College and
Hospital, Debari, Udaipur, Rajasthan, India.
Tulip Chakravarty is a postgraduate student in the
Department of Public Health Dentistry at Pacific Dental
College and Hospital, Udaipur, Rajasthan, India.
Mridula Tak is a reader in the Department of Public Health
Dentistry at Pacific Dental College and Hospital, Udaipur,
Rajasthan, India.
Dev Rathod is a postgraduate student in the Department of
Public Health Dentistry at Pacific Dental College and
Hospital, Udaipur, Rajasthan, India.
Nandini Sen is a postgraduate student in the Department of
Public Health Dentistry at Pacific Dental College and
Hospital, Udaipur, Rajasthan, India.