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Knowledge, attitude, and practice (KAP)-based health education programme for parents of adolescent fixed orthodontic patients: a mixed-methods randomized controlled trial

This mixed-methods randomized controlled trial demonstrates that a Knowledge, Attitude, and Practice (KAP)-based health education programme for parents of adolescents with fixed orthodontic appliances significantly improves parental health literacy, enhances adolescent treatment compliance, and optimizes periodontal outcomes compared to routine care.

Original authors: Xiaona Sui, Wei Zhang, Sheng Zhai, Jiale Zhu, Xin Liu

Published 2026-06-28

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CC BY 4.0

Original authors: Xiaona Sui, Wei Zhang, Sheng Zhai, Jiale Zhu, Xin Liu

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine your teenager is driving a brand-new, high-performance race car (their teeth) with a complex navigation system (braces). The mechanic (the orthodontist) has installed the system, but the car won't stay on track if the driver doesn't know how to maintain it. In this study, the researchers realized that while the teenager is the driver, the parents are the pit crew. If the pit crew doesn't know the rules of the road or how to change the tires, the car crashes.

Here is the story of how the researchers built a "Pit Crew Training Manual" for parents and tested if it worked.

The Problem: The "Blind" Pit Crew

In China, nearly half of all teenagers need braces. But fixing teeth isn't just about the doctor's skill; it's about what happens at home. The researchers found that many parents were like pit crews who had never been trained:

They didn't know what to do (Knowledge): They thought braces were self-cleaning or that bleeding gums were normal.
They didn't believe it mattered (Attitude): They thought aesthetics were the only goal, ignoring the health of the gums.
They didn't do the right things (Practice): They didn't supervise brushing or check the diet.

This led to messy teeth, inflamed gums, and teenagers who gave up on their treatment.

The Solution: The "KAP" Training Program

The team decided to build a training program based on KAP: Knowledge, Attitude, and Practice.

Step 1: Designing the Manual (The Blueprint)
Before testing, they didn't just guess what to teach. They:

Read hundreds of existing books and studies (Literature Review).
Called in 22 experts (like professors, chief doctors, and psychologists) for two rounds of "Delphi" meetings. Think of this as a summit where the world's best coaches agreed on exactly what the pit crew needs to know.
Created a 7-month curriculum covering everything from "Why do teeth move?" to "How to brush around a bracket without hurting your child."

Step 2: The Race (The Experiment)
They gathered 212 parent-teen pairs and split them into two teams:

The Control Team (The Standard Pit Crew): Got the usual care. The doctor gave a quick verbal tip about brushing and handed out a basic pamphlet.
The Intervention Team (The Super-Trained Pit Crew): Got the standard care plus the new KAP program.
- Offline: They met face-to-face four times for 60 minutes to watch videos, practice brushing on models, and ask questions.
- Online: They joined a WeChat group for 7 months where they got bi-weekly reminders, tips, and could ask questions instantly.

The Results: Who Won the Race?

After 7 months, the difference was clear. The "Super-Trained" team didn't just feel better; they performed better.

The Parents (The Crew): They scored much higher on tests about what they knew, how they felt about the treatment, and how they actually helped their kids. They went from confused to confident.
The Teens (The Drivers): Their mouths were cleaner.
- Gingival Index (Gum Health): The trained group had significantly less gum inflammation (like a car with clean, healthy tires) compared to the control group.
- Plaque Index (Dirt on the car): There was much less sticky gunk (plaque) stuck to the braces.
The Behavior: The trained teens were more likely to wear their rubber bands, show up to appointments on time, and not break their brackets. They were also happier about the whole process.

The Bottom Line: It's a Bargain

The researchers also looked at the cost.

The Cost: The training program was cheap (about $48 per family for the whole year).
The Savings: Because the teens had fewer emergencies, fewer broken braces, and better gum health, the total cost for the trained group was actually lower than the group that just got standard care.

The Takeaway

The study concludes that you can't just fix teeth; you have to fix the family's habits. By treating parents as the primary "pit crew" and giving them a structured, mix of in-person and digital training, you get cleaner teeth, happier teens, and a treatment that actually works.

What the paper doesn't say:
The authors are careful to note that this was a single test in one hospital. They don't claim this works for every single family in the world yet, and they admit they didn't track the teens for the full 2–3 years of a typical braces journey. However, for the 7 months they watched, the "Pit Crew Training" worked perfectly.

Technical Summary: KAP-Based Health Education for Parents of Adolescent Orthodontic Patients

Problem Statement
Malocclusion affects approximately 47.92% of Chinese adolescents, representing a significant oral public health challenge. While clinical expertise is vital for orthodontic success, treatment outcomes are heavily dependent on parental supervision regarding daily oral hygiene, dietary restrictions, and appointment adherence. Current educational approaches are often fragmented, relying on one-off verbal instructions or informational handouts that lack a theoretical foundation. Consequently, many parents possess insufficient knowledge, hold biased perceptions (e.g., viewing gingival bleeding as normal), and fail to establish standardized supervision habits. This gap leads to poor adolescent compliance, exacerbated gingival and plaque issues, and increased treatment complications. There is a demonstrated need for structured, theory-based interventions specifically targeting parents to bridge the disconnect between awareness and practice.

Methodology
The study employed a two-phase mixed-methods design:

Program Development (Phase 1):
- Literature Review: A systematic review of databases (PubMed, CNKI, etc.) and guidelines identified evidence for a preliminary educational draft based on the Knowledge–Attitude–Practice (KAP) framework.
- Delphi Consultation: A two-round Delphi process involving 22 multidisciplinary experts (orthodontists, pediatric nurses, psychologists, health educators) refined the program. Consensus was achieved with high expert authority coefficients ($Cr > 0.93$) and significant opinion convergence ($Kendall's W$). The final program comprised three domains: Knowledge (10 secondary indicators), Belief (2 secondary indicators), and Practice (5 secondary indicators), totaling 50 tertiary indicators.
Randomized Controlled Trial (Phase 2):
- Design: A single-center, assessor-blinded, parallel-group RCT conducted from September 2023 to July 2025.
- Participants: 212 parent–adolescent dyads (adolescents aged 12–18 with fixed appliance therapy) were randomly assigned 1:1 to an intervention or control group ( $N=106$ per group).
- Intervention:
  - Control Group: Received routine orthodontic care (standard verbal advice on hygiene and diet).
  - Intervention Group: Received routine care plus a 7-month, standardized KAP-based health education program. This included four face-to-face sessions (baseline, appliance placement, 3 days post-placement, 4 weeks post-placement) utilizing demonstrations, videos, and guidebooks, supplemented by bi-weekly digital support via a dedicated WeChat group (12 follow-up engagements).
- Outcomes: Primary outcomes included parental KAP scores, adolescent Gingival Index (GI) and Plaque Index (PI), and treatment compliance (measured by a 14-item Clinical Compliance Assessment Scale). Secondary outcomes included feasibility metrics and a health economic evaluation (cost-consequence analysis).
- Analysis: Data were analyzed using SPSS v25.0 with intention-to-treat principles, utilizing independent t-tests and chi-square tests.

Key Results
After 7 months, the intervention group demonstrated statistically significant improvements across all primary metrics compared to the control group:

Parental KAP: Intervention parents achieved significantly higher scores in Knowledge ( $8.7 \pm 1.1$ vs. $7.3 \pm 1.3$ , $p=0.010$ ), Attitude ( $8.9 \pm 1.0$ vs. $7.5 \pm 1.2$ , $p=0.020$ ), and Practice ( $8.6 \pm 1.2$ vs. $7.4 \pm 1.3$ , $p=0.010$ ).
Oral Health Status: Adolescents in the intervention group exhibited significantly lower Gingival Index ( $1.2 \pm 0.3$ vs. $1.8 \pm 0.4$ , $p=0.02$ ) and Plaque Index ( $1.5 \pm 0.5$ vs. $2.1 \pm 0.6$ , $p=0.01$ ) scores.
Treatment Compliance: The intervention group showed higher overall compliance scores ( $8.5 \pm 1.2$ vs. $7.2 \pm 1.4$ , $p<0.05$ ). Specific improvements were noted in oral hygiene maintenance, appliance protection, and appointment punctuality.
Economic Evaluation: The intervention was cost-dominant. The mean total cost per participant was $48.60 in the intervention group versus $72.30 in the control group, yielding a net saving of $23.70 per patient. The Incremental Cost-Effectiveness Ratio (ICER) indicated superior clinical outcomes at a lower cost.
Feasibility: The program maintained a participation rate exceeding 95% and received high satisfaction ratings from parents.

Significance and Claims
The paper claims that this study provides evidence-based validation for a family-centered, theory-driven health education model in orthodontics. Key contributions include:

Shift to Family-Centered Care: The study successfully demonstrates that targeting parents as the primary agents of behavioral change is more effective than focusing solely on adolescents, particularly for early adolescents who lack full autonomy.
Methodological Advancement: It introduces a hybrid online-offline intervention model that integrates face-to-face technical training with continuous digital follow-up, addressing the limitations of traditional, passive information dissemination.
Clinical and Economic Impact: The research establishes a direct link between parental education and tangible clinical improvements (reduced GI/PI) and treatment compliance. Furthermore, it proves the intervention is not only clinically effective but also economically sustainable, offering a scalable strategy for public health management and routine orthodontic care.
Limitations: The authors modestly acknowledge limitations, including the single-center design, the 7-month follow-up period (which may not capture the full 2–3 year treatment cycle), and the lack of an attention-control group to isolate specific intervention components. They call for multi-center studies and longer-term follow-up to verify generalizability and sustainability.

In conclusion, the authors posit that integrating brief, KAP-oriented parental counseling into routine orthodontic visits is a replicable and effective strategy for improving adolescent oral health outcomes.