Modeling of the Theory of Planned Behavior to Predict Determinants of Oral Health Behavioral Intention in Mothers of Children under 6 Years of Age in Iraq
Abstract
Introduction: The American Academy of Pediatric Dentistry (AAPD) recommends improving oral health behaviors as essential for the prevention of Early Childhood Caries (ECC), and several studies have evaluated different approaches to explaining human behavior through behavioral and cognitive-behavioral theories. This study aimed to explain predictors of mothers’ behavioral intention regarding the oral health of their under-6-year-old children in Iraq based on the Theory of Planned Behavior using structural equation modeling. Materials and Methods: This cross-sectional study was conducted using a multistage random sampling method, including 926 mothers of under-six-year-olds in Iraq in 2023. A valid questionnaire based on the Theory of Planned Behavior evaluated attitude, perceived behavioral control, subjective norms, and behavioral intention. Descriptive analysis and structural equation modeling (SEM) were used to describe the data and examine the association among the variables. Results: Out of 926 children, 59.5% were girls. The mean age of the children was 4.0 (SD = 0.9) years, and the mean age of the mothers was 30 (SD = 5.2) years. The mean scores of the attitude, subjective norms, perceived behavioral control, and behavioral intention were 17.5 out of 20, 14.8 out of 20, 18.7 out of 32, and 20.4 out of 24, respectively. Subjective norm score (estimation = 0.12, p-value < 0.001), perceived behavioral control score (estimate = 0.06, p-value < 0.001), and attitude score (estimation = 0.15, p-value < 0.001) positively predicted behavioral intention, with perceived behavioral control being the strongest predictor. Conclusion: The TPB was supported for predicting behavioral intention in our study population. The health holders should consider the TPB constructs, in particular perceived behavioral control, for improving behavioral intention. Keywords: Children; Preschool; Intention; Oral health; Theory of planned behavior.
1. World Health Organization. (2022). Global oral health status report: towards universal health coverage for oral health by 2030. World Health Organization. https://iris.who.int/handle/10665/364538.
2. Barranca-Enríquez A, Romo-González T. Your health is in your mouth: A comprehensive view to promote general wellness. Front Oral Health. 2022 Sep 14;3:971223. doi: 10.3389/froh.2022.971223.
3. Section On Oral Health, Segura A, Boulter S, Clark M, Gereige R, Krol DM, et al. Maintaining and Improving the Oral Health of Young Children. Pediatrics. 2014;134(6):1224-9. .
4. Bencze Z, Mahrouseh N, Andrade CAS, Kovács N, Varga O. The burden of early childhood caries in children under 5 years old in the European Union and associated risk factors: An ecological study. Nutrients. 2021;13(2):455.
5. Ending childhood dental caries: WHO implementation manual. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0IGO
6. Al-kinane SM, Al-janabi WH, Al-kinane MM. genetic contribution to early childhood caries in pre-school aged children in Iraq. Pakistan Heart Journal. 2023;56(2):1023-31
7. El Tantawi M, Folayan MO, Mehaina M, Vukovic A, Castillo JL, Gaffar BO, et al. Prevalence and Data Availability of Early Childhood Caries in 193 United Nations Countries, 2007-2017. Am J Public Health. 2018;108(8):1066-72
8. Kowash MB, Alkhabuli JO, Dafaalla SA, Shah A, Khamis AH. Early childhood caries and associated risk factors among preschool children in Ras Al-Khaimah, United Arab Emirates. European Archives of Paediatric Dentistry. 2017 Apr;18(2):97-103.
9. Shalan HM, Abobakr RM. Oral Health Status among Egyptian Preschool Children. Egyptian Dental Journal. 2018;64(2-April (Orthodontics, Pediatric & Preventive Dentistry)):875-82
10. Alhabdan YA, Albeshr AG, Yenugadhati N, Jradi H. Prevalence of dental caries and associated factors among primary school children: a population-based cross-sectional study in Riyadh, Saudi Arabia. Environmental health and preventive medicine. 2018;23:1
11. Javadzadeh E, Razeghi S, Shamshiri A, Miri HH, Moghaddam F, Schroth RJ, Mohebbi SZ. Prevalence and socio-behavioral determinants of early childhood caries in children 1–5-year-old in Iran. Plos one. 2023;18(11):e0293428
12. Şengül F, Urvasızoğlu G, Derelioǧlu S, Seddik T, Çelikel P, Baş A. Early childhood caries in 4-to 5-year-old children in Erzurum, Turkey. Frontiers in public health. 2021;9:725501
13. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Consequences and preventive strategies. The Reference Manual of Pediatric Dentistry Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:88-91
14. American Academy of Pediatric Dentistry Clinical Affairs Committee Infant Oral Health Subcommittee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Pediatric Dentistry 2005. 2006; 27: 68–71
15. Pitts N, Baez R, Diaz-Guallory C, et al. Early Childhood Caries: IAPD Bangkok Declaration. Int J Paediatr Dent. 2019;29:384–3869.
16. Daniel W. McNeil . Behavioral and Cognitive-Behavioral Theories in Oral Health Research: Current State and Future Directions Community Dent Oral Epidemiol. 2023 February ; 51(1): 6–16. doi:10.1111/cdoe.12840.
17. Xu J, Pan Y, Li Q. Influencing factors of health screening among retirees: an extended TPB approach. Frontiers in Public Health. 2024;12.
18. Ajzen I. Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. J Appl Psychol. 2006;3(44):665–683.
19. Elyasi M, Lai H, Major PW, Baker SR, Amin M. Modeling the Theory of Planned Behaviour to predict adherence to preventive dental visits in preschool children. PLoS One. 2020;15(1):e0227233.
20. Lavin D, Groarke A. Dental foss behaviour: a test of the predictive utility of the theory of planned behaviour and the efects of making implemen tation intentions. Psychol Heal Med. 2005;10(3):243–52.
21. Amin M, Elyasi M, Bohlouli B, ElSalhy M. Application of the theory of planned behavior to predict dental attendance and caries experience among chil dren of Newcomers. Int J Environ Res Public Health. 2019;16(19):3661
22. Ramlall I. Applied structural equation modelling for researchers and practitioners: Using R and Stata for behavioural research: Emerald Group Publishing Limited; 2016.
23. Al-Sarray RAH, Shamshiri A, Alzubidi M, Gholami M, Mohebbi SZ. Development and psychometric evaluation of a theory of planned behavior model-based instrument for evaluation of determinants of oral health behaviors in mothers of children younger than six years in Iraq. BMC Oral Health. 2025 Feb 3;25(1):181.
24. Luzzi L, Spencer AJ. Factors influencing the use of public dental services: An application of the Theory of Planned Behaviour. BMC Health Services Research. 2008;8(1):93.
25. Buunk-Werkhoven YA, Dijkstra A, van der Schans CP. Determinants of oral hygiene behavior: a study based on the theory of planned behavior. Community Dent Oral Epidemiol. 2011;39(3):250-9.
26. Shitu K, Alemayehu M, Buunk-Werkhoven YAB, Handebo S. Determinants of intention to improve oral hygiene behavior among students based on the theory of planned behavior: A structural equation modelling analysis. PLoS One. 2021;16(2):e0247069.
27. Bramantoro T, Basiroh E, Berniyanti T, Setijanto RD, Irmalia WR. Intention and Oral Health Behavior Perspective of Islamic Traditional Boarding School Students Based on Theory of Planned Behavior. Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2020;20.
28. Rajeh MT. Modeling the theory of planned behavior to predict adults’ intentions to improve oral health behaviors. BMC Public Health. 2022;22(1):1391.
29. Armitage CJ, Conner M. Efficacy of the Theory of Planned Behaviour: a meta-analytic review. Br J Soc Psychol. 2001;40(Pt 4):471-99.
30. Sheeran P. Intention—behavior relations: a conceptual and empirical review. European review of social psychology. 2002;12(1):1-36.
31. Dumitrescu AL, Wagle M, Dogaru BC, Manolescu B. Modeling the theory of planned behavior for intention to improve oral health behaviors: the impact of attitudes, knowledge, and current behavior. J Oral Sci. 2011;53(3):369-77.
32. Åstrøm AN, Lie SA, Gülcan F. Applying the theory of planned behavior to self-report dental attendance in Norwegian adults through structural equation modelling approach. BMC Oral Health. 2018;18(1):95.
33. Badri P, Saltaji H, Flores-Mir C, Amin M. Factors affecting children's adherence to regular dental attendance: a systematic review. J Am Dent Assoc. 2014;145(8):817-28.
34. Mohammadkhah F, Amirhajelu RM, Bakhtiar M, Salemi SA, Kevenjan M, Jeihooni AK. The effect of training intervention based on the theory of planned behavior on oral and dental health behaviors in pregnant women. BMC Oral Health. 2023;23(1):521.
35. Gandomi F, Sharif-Zadeh GR, Moodi M, Akbari N, Gandomi N. Predicting Dental Caries Preventive Behaviors Among Pregnant Women Based on Self-Efficacy and the Theory of Planned Behavior. Mod Care J. 2017;14(4):e68206.
2. Barranca-Enríquez A, Romo-González T. Your health is in your mouth: A comprehensive view to promote general wellness. Front Oral Health. 2022 Sep 14;3:971223. doi: 10.3389/froh.2022.971223.
3. Section On Oral Health, Segura A, Boulter S, Clark M, Gereige R, Krol DM, et al. Maintaining and Improving the Oral Health of Young Children. Pediatrics. 2014;134(6):1224-9. .
4. Bencze Z, Mahrouseh N, Andrade CAS, Kovács N, Varga O. The burden of early childhood caries in children under 5 years old in the European Union and associated risk factors: An ecological study. Nutrients. 2021;13(2):455.
5. Ending childhood dental caries: WHO implementation manual. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0IGO
6. Al-kinane SM, Al-janabi WH, Al-kinane MM. genetic contribution to early childhood caries in pre-school aged children in Iraq. Pakistan Heart Journal. 2023;56(2):1023-31
7. El Tantawi M, Folayan MO, Mehaina M, Vukovic A, Castillo JL, Gaffar BO, et al. Prevalence and Data Availability of Early Childhood Caries in 193 United Nations Countries, 2007-2017. Am J Public Health. 2018;108(8):1066-72
8. Kowash MB, Alkhabuli JO, Dafaalla SA, Shah A, Khamis AH. Early childhood caries and associated risk factors among preschool children in Ras Al-Khaimah, United Arab Emirates. European Archives of Paediatric Dentistry. 2017 Apr;18(2):97-103.
9. Shalan HM, Abobakr RM. Oral Health Status among Egyptian Preschool Children. Egyptian Dental Journal. 2018;64(2-April (Orthodontics, Pediatric & Preventive Dentistry)):875-82
10. Alhabdan YA, Albeshr AG, Yenugadhati N, Jradi H. Prevalence of dental caries and associated factors among primary school children: a population-based cross-sectional study in Riyadh, Saudi Arabia. Environmental health and preventive medicine. 2018;23:1
11. Javadzadeh E, Razeghi S, Shamshiri A, Miri HH, Moghaddam F, Schroth RJ, Mohebbi SZ. Prevalence and socio-behavioral determinants of early childhood caries in children 1–5-year-old in Iran. Plos one. 2023;18(11):e0293428
12. Şengül F, Urvasızoğlu G, Derelioǧlu S, Seddik T, Çelikel P, Baş A. Early childhood caries in 4-to 5-year-old children in Erzurum, Turkey. Frontiers in public health. 2021;9:725501
13. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Consequences and preventive strategies. The Reference Manual of Pediatric Dentistry Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:88-91
14. American Academy of Pediatric Dentistry Clinical Affairs Committee Infant Oral Health Subcommittee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Pediatric Dentistry 2005. 2006; 27: 68–71
15. Pitts N, Baez R, Diaz-Guallory C, et al. Early Childhood Caries: IAPD Bangkok Declaration. Int J Paediatr Dent. 2019;29:384–3869.
16. Daniel W. McNeil . Behavioral and Cognitive-Behavioral Theories in Oral Health Research: Current State and Future Directions Community Dent Oral Epidemiol. 2023 February ; 51(1): 6–16. doi:10.1111/cdoe.12840.
17. Xu J, Pan Y, Li Q. Influencing factors of health screening among retirees: an extended TPB approach. Frontiers in Public Health. 2024;12.
18. Ajzen I. Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. J Appl Psychol. 2006;3(44):665–683.
19. Elyasi M, Lai H, Major PW, Baker SR, Amin M. Modeling the Theory of Planned Behaviour to predict adherence to preventive dental visits in preschool children. PLoS One. 2020;15(1):e0227233.
20. Lavin D, Groarke A. Dental foss behaviour: a test of the predictive utility of the theory of planned behaviour and the efects of making implemen tation intentions. Psychol Heal Med. 2005;10(3):243–52.
21. Amin M, Elyasi M, Bohlouli B, ElSalhy M. Application of the theory of planned behavior to predict dental attendance and caries experience among chil dren of Newcomers. Int J Environ Res Public Health. 2019;16(19):3661
22. Ramlall I. Applied structural equation modelling for researchers and practitioners: Using R and Stata for behavioural research: Emerald Group Publishing Limited; 2016.
23. Al-Sarray RAH, Shamshiri A, Alzubidi M, Gholami M, Mohebbi SZ. Development and psychometric evaluation of a theory of planned behavior model-based instrument for evaluation of determinants of oral health behaviors in mothers of children younger than six years in Iraq. BMC Oral Health. 2025 Feb 3;25(1):181.
24. Luzzi L, Spencer AJ. Factors influencing the use of public dental services: An application of the Theory of Planned Behaviour. BMC Health Services Research. 2008;8(1):93.
25. Buunk-Werkhoven YA, Dijkstra A, van der Schans CP. Determinants of oral hygiene behavior: a study based on the theory of planned behavior. Community Dent Oral Epidemiol. 2011;39(3):250-9.
26. Shitu K, Alemayehu M, Buunk-Werkhoven YAB, Handebo S. Determinants of intention to improve oral hygiene behavior among students based on the theory of planned behavior: A structural equation modelling analysis. PLoS One. 2021;16(2):e0247069.
27. Bramantoro T, Basiroh E, Berniyanti T, Setijanto RD, Irmalia WR. Intention and Oral Health Behavior Perspective of Islamic Traditional Boarding School Students Based on Theory of Planned Behavior. Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2020;20.
28. Rajeh MT. Modeling the theory of planned behavior to predict adults’ intentions to improve oral health behaviors. BMC Public Health. 2022;22(1):1391.
29. Armitage CJ, Conner M. Efficacy of the Theory of Planned Behaviour: a meta-analytic review. Br J Soc Psychol. 2001;40(Pt 4):471-99.
30. Sheeran P. Intention—behavior relations: a conceptual and empirical review. European review of social psychology. 2002;12(1):1-36.
31. Dumitrescu AL, Wagle M, Dogaru BC, Manolescu B. Modeling the theory of planned behavior for intention to improve oral health behaviors: the impact of attitudes, knowledge, and current behavior. J Oral Sci. 2011;53(3):369-77.
32. Åstrøm AN, Lie SA, Gülcan F. Applying the theory of planned behavior to self-report dental attendance in Norwegian adults through structural equation modelling approach. BMC Oral Health. 2018;18(1):95.
33. Badri P, Saltaji H, Flores-Mir C, Amin M. Factors affecting children's adherence to regular dental attendance: a systematic review. J Am Dent Assoc. 2014;145(8):817-28.
34. Mohammadkhah F, Amirhajelu RM, Bakhtiar M, Salemi SA, Kevenjan M, Jeihooni AK. The effect of training intervention based on the theory of planned behavior on oral and dental health behaviors in pregnant women. BMC Oral Health. 2023;23(1):521.
35. Gandomi F, Sharif-Zadeh GR, Moodi M, Akbari N, Gandomi N. Predicting Dental Caries Preventive Behaviors Among Pregnant Women Based on Self-Efficacy and the Theory of Planned Behavior. Mod Care J. 2017;14(4):e68206.
| Files | ||
| Issue | Vol 13, No 2 (Spring 2026) | |
| Section | Original Article(s) | |
| Keywords | ||
| Children; Preschool; Intention; Oral health; Theory of planned behavior. | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Hadi Al-Sarray RA, Amirian E, Alzubidi M, Mohebbi SZ. Modeling of the Theory of Planned Behavior to Predict Determinants of Oral Health Behavioral Intention in Mothers of Children under 6 Years of Age in Iraq. J Craniomaxillofac Res. 2026;2026(2):210-220.
