Abstract
The use of social media for educational purposes can effectively provide parents with valuable information. This study aimed to analyze the effectiveness of two different social media–based educational approaches on the knowledge, attitude, practice (KAP) and oral health literacy (OHL) of mothers of kindergarten regarding ECC. The two approaches shared identical educational information via interactive engagement on Instagram (IG) and self-led study using a digital flipbook (DF) distributed via WhatsApp. A quasi-experimental study design with purposive sampling at the school level was conducted among mothers of similar socioeconomic status, age, and educational level. Education was provided over 2 weeks, and validated questionnaires were used both pre- and post-intervention to assess the KAP and OHL. Seventy-seven mothers of kindergarten were enrolled and divided into two groups consist of IG (n = 36) and DF (n = 41), out of which 63 (30 IG, 33 DF) completed the study. Furthermore, a statistically significant increase in OHL scores was observed in both groups (p < 0.05). A statistically significant moderate to strong positive correlation was noted between the KAP and OHL scores (p < 0.05). These findings indicate that education through both IG and DF was effective in improving the mothers’ KAP and OHL, with no significant differences in scores between the two approached.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-09049-0.
Keywords: Knowledge, Attitude and practice, Dental health education, Oral health literacy, Social media
Introduction
Childhood caries is a widespread problem. According to the results of the 2018 Basic Health Research of Indonesia, 45.3% of Indonesians experience tooth decay, including 54.0% of children aged 5–9 years and 36.4% of children aged 3–4 years who are affected by cavities. According to the 2018 Basic Health Research data, not all children with oral health issues receive the necessary treatment. Only 14.6% of 5–9-year-olds with oral health problems received care from dental professionals, although 67.3% had dental and oral issues. Similarly, only 4.3% of 3–4-year-olds with oral health problems received care from dental professionals, despite 41.4% having such issues [1]. The prevalence of early childhood caries (ECC) is high in Southeast Asian countries, particularly in Indonesia. The prevalence of cavities in toddlers in Indonesia is as high as 90.05% [2].
Parental behavior is one of the factors contributing to ECC. Children under 5 years old generally begin forming early habits and routines adopted from their surrounding environment, commonly referred to as primary socialization [3]. At this stage, children tend to adopt behaviors modeled by their parents. Based on the study, mothers play a more important role compared to fathers or other caregivers. Maternal behavior has a direct impact on children, as mothers control decision-making in their children’s lives. The knowledge and attitude of mothers play a role in preventive practices and health promotion [4]. Thus, parents must possess adequate knowledge about oral health to reduce the high incidence of ECC among children.
According to survey data from the Pew Research Center in the United States, 91% of parents in the country have internet access, and 83% of them use social media on a daily basis [5]. Data suggest that social media use is common in Indonesia, which ranks third in Instagram (IG) usage with 63 million users, indicating that three out of ten people in the country use the platform [6]. Therefore, social media could serve as an effective educational platform to enhance public knowledge. The development of digital media facilitates the rapid and effective dissemination of information, bringing about changes in knowledge, literacy, and attitudes among information receivers [7].
Based on previous research, there is a need for more evidence on the role of social media in enhancing public education, particularly regarding the in-depth influence of educational interventions on platforms like Instagram (IG) compare to digital flipbooks (DF) in relation to knowledge, attitude, practice (KAP), and oral health literacy (OHL). A DF is an interactive electronic book that looks similar to a physical book but with additional interactive elements, such as links and navigation. Testing these two approaches could provide evidence about which types of social media effectively serve as educational tools for changing health behaviors. Consequently, this study aimed to analyze the effectiveness of education through (a) active interaction via IG or (b) a one-time receipt of a DF on the KAP and OHL of mothers in relation to ECC.
Materials and methods
This study has complied to the STROBE protocol. The study used a quasi-experimental design, in which educational interventions were provided to mothers of kindergarten via IG or DF over a period of 2 weeks. The respondents were Mother from Five schools of kindergarten in Duren Sawit district area were purposively sampled to participate in the study consist of Negeri Pembina Kindergarten, Islam Hifzhul Amanah Kindergarten, Islam Al Hikmah Kindergarten, Al Hidayah Kindergarten, and Islam Al Muhajirin Kindergarten. They were chosen for their similar on parental socioeconomic status and education levels to help control for these potential confounding factors.
The socioeconomic status, age, education, and social media usage as WhatsApp or IG of 79 mothers interested in participating were collected. Those who did not use social media and those who were outliers in terms of socioeconomic status, age, or education were excluded from the study (n = 2). Subsequently, 77 mothers who were active on social media and similar in terms of socioeconomic status, age, and educational level were selected to participate in the study.
Allocation to the intervention group was done randomly at the school level; for example, School A received the intervention via IG, whereas School B received it via a DF shared through WhatsApp. One mother at a school was not active on the allocated social media platform (IG) and was included in the DF group from the beginning of the research. The IG group (n = 36) received education by engaging with an IG account (materigigi_edu) for 2 weeks, whereas the other group (n = 41) received education through a DF for self-study distributed to them once via WhatsApp and without further interaction with the researcher. All participants were required to complete a pre-test questionnaire at the start of the study before exposure to their allocated intervention. The participants were exposed to the educational interventions for 2 weeks before completing a follow-up post-test. The pre-test and post-test were conducted offline at school to prevent respondents from copying answers and to allow monitoring of the questionnaire completion process.
This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Faculty of Dentistry Universitas Indonesia (approval number: 56/Ethical Approval/FKGUI/X/2025). All participants signed an informed consent form.
Mother’s education intervention via IG
The ECC educational material was delivered to the IG group twice a week over a 2-week span, featuring an interactive question-and-answer session. The first post included information on the importance of baby teeth. The second post addressed the types and development of baby teeth and permanent teeth. The third post included material on factors contributing to ECC, and the fourth post covered methods for preventing ECC. Each week, participants were encouraged to read the material and respond to questions related to the topics posed by the researcher via the IG account.
Mother’s education via DF
In the DF group, the ECC material was distributed through a one-time distribution of a DF in a non-interactive WhatsApp group. Participants were asked to independently study the content of the DF, which included the same educational material as presented in the IG feeds.
The KAP and OHL questionnaires
Two questionnaires were used to assess the KAP and OHL. The first one was adapted from the study by Jain et al. (2014), consisting of 25 items, including 10 knowledge-related questions, 6 attitude-related questions, and 9 practice-related questions [8]. The second one was adapted from the Oral Health Literacy Inventory for Parents (OHLI-P) developed by Richman et al. (2011). The measurement tool was transformed into a questionnaire comprising 64 questions, divided into the following three sections: word recognition (14 questions), vocabulary knowledge (15 questions), and comprehension (35 questions) [9].
The KAP and OHLI-P questionnaires underwent reliability and validity testing using data from 27 participants who were not included in the main study (the minimum number required was 20) before being employed in the main research. The validity of the OHLI-P questionnaire was confirmed using the bivariate Pearson test, which examined three sections of the questionnaire: word recognition, vocabulary knowledge, and comprehension. Reliability testing was conducted using Cronbach’s alpha for internal consistency. Based on this reliability test, the Cronbach’s alpha score for word recognition was 0.730, indicating acceptable reliability. In vocabulary knowledge, the Cronbach’s alpha score was 0.864, indicating good reliability. In comprehension, the Cronbach’s alpha score was 0.755 (acceptable), indicating that the questionnaire used in the study was considered reliable.
The validity testing of the KAP questionnaire also employed the bivariate Pearson test. The combined score from all three sections (knowledge, attitude, and practice) was valid. Moreover, reliability testing was conducted using Cronbach’s alpha for internal consistency. Based on this reliability test, the Cronbach’s alpha score obtained was 0.762 (acceptable), indicating that the questionnaire used in this study was reliable.
To assess the external consistency of the OHLI-P and KAP questionnaires, a test-retest was conducted using Pearson’s correlation for the total OHLI-P scores, yielding a result of 0.857, which is categorized as good reliability. The KAP questionnaire score obtained was 0.781, which was categorized as acceptable, indicating that the questionnaire’s external consistency was reliable.
Sample size
The total sample size was calculated using the G Power 3.1.9.4 application, which required 21 participants per group for a power of 85%, resulting in a total sample size of 42. Seventy-seven mothers were initially included in the study and were requested to complete the KAP and OHLI-P questionnaires via Google Forms. The forms were filled out independently by each mother, offline, and under the researcher’s supervision.
Statistical analysis
Data analysis was conducted after the educational sessions and data collection had been completed. Completed pre- and post-test data were available for 66 participants (30 IG and 33 DF; Fig. 1). The average scores for KAP, OHLI-P (word recognition), OHLI-P (vocabulary), and OHLI-P (comprehension) were analyzed using descriptive statistics. The differences in average scores between the pre-test and post-test KAP and OHL were assessed using the Wilcoxon signed-rank test and paired t-test. Differences in scores between the IG and DF groups were tested using the Mann–Whitney U test. The correlation between KAP and OHL was examined using the Spearman test. All statistical analyses were conducted with a significance level set at 5% (p ≤ 0.05).
Fig. 1.
Flow diagram of research subjects
Results
Mother’s KAP score before and after education
Participants in the DF group (n = 33) had lower average pre-test scores compared to those in the IG group (n = 30; Table 1). However, the increase in scores between the pre-test and post-test was found to be higher in the DF group compared to that in the IG group. The post-test scores of participants who received education through the DF were higher than those in the IG group.
Table 1.
Mean difference test between the scores of knowledge, attitude, practice of mothers in the instagram education group & digital flipbook
| Questionnaire | n | Mean ± SD | P value |
|---|---|---|---|
| Education Via Instagram | |||
| Knowledge pretest score | 30 | 8.00 ± 1.531 | 0.036* |
| Knowledge post test score | 30 | 8.53 ± 1.502 | |
| Attitude pretest score | 30 | 5.30 ± 0.535 | 0.371 |
| Attitude post test score | 30 | 5.43 ± 0.568 | |
| Practice pretest score | 30 | 4.80 ± 0.961 | < 0.001* |
| Practice post test score | 30 | 5.97 ± 1.129 | |
| Education via Digital Flipbook | |||
| Knowledge pretest score | 33 | 7.33 ± 1.931 | 0.004* |
| Knowledge post test score | 33 | 8.45 ± 1.716 | |
| Skor Attitude pretest | 33 | 5.27 ± 0.911 | 0.053 |
| Skor Attitude post test | 33 | 5.61 ± 0.609 | |
| Skor Practice pretest | 33 | 4.70 ± 1.212 | < 0.001* |
| Skor Practice post test | 33 | 6.00 ± 1.639 | |
Wilcoxon Test and± Dependent T-Test
As shown in Table 1, both groups showed a change in post-intervention KAP scores. A statistically significant difference in knowledge and practice scores was observed between the IG and DF groups (p < 0.05); however, there was no statistically significant difference in the average attitude scores between the two groups.
Mother’s OHL score before and after education
Table 2 shows that the total scores for OHLI-P reflected a change in both groups. A statistically significant change was found in the word recognition, vocabulary, and comprehension scores in both groups (p < 0.05).
Table 2.
Mean difference test between the OHLI-P scores of mothers in the Instagram education group & digital flipbook
| Questionnaire | n | Mean ± SD | P value |
|---|---|---|---|
| Education Via Instagram | |||
| OHLI-P (word recognition) pretest scores | 30 | 9.37 ± 3.681 | < 0.001* |
| OHLI-P (word recognition) post test scores | 30 | 12.47 ± 3.246 | |
| OHLI-P (vocabulary) pretest scores | 30 | 12.27 ± 3.279 | < 0.001* |
| OHLI-P (vocabulary) post test scores | 30 | 14.18 ± 1.637 | |
| OHLI-P (comprehension) pretest scores | 30 | 30.48 ± 2.881 | < 0.001* |
| OHLI-P (comprehension) post test scores | 30 | 32.46 ± 2.535 | |
| Education via Digital Flipbook | |||
| OHLI-P (word recognition) pretest scores | 33 | 8.42 ± 3.446 | < 0.001* |
| OHLI-P (word recognition) post test scores | 33 | 13.09 ± 2.269 | |
| OHLI-P (vocabulary) pretest scores | 33 | 11.98 ± 3,303 | 0.001* |
| OHLI-P (vocabulary) post test scores | 33 | 14.21 ± 1.976 | |
| OHLI-P (comprehension) pretest scores | 33 | 29.84 ± 2.578 | < 0.001* |
| OHLI-P (comprehension) post test scores | 33 | 33.06 ± 1.5499 | |
Wilcoxon Test
Impact of mother’s education on KAP and OHL
As shown in Table 3, no statistically significant difference in the OHLI-P and KAP scores was observed between the IG and DF groups. A statistically significant moderate to strong positive correlation was found between the KAP and OHLI-P scores in both groups (p < 0.05; Table 4).
Table 3.
Mean difference test in total post-test scores between the Instagram education group and digital flipbook
| Post test | n | Mean ± SD | P value |
|---|---|---|---|
| KAP scores via Instagram education | 30 | 19.93 ± 1,929 | 0.341 |
| KAP scores via digital flipbook education | 33 | 20.06 ± 3.051 | |
| OHLI-P (word recognition) scores via Instagram education | 30 | 12.47 ± 2.269 | 1.000 |
| OHLI-P (word recognition) scores via digital flipbook education | 33 | 13.09 ± 2.269 | |
| OHLI-P (vocabulary) scores via Instagram education | 30 | 14.18 ± 1.637 | 0.798 |
| OHLI-P (vocabulary) scores via digital flipbook education | 33 | 14.21 ± 1.976 | |
| OHLI-P (comprehension) via Instagram education | 30 | 32.46 ± 2.535 | 0.769 |
| OHLI-P (comprehension) via digital flipbook education | 33 | 33.06 ± 1.549 |
Mann Whitney-U Test
Table 4.
Correlation of post-test scores for Knowledge, Attitude, Practice (KAP) and OHLI-P scores in the Instagram & digital flipbook education group
| n | Mean ± SD | r | P value | |
|---|---|---|---|---|
| Education Via Instagram | ||||
| KAP score | 30 | 19.93 ± 1.929 | 0.467 | 0.009* |
| OHLI-P (word recognition) score | 30 | 12.47 ± 3.246 | ||
| KAP score | 30 | 19.93 ± 1.929 | 0.432 | 0.017* |
| OHLI-P (vocabulary) score | 30 | 14.18 ± 1,63 | ||
| KAP score | 30 | 19.93 ± 1,929 | 0.392 | 0.032* |
| OHLI-P (comprehension) score | 30 | 32.46 ± 2.535 | ||
| Education Via Digital Flipbook | ||||
| KAP score | 33 | 20.06 ± 3.051 | 0.409 | 0.018* |
| OHLI-P (word recognition) score | 33 | 13.09 ± 2.269 | ||
| KAP score | 33 | 20.06 ± 3.051 | 0.563 | 0.001* |
| OHLI-P (vocabulary) score | 33 | 14.21 ± 1.976 | ||
| KAP score | 33 | 20.06 ± 3.051 | 0.440 | 0.010* |
| OHLI-P (comprehension) score | 33 | 33.06 ± 1.549 | ||
Spearman Test
Discussion
This study indicates that mothers of kindergarten children who were exposed to information about ECC on IG or DF demonstrated higher levels of KAP after the intervention. This aligns with the KAP-O framework theory and the KAP theory by Schwartz (1976) in Rav-Marathe KSR et al., 2016. Based on these theories, it is assumed that knowledge, attitude, and practice are interrelated [10]. This can explain the improvement in the knowledge and practice domains in the current study. Although previous studies investigating educational interventions on KAP did not specifically focus on the oral health of children, a recent study illustrated the effective role of educational interventions in improving KAP among parents [11].
No statistically significant differences were observed between the pre-test and post-test attitude scores in either the IG or DF group in the present study. While some theories and studies suggest a link between increased knowledge and improved attitude, this short-term study’s results do not support that conclusion. The effects on attitude may be smaller, requiring larger sample sizes to demonstrate any real difference. However, several studies show similar results to ours regarding the absence of significant changes in attitude within the KAP domain. A study demonstrated that educational interventions and the use of SMS as an educational tool resulted in significant improvements in knowledge and practice, while attitudes were less affected [12]. An education delivery method focused on discussion may have a more significant impact on attitude improvement. This is reflected in the theory of learning needs, which explains that modifying someone’s attitude and perspective on a problem is achieved through discussion. In group discussions, an individual receiving education can actively engage and participate. Since neither educational intervention in this study included group discussions, this may explain the research results, specifically the absence of significant improvement in attitude [13].
The study results indicate a significant increase in OHLI-P scores for word recognition, vocabulary knowledge, and understanding in the IG and DF groups, indicating that the educational intervention was effective in improving the OHL of mothers, at least in the short term. This finding is supported by a study by Ebrahaimi et al.,2022 found that examined the effectiveness of education delivery through SMS and demonstrated that the intervention effectively improved OHL in individuals, especially adults [14]. In the current study, no significant difference in post-test scores for KAP and OHLI-P was observed between the two methods, indicating that both educational methods are effective in improving education. This is supported by the theory that using visual media, such as DF and IG content, can enhance information retention through visual stimuli, particularly for visual learners [13].
Moderate to strong positive correlations were observed between the total post-test scores for KAP and OHLI-P, with statistical significance in both the IG and DF groups. This finding is supported by previous studies, such as the one by Nutbeam, which illustrates a relationship between health literacy and KAP that impacts health outcomes [15].
However, this study has some limitations. The pre-intervention test scores proved to be dissimilar between the two groups, with higher starting scores in the IF versus the DF groups, indicating that the effectiveness of the DF might be underestimated. While significant efforts were undertaken to ensure that the mothers were similar in terms of socioeconomic status, age, and educational level, fully randomizing the allocation of interventions to control for bias was not feasible. Future research in this area should consider randomized allocation to intervention groups, taking into account baseline knowledge and other potentially important demographics, such as the maternal level of education.
In conclusion, education through IG and DF proved to be effective in improving the KAP and OHL of mothers after 2 weeks. Further research is warranted to verify the long-term maintenance of these improvements.
Supplementary Information
Acknowledgments
Clinical trial number
It is not applicable.
Authors' contributions
**Darwita, Risqa Rina** : Contributed to conception and design; Contributed to analysis and interpretation data; Drafted the manuscript; Revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy **Fasya, Raissa** : Contributed to conception and design; Contributed to analysis and interpretation data; Drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy **Setiawati, Febriana** : Contributed to analysis and interpretation data; Revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. Douglas, Gail : Contributed to analysis and interpretation data; Drafted the manuscript; Revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy **Adiatman, Melissa** : Contributed to analysis and interpretation data; Drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy **Bahar, Armasastra** : Contributed to analysis and interpretation data; Drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. All author gave their final approval and agree to be accountable for all aspects of the work.
Funding
Universitas Indonesia PUTI Q1 Grant No. PKS-149/UN2.RST/HKP.05.00/2025.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on request (raw data have been attached in supplementary files).
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Faculty of Dentistry Universitas Indonesia (approval number: 56/Ethical Approval/FKGUI/X/2025). All participants signed an informed consent form.
Consent for publication
It is not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on request (raw data have been attached in supplementary files).