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Canadian Journal of Dental Hygiene logoLink to Canadian Journal of Dental Hygiene
. 2021 Feb 15;55(1):30–38.

Development and pilot testing of an oral hygiene self-care photonovel for Punjabi immigrants: a qualitative study

Navdeep Kaur *, Daniel Kandelman §, Louise Potvin ‡
PMCID: PMC7906123  PMID: 33643415

Abstract

Introduction:

The purpose of this research study was to develop and pilot test a culturally and linguistically appropriate oral hygiene self-care photonovel for Punjabi immigrants.

Methods:

Purposeful sampling technique was used to recruit 5 members of a Punjabi community organization (the Sikh Women’s Association of Montreal) for participation in 3 focus group sessions in August 2015. A thematic content analysis approach was used to sort the data, enabling identification of the storyline and photonovel contents from the themes that emerged. Comic Life 3 version 3.1.1 software was used to create a “Safeguard Your Smile” (SYS) photonovel, which was printed for pilot testing. Ten additional participants were recruited for this pilot testing, enabling further revision of the photonovel based on their suggestions.

Results:

Four major themes emerged from the focus group discussions: 1) lack of understanding of oral hygiene self-care and risk factors; 2) lack of oral hygiene self-care-related awareness and routine; 3) lack of emphasis on prevention by oral health care providers; and 4) perceived barriers to accessing dental health care. Thematic content analysis revealed a lack of knowledge of oral hygiene self-care skills and routine. Guided by these overarching themes, a final version of the photonovel script was created including photographs of key characters. The photonovel was subsequently printed for pilot testing. Pilot test results revealed close to 80% of participants agreed that the SYS photonovel was culturally and linguistically appropriate and easy to understand.

Conclusions:

A culturally and linguistically appropriate photonovel may be a useful tool for enhancing oral hygiene self-care knowledge among ethnic communities. Further studies are required to test the effectiveness of such a tool.

Keywords: focus group discussions, oral hygiene self-care, photonovel, Punjabi immigrants

PRACTICAL IMPLICATIONS OF THIS RESEARCH.

  • Immigrant populations tend to have lower health literacy levels than their native-born counterparts. Low health literacy is associated with poor health outcomes.

  • This study describes the development of a photonovel to convey basic oral hygiene selfcare information to an underserved immigrant group in Montreal, Canada.

  • Photonovels are a culturally and linguistically appropriate tool for enhancing oral hygiene self-care knowledge among ethnic communities.

INTRODUCTION

The Canadian Council on Learning has defined health literacy (HL) as a “person’s ability to access, understand, evaluate and communicate information in a way to promote, maintain and improve health in a variety of settings across the life course.”1 The fundamental idea behind HL is that the greater one’s knowledge and understanding of, and skills for managing one’s health, the better one’s health will be.2 Studies show that low HL is a barrier to health care and is associated with poor treatment adherence, high rates of hospitalization3 , and poor health outcomes4 .

Evidence from Canadian HL literature suggests that low HL levels are more prevalent among certain population subgroups such as Indigenous peoples, immigrants, and seniors.1 Results of an International Adult Literacy and Skills Survey (IALSS) show that approximately 60% of immigrants fell below level 3 in prose literacy as compared to 37% of native-born Canadians.1,5 Prose literacy refers to the knowledge and skills needed to understand and use information from texts, including editorials, news stories, brochures, and instruction manuals. According to the Instititut de la statistique du Québec, 55% of Quebec adults fall below the level 3 prose literacy threshold (i.e., the minimum threshold required for coping with demands of daily life) which inhibits their health information seeking ability and contributes to poor health outcomes.6

Health literacy refers not only to the abilities of individuals, but also to the communication practices of health information providers.7 The complexity of current verbal and written health communications is challenging for immigrants with low HL who may not always understand the information they read and what health professionals tell them.8 It has been reported that a significant gap exists between the reading skills of patients with low HL and the language in health-related educational materials provided by health care professionals.9,10

The concept of oral health literacy (OHL) unites health literacy and oral health, and recent studies have suggested it as a potential pathway to reduce oral health disparities. Healthy People 2010 (an American document outlining national health-related goals) has defined OHL as the “degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make oral health related decisions.”11 Studies have shown that low OHL is associated with 1) poor oral health knowledge12-14 ; 2) poor oral health behaviours15-17 ; 3) less dental services utilization18,19 ; and 4) poor oral health status20-24 . Ueno et al.16 demonstrated a significant relationship between the low level of OHL, poor oral health behaviours, and poor oral hygiene status. Current OHL measurement tools are modified versions of the Rapid Estimate of Adult Literacy in Medicine (REALM)25 and the Test of Functional Health Literacy in Adults (TOFHLA)26 . Despite their potential to assess word recognition and basic reading skills, current tools have failed to capture the full complexity of an individual’s OHL level.27-29

Ghiabi et al.,30 who studied the oral health status of Canadian immigrants, confirmed that oral disease rates are much higher among immigrants and refugees as compared to native-born Canadians. Their study reported that almost 53% of immigrants had untreated dental decay, 89% had mild gingivitis, and almost 73% had mild to moderate periodontitis as compared to 32% of Canadians.30 Bedos et al.31 conducted a survey of 5,795 immigrant women in Quebec and found that more recent immigrants used fewer preventive services as compared to established immigrants and non-immigrants. They attributed this difference in part to financial and cultural barriers.31 Additionally, Bedos32 affirmed that low-income adults in Quebec consulted a dentist less often for preventive care and waited longer when they had a dental problem as compared to high-income adults. Evidence from western Canada showed that older Punjabi immigrants have difficulty accessing a dentist and they manage their oral diseases with either home remedies, emergency room visits or during their visits to India.33 Furthermore Marshall et al.34 reported that Punjabi and Chinese populations have explained that their unmet general health and dental care needs are due to economic reasons, unfamiliarity with the Canadian health care system, and low HL. Atchinson et al.35 confirmed these findings, reporting that immigrants have lower OHL as compared to non-immigrants.

The Canadian Public Health Association (CPHA) stated that improvements in HL, in which immigrants are particularly disadvantaged, are critical to producing positive health outcomes and reducing health disparities. 5 Nutbeam36 proposed that improvements in HL involve helping people to gain knowledge and skills, and to develop their motivation and confidence to act on knowledge through more personal forms of communication and community-based outreach. The World Health Organization’s (WHO) report, Health Literacy: The Solid Facts, suggests developing and employing specific “migrant-friendly strategies,” and engaging immigrants, individuals, and communities through cultural mediators when planning and implementing HL improvement efforts.37 Furthermore, use of plain language is emphasized as well as use of audiovisual aids, such as images, photographs, and graphic illustrations.37

Poureslami et al.38 used a participatory approach, including culturally relevant educational videos and a pictorial pamphlet, to improve self-management of asthma among Punjabi, Mandarin, and Cantonese immigrants with low HL. Their findings demonstrated that such a participatory approach and use of culturally and linguistically appropriate materials are effective means to improve the health of ethnocultural communities.38 Among the few notable Canadian HL interventions, such a community participatory approach using an educational tool called a photonovel has been considered to be effective among immigrant women with low HL.39 Nimmon et al.39 used a photonovel to educate participants about how to promote good health by making healthy food choices and adopting an exercise routine. This study concluded that this type of participatory approach—using a photonovel and social network as interventions—was key to encouraging women to make healthy food choices and adopt an exercise routine.39 In addition, access to culturally and linguistically appropriate health information enabled individuals with low HL to make informed health-related choices and decisions.39 Another example of the use of this type of technique was reported by McGinnis et al.40 who effectively used a photonovel to educate community members in the Tampa Bay area in Florida about prostate cancer.

A photonovel resembles a comic book but instead of drawings it contains photographs of real people and has limited text balloons, which are considered an effective means of conveying health-related messages to individuals with low HL.39,40 The photonovel is based on Paulo Freire’s theory of critical consciousness, which posits that critical consciousness develops through dialogue and participatory action.41 When people develop critical consciousness, they apply their critical thinking skills to analyse information, increase awareness, and participate actively in using information to make informed decisions that allow for greater self-efficacy and empowerment.42 A document published by the United Nations Educational, Scientific and Cultural Organization (UNESCO)43 and a guide authored by Nimmon et al.44 provide comprehensive, stepwise processes for creating and publishing a photonovel.

Eliminating oral health disparities has become a national public health priority in most western countries. 45 It is reported that oral diseases are prevalent among Canadian immigrants46 due to limited awareness of preventive and oral health promotion measures.47 Although photonovels about hepatitis B screening48 , tuberculosis49 , and nutrition knowledge50 have been developed, there is a scarcity of research studies related to the development and evaluation of photonovels about oral hygiene self-care. The purpose of the present study was to develop and pilot test a culturally and linguistically appropriate oral hygiene self-care photonovel for Punjabi immigrants.

Specific objectives

  1. To conduct focus group discussions to understand perceptions, knowledge, needs, barriers, and enablers related to oral hygiene self-care behaviour of Punjabi immigrants

  2. To develop a culturally and linguistically appropriate photonovel for Punjabi immigrants from information gained through focus group discussions

  3. To pilot test cultural relevance, format, and comprehensibility of the content of the developed photonovel

METHODS

Ethics approval

Prior to beginning the process of photonovel development, the researchers obtained ethical approval from the ethics review board at the Université de Montréal (Comité d’éthique de la recherche en santé [CERES]). As an incentive, the study participants received a soft toothbrush, dental floss, and fluoridated toothpaste (0.254% sodium fluoride).

Informed consent

A free and informed written consent was secured from the study participants prior to their recruitment or involvement in the study. As part of the process of obtaining their free and informed consent, the lead study researcher informed each participant of the basic elements of the study in simple language suitable to the participants’ level of understanding. The basic elements included the purpose of the research, the participant’s role in the study, risks and benefits of participation, the use of data, and precautions taken concerning data security such as confidentiality and anonymity. The lead researcher also provided opportunities for all participants to ask questions.

Focus group participants were specifically asked for their consent regarding use of any technical data gathered, such as audio/visual/photographic records, and were informed of their right to refuse and reject use of such devices or to withdraw from the study at any time if they wished. Information and questions were addressed in both languages (Punjabi and English) by the lead researcher. After the verbal exchange, participants were presented with a written consent document and given sufficient time to read it before agreeing to participate. Consent forms were available in both English and Punjabi languages and participants chose their preferred language to read and sign their consent.

Study design and description of participant

This study used a qualitative focus group design and a purposeful sampling technique to recruit 5 participants for the development of the photonovel from our community partner organization, the Sikh Women’s Association of Montreal. Participants were Punjabi immigrants, all women, and their ages ranged between 30 and 60 years. For pilot testing, an additional 10 participants were recruited from the same organization and the photonovel was revised according to suggestions made during this pilot testing.

Data collection

Focus group discussions were conducted at times and locations convenient for the participants. These discussions were conducted in the Punjabi language. Three sessions were held, with each session lasting between 60 and 90 minutes. The aim of the first focus group session was to understand the perceptions, knowledge, needs, barriers to, and enablers of, oral hygiene self-care behaviour among Punjabi immigrants. The lead researcher acted as a moderator for each of the 3 sessions and used a brief interview guide to facilitate the focus group discussions that were audiorecorded, translated from Punjabi to English, and transcribed verbatim. A participatory approach was used throughout the development of this photonovel to ensure procedural clarity, accuracy, and verifiable approaches throughout the data analysis. Due to financial constraints, researchers could not hire a professional translator for translation from Punjabi to English. However, a careful cross-checking of the translation against the original audio file was performed by 2 members of our partner organization who had expertise in both English and Punjabi languages; the translation was revised accordingly.

Data analysis

The data analyses included transcription, debriefing, codification, data display, thematic content analysis, and interpretation. The focus group’s discussions were transcribed verbatim from the audio recordings and coded by the lead researcher. Two investigators (NK and DK) read through each transcript carefully to identify specific themes and highlighted the significant statements with a constant debriefing to facilitate the analysis. They conducted thematic content analysis to label and sort the data into themes and sub-themes to identify the emerging interpretations and results.

Photonovel development

The subsequent 2 sessions focused on development of the photonovel following the guidelines specified by UNESCO43 and by Nimmon et al.44 According to Nimmon and colleagues, there are 10 steps to the development of a collaborative photonovel: 1) forming a group; 2) naming a problem; 3) considering the audience; 4) writing a story; 5) developing characters and costumes; 6) taking photographs; 7) preparing the dialogue; 8) using digital technology; 9) seeking audience feedback; and 10) publishing the photonovel.44 Overall, the materials needed are relatively easy to procure and the production of a photonovel is a simple process.

The creation of the photonovel took approximately 10 hours in total, but the timing of the focus group sessions was discussed and scheduled based on the availability and at the convenience of the participants. Next, the storyline and content of the photonovel were drafted using key issues identified during the first focus group session.

Guided by the overarching themes that emerged from the focus group discussions, a final version of the photonovel script was written, photographs of key characters were included, and a copy of the photonovel was printed for pilot testing. The oral health education component focused on explaining the main causes of common gum problems. Next, instructions for oral hygiene care routines and techniques were included. Comic Life 3 (version 3.1.1) software, which offers fonts, templates, panels, balloons, and captions, was used to create the final printed copy of the photonovel.

Pilot testing of the photonovel

The final printed copy of the photonovel was pilot tested among Punjabi community members. Ten additional participants were selected for this part of the study using a snowball sampling technique. A 10-item questionnaire for participants was developed based on evaluation questions by Roter et al.51 The pilot testing questionnaire included questions regarding cultural relevance (Does it matter that when you read the “Safeguard Your Smile” [SYS] photonovel the people in the story are like you? Is the SYS photonovel a reflection of your own cultural oral health values?); comprehensibility of contents (Do you agree that contents of the SYS photonovel are easy to understand?); and format of the photonovel. The questionnaire included some questions requiring a yes or no response; others used a 5-point Likert scale.

Considering the time required and difficulty in recruiting members to review the photonovel, the researchers predetermined that once a saturation point was reached, pilot testing would stop. A decision was made to evaluate the collected data from the first 8 participants and then see if the remaining 2 participants provided new input or information beyond what was obtained from previous participants. Thus, after reaching the saturation point, the research team stopped testing the questionnaire since no new or relevant insights seemed to be emerging.

RESULTS

Part A. Focus group findings

Four major themes emerged from the focus group discussions: 1) lack of understanding of oral hygiene self-care-related knowledge and risk factors; 2) lack of oral hygiene self-care-related awareness and routine; 3) lack of emphasis on prevention by oral health care providers; and 4) perceived barriers to dental health care (Table 1).

Table 1.

Overarching themes of focus group discussions

Themes

1

Lack of understanding of oral hygiene self-care-related knowledge and risk factors

2

Lack of oral hygiene self-care-related awareness and routine

3

Lack of emphasis on prevention by oral health care providers

4

Perceived barriers to dental health care
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Lack of understanding of oral hygiene self-care-related knowledge and risk factors

In general, the focus group members lacked knowledge of how dental plaque contributes to the development of gum diseases. Participants reported that the main source of their oral hygiene self-care knowledge and skills was their family members. Furthermore, they expressed that oral health care providers generally shared post-treatment instructions only and rarely shared detailed information about knowledge and skills related to oral hygiene self-care. Overall, all participants were aware of the importance of good dental health in life.

I have seen few of my close family members, my mother-in-law and my grandmother that when once natural teeth from your mouth are gone it is never the same thing.

If you want to enjoy your life and your natural teeth are not healthy, [you] kind of lose it.

Although a tooth of my husband hurts but he doesn’t want to get it extracted because he says that there is no substitute for real teeth. If you continue extracting one after another, your whole mouth will get empty.

I had many ups and downs with dental problems. I suggest that you may reduce your other expenses and do some saving to take care of your teeth it is very important because in my experience there are so many foods that we can’t enjoy without teeth.

Lack of oral hygiene self-care-related awareness and routine

All participants said that they had a daily toothbrushing routine but none of them had a daily routine of dental flossing and tongue cleaning. Furthermore, they reported having no awareness of the need to floss and to clean their tongue. This lack of awareness related to dental flossing stood out as a main barrier to flossing daily.

I brush twice daily, and I don’t floss, my daughter sometimes flosses but no one else in my family does flossing.

I saw my husband does it sometime, it looks like a thread but neither me nor my children ever did it.

I never learned to floss, and I don’t like it but if something is stuck in teeth, I use toothpick and I have gaps in my teeth.

Honestly, they never showed me the method that this is how we should floss.

Tongue cleaning, very rarely, it is not a regular thing for me.

Thus, there was a clear need for enhanced knowledge of proper techniques of oral hygiene self-care behaviour, particularly of flossing.

Lack of emphasis on prevention by oral health care providers

The focus group also provided insight into a lack of emphasis on prevention by their oral health care providers and stated that they had primarily received post-treatment instructions and rarely preventive guidance related to oral hygiene self-care from their oral health care providers.

My husband had a dental problem, and we went to a dentist. They always suggest getting it extracted and that is their end solution.

I went to a dentist here (Canada) and he said that your last tooth is not growing properly and without any need he extracted it.

A subtheme emerged from this main theme: a lack of involvement of clients in treatment decision making.

My husband had a tooth problem, and he went to a dentist here (Canada) and instead of treating it dentist told him to extract it. My husband said that I do not want to extract it, first try to treat it instead of extracting. They did not do any treatment and after that my husband never went again. He said that he will get it treated when he will visit India. My husband still has the problem, and he is waiting to go to India in November to get it checked up and treated there.

Perceived barriers to dental health care

Two subthemes emerged from the analysis of this main theme. First, language was identified by focus group participants as one of the barriers to dental health care.

My mother-in-law came here [Canada] and she had a problem with her teeth. But she could not go to a dentist since immigrants do face problems here, first is the language problem, second someone has to accompany her as she can’t go alone.

Second, financial barriers in the form of a) lack of dental insurance coverage and b) lack of satisfactory treatment options were described by focus group participants.

(a) Lack of dental insurance coverage: A great deal of discussion was centred on lack of dental insurance coverage and the high cost of dental treatments in Canada as compared to India. It was emphasized that the high cost of treatment is a major barrier to accessing oral health care and it has a negative impact on people’s aspirations for good oral health care. For example, it was considered a major factor influencing their decision to access dental care in Canada or to postpone it and seek care during their next visit to India.

Due to financial problems, we can’t pay the dental expense, and this is the biggest problem.

I went to a dentist but when he told me the expense, I told him that I can’t get that treatment, then, I went to India and got a filling done but that filling came out in the past 4–5 years but I have not gone to a dentist here [Canada] to ask what to do about it.

It has been more than 10 years and I do not remember exactly but since it was expensive that is why I did not agree to get dental treatment.

I have four wisdom teeth and dentist is telling me that I should get them extracted, I said ok, but when he gave me an estimate that ok was gone because it was too expensive. Then I thought since my wisdom teeth are not giving me any trouble, so I don’t want to get them extracted now.

I had some cavities, but I never went to doctor here [Canada] but when I went to India, I got my fillings done from there.

(b) Lack of satisfactory treatment: Those participants who sought dental care in India and were satisfied with the care received said the only problem was that, if anything goes wrong with their dental prosthesis or treatment, dentists in Canada would not repair their dental prosthesis.

In fact, for my mother-in-law they extracted all of her teeth and replaced with full permanent dentures in India. But its shape is so bad that when she laughs it seems as if it will fall off. It is so expensive here [Canada]. So now she will go back again to India and get it fixed again and my father-in-law as well because the denture he had from India is also broken.

Once I went to the dentist in India since I had pain because I had a cavity, I told him I had pain. It was a complete tooth and just a small cavity that could have been treated somehow. But he put me on chair and extracted my tooth, not only he extracted but he also broke the root of it and left some part of it remaining. And while he was extracting, I heard a noise of ‘tuck’ and I told him also that something is left but he said there is nothing. It was such a solid tooth and when I had a check-up here [Canada] that left out root was seen in the X-ray. There was gum covering it and it used to hurt me and then dentist extracted it here, he told me there are some more expenses that I need to get like one bridge worth of $10,000 but I never got it done after.

Part B. Pilot testing findings for the “Safeguard Your Smile” photonovel

Sociodemographics of the participants

All 10 participants in part B of the study were born in Punjab and reported the Punjabi language as their mother tongue. More than half (6) of the participants were females. Seven of the ten participants ranged in age from 48 years to 68 years; the other three were under 48 years of age. The education level of 8 participants was considered “intermediate” since 6 participants reported college/technical education and 2 reported having completed university. Two participants were full-time workers, two were homemakers, and six were retired. In total, 6 participants reported having dental insurance. As shown in Table 2, most of the participants responded positively to the SYS photonovel. The format of the photonovel, ease of understanding, and clarity of message were reported as positive features.

Overall, 9 participants reported that the SYS photonovel was a good tool for oral hygiene self-care and through it they gained knowledge and skills to perform good oral hygiene self-care. Eight participants perceived that the photonovel was culturally and linguistically relevant and easy to understand. Revisions were made based on suggestions from the participants during pilot testing, including the correction of spelling errors and further simplification of the dialogue. Table 2 presents the responses of the 10 participants who read and evaluated the SYS photonovel during pilot testing. The final version of the photonovel (with English translations) is available for viewing online at https://files.cdha.ca/Profession/Journal/Safeguard_Your_Smile_Photonovel.pdf

DISCUSSION

This study used a 2-pronged approach in developing and testing the acceptance of an oral hygiene photonovel for use in a Punjabi immigrant population. This study’s findings confirmed that a photonovel developed by community members can be an effective tool to enhance oral hygiene self-care knowledge within the community. Four themes identifying various perceptions held by Punjabi immigrants regarding oral hygiene self-care were generated. Guided by these overarching themes, a final version of the photonovel script was created and pilot tested. To our knowledge, this is a novel study. Therefore, a comparison of themes generated cannot be made with other studies.

Previous studies of photonovels addressing different health conditions among people with low literacy levels have reported a significant positive impact of the printed photonovel on the knowledge enhancement of participants.52-60 The pilot testing of the SYS photonovel confirmed its ability to serve as a potential tool for enhancement of knowledge about oral hygiene self-care (as reported by 90% of the participants). Close to 80% of participants perceived that the SYS photonovel was culturally and linguistically relevant and easy to understand. Additionally, the plain-language storytelling component of the photonovel, beginning with a description of improper brushing, followed by instructions for flossing and information on healthy nutrition, may empower and educate participants to establish healthy oral hygiene self-care routines. This study’s finding of the impact of the SYS photonovel on enhancement of knowledge of participants is encouraging and consistent with previous studies52-59 that measured different health conditions and outcomes.

Table 2.

Responses of participants to questions about the “Safeguard Your Smile” (SYS) photonovel

1

Do you agree that contents of the SYS photonovel are easy to understand?

Strongly agree

8

Agree

2

2

 Do you agree that SYS photonovel is developed by someone who knows the Punjabi community well?

Strongly agree

10

3

How much time did it take you to read the SYS photonovel?

Average

8 minutes

4

Does it matter that when you read SYS photonovel the people in the story are like you?

Yes

8

No

1

Somewhat

1

5

Is the SYS photonovel a reflection of your own cultural oral health values?

Yes

7

No

2

Somewhat

1

6

Do you agree that SYS photonovel is a good tool to learn oral hygiene self-care knowledge?

Strongly agree

9

Agree

1

7

Do you think that after reading the SYS photonovel you have gained knowledge and skills on how to take good oral hygiene self-care?

Yes

8

No

1

Somewhat

1

8

Do you think it helps to have oral health materials like this to gain knowledge if you do not speak French/English?

Yes

10

9

Will you recommend SYS photonovel to other members of the Punjabi community?

Yes

10
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Study limitations

A limitation of this study was its small sample size. In addition, the content of the photonovel was primarily based on the focus group discussion among Punjabi immigrants, raising the possibility that the information included in the photonovel may not be applicable or relevant to other ethnocultural communities. Two previous trials evaluating the impact of photonovels on depression-related outcomes have reported significant improvements in outcomes, such as self-efficacy, intent to seek treatment, stigma towards antidepressant medication, and mental health care stigma.55,59 However, the present study lacked pre- and post-assessment of OHL and skills acquired.

Furthermore, all participants of the focus group were females. The main reasons for having only women in our sample were that our partner organization (the Sikh Women's Association of Montreal) has only female members. Researchers attempted to include males through invitations and referrals of potential participants from our partner organization. The men said they were unavailable due to their busy work schedules. In the Punjabi community, the overall responsibility for nurturing and ensuring the good health of family generally falls to the women. Therefore, we hypothesize that it felt quite natural to the participants that women were involved in health management issues. However, diversity in study populations is important. It is possible that this question may be raised in other patriarchal societies in future. Future studies should include both men and women as the main characters in health education photonovels.

CONCLUSION

Despite the aforementioned limitations, the “Safeguard Your Smile” SYS photonovel was well received by the Punjabi community participants who pilot tested it and affirmed it could be an effective tool in improving the oral hygiene self-care knowledge and skills of Punjabi immigrants. Although this study was developed specifically for a unique cultural group and subsequently lacks generalizability to other cultural groups, it can serve as a model for others with an interest in developing their own unique photonovels targeted at improving the HL of their community.

Although photonovel interventions have been effective in improving knowledge and raising awareness of health issues, improvements in knowledge do not always translate into improvements in health.60 Future studies should evaluate whether photonovels are effective in improving clinical outcomes among participants.

The ultimate aim of the SYS photonovel is to use it in future studies to enhance the OHL of the Punjabi immigrant community in order to improve their oral hygiene self-care skills and to motivate positive oral health behaviour change. Our future randomized controlled clinical trial will evaluate whether this photonovel actually improves the oral hygiene self-care outcomes of this population group compared with a similar control group lacking access to the photonovel. Last but not least, in this study a printed format of the SYS photonovel was used. Future research is needed to evaluate the effectiveness of photonovel interventions in other formats such as an electronic format available online.

CONFLICT OF INTEREST

The authors have no conflicts of interest to declare.

Acknowledgments

The authors are thankful to Laura Nimmon, an assistant professor in the Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, for providing suggestions and feedback on the photonovel development process. We also thank the members of the Sikh Women's Association of Montreal for their participation in this study.

Footnotes

CDHA Research Agenda category: access to care and unmet needs

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