Oral Health Knowledge, Reading Comprehension, and Behavior Change After Implementing the eBook for Oral Health Literacy© Curriculum with 3rd Graders During COVID-19: Implications for School Health Education

Valerie Ubbes; Miguel A. Miranda; Michael O’Connell

Vol. 17 No. 5 (2025) IEJEE

Oral Health Knowledge, Reading Comprehension, and Behavior Change After Implementing the eBook for Oral Health Literacy© Curriculum with 3rd Graders During COVID-19: Implications for School Health Education

Valerie Ubbes
Miguel A. Miranda
Michael O’Connell

Published September 28, 2025 | Pages: 642-661 | Views: 384

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Abstract

We conducted a pilot study with elementary school children who took a repeated written pretest prior to reading one chapter weekly from the eBook for Oral Health Literacy© curriculum over eight weeks. Students also completed a reading comprehension test after reading each chapter. Students had to recall and write answers to the fill-in-the-blank questions with accurate spelling to mirror exact sentences from the eBook chapters. The theory-based scripts emphasized action verbs to promote skill development of decision making and goal setting for oral health behaviors. Each eBook chapter highlighted a brief visual-textual-gestural narrative for several oral health behaviors (e.g., brushing, flossing, rinsing, dental checkups). There were three research questions: 1) Will the knowledge, attitude, and behaviors of third graders change over time after reading eight chapters of the eBook for Oral Health Literacyⓒ curriculum? 2) Is there a relationship between the knowledge, attitude, and behavior pretest scores and the reading comprehension and written spelling posttest scores of the oral health literacy curriculum? and 3) Is there a relationship between the class attendance of students and their pretest scores on eight chapters of the eBook for Oral Health Literacyⓒ curriculum one year after the COVID-19 quarantine? Mixed-effects logistic regression models were employed. Pretest responses of oral health knowledge, attitudes, and behaviors were the dependent variables, and the eBook chapter numbers (n = 8) were the independent variables to see if there were changes in students’ pretest responses over time. The model accounted for the age and gender of each student as fixed effects; a random effect was used to account for student variability. Third graders significantly enhanced their oral health knowledge and behaviors as indicated by reading comprehension and written spelling scores. Chapter 1 was the reference variable. Chapters 2, 4, 5, 6, 7, and 14/15 were significant predictors for student responses on pretest knowledge questions, and Chapters 3, 4, 5, 6, 7, and 14/15 were significant predictors for student responses on pretest behavioral questions. Chapter 5 was a significant predictor of knowledge, attitude, and behavior pretest scores. To determine the impact of pretest scores on student attendance during COVID-19, a generalized linear mixed model employed student attendance as the dependent variable and student pretest scores as the independent variables. Significant relationships resulted between student attendance and pretest answers on Behavior Question 1 (p = 0.004) for brushing teeth; on Knowledge Question 2 (p < 0.001) for having a toothbrush; and on Knowledge Question 8 (p = 0.020) for having any cavities. Posttest reading comprehension and written spelling scores were significantly associated with attendance (p=0.009).

We conducted a pilot study with elementary school children who took a repeated written pretest prior to reading one chapter weekly from the eBook for Oral Health Literacy© curriculum over eight weeks. Students also completed a reading comprehension test after reading each chapter. Students had to recall and write answers to the fill-in-the-blank questions with accurate spelling to mirror exact sentences from the eBook chapters. The theory-based scripts emphasized action verbs to promote skill development of decision making and goal setting for oral health behaviors. Each eBook chapter highlighted a brief visual-textual-gestural narrative for several oral health behaviors (e.g., brushing, flossing, rinsing, dental checkups). There were three research questions: 1) Will the knowledge, attitude, and behaviors of third graders change over time after reading eight chapters of the eBook for Oral Health Literacyⓒ curriculum? 2) Is there a relationship between the knowledge, attitude, and behavior pretest scores and the reading comprehension and written spelling posttest scores of the oral health literacy curriculum? and 3) Is there a relationship between the class attendance of students and their pretest scores on eight chapters of the eBook for Oral Health Literacyⓒ curriculum one year after the COVID-19 quarantine? Mixed-effects logistic regression models were employed. Pretest responses of oral health knowledge, attitudes, and behaviors were the dependent variables, and the eBook chapter numbers (n = 8) were the independent variables to see if there were changes in students’ pretest responses over time. The model accounted for the age and gender of each student as fixed effects; a random effect was used to account for student variability. Third graders significantly enhanced their oral health knowledge and behaviors as indicated by reading comprehension and written spelling scores. Chapter 1 was the reference variable. Chapters 2, 4, 5, 6, 7, and 14/15 were significant predictors for student responses on pretest knowledge questions, and Chapters 3, 4, 5, 6, 7, and 14/15 were significant predictors for student responses on pretest behavioral questions. Chapter 5 was a significant predictor of knowledge, attitude, and behavior pretest scores. To determine the impact of pretest scores on student attendance during COVID-19, a generalized linear mixed model employed student attendance as the dependent variable and student pretest scores as the independent variables. Significant relationships resulted between student attendance and pretest answers on Behavior Question 1 (p = 0.004) for brushing teeth; on Knowledge Question 2 (p &lt; 0.001) for having a toothbrush; and on Knowledge Question 8 (p = 0.020) for having any cavities. Posttest reading comprehension and written spelling scores were significantly associated with attendance (p=0.009).

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Keywords

Oral Health Literacy, Oral Health Knowledge, Oral Health Behaviors, Reading Comprehension, Mixed-Effects Logistic Regression Model, eBook Curriculum, Teeth Brushing, COVID-19

Affiliations

Valerie Ubbes

Miami University

Miguel A. Miranda

University of Louisville School of Dentistry

Michael O’Connell

Miami University

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How to Cite

Ubbes, V., Miranda, M. A., & O’Connell, M. (2025). Oral Health Knowledge, Reading Comprehension, and Behavior Change After Implementing the eBook for Oral Health Literacy© Curriculum with 3rd Graders During COVID-19: Implications for School Health Education. International Electronic Journal of Elementary Education, 17(5), 642–661. Retrieved from https://iejee.com/index.php/IEJEE/article/view/2432