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Motivational Interview (MI) Intervention with a Combination Method Face-To-Face with During on the OHI-S Status of Adolescents in Gorontalo

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30 March 2026

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31 March 2026

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Abstract
Background/Objectives: The dental and oral health status of adolescents in Indonesia, especially in Gorontalo City, remains concerning with a high caries prevalence. Conventional education efforts are less effective in forming sustainable healthy behaviors. This study aims to analyze the effectiveness of the application-based Motivational Interviewing (MI) implementation to improve the dental and oral health status of adolescents. Methods: The study used a quasi-experimental one-group pre-test post-test design involving 100 adolescents aged 15–18 years and 30 health cadres. Subjects were divided into an application-based MI intervention group (n=50) and a control group (n=50). The intervention was given for three months, with regular measurements of knowledge, toothbrushing behavior, and oral hygiene status (OHIS). Statistical analysis used the Wilcoxon Signed Ranks Test and Mann Whitney test. Results: There was a significant increase in knowledge scores, toothbrushing behavior, and OHIS status in the combined MI intervention group (P-value<0.001) compared to the control group. The integration of face-to-face and digital methods proved more effective in forming sustainable healthy behaviors. Conclusions: Hybrid MI combining mobile application support with face-to-face counseling is significantly more effective in improving oral hygiene status among adolescents compared to conventional education. This model is recommended as an adaptive promotive–preventive strategy for adolescent oral health programs.
Keywords: 
motivational interviewing
;  
application
;  
dental health
;  
adolescents
;  
digital health
Subject: 
Public Health and Healthcare  -   Public Health and Health Services

1. Introduction

Oral health is a crucial aspect of general health that significantly impacts an individual's quality of life. A healthy mouth not only means being free from diseases such as oropharyngeal cancer, infections, and gum disease, but also supports vital functions such as chewing, speaking, and expressing emotions [1,2,3,4]. Research shows a close relationship between oral health and various systemic diseases, such as diabetes, digestive disorders, stroke, and cardiovascular disease [5,6]. In Indonesia, according to the 2018 Basic Health Research (Riskesdas), oral health problems remain very high, with a prevalence of dental caries reaching 80% and an average DMF-T index of 4.6, far above the WHO standard [7]. This condition is exacerbated by low knowledge, limited access to dental health services, and poor dental care practices, especially among adolescents [8,9,10,11]. Dental caries and periodontal disease, which are common in adolescents, are generally caused by poor oral hygiene, allowing the accumulation of plaque containing pathogenic bacteria such as Streptococcus mutans and Lactobacillus, which can lead to pain, infection, and even tooth loss [12,13,14].
Dental health education efforts, such as Dental Health Education (DHE), are often not optimal in fostering sustainable behavior change [15,16,17,18,19]. One approach currently considered effective is Motivational Interviewing (MI), a client-centered counseling technique aimed at increasing intrinsic motivation to change health behaviors [20,21]. However, the implementation of conventional MI in schools and healthcare facilities still faces challenges, ranging from limited time and resources to minimal participant involvement. Furthermore, in Gorontalo Province, dental and oral health problems among adolescents are recorded as higher than the national average. Conventional counseling, which is one-way and passive, is less effective in fostering sustainable healthy behaviors in digital youth who are closely connected to technology [22,23,24,25,26,27].
The development of information technology, particularly mobile-based applications, opens up new opportunities for more interactive, personalized, and sustainable dental health promotion. The integration of app-based MI is considered to strengthen motivation, increase engagement, and shape more consistent healthy behaviors in adolescents [28,29,30,31]. Based on the problem description, it is clear that the high rate of dental caries in adolescents is difficult to overcome without effective oral health promotion and ongoing counseling education utilizing information technology. Therefore, this study was designed to answer the problem formulation: "Can the implementation of app-based Motivational Interviewing counseling improve the dental and oral hygiene status of adolescents?" Specifically, this study aims to analyze the effect of the implementation of app-based Motivational Interviewing by health cadres in improving the dental and oral health of adolescents in Gorontalo City. It is hoped that the results of this study can contribute to the development of innovative, effective, and evidence-based dental health promotion strategies in the digital era.

2. Materials and Methods

2.1. Study Design

This study applied a quasi-experimental non randomized with repeated measurements to evaluate the effectiveness of the combined MI intervention. The intervention was associated with improvements that were observed across the three-month follow-up period. Outcomes, including knowledge, tooth brushing behavior, and OHIS status, were assessed at baseline and at three post-test intervals corresponding to the end of the first, second, and third months. The comparison group received only face-to-face and served as a comparison for natural changes in oral health behavior.

2.2. Study Setting and Participants

This study was conducted in Gorontalo City, Indonesia, over a period of three months and involved 30 counselor cadres (dentists and dental nurses) and 100 adolescents aged 15–18 years. Participants were allocated into groups based on school clusters, with schools categorized into Group A (combined MI intervention) and Group B (face-to-face MI only). This approach was adopted to minimize contamination between participants within the same school environment. Due to this clustering strategy, randomization was not performed. Consequently, the possibility of selection bias cannot be excluded, and baseline equivalence between groups may not be fully ensured. However, both groups were drawn from comparable school settings within the same geographic area to reduce major contextual differences. The sample size was determined using the formula for comparing two independent means, with a significance level of 0.05 and a statistical power of 80%. Based on previous studies reporting a mean difference in OHI-S of 0.8–1.0 and a standard deviation of 1.2–1.4, the minimum required sample size was 45 participants per group. After accounting for a potential 10% dropout rate, the sample size was increased to 50 participants per group (total n = 100). This calculation was further verified using G*Power version 3.1, which indicated a minimum requirement of 90 participants; therefore, the total sample size was rounded up to 100 to enhance the statistical power of the study.

2.3. Intervention Description

The intervention consisted of motivational interviewing (MI) delivered in two formats: face-to-face MI and a combination of face-to-face MI with an application-based component. The face-to-face MI sessions were conducted by a licensed dentist and delivered directly in the school setting. These sessions focused on improving oral hygiene knowledge and tooth-brushing behavior through personalized counseling, goal setting, and behavioral reinforcement. Each session lasted approximately 30–45 minutes and was conducted weekly during the intervention period. In the combined MI group, participants additionally received an application-based intervention that could be accessed at any time. The application incorporated MI-based guidance, allowing participants to continuously engage with motivational content beyond face-to-face sessions. It also included reminders to promote oral hygiene practices, particularly regular tooth brushing. The application was supported by an AI-based system designed to assist participants throughout the MI process. Participants were guided to complete questionnaires within the application at each stage of the intervention, facilitating continuous engagement and self-monitoring. Participants were encouraged to use the application daily throughout the study period. Follow-up assessments were conducted at baseline, month 1, month 2, and month 3 to evaluate changes in knowledge, tooth-brushing behavior, and oral hygiene status.

2.4. Data Collection Instruments

Data were collected using structured instruments to assess knowledge, tooth-brushing behavior, and oral hygiene status. Knowledge was measured using a questionnaire consisting of 15 items covering key aspects of oral health, including dental hygiene practices, causes of dental caries, and preventive measures. Tooth-brushing behavior was assessed using a 24-item questionnaire evaluating the frequency, timing, and technique of tooth brushing. For both knowledge and tooth-brushing behavior, responses were scored using a dichotomous system, with “1” assigned for correct answers and “0” for incorrect answers. Total scores were calculated by summing item responses, with higher scores indicating better knowledge and behavior. The instruments were reviewed by experts in dental public health to ensure content validity and were pilot-tested prior to data collection to ensure clarity and consistency of the items. Oral hygiene status was assessed using the Oral Hygiene Index-Simplified (OHI-S) through clinical examination conducted by trained personnel following standardized procedures. OHI-S scores were categorized as good (0.0–1.2), fair (1.3–3.0), and poor (3.1–6.0).

2.5. Data Analysis

Data were analyzed using non-parametric statistical tests. The Wilcoxon signed-rank test was used to evaluate within-group differences between pre-test and post-test measurements. The Mann–Whitney U test was applied to assess differences between the intervention and comparison groups. The use of non-parametric tests was justified due to the non-normal distribution of the data and the ordinal nature of the measurement scales. Given the repeated-measures design, analyses were conducted using pairwise comparisons across time points. Effect sizes were calculated using the formula r = Z/√N.

2.6. Ethical Considerations

This study received ethical approval from the Research Ethics Committee of the Faculty of Dentistry, Hasanuddin University, Indonesia (Approval No. 046/KEPK FKG-RSGMP UH/EE/XI/2024; 13 November 2024). This study was not registered as a clinical trial because it employed a quasi-experimental design and did not meet the criteria for mandatory clinical trial registration.

3. Results

Improvements in knowledge, tooth-brushing behavior, and OHI-S scores were observed across follow-up measurements. However, the analysis was conducted using pairwise comparisons, and no formal longitudinal analysis was performed to assess trends over time.

3.1. Baseline Characteristics of Adolescents

A total of 100 adolescents participated in this study, with 50 allocated to the combined MI group and 50 to the face-to-face MI group. Baseline comparability between groups was assessed using the Mann–Whitney U test. There were no statistically significant differences between groups in age, baseline knowledge score, tooth-brushing behavior, or OHI-S score (p > 0.05). However, slight differences in median values were observed between groups, suggesting that baseline equivalence cannot be fully assured. Therefore, the results should be interpreted with caution.

3.2. Analysis of differences in Knowledge of MI Interventions Face to face with a Combination (Face to Face with During)

Within-group analysis showed a statistically significant increase in knowledge scores in both groups following the intervention (p < 0.05), as presented in Table 1. However, the median post-test score in the combined MI group was higher than that in the face-to-face group, indicating that the addition of application-based Motivational Interviewing (MI) may have reinforced knowledge acquisition more effectively. Furthermore, the comparison between the two groups demonstrated that the integration of face-to-face methods with application-based intervention was more effective in enhancing understanding and improving respondents' knowledge than the provision of direct information alone (Table 2).

3.3. Analysis of Differences in Tooth Brushing Behavior (Tooth Brush Practice) Before and After Intervention

Both groups demonstrated significant improvements in tooth-brushing behavior after the four-month intervention period (p < 0.05), as shown in Table 2. The combined MI group exhibited a larger median increase compared to the face-to-face MI group, suggesting that digital follow-up support contributed to sustained behavioral change (Table 3).

3.4. Analysis of Differences in OHIS status Before and After Intervention

OHI-S scores significantly decreased in both groups, indicating improved oral hygiene status (p < 0.05). The reduction was more pronounced in the combined MI group, reflecting a greater clinical improvement in plaque and debris control among adolescents who received both face-to-face and application-based MI support. Negative median change values indicate a reduction in OHI-S scores, reflecting improvement in oral hygiene status (Table 4).

4. Discussion

4.1. Analysis of Differences in Knowledge of MI Interventions Face to Face with a Combination (Face to Face with During)

The results of this study indicate that Motivational Interviewing (MI) interventions delivered in combination through face-to-face and during sessions significantly increased respondents' knowledge. The consistent increase in mean knowledge scores at each measurement stage reflects the effectiveness of this approach in strengthening participants' understanding [32,33]. This finding aligns with numerous studies that emphasize the superiority of MI, particularly when combined with interactive methods such as face-to-face sessions. Lundahl et al. (2010), through their meta-analysis, emphasized that MI is highly effective in various contexts, particularly when conducted in direct interaction, as it can optimally increase participant motivation and engagement [34].
Furthermore, research by Baer et al. supports these findings by showing that face-to-face sessions not only increase knowledge but also strengthen participant engagement in the behavior change process. High engagement in face-to-face sessions is believed to create a more interactive discussion atmosphere, allowing participants to better understand the material presented and express questions or concerns directly. On the other hand, the group that received only the during intervention without MI also experienced an increase in knowledge, although the magnitude of the change was much smaller [35]. This illustrates that while digital media or during can be an effective and flexible learning tool, the presence of a face-to-face component still plays a crucial role in optimizing the knowledge-building process. A study conducted in the Journal of Medical Internet Research (JMIR) supports this conclusion by showing that digital-based MI is indeed effective, but the intensity and quality of behavior change tend to be greater in interventions involving face-to-face interaction.
Overall, the results of this study emphasize the importance of integrating face-to-face and in-person approaches in implementing MI-based interventions. This combined approach not only significantly improves knowledge but also strengthens participants' engagement and motivation in the learning process. Therefore, to achieve optimal results, it is recommended that health education interventions or other behavioral training utilize a blended strategy, combining face-to-face sessions with reinforcement through digital media or during the process. This approach has been shown to be more effective than relying solely on one method, as supported by findings from various studies published in reputable international journals.

4.2. Analysis of Differences in Tooth Brushing Behavior (Tooth Brush Practice) Before and After Intervention

The results of this study confirm that Motivational Interviewing (MI) interventions delivered in combination—both face-to-face and during sessions—have a significant impact on improving tooth-brushing behavior in adolescents. The significant increase in average behavior in this group indicates that intervention methods involving direct interaction and continuous reinforcement throughout the intervention process are able to encourage more optimal behavior change [36,37,38,39]. These findings align with international studies that suggest that MI, particularly in combined or blended models, is highly effective in modifying health behaviors in adolescents, including oral hygiene practices.
Research by Freudenthal & Bowen (2020) in the Journal of Dental Research showed that adolescents who received in-person MI intervention with digital support or regular reinforcement tended to maintain behavioral changes better than those who received only traditional education. Face-to-face interactions provide facilitators with the opportunity to build more personal relationships, motivate participants, and tailor messages to individual needs, while reinforcement throughout the process helps ensure messages are remembered and implemented [40,41,42].
Meanwhile, the group receiving only face-to-face intervention without MI elements also experienced an increase in toothbrushing behavior, although the magnitude of the change was not as large as the combined MI group. This suggests that face-to-face education is indeed effective in increasing knowledge and behavior, but not optimal in facilitating sustainable behavior change. A study in the Journal of Medical Internet Research (JMIR) also reported that the MI approach combined with other methods is superior in internalizing healthy behaviors, as it can increase participants' self-efficacy and commitment to change [43,44,45].
Overall, these results confirm that intervention strategies combining MI with face-to-face and during-the-hour approaches are more effective in establishing and maintaining healthy behaviors in adolescents, particularly tooth brushing behavior. Integrating these two methods not only increases the effectiveness of the intervention but also provides a more holistic and sustainable learning experience for participants. Therefore, the combined implementation of MI is recommended for adolescent health education programs to achieve more significant and sustainable behavior change.

4.3. Analysis of Differences in OHIS status Before and After Intervention

These findings reinforce previous research showing that a multimodal approach to health interventions, particularly utilizing digital technology as a support, can increase the effectiveness of behavior change. Studies published in the Journal of Medical Internet Research (JMIR) and Patient Education and Counseling confirm that integrating MI with online support—such as app reinforcement, reminder messages, or online education—can extend the duration of intervention effects, improve information retention, and make it easier for participants to incorporate health practices into their daily lives [46,47,48,49]. Furthermore, the use of digital technology in health intervention programs facilitates more flexible and continuous access to information. This allows adolescents to receive ongoing motivation and reminders outside of face-to-face sessions, resulting in more consistent and sustainable behavior change. Other studies have also shown that adolescents tend to be more responsive to interactive, technology-based approaches, which can increase engagement and self-efficacy in maintaining oral hygiene [50,51,52,53].
Although no statistically significant baseline differences were identified, small variations in median scores were observed, particularly in knowledge, tooth-brushing behavior, and OHI-S scores. These differences may have influenced the magnitude of change observed after the intervention. Therefore, the findings should be interpreted with caution
Overall, the results of this study emphasize the importance of adopting intervention strategies that integrate face-to-face and online methods in health behavior change efforts. This approach not only increases the effectiveness of interventions but also provides more adaptive and relevant experiences for adolescents in the digital age. Therefore, the combined use of MI can be recommended as an effective strategy in oral health education programs for adolescents, to encourage better and more sustainable tooth brushing behaviors

5. Conclusions

The implementation of app-based motivational interviewing (MI) counseling was associated with improvements in the dental and oral health status of adolescents in Gorontalo City. The integration of digital technology into MI interventions may enhance motivation and engagement in promoting oral health behaviors. However, these findings should be interpreted with caution due to the quasi-experimental design, potential baseline differences, and the lack of longitudinal analytical approaches. Therefore, the results reflect associations rather than definitive causal effects. Despite these limitations, the integration of app-based MI shows potential as an innovative approach to support oral health promotion among adolescents. Further studies using more rigorous designs are needed to confirm its effectiveness and long-term impact.

Study Limitations

This study has several limitations that should be considered when interpreting the findings. First, the quasi-experimental design without randomization, including the allocation of participants based on school clusters, introduces a potential risk of selection bias and limits the ability to establish causal relationships between the intervention and outcomes. Differences in underlying characteristics between groups may have influenced the results.
Second, the sample was drawn from a single geographic area, which may restrict the generalizability of the findings to adolescents in other regions or settings. Third, although multiple follow-up measurements were conducted, the study did not apply longitudinal analytical approaches to fully assess changes across time points, limiting the ability to draw firm conclusions regarding sustained behavioral change. In addition, the relatively short follow-up period further restricts the evaluation of long-term effects.
Furthermore, the assessment of tooth-brushing behavior relied partly on self-reported measures, which may be subject to reporting bias. Finally, the individual contribution of each intervention component (face-to-face MI and application-based MI) could not be isolated in this study.
Therefore, the findings should be interpreted with caution. Future studies using randomized controlled designs, larger and more diverse samples, longer follow-up periods, and more robust longitudinal analytical methods are recommended to strengthen the evidence base.

Author Contributions

All authors contributed substantially to the conception, design, data collection, analysis, and interpretation of the research. D.I.K: Conceptualization, Formal analysis, Investigation, Methodology, Project Administration, Resources, Visualisation, Writing – original draft, Writing – review & editing. A.I.A: Supervision, Writing – review & editing. I.N.A: Supervision, Writing – review & editing. I.S: Writing – review & editing, A.A: Writing – review & editing, I.F.I: Writing – review & editing, N.H: Writing – review & editing, I: Methodology, Writing – orginal draft, Writing – review & editing. All authors read and approved the final manuscript.

Funding

This research received no external funding

Institutional Review Board Statement

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Data sharing complies with ethical restrictions set by the Research Ethics Committee of Hasanuddin University. Ethics Approval Number: 046/KEPK FKG-RSGMP UH/EE/XI/2024. Approval Date: 13 November 2024.

Data Availability Statement

The data underlying this study cannot be made publicly available due to ethical considerations related to the protection of adolescent participants’ personal information. Anonymized data may be provided by the corresponding author upon reasonable request and subject to approval from the relevant ethics and institutional review boards.

Acknowledgments

The authors wish to express their sincere gratitude to the Faculty of Dentistry, Hasanuddin University, for providing academic and logistical support during this research. The authors deeply appreciate the participation of all teachers, students, and parents who generously contributed their time and cooperation throughout the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
OHI-S Oral Hygiene Index Status
MI Motivational Interview

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Table 1. Baseline Characteristics of Adolescents.
Table 1. Baseline Characteristics of Adolescents.
Variable Combined MI (n=50)
Median (IQR)		 Face-to-Face MI (n=50)
Median (IQR)		 P-value*
Age (years) 16 (15-17) 16 (15-17) 0.842
Knowledge score 4 (3-5) 5 (4-6) 0.091
Tooth-brushing behavior 10 (8-12) 12 (10-13) 0.073
OHI-S score 3.2 (2.4 – 3.8) 2.8 (2.0-3.5) 0.112
Sources: Primary Data, 2025 *Mann-Whitney U test
Table 2. Analysis of Differences in Knowlwdgw Before and After Combined Interventions.
Table 2. Analysis of Differences in Knowlwdgw Before and After Combined Interventions.
Group Pre-test Median
(IQR)		 Post-test 3 Median
(IQR)		 Z r p
Combined MI 4 (3-5) 8 (7-9) -6.15 <0.001
Face-toFace MI 5 (4-6) 7 (6-8) -5.00 0.003
* p < 0.05 indicates statistical significance.
Table 3. Analysis of differences in tooth brushing behavior in adolescents who were given MI in combination (face to face and during) with MI given face to face.
Table 3. Analysis of differences in tooth brushing behavior in adolescents who were given MI in combination (face to face and during) with MI given face to face.
Group Pre-test Median
(IQR)		 Post-test 3 Median
(IQR)		 Z p
Combined MI 10 (8-12) 15 (14-16) -6.17 <0.001
Face-toFace MI 12 (10-13) 13 (12-14) -3.16 0.003
* p < 0.05 indicates statistical significance.
Table 4. Analysis of differences in tooth brushing behavior in adolescents who were given MI in combination (face to face and during) with MI given face to face.
Table 4. Analysis of differences in tooth brushing behavior in adolescents who were given MI in combination (face to face and during) with MI given face to face.
Group Pre-test Median
(IQR)		 Post-test 3 Median
(IQR)		 Z p
Combined MI 3.2 (2.4-3.8) 1.4 (1.0-2.0) -6.03 <0.001
Face-toFace MI 2.8 (2.0-3.5) 2.0 (1.5-2.8) -3.48 0.003
* p < 0.05 indicates statistical significance.
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