Published online: 2020-09-08

THIEME
Original Article 1

Application of Health Belief Model on Child’s Dental

Visit Postponement during the COVID-19 Pandemic
Arlette Suzy Setiawan1, Cucu Zubaedah2

1 Department of Paediatric Dentistry, Faculty of Dentistry, Address for correspondence Arlette Suzy Setiawan, drg., Sp.KGA(K),
Universitas Padjadjaran, Jl. Sekeloa Selatan 1, Bandung, Indonesia M.Si, Department of Paediatric Dentistry, Faculty of Dentistry,
2 Department of Public Health, Faculty of Dentistry, Universitas Universitas Padjadjaran, Jl. Sekeloa Selatan 1, Bandung, Indonesia
Padjadjaran, Jl. Sekeloa Selatan 1, Bandung, Indonesia (e-mail: [email protected]).

Eur J Dent

Abstract Objective The aim of this article is to analyze parental perception on child’s dental
visit postponement using health belief model (HBM) during the pandemic of COVID-19.
Materials and Methods Cross-sectional survey design was chosen with a purposive
sample recruited online by distributing questionnaires consisting 26 items of HBM
construct. Data were analyzed descriptively by SPSS version 22.
Keywords Result A total 111 respondents participated in the study. Respondents perception
►►health belief model were found indifferent in perceived susceptible (χ = 3.07), perceived severity (χ = 2.99),
►►dental visit and perceived barrier (χ = 3.38). Whilst confirmed in perceived benefit (χ = 2.54), cue
postponement of action (χ = 2.05), self-efficacy (χ = 2.08), and locus of control (χ = 2.88).
►►COVID-19 Conclusion This study provided evidence that HBM is applicable to children's dental
►►pandemic visit postponement during the pandemic of COVID-19.

Introduction in places where many children meet, namely playgrounds,

schools, and child care centres.3 Therefore, during this pan-
Official data on the number of children affected by corona- demic study from home is applied by the government.
virus disease 2019 (COVID-19) in Indonesia are yet to be As any other respiratory viruses, SARS-CoV-2 is also
released, but several national newspapers have reported the transmitted via droplets that are generated by coughing or
existence of pediatric patients with COVID-19 like symptoms. sneezing. It is less widely known that normal speaking also
Pediatric cases of COVID-19 infection are typically mild, but produces thousands of oral fluids droplets. Recently, speech
underlying coinfection may be more common in children droplets generated by asymptomatic carriers of SARS-CoV-2
than in adults, according to an analysis of clinical, laboratory, are increasingly considered to be a likely mode of disease
and chest computed tomographic features of pediatric inpa- transmission.4 In addition, according to a latest report on
tients in Wuhan, China.1 Although symptoms in children are COVID-19, the virus is detectable in saliva, which had drawn
often mild or even without symptoms, it does not mean there attention to a risk catching the disease in an environment that
are no children at risk of more serious illness. Children are includes a large number of saliva, such as dental treatment.5
susceptible to severe acute respiratory syndrome coronavi- As COVID-19 is mainly spread through droplets and con-
rus 2 (SARS-CoV-2) infection.2 The risk attributable to severe tacts, potential airborne dissemination has been ruled out
illness of COVID-19 in children is difficult to see. In addition, except for surroundings where aerosol generation is of con-
children also can play a major role in community-based virus cern, including but not limited to endotracheal intubation,
transmission.3 In other words, children could be facilitators bronchoscopy, and the patient being disconnected from
of viral transmission.2 This transmission occurs more easily a ventilator.6 Considering the high risk of transmission of

DOI https://doi.org/ ©2020 Dental Investigation

10.1055/s-0040-1715784 Society
ISSN 1305-7456.
2 Health Belief Model on Child’s Dental Visit Postponement Setiawan, Zubaedah

COVID-19 in dental setting, as the development of confirmed 5 strongly disagree). Questions were not only about how to
cases has increased, several dental care facilities in Indonesia prevent COVID-19 but also about how to prevent dental dis-
and many other affected countries have been completely eases that possibly may occur to postpone the dental visits
closed or have been only providing minimal treatment for in the first place. The questionnaires have been pretested
emergency cases.7 In addition to emergency cases, other online to a community within Antapani District in Bandung
dental visits are recommended to be postponed to break City, Indonesia. After processing the pretest result using
the chain of COVID-19 transmission. Along with this recom- Cronbach-α, reliability co-efficient of 0.84 was obtained,
mendation, communities were recommended to maintain making the instrument highly reliable.
healthy behavior during the pandemic. However, this con-
text must be accompanied by a community understanding of Data Analysis
other health behavior, such as oral health behavior along with The data collected was cleaned, coded, and processed
other factors in preventing the COVID-19 exposure itself. using Statistical Package for Social Science (SPSS) version
Promoting health behaviors is key in preventing a disease8; 22.0 software. The result was represented in the form of fre-
in this case dental disease plays a role in delaying dental vis- quencies, percentages, and means. The bivariate relationship
its to prevent COVID-19 exposure. Therefore, it is very neces- was determined between the demographic characteristics of
sary to promote healthy behavior through behavior change respondents and construct of the HBM.
models.9 One important model that has been proven to predict
health behavior is the health belief model (HBM), which was
Result
developed by Hochbaum and Rosenstock in the 1950s.10 HMB
initially has a perception of vulnerability, perceived severity, The objective of the study was to analyze how the construct
perceived obstacles, perceived benefits, and cues to act as con- of the HBM (perceived susceptibility, perceived severity, per-
structs; self-efficacy is then added. According to HBM, when ceived benefit, perceived barrier, cues to action, self-efficacy,
an individual sees themselves as vulnerable or at risk for cer- and locus of control) relates to postponing child’s dental
tain health conditions (perception of susceptibility), he must visit during the pandemic of COVID-19. Thus, the result
be aware of the seriousness or consequences of the disease from respondents on perceived susceptibility is presented in
(perception of severity), believing in positive results when pre- ►Table 1.
ventive action is taken (perceived benefits) and that the bene- ►Table 1 represents the analysis of the responses regard-
fits are greater than the related obstacles (perceived barriers), ing respondents perceived susceptibility on child’s dental
there are also activities or events that motivate individual visit postponement. Respondents who responded that chil-
prevention behavior (cues of action) coupled with confidence dren could be exposed to COVID-19 (37%, χ = 2.84, SD=1.20)
to bring the desired behavior (self-efficacy), that is, belief in were almost as high as those who gave responses that they
yourself to master the courage to execute the required behav- didn’t know (37.8%, χ = 2.84, SD=1.20). Meanwhile, the level
ior will greatly help the individual demonstrate the necessary of acceptance as to whether the respondent was worried that
behavioral changes.11 This study is aimed to analyze parental their children might be getting viral exposure from the den-
perception on child’s dental visit postponement using HBM
tist was high (35.1%, χ = 3.15, standard deviation [SD] = 1.27).
during the pandemic of COVID-19.
The SD showed that the respondents’ responses were clus-
tered around the mean. The general mean of respondent per-
Materials and Methods ceived susceptibility of their children’s risk exposed to the
virus was determined to be indifferent (general mean = 3.07).
Design and Sample On perceived severity, the results in ►Table 2 provided the
Cross-sectional survey design was chosen as an appropriate participant thought about the negative consequences a child
design for this study that was performed between March, associates with getting exposed to virus.
2020 and May, 2020. A purposive sample was recruited As shown in ►Table 2, most participants believe that
online by distributing questionnaires through a clickable their children will not be able to isolate themselves if they
link among caregivers of patients registered at two pediat- are exposed by the virus (χ = 3.32 with SD = 1.31). The SD
ric dental clinics in Bandung. Only caregivers with children indicates that the respondents were unanimous in their
below 12 years of age were included in this study. The study responds. As for the consequences such as a child can get
was ethically approved by Universitas Padjadjaran Ethical seriously ill after being exposed to the virus, participants
Committee, to establish informed consent; all respondents who respond agree and disagree are almost in the same
received a detailed explanation of the study purpose and proportion (40.5 vs. 38.8%; χ = 2.98, SD = 1.33). Most par-
their rights to confidentiality. The structured question- ticipant responded that they don’t know whether the virus
naires took 15 to 20 minutes to complete, which consisted may lower child’s immune system (33.3%) or appetite
26 questions on sociodemographic data of respondents, (33.3%). Thus, from the analysis, participant’s perceived
including perceived susceptibility, perceived severity, per- severity was indifferent (χ = 2.99). This is an indication that
ceived benefit, perceived barrier, cues to action, self-efficacy, the majority of respondents perceived that they don’t know
and locus of control. Also, 5-point Likert scale was applied the severity of the virus, and could give their child in to
to value the responses to each item (1 strongly agree to treatment.

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 Health Belief Model on Child's Dental Visit Postponement Setiawan, Zubaedah 3

Table 1 Perceived susceptibility Table 2 Perceived severity

Variable Frequency Percentage χ SD Variable Frequency Percentage χ SD
Child’s risk of 2.84 1.20 Having the child to 3.32 1.31
exposure to the self-isolate
virus
Strongly agree 16 14.4
Strongly agree 18 16.3
Agree 16 14.4
Agree 23 20.7
Don’t know 14 12.6
Don’t know 42 37.8
Disagree 46 41.4
Disagree 15 13.5
Strongly disagree 19 17.2
Strongly disagree 13 11.7
Declining immune 2.80 1.18
Viral exposure 3.25 1.30 system
from clinic
Strongly agree 20 18.0
environment
Agree 22 19.8
Strongly agree 16 14.4
Don’t know 37 33.3
Agree 14 12.6
Disagree 24 21.6
Don’t know 27 24.3
Strongly disagree 8 7.2
Disagree 34 30.6
Getting seriously ill 2.98 1.33
Strongly disagree 20 18.1
Strongly agree 18 16.2
Viral exposure 3.03 1.35
from other Agree 27 24.3
patients
Don’t know 23 20.7
Strongly agree 19 17.1
Disagree 25 22.5
Agree 23 20.7
Strongly disagree 18 16.3
Don’t know 22 19.8
Decreasing appetite 2.88 1.18
Disagree 29 26.1
Strongly agree 16 14.4
Strongly disagree 18 16.3
Agree 25 22.5
Viral exposure 3.15 1.27
Don’t know 37 33.3
from the dentist
Disagree 22 19.8
Strongly agree 11 9.9
Strongly disagree 11 10.0
Agree 28 25.2
Abbreviation: SD, standard deviation.
Don’t know 26 23.4
Disagree 25 22.5
χ = mean.
Strongly disagree 21 19
a child’s dental visit postponement. But, in relation to the
Abbreviation: SD, standard deviation.
pre-existing child’s dental disease, the most respondents
χ = mean.
(χ = 2.62, SD = 0.74) responded that it would hinder the
child’s dental visit postponement. Generally, the mean of the
respondents’ perceived barriers was confirmed (χ = 3.38).
On perceived benefits, the results in ►Table 3 provide
This indicates that the majority of respondents perceived
what the respondents thought about the benefit of post-
that there were no barriers in postponing child’s dental visit
poning their child’s dental visit during the pandemic to pre-
during this pandemic. Another area considered in HBM was
vent SARS-CoV-2 exposure. Most respondents believed that
cues to action to postpone child’s dental visit as indicated in
postponing their child’s dental visit was likely to develop
►Table 5.
a healthy behavior (χ = 2.16, SD = 0.75) along with hand
The results in ►Table 5 show that most respondents
hygiene habit (χ = 2.14, SD = 0.77). In relation to respondents
agreed (χ = 2.06, SD = 0.91) that they can do a domestic treat-
believing that postponing child’s dental visit was not likely
ment (first aid measures) to overcome child’s dental pain
to limit their children from sweet snacking, the values were
before consulting the dental office. Similarly, online consul-
χ = 3.27, SD = 1.16. The general mean of perceived benefit
tation with the dentist (χ = 2.06, SD = 0.91) will be the action
was χ = 2.54, an indication that the majority of respondents that they would take if their child experiences dental pain
perceived there were benefits for postponing dental visit.
during this pandemic. Over all, the general mean (χ = 2.05)
►Table 4 depicts the analysis of the responses regard-
indicates that the awareness of respondents in the efforts in
ing perceived barriers to postpone child’s dental visit. The
postponing child’s dental visit was good.
respondents did not agree that their health beliefs (χ = 3.80, Results in ►Table 6 show that most respondents
SD = 0.97) would not be a barrier for them to postponing the (56.76%) will postpone their child’s dental visit. This result
dental visits. Similarly, their inability to overcome a child’s also applies to respondents who thought about what
dental pain (χ = 3.87, SD = 0.97) would not be a barrier in they will do, such as consulting online about their child’s

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4 Health Belief Model on Child’s Dental Visit Postponement Setiawan, Zubaedah

Table 3 Perceived benefit Table 4 Perceived barriers

Variable Frequency Percentage χ SD Variable Frequency Percentage χ SD
Developing 2.16 0.75 Pre-existing den- 2.62 0.74
healthy behavior tal disease
Strongly agree 23 20.72 Strongly agree 8 7.21
Agree 47 42.34 Agree 35 31.53
Don’t know 41 36.94 Don’t know 59 53.15
Disagree 0 0 Disagree 9 8.11
Strongly disagree 0 0 Strongly disagree 0 0
Developing hand 2.14 0.77 Unable to 3.72 1.02
sanitary habit overcome child’s
Strongly agree 25 22.52 dental pain
Agree 46 41.44 Strongly agree 4 3.60
Don’t know 39 35.13 Agree 11 9.91
Disagree 1 0.01 Don’t know 20 18.02
Strongly disagree 0 0 Disagree 53 47.75
Habituating tooth 2.59 1.01 Strongly disagree 23 20.73
brushing Health belief 3.80 0.97
Strongly agree 16 14.41 hindering the
postpone
Agree 36 32.43
Strongly agree 4 3.60
Don’t know 42 37.84
Agree 3 2.70
Disagree 12 10.81
Don’t know 32 28.83
Strongly disagree 5 4.51
Disagree 44 39.64
Limiting sweet 3.27 1.16
snacking Strongly disagree 28 25.23
Strongly agree 8 7.21 Abbreviation: SD, standard deviation.
Agree 18 16.22 χ = mean.
Don’t know 42 37.84
between the demographic variables and the construct of
Disagree 22 19.82
the HBM is provided in ►Table 8.
Strongly disagree 21 18.91
The analysis of ►Table 8 reveals that there were only
Abbreviation: SD, standard deviation. two strong and nine moderate correlated relationships.
χ = mean. First, self-efficacy strongly correlated with cue of action. As
expected, an increase in individual’s self-efficacy is likely
to trigger an action to postpone child’s dental visit. Second,
dental pain (67.57%), training tooth brushing to their chil- locus of control strongly correlated with perceived severity.
dren (69.37%), and limiting their sweet snacking (66.67%). Individuals having negative control over a situation that may
In general, the mean χ = 2.08 indicates that the respon- lead to a situation are likely to have low perceptions of what
dents have their belief in their capacity to execute behav- the consequences would be following their actions.
iors necessary to postpone child’s dental visit during this
pandemic. Discussion
The concept that refers to how strongly respondents
believe they have control over the situations that affect The objective of the study was to determine how some of
their lives can be analyzed from the result in ►Table 7. the construct of HBM relate to caregiver’s postponing their
child’s dental visit during the pandemic of COVID-19. The
Most of the respondents (51%, χ = 3.31, SD = 1.30) dis-
conceptual framework is guided by the HBM. This type of
agreed that they were responsible for not being a role
psychological model used in predicting whether a person
model to their children in toothbrushing habits. But, in
will carry out an activity that is needed to prevent an illness
relation to being responsible to child’s dental pain, most
or not, depends on the person's beliefs or perceptions about
respondents (36.94%) thought indifferently, while in
the seriousness of the disease, the advantages and disadvan-
specific cases like not limiting their child’s sweet snack-
tages of prevention activities, and one's own ability to carry
ing habits, most respondents highly (54.06%) thought of
out activities. The perceived susceptibility of a person to a
themselves to be responsible. The general mean (χ = 2.88)
disease, the perception of the severity of the disease, the
shows that locus of control for respondents was indifferent
perceived benefits of preventive action, perceived barriers to
in postponing child’s dental visit. Bivariate relationship
preventive action, certain cues for taking preventive actions,

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 Health Belief Model on Child's Dental Visit Postponement Setiawan, Zubaedah 5

Table 5 Cues to action Table 6 Self-efficacy

Variable Frequency Percentage χ SD Variable Frequency Percentage χ SD

Postponing child’s 2.18 0.92
Domestic treat- 2.06 0.91
dental visit
ment of child’s
dental pain Strongly agree 33 29.73
Strongly agree 38 34.23 Agree 30 27.03
Agree 33 29.73 Don’t know 43 38.74
Don’t know 35 31.53 Disagree 5 4.50
Disagree 5 4.51 Strongly disagree 0 0
Strongly 0 0 Online consultation 2.03 1.05
disagree with the dentist
Online consul- 2.05 0.91 Strongly agree 45 40.54
tation with the
Agree 30 27.03
dentist
Don’t know 26 23.42
Strongly agree 38 34.23
Disagree 8 7.21
Agree 35 31.53
Strongly disagree 2 1.80
Don’t know 33 29.73
Modeling tooth 2.05 1.02
Disagree 5 4.51
brushing
Strongly 0 0
Strongly agree 41 36.94
disagree
Agree 36 32.43
Limit child’s 2.04 0.91
sweet snacks Don’t know 24 21.62
Strongly agree 39 35.13 Disagree 8 7.21
Agree 34 30.63 Strongly disagree 2 1.80
Don’t know 33 29.73 Limit child’s sweet 2.05 1.03
snacks
Disagree 5 4.51
Strongly agree 42 37.84
Strongly 0 0
disagree Agree 32 28.83
Guiding child in 2.06 0.93 Don’t know 28 25.23
tooth brushing Disagree 7 6.30
Strongly agree 39 35.13 Strongly disagree 2 1.80
Agree 31 27.93
Abbreviation: SD, standard deviation.
Don’t know 36 32.43 χ = mean.
Disagree 5 4.51
Strongly 0 0
disagree
In terms of other constructs of the model, as the study
Abbreviation: SD, standard deviation. revealed, perceived benefit, cue of action, and self-efficacy
χ = mean. were confirmed in postponing child’s dental visit. Perceived
benefits are another construct of HBM that refers to one’s
beliefs about the benefit of recommended behaviors in
and one's self-efficacy all interact within a person to deter- reducing the risk of a diseases or its consequences.13 In the
mine that person’s readiness to take preventative measures.12 present study, respondents perceived that there were bene-
Results from the study show that respondents’ perceived fits that they will get after performing an action. In this study,
susceptibility of their children’s risk of getting exposed to respondents described their thought about the benefit of tak-
the virus was that of being indifferent. Human beings, in ing preventive measure of postponing their children’s den-
general, need some form of motivation to change a par- tal visit during the pandemic, including developing positive
ticular behavioral pattern.11 The study discovered that the healthy behavior that will be useful for everyday life after the
respondents perceived their children susceptibility of get- pandemic. Perceived benefit is formed based on individual’s
ting exposed to COVID-19 in a dental setting as indifferent. opinions about the used value of a new behavior in reducing
This might be due to a lack of knowledge about COVID-19 the risk of developing a disease. Communities tend to adopt
in children.3 In other words, most mild cases of COVID-19 healthier behaviors when there is a belief in themselves that
in children affected respondents’ perception of their child’s the behavior of adoption will reduce the chance of devel-
susceptibility. This result also applies to respondents’ per- oping more severe illness in them.14 Based on the HBM, the
ception of severity. guidance that people receive from their surroundings (cues

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6 Health Belief Model on Child’s Dental Visit Postponement Setiawan, Zubaedah

to actions) is effective in developing their behavior.15 Cue of sweet snack, and guiding child in tooth brushing. These were
action in this study was domestic treatment of child’s den- all actions that were easy to be conquered by caregivers.
tal pain, online consultation with the dentist, limiting child’s Health-related behaviors are also a function of per-
ceived barriers to taking action. Perceived barriers refer
Table 7 Locus of control to an individual’s assessment of the obstacles to behavior
change. Even if an individual perceives a health condition
Variable Frequency Percentage χ SD
as threatening and believes that a particular action will
Not a role model 3.31 1.30 effectively reduce the threat, barriers may prevent engage-
for tooth brushing
ment in the health-promoting behavior. In other words,
Strongly agree 15 13.51
the perceived benefits must outweigh the perceived bar-
Agree 14 12.61 riers in order for behavior change to occur.16 In this study
Don’t know 25 22.52 the aspect that may hinder the child’s dental visit post-
Disagree 35 31.53 ponement is the pre-existing dental disease. Most parents
Strongly disagree 22 19.82 are not aware of their child’s dental disease until the child
has a complaint.17
Responsible for 3.06 1.24
child’s dental pain
Strongly agree 14 12.61 Conclusion
Agree 20 18.02
This study provided evidence that HBM is applicable to chil-
Don’t know 41 36.94 dren's dental visit postponement during the pandemic of
Disagree 17 15.32 COVID-19. By knowing parents’ health beliefs, a counselling
Strongly disagree 19 17.12 plan can then be made related to the postponement in visit-
Did not limit sweet 2.26 0.90 ing the dentist during this pandemic. Moreover, policy mak-
snacking ers should increase the accessibility of dental resources to
Strongly agree 28 25.23 enhance the utilization of dental care and dental education
Agree 32 28.83
during this period. The limitation of this study is the lack of
male respondents, so the results cannot analyze differences in
Don’t know 45 40.54
male and female health beliefs. The form of response bias from
Disagree 6 5.40
respondents may also limit the study. The point is that the
Strongly disagree 0 0 information provided by respondents through a questionnaire
Abbreviation: SD, standard deviation. sometimes doesn't show the actual opinion of the respon-
χ = mean. dents. This can happen because of the inability of respondents

Table 8 Bivariate relationship between the demographic variables and the construct of the HBM
Correlation Age Sex Education Perceived Perceived Perceived Perceived Cues to Self- Locus of
susceptibility severity benefit barriers action efficacy control
Age 1
Sex ̵0.075 1
Education ̵0.106 ̵2.95 1
Perceived 0.027 0.050 0.108 1
susceptibility
Perceived 0.062 ̵0.056 0.059 0.745 1
severity
Perceived ̵0.025 v0.169 ̵0.056 0.009 ̵0.007 1
benefit
Perceived ̵0.222 ̵0.075 0.195 ̵0.087 0.014 ̵0.258 1
barriers
Cues to ̵0.215 ̵0.198 0.270 0.305 0.271 0.344 ̵0.245 1
action
Self-efficacy 0.366 ̵0.209 0.093 0.104 0.108 0.382 ̵0.499 0.694* 1
Locus of 0.441 ̵0.158 0.159 0.489 0.508* 0.095 0.057 0.362 0.372 1
control
Abbreviation: HBM, health belief model.
*significance alpha 5%

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 Health Belief Model on Child's Dental Visit Postponement Setiawan, Zubaedah 7

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Conflict of Interest
between parental dental belief and formation of dental fear
None declared. among preschool children in Indonesia. Eur J Dent 2019;
13(3):426–431
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