Introduction
Research has shown that orthodontic patients are more likely to retain information presented in an audiovisual format. However, there has been little research on the effectiveness of audiovisual information provided through different routes such as the Internet. This parallel-group randomized controlled trial assessed whether provision of audiovisual information on the YouTube (Google, San Bruno, Calif) Web site to orthodontic patients undergoing fixed appliance treatment results in improved patient knowledge when compared with conventional methods of information provision. The effects of sex and ethnicity were also investigated.
Methods
Participants were recruited from the Department of Orthodontics of the Eastman Dental Hospital, University College London Hospitals NHS Foundation Trust, United Kingdom. The patients were 13 years of age and over, with no history of orthodontic treatment, and patient and parental (where appropriate) consent were obtained. The participants were randomized into control (n = 34) and intervention (n = 33) groups using a random number table; there was stratification based on age group, with permuted blocks of 10 patients. Both groups were given routine verbal and written patient information related to fixed appliances, and the participants in the intervention group were sent 3 e-mails over 6 weeks requesting that they view a 6-minute YouTube video containing similar information but in audiovisual format. Patient knowledge was measured using identical questionnaires answered on the day of recruitment (baseline) and again 6 to 8 weeks later. The researchers were unaware of group allocations when enrolling patients and scoring questionnaires.
Results
Sixty participants (89.55%) completed the study. Those who completed the trial in the intervention group (n = 30) demonstrated significantly greater improvements in knowledge than did those in the control group (n = 30), scoring, on average, almost 1 point more (95% CI for the difference, 0.305-1.602; P = 0.005) on the final questionnaire. Ethnicity had a statistically significant effect on improvement in knowledge, but sex did not. No harm to any patient was noted during the trial.
Conclusions
Presenting audiovisual information through the YouTube Web site to orthodontic patients resulted in a significant improvement in patient knowledge. Supplementation of verbal and written patient information with audiovisual information via the Internet is therefore worthy of consideration.
Registration
National Research and Ethics Service (REC number 12/LO/0863), United Kingdom.
Protocol
The protocol was not published before trial commencement.
Funding
No funding or conflict of interest to be declared.
Highlights
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Sixty patients were given verbal and written information about fixed appliances.
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Half were also asked to view a 6-minute video on YouTube.
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Patient knowledge was measured by using identical questionnaires.
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Those who watched the video showed a greater improvement in knowledge.
An important goal of health care professionals is to effectively communicate information to patients to improve knowledge. Many authors have examined the role that information provision plays in orthodontic treatment. Information can be transmitted to patients in many ways, and researchers have compared some of them in terms of their effectiveness. Common trends in the way that patients prefer to receive information have been identified.
Patient compliance and effective communication are integral parts of orthodontic treatment, and patients who are compliant during treatment may achieve more favorable treatment outcomes. The communication of certain elements of orthodontic treatment, such as oral hygiene, has been shown to be effective not only during treatment but also in the long term. Dentists should consider how they communicate instructions to patients to improve their compliance. Specifically, during orthodontic treatment, it has been shown that patient cooperation increases as communication between the orthodontist and the patient improves.
Patient cooperation depends on many factors, including the establishment of an effective rapport with the treating clinician. Enhanced communication has been shown to increase patient satisfaction, improve patient knowledge, and provide the motivation required to achieve compliance during treatment. The methods that orthodontists use to communicate with patients are a vital part of the information provision process because patients must understand what is required of them if they are to be compliant and motivated during treatment. Previous research has shown that providing information to orthodontic patients in a visual format is effective in terms of information retention.
In recent years, it has become relevant to study how effective the Internet and social media can be in improving patient knowledge during treatment. In the United States, 32% of the surveyed consumers stated that they had used social media for health care purposes, but recent studies have shown that hospitals in the United States are not using social media to its full capacity to communicate with patients. There has been little research on the effectiveness of online information in improving patient knowledge; however, it has been shown that orthodontic patients use the Internet for treatment-related information.
Specific objectives or hypotheses
The motivation for undertaking this study was therefore to investigate the potential benefits of using the Internet to provide audiovisual information to orthodontic patients for knowledge improvement. The aim was to determine whether presenting audiovisual information through YouTube (Google, San Bruno, Calif) to orthodontic patients undergoing fixed appliance treatment results in improvements in the knowledge related to appropriate care of the teeth and appliances during treatment.
The null hypothesis for this study was that presenting additional audiovisual information through YouTube to orthodontic patients having fixed appliance treatment does not result in an improvement in knowledge related to appropriate care of the dentition and the appliances compared with conventional provision of information.
Material and methods
Trial design
This study was designed as a prospective parallel-group randomized controlled trial with a 1:1 allocation ratio in which eligible patients who had just had fixed orthodontic appliances placed were randomly allocated into either an intervention or a control group.
Participants, eligibility criteria, and setting
The patients in this trial were all attending the Eastman Dental Hospital, University College London Hospitals NHS Foundation Trust, London, United Kingdom, for fixed appliance orthodontic treatment. The participants included patients of both sexes, aged 13 years and over. Patients were excluded if they did not have a valid e-mail address, had a history of previous orthodontic treatment, were receiving orthodontic treatment with only removable orthodontic appliances or headgear, required complex multidisciplinary treatment, or had a craniofacial syndrome. Ethical approval was obtained from the National Research and Ethics Service (reference number 12/LO/0863), and the University College London Hospitals NHS Foundation Trust Research and Development Department granted research and development approval.
Interventions
Patients in the intervention group were given routine verbal and written information; in addition, they were sent 3 e-mails over a period of 6 weeks, at fixed biweekly intervals. The e-mails asked them to view a YouTube video designed specifically for this study containing information relevant to care of their dentition and fixed appliances during treatment ( Fig 1 ). The video was uploaded to the University College London Hospitals YouTube channel as an unlisted video that was accessible only through the Web address provided in the e-mails to the patients in the intervention group. Patients in the control group received the same verbal and written information but did not receive any e-mails directing them to the YouTube video. All patients were asked to answer a 15-item single-best-answer questionnaire on the day of bond up (baseline data) and an identical questionnaire asking the same questions 6 weeks later at the end of the study. The comparison of data from the 2 questionnaires allowed changes in knowledge to be assessed.
Patients allocated to the intervention group received the standard verbal information given to orthodontic patients and the British Orthodontic Society’s information leaflets that are routinely provided to all patients in the department. The video they were asked to watch was developed for this study and provided the same information as in the verbal and written formats, but this time in an audiovisual format. The video centered on 5 major themes: coping with a newly fitted fixed appliance, eating and drinking with a fixed appliance, oral hygiene and its importance, retention, and appliance breakages and emergency appointments.
The 3 biweekly e-mails were identical and asked the patients to follow a link to the YouTube site. The first e-mail was sent on the day that these patients had their fixed appliances fitted and completed the initial questionnaire. The last e-mail was sent 4 weeks later, and the final questionnaire was completed approximately 2 weeks after that, at the first archwire change visit.
The control group did not receive e-mails directing them to view the YouTube video but were still given standard verbal information and the British Orthodontic Society’s information leaflets. Therefore, patients allocated to the control group received everything that those in the intervention group did, with the exception of the YouTube video. The information provided to the control group participants in both verbal and written forms served 2 major purposes. First, it would be unethical not to provide the usual information; second, this allowed a comparison to be made between the 2 groups relating to the effectiveness of the medium used to transmit information rather than the effectiveness of the information itself.
Outcomes (primary and secondary) and any changes after trial commencement
Two questionnaires were given to all patients in the trial. One was given on the day that the fixed appliances were placed and provided baseline data (Q1), and the second was distributed approximately 6 to 8 weeks later at the patient’s first review visit (Q2). The second questionnaire marked the end of the trial for each participant. The 2 questionnaires were identical, although the final questionnaire had 1 additional question, which asked all patients (regardless of their group) whether they had watched the YouTube video. This question accounted for the fact that someone in the intervention group might not have watched the video and the possibility that someone in the control group might have obtained the link and accessed the video. The YouTube video was classified as “unlisted” and could be accessed only through a link that was e-mailed to patients in the intervention group, so this was unlikely. The questionnaire was piloted and amendments made until the final version was developed. Each questionnaire contained 15 single-best-answer questions and asked questions closely related to the information presented to both groups of patients.
The outcome measure in this trial was the difference in scores between the 2 questionnaires. The 2 questionnaires for each patient in this study were scored manually by the first author after completion of the second questionnaire, but without knowing the patient’s group. Each questionnaire had a total score of 15, with 1 point for each correct answer. Multiple-choice questions with a single best answer were considered to be an objective assessment, where assessment bias was minimal. All questionnaires were then double marked by a second researcher (D.S.G.) to ensure reliability.
Sample size calculation
It was difficult to establish a standardized difference for a sample size calculation. Therefore, it was decided that an internal pilot would be undertaken to establish the standardized difference and calculate the sample size. This used data from the first 10 patients in each group who completed the trial. A difference in score of 1 point was considered to be a clinically relevant difference between the 2 questionnaires because there were only 15 questions. The standardized difference was then calculated by dividing the clinically relevant difference by the standard deviation of the differences; this was estimated at 1.10 from the pilot study, giving a standardized difference of 0.91. Based on a paired t test with a 5% level of significance, a power of 80%, and a standardized difference of 0.91, the optimal sample size was estimated at 20 patients in each group. However, this was inflated to 30 in each group to account for possible confounding factors and potential dropouts.
Interim analyses and stopping rules
It had been planned that an intention-to-treat analysis would be used if patients in the intervention group had not watched the YouTube video or in the unlikely event that a patient in the control group had seen the video. However, this was not required because only 1 patient in the intervention group stated that he or she had not watched the video and declined to complete the final questionnaire. No patients in the control group had watched the video.
Randomization
To ensure that the groups had similar numbers of patients as the trial progressed, block randomization was used. Randomization was by random number tables and occurred in permuted blocks of 10 patients, so that once 10 patients were recruited, there would be 5 in each group. Patients were stratified into those aged 13 to 15 years and those 16 years and over; a separate randomization list was used in each stratum to ensure that the groups had equal numbers of adults and children as the trial progressed. This was considered important to ensure that confounding bias related to different intelligence levels between the age groups would be minimized. For ethical considerations and to ensure that the patients looked for e-mails if necessary, they were clearly informed which group they were allocated to.
To reduce bias, the researchers were blinded to group allocation when each patient consented; each new patient’s group was concealed by placing this information in an opaque envelope that was opened only when the patient consented to be included.
Blinding
The researchers remained blinded to group allocations when scoring the questionnaires and entering the data into the results spreadsheet.
Statistical analysis
The statistical software used to analyze the data in this trial was SPSS (version 22.0; IBM, Armonk, NY).
Baseline demographic data were summarized for the 2 groups. The outcome data collected from the questionnaires (ie, the patient’s knowledge level) was continuous, and multivariable regression analysis was used to determine the independent effects of group, sex, ethnicity, and the Q1 questionnaire score on the patient’s knowledge in the final questionnaire (Q2). The significance level was set at 0.05 for all hypothesis tests.
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