Development of oral health resources and a mobile app for caregivers and autistic children through consensus building

Abstract

This study aimed to (1) develop evidence-based resources and (2) test face, content validity, and usability of a newly developed mobile application (app) to equip and empower caregivers with resources and skills to promote better oral health for autistic children. A series of resources on oral health, including information on oral diseases and home care and social stories on dental visits were developed. Concurrently, an app was developed by dentists, occupational therapist and software developers. The resources underwent content validation by an international panel of paediatric dentists (Expert Working Group). Face validation of the resources and usability testing of the app by parents were then carried out. Validation and feedback were obtained by the Delphi method, with consensus set at 70% agreement. A total of 12 resources and 2 social stories were developed. Consensus was achieved among the Expert Working Group regarding the content and illustrations of the resources and social stories. Both the Expert Working Group and parents agreed that the resources were easy to read and understand. Parents also found the app easy to use, aesthetically pleasing and help them to better care for their child’s oral health.

Lay Abstract

Caregivers of autistic children often lack knowledge regarding oral homecare and when and where to see the dentist. To address this need, we developed a series of information on oral health. An autistic child assisted in developing two social stories to showcase a dental visit. A mobile app was developed to deliver the above mentioned. Other features include creation of customised social stories and visual schedule and an inbox to allow dentists to send messages to parents. The developed information and social stories were reviewed by experts and parents. The app also underwent anonymous and independent testing by parents. Overall the information and app were well received by the experts and parents.

Keywords

autism Delphi mobile app technology oral health promotion

Introduction

Dental caries is one of the most prevalent disease (Bernabe et al., 2020), and leading causes of pain and poor quality of life (QoL) among neurotypical and autistic children (Lam et al., 2020; Nora et al., 2018). However, autistic children often experience numerous barriers to dental care both at home and at the dental office (Alshihri et al., 2021; Du et al., 2019). At home, sensory sensitivity towards the texture and taste of the toothbrush and toothpaste (Junnarkar et al., 2022; Stein et al., 2011) translates to sensory avoidance behaviour and poor dental hygiene practices (Jasmin et al., 2009; Khrautieo et al., 2020). At the dental office, the change in daily routine (Norton & Drew, 1994), the unpredictability of events (Ryan, 2010) and sensory input (Cermak et al., 2015) from the environment overwhelms and results in poor cooperation among autistic children (Stein et al., 2011). In addition, caregivers may lack the necessary knowledge regarding basic oral care (Junnarkar et al., 2023; Teste et al., 2021). As a result, autistic children have a high degree of unmet treatment needs compared to their neurotypical counterparts (Mansoor et al., 2018; Qiao et al., 2020), resulting in poorer QoL (de Almeida et al., 2021; Qiao et al., 2020). Similar unmet needs and barriers have also been reported among parents (Junnarkar et al., 2023), teachers (Tong et al., 2017) and allied health professionals (Junnarkar et al., 2022) in Singapore. As common oral diseases are preventable, it is imperative to raise awareness and develop evidence-based oral health promotion resources. Such resources should be accessible, include practical information and strategies to establish appropriate habits for all children at an early age and prevent new diseases at a community and individual level (Tinanoff et al., 2019).

The effectiveness of an oral health resource is not only dependent on the quality of its content but also its applicability, appropriateness and readability. This requires content and face validation from both content experts and end-users. One method to obtain such validation is by consensus building using the Delphi method (DM; Black et al., 1999; Linstone & Turoff, 1975). In this method, various questions regarding the appropriateness, subject breadth and depth and ease of understanding of the proposed content will be posed to an expert panel and stakeholders with at least seven members to obtain structured feedback from them, and through consensus building, develop recommendations or guidelines. The participants are contacted separately to ensure anonymity within the group. This allows them to express their opinions freely without external influence. The DM has been used to develop health promotion packages for patients (Gabarron et al., 2018) and clinical recommendations for professionals (Kenny et al., 2018).

While there are several mediums to deliver resources to the end-users, the ubiquity of mobile devices (e.g. smartphones and tablets) has allowed for easy delivery of knowledge and facilitate health-related behaviour change (Dennison et al., 2013). Mobile devices have shown effectiveness in improving knowledge, oral hygiene practices and overall oral health among patients (Scheerman et al., 2020; Toniazzo et al., 2019). Specifically for autistic children, clinicians have combined early intervention therapies, such as visual schedules based on Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH^®; Schopler & Reichler, 1971) with dental recommendations to improve tooth brushing compliance at the dental clinic (Lefer et al., 2019). Studies have compared delivery mediums for early intervention therapies and found similar effectiveness in improving behaviour among autistic children at the dental office (Zink et al., 2018). However, they do not address the needs of caregivers (i.e. improving knowledge and equipping practical strategies to promote oral health among autistic children).

Therefore, the aims of this study were:

Develop evidence-based oral health resources (OHR) which have international consensus for being essential in helping caregivers maintain the oral health of autistic children.

Test face, content validity and usability of a newly developed mobile application (app) to deliver the above OHR developed, and therefore equip and empower caregivers with resources and skills to promote behavioural change that can result in better oral health.

Methods

This study was divided into two phases: (1) development of OHR and mobile app and (2) content and face validation, and usability testing of mobile app through consensus building (see Figure 1).

Figure 1.

Study methods.

Phase 1: development of OHR and mobile app interface

Development of OHR

A series of resources on oral health, including common oral diseases and basic home care, and social stories on dental visits by an autistic child were planned by the study team for development. To develop the resources, a literature search was first carried out in electronic databases to identify studies on the topics of interest, followed by a review of the policies and guidelines published by various dental associations. For the social stories, photographs and video footages were captured during a dental visit of an autistic child. Parental consent and child assent were obtained prior to filming or photographing the dental visit. Following this, the first draft of OHR was developed and underwent a round of evaluation and revision by the study team.

Mobile app development

The development of a novel app followed the user-centred design methodology (UCD; McCurdie et al., 2012) involving three dentists, an occupational therapist and four software developers. The desired features for digital technology based on previous studies were considered (Zervogianni et al., 2020). Three primary features and a secondary feature were developed for the app: (1) frequently asked questions, (2) social stories and visual schedules, (3) messaging inbox (inbox) and (4) reward (see Table 1).

Table 1.

Features of mobile app.

	Frequently asked questions	Platform to deliver developed oral health resources (see Table 2)
Primary feature	Social stories and visual schedules	Platform for parents to: View social stories (e.g. visiting the dentist) and visual schedules developed by the study team or future stakeholders (e.g. daily living skills such as self-toileting steps by a school teacher) Create customised social stories and visual schedules, that is not limited to dental visits, for autistic children
Primary feature	Messaging inbox	Allows stakeholders to write specific messages or reminders to parents (e.g. dentist to parent: ‘remember to bring Thomas’s toothbrush for the next dental visit’.)
Secondary feature	Reward	Allows for accumulation of tokens upon completion of certain tasks or daily activities, for example, brushing of teeth at night Tokens can be exchanged for rewards (e.g. toys) at a partnered stakeholder’s office, for example, dental clinic

Phase 2: content and face validation, and usability testing through consensus building

Phase 2 involved consensus building using the DM among experts and end-users separately (Linstone & Turoff, 1975).

Data collection and analysis

Participants were asked to rate their level of agreement to specific statements on a pre-tested questionnaire using a five-point Likert-type rating scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). After each stage, responses were consolidated and analysed for consistency and consensus. Consensus was deemed to be achieved when 70% of the participants (Expert Working Group (EWG) or parents) selected the ‘Strongly Agree’ or ‘Agree’ options. Open-ended boxes were included after each section to obtain qualitative feedback, which were consolidated and analysed for common themes. It was planned such that if a deeper understanding of the feedback provided was required, a semi-structure interview and thematic analysis would be carried out with consented participants (see Appendix 1). Phase 2 of this study was split into two segments as follows:

Phase 2A: content validation by EWG

Participant recruitment

Nineteen paediatric dental specialists were identified, shortlisted and invited to form the EWG. The specialists selected had either previously served or are currently serving on expert panel committees of various paediatric dental associations or are known locally or internationally to have expertise in dental management of autistic children. They had no association with the study team. An invitation email was sent by an investigator to the 19 specialists individually along with two links – one to view the developed OHR and the other to an electronic feedback questionnaire. The feedback questionnaire comprised a series of structured questions developed for consensus building. Implied consent to participate was assumed when the member responded to the invitation and completed the feedback questionnaire.

During the first round, the OHR were evaluated for appropriateness, sufficiency, relevance, subjective readability and ease of understanding of the content and illustrations included. For the second round, any OHR that required major revisions (i.e. content changes) were sent out for re-evaluation. For minor revisions, the experts were asked to review the specific revision within the full context of the specific OHR. Following completion of all amendments, the OHR were then assessed for readability using the Flesch Reading Ease (FRE; Flesch, 1948) scoring system on Microsoft Word™. The validated OHR were then embedded into the newly developed app.

Phase 2B: content and face validation, and usability testing by parents

Participant recruitment

Parents of autistic children (ages 2.5–12 years) were identified and invited to participate in the study by convenient sampling. Recruitment was carried out either at a tertiary child development centre or a dental clinic at the National University Hospital (Singapore) by two investigators during the child’s visit to either clinic. Inclusion criteria included: (1) an autistic child following evaluation either by a trained developmental behavioural paediatrician clinically, or with the Autism Diagnostic Observation Scale-2nd edition (ADOS-2; Lord et al., 2012) and (2) at least one parent being able to speak and read English. Initial study participants were then encouraged to promote the study among their friends who have autistic children, and subsequent participant recruitment occurred via snowball sampling. A minimum number of 10 participants was suggested for usability testing (Faulkner, 2003).

Initial testing

The initial version of the app was installed by a study team member in the participants’ mobile devices and each participant was given a hardcopy of the feedback questionnaire. They were given 3 weeks to evaluate the app and return the feedback questionnaire. A reminder phone call was made at the end of the third week to enquire on the status of evaluation. Parents who had not completed the evaluation of the app were then given an additional 2 weeks to complete the feedback questionnaire. Throughout the evaluation period, there was minimal guidance on the usage of the app to simulate real-world usage of the app. However, parents were provided with the contact details of a study team member whom they could contact at any stage should they encounter any difficulties with the app.

Beta testing

Based on the feedback from the first round of evaluations (e.g. technical glitches, font size issues), the app underwent a round of revision. The final colour schemes and design elements were then implemented. After which, the beta version of the app was launched on Google Play (app store), and a second round of evaluation was carried out with the same methodology as described.

Questionnaire content

The feedback questionnaire consisted of two sections. The first section obtained demographic information about the parent (age, gender, education level) and additional information regarding the autistic children (age, gender and verbal ability). The verbal ability of the autistic children was based on parental report. The second section obtained feedback regarding the usability of the app. The app was objectively assessed on the following domains: quality of OHR content, as well as functionality and aesthetics of each feature. Parents were asked to state their level of agreement with various statements addressing the above domains. At the end of each section evaluating each feature, an open-ended question was included to obtain suggestions on how to improve the feature. Another question was included at the end of the survey to obtain suggestions for additional content, app features, or ways to improve usability of the mobile app.

For the first round of evaluation, the focus was on functionality and mock layout of features and clarity of menu icons, titles and texts. During the second round, questions specific to aesthetics were added in. Content and face validation of the OHR were evaluated during both rounds of testing.

In addition, six subjective questions were included to evaluate the app’s usefulness in improving parents’ oral health awareness and confidence in caring for their children’s teeth. These six questions were independent from the DM.

Community involvement

An autistic child participated in the production of the social stories. Parents of autistic children were involved by providing feedback through the above-mentioned study methods.

Results

Developed OHR

Twelve resources and two model social stories were created (see Table 2, Figure 2 and Appendix 2). Three resources, ‘Dental Decay’, ‘Gum disease in children’, ‘Trauma and Dental Trauma’, described common dental conditions; a fourth resource ‘Immediate Management of Avulsed (Knocked Out) Adult Teeth’ was a step-by-step video instruction on the emergency management of a dental avulsion. Six resources, titled ‘Oral Hygiene and Toothbrushing – Where, When, How?’, ‘Flossing’, ‘Fluoride Toothpaste’, ‘Healthy Diet’ and ‘Diet Advice for Healthy Teeth’, focused on home care tips such as toothbrushing and making healthy diet choices. Two resources, ‘Visiting the Dentist’ and ‘Finding a Dentist’, and social stories, ‘Toby Visits the Dentist’ and ‘Taking X-ray’, provided parents information and material to prepare their child for a dental visit.

Table 2.

Oral health resources.

Title	Content
Dental Caries	• Aetiology and consequences • Progression of caries: white spot lesion, cavitation, root stump and abscess • Prevention of dental caries
Gum Disease in Children	• Causes and risk factors • Signs and symptoms • Prevention of periodontal disease
Trauma and Dental Trauma	• Recognising signs and symptoms of worsening head injury • Basic information on dental trauma and the importance on seeking dental treatment immediately
Immediate Management of Avulsed (Knocked Out) Adult Teeth	• Steps on how to re-implant an avulsed permanent incisor
Oral Hygiene and Toothbrushing. Where, When, How?	• The when and where of toothbrushing • Toothbrushing techniques • Choosing a manual or electric toothbrush
Flossing	• Flossing techniques • Types of floss available
Fluoride Toothpaste	• When to use toothpaste • Using the right amount and type of toothpaste • Concerns regarding swallowing of toothpaste
Mouthrinse	• When and how to use a mouthrinse • Types of mouthrinse available
Healthy Diet	• Components of a balanced diet • Suggestions for snacking
Diet Advice for Healthy Teeth	• Age-appropriate dietary advice • Choosing sugar-free medicine
Visiting the Dentist	• Timing and aim of the first dental visit • How to prepare a child for the first dental visit
Finding a Dentist	• Links to Singapore Dental Council and local specialist dental association websites
Social Stories
Toby Visits the Dentist	• Social story on visiting the dentist
Taking X-ray	• Social story on taking dental radiographs

Figure 2.

Screenshot of oral health resources: (a) dental decay and (b) social story ‘Taking X-ray’.

Participant demographics

Expert Working Group

Among the 19 specialists invited to participate in the study, 15 replied and formed the EWG. Fourteen specialists completed both rounds of content validation (see Appendix 3), and one specialist dropped out during the first round due to lack of time. The EWG comprised of paediatric dentists from Australia (n = 2), England (n = 2), Hong Kong (n = 1), Malaysia (n = 1), Singapore (n = 3), Sweden (n = 1), Switzerland (n = 1), The Philippines (n = 1) and the United States of America (n = 2). Nine were academic university faculty, three were practising in the paediatric department of dental hospitals and two held joint appointments.

Parents and autistic children

Fifteen parents participated in the study (see Table 3). Ten parents completed the initial testing. A further five new parents were recruited and completed the beta testing. Majority of the participants (n = 14) were between the ages of 31 and 50. Mothers (n = 13) formed most of the participants. All parents had an education level of secondary school and above, with nine attaining a university degree. The characteristics of their children were also presented in Table 3. Majority are boys (14/15), and most are able to communicate in complete sentences (12/15).

Table 3.

Characteristics of parents and autistic children.

	Age (years)	Version		Gender			Education level
	Age (years)	Initial	Beta		Initial	Beta		Initial	Beta
Parents	21–30	0	0	Male	1	1	Primary	0	0
	31–40	2	3	Female	9	4	Secondary	2	1
	41–50	7	2				Diploma	0	0
	51–60	1	0				GCSE A-level	2	0
	Above 61	0	0				University and above	5	4
	Age (years)	Version		Verbal ability				Version
	Age (years)	Initial	Beta	Verbal ability				Initial	Beta
Children	3–6	3	4	Unsure				0	1
	7–12	7	1	Unable to communicate				0	0
	Gender			Uses gestures or picture cards				0	0
	Male	10	4	Single word or short phrases				0	2
	Female	0	1	Complete sentences				10	2

GCSE: General Certificate of Secondary Education.

Content and face validity, and readability of OHR

Phase 2A

Consensus was achieved among the EWG regarding the appropriateness of content and illustrations included in the OHR (see Table 4). Most of the OHR had a minimum of 12 out of 14 (86%) experts in agreement with regard to content and illustrations included. Two resources, ‘Mouthrinse’ and ‘Healthy Diet’, scored the lowest across all questions, with 10 out of 14 (71%) experts in agreement with content and 11 or 12 out of 14 (79% or 86%) experts in agreement with the illustrations included.

Table 4.

Content validation and readability score of oral health resources.

	Expert Working Group (N = 14)					Parents (N = 15; Initial N = 10, Beta N = 5)					Readability score
Oral health resources
Title	Content is appropriate	Illustrations are relevant	Illustrations will aid the target audience	Content is easy to read	Content is easy to understand	Breadth of content is sufficient	Depth of content is sufficient	Amount of illustration is sufficient	Illustrations aid in understanding the content	Content is easy to understand	Flesch Reading Ease	US Grade (Age in years)
Dental Decay	14/14100%	13/1493%	12/1486%	11/1479%	12/1486%	14/1593%	15/15100%	14/1593%	15/15100%	15/15100%	69.6	8–9(13–15)
Gum Disease for Children	11/1479%	NA^a	NA^a	13/1493%	13/1493%	13/1587%	13/1587%	13/1587%	14/1593%	14/1593%	56.3	10–12(15–18)
Oral Hygiene and Toothbrushing! Where, When, How?	13/1493%	13/1493%	13/1493%	14/14100%	14/14100%	14/1593%	14/1593%	14/1593%	14/1593%	14/1593%	69.1	8–9(13–15)
Flossing	12/1486%	13/1493%	13/1493%	13/1493%	13/1493%	13/1587%	13/1587%	13/1587%	14/1593%	14/1593%	89.1	6(11–12)
Fluoride Toothpaste	14/14100%	13/1493%	13/1493%	13/1493%	12/1486%	14/1593%	14/1593%	14/1593%	14/1593%	14/1593%	76.6	7(12–13)
Mouthrinse	10/1471%	12/1486%	11/1479%	11/1479%	11/1479%	14/1593%	13/1587%	13/1587%	14/1593%	14/1593%	72.6	7(12–13)
Healthy Diet	10/1471%	12/1486%	12/1486%	10/1471%	10/1471%	13/1587%	13/1587%	13/1587%	14/1593%	14/1593%	57.7	10–12(15–18)
Diet Advice for Healthy Teeth	13/1493%	13/1493%	13/1493%	12/1486%	11/1479%	13/1587%	13/1587%	13/1587%	14/1593%	14/1593%	60.6	8–9(13–15)
Preparing for a Dental Visit	14/14100%	NA^b	NA^b	13/1493%	14/14100%	14/1593%	14/1593%	13/1587%	15/15100%	15/15100%	72.1	7(12–13)
Finding and Visiting a Dentist	14/14100%	NA^c	NA^c	14/14100%	14/14100%	14/1593%	14/1593%	13/1587%	15/15100%	15/15100%	57.1	10–12(15–18)
Dental Trauma	13/1493%	13/1493%	12/1486%	12/1486%	12/1486%	14/1593%	14/1593%	13/1587%	14/1593%	14/1593%	67.1	8–9(13–15)
Immediate Management of Avulsed (Knocked Out) Permanent Teeth	12/1486%	12/1486%	12/1486%	13/1493%	13/1493%	14/1593%	14/1593%	13/1587%	14/1593%	14/1593%	71.8	7(12–13)
Social stories
	Content is appropriate	Pictures or videos suit the narration	Narration is easy to understand	Social stories suit the target audience	Social stories will aid the target audience	The social stories are:
	Content is appropriate	Pictures or videos suit the narration	Narration is easy to understand	Social stories suit the target audience	Social stories will aid the target audience	Well written	Easy to understand	Relevant to my child
Toby Visits the Dentist	12/1486%	13/1493%	12/1486%	12/1486%	12/1486%	15/15100%	15/15100%	15/15100%
Taking X-ray	13/1493%	13/1493%	13/1493%	11/1479%	11/1479%	15/15100%	15/15100%	15/15100%

Images were not yet added into the content during phase 2.

Refer to social stories and videos on dental instruments and dental procedures.

No images included.

Qualitative feedback

The common feedback among the EWG was to add illustrations on ‘what constitutes “unhealthy” food’ and ‘primary teeth trauma’ (see Figure 3) Other suggestion includes improving clarity to certain pictures (see Figure 4).

Figure 3.

Qualitative feedback to add illustrations for (a) unhealthy food (i) before and (ii) after; (b) primary teeth trauma (i) before and (ii) after.

Figure 4.

Feedback to improve clarity on white spot lesion (a) before and (b) after.

These amendments were completed and provided to the EWG for a second round of evaluation; no additional changes were required.

The social stories also received positive feedback from the EWG. Twelve specialists (86%) agreed with the feedback statements on the content, illustrations and ease of understanding of the social stories. As for whether the social stories would suit or aid the target audience, the level of agreement was high among the EWG, with consensus among 12/14 (86%) for ‘Toby Visits the Dentist’, and 11/14 (79%) for ‘Taking X-ray’ respectively.

Phase 2B

There was no feedback on content changes by all parents (initial and beta); as such, the results were combined and reported (see Table 4). There was consensus among the parents regarding the breadth and depth of content, and the suitability of illustrations included for each resource. All feedback statements consistently had a minimum of 13/15 (87%) parents selecting the ‘Strongly Agree’ or ‘Agree’ options. All parents (15/15, 100%) agreed that both social stories were well written and relevant for their child.

Readability assessment

Most experts agreed that the content was easy to understand. There was no difference between the readability score before and after content validation. Most of the Educational Materials (9/12) had a FRE score greater than 60 (see Table 4). This means readers of age 13 and above will generally be able to understand the material provided. The resources ‘Gum Disease for Children’, ‘Healthy Diet’ and ‘Finding and Visiting a Dentist’ had reading scores that corresponded to age 15 to 18 due to technical terms (e.g. ‘phenytoin’ and ‘dilantin’ in ‘Gum Disease for Children’; ‘paediatrician’, ‘dietician’ and ‘fortifiers’ in ‘Healthy Diet’; ‘National University Centre for Oral Health Singapore’ in ‘Finding and Visiting a Dentist’). Removal of these terms resulted a reading score corresponding to age 13 to 15. Nonetheless, parents found all content easy to understand (see Table 3), with 14/15 (93%) parents in agreement for nine resources and 15/15 (100%) parents in agreement for the remaining three resources and the two social stories.

Mobile app usability testing

Overall

Most parents (12/15, 80%) agreed that the app was easy to use. The majority of parents (12/15, 80%) agreed that the menu icons were clear, and all parents who participated during the second round (5/5, 100%) agreed that the app was visually appealing and attractive (see Table 5). As consensus was achieved for most questions among the 10 parents during the initial testing, it was decided that no second round of Delphi was to be conducted at this point to allow technical issues to be resolved. This was followed by beta testing by a new set of participants (n = 5).

Table 5.

Feedback from parents.

		Initial testing (n = 10)	Beta testing (n = 5)
Usability testing
Overall feedback	Aesthetics
	App is appealing and attractive	NA^a	5/5 (100%)
	Menu icons are clear	7/10 (70%)	5/5 (100%)
	Functionality
	It is easy to use the app	7/10 (70%)	5/5 (100%)
Frequently asked questions	Aesthetics
	Appropriate font size was used for:
	• Titles	9/10 (90%)	5/5 (100%)
	• Texts	8/10 (80%)	5/5 (100%)
	Functionality
	Navigation (e.g. swipes/scrolls/taps) are intuitive	10/10 (100%)	5/5 (100%)
Social story and visual schedule	Aesthetics
	Layout of content on the screen is appropriate	9/10 (90%)	5/5 (100%)
	Functionality
	Navigation (e.g. swipes/scrolls/taps) are intuitive	10/10 (100%)	5/5 (100%)
	Social stories and visual schedules are easy to:
	• Create	7/10 (100%)	5/5 (100%)
	• Edit	6/10 (60%)	5/5 (100%)
Inbox	Aesthetic
	Font size for texts are appropriate	NA^b	5/5 (100%)
	Functionality
	Navigation (e.g. swipes/scrolls/taps) are intuitive	NA^b	5/5 (100%)
Subjective feedback
	The app increased my awareness of the importance of oral health for my child	10/10 (100%)	5/5 (100%)
	I am:
	• better prepared to care for my child’s oral health	10/10 (100%)	5/5 (100%)
	• more confident of brushing my child’s teeth	7/10 (70%)	5/5 (100%)
	• more conscious on the diet choices I make for my child	9/10 (90%)	5/5 (100%)
	• aware of what to do when a dental injury occurs	10/10 (100%)	5/5 (100%)
	I feel more confident in the immediate management of a knocked out/avulsed tooth	10/10 (100%)	5/5 (100%)

NA: not available.

Aesthetics was not yet included in the app during initial testing.

Technical issues noted, feature was not tested.

Functionality and aesthetics

The primary features of the app were evaluated for functionality and aesthetics (see Table 5). The inbox function was only evaluated during the second round due to technical issues identified by participants during the first round whereby messages sent by the designers could not be received by the participants.

In terms of functionality, all parents agreed that the inbox and frequently asked questions were easy to navigate (swipe, scrolls, taps). Fourteen out of 15 (93%) parents agreed that the navigation for the Social Story and Visual Schedule feature was intuitive. The Social Story and Visual Schedule feature was also evaluated for ease of content creation and editing. Most parents, 7/10 (70%) in round 1 and 5/5 (100%) in round 2 found it easy to create new content. However, only 6/10 (60%) parents were able to edit their created content with ease. The common qualitative feedback being ‘access to the edit function was not intuitive’. After adjusting the feature, all parents 5/5 (100%) were able to access the edit feature with ease during the second round of testing. With regard to the clarity of texts and layout of content, there was over 80% agreement among parents for all three features; two parents provided qualitative feedback that the texts were slightly small during the first round.

Subjective feedback

All parents (15/15, 100%) agreed that the app increased their awareness on the importance of oral health of their child, and felt better prepared to care for their child’s oral health. Most parents also agreed that the app would help promote behaviour change. They (12/15, 80%) felt more confident on how to brush their child’s teeth, and were more conscious about the diet choices they make for their child (14/15, 93%; see Table 4). All parents (15/15, 100%) became aware and were more confident on the actions required when a traumatic dental injury occurs (see Table 5).

Qualitative suggestions

Although a semi-structured interview (see Appendix 1) was planned as part of the study methods, the study team and software developers agreed that the feedback obtained from the questionnaire, and informal discussion from the participants did not warrant an additional interview. As such, the semi-structured interview was not carried out. The qualitative suggestions provided by the parents included making the OHR available in other languages (e.g. Mandarin Chinese, Malay), adding other features such as Augmentative and Alternative Communication (e.g. customisable Picture Exchange Communication System) and gamification (e.g. providing the child with an augmented reality experience of the dental clinic she or he is about to visit). There was no request for additional OHR to be developed among the parents.

The app is currently available on Google Play (https://play.google.com/store/apps/details?id=sg.edu.nus.comp.care) (see Figure 5).

Figure 5.

Screenshot of mobile app (a) Google Play Store and (b) Landing page.

Discussion

This article describes the development process and usability testing of OHR incorporated into an app aimed to empower parents with oral health knowledge and appropriate strategies to effect behaviour change, such as toothbrushing at home and dental examination at the office for autistic children (Dias et al., 2010; Fenning et al., 2022). To our knowledge, this is the first article that illustrates not only the involvement of an EWG in development of evidence-based OHR for an app targeting caregivers of autistic children, but also obtaining input from parents of autistic children regarding the suitability of resources, features of the app and app usability. Consensus regarding suitability of resources, features and usability of the app was attained. Another finding of this study is the increased parental awareness of the importance of oral health and confidence to take care of their child’s oral health.

Similar to a previous study (Nash & Woolley, 2022), our study utilised a systematic approach to develop the OHR to ensure that the resources were of the highest level of evidence and aligned with guidelines by key international dental associations such as the American Academy of Paediatric Dentistry, European Academy of Paediatric Dentistry, International Association of Paediatric Dentistry, International Association of Dental Traumatology and so on. What differentiates our study is the additional step of content validation through consensus building using the DM, followed by readability assessment. Two other studies on mobile app development to improve oral health reported on content validation (Divani, 2019; Ng et al., 2022); however, there was limited information on the methods used and only a small number of experts were included.

A set of social stories was created and validated by the EWG and parents, lending our resources high credence for adhering to the current evidence standards and for being appropriate for the caregivers of autistic children. Our social stories slightly differed from previous social stories (Marion et al., 2016; Murshid, 2017). Rather than only using photographs or cartoon on a webpage or book (Marion et al., 2016; Murshid, 2017), our social story was presented with both videos and photographs. The videos showcased specific dental procedures carried out on an autistic child. This is the first documented social story incorporating video modelling strategies specifically for dental visits. Studies have shown the effectiveness of video-modelling and video-self-modelling in acquisition and maintenance of new skills and behaviours among autistic children (Banda et al., 2007; Bellini & Akullian, 2007; Wang et al., 2011). It is hoped that the videos created in this study will not only prepare autistic children for the sensory experiences expected when visiting a dentist, but also provide them with an opportunity to be encouraged and acquire positive behaviours by watching an autistic child undergoing dental treatment.

To ensure the OHR were easy to understand, evaluation by parent feedback and FRE score were carried out. Parents were able to understand the OHR even though the overall mean FRE score attained (68.3), is lower than the recommended score (70; Amini et al., 2007).

A mobile app was utilised as the communication means of choice to reach out to stakeholders due to numerous reasons. Within the local context, Singapore has a high mobile penetration rate of 158.8% for the year 2021 (total number of mobile subscriptions divided by the total population; IMDA, 2022); and with over 5 billion mobile phone subscribers globally (Cummings et al., 2013), an app has the potential to reach out to a large number of users. Second, autistic children has shown preference for digital devices (e.g. iPad) than traditional media (e.g. story book; Kagohara et al., 2013) due to the predictability when interacting with the software (e.g. mobile app; Smith et al., 2021). This preference may help reinforce the learning of target behaviour or skills, such as improving cooperation at the dentist, among autistic children (Zink et al., 2018). This technology can also allow for future expansion of resources to include other health-related topics relevant for autistic children in partnership with other stakeholders. For caregivers, the app allows for easy access for content on the go, such as a personalised social story to guide an autistic child through an anxiety-provoking or novel situation (Smith et al., 2021), which the child can also revisit or revise just prior to the appointment.

Developing a successful app requires collaboration among professionals and targeted end users as this allows professionals to understand the requirements of the target audience (Constantin et al., 2017; McCurdie et al., 2012). The most common way of understanding these requirements is to use a questionnaire that has the necessary elements for testing the quality of healthcare apps (Maramba et al., 2019; Stoyanov et al., 2015). This method has been used to evaluate other health-related mobile apps (Ng et al., 2022; Zhang et al., 2022). The common requirements reported include ease of use, being aesthetically pleasing and having credible information (Peng et al., 2016; Zervogianni et al., 2020).

Our app was developed by an interdisciplinary team of dentist and occupational therapist, with the above-mentioned features considered. Having an occupational therapist is valuable as they can provide input regarding the development of OHR (Como et al., 2021), such as including electric-powered toothbrush not only for oral hygiene but also as part of an oral desensitisation protocol for sensory seeking autistic children (Junnarkar et al., 2022). For the social stories, the occupational therapist provided input on what should be included to help prepare autistic children for dental visits; this may increase the probability of autistic children coping successfully at the dental clinic (Como et al., 2021; Junnarkar et al., 2022). The features and user interface in our app were designed based on both informal discussion with parents of autistic children during their dental visits, and evidence-based findings regarding end users’ requirements (Junnarkar et al., 2023; Zervogianni et al., 2020), an example being the inbox feature (see Table 1). Establishing good communication between parents and teachers has been shown to be essential to support student learning (Graham-Clay, 2005). Similarly, improving communication between the dental team and patients builds better relationship and service (Lin et al., 2014). In our case, the dentist can utilise this feature to send messages to parents, such as reminders for future dental visits, or even information regarding their child’s dental treatment in the event parents are not present during the visit. Currently, the inbox only allows one-way communication. Future improvement of the app can possibly allow for teledentistry between the dentist and parents and autistic children prior to the actual visit at the dental office.

After development of the app, the study team used the appropriate content from the checklist by Stoyanov et al. (2015) and operationalised it in a rating scale with DM for consensus building among parents of autistic children. Data were collected when parents used the app in the natural environment rather than a controlled environment to represent a realistic scenario (McCurdie et al., 2012). This is also to facilitate convenience for parents so they can try the app at their own free time. The consensus building found that the participants could use the app without much help and were consistent in the feedback provided on functionality, features and content creation.

The strength of our study is that interdisciplinary collaboration, involving professionals, an autistic child and parents of autistic children, and a rigorous methodology was employed throughout the development of both the OHR and mobile app. Our study also had a few limitations. Similar to previous studies (Akmal Muhamat et al., 2021; Ng et al., 2022), we had a limited pool of parents involved in the validation of the OHR and usability testing of the app. Although a minimum of five users is suggested for usability testing, a larger number may increase the possibility of detecting technical issues (Faulkner, 2003). The small number of participants may also limit effective probing for qualitative feedback. More quantitative and qualitative input and feedback that better represent the wider autistic community, including future involvement of autistic children/individuals, is likely necessary to fine-tune and maximise the potential of this app. As this study was aimed at developing and testing OHR, it did not include objective measurements of improved behaviours among caregivers or inspects on the oral health and the wellbeing of the children. This is a necessary next step in testing that will be carried out in future with wider implementation of the mobile app.

The next step of testing will be to investigate the usefulness of the app in improving knowledge and acceptance towards toothbrushing or a dental visit among a larger sample of stakeholders and children respectively. In addition, clinical studies can evaluate effectiveness of the developed social stories and visual schedules, used alone or in conjunction with a dental desensitisation protocol (Nelson et al., 2017), in improving cooperation towards toothbrushing at home and dental examinations at the clinic, and thereafter changes in oral hygiene, oral health and QoL among autistic children. Improvement to current features or addition of new features could be incorporated with inputs not only from stakeholders but also from autistic children/individuals, whom we did not include in this study. These could include oral motor functional therapy protocols used by speech and occupational therapists to aid in oral desensitisation and eventually enable mouth opening (Junnarkar et al., 2022), or improving the inbox function to allow for teledentistry. The long-term plan will involve interdisciplinary collaboration (Como et al., 2021; Junnarkar et al., 2022) for possible integration of the app into special school curriculums for autistic children or as a part of health promotion efforts by government statutory boards. Beyond the local context, it is the hope that the app will be clinically relevant, effective, sustainable and free for an international audience to promote oral health. Although the content in the app is aligned with international recommendations and validated by the international panel of experts in this study, further validation within the local population (experts and end-users) may be required, as variations in oral health beliefs and service utilisation may differ within states and across borders (Batra et al., 2019; Reda et al., 2018).

Conclusion

A set of OHR and mobile app were developed by an interdisciplinary team and evaluated by EWG and parents. Consensus was achieved regarding the content of the OHR, features and usability of the app. The app was well received by parents and the EWG and holds potential to be used in a wider community to improve dental care for autistic children.

Supplemental Material

sj-docx-1-aut-10.1177_13623613231188768 – Supplemental material for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building

Supplemental material, sj-docx-1-aut-10.1177_13623613231188768 for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building by Bing Liang Tan, Rahul Nair, Mandeep Singh Duggal, Ramkumar Aishworiya and Huei Jinn Tong in Autism

Supplemental Material

sj-docx-2-aut-10.1177_13623613231188768 – Supplemental material for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building

Supplemental material, sj-docx-2-aut-10.1177_13623613231188768 for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building by Bing Liang Tan, Rahul Nair, Mandeep Singh Duggal, Ramkumar Aishworiya and Huei Jinn Tong in Autism

Supplemental Material

sj-docx-3-aut-10.1177_13623613231188768 – Supplemental material for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building

Supplemental material, sj-docx-3-aut-10.1177_13623613231188768 for Development of oral health resources and a mobile app for caregivers and autistic children through consensus building by Bing Liang Tan, Rahul Nair, Mandeep Singh Duggal, Ramkumar Aishworiya and Huei Jinn Tong in Autism

Footnotes

Acknowledgements

The authors thank Tobias and family for participating in the development of the social stories; Dr Anand Bhojan and team from School of Computing, National University Singapore; and Ms Hepsi Priyadharsini, Senior Occupational Therapist, National University Hospital, Singapore for collaborating in the design of the mobile application. Dedicated to, and in loving memory of our dear friend/mentor Dr Rahul Nair.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The mobile app was funded by the Sunstar Donation Grant (WBS:R-221-000-112-720).

Ethical approval

Ethical approval was obtained from the NUS Institutional Review Board (NUS-IRB, Ref. No. S-19-172E), and the NHG Domain Specific Review Board (DSRB, Ref. No. 2019/00320).

ORCID iDs

Bing Liang Tan

Ramkumar Aishworiya

Supplemental material

Supplemental material for this article is available online.

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