The results of the present study indicated that the optimal brushing behavior was 20.1% in students. The result was consistent with studies in Iran that reported the optimal brushing behavior of 17.4 to 18.2% [15, 17]. In other studies conducted abroad, they reported brushing behavior at least twice a day in students in India, Bangladesh, and Nepal from 24 to 37.4% that were close to the present results [18,19,20] and the behavior was reported to be from 68 to 95.2% in studies by Kırtıloğlu et al. in Turkish students [21], Soroye et al. in Nigeria [22], Vettore et al. in the Brazilian adolescents [23], and 67.2% in a study by Peltzer et al. on students from 26 countries [24], 92.1% in a study by Rimondini et al. in Italian students [25], and 95% in a study by Jensen et al. [26] in different age groups in Sweden and the observed difference could be due to differences in income of countries, parents’ education level, gender, the way of understanding the issues, self-esteem, difference of ethnic groups and migration, cultures, different beliefs and habits in the field of oral health behavior, and integrated education of oral hygiene at schools.
Our findings indicated that students’ good brushing behavior had a statistically significant relationship with parents’ education level; and students, who had parents with higher education, significantly had better brushing behavior. The finding was consistent with studies by Vakili et al. [13], Pakpour et al. [15], who reported a significant relationship between parents’ education levels and good behavior. However, a study by Casanova et al. [27] in Mexican students did not show any significant relationship between parental education levels and frequency of brushing probably due to cultural and social differences in the research group. A possible reason for the high level of good behavior in students with highly educated parents can indicate high health literacy in their parents. Other possible reasons may be that parents are considered as role models for students and positive effects on oral health behaviors; hence, the parents’ roles should be considered in designing the educational interventions.
Our findings indicated that brushing behavior at least twice a day was higher in female students than male students. The results were consistent with most studies on this field [18, 24, 28]. A possible reason for this finding is that women care more about the beauty of their body and appearance, and thus their health than men. Therefore, they pay more attention to their health as an effective factor to increase the beauty and appearance of the body. Understanding belief systems relating to health issues is crucial in any culture for developing health promotion programs in that cultural context.
In the present study, health promotion model constructs were able to describe 58% of the variance of commitment to plan of action. Banaye Jeddi et al., [29] predicted model constructs by 26.4% of the variance of commitment to plan of action. As seen in our study, the predictive power of model constructs was high in commitment to plan of action; and the perceived self-efficacy, situational influences, and perceived barriers were the strongest predictors of commitment to plan of action. In a study by Goodarzi et al. [30] perceived self-efficacy was the strongest predictors, and in a study by Banaye Jeddi et al. [29], the perceived barriers and situational influences were the strongest predictors of the commitment to plan of action. In the present study, the important role of self-efficacy in predicting commitment to plan of action indicated that planning and implementing the educational interventions with an aim to increase self-efficacy could be effective in promoting commitment to plan of action. Given that influencing on barriers is not easily possible in most cases, an educational intervention should target the processes of reducing barriers by identifying real and perceived barriers and paying special attention to the most important ones [31].
According to the prediction of desired behavior, the commitment to plan of action and self-efficacy were significant predictors of behavior, and one-unit increase in the above constructs enhanced the chance of performing the behavior by 14 and 12% respectively. Consistent with results of our study, Zeidi et al. [32], Banaye Jeddi et al. [33], and Mehri et al. [34], reported that the commitment to plan of action was the strongest predictor of oral health behavior. However, results of studies by Morowati et al. [16], Charkazi et al. [35], and Vakili et al. [13], were inconsistent with our study. Different results of the above studies may be due to different economic, social, cultural and age conditions in the research groups. Commitment to plan of action starts up the behavioral event. This commitment leads people towards the behaviors; and the higher commitment to a specific activity increases the possibility of maintaining healthy behavior at the whole time. The commitment to plan of action refers to planning for its change, start, maintenance, and management [10]. Therefore, the more committed you are to planning to perform a behavior regardless of constraints, conditions, and possibilities, the more likely you are to engage in that behavior, and the more successful you are in achieving that goal. Since behavior is a complicated phenomenon and its change is a continuous, permanent, and goal-based process, it is impossible to achieve a logical and purposeful result without relying on the specified and planned commitment that requires knowledge about future opportunities and threats and prediction of the way of facing with them. Commitment to plan of action can lead to desirable behavior when it creates more attractiveness than other behaviors because otherwise other behaviors are preferred. It is worthwhile to consider the above point in designing educational interventions for the research group.
Consistent with our study, findings of many studies emphasize the role of self-efficacy as a significance predictor of oral health behavior [13, 14, 30, 32,33,34,35,36]. Self-efficacy is not about a person’s skills, but about his or her judgment of what he or she can do, considering all the skills he has [10]. Higher self-efficacy creates a positive feeling about the behavior and decreases perceived barriers. Therefore, its increase in students by creating the ability to overcome the existing barriers on the pathway to observance of the oral health can maintain the continuity of desired behavior. In other words, the students’ belief in their personal and inner abilities to overcome barriers is a key factor in the adhering the recommendations of oral hygiene. Given the results of the present study, we suggest a higher focus on the identification of internal and environmental perceived barriers of students in the field of oral health behavior, and then the use of strategies such as verbal persuasion, stimulating and encouraging emotional states and vicarious learning resulting from observing the performance of others to improve students’ self-efficacy.
The research limitations included the use of self-report tools and the cross-sectional nature of study; hence, we could not infer the causal relationships.