Miswak users' behavior model based on the theory of planned behavior in the country with the largest Muslim population.

BACKGROUND: Maintaining proper oral hygiene has an influence on oral health. Religious obedience may influence individual behavior. According to Islamic religious guidance, as recommended by an Islamic role model, it is obligated to maintain oral health and the recommended tool to use is miswak.
PURPOSE: To describe miswak users' behavior based on the theory of planned behavior. SUBJECTS AND METHODS: The population of this study was the students of As-Salafi Al-Fitrah Islamic Boarding School who used miswak regularly and were healthy physically and mentally. One hundred and nine samples were chosen randomly and asked to complete a semi-open and a closed-ended questionnaire.
RESULTS: Perceived behavioral control had the most dominant influence toward improving intention with β=0.211 and p<0.05. In contrast, attitude and subjective norms had less influence toward improving intention with β=0.190 and p>0.05, and β=0.164 and p<0.0001, respectively. Meanwhile, perceived behavioral control showed direct correlation toward action in model parameter with β=0.445 and p<0.0001.
CONCLUSION: Perceived behavioral control is the most dominant predisposing factor in increasing intention and attitude of miswak use.

Introduction

Individual oral health depends on one’s behavior in maintaining oral hygiene.1–3 In order to maintain oral hygiene, individual awareness to keep oral hygiene regularly is required to build appropriate behavior in maintaining oral hygiene. Religious aspect is also involved in influencing the behavior of people, as individuals, groups, or even nations.3,4 Religious faith is one of the predisposing factors in improving attitudes, motivations, and behaviors. Islam, in terms of belief or cultures and values or norms of life, also encourages its followers to keep both themselves and the environment clean, including the guidance it provides to keeping oral hygiene using miswak.2,4

The Muslim role model persuades its followers to maintain dental health using miswak as a tool to clean the oral cavity, which aims to prevent dental and periodontal diseases and keep the oral cavity fresh. This history has created an impression that use of miswak has long been a tradition of cleaning the oral cavity in Islam.2 Miswak can be used to clean the oral cavity, which is believed to have more advantages than the common toothbrushes.5–8

Indonesia is known as a country with the largest Muslim population in the world, with a Muslim population of about 204,847,000 in 2010. Approximately 87.2% of the Muslim population in the world lives in Indonesia.9,10 Therefore, our study was conducted in Indonesia. Meanwhile, As-Salafi Al-Fitrah Islamic Boarding School has students who come from all over Indonesia, so it can be considered to represent Muslims in Indonesia.

The use of miswak is basically an uncommon behavior in Indonesia; yet, the miswak users are still considerably high in number, especially in the Muslim community that has a strong belief to embrace the religion’s guidance. Therefore, our study was intended to investigate the predisposing factors of miswak use by observing some aspects, such as the surrounding norms and one’s belief to do something, which are part of the theory of planned behavior. Therefore, we considered to use the theory of planned behavior as the theory in this study.

The model used to assess behavior is one of the behavior theories that is commonly used in various disciplines, which constitutes suggested positive behavior (attitude), supported with subjective norms and perceived behavioral control, resulting in higher intention.11–13 According to the theory of planned behavior, intention is determined by the attitude, that is, favorable or unfavorable views of a behavior, subjective norm, that is, perceived social influence to perform a behavior, and perceived behavioral control, that is, the perception that the ability to perform a behavior is within individual control, all of which are interconnected.14 Each person has varying backgrounds that may affect the intention to do something. These differences exist depending on the different experiences and knowledge.14,15

Based on previous descriptions, it is necessary to investigate the miswak use behavior using the theory of planned behavior in the country with the largest Muslim population.

Subjects and methods

This study has been approved by the Health Research Ethical Commission with the certificate number 069/HRECC. FODM/VI/2017. All of the students in the boarding school were under the care of teachers as caregivers; therefore, on behalf of their parents, with the parents’ approval, the teacher assisted the student to sign the consent form as approved by the Health Research Ethical Commission. The respondents were recruited from one of the largest boarding schools in Surabaya, named as As-Salafi Al-Fitrah Islamic Boarding School Surabaya, in which students come from various regions of Indonesia. The respondents were chosen by simple random sampling method, and the inclusion criteria were students who used miswak regularly, either combined with or without regular toothbrush, and were healthy physically and mentally, which was an indicator that the respondents were able to communicate well. One hundred and nine students were randomly selected as respondents. All respondents who participated in this study agreed to participate without receiving any compensations, by signing a consent form.

The respondents were asked to complete questionnaires with semi-open and closed-ended questions. Respondents’ characteristics assessment used semi-open questions, while respondents’ behavior assessment used closed-ended questions of miswak use based on the theory of planned behavior that consisted of attitudes, subjective norms, perceived behavioral controls, motivations, and miswak use behavior.

We analyzed the data using XLstat 2017 by XLstat. The data are shown in tables and the descriptive analysis in percentage and odds ratio (OR). The multivariate analysis was completed using linear regression.

Results

Most of the respondents were 15 years old (85%). More than half were using both miswak and toothbrushes (56%), and half of respondents started using miswak when they enrolled in the Islamic boarding school (51.33%; Table 1). After getting better understanding of Islamic guidance, and supported by the surrounding community members who were all using miswak, they started using miswak without receiving any reward. Instead, they believed they will get reward from Allah subhanallahu wa ta’ala.

Table 1

Miswak users’ characteristics

Characteristics	n	%
Age (years)
<15	13	11.93
15–20	93	85.32
>20	3	2.75
Miswak use
Miswak only	48	44.04
Combined	61	55.96
Miswak use period
Since childhood	8	7.34
Since enrollment	56	51.38
For a few years	32	29.36
For a few months	13	11.92
Place of purchase
Store near school	99	90.82
Store in Islamic community	9	8.26
Neighborhood	1	0.92
Way of use
Brushed teeth	103	94.49
Bit or chewed	1	0.92
Combined	5	4.59
Shared miswak
Usually	8	7.34
Seldom	20	18.35
Never	81	74.31

Most of the respondents had positive attitudes toward miswak use. About 87% respondents had positive attitude toward the statement “Miswak can help maintain oral hygiene and health,” while the lowest attitude was toward the statement “Miswak has the ability to control oral bacteria growth” (67%; Table 2).

Table 2

Frequency of attitudes, subjective norms, perceived behavioral controls, and intentions toward miswak use

Variables	Agree		Disagree
	n	%	n	%
Attitudes toward miswak use
Oral health is as important as and is correlated to general health	95	87.16	14	12.84
Miswak has the ability to control oral microbial growth	73	66.97	36	33.03
Miswak helps maintain oral hygiene and health	96	88.07	13	11.93
Miswak use for brushing teeth has the same result as using a toothbrush and toothpaste	84	77.06	25	22.94
Miswak is the best alternative way to maintain oral health	92	84.40	17	15.60
Subjective norms toward miswak use
My religion advises to use miswak	92	84.40	17	15.60
I use miswak as the incarnation of my faith	93	85.32	16	14.68
My community also uses miswak	73	66.97	36	33.03
My community advises me to use miswak	71	65.14	38	34.86
My parents and family also use miswak	70	64.22	39	35.78
My parents and family advise me to use miswak	71	65.14	38	34.86
Perceived behavioral controls toward miswak use
I am able to use miswak at least twice a day	72	66.06	37	33.94
I am able to clean my teeth using miswak correctly	89	81.65	20	18.35
I am able to get miswak as a tool to clean my teeth	88	80.73	21	19.27
Intentions toward miswak use
I will use miswak at least twice a day	76	69.72	33	30.28
I will clean all of my teeth using miswak correctly	86	78.90	23	21.10
I will always store miswak as a tool to clean my teeth	82	75.23	27	24.77
Actions toward miswak use
I have been using miswak regularly	81	74.31	28	25.69
I clean all my teeth appropriately using miswak	90	82.57	19	17.43
I always provide miswak as a tool to clean my teeth	87	79.82	22	20.18

Our study showed that the respondents’ attitudes toward subjective norms affect the miswak use behavior, which also proved that most of the respondents had positive subjective norms toward miswak use. Most of the respondents agreed with the subjective norm statement “I use miswak as the incarnation of my faith” (87%), while only 64% agreed to the subjective norm statement “My parents and family also use miswak.”

The rates of respondents who agreed on perceived behavioral controls, intentions, and behaviors toward miswak use were compared. About 82% respondents had perceived behavioral controls toward cleansing teeth using miswak correctly, while 79% respondents had intention to do so and 83% believed they had cleansed their teeth using miswak correctly.

The most influencing attitude toward respondents’ intentions of using miswak regularly was they believed miswak had benefits to maintain the oral hygiene and health. The respondents who agreed with the statement that miswak can maintain oral hygiene and health could raise intention 4.54 times more likely than the respondents who disagreed (OR 4.54).

Based on the subjective norms, the statement with the highest influence was “People around me advise me to use miswak.” It showed that the respondents who agreed with this statement had an intention 3.36 times higher than the respondents who disagreed (OR 3.36).

The statement “I can use miswak regularly at least twice a day” had the highest impact on affecting the respondents’ intention to use miswak. The respondents who agreed with the statement had 6.56 times higher intention than those who disagreed (OR 6.56).

The most influencing attitude toward intention was the statement “Miswak is the best alternative in maintaining oral hygiene.” The respondents who agreed with the aforementioned statement had 6.27 times higher intention than those who disagreed (OR 6.27).

The statement about miswak use guidance had the highest influence toward the respondents’ intention to cleansing the teeth using miswak correctly. The respondents who agreed with the statement “There is a guidance to use miswak according to my religion” had 1.71 times higher intention than those who disagreed (OR 1.71).

The highest influence of respondents’ intention to clean their teeth appropriately using miswak was the statement “I am able to clean my teeth appropriately using miswak.” Our study showed that the respondents who agreed with the statement had 3.29 times higher intention than those who disagreed.

The most influencing statement toward the respondents’ intention to provide miswak was “Oral hygiene is as important and correlates to general health.” The respondents who agreed with the statement had 2.64 times higher intention than those who disagreed (OR 2.64).

The highest influence toward intention was the statement “I use miswak as the incarnation of my faith.” The respondents who agreed with the statement had 2.84 times higher intention than those who disagreed (OR 2.84).

The statement with the highest influence was “I am able to cleanse my teeth appropriately using miswak.” Respondents who agreed with the statement had 4.24 times higher intention than those who disagreed (OR 4.24).

The most influencing statement on the action was about miswak using habit. The respondents who agreed with the statement of miswak use behavior had 2.14 times higher intention than those who disagreed (OR 2.14; Table 3).

Table 3

Cross tabulation between intentions toward actions of miswak use behavior, cleaning teeth appropriately using miswak, and miswak provision

Intentions		Total	Action
			Miswak use behavior					Teeth cleansing using miswak correctly					Miswak provision
			Agree		Disagree		OR	Agree		Disagree		OR	Agree		Disagree		OR
			n	%	n	%		n	%	n	%		n	%	n	%
Miswak use behavior	Agree	76	60	78.95	16	21.05	2.14	66	86.85	10	13.15	2.48	64	84.21	12	15.79	2.32
	Disagree	33	21	63.63	12	36.37		24	72.73	9	27.27		23	69.70	10	30.30
Cleaning teeth appropriately using miswak	Agree	86	65	75.59	21	24.41	1.35	72	83.72	14	16.28	1.43	74	86.04	12	13.96	4.74
	Disagree	23	16	69.57	7	30.43		18	78.27	5	21.73		13	56.52	10	43.48
Miswak provision	Agree	82	62	75.60	20	24.40	1.31	74	90.24	8	09.76	6.36	71	86.59	11	13.41	4.44
	Disagree	27	19	70.38	8	29.62		16	59.25	11	40.75		16	59.26	11	40.74

Meanwhile, the action to use miswak correctly was mostly affected by the intention to provide miswak. The respondents who agreed with the statement “The intention to provide miswak could clean teeth using miswak correctly” had 6.36 times higher intention than those who disagreed (OR 6.36).

The action to provide miswak was mostly affected by the intention to cleanse teeth using miswak correctly. The respondents who agreed with the statement “The intention to clean the teeth using miswak correctly” had miswak use intention 4.74 times higher than those who disagreed (OR 4.74).

Intention was mostly influenced by perceived behavioral controls, which showed in a model parameter β=0.211 and p<0.05. Meanwhile, attitudes (β=0.190 and p=0.05) and subjective norms (β=0.164 and p>0.05) had no influence. Intention had a correlation to building behavior with β=0.594 and p<0.0001. Perceived behavioral controls were directly correlated to taking action with β=0.445 and p<0.0001 (Scheme 1).

Scheme 1

Linear regression theory of planned behaviors on miswak users. *Linear regression parameter model, p<0.05; **linear regression parameter model p<0.05 [<0.0001]).

Our analysis showed that the best result for mean and SD that described sample heterogeneity was the perceived behavioral control (9±1.62), while the highest SD was for attitudes (15±2.23).

Discussion

Based on the theory of planned behavior, behavioral intention is influenced by attitude, subjective norm, and perceived behavioral control that are interconnected with each other. Each individual has diverse variables to be considered that motivate them to conduct some behaviors. These differences are due to different experiences and levels of knowledge.11 Attitude toward behavior is determined by belief of acquired consequences from conducting behaviors called behavioral belief, which is considered based on outcome evaluation.16

In this study, the respondents had fully understood the benefits of miswak; as shown in Table 4, attitudes toward miswak had an OR >1 and a linear regression β-value reaching 0.19. This result is in accordance with the theory stating that attitude toward behavior is determined by behavioral belief.16 Positive attitude can be developed from knowing the benefits of miswak that it contains some minerals that could kill or inhibit the growth of bacteria, reduce plaque, prevent dental caries, and preserve gingiva better than conventional toothbrush and toothpaste.7,8,17–19 Some previous studies found that miswak has positive effects for oral health. Miswak has a high efficacy compared to using conventional toothbrush without toothpaste. Miswak can be used by cutting the stick to a length of 15 cm and then peeling the end top by 1 cm. The tip of miswak should be rinsed in water before using. Miswak is then bitten and brushed directly from the gingival margin of the teeth on both buccal and lingual surfaces, so that it will clean all the teeth from plaque. Miswak has antibacterial effects on cariogenic microorganisms such as Streptococcus mutans and can support periodontal health by reducing dental plaque formation. Miswak also reduces the accumulation of Candida albicans, and thus may prevent oral candidiasis.20

Table 4

Cross tabulation of behaviors, subjective norms, perceived behavioral controls toward intentions of using miswak, and cleaning teeth appropriately using miswak, and miswak provisions

Attitudes toward miswak use behaviors		Total	Miswak using behavior					Cleaning teeth using miswak appropriately					Miswak provision
			Intentions				OR	Intentions				OR	Intentions				OR
			Agree		Disagree			Agree		Disagree			Agree		Disagree
			n	%	n	%		n	%	n	%		n	%	n	%
Oral health is as important as and correlates to general health	Agree	95	69	72.63	26	27.37	2.65	77	81.05	18	18.95	2.38	74	77.90	21	22.10	2.64
	Disagree	14	7	50.00	7	50.00		9	64.29	5	35.71		8	57.14	6	42.86
Miswak is able to control oral bacterial growth	Agree	73	52	71.23	21	28.77	1.24	58	79.45	15	20.55	1.1	58	79.45	15	20.55	1.93
	Disagree	36	24	66.67	12	33.33		28	77.78	8	22.22		24	66.67	12	33.33
Miswak helps maintaining oral hygiene and health	Agree	96	71	73.96	25	26.04	4.54	75	78.13	21	21.87	0.65	73	76.04	23	23.96	1.41
	Disagree	13	5	38.46	8	61.54		11	84.62	2	15.38		9	69.23	4	30.77
Miswak use shows the same results as using a toothbrush and toothpaste	Agree	84	57	67.86	27	32.14	0.67	68	80.95	16	19.05	1.65	66	78.57	18	21.43	2.06
	Disagree	25	19	76.00	6	24.00		18	72.00	7	28.00		16	64.00	9	36.00
Miswak constitutes the best alternative for maintaining oral health	Agree	92	67	72.83	25	27.17	2.38	78	84.78	14	15.22	6.27	71	77.17	21	22.83	1.84
	Disagree	17	9	52.94	8	47.06		8	47.06	9	52.94		11	64.71	6	35.29
Subjective norms toward miswak use behaviors
There is a guidance to use miswak according to my religion	Agree	92	66	71.74	26	28.26	1.78	74	80.43	18	19.57	1.71	71	77.17	21	22.83	1.84
	Disagree	17	10	58.82	7	41.18		12	70.59	5	29.41		11	64.71	6	35.29
I use miswak as an incarnation of my faith	Agree	93	66	70.97	27	29.03	1.47	74	79.57	19	20.43	1.30	73	78.49	20	21.51	2.84
	Disagree	16	10	62.50	6	37.50		12	75.00	4	25.00		9	56.25	7	43.75
Community around me also uses miswak	Agree	73	55	75.34	18	24.66	2.18	58	79.45	15	20.55	1.10	53	72.60	20	27.40	0.64
	Disagree	36	21	58.33	15	41.67		28	77.78	8	22.22		29	80.56	7	19.44
Community around me also advises me to use miswak	Agree	71	56	78.87	15	21.13	3.36	58	81.69	13	18.31	1.59	56	78.87	15	21.13	1.72
	Disagree	38	20	52.63	18	47.37		28	73.68	10	26.32		26	68.42	12	31.58
My parents and family also use miswak	Agree	70	55	78.57	15	21.43	3.14	55	78.57	15	21.43	0.95	54	77.14	16	22.86	1.33
	Disagree	39	21	53.85	18	46.15		31	79.49	8	20.51		28	71.79	11	28.21
My parents and family advise me to use miswak	Agree	71	54	76.06	17	23.94	2.31	55	77.46	16	22.54	0.78	56	78.87	15	21.13	1.72
	Disagree	38	22	57.89	16	42.11		31	81.58	7	18.42		26	68.42	12	31.58
Perceived behavioral control toward miswak use behavior
I am able to use miswak at least twice a day	Agree	72	60	83.33	12	16.67	6.56	53	73.61	19	26.39	0.34	53	73.61	19	26.39	0.77
	Disagree	37	16	43.24	21	56.76		33	89.19	4	10.81		29	78.38	8	21.62
I am able to clean my teeth properly using miswak	Agree	89	64	71.91	25	28.09	1.71	74	83.15	15	16.85	3.29	72	80.90	17	19.10	4.24
	Disagree	20	12	60.00	8	40.00		12	60.00	8	40.00		10	50.00	10	50.00
I am able to get miswak as a stock of teeth cleansers	Agree	88	65	73.86	23	26.14	2.57	72	81.82	16	18.18	2.25	67	76.14	21	23.86	1.28
	Disagree	21	11	52.38	10	47.62		14	66.67	7	33.33		15	71.43	6	28.57

Abbreviation: OR, odds ratio.

The effect of attitudes toward miswak use behavior can be understood from the intention to cleanse the teeth using miswak correctly, which is mostly affected by the recognition of miswak as the best alternative way to maintain oral hygiene. The knowledge about miswak as a good alternative to maintain oral hygiene may improve the respondents’ motivation to cleanse the teeth using miswak. An individual will have the intention to conduct a certain behavior when he/she has positive consideration.16

Subjective norms were also proved to have an effect toward the students’ miswak use behavior. The subjective norms involved in this study were guidance from religion, communities, and parents. Religious guidance and faith incarnation as subjective norms that motivate an individual to use miswak were in accordance with the theory stating that religion may affect behavior, at an individual, a community, or a national level. Religion has strong influences on the behavior of its followers and is one of the important factors in a culture that may affect some aspects of life, such as values of life, attitudes, and habits.21–23

The effects of perceived behavioral control toward miswak use behavior could be seen from the intention to do it. Mostly, it was affected by perceived behavioral control that was shown by the behavior to use miswak twice a day regularly. The effect of perceived behavioral control as an important factor could also be observed from the intention to use miswak regularly, which was influenced by perceived behavioral controls as shown in the statement “I am able to clean my teeth properly using miswak.” If someone believes he/she is capable of cleansing the teeth using miswak, he/she will tend to have intention to always use miswak as a tool to cleanse his/her teeth.

Perceived behavioral control toward miswak user behavior, not only showed the highest OR, but also recorded as the most dominant factor in increasing the miswak user intention. It not only has influence on taking action through intention, but also has direct influence without affecting the intention. Perceived behavioral control plays an important role in deciding an action.

Based on the data, it can be summarized that if an individual is assured to be able to use miswak regularly, he/she will have a greater tendency to build the intention of miswak use behavior. This result was in accordance with the definition of perceived behavioral control as someone belief toward factors that may facilitate or discourage; to be able to do or anticipate the obstacle to do something.16

Perceived behavioral control had an effect on increasing the intention to use miswak. This can be observed from the questionnaire results concerning perceived behavioral control, intention, and miswak use behavior, which were in accordance with miswak habits, cleansing teeth using miswak, and providing miswak as a tool to clean the oral cavity. The three variables had different effects on miswak use behavior. Perceived behavioral control had the most significant effect on intention and miswak use behavior, while both attitude and subjective norm had less effect on intention to use miswak. In addition, intention had a significant effect on miswak use behavior, which represented the seriousness of using miswak.

Intention is directly correlated to the miswak use behavior since it is mostly affected by the intention to use miswak regularly. Meanwhile, the intention to provide miswak had the highest influence on using miswak. This point describes that the more often the respondents provide miswak, the higher the possibility to use miswak. As for the intention to provide miswak, if the respondents cleanse their teeth using miswak, they will always provide miswak.

Intention is also affected by attitudes, subjective norms, and perceived behavioral controls that also influence the decision to have a certain behavior.16 Thus, this study is trying to find the correlation between attitudes, subjective norms, perceived behavioral controls, and their influence on the respondents’ intention to favor a behavior, along with the correlation between intentions and actions.

In this study, the respondents’ intentions on using miswak affect their decisions to use miswak. The results match with the theory stating that intention is assumed as a motivational factor that affects behavior. Intention constitutes the indicators of how much the effort is to conduct a behavior. Intention may predict the behavioral tendency. Intention is defined as the will to conduct a behavior. Intention is not constantly static but may change as time goes by.16

Based on the theory of planned behavior, the behavioral models of miswak users in the country with the largest Muslim population are affected by attitudes, subjective norms, perceived behavioral controls, and intentions of using miswak. This study focused on miswak users only because the psychosocial aspects of miswak users are not fully understood. Therefore, it is necessary to examine any further psychosocial factors that potentially affect a person to use miswak which is less common compared to using toothbrush. Against prior situation, this study focuses on individuals who use miswak regularly and not regularly. Unfortunately, this study is limited to miswak users in a limited community and does not analyze the method used by miswak users. Thus, further studies on a wider community are recommended.

Conclusion

Based on this study, it is concluded that perceived behavioral control constitutes the most dominant factor in increasing the intention and behavior of using miswak. Since miswak has been studied recently and has shown several benefits for oral health, such as antibacterial action and higher efficacy, compared to toothbrush, it can be used to complement toothbrush as recommended by Islamic religious guidance, or used as a supplementary only, as an effort to maintain oral health by adopting religious approach. Therefore, religious approach could be an effective approach to enhance positive oral health behavior in a community, especially in Islamic community.