Evaluation of implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan

Evaluation of implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan Farhood Farokhi, Amir Hossein Khazaei, Zahra Ghorbani, Marzie Deghatipour This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8298265/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background This study evaluates the implementation of the Ministry of Health’s educational package on oral health among Health Care Providers (HCPs) and health volunteers (Behvarz) in Zahedan. The research focuses on assessing knowledge, attitudes, and practices (KAP) before and after the intervention, with the goal of identifying areas for improvement and providing evidence-based recommendations for policy and practice. Methods A cross-sectional descriptive-analytical study was conducted among 395 participants, including 104 health volunteers and 291 health care providers. Pre- and post-test KAP scores were measured using a validated questionnaire designed to assess the impact of a structured educational intervention. The study included theoretical and practical workshops led by dental experts. Data were analyzed using paired t-tests, ANCOVA, and descriptive statistics to evaluate changes in KAP and assess demographic influences, including age, gender, and work experience. Results The intervention led to significant improvements in KAP scores across all participants. Behvarz consistently outperformed HCPs in both pre- and post-test scores. For knowledge, post-test mean scores were 6.63 ± 2.01 for Behvarz and 5.58 ± 1.33 for HCPs (p < 0.001). Attitude scores increased from 28.98 ± 4.67 to 36.88 ± 9.35 for Behvarz and from 25.81 ± 2.79 to 33.29 ± 8.16 for HCPs (p = 0.001). Practice scores improved from 22.10 ± 5.45 to 25.93 ± 8.08 for Behvarz and from 17.55 ± 3.85 to 23.19 ± 7.03 for HCPs (p = 0.081). Gender differences were not statistically significant, but older participants and those with more work experience showed higher scores. Post-test KAP scores in the intervention group were significantly higher than the control group (p < 0.001). Conclusion The educational package significantly enhanced oral health KAP among health care providers and volunteers, particularly Behvarz. These findings highlight the effectiveness of structured, community-oriented interventions in improving healthcare delivery. Education Knowledge Health care provider Figures Figure 1 Figure 2 Figure 3 INTRODUCTION The impact of oral and dental health on overall health is significant. Due to natural physiological changes, pregnancy is a particularly vulnerable period in terms of oral health. Pregnant women and their health care providers need increased awareness of the many changes that occur in the oral cavity during pregnancy. Preventive interventions in the first year of a child’s life may be most effectively implemented with the assistance of medical providers trained in oral screenings and in referring infants and toddlers for dental care ( 1 ). In 2014, the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) released “Integration of Oral Health and Primary Care Practice,” which identified interprofessional clinical competencies for appropriate oral healthcare delivery by primary care providers, including nurses, nurse-midwives, general physicians, pediatricians, and physician assistants ( 1 ). Early childhood caries (ECC) has been identified as a major public health issue, and oral health providers are encouraged to implement preventive programs and actions to reduce the risk of ECC ( 2 ). Health and medical services in Iran are delivered through a health network system. It should also be noted that the lack of timely adherence to oral healthcare and disease prevention leads to tooth loss at younger ages and may result in more severe and serious consequences. Without preventive efforts, society and the government will be forced to bear the high costs of providing human resources, materials, and equipment ( 3 ). Since it was not feasible to cover all age groups in Iran’s health services, those who were more vulnerable to oral diseases and more accessible based on existing plans—such as pregnant and breastfeeding women and children—were selected as the target group. The main goal of the integration project was to define these target groups. In 1995, the project was launched in some counties to promote community oral health by increasing public awareness and enhancing primary healthcare (PHC) ( 3 , 4 ). It is currently offered as part of health services through the national health network system in all healthcare centers. Iran’s dental healthcare delivery system consists of four levels; Community Health Workers (Behvarz), Oral Health Care Providers, Dentists and Specialists ( 5 ). Community Health Workers (Behvarz): These are male or female workers with at least a high school diploma, aged 17 to 22 at the beginning of their service, residing in the rural service area they serve. They are trained by Behvarz instructors in Behvarz schools in oral health promotion and work in rural "Health Houses," providing primary healthcare services to people at the first level of the healthcare network ( 6 ). Oral Health Care Providers: They work in rural health centers and supervise community health workers (Behvarz) in local health houses. Additionally, they provide primary oral healthcare services such as tooth extractions, fluoride therapy, and scaling. Dentists: They are responsible for providing first- and second-level services such as oral health education, extractions, caries restoration, pulpotomy, fissure sealant application, fluoride therapy, and scaling. Dentists, together with oral health technicians and dental assistants, are responsible for the prevention, management, and treatment of oral and dental diseases in both urban and rural health centers. Specialists: They provide advanced treatments across various dental specialties in university-affiliated health centers located in cities ( 6 ). Following the Health Transformation Plan in Iran, health care providers now operate in comprehensive health centers and bases, while Behvarz workers continue to work in rural health houses ( 6 ). The PHC team consists of health care providers and Behvarz personnel. Health care providers play a key role in education and prevention of common oral diseases, providing healthcare services and maintaining close interactions with pregnant women, mothers, and their children. After completing 147 hours of in-person training and 578 hours of distance learning, and passing a final exam, trainees in suburban centers are officially recognized as “health care providers.” Each health care provider typically serves a population of 2,000 to 2,500 people. It is noteworthy that out of the 725 training hours allocated to the health team, only 10 hours are dedicated to oral health—an insufficient amount that requires reconsideration ( 6 ). Evidence clearly shows that oral health—especially dental caries among pregnant women in Iran—is a serious concern. It appears that initiating community-based interventions with an integrated oral health approach could help control dental caries in both mothers and children. Considering the importance of this issue, the lack of similar studies, and the need to lay the groundwork for future research, conducting this study was deemed essential. Therefore, in this study we evaluated the implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan. MATERIALS AND METHODS Data source and study design This cross-sectional (descriptive-analytical) study was conducted in 2025. The sample consisted of all Behvarz and health care providers in Zahedan. The sampling method was a census approach, simple and convenient. The data collection tool was a two-part questionnaire. The first part collected demographic information, including age, gender, work experience, and occupational category. The second part consisted of 15 items evaluating the knowledge of staff at urban and rural comprehensive health service centers regarding oral health. This questionnaire was developed for this study (Supplementary file). The validity and reliability of the questionnaire were confirmed in a thesis by Daghatipoor (Thesis No. 426, dated 12/07/1399 in the Persian calendar), with a Cronbach’s alpha coefficient greater than 0.75. Scoring for the 15 questions was as follows: 1 point for each correct answer and 0 for incorrect answers, with the total possible score ranging from 0 to 15. Written informed consent was obtained from all participants. Study implementation method Following approval from the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1403.256), the study commenced. All health care providers and Behvarz in comprehensive health centers and health houses in Zahedan were invited to participate in two four-day sessions. Before the study began, the purpose and significance of the research were explained to participants. After coordination with the provincial and county health centers, participants were invited to attend on designated days. The questionnaire used in this study was developed based on the Ministry of Health's Oral Health Training Manual and validated by a specialist in community dentistry. Initially, all participants completed a pre-test questionnaire. Then, a series of theoretical and practical educational intervention workshops were conducted by a community dentistry specialist and a dental student. After the workshops, a post-test was administered to all participants. At the end of the study, all participant questions were answered. Statistical analysis In this study, various statistical tests were used to assess changes in participants' knowledge, attitudes, and practices before and after the intervention. An independent t-test was used to compare mean scores between Behvarz and health care provider groups. A paired t-test was used to analyze pre- and post-test score changes. In addition, ANCOVA (Analysis of Covariance) was used to control for the effects of demographic variables (age, gender, work experience) and baseline scores. Data were analyzed using SPSS version 26, with a significance level set at p < 0.05. RESULTS A total of 395 participants (104 Behvarz and 291 health care providers) with a mean age of 38.59 ± 6.27 years took part in the study. The majority of participants (78%) were female. The distribution of participants by gender, job title, age, and work experience is presented in Table 1 . Table 1 Distribution of participants by gender, job title, age, and work experience. Variable Levels Pre-test Post-test T -test Gender Male (N%) 10 (25.0%) 14 (20.6%) 0.59 Female (N%) 30 (75.0%) 54 (79.4%) Total 40 (100.0%) 68 (100%) Job Title Health Care Provider (N%) 17 (42.5%) 31 (45.6%) 0.75 Behvarz (N%) 23 (57.5%) 37 (54.4%) Total 40 (100.0%) 68 (100.0%) Age Mean (SD) 38.85 (6.21) 38.44 (6.34) 0.75 Work Experience Mean (SD) 18.12 (6.67) 16.84 (6.98) 0.39 Chi-square or Fisher exact test was used. Table 2 presents the mean pre-test scores for knowledge (range: 0 to 10), attitude (range: 10 to 50), and performance (range: 10 to 40) among participants in the intervention and control groups. The pre-test scores for knowledge and performance were significantly higher in the intervention group ( p = 0.005, p = 0.004, respectively). However, the pre-test attitude scores did not show a significant difference between the two groups ( p = 0.19). Table 2 Pre-test scores of oral health knowledge, attitude, and practice in the intervention and control groups. Scores Intervention Mean (SD) Control Mean (SD) P value Knowledge 5.45 (1.28) 4.85 (0.88) 0.005 Attitude 28.27 (3.84) 27.16 (4.44) 0.19 Practice 21.97 (6.25) 18.96 (4.31) 0.004 *For comparison between Pre-test Knowledge, Attitude, and Practice scores and places Independent T-test was used. The pre-test scores for knowledge, attitude, and performance were significantly higher among Behvarz compared to health care providers ( p < 0.05) (Table 3 ). Table 3 Pre-test scores of oral health knowledge, attitude, and practice in the HCP and Behvarz groups. Scores HCP Mean (SD) Behvarz Mean (SD) P-value Knowledge 4.54 (0.85) 5.50 (1.06) < 0.001 Attitude 25.81 (2.79) 28.98 (4.67) < 0.05 Practice 17.55 (3.85) 22.10 (5.45) < 0.05 *For comparison between Pre-test Knowledge, Attitude, and Practice scores and PHCPs Independent T-test was used. Table 4 shows the mean (SD) pre-test knowledge, attitude and practice of the study participants. Pre-test knowledge, attitude and practice scores did not differ significantly by gender. Table 4 Pre-test scores of oral health knowledge, attitude, and practice by gender. Score Male Mean (SD) Female Mean (SD) P-value Knowledge 5.00 (1.25) 5.09 (1.04) 0.16 Attitude 26.54 (3.26) 27.87 (4.45) 0.12 Practice 21.46 (4.28) 19.68 (5.51) 0.14 Post-test Knowledge, Attitude, and Practice scores were higher in intervention group compared to control. Statistical analyzes showed that Behvarzs had gained better scores than HCPs (Figs. 1 and 2 ). Figure 3 illustrates the comparison of pre-test, and post-test KAP scores analysis in intervention and control groups. PHCPs’ KAP scores regarding oral health were better in post-test and in intervention group. In addition, the analysis of ANCOVA revealed that after adjusting for pre-test scores, gender, and work experience, the KAP scores were significantly higher in intervention group. Also, the KAP scores were significantly higher in Behvarzes, compared to HCPs (Table 5 ). Table 5 Evaluation of the Implementation of the Educational Package Developed by the Ministry of Health, Treatment, and Medical Education by Health care providers and Behvarz in Zahedan. Scores Variables Pre-test p-value T -test Post-test ANCOVA least square mean(CI) P-value ANCOVA Mean SD Mean SD L S Mean difference Low bound Up bound Knowledge pre-test Pre- test 5.45 1.28 0.005 8.12 1.22 2.65 2.44 2.86 < 0.001 Post-test 4.85 .88 5.01 .87 Health care provider 4.54 .85 < 0.001 5.58 1.33 .351 0.08 0.61 0.009 Behvarz 5.50 1.06 6.63 2.01 Attitude pre-test Intervention 28.27 3.84 0.19 45.40 3.42 16.06 14.38 17.73 < 0.001 Control 27.164 4.44 29.28 4.97 Health care provider 25.812 2.795 < 0.001 33.29 8.16 3.45 1.47 5.42 0.001 Behvarz 28.983 4.674 36.88 9.35 Practice pre-test Intervention 21.97 6.25 0.004 32.70 3.975 12.54 10.72 14.36 < 0.001 Control 18.96 4.31 20.01 5.065 Health care provider 17.55 3.85 < 0.001 23.19 7.036 1.90 -0.24 4.05 0.081 Behvarz 22.10 5.45 25.93 8.088 For comparison between Pre-test Knowledge, Attitude, and Practice scores and places in Behvarz and HCP Independent T-test was used. For comparison between Post-test Knowledge, Attitude, and Practice in Behvarz and HCP at end point ANCOVA test was used. DISCUSSION The findings of this study demonstrate significant improvements in the knowledge, attitudes, and practices of health care providers and Behvarz regarding oral health education in Zahedan following the implementation of the educational package developed by the Ministry of Health, Treatment, and Medical Education. These results, in addition to aligning with previous studies, provide a foundation for enhancing targeted health policies and strengthening educational approaches. Before the intervention, the mean knowledge scores of Behvarz were significantly higher than those of health care providers ( 5.50 ± 1.06 vs. 4.54 ± 0.85, p < 0.001). This difference persisted post-intervention, with the post-test mean score being 6.63 ± 2.01 for Behvarz and 5.58 ± 1.33 for health care providers ( p < 0.001). This pattern aligns with the findings of Basir & Beigi, who reported that demographic factors such as education and gender significantly affect oral health knowledge ( 7 ). Similarly, Moli et al. found that greater experience and structured guidelines were directly associated with improved performance among primary care physicians in Malaysia, and that higher knowledge scores predicted better performance ( 8 ). The study also revealed notable improvements in attitudes toward oral health. Before the intervention, Behvarz had significantly higher attitude scores (28.98 ± 4.67) than health care providers ( 25.81 ± 2.79, p < 0.05). After the intervention, these scores increased to 36.88 ± 9.35 for Behvarz and 33.29 ± 8.16 for health care providers ( p = 0.001). These results are consistent with Singh et al. in India, who reported that although health care providers had adequate knowledge, they exhibited inconsistent attitudes toward preventive actions, highlighting the challenges in translating knowledge into practice ( 9 ). Similarly, Singhal et al. in Canada showed that health care providers generally had positive attitudes toward promoting oral health, but time constraints and lack of resources often impeded effective implementation. Our findings emphasize the value of targeted educational workshops, as evidenced by the 16.06-point increase in attitude scores in the intervention group ( p < 0.001) ( 10 ). Despite the progress in knowledge and attitude, the study highlighted a persistent gap in performance. Pre-test performance scores showed that Behvarz outperformed health care providers (22.10 ± 5.45 vs. 17.55 ± 3.85, p < 0.05). This trend continued post-intervention, with Behvarz scoring 25.93 ± 8.08 and health care providers 23.19 ± 7.03 ( p = 0.081). These findings align with Al-Kubaisi et al. in Qatar, where primary health professionals, despite positive attitudes, showed limited practical engagement in promoting oral health ( 11 ). Similarly, Singh et al. reported that although 70.2% of Indian health care providers had visited a dentist, preventive behaviors were rarely observed due to systemic challenges such as lack of structured training ( 9 ). The 12.54-point increase in performance scores in the intervention group ( p < 0.001) underscores the critical role of continuous training and support in translating knowledge into actionable outcomes. Recent studies have further affirmed the positive impact of targeted educational programs on the knowledge and attitudes of health care providers in the domain of oral health. A study by Wong and Leung evaluated the sustainability of an oral health training program for health care providers, measuring changes in knowledge, attitudes, and practices three and six months after program completion. The findings revealed that such educational interventions can lead to sustained improvements in health care providers’ knowledge and attitudes, underscoring the importance of continuous training in this area ( 12 ). Additionally, the role of Behvarz in promoting oral health is gaining more attention. A scoping review by Sultan et al. explored how Behvarz are trained using competency-based education and their impact on community health. The study concluded that with appropriate training, Behvarz can effectively deliver oral health education and facilitate behavioral change in communities, ultimately improving oral health outcomes. These findings support the integration of Behvarz into oral health promotion strategies to reduce inequalities and improve access to care ( 13 ). These findings align with our study, which showed that after implementing a structured educational program, the knowledge and attitudes of both health care providers and Behvarz significantly improved. The sustained knowledge gains and the key role of Behvarz in oral health promotion emphasize the need for ongoing training and their integration into oral health strategies to achieve comprehensive and effective community health outcomes. Gender and demographic analysis in our study revealed no significant differences in knowledge (Men: 5.00 ± 1.25, Women: 5.09 ± 1.04, p = 0.16), attitude (Men: 26.54 ± 3.26, Women: 27.87 ± 4.45, p = 0.12), or performance scores (Men: 21.46 ± 4.28, Women: 19.68 ± 5.51, p = 0.14 ) . These results differ slightly from those of Basir & Beigi, where gender differences were more pronounced, possibly due to regional or cultural variations in access to education ( 7 ). Moreover, participants with higher age and greater work experience tended to score higher across all dimensions of knowledge, attitude, and performance, a trend consistent with the findings of Moli et al. ( 8 ). The significant improvements in post-test outcomes, especially in the intervention group, demonstrate the effectiveness of structured training workshops in overcoming demographic disparities and enhancing overall performance. Statistical analyses, particularly ANCOVA, confirmed that post-test scores for knowledge, attitude, and performance were significantly higher in the intervention group after adjusting for pre-test scores, gender, and work experience ( p < 0.001). The mean post-test knowledge score in the intervention group was 8.12 ± 1.22 compared to 5.01 ± 0.87 in the control group ( p < 0.001). Attitude scores increased to 45.40 ± 3.42 in the intervention group versus 29.28 ± 4.97 in the control group ( p < 0.001). Performance scores followed a similar pattern, with the intervention group scoring 32.70 ± 3.98 compared to 20.01 ± 5.07 in the control group ( p < 0.001). These significant improvements confirm the vital role of targeted educational interventions in enhancing health outcomes, as emphasized by Yadav et al. in India, who stated that structured oral health training programs can empower primary health care providers and improve the health of rural communities ( 14 ). Challenges in implementing this study included a lack of educational resources, scheduling difficulties due to participants’ work commitments, and logistical issues such as organizing workshops across different locations. Additionally, variations in participants' baseline knowledge levels, lack of cooperation from some individuals due to workload or disinterest, and the influence of cultural and social beliefs on the acceptance of educational content were notable limitations. While this study presents strong approaches, its cross-sectional nature limits the ability to assess the long-term impact of the interventions. Future research should adopt longitudinal designs and incorporate qualitative analyses to explore underlying barriers to translating knowledge into sustainable practices. By addressing these challenges, healthcare systems can ensure that observed improvements translate into lasting community health benefits. CONCLUSION This study evaluated the implementation of the Ministry of Health's oral health educational package among Behvarz and health care providers in Zahedan, focusing on the Knowledge, Attitude, and Practice (KAP) dimensions. The results demonstrated significant improvements in all areas following the intervention, particularly among Behvarz , who consistently outperformed health care providers in both pre- and post-intervention assessments. These findings highlight the critical role of structured educational workshops and appropriate training in enhancing the effectiveness of oral health education programs. The intervention not only addressed knowledge gaps but also improved attitudes and practical behaviors related to oral healthcare. However, the persistent gap between knowledge and practice underscores the need for systemic changes, including supportive policies, adequate resources, and follow-up mechanisms to reinforce training efforts. These results align with global evidence, emphasizing the value of community-focused and targeted health education programs in improving public health outcomes. Recommendations Strengthen training: Conduct more workshops with ongoing sessions and practical training to ensure sustained learning and improved engagement. Develop clear guidelines: Draft and implement actionable and practical oral health education and practice protocols. Allocate resources: Provide necessary materials, tools, and incentives to effectively support healthcare staff. Integrate oral health: Make oral health education a formal part of health care providers' responsibilities. Enhance community roles: Leverage the community-based presence of Behvarz to deliver targeted health education. Promote collaboration: Encourage cooperation between dental professionals and primary care providers. Conduct long-term studies: Assess the sustainability of training programs through longitudinal research. Address systemic barriers: Tackle structural issues such as heavy workloads and resource limitations to improve adoption of best practices. Declarations CONFLICT OF INTEREST The authors declare no conflict of interest. COMPETING INTERESTS The authors declare that they have no competing interests. FUNDING No financial support for this study. HUMAN ETHICS AND CONSENT TO PARTICIPATE Approval from the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1403.256) was obtained. This study was in compliane with the Helsinki Declaration. Written informed consent was obtained from all participants. CONSENT FOR PUBLICATION Not Applicable FUNDING There was no financial support for this study. Author Contribution Conception and design of study and review: MD, ZG. Acquisition of data: MD, ZG, FF. Analysis of collected data: MD, ZG, FF. Interpretation of data: ZG, AHK. Drafting of paper and/or critical revision: MD, ZG, AHK. All the authors have read and approved the manuscript to be submitted to BMC Oral Health. ACKNOWLEDGEMENTS The authors wish to acknowledge Dr. Zanganeh, Mrs Noora, from Deputy for health affairs, Zahedan University of Medical Sciences for their kind help and support for this study. Thanks to Dr. Gholami, Mrs. Nehbandani) Zahedan network) and Mrs Piran (Zahedan health network) and all of primary care providers who work in Zahedan health centers for their diligent work during the clinical field work. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Workgroup OHCDPE. Oral health care during pregnancy: a national consensus statement. National Maternal and Child Oral Health Resource Center Washington, DC; 2012. Dent AAoPDJP. Symposium onthe prevention of oral disease in children and adolescents. Chicago, Ill; November 11–12, 2005: Conference papers. 2006;28(2):96–198. Ghorbani Z, Pakkhesal M, Arshi S, Eghbal MJ, Deghatipour M, Tennant M, Ardakani HM. Challenges impeding integration of oral health into primary health care. East Mediterr Health J. 2018;23(12):802–8. 10.26719/2017.23.12.802 . Samadzadeh h., hesari h., nouri m. A survey on the dmft trend in 6 to 13 years old iranian school children in 1999. Journal of dental school shahid beheshti university of medical science. 2001;19(3):262–272. Jahangiry L, Bagheri R, Darabi F, Sarbakhsh P, Sistani MMN, Ponnet K. Oral health status and associated lifestyle behaviors in a sample of Iranian adults: an exploratory household survey. BMC Oral Health. 2020;20(1):82. 10.1186/s12903-020-01072-z . Mahdavi M, Parsaeian M, Jaafaripooyan E, Ghaffari S. Recent Iranian Health System Reform: An Operational Perspective to Improve Health Services Quality. Int J Health Policy Manag. 2018;7(1):70–4. 10.15171/ijhpm.2017.89 . Basir L, Beigi S. Oral health knowledge, attitude, behavior, and self-efficacy among healthcare professionals: A cross-sectional study. Jundishapur J Health Sci. 2022;14(2). Then Moli SM, Aziz NA, Noor Azimah M, Rani H. Cross-sectional survey on primary care medical doctors' practices on oral health care in pregnancy and its association with knowledge and attitude. Med J Malaysia. 2022;77(2):217–23. Singh O, Pradhan D, Sharma L, Srivastava R. Oral health knowledge, attitudes and practices of primary healthcare workers of Lucknow district: A cross-sectional study. J Family Med Prim Care. 2022;11(2):520–5. 10.4103/jfmpc.jfmpc_1129_21 . Singhal S, Figueiredo R, Dupuis S, Skellet R, Wincott T, Dyer C, Feller A, Quiñonez C. Knowledge, attitude, willingness and readiness of primary health care providers to provide oral health services to children in Niagara, Ontario: a cross-sectional survey. CMAJ Open. 2017;5(1):E249–54. 10.9778/cmajo.20160012 . Al-Kubaisi NJ, Al-Dahnaim LA, Salama RE. Knowledge, attitudes and practices of primary health care physicians towards evidence-based medicine in Doha, Qatar. East Mediterr Health J. 2010;16(11):1189–97. Wong FMF, Leung WK. Sustainability of an Educational Program on Oral Care/Hygiene Provision by Healthcare Providers to Older Residents in Long-Term Care Institutions: A Follow-Up Study. Geriatr (Basel). 2024;9(3):84. 10.3390/geriatrics9030084 . Sultan MA, Miller E, Tikkanen RS, Singh S, Kullu A, Cometto G, Fitzpatrick S, Ajuebor O, Gillon N, Edward A, Moleman YP, Pandya S, Park I, Shen JY, Yu Y, Perry H, Scott K, Closser S. Competency-based education and training for Community Health Workers: a scoping review. BMC Health Serv Res. 2025;25(1):263. 10.1186/s12913-025-12217-7 . Yadav K, Solanki J, Adyanthaya BR, et al. Primary health center approach for oral health related knowledge, attitude and practice among primary health care workers of western India. J Dent Health Oral Disord Ther. 2016;5(3):248–51. 10.15406/jdhodt.2016.05.00150 . Additional Declarations No competing interests reported. Supplementary Files porseshnameEnglish.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 23 Mar, 2026 Reviews received at journal 21 Feb, 2026 Reviewers agreed at journal 21 Feb, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor assigned by journal 13 Feb, 2026 Editor invited by journal 21 Jan, 2026 Submission checks completed at journal 20 Jan, 2026 First submitted to journal 06 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8298265","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591783529,"identity":"da306048-38b5-4544-90ce-637b7c60df2f","order_by":0,"name":"Farhood Farokhi","email":"","orcid":"","institution":"Zahedan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Farhood","middleName":"","lastName":"Farokhi","suffix":""},{"id":591783535,"identity":"85050286-998b-49e7-a055-79bbeafcf862","order_by":1,"name":"Amir Hossein Khazaei","email":"","orcid":"","institution":"Zahedan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"Hossein","lastName":"Khazaei","suffix":""},{"id":591783536,"identity":"a0d0a8d1-ad4b-42f6-92d0-b303f04b4ab9","order_by":2,"name":"Zahra Ghorbani","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Ghorbani","suffix":""},{"id":591783538,"identity":"27c717a4-b53c-4d29-992d-f01bfcf0dda9","order_by":3,"name":"Marzie Deghatipour","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHACAwbGBgYGNjC7AoiZmRuI0iIB0XIGpIWRSC1gJmMbmMSvRbeBeePDrzvs6vikm49JV86rjeZvB2r5UbENpxazA2zFxrJnkiXYZI6lSZ7ddjx3xmHGBsaeM7fxaOExk5ZsY5Zgk8gxk2zcdiy3AaiFmbENrxbz35Jt9VAtc47lzidCixnjx7bDUC0NNbkbCGo5zFYszdh2XLJN5liyZcOxA7kbgVoO4vXL8eaNH3+2VfPLz24+eLOhpi533vnDBx/8qMCthYEZiHhADEjMHAaTB3CrhwDGHwgtdYQUj4JRMApGwQgEAFnoV85POhXqAAAAAElFTkSuQmCC","orcid":"","institution":"Zahedan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Marzie","middleName":"","lastName":"Deghatipour","suffix":""}],"badges":[],"createdAt":"2025-12-07 07:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8298265/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8298265/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102909849,"identity":"a92d7eec-0fba-49cd-81ef-42cb2271d08a","added_by":"auto","created_at":"2026-02-18 09:57:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74448,"visible":true,"origin":"","legend":"\u003cp\u003eIntervention and control group Knowledge, Attitude, and Practice post-test scores\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8298265/v1/a86bd258ccdb708ba7b260be.png"},{"id":102910152,"identity":"efa05a87-f286-42e5-a2c0-45e3080ac494","added_by":"auto","created_at":"2026-02-18 09:57:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":117436,"visible":true,"origin":"","legend":"\u003cp\u003eHCPs and Behvarzes Knowledge, Attitude, and Practice post-test scores\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8298265/v1/f1f4d5224d8193d59dfa308c.png"},{"id":102909850,"identity":"dba315a8-b590-4a00-b863-2a62225e2e6e","added_by":"auto","created_at":"2026-02-18 09:57:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40989,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge, Attitude, and Practice pre-test /post-test scores in intervention and control group.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8298265/v1/aa1714ed0a18e751e3e2f6b0.png"},{"id":102910230,"identity":"01b7fefc-8737-4c36-800b-9c72c921b76b","added_by":"auto","created_at":"2026-02-18 09:57:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":801438,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8298265/v1/e3ef8483-52c9-495b-8486-ba7b0a7b827c.pdf"},{"id":102909983,"identity":"4e8b690c-a3d6-49fb-bc43-e10dcab8a9df","added_by":"auto","created_at":"2026-02-18 09:57:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":433868,"visible":true,"origin":"","legend":"","description":"","filename":"porseshnameEnglish.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8298265/v1/df1e09b63e4ca620f0cd04b3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe impact of oral and dental health on overall health is significant. Due to natural physiological changes, pregnancy is a particularly vulnerable period in terms of oral health. Pregnant women and their health care providers need increased awareness of the many changes that occur in the oral cavity during pregnancy. Preventive interventions in the first year of a child\u0026rsquo;s life may be most effectively implemented with the assistance of medical providers trained in oral screenings and in referring infants and toddlers for dental care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2014, the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) released \u0026ldquo;Integration of Oral Health and Primary Care Practice,\u0026rdquo; which identified interprofessional clinical competencies for appropriate oral healthcare delivery by primary care providers, including nurses, nurse-midwives, general physicians, pediatricians, and physician assistants (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Early childhood caries (ECC) has been identified as a major public health issue, and oral health providers are encouraged to implement preventive programs and actions to reduce the risk of ECC (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth and medical services in Iran are delivered through a health network system. It should also be noted that the lack of timely adherence to oral healthcare and disease prevention leads to tooth loss at younger ages and may result in more severe and serious consequences. Without preventive efforts, society and the government will be forced to bear the high costs of providing human resources, materials, and equipment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Since it was not feasible to cover all age groups in Iran\u0026rsquo;s health services, those who were more vulnerable to oral diseases and more accessible based on existing plans\u0026mdash;such as pregnant and breastfeeding women and children\u0026mdash;were selected as the target group. The main goal of the integration project was to define these target groups. In 1995, the project was launched in some counties to promote community oral health by increasing public awareness and enhancing primary healthcare (PHC) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It is currently offered as part of health services through the national health network system in all healthcare centers. Iran\u0026rsquo;s dental healthcare delivery system consists of four levels; Community Health Workers (Behvarz), Oral Health Care Providers, Dentists and Specialists (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCommunity Health Workers (Behvarz): These are male or female workers with at least a high school diploma, aged 17 to 22 at the beginning of their service, residing in the rural service area they serve. They are trained by Behvarz instructors in Behvarz schools in oral health promotion and work in rural \"Health Houses,\" providing primary healthcare services to people at the first level of the healthcare network (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Oral Health Care Providers: They work in rural health centers and supervise community health workers (Behvarz) in local health houses. Additionally, they provide primary oral healthcare services such as tooth extractions, fluoride therapy, and scaling. Dentists: They are responsible for providing first- and second-level services such as oral health education, extractions, caries restoration, pulpotomy, fissure sealant application, fluoride therapy, and scaling. Dentists, together with oral health technicians and dental assistants, are responsible for the prevention, management, and treatment of oral and dental diseases in both urban and rural health centers. Specialists: They provide advanced treatments across various dental specialties in university-affiliated health centers located in cities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Following the Health Transformation Plan in Iran, health care providers now operate in comprehensive health centers and bases, while Behvarz workers continue to work in rural health houses (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The PHC team consists of health care providers and Behvarz personnel. Health care providers play a key role in education and prevention of common oral diseases, providing healthcare services and maintaining close interactions with pregnant women, mothers, and their children. After completing 147 hours of in-person training and 578 hours of distance learning, and passing a final exam, trainees in suburban centers are officially recognized as \u0026ldquo;health care providers.\u0026rdquo; Each health care provider typically serves a population of 2,000 to 2,500 people. It is noteworthy that out of the 725 training hours allocated to the health team, only 10 hours are dedicated to oral health\u0026mdash;an insufficient amount that requires reconsideration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Evidence clearly shows that oral health\u0026mdash;especially dental caries among pregnant women in Iran\u0026mdash;is a serious concern. It appears that initiating community-based interventions with an integrated oral health approach could help control dental caries in both mothers and children.\u003c/p\u003e \u003cp\u003eConsidering the importance of this issue, the lack of similar studies, and the need to lay the groundwork for future research, conducting this study was deemed essential. Therefore, in this study we evaluated the implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source and study design\u003c/h2\u003e \u003cp\u003eThis cross-sectional (descriptive-analytical) study was conducted in 2025. The sample consisted of all \u003cem\u003eBehvarz\u003c/em\u003e and health care providers in Zahedan. The sampling method was a census approach, simple and convenient. The data collection tool was a two-part questionnaire. The first part collected demographic information, including age, gender, work experience, and occupational category. The second part consisted of 15 items evaluating the knowledge of staff at urban and rural comprehensive health service centers regarding oral health. This questionnaire was developed for this study (Supplementary file). The validity and reliability of the questionnaire were confirmed in a thesis by Daghatipoor (Thesis No. 426, dated 12/07/1399 in the Persian calendar), with a Cronbach\u0026rsquo;s alpha coefficient greater than 0.75. Scoring for the 15 questions was as follows: 1 point for each correct answer and 0 for incorrect answers, with the total possible score ranging from 0 to 15. Written informed consent was obtained from all participants.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy implementation method\u003c/h3\u003e\n\u003cp\u003e Following approval from the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1403.256), the study commenced. All health care providers and \u003cem\u003eBehvarz\u003c/em\u003e in comprehensive health centers and health houses in Zahedan were invited to participate in two four-day sessions. Before the study began, the purpose and significance of the research were explained to participants. After coordination with the provincial and county health centers, participants were invited to attend on designated days.\u003c/p\u003e \u003cp\u003eThe questionnaire used in this study was developed based on the Ministry of Health's Oral Health Training Manual and validated by a specialist in community dentistry. Initially, all participants completed a pre-test questionnaire. Then, a series of theoretical and practical educational intervention workshops were conducted by a community dentistry specialist and a dental student. After the workshops, a post-test was administered to all participants. At the end of the study, all participant questions were answered.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn this study, various statistical tests were used to assess changes in participants' knowledge, attitudes, and practices before and after the intervention.\u003c/p\u003e \u003cp\u003eAn independent t-test was used to compare mean scores between \u003cem\u003eBehvarz\u003c/em\u003e and health care provider groups. A paired t-test was used to analyze pre- and post-test score changes. In addition, ANCOVA (Analysis of Covariance) was used to control for the effects of demographic variables (age, gender, work experience) and baseline scores. Data were analyzed using SPSS version 26, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 395 participants (104 \u003cem\u003eBehvarz\u003c/em\u003e and 291 health care providers) with a mean age of 38.59\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27 years took part in the study. The majority of participants (78%) were female. The distribution of participants by gender, job title, age, and work experience is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of participants by gender, job title, age, and work experience.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevels\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT -test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (N%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale (N%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (79.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eJob Title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Care Provider (N%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (42.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (45.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBehvarz\u003c/em\u003e(N%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (57.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (54.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.85 (6.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.44 (6.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.12 (6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.84 (6.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eChi-square or Fisher exact test was used.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the mean pre-test scores for knowledge (range: 0 to 10), attitude (range: 10 to 50), and performance (range: 10 to 40) among participants in the intervention and control groups. The pre-test scores for knowledge and performance were significantly higher in the intervention group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004, respectively). However, the pre-test attitude scores did not show a significant difference between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.19).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-test scores of oral health knowledge, attitude, and practice in the intervention and control groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.45 (1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.85 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.27 (3.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.16 (4.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.97 (6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.96 (4.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*For comparison between Pre-test Knowledge, Attitude, and Practice scores and places Independent T-test was used.\u003c/p\u003e \u003cp\u003eThe pre-test scores for knowledge, attitude, and performance were significantly higher among \u003cem\u003eBehvarz\u003c/em\u003e compared to health care providers (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-test scores of oral health knowledge, attitude, and practice in the HCP and Behvarz groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCP\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBehvarz\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.54 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.50 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.81 (2.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.98 (4.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.55 (3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.10 (5.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*For comparison between Pre-test Knowledge, Attitude, and Practice scores and PHCPs Independent T-test was used.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the mean (SD) pre-test knowledge, attitude and practice of the study participants. Pre-test knowledge, attitude and practice scores did not differ significantly by gender.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-test scores of oral health knowledge, attitude, and practice by gender.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.00 (1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.09 (1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.54 (3.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.87 (4.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.46 (4.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.68 (5.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-test Knowledge, Attitude, and Practice scores were higher in intervention group compared to control. Statistical analyzes showed that Behvarzs had gained better scores than HCPs (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates the comparison of pre-test, and post-test KAP scores analysis in intervention and control groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e PHCPs\u0026rsquo; KAP scores regarding oral health were better in post-test and in intervention group. In addition, the analysis of ANCOVA revealed that after adjusting for pre-test scores, gender, and work experience, the KAP scores were significantly higher in intervention group. Also, the KAP scores were significantly higher in Behvarzes, compared to HCPs (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of the Implementation of the Educational Package Developed by the Ministry of Health, Treatment, and Medical Education by Health care providers and Behvarz in Zahedan.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003eT -test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eANCOVA least square mean(CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value ANCOVA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eL S Mean difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLow bound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUp bound\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eKnowledge pre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre- test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehvarz\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003cp\u003epre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e16.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e14.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e17.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.795\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehvarz\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.674\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003cp\u003epre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e12.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e14.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBehvarz\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor comparison between Pre-test Knowledge, Attitude, and Practice scores and places in Behvarz and HCP Independent T-test was used.\u003c/p\u003e \u003cp\u003eFor comparison between Post-test Knowledge, Attitude, and Practice in Behvarz and HCP at end point ANCOVA test was used.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings of this study demonstrate significant improvements in the knowledge, attitudes, and practices of health care providers and \u003cem\u003eBehvarz\u003c/em\u003e regarding oral health education in Zahedan following the implementation of the educational package developed by the Ministry of Health, Treatment, and Medical Education. These results, in addition to aligning with previous studies, provide a foundation for enhancing targeted health policies and strengthening educational approaches.\u003c/p\u003e \u003cp\u003eBefore the intervention, the mean knowledge scores of \u003cem\u003eBehvarz\u003c/em\u003e were significantly higher than those of health care providers \u003cb\u003e(\u003c/b\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06 vs. 4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This difference persisted post-intervention, with the post-test mean score being 6.63\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;2.01 for \u003cem\u003eBehvarz\u003c/em\u003e and 5.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33 for health care providers (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This pattern aligns with the findings of Basir \u0026amp; Beigi, who reported that demographic factors such as education and gender significantly affect oral health knowledge (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Similarly, Moli et al. found that greater experience and structured guidelines were directly associated with improved performance among primary care physicians in Malaysia, and that higher knowledge scores predicted better performance (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The study also revealed notable improvements in attitudes toward oral health. Before the intervention, \u003cem\u003eBehvarz\u003c/em\u003e had significantly higher attitude scores (28.98\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;4.67) than health care providers \u003cb\u003e(\u003c/b\u003e25.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). After the intervention, these scores increased to 36.88\u0026thinsp;\u0026plusmn;\u0026thinsp;9.35 for \u003cem\u003eBehvarz\u003c/em\u003e and 33.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16 for health care providers (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). These results are consistent with Singh et al. in India, who reported that although health care providers had adequate knowledge, they exhibited inconsistent attitudes toward preventive actions, highlighting the challenges in translating knowledge into practice (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Similarly, Singhal et al. in Canada showed that health care providers generally had positive attitudes toward promoting oral health, but time constraints and lack of resources often impeded effective implementation. Our findings emphasize the value of targeted educational workshops, as evidenced by the 16.06-point increase in attitude scores in the intervention group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the progress in knowledge and attitude, the study highlighted a persistent gap in performance. Pre-test performance scores showed that \u003cem\u003eBehvarz\u003c/em\u003e outperformed health care providers (22.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45 vs. 17.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This trend continued post-intervention, with \u003cem\u003eBehvarz\u003c/em\u003e scoring 25.93\u0026thinsp;\u0026plusmn;\u0026thinsp;8.08 and health care providers 23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.081). These findings align with Al-Kubaisi et al. in Qatar, where primary health professionals, despite positive attitudes, showed limited practical engagement in promoting oral health (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similarly, Singh et al. reported that although 70.2% of Indian health care providers had visited a dentist, preventive behaviors were rarely observed due to systemic challenges such as lack of structured training (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The 12.54-point increase in performance scores in the intervention group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) underscores the critical role of continuous training and support in translating knowledge into actionable outcomes.\u003c/p\u003e \u003cp\u003eRecent studies have further affirmed the positive impact of targeted educational programs on the knowledge and attitudes of health care providers in the domain of oral health. A study by Wong and Leung evaluated the sustainability of an oral health training program for health care providers, measuring changes in knowledge, attitudes, and practices three and six months after program completion. The findings revealed that such educational interventions can lead to sustained improvements in health care providers\u0026rsquo; knowledge and attitudes, underscoring the importance of continuous training in this area (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, the role of \u003cem\u003eBehvarz\u003c/em\u003e in promoting oral health is gaining more attention. A scoping review by Sultan et al. explored how \u003cem\u003eBehvarz\u003c/em\u003e are trained using competency-based education and their impact on community health. The study concluded that with appropriate training, \u003cem\u003eBehvarz\u003c/em\u003e can effectively deliver oral health education and facilitate behavioral change in communities, ultimately improving oral health outcomes. These findings support the integration of \u003cem\u003eBehvarz\u003c/em\u003e into oral health promotion strategies to reduce inequalities and improve access to care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese findings align with our study, which showed that after implementing a structured educational program, the knowledge and attitudes of both health care providers and \u003cem\u003eBehvarz\u003c/em\u003e significantly improved. The sustained knowledge gains and the key role of \u003cem\u003eBehvarz\u003c/em\u003e in oral health promotion emphasize the need for ongoing training and their integration into oral health strategies to achieve comprehensive and effective community health outcomes.\u003c/p\u003e \u003cp\u003eGender and demographic analysis in our study revealed no significant differences in knowledge (Men: 5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25, Women: 5.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04, \u003cb\u003ep\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.16), attitude (Men: 26.54\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26, Women: 27.87\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12), or performance scores (Men: 21.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.28, Women: 19.68\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.14\u003cb\u003e)\u003c/b\u003e. These results differ slightly from those of Basir \u0026amp; Beigi, where gender differences were more pronounced, possibly due to regional or cultural variations in access to education (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Moreover, participants with higher age and greater work experience tended to score higher across all dimensions of knowledge, attitude, and performance, a trend consistent with the findings of Moli et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The significant improvements in post-test outcomes, especially in the intervention group, demonstrate the effectiveness of structured training workshops in overcoming demographic disparities and enhancing overall performance.\u003c/p\u003e \u003cp\u003eStatistical analyses, particularly ANCOVA, confirmed that post-test scores for knowledge, attitude, and performance were significantly higher in the intervention group after adjusting for pre-test scores, gender, and work experience (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean post-test knowledge score in the intervention group was 8.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22 compared to 5.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87 in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Attitude scores increased to 45.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42 in the intervention group versus 29.28\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97 in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Performance scores followed a similar pattern, with the intervention group scoring 32.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98 compared to 20.01\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07 in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These significant improvements confirm the vital role of targeted educational interventions in enhancing health outcomes, as emphasized by Yadav et al. in India, who stated that structured oral health training programs can empower primary health care providers and improve the health of rural communities (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChallenges in implementing this study included a lack of educational resources, scheduling difficulties due to participants\u0026rsquo; work commitments, and logistical issues such as organizing workshops across different locations. Additionally, variations in participants' baseline knowledge levels, lack of cooperation from some individuals due to workload or disinterest, and the influence of cultural and social beliefs on the acceptance of educational content were notable limitations. While this study presents strong approaches, its cross-sectional nature limits the ability to assess the long-term impact of the interventions. Future research should adopt longitudinal designs and incorporate qualitative analyses to explore underlying barriers to translating knowledge into sustainable practices. By addressing these challenges, healthcare systems can ensure that observed improvements translate into lasting community health benefits.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study evaluated the implementation of the Ministry of Health's oral health educational package among \u003cem\u003eBehvarz\u003c/em\u003e and health care providers in Zahedan, focusing on the Knowledge, Attitude, and Practice (KAP) dimensions. The results demonstrated significant improvements in all areas following the intervention, particularly among \u003cem\u003eBehvarz\u003c/em\u003e, who consistently outperformed health care providers in both pre- and post-intervention assessments. These findings highlight the critical role of structured educational workshops and appropriate training in enhancing the effectiveness of oral health education programs. The intervention not only addressed knowledge gaps but also improved attitudes and practical behaviors related to oral healthcare. However, the persistent gap between knowledge and practice underscores the need for systemic changes, including supportive policies, adequate resources, and follow-up mechanisms to reinforce training efforts. These results align with global evidence, emphasizing the value of community-focused and targeted health education programs in improving public health outcomes.\u003c/p\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStrengthen training: Conduct more workshops with ongoing sessions and practical training to ensure sustained learning and improved engagement.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Develop clear guidelines: Draft and implement actionable and practical oral health education and practice protocols.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAllocate resources: Provide necessary materials, tools, and incentives to effectively support healthcare staff.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIntegrate oral health: Make oral health education a formal part of health care providers' responsibilities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEnhance community roles: Leverage the community-based presence of \u003cem\u003eBehvarz\u003c/em\u003e to deliver targeted health education.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePromote collaboration: Encourage cooperation between dental professionals and primary care providers.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConduct long-term studies: Assess the sustainability of training programs through longitudinal research.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAddress systemic barriers: Tackle structural issues such as heavy workloads and resource limitations to improve adoption of best practices.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCOMPETING INTERESTS\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eFUNDING\u003c/h2\u003e \u003cp\u003eNo financial support for this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHUMAN ETHICS AND CONSENT TO PARTICIPATE\u003c/strong\u003e \u003cp\u003e Approval from the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1403.256) was obtained. This study was in compliane with the Helsinki Declaration. Written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCONSENT FOR PUBLICATION\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING\u003c/h2\u003e \u003cp\u003eThere was no financial support for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and design of study and review: MD, ZG. Acquisition of data: MD, ZG, FF. Analysis of collected data: MD, ZG, FF. Interpretation of data: ZG, AHK. Drafting of paper and/or critical revision: MD, ZG, AHK. All the authors have read and approved the manuscript to be submitted to BMC Oral Health.\u003c/p\u003e\u003ch2\u003eACKNOWLEDGEMENTS\u003c/h2\u003e \u003cp\u003eThe authors wish to acknowledge Dr. Zanganeh, Mrs Noora, from Deputy for health affairs, Zahedan University of Medical Sciences for their kind help and support for this study. Thanks to Dr. Gholami, Mrs. Nehbandani) Zahedan network) and Mrs Piran (Zahedan health network) and all of primary care providers who work in Zahedan health centers for their diligent work during the clinical field work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorkgroup OHCDPE. Oral health care during pregnancy: a national consensus statement. National Maternal and Child Oral Health Resource Center Washington, DC; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDent AAoPDJP. Symposium onthe prevention of oral disease in children and adolescents. Chicago, Ill; November 11\u0026ndash;12, 2005: Conference papers. 2006;28(2):96\u0026ndash;198.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhorbani Z, Pakkhesal M, Arshi S, Eghbal MJ, Deghatipour M, Tennant M, Ardakani HM. Challenges impeding integration of oral health into primary health care. East Mediterr Health J. 2018;23(12):802\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.26719/2017.23.12.802\u003c/span\u003e\u003cspan address=\"10.26719/2017.23.12.802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamadzadeh h., hesari h., nouri m. A survey on the dmft trend in 6 to 13 years old iranian school children in 1999. Journal of dental school shahid beheshti university of medical science. 2001;19(3):262\u0026ndash;272.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJahangiry L, Bagheri R, Darabi F, Sarbakhsh P, Sistani MMN, Ponnet K. Oral health status and associated lifestyle behaviors in a sample of Iranian adults: an exploratory household survey. BMC Oral Health. 2020;20(1):82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12903-020-01072-z\u003c/span\u003e\u003cspan address=\"10.1186/s12903-020-01072-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahdavi M, Parsaeian M, Jaafaripooyan E, Ghaffari S. Recent Iranian Health System Reform: An Operational Perspective to Improve Health Services Quality. Int J Health Policy Manag. 2018;7(1):70\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15171/ijhpm.2017.89\u003c/span\u003e\u003cspan address=\"10.15171/ijhpm.2017.89\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasir L, Beigi S. Oral health knowledge, attitude, behavior, and self-efficacy among healthcare professionals: A cross-sectional study. Jundishapur J Health Sci. 2022;14(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThen Moli SM, Aziz NA, Noor Azimah M, Rani H. Cross-sectional survey on primary care medical doctors' practices on oral health care in pregnancy and its association with knowledge and attitude. Med J Malaysia. 2022;77(2):217\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh O, Pradhan D, Sharma L, Srivastava R. Oral health knowledge, attitudes and practices of primary healthcare workers of Lucknow district: A cross-sectional study. J Family Med Prim Care. 2022;11(2):520\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/jfmpc.jfmpc_1129_21\u003c/span\u003e\u003cspan address=\"10.4103/jfmpc.jfmpc_1129_21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinghal S, Figueiredo R, Dupuis S, Skellet R, Wincott T, Dyer C, Feller A, Qui\u0026ntilde;onez C. Knowledge, attitude, willingness and readiness of primary health care providers to provide oral health services to children in Niagara, Ontario: a cross-sectional survey. CMAJ Open. 2017;5(1):E249\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.9778/cmajo.20160012\u003c/span\u003e\u003cspan address=\"10.9778/cmajo.20160012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Kubaisi NJ, Al-Dahnaim LA, Salama RE. Knowledge, attitudes and practices of primary health care physicians towards evidence-based medicine in Doha, Qatar. East Mediterr Health J. 2010;16(11):1189\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong FMF, Leung WK. Sustainability of an Educational Program on Oral Care/Hygiene Provision by Healthcare Providers to Older Residents in Long-Term Care Institutions: A Follow-Up Study. Geriatr (Basel). 2024;9(3):84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/geriatrics9030084\u003c/span\u003e\u003cspan address=\"10.3390/geriatrics9030084\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSultan MA, Miller E, Tikkanen RS, Singh S, Kullu A, Cometto G, Fitzpatrick S, Ajuebor O, Gillon N, Edward A, Moleman YP, Pandya S, Park I, Shen JY, Yu Y, Perry H, Scott K, Closser S. Competency-based education and training for Community Health Workers: a scoping review. BMC Health Serv Res. 2025;25(1):263. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-025-12217-7\u003c/span\u003e\u003cspan address=\"10.1186/s12913-025-12217-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadav K, Solanki J, Adyanthaya BR, et al. Primary health center approach for oral health related knowledge, attitude and practice among primary health care workers of western India. J Dent Health Oral Disord Ther. 2016;5(3):248\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15406/jdhodt.2016.05.00150\u003c/span\u003e\u003cspan address=\"10.15406/jdhodt.2016.05.00150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Education, Knowledge, Health care provider","lastPublishedDoi":"10.21203/rs.3.rs-8298265/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8298265/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e This study evaluates the implementation of the Ministry of Health\u0026rsquo;s educational package on oral health among Health Care Providers (HCPs) and health volunteers (Behvarz) in Zahedan. The research focuses on assessing knowledge, attitudes, and practices (KAP) before and after the intervention, with the goal of identifying areas for improvement and providing evidence-based recommendations for policy and practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional descriptive-analytical study was conducted among 395 participants, including 104 health volunteers and 291 health care providers. Pre- and post-test KAP scores were measured using a validated questionnaire designed to assess the impact of a structured educational intervention. The study included theoretical and practical workshops led by dental experts. Data were analyzed using paired t-tests, ANCOVA, and descriptive statistics to evaluate changes in KAP and assess demographic influences, including age, gender, and work experience.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe intervention led to significant improvements in KAP scores across all participants. Behvarz consistently outperformed HCPs in both pre- and post-test scores. For knowledge, post-test mean scores were 6.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01 for Behvarz and 5.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33 for HCPs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Attitude scores increased from 28.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.67 to 36.88\u0026thinsp;\u0026plusmn;\u0026thinsp;9.35 for Behvarz and from 25.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79 to 33.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16 for HCPs (p\u0026thinsp;=\u0026thinsp;0.001). Practice scores improved from 22.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45 to 25.93\u0026thinsp;\u0026plusmn;\u0026thinsp;8.08 for Behvarz and from 17.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85 to 23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03 for HCPs (p\u0026thinsp;=\u0026thinsp;0.081). Gender differences were not statistically significant, but older participants and those with more work experience showed higher scores. Post-test KAP scores in the intervention group were significantly higher than the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe educational package significantly enhanced oral health KAP among health care providers and volunteers, particularly Behvarz. These findings highlight the effectiveness of structured, community-oriented interventions in improving healthcare delivery.\u003c/p\u003e","manuscriptTitle":"Evaluation of implementation of ministry of health's planning approach for health care providers and Behvarzes in Healthcare centers and Healthposts in Zahedan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 09:55:52","doi":"10.21203/rs.3.rs-8298265/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T10:51:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T20:53:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325407499735303616976379441712330482054","date":"2026-02-21T20:46:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T07:47:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333970654759727160728922221134778729552","date":"2026-02-13T14:07:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T12:57:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-13T08:48:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T05:10:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T15:04:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-01-06T08:05:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10552c5c-5182-44e5-ba14-6df30a8d9823","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T07:39:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 09:55:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8298265","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8298265","identity":"rs-8298265","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}