Effect of framed mHealth messages on oral hygiene and quality of life among Sudanese refugees in Egypt: a randomized controlled trial

BACKGROUND: Sudanese refugees in Egypt face substantial barriers to oral healthcare access, resulting in high disease burden and poor oral health-related quality of life (OHRQoL). This study evaluated impact of gain- and loss-framed mobile text messages (mHealth) on oral health status, OHRQoL, and hygiene practices among this population. METHODS: A randomized controlled parallel trial was conducted between November 2024 and December 2025 among Sudanese refugees in Alexandria, Egypt, using snowball sampling. Eligible participants (≥ 18 years) were randomly allocated (1:1:1) into gain-framed SMS (emphasizing benefits), loss-framed SMS (emphasizing consequences), or control groups. Intervention groups received 24 SMS messages over 12 months. Outcomes were assessed at baseline, 6 months, and 12 months using clinical examinations (Plaque Index and Gingival Index), OHIP-5 questionnaire for OHRQoL, and a self-reported questionnaire for oral hygiene practices. Data were analyzed using ANOVA, repeated-measures ANOVA, Chi-square, McNemar-Bowker, and multivariable linear regression. RESULTS: Of 303 enrolled participants, 261 completed the study (dropout 13.9%). At 12 months, both gain- and loss-framed groups showed significantly lower PI scores compared to control (p-value = 0.012 and 0.03, respectively), with no difference between intervention groups. PI decreased by 28.46% (gain-framed) and 26.87% (loss-framed). Multivariable regression analysis confirmed gain-framed (B = - 0.429, p-value < 0.001) and loss-framed messaging (B = - 0.330, p-value < 0.001) as independent predictors of lower 12-month PI. GI and OHIP-5 scores showed no significant improvements in intervention groups; however, OHRQoL worsened in control group over time (p-value = 0.013, η2p = 0.12). Daily toothbrushing frequency was significantly higher in intervention groups at 12 months (p-value = 0.026), with no change in flossing. CONCLUSIONS: SMS-based oral health education improved plaque control and toothbrushing frequency among refugees, regardless of framing. However, SMS alone was insufficient to improve gingival health or OHRQoL, highlighting the need to combine mHealth with clinical care. TRIAL REGISTRATION: ClinicalTrials.gov, TRN: NCT06649760, Registration date:12 October 2024.