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Question Formulation Skills Building Among Dental Hygiene Students:
A Randomized Controlled Trial

Jonathan D. Eldredge, MLS, MA, PhD, AHIP-D, FMLAa, Christine N. Nathe, RDH, MSb,

aProfessor, Health Sciences Library and Informatics Center, School of Medicine, College of
Population Health, University of New Mexico Albuquerque, New Mexico,
https://www.orcid.org/0000-0003-3136-9450 , jeldredge@salud.unm.edu

bProfessor and Director, Division of Dental Hygiene; Vice Chair, Department of Dental
Medicine, School of Medicine, University of New Mexico, Albuquerque, New Mexico,
cnathe@salud.unm.edu

Cite as: Eldredge JD and Nathe CN. Question Formulation Skills Building Among Dental
Hygiene Students: A Randomized Controlled Trial. Hypothesis. 2024;36(2). doi:
10.18060/28153.

Eldredge, Nathe. All works in Hypothesis are licensed under a CC BY-NC
4.0 DEED Attribution-NonCommercial 4.0 International. Authors own copyright of their
articles appearing in Hypothesis. Readers may copy articles without permission of the
copyright owner(s), as long as the author(s) are acknowledged in the copy, and the copy is
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copyright owner(s).

1

https://www.orcid.org/0000-0003-3136-9450
https://orcid.org/
mailto:jeldredge@salud.unm.edu
mailto:cnathe@salud.unm.edu
https://creativecommons.org/licenses/by-nc/4.0/
https://creativecommons.org/licenses/by-nc/4.0/


Peer Reviewed Article Hypothesis, Vol. 36, No. 2, 2024

Purpose: Dental hygiene students at our institution learn Evidence Based Practice skills
during their first year. We noted over the years that students markedly improved their
formulated questions after training and application of their skills with the assistance of a
rubric.

Research Question: How much training do students require in order to use the question
formulation rubric effectively: a brief 5-minute overview or a 25-minute training that includes
a student peer assessment application exercise?

Methods: Randomized controlled trial. All pre-randomized 24 students took the question
formulation pre-test on the first day of the course on January 22nd. As expected, there were
no statistical differences between the Intervention or Control group pre-test scores. The
instructors administered the post-test on February 19th after the Intervention group had
received the training and rubric with the Control group only having received the rubric with a
brief explanation.

Results: The investigators employed a paired t-test to analyze the pre- and post-test score
differences for each student in the Intervention and Control groups. Surprisingly, the students’
average post-test scores were 41.75 for the Control group and 43.67 for the Intervention group
on a 70-point scale, which were not markedly different. The initial paired t-test of the
post-test scores confirmed no statistical difference either. Further analysis revealed that six (6)
students in the Control group scored considerably higher than their classmates. Interviews
discovered that four (4) of these students collaborated with their fellow students in the
Intervention Group following the instruction so they actually did benefit from peer instruction.
In other words, some contamination occurred. The other two (2) students learned and
practiced alone using the rubric.

Conclusions: Additional analysis suggests that dental hygiene students benefit by
experiencing extra instruction, with the cautionary caveats that this study was limited by some
contamination and that it took place during the Covid-19 era.

Introduction
The modern dental hygienist must be well-versed in the concepts and skills of Evidence
Based Practice (EBP).1 Dental Hygiene degree programs regularly teach EBP skills to meet
this need.2,3,4,5 The EBP process begins with the question formulation step followed by
searching for the best available evidence to answer that question. The skill of asking an EBP
question that will yield an answer requires training and practice.6

The initial EBP step of question formulation has commonly used a four-part system known by
its acronym of PICO. This system consists of identifying the Patient, the Intervention, a
Comparison, and an Outcome. This system works for those EBP questions relating to
treatment, but not for the other estimated 50% of questions in EBP.7 Most of those other EBP
questions relate to diagnosis, prognosis, or epidemiological aspects of patient care.8,9 PICO
also becomes problematic or at least inconclusively effective in positioning the practitioner for
the second EBP step of searching for the best available evidence.10,11,12

At the University of New Mexico, we had observed our dental hygiene students struggling

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with the PICO system in our EBP training sessions for several years, lending practical
credence to the aforementioned research that had found deficiencies with PICO. One reason
for students struggling might be that most dental hygiene questions raised in EBP sessions
related to diagnosis, epidemiology, or dental materials rather than the overriding treatment
orientation of PICO. While a number of EBP question formulation frameworks exist,13 these
seemed most relevant to health information practitioners rather than to dental hygienists. An
alternative and more recent question formulation and rubric system known as FAC (Focus,
Amplify, Compose) had demonstrated promising results in a producing effective EBP
questions14 so we tried the FAC framework and rubric with our dental hygiene students. The
Center for Teaching Innovation at Cornell University defines a rubric as “a type of scoring
guide that assesses and articulates specific components and expectations for an assignment.”15

Rubrics are increasingly common in health professions education to articulate criteria and
expectations of student performance 16,17 and had been used routinely at our institution for
over a decade. The FAC framework and rubric seemed to work well in other curricula so we
decided to test it with a randomized controlled trial with our dental hygiene students.

Our hypothesis was that our dental hygiene students, once oriented to the rubric for 5 minutes
and trained for 25 minutes on the FAC question formulation approach, would score better by a
statistically significant margin compared to students only oriented for 5 minutes on the rubric.

Methods
This randomized controlled trial employed a single-center, parallel-group, two-arm
pre-test/post-test design to compare the effectiveness of two different training approaches
involving undergraduate dental hygiene students using a question formulation rubric. This
randomized controlled trial in a dental hygiene course involved 24 undergraduate students
who had completed prerequisite basic sciences courses such as anatomy and physiology
courses alongside hundreds of other undergraduate students. The dental hygiene course met
once per week for three hours. Using a random number generator, the authors randomized 12
students into a Control group that received a brief explanation of a rubric for question
formulation in a class session separate from the Intervention group. The 12 students
randomized into the Intervention group received separate instruction and engaged in hands-on
exercises aligned with the rubric. The authors measured student improvement in both the
Control group and the Intervention group using an identical pre- and post-test. The authors
received University of New Mexico Human Research Protections Office approval # 19-008 on
January 10, 2019. The detailed methods description follows.

Pre-Test

The authors asked students on the first day of the course on January 22nd to formulate a
question prompted by a baseline clinical vignette that served as the pre-test, identifying
themselves with unique four-digit numbers known only to them:

You are a dental hygienist at a rural clinic in northern New Mexico. Today you
are enjoying your career, even though you miss your dental hygienist student
friends back at the University of New Mexico. You are caring for Chris Garcia,
age 38, who has multiple sclerosis (MS). Chris is wheelchair bound and
experiences muscle weakness with occasional episodes of losing coordination in
one or the other arm. This is a moderate form of MS according to the McDonald

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Peer Reviewed Article Hypothesis, Vol. 36, No. 2, 2024

diagnostic criteria scale. Chris has never smoked tobacco and only drinks socially
on an occasional basis. Chris’ vital signs are 120/70 mmHg blood pressure, pulse
74 beats per minute, and 15 breaths per minutes for respirations. You are trying to
determine the best way to assess and treat Chris’ plaque buildup due to a lack of
access to any dental services over the past five years.

The students were directed to: “Formulate a question based on this clinical vignette that,
when answered by the dental hygienist or other colleagues, will lead to the best treatment of
this patient. Take no longer than five (5) minutes. Write legibly.”

Intervention

On February 5th the students received their introduction to EBP. In a separate classroom apart
from their other classmates, the Control group students received a 5-minute overview of the
rubric and then trained on EBP searching skills during the remaining class time. The
Intervention group met separately for their own group’s training. Intervention group students
first answered on their own the question, “Why do you think that formulating answerable
questions will be important for your individual professional education and for your career?”
Five students shared their answers with other members of the Intervention group. The
Intervention group then received the identical search training as the Control group. In
addition, the Intervention group also learned question formulation skills during a separate 25
minutes training session that aligned with the rubric (Figure 1) in an active learning18,19,20

environment with hands-on application, student peer assessment, and peer coaching elements.
David A. Kolb’s Experiential Learning Cycle21 of concrete experience, reflective observation,
abstract conceptualization, and active experimentation informed creation of these learning
experiences.

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Peer Reviewed Article Hypothesis, Vol. 36, No. 2, 2024

Figure 1. Rubric for Evaluating Formulated EBD Questions

Post-Test

Two weeks later on February 19th, the instructors administered the post-test to measure the
amount of improvement in question formulation skills that had been retained beyond only a
few hours or days in the Intervention and Control groups. All students had ongoing access to
the rubric the two-week interim and during the post-test assessment. Following the post-test,
all students received the question formulation training in class that only the intervention group
initially had received to adhere to the ethical principle of equalizing the treatment between
groups. Students in the Intervention group paired up with Control group students to practice
question formulation skills by writing questions of their own. All students completed a
question formulation exercise as part of a graded course assignment once both Control and
Intervention groups had received the same training. The two authors scored the pre- and
post-tests using the rubric depicted in Figure 1. On the few occasions where their scores

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Peer Reviewed Article Hypothesis, Vol. 36, No. 2, 2024

differed, the authors discussed and resolved their scores. The campus Clinical and
Translational Center statistician and the authors analyzed total pre-test and post-test scores
using a t-test with the Stata statistical packageTM.

Results
All 24 students took the question formulation pre-test on the first day of the course on January
22nd. The two instructors scored the students’ formulated questions with the students’
identities concealed. Table 1 describes the average age, the gender, and final course grade for
each student allocated aggregated into either Control or Intervention groups. Table 1 indicates
that the two groups were demographically the same. As expected, there were no major
differences between the Intervention or Control groups’ pre-test scores (Table 2). On a
70-point rubric, Control group students scored 14.67 and the Intervention Group students
scored 18.25 (p=0.2859).

Table 1. Demographic Characteristics

Characteristic Control Intervention
Males 1 0
Females 11 12
Average Age 24 24
Final Course Grade A A

Table 2. Pre-Test Results

Group N Mean Std Dev Std Error Minimum Maximum
Control 12 14.6667 7.84 2.26 5.0 33.0
Intervention 12 18.2500 8.20 2.37 5.0 30.0
p=0.2859

The instructors later administered the post-test after only the Intervention group had received
the 25-minute instruction session with student peer instruction using the rubric while the
Control group only had received the introduction to the rubric. The instructors scored the
Intervention and Control groups’ post-tests with the students’ identities concealed using the
same scoring rubric. All students’ scores on the post-test following the intervention of control
treatments demonstrated that students markedly improved their scores between baseline and
spot- check post-test. The Control group improved from 14.67 to 41.75 while the Intervention
group improved from 18.25 to 43.67, representing 27.08- and 25.42-point increases,
respectively, on the 70-point scale. This resulting improvement for both groups was consistent
with a previous quasi-experimental study.22

Unexpected Result

Surprisingly, the initial average spot check post-test scores on a 70-point scale between the
Intervention and Control groups were similar. The average scores on Table 3 amounted to
41.75 for the Control Group and 43.67 for the Intervention Group. An initial analysis using a
paired t-test furthermore suggested no statistical difference between the Intervention and

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Control groups. The instructors closely examined the de-identified scores one-by-one and
noticed a bifurcation in the results data. Six students in the Control group scored noticeably
higher than their fellow classmates in the Control group.

Table 3. Initial Post-Test Results

Group N Mean Std Dev Std Error Minimum Maximum
Control 12 41.75 29.18 8.42 10.0 70.0
Intervention 12 43.67 21.09 6.09 18.0 70.0
p=0.8554

One instructor interviewed these six students to learn about their experiences. Two of these
six Control group students decided to learn how to use the rubric on their own in order to
score highly on a graded assignment using the same skills later in the course. The other four
of these Control group students had sought peer instruction from their classmates in the
Intervention group. After removing these contaminated four Control group students from the
analysis of scores, the overall average scores of Intervention and Control group post-tests
became 43.67 and 27.63, respectively as noted in Table 4. These differences between the
Intervention group and Control group approached statistical significance using a paired t-test
with a p value of 0.1428. Still, the contamination muddled any clear result.

Table 4. De-Contaminated Post-Test Results

Group N Mean Std Dev Std Error Minimum Maximum
Control 8 27.63 25.57 9.04 10.0 70.0
Intervention 12 43.67 21.09 6.09 18.0 70.0
p=0.1428

Discussion
This randomized controlled trial in a larger dental hygiene degree program tested the
hypothesis that an extra 25-minute training on EBP question formulation would result in
statistically different scores on a rubric compared to a Control group. Both Control and
Intervention groups benefited from receiving a 5-minute explanation of the scoring rubric.
They scored higher than their baseline pre-test scores on their spot-check post-tests. The
Control and Intervention groups’ scores of 41.75 and 43.67 on a 70-point rubric were similar
and not statistically significantly different using a paired t-test. Most hypothetical students
likely would have wanted the higher average scores of 1.92 points more (almost a 3-point
difference on a 100-point scale) by belonging to the Intervention group even if we had
obtained similar results without removing the contaminated students in the analysis. This
difference might raise their score by half a grade in some instances. The average scores were
not markedly different and not statistically different, however. Perhaps this experiment
presents an instance where a lack of statistical significance still has a meaning for competitive
students conscious of their grades?

Limitations

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This study had three limitations. First, it took place as the US was emerging from the
Covid-19 Pandemic with its psychosocial, clinical, and logistical preoccupations. Dental
profession education programs with their sustained close physical proximity to patients during
clinical training posed challenges due to the continuous threats caused by the Covid-19
pandemic and its reoccurrences.23,24,25 Second, while our dental hygiene program was on the
larger end of the enrollment continuum nationally, our study would have always had power
issues with reaching statistical significance. An unexpected limitation, one that we had
thought that we had sufficiently guarded against, was the contamination involving four
Control group students who collaborated with students in the Intervention group.

Failure Caused by Contamination

Contamination between Intervention and Control groups occurs in an educational or
behavioral experiment when members of the Control group learn about and adhere to the
instruction intended only for the Intervention group. The contamination that unfolded in the
present study of dental hygiene students possibly reduced the differences in results to suggest
no different effect to the Intervention group. Contamination appears to be a far more
widespread issue across randomized controlled studies. One systematic review of behavioral
interventions in Type 2 diabetics revealed that 13 of the 20 studies examined were vulnerable
to contamination between groups and that 45% of the studies did not acknowledge possible
contamination. 26 One possible solution would be for all students at a single site to receive
only the Intervention or the Control while all students at another site might receive the
opposite treatment in a cluster form of randomized controlled trial.27,28 The small size of the
grant for this study would have not afforded a multi-site randomized controlled trial,
particularly when the researchers at the University of New Mexico thought they had managed
to avoid contamination with the study design. A Delphi study expert consensus confirmed that
while “Efforts to avoid or minimize contamination can be incorporated into the design,
conduct or analysis of trials. . . such strategies may be ineffective. . . ” [Page 196].29 Their
Delphi study further found that, “Contamination was thought most likely in trials conducted
in settings where respondents worked, lived or interacted closely together.”[Page 200].29

Congruently, this dental hygiene program provided numerous interactive opportunities among
its students.

Lessons Learned
This randomized controlled study provides a model for others to adapt to their particular
educational or behavioral interventions to gauge the relative benefit of the intervention over
the benefits of a control. The control need not be a placebo in the form of simply doing
nothing; the standard education or behavior treatment could prove to be a worthy control.
This study also offers the possibility of using a less complex quasi-experiment with its pre-
and post-tests, provided the researchers recognize the greater possibilities of confounding in a
quasi-experiment. This study tended to still validate the use of active learning. Beyond these
positive lessons, there are several cautionary lessons to be learned from this study:

1. Even with a keen awareness of and experiences in mitigating the dangers of
contamination, the researchers did not foresee this instance of contamination.

2. The researchers did not recognize the current undergraduate student experience that
caused the student cohort in this dental hygiene program to have many existing regular

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interactions among the students in their class due to:

• Enrollment by some dental hygiene students in a first-semester first-year course
for potential future health professionals;

• Pre-dental career club membership by most students;

• Pre-existing study group dyads and triads within the classmates;

• Cross-cutting undergraduate organization (Hellenic, sports, social, social justice
clubs, etc.) affiliations already existing among these dental hygiene students.

3. While some statistical adjustments can be made in isolated instances of contamination,
the small total numbers of students (n=24) in each cohort pushed the usable number of
non-contaminated students downward, lowering power so statistical significance could
no longer be achieved.

4. In an active learning environment that encourages students to engage regularly in peer
instruction, the challenges to avoiding contamination multiply.

5. Vigilance must be practiced to guard against contamination in randomized controlled
trials when the intervention and control groups are in interactive social, behavioral, or
educational contexts.

Conclusion
Contamination between the Intervention and Control groups apparently equalized the results
between the groups, thereby neutralizing the hypothesized benefit of a longer, more in-depth
training for the Intervention group. Although the authors made reasonable efforts to avoid
contamination between the groups, they did not recognize the pre-existing social and
academic relationships of students across the Intervention and Control groups.

Additional active learning training among students in the Intervention group for 25-minutes
beyond a brief 5-minute introduction provided to the Control group still appears to have
yielded higher scores for the Intervention group students. Given the importance of the
question formulation step in the EBP process and the limitations of this study, it should be
replicated at other dental hygiene programs.

Acknowledgements
The authors thank their students for their participation in this study. The authors appreciated
the pre-submission critical reading of their manuscript by colleagues: Ingrid Hendrix, MILS,
AHIP; Laura J. Hall, MFA. MBA; Heidi Miller Sims, and Robin A. Gatlin, RDH, MS.
Finally, professional statistician Eunice Choi’s involvement throughout the study period
helped the authors adjust to unexpected forms of contamination.

Funding
This work was supported by the University of New Mexico School of Medicine Scholarship
in Education Allocation Committee (SEAC) grant that was funded beginning May 20, 2019.

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CRediT
Jon Eldredge conceptualized the project, secured funding and human subjects research board
approval as principal investigator, conducted and administered the study, validated the rubric,
analyzed the results, curated the data, and wrote the original draft of the manuscript.

Christine Nathe, provided the resources in terms of allowing students she supervised in her
course to participate in the study, analyzed the results, and edited the final manuscript.

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