Missing links - A qualitative study investigating perceptions of teachers and parents of infant children, in two Welsh primary schools with different socioeconomic profiles, with regard to oral health

Aim: This qualitative study explores the perceptions of teachers and parents of infant children in primary schools positioned and servicing affluent and deprived populations, as intermediate and end users of oral health promotion services in the Vale of Glamorgan, Wales. Methods: A qualitative focus group methodology was chosen as the most appropriate way of exploring these issues. In addition, this method was combined with individual face to face interviews of the teaching staff. Two primary schools within the Vale of Glamorgan were chosen each representing different geographical locations within the area as well as different socioeconomic profiles. Head teachers invited parents to form a focus group of 8 participants. The head teachers from each school also agreed to be interviewed and invited one other teacher from their school to part-take in a face to face interview. Results: One school was successful in forming a focus group of 8 individuals for the study, the other was unsuccessful in forming a group but one parent was available for a face to face interview. Head teachers and teachers were interviewed in each school. Six themes emerged from the analysis of the data. These included: The dentist Design to Smile ((D2S) Oral Health Education messages Positive role modelling Responsibility School Policy Increased levels of tooth related problems were reported in school 1 whereas in school 2 tooth related problems were not reported. School 1 was involved with the Welsh Government program D2S which showed positive outcomes. Confused messages were reported by both teachers and parents which suggests that different approaches are needed in the delivery of the messages. Access for effective ongoing continuing care was problematic for the parents of the children who had experienced dental caries. Conclusion: There were clear differences in the perceptions of disease experiences of children in the staff and parent(s) of each school, with dental disease impacting on some of the children of school 1. Clear benefits were verbalised to the scheme D2S for school 1 in terms of the development of behaviours in both children and parents. This study shows positive outcomes for D2S, however there is evidence of continued isolated, compartmentalised and uncoordinated approaches to the provision of oral health promotion. More effective downstream approaches need to be developed in order to improve opportunities for oral health. These can be addressed through: Resource allocation for teaching, Training service deliverers, Dental service development. Correspondence to: Wayne Richards, Faculty of Life Sciences and Education, University of South Wales, Glyntaf Campus, Pontypridd, CF37 4BD, UK; E-mail:wayne.richards@southwales.ac. uk Received: December 15, 2016; Accepted: January 20, 2017; Published: January 23, 2017 Introduction Dental caries prevalence in the United Kingdom (UK) in 2016 are low, demonstrating considerable improvements over the last decades [1]. However, these improvements are not observed in the whole population [2]. Deprived sub-groups show considerable levels of Richards W (2017) Missing links A qualitative study investigating perceptions of teachers and parents of infant children, in two Welsh primary schools with different socioeconomic profiles, with regard to oral health Oral Health Care, 2017 doi: 10.15761/OHC.1000109 Volume 2(1): 2-7 tooth decay with some individuals needing multiple extractions under general anaesthetic[3]. Indeed data suggest in some deprived groups there has been an increase in caries prevalence, take for example the most and least deprived areas in Wales, Blaenau Gwent and the Vale of Glamorgan. Between 2007/8 and 2014/15, in Blaenau Gwent there were more caries free individuals and the dmft (decayed, missing, filled, teeth) for those with disease reduced from 5.15 to 4.46, while in the Vale of Glamorgan there were more caries free individuals and the dmft for those with disease increased from 3.25 to 3.45. This suggests a static if not increasing social division both between and within the most and least deprived sub groups, particularly within the least deprived unitary authority [4]. Social division in health has been reported extensively [5-7]. If improvements in oral health are to be achieved in the UK then the only way to achieve this is to target improvements in deprived populations. This is because the distribution of disease shows no or little caries present in higher socio-economic groups [8]which is demonstrated in the Vale of Glamorgan with 80% of five year olds being caries free in 2014/15[4]. Watt et al. suggests an upstream approach to tackle oral health promotion in order to address the populations experiencing dental caries[9]. Within this approach a common risk approach to oral health promotion is fundamental with approaches such as public policy, legislation, regulation and fiscal measures being considered as upstream. Clinical prevention and health education in practice as it has been delivered is considered to be downstream and this has failed to effectively reduced oral health inequalities. Access to general dental practice is difficult for long term oral health care for deprived groups. This has become more acute following the numerous contract changes to general dental practice National Health Service (NHS) contracts[10]. Therefore, without available, accessible and acceptable care from general dental practitioners for the sub-group experiencing disease, alternative approaches need to be considered such as school dental health education, media campaigns, training other professionals, community development, healthy settings e.g. healthy schools; these are considered to be more in the direction of upstream activities by Watt et al.[9] Primary and secondary prevention can be delivered by other nondental health care workers, and these workers can target individuals within the community at important life changing events such as the birth of a child or in a school environment. However, the effectiveness of approaches have been questioned, particularly from the viewpoint of seamless consistent cooperative approaches[11,12]. Watt et al. highlights that oral health education programmes have been isolated, compartmentalised and uncoordinated[9]. Stillman Lowe et al.suggests that effective oral health education messages need to be clear, accurate, consistent and unambiguous[13]. This qualitative study explores the perceptions of teachers and parents of infant children in primary schools positioned and servicing affluent and deprived populations, as intermediate and end users of oral health promotion services in the Vale of Glamorgan, Wales. Methods The overarching aim of this research platform was to study the perceptions of intermediate and end users of oral health promotion services in relation to dental health, risk factors for dental disease and their role in oral health promotion. Other studies include dental, healthcare professionals and the public [14] and school nurses and health visitors [12]. This study sought to explore the perceptions and knowledge of teachers and parents. A qualitative focus group methodology was adopted [15]. In addition, this method was combined with individual face to face interviews of the teaching staff. This approach was considered more appropriate since both head teachers as well as receptions teaching staff were involved. Given the hierarchical positions of authority, it was important that the teachers felt able to speak truthfully. Two primary schools within the Vale of Glamorgan were chosen each representing different geographical locations within the area as well as different socioeconomic profiles. The Vale of Glamorgan is the least deprived unitary authority in Wales, however there is a pocket of severe deprivation positioned within the authority. Therefore primary schools servicing the area in which there is deprivation would be expected to have a proportion of children from these household within the schools. A Flying Start area is defined as families living in the most disadvantaged areas in Wales. School 1 (Defined by head teacher) This is an infant and nursery school in the centre of Barry, Vale of Glamorgan. It has 125 children aged between 3-7 years, 73% white British and with 23% of pupils who speak English as an additional language. Forty two percent of the families live in a Flying Start area which is defined by the Welsh Index of Multiple Deprivation as families living in the most disadvantageous areas in Wales. Approximately 7% of pupils are entitled to free school meals. School 2 (Defined by head teacher) This is a junior school in a semi-rural location on the outskirts of Penarth serving families across the eastern Vale of Glamorgan. It has 221 pupils from 3-11 years, 64% white British and 16% of pupils who speak English as an additional language. The pupils are from varied socioeconomic backgrounds with a minority economically disadvantaged families. Approximately 11% are eligible for free school meals. Sample Parents for the focus groups were recruited via a school letter. Eight was considered to be an appropriate sample size for a focus group [16]. The head teachers invited another teacher from their own school to take part in the study. Data collection tool A 12-item interview schedule which had established face and content validity from a previous study was used for the focus groups and teacher interviews [12]. The wording of some of the questions was slightly amended only in relation to whether the participant(s) were parents or teachers. Data collection and analysis Focus groups were undertaken in quiet well ventilated rooms away from the teaching areas. Permission was gained for involvement and audio recording. A facilitator and a moderator was present. The focus group took approximately and hour and the individual interviews 30 minutes. The narrative data were subsequently transcribed verbatim. Nvivo qualitat