Journal of the National Institute of Public Health 2011 Vol.60 No.1 p.44−49＜Original＞
Child-to-child school health program (CtCSHP):
Its impact on the oral health behavior of grade 1 pupils
in the division of La Union, Philippines
Artemio Rivera L ICOS, Jr.
Department of Health, Center for Health Development-Ilocos
Abstract
Objective To determine the ef fectiveness of the Child-to-Child School Health Program (CtCSHP) on the oral healthbehavior of Grade I pupils in the Division of La Union, Philippines within ﬁve months of implementation.
Methods A randomized trial was applied to the subjects. First, an assessment of the oral health behavior of the pupils interms of toothbrushing and sodium fluoride mouth rinsing was conducted before the start of the study. The schools wererandomly distributed to either the test group or control group. The Child-to-Child School Health Program (CtCSHP), utilizing
the “Little Doctors’ Club,” and dental health education were provided to the test group, while only dental health education wasprovided to the control group. Toothbrushing and mouth rinsing with sodium ﬂuoride (hereafter simply “mouth rinsing”) were
the prevention methods used. Data was gathered using toothbrushing and mouth-rinsing cards. An assessment of the oral
health behavior and an analysis of the signiﬁcant differences between the oral health behaviors of the test and control groups
were conducted after ﬁve months after the interventions. Eight public elementary schools were randomly chosen from the two
districts in the Division of La Union to comprise the test group (four schools) and the control group (four schools). A total of
353 Grade 1 pupils took part in the study: 178 pupils in the test group and 175 pupils in the control group. To establish whether
or not there is a signiﬁcant difference between the oral health behaviors of the test and control groups, the data were entered ina statistical tool pack and analyzed with a t-test.
Results The oral health behavior of the test group in terms of toothbrushing and mouth rinsing improved during November
but deteriorated during December. Great progress was observed during the succeeding months from January to March. The
oral health behavior of the control group improved only during November, eventually declining from December to March.
Moreover, although there was no signiﬁcant difference between the test and control groups in toothbrushing for November(p=0.1018), a signiﬁcant difference was noted from the months of January to March. Regarding mouth rinsing, it was found that
there was a signiﬁcant difference between the test and control groups in all the months (<0.001).
Conclusion The study reveals that the CtCSHP was effective in improving the oral health behavior of the pupils. Thisimplies that the actual involvement of the little doctors in the CtCSHP in conducting the toothbrushing and mouth rinsing drills
contributed immensely to the attainment of their objectives. The signiﬁcant difference found between the oral health behaviorsof the test and control groups revealed further that the CtCSHP has been successful in raising and at the same time sustaining
the oral health behavior of the pupils.
Keywords: child-to-child approach, oral health behavior, toothbrushing, sodium ﬂuoride mouth rinsing.
(accepted for publication, 23rd February 2011)

Ⅰ . Introduction
The last few decades have been a period of great debate
and creativity regarding the philosophy of children’s rights,

especially child participation. The conventional concept of
the child being dependent, incapable and helpless has beenstrongly challenged. In the new paradigm, children are nolonger measured against adult parameters, whereby they

Corresponding Author: Artemio R. Licos, Jr. DDM, MPH
San Fernando City, La Union-Region I, Philippines
E-mail: licosddm@yahoo.com

44

J．Natl．Inst．Public Health，59（4）：2010Artemio Rivera LICOS, Jr.
are declared to “have not yet developed into adults” andtherefore “are not sufﬁciently competent.” [1]Today, the child-to-child approach is a growing trend
across the globe to empower children and to recognize
their potential in a nation’s development. The child-to-childapproach refers to a style of child empowerment wherechildren are active participants in their own development
and in the development of other children. In the Philippines,
the child-to-child approach has become a powerful aid in
the implementation of the “Bahay Tuluyan.” This programis aimed at improving the condition of abused or exploitedchildren and street children by providing not only services
but by also empowering and challenging them to improve
the situation in which they ﬁnd themselves [2].
There is a School and Community Health Project (SCHP)in Nepal that was conducted through the Child Initiative
Program for health–related activities in schools andcommunities, whereby a children’s club with seven to nine
members was formed and facilitated various activities, suchas school-toilet and drinking-water management campaigns.
[3] That project and the concepts discussed above gave
this researcher the idea that the same approach could be
utilized to improve the oral health status of schoolchildren.
Therefore, the researcher launched the “Child-to-Child
School Health Program” (CtCSHP) in 2006, in ten selectedpublic elementar y schools of the Division of La Union.
The initial stage of the program’s implementation was theforming of a “Little Doctors’ Club” in each school. The clubwas composed of 10 pupils from Grades 3 to 5. Basic skills
relative to good oral health practices were provided andin return, the pupils disseminated such acquired learning
to their schoolmates, according to the concept of a Childto-Child Approach. The program aimed at raising the oral
health status and improving the oral health practices among
the pupils, which is hoped to decrease the prevalenceof dental caries. The sur vey indicated that the state ofdental health in the Philippines is appalling, evident in thetoothless smiles of the children. The 2005 National Oral
Health Sur vey among the Public School Population in
the Philippines revealed that 97.1% of 6-year-old children
suf fered from dental decay.[4] One of the researcher’sstudies, entitled: “An Assessment of the dental caries statusof 12-year-old schoolchildren in the Division of La UnionRegion 1: Basis for policy recommendations” revealed
that the dental caries status of the subjects was poor. His
ﬁndings are in fact, corroborated by the results of the 2009
Expanded Universal Medical and Dental check-up of theDivision of La Union, wherein 88% of the Grade 1 pupils had
dental caries, [5] which could be attributed to their poor oral
health behavior.
The objective of this study is to determine theef fectiveness of CtCSHP in improving the oral healthbehavior, in terms of daily toothbr ushing and mouthrinsing with sodium fluoride (hereafter simply “mouth
washing”), among the Grade I pupils of the Division of
La Union, Philippines after five months of the program’s
implementation. Speciﬁcally, it is intended to (1) determine
the oral health behavior of the test group in terms of daily
toothbrushing and weekly mouth rinsing, (2) determine theoral health behavior of the control group in terms of daily
toothbrushing and weekly mouth rinsing, and (3) determine
whether or not there is a signiﬁcant difference between theoral health behavior of the test group and that of the control
group in terms of daily toothbrushing and weekly mouthrinsing. In conducting the study, the researcher was guided
by the following hypotheses: (1) the status of oral healthbehavior of the test group in toothbrushing and mouthrinsing is regular; (2) the status of oral health behaviorof the control group in toothbrushing and weekly mouthrinsing is irregular; and (3) there is no signiﬁcant difference
between the oral health behaviors of the test and control
groups in terms of daily toothbrushing and weekly mouthrinsing.

Ⅱ．Methods
This study was a randomized trial conducted in the
Department of Education, Division of La Union, Philippines.
La Union is a Province of the Philippines, and it is locatedin the Ilocos Region in Luzon. La Unión , a Spanish phrase
meaning “The Union” or “The Unity,” was formed in 1850
during the time of the Spanish colonial government. The
economy is diversified with ser vice, manufacturing, andagricultural industries spread throughout the province.[6]The research paradigm of the study is illustrated in
Figure I. First, an assessment of the oral health behaviorof the pupils in terms of daily toothbrushing and weekly
mouth rinsing was conducted before the start of the study.
The schools were randomly distributed to both test andcontrol groups. The Child-to-Child School Health Program(CtCSHP), utilizing the “Little Doctors’ Club,” and Dental
Health Education were provided to the test group. Dental
Health Education only was provided to the control group.
Two methods of dental caries prevention were utilized inthis study. The ﬁrst was daily toothbrushing using ﬂuoride
toothpaste. The ﬂuoride that remains on the teeth protects
the teeth, so rather than rinsing the mouth with water after
toothbrushing, it is best to just thoroughly spit out theremaining toothpaste.[7] The second method was weekly
mouth rinsing with a 0.2% sodium fluoride solution. The
solution is prepared by adding 2 grams of sodium ﬂuoride
to 1 liter of water. Two teaspoonfuls of the solution is placed

J．Natl．Inst．Public Health，60（1）
：2011

45

Child-to-child school health program (CtCSHP)
Assessment of the oral health behavior of the pupils before the start ofthe study
Control group

Test GroupChild-to-Child School
Health Program
through the “Little
doctors” and Dental
Health Education

Using 2 Methods ofPrevention:- Daily toothbrushing- Weekly sodium
fluoride mouth rinsing

Dental Health
Education

DATA GATHERING
Assessment of the oral healthbehavior of the test group

Assessment of the oral healthbehavior of the control group

Analysis of the significant difference of the oral healthbehavior among the test and control groups

Figure 1. Research paradigm of the study

into the mouth then, gargled vigorously for 1 minute, andspit out.[8] The Philippine government encourages theuse of sodium ﬂuoride mouth rinsing, and it costs only Php
1.98/year per child.[9]Data were gathered using the toothbrushing and mouthrinsing cards. Checkmarks in the cards show the numberof times the pupils had brushed their teeth and rinsed withsodium ﬂuoride. In the test group, a teacher supervised thelittle doctors’ initiation of the daily toothbrushing and weekly
mouth-rinsing drills. In these drills, grade I pupils form a line
and simultaneously brush their teeth (daily) and rinse theirmouths with a sodium ﬂuoride solution (weekly). After the
drills, the little doctors record each pupil’s participation byentering a check mark in their participation cards each daythat the pupil participated and an x mark each day he/she
did not participate, and submitted the cards to the teacher.
Regarding the control group, the teacher distributed thecards directly to the pupils before the drills and collected
them afterward. The data were consolidated by the teachers
in both groups. Finally, an assessment and analysis of thesignificant differences between the oral health behaviorsof the test and control groups was conducted after the 5thmonth of the drills for both groups.
The sample population was derived randomly from thetwo neighboring districts of San Juan and Bacnotan. These
districts have almost the same number of schools, 16 and 17
respectively, and all of these schools are public elementary
schools. Dental ser vices are rendered by only one publichealth dentist covering both districts. The pupils of theschools of the identified districts should manifest similar
oral health behaviors in terms of toothbrushing and mouthrinsing. Random selection was done in determining the four
schools of each district. Two schools were assigned as thetest group and another two schools were designated as thecontrol group for each district.

46

A T-test was conducted in this study to find out if there
was a significant dif ference between the oral healthbehavior of the test group and that of the control group.
The T-test was used to compare two means to determine
the probability that the difference between such means isgreater than that expected by chance.[10] Stata 11 was usedas statistical software.
Ethical approval for the study was obtained from the
National Institute of Public Health (NIPH-IBRA # 10005),
Wako City, Japan. The parents of the pupils were informed
about the purpose and design, and they signed an informed
written consent. The study was approved by the Departmentof Education through the Schools Division Superintendentof the Division of La Union, Philippines.

Ⅲ．Results
This study was carried out from November 2008 to March
2009. There were 353 Grade 1 pupils who ser ved as the
subjects, of which, 178 were in the test group and 175 werein the control group (Table 1).
Table 1. Distribution of respondents according to school.
(D1) BACNOTAN DISTRICTTEST Group

Grand
total

(D2) SAN JUAN DISTRICTMale Female Total

TEST Group

Male Female

Total(S1) Baroro

24

16

40 (S3) Nadsaag

38

36

74

(S2) Quirino

6

15

21 (S4)Urbiztondo 18

25

43

30

31

61

61

117

23

CONTROL Group

TOTAL

56

(S5) Cabaroan

31

28

59 (S7) Bacsayan 16

7(S6) Zaragosa

29

28

57 (S8) San Felipe 22

14

36

60

56

116

21

59

GRAND total＊D= district

178

CONTROL Group

TOTAL

38

175
353

＊S= school

Table 2 shows the number of pupils brushing their teeth
at each school. Among all the schools that participated in
the study, a test group school—Urbiztondo school of San
Juan district—consistently had the highest mean number
in both Januar y and March (20.98 in both months). On
the other hand, a control group school—Bacsayan schoolof San Juan district—had the lowest mean number during
December (2.30). Figure 2 further shows trends in the mean
number of pupils toothbrushing at each school. All schools
in both groups started with a high mean number of pupils
toothbrushing during the month of November but showed avery marked decline in the mean number during December.
There was a great dif ference between the groups inJanuary, when the mean number of the test group increased
dramatically, reaching the highest level, in contrast to themean number of the control group’s schools, which only
slightly increased.

J．Natl．Inst．Public Health，60（1）：2011Artemio Rivera LICOS, Jr.

Table 2. Number of Brushing in each school
Group

District(D1)
Bacnotan
Test(D2)
San Juan(D1)
Bacnotan
Control(D2)
San Juan＊D= district

School

Nov.

Dec.

Jan.

Feb.

Mar.

Mean 14.75(S1)Baroro（N=40) SD
5.40

7.45 17.13 17.33 17.13

Mean 16.24(S2) Quirino（N=21) SD
2.36

4.52 18.86 18.76 18.52

Mean 10.81(S3) Nadsaag（N=74) SD
2.73

6.86 15.61 16.61 15.42(S4) Urbiztondo Mean 10.23（N=43) SD
4.04

5.88 20.98 20.37 20.98

2.24

1.47

2.04

3.35

1.49

3.64

2.45

1.64

3.30

2.52

1.50

4.17

3.26

1.12

1.02

1.12

Mean 18.34 11.41(S5)Cabaroan（N=59) SD
1.56 3.05

8.03

6.42

5.42

3.31

0.70

1.46

Mean 13.86(S6) Zaragosa（N=57) SD
6.04

8.63

6.63

6.68

4.75

4.10

2.19

1.23

1.01

Mean
(S7) Bacsayan（N=23) SD

6.00

2.30

6.74

6.39

5.70

5.15

3.10

0.54

0.50

3.23

(S8) San Felipe Mean
（N=36) SD

8.39

4.39

7.17

8.81

6.42

7.72

3.75

2.30

3.72

2.97

mean number (3.91) from November ‘08 to March ‘09. A
control group school, Zaragosa of Bacnotan district, hada zero value during March (0.00). Figure 4 further shows
trends in the mean number of pupils mouth rinsing at eachschool. All schools in both groups had a high mean number
during November but showed a ver y marked decline in
December. In January, there was a great difference between
the groups: the test group was signiﬁcantly higher in termsof mouth rinsing than the control group’s schools, which
p <0.001

p = 0.102

p <0.001

p <0.001

p = 0.009＊S= school

Figure.4 Trends in mean number of Toothbrushing of each group
Table 3. Number of SFMR in each school
Group District

School

Nov.

Dec.

Jan.

Feb.

Mar.

Mean

2.83

1.55

3.40

3.65

3.30

（N=40) SD(D1)
Bacnotan (S2) Quirino
Mean

1.30

0.78

0.90

0.86

0.72

2.67

1.57

3.62

3.48

3.00

(S1) Baroro（N=21) SD

0.58

0.81

0.80

0.68

0.00

Mean

2.26

2.03

3.39

3.54

3.45

（N=74) SD(D2)
San Juan (S4) Urbiztondo Mean

0.83

0.88

0.86

0.50

0.50

2.26

1.35

3.91

2.53

2.65

Test

(S3) Nadsaag（N=43) SD

0.79

0.95

0.29

0.83

0.78

Mean

3.69

2.69

0.10

0.20

0.49

（N=59) SD(D1)
Bacnotan (S6) Zaragosa
Mean

0.50

0.56

0.36

0.76

0.95

2.98

2.77

0.33

0.12

0.00

(S5) Cabaroan（N=57) SD

Control

Figure.2 Trends in mean number of Toothbrushing of each scool

Figure 3 presents trends in the groups’ mean numbersof pupils toothbrushing daily from November ’08 to March‘09. It can be seen from the figures that there was no
signiﬁcant difference in the mean number during November(p=0.1018). The control group did show a higher mean
number, but the difference was not great. In December, thecontrol group again showed a higher mean number of pupils
toothbrushing daily, though there was not a significant
dif ference between the two groups (p=0.009). However,from Januar y to March a significant difference between
the two groups was seen. The test group showed a marked
dif ference as compared to the control group (<0.001).
The test group had a higher mean number of pupils
toothbrushing daily than that of the control group.
Table 3 shows the number of pupils par ticipating in
sodium ﬂuoride mouth rinsing (referred to as SFMR in thetable) in each school. It shows that among the test group’s
schools, Urbiztondo of San Juan district had the highest(S7) Bacsayan(D2)
San Juan(S8) San Felipe

Mean

1.01

0.42

0.93

0.54

0.00

2.00

1.43

0.61

0.74

0.26

SD

1.28

1.12

1.12

1.05

0.86

Mean

2.75

1.39

0.14

0.50

0.36

SD

1.65

0.93

0.35

0.97

0.83

＊SFMR= sodium ﬂuoride mouth rinsing

Figure.4 Trends in mean number of SFMR of each school

J．Natl．Inst．Public Health，60（1）
：2011

47

Child-to-child school health program (CtCSHP)
displayed a dramatic decline with a very low mean number
in all months except for November.
Figure 5 shows trends in the mean number of pupils
mouth rinsing in each of the test and control groups’ schools
from November ’08 to December ’09. It can be gleaned fromthe ﬁgures that the difference between the two groups was
signiﬁcant. For November and December, the control group
had a higher mean number as compared to the test group.
However, for the succeeding months, the test group showeda signiﬁcantly higher mean number of pupils mouth rinsing
than the control.
<0.001<0.001<0.001<0.001<0.001Figure.5 Trends in mean number of SFMR of each group

Ⅳ．Discussions
The child-to-child approach has already been used in
the Philippines, for example in “Bahay Tuluyan,”[2] which
continues to integrate the child-to-child approach into all
par ts of the program, as it is an ef fective tool for childparticipation.
In harmony with this approach, a researcher in the
Division of La Union launched the “Child-to-Child School
Health Program” (CtCSHP), wherein pupils take an activerole in improving the oral health behavior and practices of
their schoolmates, such as daily toothbrushing and mouthrinsing.
Before the start of the study, it was shown that both thetest group and control group manifested almost the samestate of oral health behavior, that is, neither were performing
the daily toothbrushing and weekly mouth rinsing at school.
The mean numbers for toothbrushing and mouth rinsing
obtained during November for both the test group andcontrol group suggested an improved state of oral healthbehavior. The deterioration in the oral health behaviorof both groups during December was not alarming or
surprising because there were days in this month whichwere not regarded or counted due to the semester break
and holidays, when pupils were not at school.
The data obtained during January, February and Marchcreated an opposing trend in the oral health behavior of48

the respondents between the control and test groups as
reﬂected in ﬁgures 2 and 4. The ﬁgures portray that the oral
health behavior of the subjects of the test group progressed,
while the oral health behavior of those of the control group
deteriorated.
The oral health behavior of the test group, both in termsof toothbrushing and mouth rinsing escalated, especiallyduring January, and was sustained in the following monthsof February and March. In fact, the pupils of the test group
had almost perfected the tasks of brushing their teeth daily
and using mouth rinse weekly at school.
As the test group advanced in their oral health behavior,
the control group seemed to lag behind, which is evident in
the downward trend shown in ﬁgures 2 and 4. The reason
for the improved oral behavior of the control group in
November would have been their excitement in using their
toothbrushes and their eagerness to use the sodium ﬂuoride
for mouth rinsing. However, when their excitement andeagerness had waned, their oral health behavior went backto a poor state, as seen in the following months. This showsthat there are still pupils who are not regularly exposed tofluoride or who are not adequately informed about dental
hygiene practices, thus, there is potential for public healthinterventions to improve their dental health.[11]Moreover, the findings disclosed in figure 3 show that
there was a statistical dif ference in daily toothbrushing
between the test and contr ol gr oups ever y month
except November (p=0.1018), when the control group
showed a higher mean number of daily toothbrushing. In
the month of December, the control group also showeda higher mean number of daily toothbrushing, but there
was not a significant difference between the two groups(p=0.009). That the control group had a higher mean
number could be due to the exposure of such program. The
little doctors of the test group had to ﬁnd time and set theirminds to the program. However, from Januar y to March,a significant difference between the two groups was seen.
The test group showed a marked difference as compared tothe control group (<0.001) and had a higher mean numberof pupils toothbrushing daily. This indicates that the test
group had better performance in daily toothbrushing, which
may have been due to the little doctors who were in chargeof the program, while the control had no little doctors andperformed the toothbrushing drill on their own. Figure
5 shows that for November and December, the control
group had a higher mean number of pupils mouth rinsing
as compared to the test group. However, for the following
months, the test group showed a signiﬁcantly higher mean
number of pupils mouth rinsing than the control. Hence,
it can be fur ther inferred that the CtCSHP utilizing thelittle doctors was ef fective in bolstering the oral healthJ．Natl．Inst．Public Health，60（1）：2011Artemio Rivera LICOS, Jr.
behavior of the pupils in terms of their daily toothbrushing
and weekly sodium fluoride mouth rinsing. The findingsof this study support the idea that children, from whatever
circumstances, are capable of helping themselves. Children
who have acquired the appropriate skills, knowledge andattitude through various training programs are then able
to share those assets with other children. Children who
are able to effectively share their skills with other children
are generally good leaders, role models and facilitators.2)
Schoolteachers also ser ved a vital role in this study: theoral health knowledge was transferred from the dental
professionals to the schoolteachers, and then to the children
and their parents. Schoolteachers helped schoolchildren
establish a healthy lifestyle that is both productive andsatisfying.[12] In this study, the teachers super vised andmonitored the pupils’ daily toothbrushing and mouth rinsing
drills in school.
Based on the study results, the null hypothesis in question
was rejected. The Child-to-Child School Health Program”(CtCSHP) was an effective way to improve oral hygiene andestablish positive oral health behavior in the Division of La
Union, Philippines.

Acknowledgement
The researcher would like to thank: the Japan
government, for providing the grants for study at the
National Institute of Public Health; the Foundation for
Public Health Promotion, for covering part of the researchexpenses; the Depar tment of Education, Division of La
Union headed by the Schools Division Superintendent, Dr.
Edna C. Leal, for their support and approval in conducting
the study; the pupils and teachers who participated in the
study; and the Department of Health, CHD- Ilocos, headedby the OIC- Director IV, Dr. Valeriano V. Lopez, Jr., for theirsuppor t. In addition, the researcher would like to of fer
special thanks to: Dr. Yuichi Ando, the researcher’s thesis
advisor; Fr. Jonathan Bitoy, CMF; Mr. Joseph Cristobal;
Dr. Madeline Retuta; Dr. Rosario Pamintuan; Ms. Joslyn
Bautista; Dr. Liezl Mique; Dr. Vanessa Cayabyab; Engr. Luis
Arlantico Tattao; and Ms. Ana Linda Cabanban for theirvaluable intellectual advice, as well as to my family—Jovy,
Litley, Winsley and Yaley—for the inspiration and love, andmost of all, to our Almighty God.

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