School oral health program and outcome evaluation

Evaluation of School Oral Health Program in a Regionof Central Nepal

Kakuhiro Fukai1，2），Hiroko Yano2），Seishiro Kamachi2），Shuich Nakamura2）
Fukai Institute of Health Science, 3-86 Hikonari, Misato-shi, Saitama, 341-003, Japan
Association of Dental cooperation in Nepal

1）
2）

Abstract： Objectives: To evaluate the oral health outcomes of a school oral health program and to assess
factors related to oral health status and oral health behavior of children.
Design: Cross-sectional and 10-year follow-up study. The data was collected by self-administeredquestionnaire and dental examination based on the WHO method. Statistical analysis was performed with multiple logistic regression analysis.
Participants: The participants were 436 school children ages 11-16 years in 4 villages in central
Nepal.
Results: The percentage of children practicing oral hygiene behavior such as tooth brushing andusing toothpaste was more than 80%, and higher in females than males (p<0.01). However, 46.5%of females consumed sweets 2-3 times a week or more, compared with 28.7% of males (p<0.01).
More than 70% of respondents had good oral health knowledge concerning measures to prevent
oral disease. Dental caries reduction was observed among 14-16 year-old children who participated in the fluoride mouth-rinsing program for 4 years or more. Factors contributing to lower
sweets intake were gender (male), positive dental visit history, high oral health knowledge score,and positive oral health information source score. Factors contributing to reduction of dental
caries (DMFT>1) were school oral health workers’
registration period (>6 yrs) and duration of fluoride mouth-rinsing program (>4 yrs).
Conclusion: This study shows that the school oral health program contributed to improvement of
the oral health status and oral health behavior of children.
Key words : oral health behavior, oral health status, school oral health program, Nepal

Introduction
Oral health disparity worldwide is a key issue【correspondence】
Kakuhiro Fukai
Fukai Institute of Health Science
3-86 Hikonari, Misato-shi, Saitama, 341-003, Japan
Tel：+81-48-957-3315 Fax：+81-48-957-3315
E-mail：fukaik@fihs.org
Accepted for publication：30 October 2012

for researchers, dental practitioners, and healthpolicy decision makers. Despite reduction in theprevalence of dental caries in many developed
countries, children from disadvantaged communities continue to experience higher oral disease levels1-6）． Increasing levels of dental caries among̶ 152 ̶

ヘルスサイエンス・ヘルスケア

Volume 12，No.2（2012）

children have been observed in some developing

Methods

countries7，8）． It is especially difficult for thoseThis study consisted of two parts: cross-section-

countries to establish community-based oral healthal and follow-up. The participants were 436 school

care due to limited human and financial resources.

children ages 11-16 years. The data was collected

Schools provide an ideal setting for promoting oral

by written questionnaire and dental examination

health. In 2003, the World Health Organization

in four villages in a district of central Nepal in

published the document,“Oral Health Promotion:

2004.

An Essential Element of a Health-promoting

Questionnaire items covered socioeconomic fac-

School”as part of an information series on school

tors, oral health behavior, oral health knowledge

healt9）． A number of developing countries haveand attitude, health information sources, andrecently introduced school-based oral health educa-

parental attitudes about oral health. The conceptu-

tion and preventive programs aimed at improving

al framework for evaluation of oral health behavior

the oral health behavior and status of the childand oral health status is indicated in Figure 1. The．(Petersen PE et al., 2004). Howev-

schools in these villages have school oral healther, few outcome evaluations of the programs areprograms such as teacher training, regular oral

available.

health education, oral health screening by teach-

10，11）

population

The aims of this study are to evaluate the oral

ers, and fluoride mouth rinsing (Table 1). This

health outcomes of a 10-year school oral healthschool oral health program started in 1994. The

program and to assess the factors related to oral

duration of the program in each village is 10 years

health status and oral health behavior of children.

(Thecho), 6 years (Dhapakhel), and 3 years(Sunakothi and Chapagaun). The outcomes of the

Fig 1

Conceptual framework of oral health behavior and oral health status in this study
Table 1

School oral health program̶ 153 ̶

School oral health program and outcome evaluation

programs were measured in terms of oral healthgroup. Main areas of activity are dental treatment,

behavior, oral health status, and oral health related

school-based oral health promotion program, moth-

QOL. In assessing the program outcomes, statisti-

er and child health program, and oral health work-

cal analysis was performed by multiple logistic

ers training.

regression analysis (stepwise procedure) and ChiResults

square test.
Gender, ethnicity, and regional differences ofTable 2 shows the number of schoolteachers

outcomes were assessed with Chi-square test. In

who have participated in the oral health workers

addition, the effectiveness of the fluoride mouth-

training program. Duration of participation ranged

rinsing program was evaluated. Dependent factors

from 3 years to 10 years. There have been 92

in the multiple logistic regression analysis weretrainees from 31 schools in total.

local sweet intake behavior and prevalence of den-Table 3 shows the number of participants in thetal caries. Independent factors were gender, eth-school-based fluoride mouth-rinsing program. The

nicity, village of residence, period of registration ofduration of the FMR program was 10 years, 7school oral health workers (OHW), duration of fluo-

years or 2 years, depending on the village. The

ride mouth-rinsing program, oral hygiene behavior,

total number of participants in the FMR program

dental clinic access, score of health information

was 5,138 children.
Table 4 illustrates gender differences in oral

sources, and score of dental health knowledge.
The community-based oral health promotion

health behavior and oral health status of children

approach evaluated by this study was initiated inages 11-13 years. The percentage of children prac-

1989 through cooperation with a Japanese NGO

ticing oral hygiene behavior such as tooth brush-

Table 2

Schoolteacher participants in the oral health workers training program

Table 3

Participants in school-based fluoride mouth-rinsing program̶ 154 ̶

ヘルスサイエンス・ヘルスケア

Volume 12，No.2（2012）

ing and using toothpaste was more than 80%, andby 48.7% of males and 37.4% of females (p<0.05).

higher in females than males (p<0.01). However,

Caries prevalence was approximately 30%; DMFT

46.5% of females consumed sweets 2-3 times awas 0.45 in males and 0.64 in females.

week or more, compared with 28.7% of males

Table 5 illustrates community differences in oral

(p<0.01). More than 70% of respondents had good

health behavior and oral health status of children

oral health knowledge concerning measures toages 11-13 yrs. In oral hygiene behavior, sweets

prevent oral disease. As for oral health related

intake behavior and dental visit experience, signifi-

QOL, tooth pain during the previous year was felt

cant differences were found between villages

Table 4

Table 5

Gender differences in oral health behavior and oral health status of children ages 11-13 yrs.

Community differences in oral health behavior and oral health status of children ages 11-13 yrs.

̶ 155 ̶

School oral health program and outcome evaluation(p<0.01, p<0.05). Additionally, oral health knowl-

oral health knowledge score (OR: 0.17, 95%CI: 0.07-

edge concerning fluoride and perception of teeth

0.44) was found to be a significant factor. For 11-16

and mouth appearance were also clearly linked to

year-olds, contributing factors were gender (male),community of residence.

positive dental visit history, high oral health knowl-

Table 6 indicates differences in oral healthedge score, and positive oral health information

behavior and oral health status of children aged

source score (p<0.05). The odds ratio for these fac-

11-13 years that are linked to ethnicity.

tors ranged from 2.07 to 2.24.

Table 7 shows the relationship between the

The factors affecting dental caries (DMFT>1)

duration of fluoride mouth-rinsing program andare shown in Tables 10 and 11. The registration

DMFT index of children aged 11-13 yrs and 14-16

period of school oral health workers (>6 yrs) was

yrs. Dental caries reduction was observed among

found to be a significant factor in the 11-13 years

14-16 year-old children who participated in thisage group, while duration of the fluoride mouth-

program for 4 years or more.

rinsing program (>4 yrs) affected DMFT in 11-16

Multiple logistic regression analyses of factors
affecting sweets intake behavior are indicated in

year-olds. The odds ratios (95%CI) were 0.56 (0.330.97) and 0.53 (0.34-0.84) respectively.

Tables 8 and 9. In the 11-13 yrs age group, highTable 6Ethnic differences in oral health behavior and oral health status of children ages 11-13 yrs.

Table 7 The relationship between duration of fluoride mouth rinsing and DMFT index of children (11-13 yrs, 14-16 yrs)

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Volume 12，No.2（2012）

Table 8 Multiple logistic regression analysis of the relationship between sweets intake (more than once a day) andsocio-demographic and behavioral factors (11-13 yrs)
(SPSS backward stepwise procedure utilizes the liklehood ratio test)

Table 9 Multiple logistic regression analysis of the relationship between sweets intake (more than once a day) andsocio-demographic and behavioral factors (11-16 yrs)
(SPSS backward stepwise procedure utilizes the liklehood ratio test)

Table 10 Multiple logistic regression analysis of the relationship between prevalence of dental caries (DMFT>1)
and multivariable factors (11-13 yrs)
(SPSS backward stepwise procedure utilizes the liklehood ratio test)

Table 11 Multiple logistic regression analysis of the relationship between prevalence of dental caries (DMFT>1)
and multivariable factors (11-16 yrs)
(SPSS backward stepwise procedure utilizes the liklehood ratio test)̶ 157 ̶

School oral health program and outcome evaluation

Discussionof children in a community can be reached as a

The initial focus of our local health promotion

single group ; 3) teachers provide a reliable source

activities was the training of oral healthcare work-of manpower to implement the program ; 4) edu-

ers. In this region, where dentists and other oral

cation and evaluation systems are already in place;health professionals are virtually nonexistent, weand 5) joint activities with local businesses can alsobegan by holding a one-week training course to

be facilitated. Additionally, oral health education istrain local people in basic oral healthcare knowl-a good way for schools to teach positive dailyedge and skills. This first course was held in 1994,

health practices related to eating habits andand participants consisted of local health center

hygiene. We began introducing school oral healthemployees and public officials. However, it became

activities in 1994. The Japanese volunteers began

clear that these participants were not very moti-

by visiting several schools in Thecho and holding

vated and showed little enthusiasm for the course.

tooth-brushing lessons for the students and discus-

The next year, therefore, we shifted our focus andsions with the teachers. From that point, as theheld a similar course for schoolteachers, who

number of graduates from our oral health person-

turned out to have far more motivation and inter-nel training courses increased, we began spending

est.

more of our time in discussion and curriculum

The one-week curriculum-based healthcare per-planning with these trainees, gradually leaving

sonnel training courses were held during our mis-more and more of the in-school education to them.

sions at Thecho village. We used three textbooks

Within 4 years, we were able to implement oral

written in Nepali and English. The curriculum con-health education programs in all the elementary

sisted of lectures and practical training, and cov-

schools in Thecho, and then these programs

ered the basics of tooth anatomy as well as the

spread out to the nearby villages.

cause and prevention of dental caries and gum dis-

During this time, we also found that there was

ease. Beginning in 1998, we also held an advanced

great disparity between schools in terms of thecourse for graduates of the beginner course. The

children’s health and environment. For this reason,

advanced course introduced health education

we worked on establishing lines of communication

skills, the making of health-related educational

between teachers at different schools, and we alsomaterials, and dental check-up skills. And now thebegan the mother/child health program to teach

Nepali graduates of this program are playing an

about the dangers of increased sugar intake. We

increasingly important role, taking on teachingencouraged the spread of knowledge and skills

responsibilities.

from teacher to teacher by having graduates of

Health education in schools is one of the mostour oral health personnel training course go toeffective measures for promoting lifelong oral

nearby villages and teach the same course there.

health among individuals in both developed andAt this point, we were already seeing the birth of．There are a number of

an independent school health education program

benefits that make school oral health programs

administered by the Nepalis themselves, and thisparticularly effective : 1) the elementary school

program has now reached a total of four villages.

12，13）

developing countries

years are the time when children’s permanent

The other aspect of our school oral health pro-teeth come in, making the risk of dental caries

gram was the fluoride mouth-rinsing program.

especially high during these years ; 2) the majority

Since education programs take years to establish

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ヘルスサイエンス・ヘルスケア

Volume 12，No.2（2012）and even longer to produce results, we needed a

for a weekly health-related activity, resulting in amore immediate preventive program to combat

heightened awareness of health and hygiene

the rapid increase in caries that was resulting

issues.

from increased sugar intake due to urbanization.
Because of its teeth-strengthening properties, fluo-

Our goals for the school oral health programride application is the most effective method ofwere in three areas. The first was that students

caries prevention. Fluoride toothpaste is widely

would achieve basic knowledge of oral healthconsidered the most practical way of achieving

issues (causes of oral diseases and preventive

this effect, but it requires an economic environ-

methods). Specifically, we wanted students toment in which families have the means to buy theunderstand the relationship between sugar andtoothpaste. Therefore, in our region of operations,

tooth decay, to learn how to brush their teeth ade-

we decided to implement the more cost-effective

quately, and to understand the effects of fluoride

fluoride mouth-rinsing program. This program

mouth rinsing.

consisted of a weekly one-minute rinse with a 0.2%

The second goal was for teachers to understandNaF solution. It is a very simple method of admin-

oral health issues (causes of oral diseases and pre-istration, but special training and safety precau-

ventive methods) and develop oral health educa-

tions were required in order to ensure the safetion skills in order to teach age-appropriate oral

storage, measurement, and use of fluoride powder

health information to their students. The third goalat these elementary schools.

was to put in place an oral health education cur-

In 1994, we selected two Nepalis who had par-riculum that is integrated into the schools’
generalticipated in our other activities and carefully

health and primary health care (PHC) pro-trained them in the proper procedures for measur-grams14，15）．

ing the fluoride powder and mixing the mouthrinsing solution. We were concerned about

In the multivariable analyses, dental caries

whether they would be able to master these pro-prevalence in children was associated withcedures during the short period of our 10-day mis-

involvement in the fluoride mouth rinsing pro-sion. However, their eagerness to learn proved

gram, presence of school oral health workers, oral

quite strong, and it was decided that they would

health knowledge/belief, and oral health informa-

go ahead and begin a 6-month trial program withtion sources.

2 classes (50 students) in one of the Thecho ele-

In conclusion, this study shows that the school

mentary schools. That summer when we returned

oral health program contributed to improvement

to Nepal, we found the students carrying out theof the oral health status and oral health behavior

fluoride mouth-rinsing program perfectly. Fromof children.

that starting point, we began expanding the distribution of the fluoride powder, along with an evalu-

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̶ 160 ̶