Impact of oral health education on primary school children before

HEALTH PROMOTION INTERNATIONAL© Oxford University Press 1996

Vol. 11, No. 3Printed in Great Britain

Impact of oral health education on primary schoolchildren before and after teachers9 training in Tanzania

URSULINE NYANDINDIDepartment of Preventive and Community Dentistry, University of Dar es Salaam, Tanzania

ANNELI MBLENHealth and Development Cooperation Group, National Agency for Welfare and Health in Finland,Helsinki, Finland

TUIJA PALIN-PALOKASDepartment of Preventive Dentistry and Cariology, University of Kuopio, Finland

VALERIE ROBISONDepartment of Dental Ecology, University of North Carolina, USA

SUMMARYOral health education is part of the primary schoolcurriculum in Tanzania. However, most of the teachersresponsible for it lack training and motivation for thetask. Their oral health education sessions are deficient incontent and in methods, only addressing oral hygiene bylectures. Thus, modified oral health education wasdesigned and teacher training workshops were carriedout in one district by a dental team in liaison with schooladministrators. After training, the teachers taught avariety of oral health issues and pupils actively studiedthe concepts and practical skills for dietary choices andtoothbrushing. This report describes the impact of oralhealth education given by teachers before and after theyhad been trained in the workshops. The impact of thesessions was assessed as changes in the pupils' oral health

knowledge, attitudes and practices. Three random sam-ples, each with 200 pupils, including conventional andmodified session groups and a reference group not givenoral health education at school, were interviewed andexamined. The group that received modified oral healtheducation had better knowledge of oral health, reportedreduced consumption of sugary foods and increasedtoothbrushing frequency, and had better 'mswaki'(chewing-stick) making skills and slightly improvedoral hygiene; in comparison with the referents. Thegroup with conventional oral health education had some-what better oral health knowledge but their practiceswere no better than the referents'. The results emphasizethe need for providing training, guidance and feedback toimplementors of oral health education programmes.

Key words: impact, oral health education, schools, Tanzania

INTRODUCTION

As compared with the prevailing fatal diseases,mainly communicable diseases like malaria,pneumonia and diarrhoea, oral diseases are nota major health problem in Tanzania. Oraltumours and injuries are rare. However, themajority of adults and school-age children inTanzania are affected by gum disease and/or

dental caries (Ministry of Health and SocialWelfare, 1988; Mosha el al., 1994).

Among primary school-age children in Tanza-nia toothbrushing seems to be prevalent but oralhygiene is, nevertheless, poor and gingivitis iscommon (Frencken et al., 1986; Kerosuo et al.,1986; Mandari, 1988; Nyandindi, 1988; Normark

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194 U. Nyandindi et al.

and Mosha, 1989; Mumghamba, 1990; Nyan-dindi et al, 1994a). Studies undertaken amongthe children in this age group also indicate lowconsumption of sugary foods but wide preferencefor them (Nyandindi, 1988; N0rmark andMosha, 1989; Nyandindi et al, 1994a). Cariesaffects about a third of the primary school-agechildren (Frencken et al., 1986, 1990; Kerosuo etal., 1986; Mandari, 1988; Nyerere, 1988; Bloch etal., 1989; Axell and Johansson, 1993; Mosha etal., 1994). The average number of decayed, miss-ing and filled teeth per child (dmft or DMFT) islow; for example, the DMFT index for 12-year-olds is within the global goal of three or less bythe year 2000. Oral health knowledge among thechildren is poor (Nermark and Mosha, 1989;Nyandindi et al., 1994a).

An oral health education programme aimed atfostering proper oral health behaviour amongschool-age children was started in Tanzania in1982, and is being implemented by teachers atprimary schools (Ministry of Health and SocialWelfare, 1988). There are 10 437 primary schools(first to seventh grades) attended by 3.5 millionchildren (~ 15% of the total population) in a year(Ministry of Education and Culture, 1992). Oralhealth education is scheduled for first-grade aspart of health lessons taught by the classroomteachers in two 30-min lessons a week (Taasisi yaElimu, 1987). Considering the oral health situa-tion of school-age children in Tanzania, currentoral health education does not seem adequate incontent and methods. It consists mainly of oralhygiene issues taught in lectures only (Taasisi yaElimu, 1987; Nyandindi et al, 1995). Moreover,the Tanzanian primary school teachers' knowl-edge, skills and motivation for giving oral healtheducation are poor and most of them have hadno training for the task (Nyandindi et al, 1994b).

With the aim of improving the quality ofschool oral health education within the limitedresources in Tanzania, a new manual for teachingthe subject and a teacher's training programmewere designed and provided to the teachers of onedistrict, Ilala. These actions were organized by ateam consisting of the present researchers, thedistrict's dental personnel and the district'sschool administrators. The manual and trainingwere planned to meet the surveyed oral healtheducation needs of pupils and to suit local reali-ties. All teachers (n = 125) in the district super-vising first-grade classes, in which oral healtheducation is scheduled, attended the trainingworkshops and were provided with the manual

as well as some other teaching aids. The districtdental personnel carried out the workshops.

The teachers' performance in teaching the oralsubject was assessed by observing their oralhealth education sessions 2 months after thetraining. The sessions had improved substantiallyin both content and methods in comparison tothose observed before the teachers' training. Theteachers now addressed both oral hygiene anddiet, and used demonstration and practical meth-ods to teach pupils the practical skills for healthydietary choices and effective toothbrushing(Nyandindi et al, 1995).

The aim of this study was to further evaluatethe impact of the teachers' training, by assessingthe improvements in their pupils' oral healthknowledge, attitudes, practices and skills, in com-parison with the pupils' situation before theteachers' training.

SUBJECTS AND METHODS

Study design and samplesThe evaluation of the impact of the conventionaland the modified oral health education amongpupils was conducted at five (out of 35) urbanprimary schools and five (out of nine) ruralprimary schools which were randomly selectedfrom urban and rural areas in the Ilala district. Abetween-group study design (Adams and Schva-neveldt, 1985) involving three samples of pupilswas used: a reference group, a conventional ses-sion group and a modified session group.

Each sample (group) consisted of 200 first-grade pupils who were randomly chosen fromeach of the ten schools involved. In these schools,first-graders had been divided into two or morestreams (classes) of usually over 50 pupils each.One of the school-entering classes of 1990 at eachof the ten schools was randomly chosen andstratified by gender. Then, ten boys and tengirls were randomly chosen from each stratumto form the reference group (aged 5-15 years,mean 8.99, SD 1.84 years). These children hadnot received oral health education at school at thetime of study but would be given it later in theyear as scheduled in their curriculum. Anotherrandomly chosen first-grade class of 1990 in eachof the ten schools was given oral health educationby their classroom teachers, in their usual way.Each of these classes was also stratified by genderand ten boys and ten girls were randomly selected


from each stratum to comprise the conventionalsession group (aged 6-15 years, mean 9.55, SD1.96 years). The same teachers who had con-ducted the conventional sessions also taught themodified sessions to their new first-grade classesthe following year (1991), after they had beentrained in the workshops. From each of these newclasses, ten boys and ten girls chosen randomlyfrom each gender stratum comprised the modi-fied session group (aged 5-15 years, mean 9.46,SD 2.05 years).

The oral health education sessionsThe content and the methods of the conventionaland modified sessions have been previouslyreported (Nyandindi et al., 1995) and are onlybriefly described here.

The conventional oral health education ses-sions were held in classrooms. The classes wereoften very large (37-184 pupils), with manypupils sitting on the floor as there were too fewdesks. To teach the conventional sessions, beforethe teachers' training, each teacher brought alongthe 'Ministry of Education' health educationguide, but no other teaching aids. The teacherstaught oral hygiene for about 30 min (one schoolperiod). Daily toothbrushing was stressed forprevention of bad breath or tooth decay. Theteachers recommended both factory-made tooth-brushes and self-made 'miswaki' (chewing-sticks)as effective but gave no advice on how to produceor use them. They encouraged pupils to usetoothpaste, but also charcoal and ash as lesscostly substitutes. The pupils remained passivethroughout the lectures.

The modified oral health education sessionsgiven by the teachers after their workshop train-ing were attended by as large number of pupils asthe conventional sessions. The teachers now usedthe new manual and other teaching aids, and thepupils brought with them materials for practicingtoothbrushing and 'mswaki' making from home.In accordance with the guidance given, eachteacher conducted the sessions in two successiveparts. The first part took place in a classroom for30 min; basic functions and morphology of teeth,and the causes and prevention of gum disease andtooth decay were discussed. The pupils also prac-ticed in identifying non-sugary food items harm-less to teeth. The second part lasted for about onehour, focused on toothbrushing, and took placeoutside the classrooms (due to lack of wash-basins). The teacher demonstrated and everychild practiced how to make a 'mswaki' and

Impact of oral health education 195

how to brush teeth properly. Each teacher super-vised the children's performance. They instructedthe children to regularly replace their tooth-brushes, of any type, and also encouraged themto use toothpaste, but discouraged brushing withcharcoal and ash. The teachers also asked pupilsto spread their new oral health knowledge andskills to their families. Unlike the former sessions,in the modified sessions the pupils were activelyinvolved throughout the sessions.

Data collection

The samples of pupils given each of the two typesof oral health education were studied 4 monthslater. The methods for assessing the impact, asregards oral health knowledge, attitudes, prac-tices and skills of these children, were the same asthose used with the referents and have beendescribed in a previous report (Nyandindi et al.,1994a). The children were interviewed in a class-room by a teacher and a health education workertrained for the task. For assessment of oralhygiene, the outer and inner surfaces of eachpupil's 12 index teeth (first permanent molars,second deciduous molars and permanent centralincisors) were examined by a dentist, who did notyet know the pupils' status of exposure to oralhealth education. This was done outdoors indaylight in an ordinary chair using only adental mirror. Plaque was recorded as presentonly when clearly visible on the index surface.Repeated examination of plaque within the sameday among 20 subjects (10%) examined first ineach sample (referents, conventional and modi-fied session groups) showed high intra-rater relia-bility; the mean kappa values were 0.93, 0.95 and0.93 respectively. The children's abilities to makea 'mswaki', which is being recommended as alow-cost alternative to the modern toothbrush,were also examined. Each child was given a tree-twig, a knife and a cup of water, and made a'mswaki', which was recorded as suitable only ifit had soft bristles and was at least 18 cm long sothat one could reach molars with the brush.The impacts of oral health education on pupils'oral health knowledge, attitudes, practices andskills were compared between the conventionaland the modified session groups, and the findingsfrom each session group were also compared withthe knowledge, attitudes, practices and skills ofthe reference children. Chi-square statistics andStudent's /-test were used to evaluate the differ-ences between the groups.



RESULTS

Oral health knowledgeAmong the pupils who had participated in themodified oral health education sessions, knowl-edge about tooth decay and gum disease (theiroccurrence, causes and prevention) was signifi-cantly better than among the children in thereference group or conventional session group.Among the pupils who had attended the conven-tional oral health education sessions, only knowl-edge about gum disease was better than amongthe referents. Irrespective of their exposure toschool oral health education, the majority ofthe children studied said they brushed theirteeth to prevent tooth decay. Only among chil-dren who attended the modified sessions, wasprevention of gum disease one of the motivesfor toothbrushing (Table 1).

Dietary practices and attitudes

When asked about their dietary habits 4 monthsafter the first sessions, about a third of thechildren studied, irrespective of their oral healtheducation exposure, had not eaten any sugaryitems during the previous day. The rest, abouttwo-thirds, had eaten sugary foodstuffs once ortwice, mostly sugared tea, ice-cream, biscuits, softdrinks or sweets (Table 2). Notably, among the

children who had attended the modified oralhealth education sessions, sugar consumption(in tea) was less frequent than among the con-ventional session group and the referents. Thefive most common non-sugary foods eaten theprevious day were hard porridge, rice, vegetables,meat and cassava. When the most commonlyeaten five sugary and five non-sugary foodswere displayed for each pupil to choose thefavourite one, significantly (p = 0.001) fewerchildren in the modified session group (31%)then in the other groups (40% in the conven-tional session group, 48% in the reference group)chose a sugary item. The modified session grouphad the best knowledge about the harmfulness ofsugary food items to teeth, whereas many chil-dren in the reference and conventional sessiongroups regarded soft drinks and biscuits as harm-less to teeth (Table 2).

Oral hygiene practices and attitudesMost children who had participated in the mod-ified sessions brushed their teeth twice a day,while in the other groups children usuallybrushed only once. About 80% of all childrenstudied said they used a factory-made tooth-brush, and 90% or more preferred a factory-made brush over the traditional 'mswaki'. Morepupils in the modified session group than in theother groups had the skill for making a proper

Table 1: Oral health knowledge compared between the conventional (C) and modified(M) session groups, and between each session group and the referents (R)

Knew about tooth decayOccurrence (common)Cause (sugary snacks)Prevention (avoid sugar)

Knew about gum diseaseOccurrence (common)Cause (poor toothbrushing)Prevention (toothbrushing)

Motive for toothbrushingTo avoid tooth decayTo make teeth whiteTo avoid gum diseaseNo reason

Referents

(n = 200)

%

283927

113852

583606

Pupils whohealth

Conventional

%

354624

106583

731818

(n = 200)

C versus

• • «

• • •

• * •

• • •

received oraleducation

Modified(n = 200)

R % M versus R C versus M

638450

567880

816

130

• •• •<* • * «4

• * • *4

• * • *4

• • • *

%

• • •

• • •* • * ***

na na

nu na

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p < 0.05, **p < 0.01,***p $ 0.001, "" not applicable).



Table 2: Self-reported practices and beliefs about sugary foods compared between theconventional (C) and modified (M) session groups, and between each session groupand the referents (R)

Referents Pupils who received oralhealth education

Conventional(n = 200) (n = 200)

% % C versus R

Modified(n = 200)

M versus R C versus M

Pupils who had consumedsugary items (once or twice)the previous day

Tea with sugarSweetsIce-creamSoda drinksBiscuits

Pupils who regarded sugaryitems as harmful to teeth

Tea with sugarSweetsIce-creamSoda drinksBiscuits

6517141311

7669933755

6011121010

7380963854

449

141013

8089846268

•***

* • *• *

**•**

• • *• * *

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p < 0.01,***p s£ 0.001).

Table 3: Self-reported oral hygiene practices and attitudes compared between the con-ventional (C) and modified (M) session groups, and between each session group andthe referents (R)

Toothbrushing frequencyOnce a dayAt least twice a day

Items used for toothbrushingIndustrial toothbrushChewing-sticks ('miswaki')ToothpasteCharcoalAsh

Skilled in making 'mswaki'Type of toothbrush preferred

Industrial'mswaki'

Regarded toothpaste essential

Referents

(n = 200)

%

7822

802057239

35

955

76

Pupils who> received oralhealth education

Conventional(n

% C

5743

802055385

37

928

74

= 200)

versus

**•• ••

**

Modified(n = 200)

R % M versus R C

2377

78225726

186

901075

* • •* • *

na**•

versus M

••*•**

• *na

• **

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p ^ ".01***D a£ 0.001. na not aDDlicableV*p s£ 0.001, na not applicable).



Table 4: Pupils with no visible plaque by the index teeth compared between the con-ventional (C) and modified (M) session group, and between each session group andthe referents (R)

Upper teethRight firstpermanent molarRight seconddeciduous molarRight permanentcentral incisorLeft permanentcentral incisorLeft seconddeciduous molarLeft firstpermanent molar

Lower teethLeft firstpermanent molarLeft seconddeciduous molarLeft permanentcentral incisorRight permanentcentral incisorRight seconddeciduous molarRight firstpermanent molar

OuterInnerOuterInnerOuterInnerOuterInnerOuterInnerOuterInner

OuterInnerOuterInnerOuterInnerOuterInnerOuterInnerOuterInner

Referents

(n = 200)

%

3481970838783882377

754

494

731957695667761849

2

Pupils who received oralhealth education

Conventional Modified

%

95330678383828226701460

526

7316616861697715523

(n = 200)

C versus

4

na

(n = 200)

R % M versus R C versus M

18 * *•5138 •**74878390 *82307314 •57

61 •5

762269 *78 • *76 *•* **77 •7721555

Differences between groups evaluated by chi-square statistics (d.f.< 0.001, ™ not applicable).

1, *p ^0.05, **p «S 0.01, ***p

'mswaki' (Table 3). Three-quarters of all studiedchildren, regardless of their oral health educationexposure, considered toothpaste essential fortooth-cleaning, but only about half said theyused it. Among the children in the conventionalsession group, brushing with charcoal was morecommon compared with the modified sessiongroup or the referents.

The children who had participated in the mod-ified sessions had slightly better oral hygiene thanthe other pupils 4 months after the first sessions.The mean number of tooth surfaces (24 surfacesexamined) with visible plaque was smaller (10.5,SD 4.7) among the modified than among theconventional session group (11.7, SD 4.9) andthe referents (12.0, SD 4.4). The difference wasstatistically significant only between the modifiedsession group and the reference group (r = 3.28,

p = 0.001). In all groups, clean tooth areas weremore often the inner than the outer surfaces ofupper teeth, the outer than the inner surfaces oflower teeth, and the front than the back teeth.The children in the modified session group couldclean some of these tooth areas more effectivelythan children in the other groups (Table 4). Noassociation between age and oral hygiene wasfound in any of the three groups of children.

DISCUSSION

The between-group study design involving threecluster samples of first-graders (reference group,conventional session group and modified sessiongroup), was used to evaluate the impact of thetwo types of school oral health education. This


study design prevents carry-over effects as eachstudy group is exposed to only one type ofintervention, and each group is studied onlyonce which reduces the chance of their guessingwhat they may think the interviewer wants(Adams and Schvaneveldt, 1985). Spill-over ofthe interview or session contents between thesamples was not very likely as the children werefrom different classes. The three samples wererandomly chosen and had comparable back-ground characteristics; they consisted of first-grade children, had similar age ranges, hadequal proportion of boys and girls and of urbanand rural children, and were from the sameschool locations within a district.

The wide age range (5-16 years) among thefirst-graders studied is typical of the classes inTanzania although the officially recommendedage for children's enrolment into school is7 years (Ministry of Education and Culture,1992). Even then, the reference group's oralhealth knowledge, attitudes and practices werefound to be almost the same by age (Nyandindi etal., 1994a). Tanzanian children of any age seemto have limited opportunities to learn properdental ideas or practices before going to school,as the Tanzanian mothers' own awareness ofdental matters is very limited (Kabalo andMosha, 1989). In school, all lessons are taughtby grade levels irrespective of the pupils' ages.Thus, first-graders, for whom oral health educa-tion is scheduled (Taasisi ya Elimu, 1987; Wizaraya Elimu, 1988), notwithstanding their ages, wereinvolved in the present evaluation.

School oral health education provided bydental personnel or schoolteachers in developedcountries has usually improved pupils' oralhealth knowledge, attitudes or status, but notalways (Frazier, 1992; Brown, 1994). In Africancountries, the few available evaluative studies ofschool oral health education (Evian et al., 1978;Olsson, 1978; Doherty, 1983; Hartshorne et al.,1989; van Palenstein et al., 1992) also show moreelements of success than of failure. The studieshave focused on effects and seldom describe theinput or processes (e.g. teachers' training in oralhealth education or the school oral health educa-tion sessions) which presumably affect the pro-gramme impact or outcomes among the pupils.

Pupils who attend the conventional oral healtheducation sessions in the primary schools inTanzania seem to gain limited knowledge aboutgingival health. Their frequency of toothbrushingseems to increase. They like to use factory-made


toothbrushes rather than 'miswaki' (chewing-sticks) which are suggested in the conventionalsessions. The current school oral health educa-tion regime recommends and actually seems toincrease the use of charcoal (a tooth-erosivesubstance) as 'toothpaste', a practice commonin Tanzanian society (Sarita and Tuominen,1992). The pupils hardly seem to learn aboutprevention of tooth decay.

Conventional oral health education in Tanza-nian schools is taught according to the 'Ministryof Education' curriculum guide (Taasisi yaElimu, 1987) which addresses oral hygiene only.The guide mentions use of practice sessions forteaching toothbrushing skills, but the sessionswere observed to be mainly lectures (Nyandindiet al., 1995) as has been the case in many tradi-tional programmes (Frazier et al., 1983). Supportfrom dental personnel is called for in theNational Plan for Oral Health (Ministry ofHealth and Social Welfare, 1988), but most pri-mary school teachers have no training fromdental personnel for the task of oral healtheducation. Moreover, they seem to have inade-quate knowledge, skills and motivation for carry-ing out this task (Nyandindi et al., 1994b). Asdescribed elsewhere (Bartlett, 1981), the largerclass sizes and the short time allocated to thetopic of health in Tanzanian primary schools canencourage the use of lectures. With these short-falls in the implementation of the programme,successful impact or outcomes cannot beexpected.

The pupils who attended the modified oralhealth education sessions seemed to have gainedknowledge about gingival health. Commercialtoothbrushes and toothpaste seem to be relativelycostly and scarce in rural areas for many indivi-duals in Tanzania to buy regularly (Muya et al.,1984; Nyandindi et al., 1994c). However, theeffort made during the modified sessions toencourage the use of 'miswaki', as suggested inthe national guidelines for school oral healtheducation (Nermark et al., 1986; Taasisi yaElimu, 1987), did not succeed. The pupilsgained good skills in making 'miswaki' and prac-ticed brushing with them, but continued to dislikethem. It has been reported from elsewhere inAfrica (Narmark, 1991) that chewing-sticks aredisliked and regarded as primitive. This suggestsa need to reconsider the type of toothbrushpromoted in Tanzania. The modified sessionsalso failed to increase the use of toothpastewhich was considered essential for tooth-cleaning



by the pupils, or to reduce the use of charcoal as asubstitute. This seems to be rather a matter of thechildren's economic realities.

The modified sessions with supervised brushingpractice seem to have improved the pupils' brush-ing frequency and, to some extent, their oralhygiene. Repeated sessions would probablyhave brought a better impact in oral hygiene, ashas been emphasized elsewhere (Emler et al.,1980; Houle, 1982). This could not be accom-plished prior to this evaluation 4 months after thesessions, due to the teachers' time pressures.There are many important topics of health forfirst-graders to be covered within the one-hour-a-week frame (Taasisi ya Elimu, 1987). Neverthe-less, the teachers agreed that, as part of theroutine morning hygiene checkups of pupils atschool, they would remind pupils to brush theirteeth properly. Another possible factor hinderingfurther improvement of the pupils' oral hygienecould be that their commercial toothbrushes hadnot been replaced often enough to remain effec-tive.

The modified session group also seemed tohave gained improved knowledge about thecause and prevention of tooth decay. Their self-reported low preference for sugary snacks ascompared with the referent children may, tosome extent, reflect their newly gained knowledgeof expected behaviour. This was their first oralhealth education experience at school and thepupils might have been receptive to the newideas. Economic environment, rather than perso-nal decisions alone, also appears to contribute tothe low frequency of sugar consumption of Tan-zanian children, even without health education.Tooth decay is more common in the affluent thanpoorer rural people in Tanzania (Mandari, 1988),and sugary snacks seem expensive for school-agechildren from low-income families (Nyandindi etal., 1994c). Sugar consumption may increase withimprovements in the economy and changes inlifestyle in Tanzania, thus educating childrenabout healthy diet is essential in order to preventcaries in the future.

The results show the importance of assessinghealth education activities, as has been empha-sized previously (Green and Lewis, 1986; Sarvelaand McDermott, 1992). Operational programmesmay not always be implemented in the appro-priate way, or bring about the desired impact oroutcomes. The conventional oral health educa-tion in the Tanzanian primary schools does notseem to be effective. The process appears to be

poor and to lack adequate support to the imple-mentors—the schoolteachers. Teacher trainingand motivation is needed for their role in healtheducation (WHO/UNESCO/UNICEF, 1992).The present results suggest that, with appropriatetraining workshops and guidance, teachers maygain proficiency in teaching oral health matters,and the gains from school oral health educationamong the pupils in Tanzania may improve. Theenvironments have to be improved and consid-ered with regard to their support for the chil-dren's oral health education. An interventioninvolving the oral health providers, the schoolpersonnel, and children and their parents needsto be attempted to see what effect it could have onimpact of school oral health education in Tan-zania.

ACKNOWLEDGEMENTS

We thank the pupils and the teachers for co-operation. This study was supported by theMuhimbili Dental School Development Projectof the University of Kuopio.

Address for correspondence:Dr Ursuline NyandindiDepartment of Preventive and Community DentistryFaculty of DentistryUniversity of Dar es SalaamPO Box 65014Dar es SalaamTanzania

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Documents

Impact of oral health education on primary school children before