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promotion
Stella Y.L. Kwan,1 Poul Erik Petersen,2 Cynthia M. Pine,3 & Annerose Borutta 4
Abstract Schools provide an important setting for promoting health, as they reach over 1 billion children worldwide and, through
them, the school staff, families and the community as a whole. Health promotion messages can be reinforced throughout the most
inuential stages of childrens lives, enabling them to develop lifelong sustainable attitudes and skills. Poor oral health can have
a detrimental effect on childrens quality of life, their performance at school and their success in later life. This paper examines the
global need for promoting oral health through schools. The WHO Global School Health Initiative and the potential for setting up
oral health programmes in schools using the health-promoting school framework are discussed. The challenges faced in promoting
oral health in schools in both developed and developing countries are highlighted. The importance of using a validated framework
and appropriate methodologies for the evaluation of school oral health projects is emphasized.
Keywords Oral health; Oral hygiene; Schools; School health services; Health education, Dental; Food services; Health behavior;
Health promotion/methods; Health policy (source: MeSH, NLM).
Mots cls Hygine buccale; Hygine bucco-dentaire; Etablissement scolaire; Education sanitaire dentaire; Service hygine scolaire;
Restauration; Hygine de vie; Promotion sant/mthodes; Politique sanitaire (source: MeSH, INSERM).
Palabras clave Salud bucal; Higiene bucal; Servicios de salud escolar; Escuelas; Educacin en salud dental; Servicios de alimentacin;
Conducta de salud; Promocin de la salud/mtodos; Poltica de salud (fuente: DeCS, BIREME).
Voir page 684 le rsum en franais. En la pgina 684 gura un resumen en espaol.
Introduction fects the appearance, quality of life, nutritional intake and, con-
sequently, the growth and development of children. The bur-
Oral health is fundamental to general health and well-being. A
den of oral disease is considerable. Tooth decay and gum disease
healthy mouth enables an individual to speak, eat and socialize
are among the most widespread conditions in human popula-
without experiencing active disease, discomfort or embarrass-
tions, affecting over 80% of schoolchildren in some countries
ment. Children who suffer from poor oral health are 12 times
(46). The prevalence of other oral disorders such as dental
more likely to have restricted-activity days than those who do
erosion and enamel defects is rising (5, 6). Many children have
not (1). More than 50 million school hours are lost annually
experienced oral trauma, a substantial proportion of whom are
because of oral health problems which affect childrens perfor-
under the age of 5 years (7). Some tobacco-containing products
mance at school and success in later life (2).
are marketed directly at children and adolescents; people who
Schools provide an effective platform for promoting oral
start consuming these products at an early age may have an
health because they reach over 1 billion children worldwide.
increased risk of oral cancer in later life (8). Noma, a devastat-
The health and well-being of school staff, families and com-
ing and potentially life-threatening condition, affects a large
munity members can also be enhanced by programmes based
number of children in Africa, Asia and Latin America (9).
in schools (3). Oral health messages can be reinforced through-
Oral disease is one of the most costly diet- and lifestyle-
out the school years, which are the most inuential stages of
related diseases (10, 11). The cost of treating dental decay
childrens lives, and during which lifelong beliefs, attitudes
alone could easily exhaust a countrys total health care budget
and skills are developed. This article examines the potential for
for children (12). However, the cost of neglect is also high in
promoting oral health through schools, based on the WHO
Health-Promoting School (HPS) framework. terms of its nancial, social and personal impacts (13).
Many oral health problems are preventable and their early
onset reversible. However, in several countries a considerable
Need for oral health promotion in schools number of children, their parents and teachers have limited
Oral disease can lead to pain and tooth loss, a condition that af- knowledge of the causes and prevention of oral disease (1417),
1
Dental Public Health, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, England. Correspondence should be sent to this author (email: s.kwan@leeds.ac.uk).
2
Oral Health Programme, World Health Organization, Geneva, Switzerland.
3
Department of Clinical Dental Sciences, School of Dentistry, University of Liverpool, England.
4
Department of Preventive Dentistry, Dental School of Erfurt, Friedrich-Schiller University of Jena, Germany.
Ref. No. 04-020305
(Submitted: 18 February 2005 Final revised version received: 24 June 2005 Accepted: 27 June 2005)
compounded by a lack of affordable uoride toothpaste and poor with conicts. Healthy behaviours and lifestyles developed at
access to oral health care. The problems are exacerbated by the a young age are more sustainable. Messages can be reinforced
consumption of sugary snacks and carbonated drinks which is throughout the school years.
high among children and adolescents (18).
Given that many risk behaviours stem from the school-
age years, schools have powerful inuences on childrens devel-
Global School Health Initiative
opment and well-being (1820). The need for the promotion Based on the guiding principles of the Ottawa Charter for
of oral health in schools is evident and it can easily be integrated Health Promotion and the recommendations of WHOs Expert
into general health promotion, school curricula and activities. Committee on Comprehensive School Health Education and
Children can be provided with skills that enable them to Promotion, the WHO Global School Health Initiative was
make healthy decisions, to adopt a healthy lifestyle and to deal launched in 1995. The Initiative aims to foster health-promoting
Whereas there are comprehensive on-site oral health facilities that help children develop self-esteem and condence as well
in schools in some industrialized countries, many schools in as reducing stress and conicts in schools should form part of
developing countries do not have adequate infrastructure and the curriculum. Children and school staff should be equipped
resources to provide these services. In some developing coun- with the skills that help them prevent and, if unavoidable, deal
tries, the provision of emergency care, tooth extraction and basic with interpersonal conicts, stress, peer pressure and other social
restorative and preventive oral care may prove very important. forces. The provision of counselling and support services for
Schools may be the only place for children, who are at the high- students and staff would be invaluable.
est risk of dental disease, to gain access to oral health services.
Health promotion for school staff
Nutrition and food services Healthy and tobacco-free school environments, together with
Healthy eating programmes should be developed to ensure supportive organizational and management structures, help
that the canteens, tuck shops, kiosks and vending machines reduce stress and promote healthy living. It is essential for
in schools are providing nutritious meals and healthy snacks. the school to provide health-promoting facilities such as well-
Children can be empowered to develop healthy dietary habits designed and health-oriented classrooms, ofces, staffrooms
from an early age through school health education. Oral health and canteens, and to make provision for exercise, relaxation and
can form part of schemes for the promotion of general health, support services. Oral health should form an integral compo-
as with the breakfast clubs that have been set up to support nent of these initiatives. A well-designed oral health training
healthy eating, and be incorporated into the assessment and programme that is responsive to their needs should be provided
surveillance of nutritional status. Outside caterers and suppliers regularly to staff as part of in-service development. It should
should be encouraged to support healthy eating initiatives in enable staff members to acquire skills and sustain healthy
schools. lifestyles, and to integrate their knowledge and skills into their
teaching. Working with the school health team, parents and
Physical exercise and leisure activities the local community, they can identify essential policies and
Although sports and physical activities are benecial to health, practices that promote oral health and general well-being in
students should be educated about the harmful effects of iso- school and the community.
tonic drinks with high acidity and sugar content that can lead
to dental caries and erosion (24). To reduce the risk of oral Relationships and collaboration between the
trauma, the use of mouth guards should be encouraged in school and the community
high-risk contact sports (25). Parents can be trained to reinforce oral health messages at home
and act as facilitators in outreach programmes for children who
Mental health and well-being do not attend schools. Such programmes can help promote
Stress may lead to poor diet, smoking and violent behaviours oral health to these families and may encourage them to be-
that are detrimental to health (26, 27). School programmes come part of the school community. Through the students,
Table 3. Examples of oral health programmes and activities used with schoolchildren in Denmark
Age (years) Oral health topics Materials and visual aids Settings
02.5 Information to parents about oral health, Picture books, posters, slides, video, Day-care centres
teething, toothbrushing, breastfeeding, models, food Mothers groups Library
dummies/bottles, nutrition, caries,
medicine, dental trauma
2.55 Same as above Leaets, models, drawing and colouring Dental clinics
sheets, puppet shows, role-playing, songs Play meetings in clinics
6 6-year-old teeth, oral hygiene, nutrition/ Picture books, slides, video, puppet shows, Classroom
food pyramid, shape and function of models, shing games, food, jigsaws,
different teeth puzzles, drawing/exercise sheets
79 Dentitions, function and structure of teeth, Slides, videos, shing games, food, leaets Classroom
caries process. Body/oral consciousness, on nutrition, models
hygiene, trauma
1012 Body, nutrition, hidden sugar and types Slides, videos, overhead projections, picture Classroom
of sweet, caries process, dental plaque, books, role-playing, cultivation of bacteria,
bacteria, caries registration, self- worksheets, recipes, models
examination
1315 Health and well-being and oral health in Overhead projections, slides, videos, Classroom
general, structure of the tooth and its leaets, X-rays, newspaper articles, Collaboration with health
supporting tissues, initial caries and oral worksheets, music, dental oss, nutrition, nurse and teachers
hygiene, approximal caries, healthy computer programmes, statistics
lifestyles, tobacco and nutrition,
sweet drinks, hidden sugar
1617 Gingivitis/periodontitis, change to adult Slides, videos, leaets, newspaper articles, Classroom
dental health care quality-of-life game, computer program Dental clinics
other members of the family can benet from an oral health Cost of implementing health-promoting school
promotion programme initiated by the school. policies
The interaction between the school, the home and the The costs of implementing HPS policies should be considered
community is critical (28). Family and community members at several levels, namely, at the global, geo-political, national
can be involved in the planning and decision-making process, levels, and, within a country, at the regional and the local health
for example, by being part of the school health team or com- and education authority levels, and nally, at the school level.
munity advisory committee. They can take part in school-led At the higher levels, costs relate to policy development and
oral health activities at school and in the community, such as maintenance of up-to-date advice including regular reviews of
breakfast clubs, oral health days, exhibitions and health fairs. the evidence base. WHO has taken a lead role in the area of
Community support is crucial in lobbying for a healthy en- policy development related to HPSs.
vironment, clear food labelling and water uoridation. The
The reality and costs of implementation vary between
media offer a powerful channel for the delivery of oral health
countries, and, at regional levels, may be difcult to identify
messages (29). The media should be educated to refrain from
and apportion separately. At the local level, costs depend on the
targeting children and adolescents in tobacco advertising cam-
paigns and from the promotion of foods and drinks that are existing infrastructure, and on the funding and support avail-
high in sugar, salt and fat. able from government and other organizations. At the school
level, costs include the initial training for policy development
Examples of health-promoting schools from China and review, modication to the school environment, provision
and Denmark of healthier alternatives, health education activities and con-
Depending on local circumstances, various approaches have tinuing support for school staff, children and parents.
been adopted by schools. Whereas some schools may attempt A differential pricing policy for healthier snacks has been
to incorporate a number of components simultaneously, others found to increase their selection by children (32). In Norway
may build on existing good practice and initiatives on a project- (33), providing a free piece of fruit or a vegetable has been
by-project basis. Schools in different countries may place a dif- found to be an effective strategy to increase schoolchildrens
ferent emphasis on the various components of an HPS, taking intake of fruit and vegetables and a similar free fruit scheme
into account the local infrastructure and available resources. has been set up in schools in the United Kingdom. Subsi-
Examples from China (30) and Denmark (31) are illustrated dizing the cost of healthier snacks to reduce their price has
in Fig. 1 and Fig. 2, respectively. clear resource implications, but may be more appropriate in
Training workshops
for teachers
communities where maintenance of food choice is regarded Process and outcome measures can be set for each com-
as a practical alternative to banning the sale in school of less ponent of an HPS (Box 1) (6). They include the assessment
healthy options. of the school environment such as the provision of healthy
The costs of implementing HPS programmes should be foods and drinks, sufcient sanitation and safe water for oral
considered alongside the health benets. This is a considerable health activities. The targets for policy development to address
challenge as costs are immediate and relatively easily measured, the key components of an HPS can be set for short-term evalu-
but benets in terms of changed behaviour and increased life ation, followed by evaluation of the effectiveness of various
chances are long-term and may be difcult to attribute to a interventions, such as oral health education in the classroom,
single intervention. Hence there is a need for a structured exposure to uoride, changes in knowledge about oral health,
approach to evaluation. attitudes, behaviours and lifestyles, as well as clinical outcomes
and impact of interventions. The sustainability of an HPS and
Evaluation its relationship with the wider community, partnerships and
According to WHO, at least 10% of programme resources networks should be considered in long-term evaluations. How-
should be allocated to evaluation (34). Evaluation helps inform ever, it is important to employ appropriate evaluation strategies.
and strengthen school health programmes and determines Although the scientic merits of randomized controlled trials
the extent to which the programme is being implemented are well-recognized, they may not always be suitable for the
as planned; it assesses processes and outputs, impact and evaluation of oral health promotion (35). Both qualitative
effectiveness of the programme and, if any aspects have not and quantitative methodologies have a role to play. A pluralistic
worked well, identies the key lessons learned. It is important approach to evaluation can strengthen its validity and help
to provide feedback to policy-makers, sponsors and those who circumvent the limitations of the individual evaluation
have been involved in the planning, development and delivery approaches (36).
of programmes. Evaluation can be used to reward the efforts
of schools, students, teachers, parents and the community Challenges faced in promoting oral health in
and, by demonstrating the benets, to encourage others to schools
help more schools to become HPSs. Quality evidence can be A lack of sustainable funding, resources and trained personnel
used by schools to convince policy-makers, sponsors and other (professionals and volunteers) has been identied (37). The
stakeholders to provide continued support to, and to become conicting priorities and agenda of the school, health, educa-
involved in, HPS programmes. tion and local authorities, may mean that the implementation
of oral health activities within a programme for general health school oral health services, particularly on the school premises,
promotion and the school curriculum proves too challenging. may not be feasible. All components of an HPS may not be
Health and safety constraints and fear of litigation may be a encompassed in all HPSs (39), and it is particularly challenging
deterrent. Tuck shops, vending machines and sponsorship from to create a coherent, complementary and integrated approach
industry may be an important means of income generation, a within the local constraints.
consideration that can inuence food policies in schools. Given These problems are more acute in developing countries
the competing demands of an already full curriculum, teachers where they may be compounded by poverty, gender inequality
may be reluctant to include oral health in their teaching, because and political instability (3). Many children, particularly girls,
they wish to avoid disruption to other school activities. Training have limited access to education. Some schools are located in
and effective communication between health professionals and polluted areas with dangerous trafc and lack safe drinking-
teachers are crucial, as is support from parents (38). Providing water and sanitation (40). Affordable toothbrushes, toothpaste
and other oral health education materials are not readily avail- the United Nations Educational, Scientic and Cultural Orga-
able (41, 42). Industrial partners and manufacturers have an nization (UNESCO) and the Joint United Nations Programme
important role to play in improving this situation. A shortage on HIV/AIDS (UNAIDS). Again, effective collaboration with
of trained dental personnel means that teachers are often other sectors and programmes is fundamental.
expected to teach as well as to provide basic dental treatment In conclusion, there is a pressing need for oral health
and oral health education, responsibilities that teachers are to be promoted in schools worldwide. The potential for
considered ill-equipped to carry out (43). Without supportive developing a comprehensive programme using the HPS
policies, infrastructure, budget and commitment from various approach is considerable. Commitment from central and
government departments, the obstacles faced by schools and local government, schools, families and the community is
teachers in promoting oral health may remain insurmountable. critical. It is imperative for public health authorities and
Support from global, regional, national and local HPS alli- health professionals to provide sustainable support, in terms
ances and networks can prove invaluable in helping schools to of technical assistance, funding and/or learning materials to
overcome some of these barriers. Funding may be available for facilitate schools becoming HPSs. O
specic projects from central and local governments, as well as
from nongovernmental organizations and other bodies such as Competing interests: none declared.
Education International, the Education Development Centre,
Rsum
Promotion de la sant dans les coles : une opportunit de promouvoir la sant bucco-dentaire
Les coles offrent un cadre important pour la promotion de la matire de promotion de la sant bucco-dentaire travers les
sant, dans la mesure o elles permettent de toucher plus dun tablissements scolaires. Il prsente lInitiative mondiale pour la
milliard denfants dans le monde et, travers eux, le personnel sant lcole de lOMS et les possibilits de mettre sur pied des
enseignant, les familles et la communaut dans son ensemble. Il programmes de sant bucco-dentaire dans les tablissements
est possible de renforcer les messages de promotion de la sant scolaires laide du cadre de promotion de la sant lcole. Il
mesure que les enfants traversent les stades les plus inuenables met en lumire les difcults rencontres par la promotion de la
de la vie, ce qui les conduit dvelopper des attitudes et des sant bucco-dentaire lcole dans les pays dvelopps, comme
comptences quils conserveront durant toute leur existence. Une dans ceux en dveloppement. Il souligne limportance dutiliser un
mauvaise sant bucco-dentaire peut tre prjudiciable pour la cadre valid et des mthodes appropries pour valuer les projets
qualit de vie, les performances scolaires et la russite ultrieure de promotion de la sant bucco-dentaire en milieu scolaire.
des enfants. Le prsent article examine les besoins mondiaux en
Resumen
Escuelas promotoras de la salud: una oportunidad para promover la salud bucodental
Las escuelas brindan un entorno interesante para promover la la salud bucodental a travs de las escuelas. Se examinan la
salud, pues permiten alcanzar a mil millones de nios en todo el Iniciativa Mundial de Salud Escolar de la OMS y las posibilidades
mundo y, a travs de ellos, al personal escolar, a las familias y al de poner en marcha programas de salud bucodental en las escuelas
conjunto de la comunidad. Los mensajes de promocin de la salud utilizando el marco escolar de promocin de la salud. Se ponen
pueden reforzarse a lo largo de las etapas ms determinantes de la de relieve los retos que deben afrontarse para promover la salud
vida de los nios, capacitando as a stos para desarrollar actitudes bucodental en las escuelas tanto en los pases desarrollados como
y aptitudes permanentes. Una salud bucodental deciente puede en los pases en desarrollo, y se subraya la importancia de usar
repercutir gravemente en la calidad de vida de los nios, en su un marco validado y metodologas apropiadas para evaluar los
rendimiento escolar y en sus logros en etapas posteriores de la proyectos de salud bucodental en las escuelas.
vida. En este artculo se analiza la necesidad mundial de fomentar
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