|Year : 2016 | Volume
| Issue : 2 | Page : 126-130
Effectiveness of two oral health education intervention strategies among 12-year-old school children in North Bengaluru: A field trial
Roomani Srivastava, R Murali, A Shamala, Mansi Yalamalli, A Vinod Kumar
Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||10-Jun-2016|
Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences, Hunsamaranhalli, International Airport Road, Bengaluru - 562 157, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Oral hygiene practices are not taught as meticulously as general hygiene in schools. There is a dire need for effective and convenient oral health education program in schools. Aim: To assess the effectiveness of two different health education interventions in 12-year-old school children in Bengaluru. Materials and Methods: A field trial was conducted in two schools of North Bengaluru which were randomly selected and allotted to Group A (received oral health education from a class teacher, trained by a dental professional; n = 30) and Group B (received the same education from the dental professional; n = 33). Oral prophylaxis for both the groups was done at baseline. Assessment of oral hygiene was done for all the subjects using Silness and Loe plaque index and oral hygiene index-simplified (OHI-S) along with reinforcement of health education at 3, 6, and 12 weeks. An adapted version of the World Health Organization Oral Health Questionnaire for children was administered to the participants at the beginning and end of the study to assess the oral health knowledge and practice. Mann–Whitney U-test and t-test were used for comparing the mean scores of two groups. Results: A statistically significant difference was found between Group A and Group B in the plaque scores at all 3 follow-ups (P < 0.001) and in OHI-S scores last two follow-ups (P < 0.05). There was an increase in knowledge score postintervention for both groups which was significant; however only Group B be showed significant improvement in practice (P < 0.05). Conclusions: Oral health education conducted by the dentist was found to be more effective than that given by a trained teacher.
Keywords: Health education, oral hygiene, school child
|How to cite this article:|
Srivastava R, Murali R, Shamala A, Yalamalli M, Kumar A V. Effectiveness of two oral health education intervention strategies among 12-year-old school children in North Bengaluru: A field trial. J Indian Assoc Public Health Dent 2016;14:126-30
|How to cite this URL:|
Srivastava R, Murali R, Shamala A, Yalamalli M, Kumar A V. Effectiveness of two oral health education intervention strategies among 12-year-old school children in North Bengaluru: A field trial. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2020 Jan 18];14:126-30. Available from: http://www.jiaphd.org/text.asp?2016/14/2/126/181895
| Introduction|| |
It is well-established that habits learned early in life are better retained in the long run. Children with their impressionable minds serve as the perfect target group for instilling correct oral hygiene practices. The need to introduce effective and convenient oral health education program in schools is paramount today owing to high absenteeism rates as a result of poor oral health. It is estimated that more than 50 million school hours are lost annually because of poor oral health.
Schools have been suggested as the best platform to impart this oral health education as they are estimated to reach over one billion children worldwide. Based on the principles of the Ottawa Charter for health education and the recommendations of World Health Organization (WHO) Expert Committee on Comprehensive School Health Education and Promotion, the WHO launched the Global School Health Initiative in 1995. It aims to strengthen health promotion and education activities through school. One of the core strategies of this initiative is building capacities to advocate for improved school health programs.
The demand for new resource persons to serve as health educators can be met by individuals to whom teaching comes naturally, i.e., the teachers in the schools. Having a teacher deliver oral health education can have a number of advantages; children are likely to feel more at home receiving instructions from a familiar person rather than an outsider, interaction is better, and it is easier for teachers to reinforce the same at regular intervals.,,
It will therefore be fruitful to train teachers regarding oral hygiene methods and delivery of oral health education following which they can take the lead and teach their students the same. However, before employing mass teacher training programs, it is essential to know whether the oral health education intervention as given by the teacher is likely to have the same effect of that provided by a dentist.
Thus, the aim of this study was to assess the effectiveness of two health education intervention strategies in 12-year-old school children in North Bengaluru.
| Materials and Methods|| |
A double-blind field trial was conducted among 12-year-old school-going children in North Bengaluru. Ethical approval was obtained to conduct this study from the Institutional Review Board of the Dental Institute. The required permissions were sought from the authorities of the respective schools. Informed consent was obtained from parents of the participating children to perform oral examination and oral prophylaxis and verbal assent was obtained from the children in the presence of the class teacher.
The sample size for this study was determined using G*power software version 188.8.131.52 (Heinrich-Heine-Universitat Düsseldorf, Germany). The power was set at 80%, and alpha and effect size were maintained at 0.05 and 0.5, respectively. The sample size thus as determined by G*Power was 27 for one group. Two schools were randomly selected (lottery method) from the schools of North Bengaluru. One of the schools was randomly assigned to Group A (teacher-led group) and the other to Group B (dentist led group). All the 12-year-old children present in the said school on the 1st day of the examination were included in the study. Children with learning disabilities and those incapable of maintaining their oral hygiene themselves were excluded from the study. Hence, there were 30 subjects in Group A and 33 subjects in Group B [Figure 1].
Training and calibration
Intraexaminer calibration was done for the said examiner by re-examining 10 subjects from each group on the first visit (3 weeks) and determining the intraexaminer reliability (Cohen's Kappa) based on the readings (Kappa = 0.94).
Oral health education was provided to one group by a trained class teacher who had undergone prior training by a dental health professional regarding the health education model to be employed and the contents of the oral health education to be given to the children. The teacher was evaluated after the training by asking questions at the end of the session. The teacher then conducted health education for 10 students (not involved in the study) in the presence of dentist, and further clarifications were made if required.
Oral prophylaxis was done on the 1st day of the study to ensure that the plaque index (PI) and oral hygiene index-simplified (OHI-S) scores were zero at baseline. The study involved delivering oral health education using “communication-based behavior change” model of health education. The children received the first round of health education on the 1st day of the study which was followed by reinforcements at 3, 6, and 12 weeks intervals. The health education to Group A was rendered by a trained class teacher, and Group B received oral health education from a dental health professional. The materials used (pamphlets and models) to provide the oral health education was the same in both the groups. Uniformity was maintained regarding the duration of health education and a number of reinforcements. An adapted version of the WHO Oral Health Questionnaire for Children, 2013 (modified for the present study) was administered to both the groups at the start of the study and again after 12 weeks. This questionnaire was pilot tested and Cronbach's alpha was calculated and found to be 0.72. The responses to the questions were coded and divided into knowledge and practice (KAP) categories for the purpose of analysis and interpretation.
Clinical examination involved assessing the plaque scores and oral hygiene of the children at 3, 6, and 12 weeks intervals by a single examiner who was not aware of whether the group was led by dentist or teacher. Silness and Loe PI, 1967, and OHI-S, 1964 were used for this purpose., Silness and Loe PI has been reported to have a good reliability and is efficient in detecting small amounts of debris as reported by Spolsky and Gornbein  and Poulsen et al., respectively. The specialty of this index is that it focuses on the thickness of plaque in the gingival third of the tooth, which is most significant in terms of progress of the disease. OHI-S was used to assess the overall oral hygiene of the subject and also to account for the presence of calculus.
The data collected were compiled using MS-Office Excel and was subjected to statistical analysis using the Statistical Package for Social Sciences for Windows version 10.5 (SPSS Inc., Chicago, IL, USA). Statistical significance was set at P < 0.05. Descriptive and inferential statistics were used to analyze the data. Shapiro–Wilk's test was performed to ascertain the normalcy of the data. Paired t-test was used to analyze before and after scores of the oral health questionnaire. Mann–Whitney U-test was used to compare the PI and OHI-S scores of the two groups at 3, 6, and 12 weeks. Kruskal–Wallis ANOVA was used to analyze the oral hygiene and plaque scores within each group at 3, 6, and 12 weeks.
| Results|| |
A total of 63 children were examined out of which 30 belonged to Group A and 33 to Group B. Of 30 children in Group A, 16 were boys and 14 were girls, whereas in Group B, 20 were boys and 13 were girls. Difference in PI and OHI-S scores was not significant with respect to gender.
The mean PI and OHI-S scores within groups were not statistically significant for either of the groups at all three examinations indicating that the reinforcements of oral health education were effective in maintaining low PI and OHI-S scores throughout the period of the study [Table 1].
|Table 1: Intragroup comparison of mean plaque index and oral hygiene index-simplified scores|
Click here to view
[Table 2] shows the comparison of PI scores between the two groups at each visit. The difference in the PI scores between the two groups was found to be statistically significant. The scores for Group B were lower than that of Group A.
|Table 2: Comparison of plaque index scores of the two groups at each visit|
Click here to view
[Table 3] shows the comparison of OHI-S scores between the two groups at each visit. The difference in the scores between the two groups was found to be statistically significant at each visit except the first visit. The OHI-S scores of Group B were lower than that of Group A.
|Table 3: Comparison of oral hygiene index-simplified Scores of the two groups at each visit|
Click here to view
[Table 4] shows the before and after comparison of KAP scores of both the groups based on the responses to the questionnaire. The improvement in knowledge score was statistically significant for both the groups at the end of the study (P < 0.05). The improvement in practice score was statistically significant (P < 0.001) in case of Group A; however, there was no improvement in practice scores of Group B.
|Table 4: Pre- and post-comparison of oral health knowledge and practice scores of each group|
Click here to view
In general, the health education delivered by a dental professional was found to be more effective as compared to that delivered by a teacher. Nevertheless, some improvement was also seen in the teacher-led group.
| Discussion|| |
This study was conducted to determine the effectiveness of oral health education delivered by dentist and by a teacher among 12-year-old children. This age group was selected as it is one of the index age groups by the WHO and this age group also met the purpose of the study which was to target children who are in the influential phases of their life and habits, beliefs, skills, and attitudes thus developed would tend to last longer. Only one school was selected per intervention group as the inclusion of more schools may have led to confounding results owing to variations in teaching methods of different schools. The PI and OHI-S were better in the dentist-led group as compared to the teacher-led group, and this difference was found to be significant [Table 2] and [Table 3].
Ajithkrishnan et al. and Bhardwaj et al. found improvement in plaque scores 3 months after rendering oral health education to 12–15-year-old children. Sanadhya et al. reported a significant reduction in mean OHI-S scores following health education after a period of 1 year. Gauba et al. found statistically significant (P < 0.001) improvements in KAP scores, PI scores, gingival index scores, and caries activity were reported at 3 weeks and 6 months follow-up examination when oral health education given by a dental professional. These findings also supported the findings of this study.
In this study, difference in scores in subsequent examinations in either of the groups was not significant, i.e. increase in the PI and OHI-S from the reading of zero at baseline was very minimal and similar at all 3 follow-ups [Table 1]. This highlighted that reinforcement had a positive effect of limiting the increase in PI and OHI-S scores. This finding was in accordance with the study conducted by D'Cruz and Aradhya  which reported that reinforcements were effective in limiting plaque scores.
This study used the identical method for oral health education for both teacher-led and dentist-led group, thus did not allow a comparison of different mediums employed in imparting health education.
This study showed no statistical significance in the difference in knowledge scores of the two groups after intervention [Table 5], this indicated that the oral health education given by both teacher and dentist using the same method was equally effective in increasing the knowledge of children regarding oral health. Furthermore, an increase in knowledge scores from baseline was significant for both the groups. Thus, the teacher-led group also showed significant results with respect to knowledge scores. In a study conducted in Tanzania by Nyandindi et al., children who had participated in the modified sessions (after training of teachers) had slightly better oral hygiene than the other pupils who were not a part of these sessions and hence were not given oral health education by trained teachers.
|Table 5: Intergroup comparison of knowledge and practice scores after intervention|
Click here to view
In this study, there was a statistically significant difference in the outcomes of the dentist-led group and the teacher-led group. This finding is different from that reported by John et al. in which the dentist-led group and the teacher-led group performed at par (no significant difference in Debris Index scores). In the same study, however, an additional group was evaluated in which dentists dressed as cartoon characters delivered health education, the outcome of this group was better than the other two, and the difference was statistically significant.
Haleem et al. conducted a cluster randomized control trial to evaluate five different methods of health education delivery, i.e., dentist led, teacher-led, peer-led, self-learning, and a control group. The results reported by this study were not in accordance with this study as the dentist- and teacher-led groups showed no statistically significant difference. The reason for the teacher-led group not showing similar results as that of the dentist-led group for PI and OHI-S scores could be that teachers themselves lack sufficient exposure to motivate children to improve their oral health behavior.
Limitations and recommendations
This study has certain limitations. Comparison was done only among two groups (dentist led and teacher-led) in this study; more groups such as peer-led or self-learning groups can be added to get more information to develop the best method to impart oral health education to school children.
The teacher in this study underwent a 1-time training on oral health education. For them to successfully impart oral health education to their students, the teacher has to be thorough with the content and more number of reinforcements may be helpful. Hence, teachers must undergo training for imparting oral health education as they are the ones who can influence the young minds the most. Oral health education should be incorporated in the training program of teachers with regular reinforcements.
| Conclusions|| |
This study concluded that the dentist-led group showed lower PI and OHI-S scores as compared to the teacher-led group. Both the groups showed statistically significant improvement in knowledge, whereas only the dentist-led group showed statistically significant improvement in oral health practice. Thus, the study concludes that effective oral health education training programs for teachers may be the key to achieve a good oral health among school children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting schools: An opportunity for oral health promotion. Bull World Health Organ 2005;83:677-85.
Prabhu S, Joseph J. Oral health education for improving oral health status of school children – A systematic review. J Dent Med Sci 2015;14:101-6.
WHO's Global School Health Initiative. Health-promoting Schools. A healthy setting for living, learning and working. Geneva: World Health Organization; 1998.
Albertini T, Boffa J, Kaplis NA. A dental health education program in the open classroom: Report of a pilot study. J Sch Health 1973;43:566-71.
Boyer EM. Classroom teachers' perceived role in dental health education. J Public Health Dent 1976;36:237-43.
Jürgensen N, Petersen PE. Promoting oral health of children through schools – Results from a WHO global survey 2012. Community Dent Health 2013;30:204-18.
McGuire WJ. Public communication as a strategy for inducing health-promoting behavioral change. Prev Med 1984;13:299-319.
World Health Organization. Oral Health Survey Basic Methods. 5th
Edition. Geneva. World Health Organization; 2013.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:610-6.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Spolsky VW, Gornbein JA. Comparing measures of reliability for indices of gingivitis and plaque. J Periodontol 1996;67:853-9.
Poulsen S, Holm-Pedersen P, Kelstrup J. Comparison of different measurements of development of plaque and gingivitis in man. Scand J Dent Res 1979;87:178-83.
Ajithkrishnan CG, Thanveer K, Sudheer H, Abhishek S. Impact of oral health education on oral health of 12-15 year old school children of Vadodara city, Gujrat State. J Int Oral Health 2010;2:15-20.
Bhardwaj VK, Sharma KR, Luthra RP, Jhingta P, Sharma D, Justa A. Impact of school-based oral health education program on oral health of 12 and 15 years old school children. J Educ Health Promot 2013;2:33.
Sanadhya YK, Thakkar JP, Divakar DD, Pareek S, Rathore K, Yousuf A, et al.
Effectiveness of oral health education on knowledge, attitude, practices and oral hygiene status among 12-15-year-old schoolchildren of fishermen of Kutch district, Gujarat, India. Int Marit Health 2014;65:99-105.
Gauba A, Bal IS, Jain A, Mittal HC. School based oral health promotional intervention: Effect on knowledge, practices and clinical oral health related parameters. Contemp Clin Dent 2013;4:493-9.
D'Cruz AM, Aradhya S. Impact of oral health education on oral hygiene knowledge, practices, plaque control and gingival health of 13- to 15-year-old school children in Bangalore city. Int J Dent Hyg 2013;11:126-33.
Nyandindi U, Milen A, Palin-Palokas T, Robison V. Impact of oral health education on primary school children before and after teachers training in Tanzania. Health Promot Int 1996;11:193-201.
John BJ, Asokan S, Shankar S. Evaluation of different health education interventions among preschoolers: A randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 2013;31:96-9.
Haleem A, Siddiqui MI, Khan AA. School-based strategies for oral health education of adolescents – A cluster randomized controlled trial. BMC Oral Health 2012;12:54.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]