POLICY AND PRACTICE
Health-promoting schools: an opportunity for oral health promotion
Promotion de la santé dans les écoles : une opportunité de promouvoir la santé bucco-dentaire
Escuelas promotoras de la salud: una oportunidad para promover la salud bucodental
Stella Y.L. KwanI,1; Poul Erik PetersenII; Cynthia M. PineIII; Annerose BoruttaIV
IDental Public Health, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, England
IIOral Health Programme, World Health Organization, Geneva, Switzerland
IIIDepartment of Clinical Dental Sciences, School of Dentistry, University of Liverpool, England
IVDepartment of Preventive Dentistry, Dental School of Erfurt, Friedrich-Schiller University of Jena, Germany
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 influential stages of children's lives, enabling them to develop lifelong sustainable attitudes and skills. Poor oral health can have a detrimental effect on children's 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).
RÉSUMÉ
Les écoles offrent un cadre important pour la promotion de la santé, dans la mesure où elles permettent de toucher plus d'un milliard d'enfants dans le monde et, à travers eux, le personnel enseignant, les familles et la communauté dans son ensemble. Il est possible de renforcer les messages de promotion de la santé à mesure que les enfants traversent les stades les plus influençables de la vie, ce qui les conduit à développer des attitudes et des compétences qu'ils conserveront durant toute leur existence. Une mauvaise santé bucco-dentaire peut être préjudiciable pour la qualité de vie, les performances scolaires et la réussite ultérieure des enfants. Le présent article examine les besoins mondiaux en matière de promotion de la santé bucco-dentaire à travers les établissements scolaires. Il présente l'Initiative mondiale pour la santé à l'école de l'OMS et les possibilités de mettre sur pied des programmes de santé bucco-dentaire dans les établissements scolaires à l'aide du cadre de promotion de la santé à l'école. Il met en lumière les difficultés rencontrées par la promotion de la santé bucco-dentaire à l'école dans les pays développés, comme dans ceux en développement. Il souligne l'importance d'utiliser un cadre validé et des méthodes appropriées pour évaluer les projets de promotion de la santé bucco-dentaire en milieu scolaire.
Mots clés: Hygiène buccale; Hygiène bucco-dentaire; Etablissement scolaire; Education sanitaire dentaire; Service hygiène scolaire; Restauration; Hygiène de vie; Promotion santé/méthodes; Politique sanitaire (source: MeSH, INSERM).
RESUMEN
Las escuelas brindan un entorno interesante para promover la salud, pues permiten alcanzar a mil millones de niños en todo el mundo y, a través de ellos, al personal escolar, a las familias y al conjunto de la comunidad. Los mensajes de promoción de la salud pueden reforzarse a lo largo de las etapas más determinantes de la vida de los niños, capacitando así a éstos para desarrollar actitudes y aptitudes permanentes. Una salud bucodental deficiente puede repercutir gravemente en la calidad de vida de los niños, en su rendimiento escolar y en sus logros en etapas posteriores de la vida. En este artículo se analiza la necesidad mundial de fomentar la salud bucodental a través de las escuelas. Se examinan la Iniciativa Mundial de Salud Escolar de la OMS y las posibilidades de poner en marcha programas de salud bucodental en las escuelas utilizando el marco escolar de promoción de la salud. Se ponen de relieve los retos que deben afrontarse para promover la salud bucodental en las escuelas tanto en los países desarrollados como en los países en desarrollo, y se subraya la importancia de usar un marco validado y metodologías apropiadas para evaluar los proyectos de salud bucodental en las escuelas.
Palabras clave: Salud bucal; Higiene bucal; Servicios de salud escolar; Escuelas; Educación en salud dental; Servicios de alimentación; Conducta de salud; Promoción de la salud/métodos; Política de salud (fuente: DeCS, BIREME).
Introduction
Oral health is fundamental to general health and well-being. A healthy mouth enables an individual to speak, eat and socialize without experiencing active disease, discomfort or embarrassment. Children who suffer from poor oral health are 12 times more likely to have restricted-activity days than those who do not (1). More than 50 million school hours are lost annually because of oral health problems which affect children's performance at school and success in later life (2).
Schools provide an effective platform for promoting oral health because they reach over 1 billion children worldwide. The health and well-being of school staff, families and community members can also be enhanced by programmes based in schools (3). Oral health messages can be reinforced throughout the school years, which are the most influential stages of children's lives, and during which lifelong beliefs, attitudes and skills are developed. This article examines the potential for promoting oral health through schools, based on the WHO Health-Promoting School (HPS) framework.
Need for oral health promotion in schools
Oral disease can lead to pain and tooth loss, a condition that affects the appearance, quality of life, nutritional intake and, consequently, the growth and development of children. The burden of oral disease is considerable. Tooth decay and gum disease are among the most widespread conditions in human populations, affecting over 80% of schoolchildren in some countries (46). The prevalence of other oral disorders such as dental erosion and enamel defects is rising (5, 6). Many children have experienced oral trauma, a substantial proportion of whom are under the age of 5 years (7). Some tobacco-containing products are marketed directly at children and adolescents; people who start consuming these products at an early age may have an increased risk of oral cancer in later life (8). Noma, a devastating and potentially life-threatening condition, affects a large number of children in Africa, Asia and Latin America (9).
Oral disease is one of the most costly diet- and lifestyle-related diseases (10, 11). The cost of treating dental decay alone could easily exhaust a country's total health care budget for children (12). However, the cost of neglect is also high in terms of its financial, social and personal impacts (13).
Many oral health problems are preventable and their early onset reversible. However, in several countries a considerable number of children, their parents and teachers have limited knowledge of the causes and prevention of oral disease (1417), compounded by a lack of affordable fluoride toothpaste and poor access to oral health care. The problems are exacerbated by the consumption of sugary snacks and carbonated drinks which is high among children and adolescents (18).
Given that many risk behaviours stem from the school-age years, schools have powerful influences on children's development and well-being (1820). The need for the promotion of oral health in schools is evident and it can easily be integrated into general health promotion, school curricula and activities. Children can be provided with skills that enable them to make healthy decisions, to adopt a healthy lifestyle and to deal with conflicts. Healthy behaviours and lifestyles developed at a young age are more sustainable. Messages can be reinforced throughout the school years.
Global School Health Initiative
Based on the guiding principles of the Ottawa Charter for Health Promotion and the recommendations of WHO's Expert Committee on Comprehensive School Health Education and Promotion, the WHO Global School Health Initiative was launched in 1995. The Initiative aims to foster health-promoting schools (HPSs); these are schools that constantly strengthen their capacity as a healthy setting for living, learning and working (21). It seeks to mobilize and strengthen health promotion and education activities through schools to improve the health of students, school staff, families and the community.
The Initiative comprises four key strategies, namely, building capacity to advocate for improved school health programmes; creating networks and alliances for the development of HPSs; strengthening national capacity; and research to improve the effectiveness of school health programmes. The Initiative helps countries develop strategies and collaboration between health and education agencies as well as programmes to improve health through schools. Global, regional and local networks have been developed to enable schools to share their experiences. Numerous technical reports have been published by WHO since 1995 to help schools to become HPSs.
Setting up oral health programmes in schools
Using the structures and systems already in place, a school is an efficient setting for the promotion of oral health. Promotion of oral health can trigger the installation of vital facilities such as safe water and sanitation. Initiatives that adopt the HPS strategies are effective, leading to potential long-term cost savings (22). The key components of an HPS are healthy school environment, school health education, school health services, nutrition and food services, physical exercise and leisure activities, mental health and well-being, health promotion for staff and community relationships and collaboration. Each area offers many opportunities for addressing oral health issues either as a specific project or as part of a general health promotion strategy. It is crucial that these initiatives are supported by school health policies (Table 1). Although a specific policy can be developed to tackle a single issue, it may be useful to address several problems or a number of risk factors in a single policy.
Healthy school environment
Oral health can be promoted through initiatives that aim at providing a supportive school environment. Safe playgrounds and buildings together with a smoke-free and stress-free environment and the availability of healthy foods can help reduce the risk to oral and general health and promote sustainable healthy lifestyles. A ban on selling unhealthy snacks in schools could be a starting point. Safe water and sanitation facilities are essential for toothbrushing drills and for controlling cross-infection. Oral health promotion should also address the sale of unhealthy foods and drinks and of tobacco-containing products to students in the vicinity of school premises.
School health education
Providing education on oral health in schools helps children to develop personal skills, provides knowledge about oral health and promotes positive attitudes and healthy behaviours. Oral health education can be taught as a specific subject or as part of other subjects, addressing the underlying physical, psychological, cultural and social determinants of oral and general health. Integrated approaches with active participation promote sustainable changes in behaviour (22). Oral health issues can be incorporated effectively into the curriculum (Table 2) (6, 23). Appropriate training of teachers and peer educators is critical. In some countries, oral health education is provided by municipal dental health services (Table 3).
School health services
In addition to offering training and expertise and supplying oral health materials, the school health team works with the primary health care team to provide oral health education, screening, diagnosis, needs assessment, preventive care, treatment, regular monitoring and, for more complicated conditions, referral to other dental or medical specialists and secondary care. Models for delivering such services vary immensely between countries. Whereas there are comprehensive on-site oral health facilities in schools in some industrialized countries, many schools in developing countries do not have adequate infrastructure and resources to provide these services. In some developing countries, the provision of emergency care, tooth extraction and basic restorative and preventive oral care may prove very important. Schools may be the only place for children, who are at the highest risk of dental disease, to gain access to oral health services.
Nutrition and food services
Healthy eating programmes should be developed to ensure that the canteens, tuck shops, kiosks and vending machines in schools are providing nutritious meals and healthy snacks. Children can be empowered to develop healthy dietary habits from an early age through school health education. Oral health can form part of schemes for the promotion of general health, as with the breakfast clubs that have been set up to support healthy eating, and be incorporated into the assessment and surveillance of nutritional status. Outside caterers and suppliers should be encouraged to support healthy eating initiatives in schools.
Physical exercise and leisure activities
Although sports and physical activities are beneficial to health, students should be educated about the harmful effects of isotonic drinks with high acidity and sugar content that can lead to dental caries and erosion (24). To reduce the risk of oral trauma, the use of mouth guards should be encouraged in high-risk contact sports (25).
Mental health and well-being
Stress may lead to poor diet, smoking and violent behaviours that are detrimental to health (26, 27). School programmes that help children develop self-esteem and confidence as well as reducing stress and conflicts in schools should form part of the curriculum. Children and school staff should be equipped with the skills that help them prevent and, if unavoidable, deal with interpersonal conflicts, stress, peer pressure and other social forces. The provision of counselling and support services for students and staff would be invaluable.
Health promotion for school staff
Healthy and tobacco-free school environments, together with supportive organizational and management structures, help reduce stress and promote healthy living. It is essential for the school to provide health-promoting facilities such as well-designed and health-oriented classrooms, offices, staffrooms and canteens, and to make provision for exercise, relaxation and support services. Oral health should form an integral component of these initiatives. A well-designed oral health training programme that is responsive to their needs should be provided regularly to staff as part of in-service development. It should enable staff members to acquire skills and sustain healthy lifestyles, and to integrate their knowledge and skills into their teaching. Working with the school health team, parents and the local community, they can identify essential policies and practices that promote oral health and general well-being in school and the community.
Relationships and collaboration between the school and the community
Parents can be trained to reinforce oral health messages at home and act as facilitators in outreach programmes for children who do not attend schools. Such programmes can help promote oral health to these families and may encourage them to become part of the school community. Through the students, other members of the family can benefit from an oral health promotion programme initiated by the school.
The interaction between the school, the home and the community is critical (28). Family and community members can be involved in the planning and decision-making process, for example, by being part of the school health team or community advisory committee. They can take part in school-led oral health activities at school and in the community, such as breakfast clubs, oral health days, exhibitions and health fairs. Community support is crucial in lobbying for a healthy environment, clear food labelling and water fluoridation. The media offer a powerful channel for the delivery of oral health messages (29). The media should be educated to refrain from targeting children and adolescents in tobacco advertising campaigns and from the promotion of foods and drinks that are high in sugar, salt and fat.
Examples of health-promoting schools from China and Denmark
Depending on local circumstances, various approaches have been adopted by schools. Whereas some schools may attempt to incorporate a number of components simultaneously, others may build on existing good practice and initiatives on a project- by-project basis. Schools in different countries may place a different emphasis on the various components of an HPS, taking into account the local infrastructure and available resources. Examples from China (30) and Denmark (31) are illustrated in Fig. 1 and Fig. 2, respectively.
Cost of implementing health-promoting school policies
The costs of implementing HPS policies should be considered at several levels, namely, at the global, geo-political, national levels, and, within a country, at the regional and the local health and education authority levels, and finally, at the school level. At the higher levels, costs relate to policy development and maintenance of up-to-date advice including regular reviews of the evidence base. WHO has taken a lead role in the area of policy development related to HPSs.
The reality and costs of implementation vary between countries, and, at regional levels, may be difficult to identify and apportion separately. At the local level, costs depend on the existing infrastructure, and on the funding and support available from government and other organizations. At the school level, costs include the initial training for policy development and review, modification to the school environment, provision of healthier alternatives, health education activities and continuing support for school staff, children and parents.
A differential pricing policy for healthier snacks has been found to increase their selection by children (32). In Norway (33), providing a free piece of fruit or a vegetable has been found to be an effective strategy to increase schoolchildren's intake of fruit and vegetables and a similar free fruit scheme has been set up in schools in the United Kingdom. Subsidizing the cost of healthier snacks to reduce their price has clear resource implications, but may be more appropriate in communities where maintenance of food choice is regarded as a practical alternative to banning the sale in school of less healthy options.
The costs of implementing HPS programmes should be considered alongside the health benefits. This is a considerable challenge as costs are immediate and relatively easily measured, but benefits in terms of changed behaviour and increased life chances are long-term and may be difficult to attribute to a single intervention. Hence there is a need for a structured approach to evaluation.
Evaluation
According to WHO, at least 10% of programme resources should be allocated to evaluation (34). Evaluation helps inform and strengthen school health programmes and determines the extent to which the programme is being implemented as planned; it assesses processes and outputs, impact and effectiveness of the programme and, if any aspects have not worked well, identifies the key lessons learned. It is important to provide feedback to policy-makers, sponsors and those who have been involved in the planning, development and delivery of programmes. Evaluation can be used to reward the efforts of schools, students, teachers, parents and the community and, by demonstrating the benefits, to encourage others to help more schools to become HPSs. Quality evidence can be used by schools to convince policy-makers, sponsors and other stakeholders to provide continued support to, and to become involved in, HPS programmes.
Process and outcome measures can be set for each component of an HPS (Box 1) (6). They include the assessment of the school environment such as the provision of healthy foods and drinks, sufficient sanitation and safe water for oral health activities. The targets for policy development to address the key components of an HPS can be set for short-term evaluation, followed by evaluation of the effectiveness of various interventions, such as oral health education in the classroom, exposure to fluoride, changes in knowledge about oral health, attitudes, behaviours and lifestyles, as well as clinical outcomes and impact of interventions. The sustainability of an HPS and its relationship with the wider community, partnerships and networks should be considered in long-term evaluations. However, it is important to employ appropriate evaluation strategies. Although the scientific merits of randomized controlled trials are well-recognized, they may not always be suitable for the evaluation of oral health promotion (35). Both qualitative and quantitative methodologies have a role to play. A pluralistic approach to evaluation can strengthen its validity and help circumvent the limitations of the individual evaluation approaches (36).
Challenges faced in promoting oral health in schools
A lack of sustainable funding, resources and trained personnel (professionals and volunteers) has been identified (37). The conflicting priorities and agenda of the school, health, education and local authorities, may mean that the implementation of oral health activities within a programme for general health promotion and the school curriculum proves too challenging. Health and safety constraints and fear of litigation may be a deterrent. Tuck shops, vending machines and sponsorship from industry may be an important means of income generation, a consideration that can influence food policies in schools. Given the competing demands of an already full curriculum, teachers may be reluctant to include oral health in their teaching, because they wish to avoid disruption to other school activities. Training and effective communication between health professionals and teachers are crucial, as is support from parents (38). Providing school oral health services, particularly on the school premises, may not be feasible. All components of an HPS may not be encompassed in all HPSs (39), and it is particularly challenging to create a coherent, complementary and integrated approach within the local constraints.
These problems are more acute in developing countries where they may be compounded by poverty, gender inequality and political instability (3). Many children, particularly girls, have limited access to education. Some schools are located in polluted areas with dangerous traffic and lack safe drinking-water and sanitation (40). Affordable toothbrushes, toothpaste and other oral health education materials are not readily available (41, 42). Industrial partners and manufacturers have an important role to play in improving this situation. A shortage of trained dental personnel means that teachers are often expected to teach as well as to provide basic dental treatment and oral health education, responsibilities that teachers are considered ill-equipped to carry out (43). Without supportive policies, infrastructure, budget and commitment from various government departments, the obstacles faced by schools and teachers in promoting oral health may remain insurmountable. Support from global, regional, national and local HPS alliances and networks can prove invaluable in helping schools to overcome some of these barriers. Funding may be available for specific projects from central and local governments, as well as from nongovernmental organizations and other bodies such as Education International, the Education Development Centre, the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Again, effective collaboration with other sectors and programmes is fundamental.
In conclusion, there is a pressing need for oral health to be promoted in schools worldwide. The potential for developing a comprehensive programme using the HPS approach is considerable. Commitment from central and local government, schools, families and the community is critical. It is imperative for public health authorities and health professionals to provide sustainable support, in terms of technical assistance, funding and/or learning materials to facilitate schools becoming HPSs. 
Competing interests: none declared.
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Submitted: 18 February 2005 Final revised version received: 24 June 2005 Accepted: 27 June 2005
1 Correspondence should be sent to this author (email: s.kwan@leeds.ac.uk).