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    A framework for integrated school oral health promotion within the Health Promoting Schools Initiative in KwaZulu-Natal.
    (2015) Reddy, Moganavelli.; Singh, Shenuka.
    Introduction: Schools can provide a perfect setting for the implementation of health and oral health promotion activities. However, a change in focus was needed at schools from the traditional topic-based approach to health education to a more holistic approach to health and oral health promotion. The Health Promoting School Initiative provides an integrated, holistic, collaborative and co-ordinated approach to health. This initiative can therefore provide a platform for the integration of oral health promotion activities within health promotion activities at these schools. However, the extent to which oral health promotion is incorporated into health promotion activities and whether oral health, promotion programmes have been implemented at these schools is unclear in South Africa. Aim: This study set out to develop a framework to use a systematic approach to critically assess the viability of including oral health promotion elements within the Health Promoting School Initiative to establish the appropriateness of this mechanism for school-based oral health service delivery. Methods This study was explorative and since the integration of oral health promotion into the school programme is multifaceted, a combination of both qualitative and quantitative data was collected. It was conducted in three phases. Qualitative data was obtained through in depth interviews and self administered questionnaires in the first phase of the study. The second phase of the study comprised of the implementation of an intervention based on the findings in the first phase of the study. The third phase of the study obtained qualitative data using focus group discussions. A situational analysis was conducted in the first phase of the study. All policy documents, strategic plans and reports from the national and provincial departments of health and education that were relevant to oral health were reviewed in this study. The purpose of this was to ascertain priorities and strategies for oral health promotion at schools. Quantitative data was obtained using the World Health Organization Decayed Missing Filled Teeth (WHO DMFT) Tool to determine dental needs of the learners. A self administered questionnaire and data capture sheet was also included. Quantitative data were quantified according to codes, and verified. The data was analysed with SPSS version 21.0. Inferential techniques used for data analysis included correlations and chi-square test values which were interpreted using p-values. The transcription obtained from interviews in Phase 1 and focus group discussions in Phase 3, and qualitative responses to the questionnaire were analysed separately. Responses from interviews and focus group discussions were first transcribed verbatim and organised according to the questions. The raw data was then checked and verified for quality purposes. Triangulation was used for evaluation of the data. Thematic data analysis using inductive and iterative techniques was used for qualitative data. Open coding, axial coding and selective coding was used to analyse the data. Objectives: 1. To identify current policies or priorities for health promotion and oral health promotion in policies, strategic plans and annual reports of the Department of Health and Department of Education. 2. To conduct a situational analysis of existing services and an epidemiological profile to determine unmet oral health needs of six year old learners at the selected Health Promoting Schools in KwaZulu-Natal using a questionnaire, interview schedule, data capture sheet and the WHO DMFT Tool. 3. To determine the presence or absence of school based oral health promotion programmes at the selected schools using a questionnaire and interview schedule. 4. To introduce oral health promotion programmes in schools where there are no or interrupted oral health service delivery to determine the feasibility of these programmes. 5. To determine the opportunities and barriers for the incorporation of oral health promotion within the Health Promoting School Initiative through focus group discussions. 6. To compare this programme to schools that have existing oral health promotion programmes. Results and Discussion: The results obtained in the three phases of the study were integrated, discussed and then coherently presented in this chapter. The qualitative and quantitative data obtained from Appendices 1, 2, 3, 4 and 5 are described and discussed in accordance with objectives 1, 2 and 5 of the study. The inextricable link between these objectives is demonstrated appropriately throughout the analysis. Four salient themes emanated from the data. These themes were aligned to objectives 1, 2 and 5 of the study. The data are presented as categories that are linked into a framework of consistent behaviour, connections and consequences that are relevant to a particular phenomenon. The framework used to guide this study provided a systematic and negotiated approach to the planning, implementation and review of the oral health promotion intervention to achieve the desired goals in an appropriate period of time. The framework also provided a multi-level approach for oral health care delivery that included macro, meso and micro influences. The framework identified critical areas for assessment for those involved in planning and implementing integrated school health programmes. Potential target areas for oral health promotion interventions were also identified. Processes that advocate and encourage social cohesion, partnership development and resource sharing were also identified. Process evaluation investigated how well the planned intervention had been implemented. It also identified the factors that facilitated or impeded the implementation. In this study, 27% of the six year old children were caries-free giving a caries rate of 73%. The mean dmft for the study sample was 3.65. The average dmft per school ranged from a high of 6.8 to a low of 1.1 with both these extremes recorded in the rural districts. Overall 94% of the learners required some type of treatment with the majority (90%) requiring preventive care. The Unmet Treatment Need (UTN) was 97%. Although the Health Promoting School Initiative was chosen because it provides a supportive environment to improve health, several barriers were present for the successful integration of oral health promotion into this initiative. The study findings indicated an absence of oral health promotion initiatives in the curriculum. Educators also noted that they were restricted to what was prescribed in the curriculum and therefore found it difficult to include oral health promotion as suggested by the researcher. Additionally, almost 70% of study participants (educators) lacked knowledge and skills in oral health promotion. This resulted in a lack of confidence in the implementation of an oral health promotion programme. The study findings also noted a lack of in-service training provided in oral health promotion to educators. These factors therefore impacted on the integration of oral health promotion into the school programme. It was further noted that if oral health promotion activities such as tooth brushing and fluoride rinses are included in the school programme, this would have implications in terms of time management for educators as these activities would encroach upon their teaching time. Sustainability of these activities would also be a problem as a result of inadequate resources, funding, knowledge and supporting structures. The study findings indicate that the barriers identified in this study are similar to what has been reported more than ten years ago. This implies that although the Department of Health in collaboration with the Department of Education has adopted the Health Promoting School Initiative, they have not provided the necessary resources to sustain these programmes. It was therefore suggested that a multilayered approach to health and oral health promotion be implemented as opposed to a blanket programme so that a greater mix of available strategies could be considered from district to district. Although there were many limitations to this programme some benefits were identified. All (100%) participants identified the importance of the inclusion of oral health promotion into the curriculum, especially in rural areas. Educators at two schools (15%) were of the opinion that oral health education should be reinforced in the curriculum by introducing examples and activities. Some educators (46%) also felt that this programme was of benefit to them as it had created awareness to oral health. This therefore empowered educators to take control of the programme by creating awareness to the importance of oral health and providing guidance on the implementation of the programme. Conclusions and Recommendations: The aim was achieved by developing and using a conceptual framework to integrate oral health promotion within the context of the Health Promoting Schools Initiative. This framework provided a systematic and negotiated approach for the planning, implementation and review of the oral health promotion intervention based on the needs of the six year old learners at the identified schools. The strength of this framework was underpinned in its multi-level approach to ensure quality of oral health care delivery. The limitations of this framework were that it was not tested for effectiveness to bring about behaviour change as this was a long term goal. Additionally, the cost-effectiveness of this framework was not investigated. Although current policies and strategic plans (100%) in South Africa and KwaZulu-Natal have prioritised primary prevention and promotion, integrated approach and the common risk factor approach, study findings indicate that not all these strategies have been translated into practice. This therefore suggests that current oral health services are inconsistent and fragmented. Currently there is inequality and inequity in the delivery of oral health services in schools. Strategies for oral health promotion have not been translated into practice indicating that oral health services are currently not properly aligned. Lack of collaboration between the Department of Health and Department of Education has resulted in a lack of coordination between the Health Promoting Schools Initiative and School Health Services in terms of policy and guidelines with education policies and guidelines. It was established from research findings that oral health promotion is not incorporated into general health promotion in the school curriculum. Current water supplies and sanitation are still inadequate (50%) in rural schools. Although most(71.4%) of the schools in the rural areas have access to a community clinic, resources are limited and poor road conditions and transport prevent attendance at these clinics. The majority (87%) of the schools currently have limited control over what is being sold at their tuck shops and by vendors. There is also a lack of support from the Department of Education in terms of funding for oral health promotion programmes. An increase in the prevalence of dental caries suggests that this has not been adequately addressed in KwaZulu-Natal. The decrease in fillings suggests that there is a decrease in oral health service provision for restorative procedures. There is therefore a need for improvement in oral health service delivery. As a result of the current focus being on policy formulation and not the translation of policy into sustainable programmes, it was recommended that there was a need for multiple stakeholder involvement in policy monitoring with specific strategies for implementation and evaluation of oral health promotion activities. There was also a need to ensure stakeholder involvement in the development of oral health learning material at school level. More research needs to be done to explore the mechanism to support and address inequity in oral health promotion related service delivery at schools and to test the adaptability of the framework in other health related settings both provincially and nationally.