HEALTH PROMOTING SCHOOLS, AN ENTRY POINT TO HEALTH PROMOTION IN COMMUNITIES.
Brighter smiles Africa was established collaboratively by Department of dentistry-Makerere University and University of British Columbia, using "health promoting schools" as an entry point to health promotion in communities. Four Health-promoting schools in rural communities of Kalisizo, Kawolo, Hoima and Kiboga in Rakai, Mukono, Hoima and Kiboga districts respectively were initially selected as pilot schools, with more than 2500 children enrolled prior to adding a fifth health-promoting school in Senge village, Wakiso district. The schools had to have parents who were interested in the program, and teachers who were prepared to include health topics in the curriculum and who were supportive of the health promoting activities. The primary problem was "the burden of oral diseases secondary to poor oral health in children". Our intervention would reduce dental caries, halitosis (bad breath), gingivitis and other periodontal diseases, prevent systemic effects that are mediated by circulating oral inflammatory products (Cytokines) which increase the risk of heart disease, stroke, diabetes and premature labour and to use oral health as an entry point to promotion of other aspects of health.
After obtaining conset from the ethics review board of Makererere University, interested Makerere University dental students and their colleagues from University of British Columbia traveled to the selected schools from where they oriented the community political leaders, school head-teachers, teachers and parents via formal presentations to the relevance of oral health, the benefits of tooth brushing and topical fluoride application on children's teeth, and the value of progressing from the initial focus of oral health to address other health issues. Consent was obtained at public presentations where either Yes or No response to participation was requested from the community leaders and parents present. Only one family declined. Parents who were not present were deemed to have consented. School supplies including textbooks, pens, pencils and soccer balls were given in recognition of the time and commitment these individuals were asked to invest. Baseline data were collected on children’s demographics, oral health practices, diet, and a score of decayed, missing and filled teeth. Toothbrushes and toothpaste were provided to all children. Storage cupboards containing racks with numbered holes were designed to hold the toothbrushes to avoid cross-contamination leading to infections, and local carpenters were hired to make them. Teachers were instructed on how to teach and lead daily at-school tooth brushing for their classes. Students developed educational materials for in-school teaching to ensure local language content and cultural relevance. Children with primary, mixed and early permanent dentition had their teeth fluoridated with fluoride varnish. Each month three members of our team went to the participating schools to repeat the health education concepts and reinforce tooth brushing practices. From the second year since the commencement of our intervention onwards, the team visits each health-promoting school community annually to support the program, collects demographic and caries data, examines all of the enrolled children’s teeth, and interviews stakeholders to find out their perceptions of the program’s benefits and to develop any modifications and improvements required.
Since the commencement of the program, more than 91 university students have collaborated to deliver this community-based health education and prevention program. Informally, teachers report noticeable improvements in the oral health of pupils and express continued enthusiasm for and demonstrate full participation in the daily brushing program. We also noticed that children are teaching their siblings and parents what they are learning about health from school. Children have significant qualitative and quantitative improvement in oral health and reduced absence from classes secondary to ill oral health. Children have effectively stopped using agents that negatively influence oral flora (soap) or cause abrasion of tooth enamel (ash). Sharing knowledge with siblings and parents, and advocacy for all family members to brush at home indicate knowledge transfer and promotion of healthy practices. Nutrition has partly been addressed in one of the health-promoting schools by starting a school garden planting on a more than two acres piece of land to provide lunch for pupils while at school. Efforts have been made to expand the program to address other health concerns, so that the program now includes topics in reproductive health, malaria prevention, and diarrheal disease prevention through hand washing practices, use of clean water and sanitation. Teachers credit the program with generating more positive attitudes towards health-related practices for the whole community.
To our knowledge as a team, this was the first use of "topical fluoride varnish" in a community based dental caries preventive approach in sub-Saharan Africa. The program has proved to be an excellent platform for the development of a symbiotic relationship between developed and developing world university students and between universities and rural communities. The successes registered have shown the feasibility and relevance of health-promoting schools in Uganda. After establishing the program using the promotion of oral health, a simple, achievable task where success generated enthusiasm and confidence, community-identified issues then drive the direction of the relationship between the communities and the university and expand the scope of the health education content and range of healthy behaviors promoted. Health-promoting schools provide a practical and effective health intervention at low cost, with measurable outcomes of success over a short timeframe. Communities in other countries can replicate the key features and steps of this program to establish similar health-promoting school activities.