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Oxford University Press 1996 Printed in Great Britain

Impact of oral health education on primary school

children before and after teachers9 training in Tanzania
Department of Preventive and Community Dentistry, University of Dar es Salaam, Tanzania
Health and Development Cooperation Group, National Agency for Welfare and Health in Finland,

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Helsinki, Finland
Department of Preventive Dentistry and Cariology, University of Kuopio, Finland
Department of Dental Ecology, University of North Carolina, USA

Oral health education is part of the primary school knowledge, attitudes and practices. Three random sam-
curriculum in Tanzania. However, most of the teachers ples, each with 200 pupils, including conventional and
responsible for it lack training and motivation for the modified session groups and a reference group not given
task. Their oral health education sessions are deficient in oral health education at school, were interviewed and
content and in methods, only addressing oral hygiene by examined. The group that received modified oral health
lectures. Thus, modified oral health education was education had better knowledge of oral health, reported
designed and teacher training workshops were carried reduced consumption of sugary foods and increased
out in one district by a dental team in liaison with school toothbrushing frequency, and had better 'mswaki'
administrators. After training, the teachers taught a (chewing-stick) making skills and slightly improved
variety of oral health issues and pupils actively studied oral hygiene; in comparison with the referents. The
the concepts and practical skills for dietary choices and group with conventional oral health education had some-
toothbrushing. This report describes the impact of oral what better oral health knowledge but their practices
health education given by teachers before and after they were no better than the referents'. The results emphasize
had been trained in the workshops. The impact of the the needfor providing training, guidance andfeedback to
sessions was assessed as changes in the pupils' oral health implementors of oral health education programmes.

Key words: impact, oral health education, schools, Tanzania


As compared with the prevailing fatal diseases, dental caries (Ministry of Health and Social
mainly communicable diseases like malaria, Welfare, 1988; Mosha el al., 1994).
pneumonia and diarrhoea, oral diseases are not Among primary school-age children in Tanza-
a major health problem in Tanzania. Oral nia toothbrushing seems to be prevalent but oral
tumours and injuries are rare. However, the hygiene is, nevertheless, poor and gingivitis is
majority of adults and school-age children in common (Frencken et al., 1986; Kerosuo et al.,
Tanzania are affected by gum disease and/or 1986; Mandari, 1988; Nyandindi, 1988; Normark
194 U. Nyandindi et al.
and Mosha, 1989; Mumghamba, 1990; Nyan- as well as some other teaching aids. The district
dindi et al, 1994a). Studies undertaken among dental personnel carried out the workshops.
the children in this age group also indicate low The teachers' performance in teaching the oral
consumption of sugary foods but wide preference subject was assessed by observing their oral
for them (Nyandindi, 1988; N0rmark and health education sessions 2 months after the
Mosha, 1989; Nyandindi et al, 1994a). Caries training. The sessions had improved substantially
affects about a third of the primary school-age in both content and methods in comparison to
children (Frencken et al., 1986, 1990; Kerosuo et those observed before the teachers' training. The
al., 1986; Mandari, 1988; Nyerere, 1988; Bloch et teachers now addressed both oral hygiene and
al., 1989; Axell and Johansson, 1993; Mosha et diet, and used demonstration and practical meth-
al., 1994). The average number of decayed, miss- ods to teach pupils the practical skills for healthy
ing and filled teeth per child (dmft or DMFT) is dietary choices and effective toothbrushing
low; for example, the DMFT index for 12-year- (Nyandindi et al, 1995).
olds is within the global goal of three or less by The aim of this study was to further evaluate
the year 2000. Oral health knowledge among the the impact of the teachers' training, by assessing
children is poor (Nermark and Mosha, 1989; the improvements in their pupils' oral health

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Nyandindi et al., 1994a). knowledge, attitudes, practices and skills, in com-
An oral health education programme aimed at parison with the pupils' situation before the
fostering proper oral health behaviour among teachers' training.
school-age children was started in Tanzania in
1982, and is being implemented by teachers at
primary schools (Ministry of Health and Social
Welfare, 1988). There are 10 437 primary schools SUBJECTS AND METHODS
(first to seventh grades) attended by 3.5 million
children (~ 15% of the total population) in a year Study design and samples
(Ministry of Education and Culture, 1992). Oral The evaluation of the impact of the conventional
health education is scheduled for first-grade as and the modified oral health education among
part of health lessons taught by the classroom pupils was conducted at five (out of 35) urban
teachers in two 30-min lessons a week (Taasisi ya primary schools and five (out of nine) rural
Elimu, 1987). Considering the oral health situa- primary schools which were randomly selected
tion of school-age children in Tanzania, current from urban and rural areas in the Ilala district. A
oral health education does not seem adequate in between-group study design (Adams and Schva-
content and methods. It consists mainly of oral neveldt, 1985) involving three samples of pupils
hygiene issues taught in lectures only (Taasisi ya was used: a reference group, a conventional ses-
Elimu, 1987; Nyandindi et al, 1995). Moreover, sion group and a modified session group.
the Tanzanian primary school teachers' knowl- Each sample (group) consisted of 200 first-
edge, skills and motivation for giving oral health grade pupils who were randomly chosen from
education are poor and most of them have had each of the ten schools involved. In these schools,
no training for the task (Nyandindi et al, 1994b). first-graders had been divided into two or more
With the aim of improving the quality of streams (classes) of usually over 50 pupils each.
school oral health education within the limited One of the school-entering classes of 1990 at each
resources in Tanzania, a new manual for teaching of the ten schools was randomly chosen and
the subject and a teacher's training programme stratified by gender. Then, ten boys and ten
were designed and provided to the teachers of one girls were randomly chosen from each stratum
district, Ilala. These actions were organized by a to form the reference group (aged 5-15 years,
team consisting of the present researchers, the mean 8.99, SD 1.84 years). These children had
district's dental personnel and the district's not received oral health education at school at the
school administrators. The manual and training time of study but would be given it later in the
were planned to meet the surveyed oral health year as scheduled in their curriculum. Another
education needs of pupils and to suit local reali- randomly chosen first-grade class of 1990 in each
ties. All teachers (n = 125) in the district super- of the ten schools was given oral health education
vising first-grade classes, in which oral health by their classroom teachers, in their usual way.
education is scheduled, attended the training Each of these classes was also stratified by gender
workshops and were provided with the manual and ten boys and ten girls were randomly selected
Impact of oral health education 195
from each stratum to comprise the conventional how to brush teeth properly. Each teacher super-
session group (aged 6-15 years, mean 9.55, SD vised the children's performance. They instructed
1.96 years). The same teachers who had con- the children to regularly replace their tooth-
ducted the conventional sessions also taught the brushes, of any type, and also encouraged them
modified sessions to their new first-grade classes to use toothpaste, but discouraged brushing with
the following year (1991), after they had been charcoal and ash. The teachers also asked pupils
trained in the workshops. From each of these new to spread their new oral health knowledge and
classes, ten boys and ten girls chosen randomly skills to their families. Unlike the former sessions,
from each gender stratum comprised the modi- in the modified sessions the pupils were actively
fied session group (aged 5-15 years, mean 9.46, involved throughout the sessions.
SD 2.05 years).
Data collection
The oral health education sessions
The content and the methods of the conventional The samples of pupils given each of the two types
and modified sessions have been previously of oral health education were studied 4 months
reported (Nyandindi et al., 1995) and are only later. The methods for assessing the impact, as

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briefly described here. regards oral health knowledge, attitudes, prac-
The conventional oral health education ses- tices and skills of these children, were the same as
sions were held in classrooms. The classes were those used with the referents and have been
often very large (37-184 pupils), with many described in a previous report (Nyandindi et al.,
pupils sitting on the floor as there were too few 1994a). The children were interviewed in a class-
desks. To teach the conventional sessions, before room by a teacher and a health education worker
the teachers' training, each teacher brought along trained for the task. For assessment of oral
the 'Ministry of Education' health education hygiene, the outer and inner surfaces of each
guide, but no other teaching aids. The teachers pupil's 12 index teeth (first permanent molars,
taught oral hygiene for about 30 min (one school second deciduous molars and permanent central
period). Daily toothbrushing was stressed for incisors) were examined by a dentist, who did not
prevention of bad breath or tooth decay. The yet know the pupils' status of exposure to oral
teachers recommended both factory-made tooth- health education. This was done outdoors in
brushes and self-made 'miswaki' (chewing-sticks) daylight in an ordinary chair using only a
as effective but gave no advice on how to produce dental mirror. Plaque was recorded as present
or use them. They encouraged pupils to use only when clearly visible on the index surface.
toothpaste, but also charcoal and ash as less Repeated examination of plaque within the same
costly substitutes. The pupils remained passive day among 20 subjects (10%) examined first in
throughout the lectures. each sample (referents, conventional and modi-
The modified oral health education sessions fied session groups) showed high intra-rater relia-
given by the teachers after their workshop train- bility; the mean kappa values were 0.93, 0.95 and
ing were attended by as large number of pupils as 0.93 respectively. The children's abilities to make
the conventional sessions. The teachers now used a 'mswaki', which is being recommended as a
the new manual and other teaching aids, and the low-cost alternative to the modern toothbrush,
pupils brought with them materials for practicing were also examined. Each child was given a tree-
toothbrushing and 'mswaki' making from home. twig, a knife and a cup of water, and made a
In accordance with the guidance given, each 'mswaki', which was recorded as suitable only if
teacher conducted the sessions in two successive it had soft bristles and was at least 18 cm long so
parts. The first part took place in a classroom for that one could reach molars with the brush.
30 min; basic functions and morphology of teeth, The impacts of oral health education on pupils'
and the causes and prevention of gum disease and oral health knowledge, attitudes, practices and
tooth decay were discussed. The pupils also prac- skills were compared between the conventional
ticed in identifying non-sugary food items harm- and the modified session groups, and the findings
less to teeth. The second part lasted for about one from each session group were also compared with
hour, focused on toothbrushing, and took place the knowledge, attitudes, practices and skills of
outside the classrooms (due to lack of wash- the reference children. Chi-square statistics and
basins). The teacher demonstrated and every Student's /-test were used to evaluate the differ-
child practiced how to make a 'mswaki' and ences between the groups.
196 U. Nyandindi et al.
RESULTS children who had attended the modified oral
health education sessions, sugar consumption
Oral health knowledge (in tea) was less frequent than among the con-
Among the pupils who had participated in the ventional session group and the referents. The
modified oral health education sessions, knowl- five most common non-sugary foods eaten the
edge about tooth decay and gum disease (their previous day were hard porridge, rice, vegetables,
occurrence, causes and prevention) was signifi- meat and cassava. When the most commonly
cantly better than among the children in the eaten five sugary and five non-sugary foods
were displayed for each pupil to choose the
reference group or conventional session group. favourite one, significantly (p = 0.001) fewer
Among the pupils who had attended the conven- children in the modified session group (31%)
tional oral health education sessions, only knowl- then in the other groups (40% in the conven-
edge about gum disease was better than among tional session group, 48% in the reference group)
the referents. Irrespective of their exposure to chose a sugary item. The modified session group
school oral health education, the majority of had the best knowledge about the harmfulness of
the children studied said they brushed their sugary food items to teeth, whereas many chil-

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teeth to prevent tooth decay. Only among chil- dren in the reference and conventional session
dren who attended the modified sessions, was groups regarded soft drinks and biscuits as harm-
prevention of gum disease one of the motives less to teeth (Table 2).
for toothbrushing (Table 1).
Oral hygiene practices and attitudes
Dietary practices and attitudes Most children who had participated in the mod-
When asked about their dietary habits 4 months ified sessions brushed their teeth twice a day,
after the first sessions, about a third of the while in the other groups children usually
children studied, irrespective of their oral health brushed only once. About 80% of all children
education exposure, had not eaten any sugary studied said they used a factory-made tooth-
items during the previous day. The rest, about brush, and 90% or more preferred a factory-
two-thirds, had eaten sugary foodstuffs once or made brush over the traditional 'mswaki'. More
twice, mostly sugared tea, ice-cream, biscuits, soft pupils in the modified session group than in the
drinks or sweets (Table 2). Notably, among the other groups had the skill for making a proper

Table 1: Oral health knowledge compared between the conventional (C) and modified
(M) session groups, and between each session group and the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Knew about tooth decay

Occurrence (common) 28 35 63 <
** 4 %
Cause (sugary snacks) 39 46 84
24 * *4
Prevention (avoid sugar) 27 50
Knew about gum disease
* *4
Occurrence (common) 11 10 56
Cause (poor toothbrushing) 38 65 78
Prevention (toothbrushing) 52 83 80
Motive for toothbrushing
To avoid tooth decay 58 73 * 81
To make teeth white 36 18 6 ** ***
To avoid gum disease 0 1 13 na na
No reason 6 8 0 nu na

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p < 0.05, **p < 0.01,
***p $ 0.001, "" not applicable).
Impact of oral health education 197

Table 2: Self-reported practices and beliefs about sugary foods compared between the
conventional (C) and modified (M) session groups, and between each session group
and the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R M versus R C versus M

Pupils who had consumed

sugary items (once or twice)
the previous day
Tea with sugar 65 60 44 **
Sweets 17 11 9 *
Ice-cream 14 12 14
Soda drinks 13 10 10

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Biscuits 11 10 13
Pupils who regarded sugary
items as harmful to teeth
Tea with sugar 76 73 80
Sweets 69 80 89 **
Ice-cream 93 96 84 * *
Soda drinks 37 38 62 ** **
Biscuits 55 54 68 **

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p < 0.01,
***p s 0.001).

Table 3: Self-reported oral hygiene practices and attitudes compared between the con-
ventional (C) and modified (M) session groups, and between each session group and
the referents (R)
Referents Pupils who> received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Toothbrushing frequency
Once a day 78 57 ** 23 * *
At least twice a day 22 43 77 ** **
Items used for toothbrushing
Industrial toothbrush 80 80 78
Chewing-sticks ('miswaki') 20 20 22
Toothpaste 57 55 57
Charcoal 23 38 ** 26 *
Ash 9 5 1 na na
Skilled in making 'mswaki' 35 37 86 ** **
Type of toothbrush preferred
Industrial 95 92 90
'mswaki' 5 8 10
Regarded toothpaste essential 76 74 75

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p ^ ".01
*p a 0.001, na not aDDlicableV
s 0.001. applicable).
198 U. Nyandindi et al.
Table 4: Pupils with no visible plaque by the index teeth compared between the con-
ventional (C) and modified (M) session group, and between each session group and
the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Upper teeth
Right first Outer 3 9 18 * *
permanent molar Inner 48 53 51
Right second Outer 19 30 38 **
deciduous molar Inner 70 67 74
Right permanent Outer 83 83 87
central incisor Inner 87 83 83
Left permanent Outer 83 82 90 *

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central incisor Inner 88 82 82
Left second Outer 23 26 30
deciduous molar Inner 77 70 73
Left first Outer 7 14 14
permanent molar Inner 54 60 57
Lower teeth
Left first Outer 49 52 61
permanent molar Inner 4 6 5
Left second Outer 73 73 76
deciduous molar Inner 19 16 22
Left permanent Outer 57 61 69 *
central incisor Inner 69 68 78 *
Right permanent Outer 56 61 76 ** **
central incisor Inner 67 69 77
Right second Outer 76 77 77
deciduous molar Inner 18 15 21
Right first Outer 49 52 55
permanent molar Inner 2 3 na 5

Differences between groups evaluated by chi-square statistics (d.f. 1, *p ^0.05, **p S 0.01, ***p
< 0.001, not applicable).

'mswaki' (Table 3). Three-quarters of all studied p = 0.001). In all groups, clean tooth areas were
children, regardless of their oral health education more often the inner than the outer surfaces of
exposure, considered toothpaste essential for upper teeth, the outer than the inner surfaces of
tooth-cleaning, but only about half said they lower teeth, and the front than the back teeth.
used it. Among the children in the conventional The children in the modified session group could
session group, brushing with charcoal was more clean some of these tooth areas more effectively
common compared with the modified session than children in the other groups (Table 4). No
group or the referents. association between age and oral hygiene was
The children who had participated in the mod- found in any of the three groups of children.
ified sessions had slightly better oral hygiene than
the other pupils 4 months after the first sessions.
The mean number of tooth surfaces (24 surfaces DISCUSSION
examined) with visible plaque was smaller (10.5,
SD 4.7) among the modified than among the The between-group study design involving three
conventional session group (11.7, SD 4.9) and cluster samples of first-graders (reference group,
the referents (12.0, SD 4.4). The difference was conventional session group and modified session
statistically significant only between the modified group), was used to evaluate the impact of the
session group and the reference group (r = 3.28, two types of school oral health education. This
Impact of oral health education 199
study design prevents carry-over effects as each toothbrushes rather than 'miswaki' (chewing-
study group is exposed to only one type of sticks) which are suggested in the conventional
intervention, and each group is studied only sessions. The current school oral health educa-
once which reduces the chance of their guessing tion regime recommends and actually seems to
what they may think the interviewer wants increase the use of charcoal (a tooth-erosive
(Adams and Schvaneveldt, 1985). Spill-over of substance) as 'toothpaste', a practice common
the interview or session contents between the in Tanzanian society (Sarita and Tuominen,
samples was not very likely as the children were 1992). The pupils hardly seem to learn about
from different classes. The three samples were prevention of tooth decay.
randomly chosen and had comparable back- Conventional oral health education in Tanza-
ground characteristics; they consisted of first- nian schools is taught according to the 'Ministry
grade children, had similar age ranges, had of Education' curriculum guide (Taasisi ya
equal proportion of boys and girls and of urban Elimu, 1987) which addresses oral hygiene only.
and rural children, and were from the same The guide mentions use of practice sessions for
school locations within a district. teaching toothbrushing skills, but the sessions
The wide age range (5-16 years) among the were observed to be mainly lectures (Nyandindi

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first-graders studied is typical of the classes in et al., 1995) as has been the case in many tradi-
Tanzania although the officially recommended tional programmes (Frazier et al., 1983). Support
age for children's enrolment into school is from dental personnel is called for in the
7 years (Ministry of Education and Culture, National Plan for Oral Health (Ministry of
1992). Even then, the reference group's oral Health and Social Welfare, 1988), but most pri-
health knowledge, attitudes and practices were mary school teachers have no training from
found to be almost the same by age (Nyandindi et dental personnel for the task of oral health
al., 1994a). Tanzanian children of any age seem education. Moreover, they seem to have inade-
to have limited opportunities to learn proper quate knowledge, skills and motivation for carry-
dental ideas or practices before going to school, ing out this task (Nyandindi et al., 1994b). As
as the Tanzanian mothers' own awareness of described elsewhere (Bartlett, 1981), the larger
dental matters is very limited (Kabalo and class sizes and the short time allocated to the
Mosha, 1989). In school, all lessons are taught topic of health in Tanzanian primary schools can
by grade levels irrespective of the pupils' ages. encourage the use of lectures. With these short-
Thus, first-graders, for whom oral health educa- falls in the implementation of the programme,
tion is scheduled (Taasisi ya Elimu, 1987; Wizara successful impact or outcomes cannot be
ya Elimu, 1988), notwithstanding their ages, were expected.
involved in the present evaluation. The pupils who attended the modified oral
School oral health education provided by health education sessions seemed to have gained
dental personnel or schoolteachers in developed knowledge about gingival health. Commercial
countries has usually improved pupils' oral toothbrushes and toothpaste seem to be relatively
health knowledge, attitudes or status, but not costly and scarce in rural areas for many indivi-
always (Frazier, 1992; Brown, 1994). In African duals in Tanzania to buy regularly (Muya et al.,
countries, the few available evaluative studies of 1984; Nyandindi et al., 1994c). However, the
school oral health education (Evian et al., 1978; effort made during the modified sessions to
Olsson, 1978; Doherty, 1983; Hartshorne et al., encourage the use of 'miswaki', as suggested in
1989; van Palenstein et al., 1992) also show more the national guidelines for school oral health
elements of success than of failure. The studies education (Nermark et al., 1986; Taasisi ya
have focused on effects and seldom describe the Elimu, 1987), did not succeed. The pupils
input or processes (e.g. teachers' training in oral gained good skills in making 'miswaki' and prac-
health education or the school oral health educa- ticed brushing with them, but continued to dislike
tion sessions) which presumably affect the pro- them. It has been reported from elsewhere in
gramme impact or outcomes among the pupils. Africa (Narmark, 1991) that chewing-sticks are
Pupils who attend the conventional oral health disliked and regarded as primitive. This suggests
education sessions in the primary schools in a need to reconsider the type of toothbrush
Tanzania seem to gain limited knowledge about promoted in Tanzania. The modified sessions
gingival health. Their frequency of toothbrushing also failed to increase the use of toothpaste
seems to increase. They like to use factory-made which was considered essential for tooth-cleaning
200 U. Nyandindi et al.

by the pupils, or to reduce the use of charcoal as a poor and to lack adequate support to the imple-
substitute. This seems to be rather a matter of the mentorsthe schoolteachers. Teacher training
children's economic realities. and motivation is needed for their role in health
The modified sessions with supervised brushing education (WHO/UNESCO/UNICEF, 1992).
practice seem to have improved the pupils' brush- The present results suggest that, with appropriate
ing frequency and, to some extent, their oral training workshops and guidance, teachers may
hygiene. Repeated sessions would probably gain proficiency in teaching oral health matters,
have brought a better impact in oral hygiene, as and the gains from school oral health education
has been emphasized elsewhere (Emler et al., among the pupils in Tanzania may improve. The
1980; Houle, 1982). This could not be accom- environments have to be improved and consid-
plished prior to this evaluation 4 months after the ered with regard to their support for the chil-
sessions, due to the teachers' time pressures. dren's oral health education. An intervention
There are many important topics of health for involving the oral health providers, the school
first-graders to be covered within the one-hour-a- personnel, and children and their parents needs
week frame (Taasisi ya Elimu, 1987). Neverthe- to be attempted to see what effect it could have on
less, the teachers agreed that, as part of the impact of school oral health education in Tan-

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routine morning hygiene checkups of pupils at zania.
school, they would remind pupils to brush their
teeth properly. Another possible factor hindering
further improvement of the pupils' oral hygiene ACKNOWLEDGEMENTS
could be that their commercial toothbrushes had
not been replaced often enough to remain effec- We thank the pupils and the teachers for co-
tive. operation. This study was supported by the
The modified session group also seemed to Muhimbili Dental School Development Project
have gained improved knowledge about the of the University of Kuopio.
cause and prevention of tooth decay. Their self- Address for correspondence:
reported low preference for sugary snacks as Dr Ursuline Nyandindi
compared with the referent children may, to Department of Preventive and Community Dentistry
some extent, reflect their newly gained knowledge Faculty of Dentistry
of expected behaviour. This was their first oral University of Dar es Salaam
health education experience at school and the PO Box 65014
pupils might have been receptive to the new Dar es Salaam
ideas. Economic environment, rather than perso- Tanzania
nal decisions alone, also appears to contribute to
the low frequency of sugar consumption of Tan-
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