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Braz Dent Sci 2014 Oct/Dec;17(4)
65
UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
Ciência
Odontológica
Brasileira
ORIGINAL ARTICLE
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
As visões dos professores sobre as barreiras para a implementação da educação em saúde bucal para escolares:
um estudo qualitativo
Fabíola Mayumi Miyauchi KUBO1, Janice Simpson de PAULA1, Fábio Luiz MIALHE1
1 – Department of Community Dentistry – Piracicaba Dental School – University of Campinas – Piracicaba – SP – Brazil.
RESUMO
Objetivo: Explorar as barreiras encontradas
por professores do ensino fundamental para
implementarem a educação em saúde bucal em seus
ambientes de trabalho. Material e Métodos: Um
questionário semiestruturado foi respondido por uma
amostra de 89 professores do ensino fundamental,
com idades entre 18 a 65 anos, que trabalhavam
em escolas públicas do ensino fundamental do
município de Indaiatuba, SP, Brasil. Os dados
foram analisados por meio do Discurso do Sujeito
Coletivo (DCS), que apresenta como base teórica
a Teoria das Representações Sociais. Resultados:
A maioria dos professores afirmou que ensinavam
a seus alunos algum conteúdo de saúde bucal. No
entanto, relataram dificuldades para a realização
desta tarefa, tais como: a falta de material e / ou
atividades apropriadas disponíveis para ensinar
conteúdos de saúde bucal de forma adequada; as
crianças não recebem educação em saúde bucal em
casa e / ou não são incentivadas por suas famílias; as
crianças não atribuem qualquer valor a saúde bucal
e/ou não seguem as orientações disponibilizadas.
Os professores também expressaram a necessidade
de parcerias com faculdades de odontologia, a fim
de ajudá-los a implementar projetos de saúde bucal
nas escolas de ensino fundamental. Conclusão:
Os resultados ressaltam a necessidade dos setores
da saúde e educação oferecerem suporte para que
os professores do ensino fundamental possam
implementar e manter programas de educação em
saúde bucal nas escolas.
ABSTRACT
Objective: To explore the barriers encountered by
primary school teachers in implementing oral health
education in their settings. Material and Methods:
A semi-structured questionnaire was answered
by a sample of 89 primary schoolteachers aged 18
to 65 years, working in primary public schools in
Indaiatuba, SP, Brazil. The data were quantitatively
analyzed by means of Discourse of Collective Subject
(DCS), which is based on a theoretical framework
of Social Representations Theory. Results: The
majority of teachers said they were teaching their
students some oral health content. However, they
reported difficulties in teaching oral health content
in school, such as: the lack of material and/or
appropriate activities to teach the subject of oral
health properly; children do not receive oral health
education at home and/or they are not encouraged
by their families; students do not place any value on
oral health and/or do not follow guidance provided.
Teachers also expressed the need for partnerships
with dental schools to help them implementing oral
health projects in primary schools. Conclusion: The
results emphasize the need for health and educational
sectors to support primary school teachers in the
implementation and maintenance of oral health
education programs in schools.
KEYWORDS
Health education; School health; Dental school;
Preventive dentistry; Teacher.
PALAVRAS-CHAVE
Educação em saúde; Saúde escolar; Escolas de
odontologia; Odontologia preventiva; Docentes.
Braz Dent Sci 2014 Oct/Dec;17(4)
66
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
INTRODUCTION
It is known that oral diseases have impacts
on children’s and adolescents’ quality of life,
leading to pain, discomfort and missed days
at school [1-3]. Therefore, schools are the
key settings to implement health promotion
interventions, with the aim of improving
schoolchildren’s general and oral health [4-6].
Health education programs at school are
capable of improving the level of children´s
knowledge, for better control of the health-
illness process, and are considered an effective
and low cost option for the democratization of
knowledge about health [7].
Therefore, enabling school staff to provide
schoolchildren with information about health
care would help them to gain knowledge, skills
and attitudes to maintain and enhance their oral
health [4]. Within this context, schoolteachers
are considered fundamental agents in school
health programs and lack of training and
support creates a greater barrier for effective
implementation of school health education
interventions [8,9]. These professionals coexist
with children on a daily basis, and they also
have links with the schoolchildren’s families
and school communities, thereby becoming
multiplying agents of health both within and
outside of the institutions where they work [8].
However, factors related to staff and their
environment such as the perceptions of their
role in health education and the effectiveness
of their interventions, their confidence in
teaching health education, in addition to the
support and facilities provided by the principals
for these activities are important barriers
influencing the effectiveness of implementation
and maintenance of these activities in schools
[8-11]. Therefore, it is important to investigate
the points of view of schoolteachers about their
facilities and difficulties in order to ensure the
appropriate conditions for them to elaborate
and implement health programs, and to put
their skills into practice [12].
The aim of this study was to explore the
barriers encountered by primary school teachers,
which affect the implementation of oral health
education in school settings.
MATERIALS AND METHODS
The Research Ethics Committee of
the Piracicaba Dental School, University of
Campinas, Brazil, approved the study, Protocol
No. 111/2008.
The study population consisted of primary
school teachers from Indaiatuba, SP, Brazil, who
were working with schoolchildren aged 6-10
years. Twenty-seven primary public schools
were identified and 10 schools were randomly
selected. All 120 primary teachers working at
the selected schools were invited to take part in
the study by a pre-notification letter, containing
a Term of Free and Informed Consent form, a
questionnaire and a thank you letter.
Instrument
Data were collected by means of a
questionnaire sent by mail to teachers in the
selected schools, containing questions about age
and length of time they had been working as
primary school teachers, asking if they worked
with oral health content in the classroom, and
the following open-ended question: Which are
difficulties that you encounter when teaching
oral health content to your students? After 10
days the researcher went to all schools to collect
the questionnaires. A pilot study was conducted
with 10 participants from another school, to test
the methodology and the instrument used.
Analysis
Data were organized and analyzed,
based on the methodological strategy of the
Discourse of the Collective Subject (DCS),
which is based on a theoretical framework
of the social representations theory [13-15].
According Lefèvre and Lefèvre, the DCS is
characterized as a proposal for organizing and
tabulating qualitative data, extracting from each
Braz Dent Sci 2014 Oct/Dec;17(4)
67
of the interviews the Central Ideas (CI) and the
corresponding Key Expressions (KE) [15]. With
the KE of the similar CI, we construct one or more
synthetic discourses in the first-person singular,
which correspond to the collective ideas,
perceptions and feelings about a theme; that is,
the DCS. Thus, the DCS expressed the opinion
or collective thinking, considering the collective
opinion as an empirical fact, and consisted of
the unification and the grouping of various
discourses of subjects with the same central
ideas, allowing, in theory, to collectivize their
speeches, expressing the social representation
of a given social group in a first-person singular
form of presentation.
RESULTS
Of all the questionnaires sent, 89 were
completed and returned, i.e., the response rate
was 74.2%.
The mean age of school teachers was 37.06
(sd = 7.85) years, and among these individuals,
86 (96.6 %) were women and 3 (3.4 %) were
men. The average length of time working as a
primary school teacher was 12.86 years (sd =
6.51).
The majority of participants (80)
responded that they taught oral health content
to schoolchildren.
Seven thematic axes about the difficulties
and barriers teachers felt they encountered
when teaching oral health content to students
were obtained from their responses. One teacher
could share more than one DCS.
DCS 1 - “Lack of material and/or
appropriate activities to teach the oral health
issue properly”. This theme was shared by 26
primary school teachers.
One of the difficulties is the lack of
appropriate materials. We lack clear and
precise information in easy language,
written for children. We need less technical
literature on the subject; that is, we need
literature that is easy to understand, or
even entertaining. We should have more
dynamic materials such as videos. There is
a lack of materials such as posters, texts,
videos, lectures, etc. It is not easy to find
posters about the problems caused by dental
caries. Today there is a lack of posters that
can show the internal part of the tooth so
we can have a better understanding of the
damage caused by caries. In this sense, we
need to develop more practical activities
and to show students the real importance
of toothbrushing and oral health. However,
it is not easy to find activities that fit into
the contents of Portuguese and Mathematics
lessons. One difficulty that I meet when I
work on oral health is not having a manual
addressing the subject. I suggest we write
a play and present it in schools, to inform
children about a serious subject in an
amusing way.
DCS 2 - “Lack of time in the weekly schedule
to be able to address the issue of oral health
effectively”. This theme was shared by 7 primary
school teachers.
One difficulty is the lack of time. There are
many contents to be taught, but at some
point in class, I work to meet these needs.
With only one class per week, time is very
short. It is a short time to get through the
program content of the grades, given the
large number of students.
DCS 3 - “The students do not receive
education on oral health at home and/or it is not
encouraged by their families”. This theme was
shared by 20 primary school teachers.
The greatest difficulty is family participation,
some do not check whether the toothbrush
is in the schoolbag and the child ends up
hindering the participation of all the other
students. Parents do not take the children
to the dentist periodically. In my opinion,
it is a cultural problem. There are families
who do not give due importance, who lend
or borrow toothbrushes from one another,
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
Braz Dent Sci 2014 Oct/Dec;17(4)
68
who do not use fluoride or dental floss
and who hardly ever go to the dentist. It
is also usually a financial matter. Some
students lack basic knowledge of hygiene
and body care because they do not have this
information at home. At school adequate
guidance is given, but at home they do
not have guidance or sometimes it is not
given with the same degree of commitment.
Because they do not have this habit at
home, they often resist brushing their teeth
after meals, and it is constantly necessary
to review the importance of brushing. The
greatest difficulty lies in the fact that many
students do not receive any family guidance
and they are always dirty, they do not brush
their teeth and they have lice. Therefore, it
is difficult to give continuity to this outside
the school (home) environment so that they
also take care of oral health. Parents do not
teach their children these values. There is no
continuity. Last week, a student said that
her mother had taken the toothbrush I had
given her, and used it to dye her hair. Some
families, perhaps due to lack of information,
end up using the children’s toothbrushes at
home in other family members, or they lose
the toothbrushes showing little care, that is
why (some teachers) keep the toothbrushes
at school. However, another problem occurs
when some children end up only brushing
their teeth at school because they do not
have another toothbrush at home, or due
to the lack of a family habit. Therefore, I
think it is difficult to get students to get
into the habit of good hygiene if there is no
continuity at home.
DCS 4 - “Lack specific knowledge by
teachers”. This theme was shared by 8 primary
school teachers.
The difficulty is the lack of specific
knowledge. There is professional ignorance.
My difficulty is that I know very little about
the subject; what I know is related to my
own experiences gained by the explanation
I received from dentists. I do not have in-
depth knowledge. Specifically, I lack of
knowledge on some oral problems such as
tartar and bacterial plaque.
DCS 5 - “Lack of outside specialists at
schools, such as dentists, social assistants and
other agents.” This theme was shared by 12
primary school teachers.
The biggest difficulty found is the lack of
a professional’s presence at school more
frequently. We need the professional
guidance so we can teach our students with
more assurance. It would be nice if we had
lectures given by professionals from the
area, with examples and games. It would
be interesting to watch some videos on the
subject with a specialist to explain better. We
also need to find professionals who would
give lectures, in a more dynamic manner
and who would attend us when requested.
Perhaps, the presence of specialized
professionals on the subject acting in plays
and practicing proper brushing once a week
would be useful. I believe that we have a
lot to teach our students, in addition to
projects and teaching them to read and
write. Therefore, there should be a health
agent to help us. The ideal would be the
presence of a dentist at school more often,
to give us support on the issues in which
we need help. A more constant presence of
a specialist in the area for better control of
the oral problems presented by the students.
DCS 6 - “Students do not place any value
on oral health and/or do not follow guidance
given.” This theme was shared by 14 primary
school teachers.
Many students do not show that they place
sufficient value on oral hygiene; they lose
and / or constantly forget the toothbrush
at home, drink liquids (water, juice) from
their colleagues’ containers (bottles).
When children begin school, they bring
with them favorable and unfavorable
behaviors regarding health and hygiene.
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
Braz Dent Sci 2014 Oct/Dec;17(4)
69
When discussing these contents, I notice
the difficulties some students have, because
these routines are not part of their daily
life. Although the hygiene materials are
donated, when they are taken home they
are usually lost and the family has no
interest in encouraging them to behave
differently. For example, many students
forget to bring their toothbrush to school.
The difficulty is practical; many do not
have the responsibility or take the care to
bring the toothbrush, which is provided by
the school, to brush their teeth after the
snack. Despite all the guidance, there are
still students who are not concerned about
this, and forget their toothbrushes at home.
Most of them do not want to brush their
teeth, and I show them how important it is,
because they will have toothache due to food
remainders that accumulate; and if they
lose their permanent teeth, no other teeth
will grow, etc. The majority of students do
not have the toothbrushing habit and they
eat many sweets, making the teacher’s job
more difficult.
DCS 7 - “There are no difficulties”. This
theme was shared by 11 primary school teachers.
Within the objectives proposed in planning,
there are no difficulties. I see no difficulties
in handling these contents, because they
are part of the curriculum and pedagogical
interventions. I really do not find any
difficulties; the children like the activities
and participate. We find no difficulties,
because we receive materials (pamphlets,
etc.) from the Secretary of Health. We have
computer laboratories, in which we are able
to research. There is no resistance by the
students’ and families’ when we discuss this
issue in class.
DISCUSSION
Given the high concentration of children
attending primary school, the school is
considered an ideal setting for the development
of health-promoting actions [4]. Thus, primary
school teachers, if well trained and supported,
can become multipliers of children’s health
within the school units, as they are people who
generally act as role models for children and
have their confidence [16].
Teachers has an important role in the
implementation of health issues within the
school setting and we try to understand their
point of view with regard to this subject, in order
to reduce the gap between academic discussion
and what happens in everyday life at the school.
Although we observed that most of the teachers
in this study affirmed that they taught oral
health content, similar to findings in previous
studies, they identified several barriers [17].
One of the difficulties in working
with dental health education, described by
schoolteachers, was the lack of material with
clear and accurate information, and in a
language that the child could easily understand.
According to teachers, they need
appropriate materials developed with clear and
precise information and in an easy language for
children to understand (DCS 1). The perception
of this barrier to teaching oral health topics was
similar to findings mentioned by teachers in
North Carolina and Tanzania [18,19].
It is known that health education
materials are important resources to improve
the quality of educational process, reinforce and
expand the verbal information given by teachers
and dental teams [20,21].
In the case of written materials such as
posters, pamphlets, leaflets and others used
to communicate oral health information;
they should be created with care to maximize
readability and comprehension [22]. However,
many of them are created with a high level of
complexity, containing conflicting information
and demanding high levels of reading
skills, which makes them of limited value to
educational activities with schoolchildren and
even their families [22]. Studies conducted with
secondary schoolchildren asking them to explain
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
Braz Dent Sci 2014 Oct/Dec;17(4)
70
the meaning of a selection of words in common
use in dental health education indicated that
health education materials reflect the reading
ability of the designers rather than the ability
of the potential target group [23,24]. Therefore,
it is important that written materials developed
for primary schoolchildren contain the best
scientific evidence, using language appropriate
for their level of reading skills. Moreover,
the information available in them should be
entertaining as well as instructional in order
to facilitate and motivate the child to learn the
health content and attitudes to health.
School textbooks can be to be the
most common source of reliable oral health
information used by primary school teachers to
develop oral health activities with their students
[25]. A preventive program was developed in
the elementary schools of Bergamo, Italy, based
on a children’s book with the goal of improving
their knowledge about primary dentition,
dental plaque, nutrition, oral hygiene, fluoride
and regular dental visits. The authors found a
significant difference in the reduction of the
plaque index among children from experimental
and control groups [26]. However, in addition
to other printed materials, it is important to
pay attention to the quality of the content of
the material used. Studies conducted with
textbooks adopted in schools in Brazil and U.S.
have verified that they present great discrepancy
regarding the quality and scope of the oral health
content, and many of them had incomplete and
/ or misleading information [27-29]. Therefore,
continuous evaluation by dental researchers
of the quality of contents presented in school
textbooks for health lessons is recommended
to ensure that teachers are teaching accurate
oral health information to children. In addition,
health materials for teachers and children
should be developed in a way to encourage
their active participation in the construction of
knowledge, rather than being passive recipients
of information from books, posters, leaflets and
videos. Furthermore, according to Nyandindi et
al. [18], dental staff should encourage and guide
teachers to prepare such materials locally in
order to make then socio-culturally appropriate
and cheap.
Even though quality educational materials
for teachers are available, this condition is no
guarantee that they will develop educational
activities with their students. In the study of
Nyandindi et al. [18] in Tanzania, the Ministry
of Education and Culture developed and
distributed guidelines for health lessons, and
a teachers’ handbook with oral health content
[18]. They observed, however, that teachers
stressed the shortage of time and their workload
at school, and considered health topics to be
moderately important after reading, writing
and mathematics. In the present study, the lack
of time in the weekly schedule for developing
the issue of oral health effectively was a barrier
shared by 7 (7.9 %) of primary schoolteachers
and was lower percentage than the findings of
Ramroop et al. in Trinidad and Tobago, where
47 % of teachers perceived this barrier [11]. This
may reflect differences between the countries in
the organization of schools and their priorities,
content of school curriculum, number of children
per class, and other types of pressures on
teachers, which adversely affect their capacity
and motivation to teach oral health topics
[4,11,30]. Therefore, it is important for dental
health promoters to consider the importance of
all educational staff, including head teachers or
school directors/managers to support teachers
to develop health education and promotion
activities in a satisfactory way [4,8].
In addition to schools, the family
environment has a great impact on children´s
oral health. It is known that parents’ oral
health behaviors have a direct influence on
children’s knowledge, attitudes and behaviors
related to oral health [31]. When children were
not supported at home, they would not put in
to practice what they had learned at school
[32]. The teachers in our study also had this
perception about the lack of education and
motivation related to oral health behaviors
of schoolchildren in their homes (DCS 3) and
at school (DCS 6), which is consistent with
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
Braz Dent Sci 2014 Oct/Dec;17(4)
71
previous studies [11,33,34]. As a result, this
perception could restrain from them forming
partnerships with parents in order to improve
their knowledge and awareness about how to
take care of their children’s oral health. Despite
the evidence that the involvement of parents
is essential for the effectiveness of oral health
programs [4,35] studies have demonstrated
that teachers reported engaging in oral health
activities with children more frequently than
the children did with their parents, and there
appears to be scarcely any interaction between
teachers and parents as regards oral health
[19,33,32,36]. Parents and community leaders
are important key persons to support the need for
high quality oral health education and promotion
programs at school, and that type of attitude has
limited the extent of health education impact
outside the school setting [37]. It should be
noted that even when children are in situations
of social vulnerability, primary schools have a
great potential for improving their health and
socializing them with healthy attitudes and
behaviors that could be reproduced in their
homes [4,38,39]. Therefore, it is important to
consider the economic and sociocultural context
in which teachers and students are included
when planning and implementing health
promotion activities in school settings.
The lack of specific knowledge was one
of the difficulties pointed out by school teachers,
in teaching oral health content (DCS 4), which
is in line with findings from several previous
studies [4,8,11,32,40,41]. The quality of oral
health education teachers provide is dependent
on their knowledge and skills to do so, and they
could be qualified for this function if they were
trained by dental staff and motivated by their
principals, school administrators and colleagues
[8,18].
Research has evaluated the effectiveness
of various ways of instructing teachers about
oral health. Arikan and Sönmez aimed to
evaluate the effectiveness of informing primary
school teachers in Ankara, Turkey with regard
to dental trauma by means of a leaflet [42].
Questionnaires containing questions about
crown fracture, lateral luxation, root fracture,
and avulsion were applied at baseline and after
1 month of the distribution of the information
leaflet. It was observed that the rate of correct
answers increased for each of the individual
questions, and the total scores for the
questionnaire increased significantly.
Lieger et al. investigated the knowledge
of school teachers about the emergency
management of dental trauma, after an
educational poster campaign in the Canton of
Bern, Switzerland [43]. The authors observed
that teachers who worked in schools with poster
distribution had better knowledge in handling
tooth injuries than those from schools with no
poster campaign.
Frujeri and Costa evaluated the influence
of an educational intervention on different
groups of professionals from the city of Brasília,
DF, Brazil, including elementary school teachers,
by means of a lecture addressing the knowledge
and prevention and emergency management
of the avulsed tooth [44]. The authors
observed a statistically significant change in
the performance of professional groups after
information was provided. However, the gain
of specific knowledge is not guarantee that
teachers will remain motivated and willing to
develop educational activities in schools [32]. As
noted earlier, lack of time and the large number
of daily activities can be barriers to the teachers’
development of and commitment to oral health
education. One way to overcome this barrier is
by integrating oral health into a general health
promotion curriculum and activities [4].
A group of teachers found that the more
frequent presence of health professionals at
schools, using interesting visual aids, could
improve the effectiveness of oral health activities
in schools (DCS 5). In spite of the benefits
of oral health professionals, different power
relationships and educational roles may result
from these meetings. The first is one, in which the
health sector imposes on the educational staff,
in a top-down way, the development of activities
Teachers’ view about barriers in implementing oral
health education for school children: a qualitative study
Kubo FMM et al.
Braz Dent Sci 2014 Oct/Dec;17(4)
72
that highlight the acquisition of biomedical
information by teachers and children generally,
through a pedagogy of transmission and based
on the KAP model (Knowledge, Attitudes and
Practices) of health education. The KAP model
assumes that a health behavior is attached to a
logical and sequential process originated from the
acquisition of scientifically correct knowledge,
which can create a positive attitude resulting in
a change of behavior (practice) [45]. According
to this model, teachers uncritically reproduce
to their students the biomedical information
received from health professionals, using one-
way communication methods regardless of the
social contexts of schoolchildren.
Another situation occurs when true
partnerships are established between health
and educational staffs in the organization
of teacher training through participatory
methodologies. Here, teachers have an active
role in planning, implementing and evaluating
health education activities with the cooperation
of the health professionals. Here, activities are
aimed to instigate curiosity, critical thinking
and empowerment of children, and attitudes
of self-care are formulated, taking into account
the socio-cultural context of children. Therefore,
health professionals could contribute to oral
health promotion in schools by providing
information and training skills for school staff
and children by active participation, and given
them the appropriate support to develop these
activities considering the socio-cultural context
in which teachers and students are inserted
[4,7,34,46].
Finally, some teachers reported having
no difficulties in teaching oral health topics
because they received material, institutional
and family support to satisfactorily develop
these activities at school (DCS 7). It is noted
that the socioeconomic and cultural context of
the school and the family has significant impact
on the formation of a positive context for the
development of activities that promote oral
health. Thus, the circumstances in which these
activities are developed should be an important
aspect to be considered when planning,
implementing and evaluating the effectiveness
of oral health education in schools.
CONCLUSION
In conclusion, we found that the poor
provision of educational materials, lack of
professional, institutional and family support
were shared by primary schoolteachers, who
considered these as important barriers to
developing health education in schools. Therefore,
health and educational sectors should consider
these aspects when planning and implementing
these interventions, in order to strengthen the
effectiveness of their interventions.
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Braz Dent Sci 2014 Oct/Dec;17(4)
73
Fábio Luiz Mialhe
(Corresponding address)
Department of Community Dentistry, University of Campinas,
Piracicaba Dental School
Avenida Limeira 901, Piracicaba, SP, Brazil
Postal Code: 13414-903
e-mail: mialhe@fop.unicamp.br
Date submitted: 2014 Jul 28
Accept submission: 2014 Oct 27
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