Evaluating a Primary School-Based Caries Prevention Intervention

This report provides a comprehensive overview of a primary school-based intervention for preventing dental caries, particularly in the Rochdale area where caries rates are significantly higher than the national average. It begins by outlining existing health improvement approaches and highlighting the need for targeted interventions for primary school children, contrasting this with current programs focused on the elderly. The report reviews existing literature on caries prevention strategies, emphasizing the limitations of previous interventions in incorporating behavioral theories such as social learning theory and the theory of planned behavior. It then delves into the challenges of implementing such interventions, focusing on behavioral change and addressing socio-ecological factors. The report further describes the initiative, including its reach, uptake, channels, and sources, and discusses how theoretical approaches and socio-ecological influences are integrated to enhance the intervention's effectiveness. Ultimately, the report underscores the importance of addressing oral health disparities in children and provides a framework for implementing evidence-based caries prevention programs in primary school settings.

Running head: PRIMARY SCHOOL-BASED INTERVENTION FOR CARIES
Primary school-based intervention for preventing caries
Name of the student:
Name of the university:
Author note

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
Table of Contents
Section A:...................................................................................................................................2
Overview of health improvement approaches........................................................................2
Existing reviews.....................................................................................................................3
Theoretical approach..............................................................................................................5
Section B....................................................................................................................................7
Challenges in implementation of the interventions:...............................................................7
Evaluation of the intervention:...............................................................................................8
Section C:.................................................................................................................................10
Clear description or examples of the initiative:...................................................................10
Reach, uptake, channels and sources:..................................................................................11
Theoretical approaches and socio-ecological influences:....................................................12
References:...............................................................................................................................14
Appendix:.................................................................................................................................18

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
Section A:
Overview of health improvement approaches
Rochdale is a town located in Greater Manchester, England and has a borough that
works in partnership with the schools, health professionals and providers for improving the
oral health status of the residents. The Borough Council focuses on the importance of a
healthy mouth and promotes the maintenance of good oral hygiene for preventing the onset of
dental problems. The Oral Health Improvement for the Elderly Programme has been enforced
and implemented by the Rochdale Borough Council, Rochdale Clinical Commissioning
Group, and NHS Heywood, with the aim of enhancing the oral health of the elderly.
Furthermore, the area is one of its kind in greater Manchester that has invested adequate
funds for creating training provisions for care homes, community services, hospital staff and
home care, in order to check and clean the mouths of the older and vulnerable population
(National Institute for Health and Care Excellence 2014). The community also takes efforts to
lower the likelihood of the vulnerable population to contract hospital acquired pneumonia
(Hmr.nhs.uk 2018).
Regardless of the fact that dental caries are a preventable health condition, upon
assessment by the local authority, an estimated 47% five year old individuals were found to
suffer from dental caries, in Rochdale. This proportion was found to be twice the national
average. This justifies the role of the Borough Council in implementing oral health programs.
Of all Oral Health Need Assessments (OHNA) that were completed, 35% were done during
2016-2017, and an estimated 50% were completed during 2014-2015 (Public Health England
2018).
The Annual Health Report also suggests that the Borough Council has taken into
account the introduction of sweetened beverage duty at a rate of 20paise, for addressing the

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
problems associated with poor dental health that are prevalent in the target population (Public
Health England 2018). Some of the common oral health improvement programs that have
been enforced and implemented by the UK local authorities encompass oral health training,
healthy drink and food policies, targeted provision for toothpaste and toothbrush, monitored
tooth brushing in school settings, community water fluoridation programs, and help from peer
support workers. The aforementioned data suggest that much efforts have been adopted by
the government for improving oral health. However, oral health issues such as, dental caries
amid primary school students remains relatively unaddressed.
Existing reviews
Marinho et al. (2013) affirmed the use of topically administered fluoride varnishes for
the prevention of dental caries in adolescents and children. Upon conducting a meta-
regression, the researchers failed to establish a noteworthy association between the
application of fluoride varnish and severity of dental caries among children. Owing to the fact
that there was less information on the effect exerted by fluoride varnishes on the proportion
of kids who develop dental caries, no definite conclusion regarding effectiveness of
preventive intervention could be reached. However, Cooper et al. (2013) was effective in
determining a potential setting that can be implemented across all primary schools for the
implementation of behavioural interventions for supporting children adopt a healthy
behaviour.
There is mounting evidence for the fact that child developmental theories typically
place a focus on the ways by which children alter and grow over the entire course of their
childhood, and also focus on different domains of child development namely, emotional,
cognitive and social growth (Dweck 2013). Although Cooper et al. (2013) elaborated on the
implementation of different behavioural interventions, none of them were allied with the
developmental theories, thereby establishing a gap in the evidence.

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
Reasoned action theory has been recognised as one of the most extensively used
theories in health intervention and behavior research (Montano and Kasprzyk 2015). The
theoretical perspective of the theory on beliefs, underpinning behavior proposition a notional
understanding of impact that health messages bring about in behavior change. In the words of
Conner et al. (2017) this theory also can be implemented in the form of a practical tool for
classifying principles that appear favourable for addressing health messages. However, the
primary school based oral health intervention techniques have rarely focused on this theory.
A detailed analysis of health behaviour modification interventions for dental caries
prevention further suggested that behavioural alteration techniques were restricted to
information on significances, information-behaviour associations, and education and
demonstration of actions. However, none of the implemented interventions were grounded on
behaviour change theory (Adair, Burnside and Pine 2013).
Another recent review by Albino and Tiwari (2016) on behavioural techniques to
avert childhood caries elaborated on the complex interplay of microbial, genetic,
biochemical, physical, environmental, behavioural and social factors, in relation to dental
caries etiology. Motivational interviewing was considered as an effective strategy for
modifying the decision related to individual oral health. This form of intervention can be
allied with the behavioural child development theories that elaborated on the description of
human behaviour in terms of a range of environmental influences. The intervention can be
further associated with classical conditioning owing to the fact that behaviour are often learnt
in childhood by means of repetitive connotation between a stimulus and response. Batliner et
al. (2018) also conducted a randomised clinical trial with the aim of determining the
effectiveness of motivational interviewing for early caries prevention. They suggested that
while this behavioural intervention was responsible for greatly enhancing maternal
knowledge on oral health and hygiene, it had little or no effect on the oral health behaviour

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
manifested by the children, who formed the target population. This also led to the
establishment of the role of social factors in determining the oral health among children.
Upon evaluating the relationship between parental attitude on dental care of their
children with socioeconomic status and parental education, it was found that parents with
greater educational attainment obtained satisfactory income cared on instructions related to
oral hygiene and preventive dental check-ups (36.7% and 40.8% ; P < 0.01 and P < 0.001).
Hence, the behavioural intervention should take into account the educational attainment of
parents, their knowledge, and socioeconomic status, prior to its implementation (Saldūnaitė
et al. 2014). This can be directly correlated with Bandura’s social learning theory that is
based on the fact that behaviours are usually learned by children through reflection and
modelling. Witnessing the activities of others, counting on peers and parents, help children
advance new abilities and attain novel information.
This was in accordance with the fact that a plethora of life course factors such as,
biological, sociodemographic, oral and psychological health behaviour, in addition to dental
status of the mothers were found associated with the onset and development of dental caries
among kids (Abreu et al. 2015). Hence, increasing the knowledge on oral health among
parents will prove more effective in making children adhere to activities that prevents dental
caries. Blake et al. (2015) suggested the effectiveness of classroom-based interactive
educational sessions, delivered by dental professionals in improving the oral health among
primary school children. The findings indicated the short-term improvements that the
program brought about in children’s oral health knowledge, thus confirming its
implementation in primary school settings.

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
Theoretical approach
While most of the aforementioned interventions failed to demonstrate any positive
correlation with behavioural theories, an analysis of the gathered evidences suggest that the
social theory of learning and theory of planned behaviour will prove effective in the
implementation of interventions across primary schools. The social learning theory can be
addressed during implementation formulation owing to the fact that learning encompasses a
cognitive process and occurs during social context and most often occurs via direct
instructions and observations (Akers 2017). Hence, even in absence of any specific
reinforcement that strengthens good oral behaviour among children, they can be made to
show adherence to oral hygiene techniques by modeling. Parents can act as live models by
demonstrating desired behaviours that are imperative for preventing dental caries, which
when imitated by children, will reduce their chances of getting affected by dental caries.
However, the theory of planned behaviour will prove more effective during implementation
of the intervention in primary school settings. Owing to the fact that the theory focuses on
human behaviour and the interplay between normative beliefs, behavioural beliefs, and
control beliefs, taking into account the three factors would ensure success of the intervention
(Ajzen 2015).
Furthermore, the model also postulates that oral behaviour is usually anticipated by
the goal to perform the actions and also by professed behavioural mechanism when the deeds
are not under comprehensive volitional control. In other words, the intention to accomplish
good oral behaviour is controlled by the comparative prominence of the aforementioned three
factors. One major reason for using this theory in preventing dental caries among children is
the fact that an estimated 26% children missed school days due to dental infection and pain,
and an average of three days were missed by them due to persistent dental problems. This is
further confirmed by the fact that 67% parents report presence of dental pain in their children

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
(Public Health England 2018). This elaborates the fact that oral health prevention programs
for children have not been adequately implemented by the Borough Council.
Recent news reports also suggest that 170 youngsters have regular teeth extraction in
the hospitals each day in Britain, a condition termed ‘oral health crisis’. An estimated 42,911
individuals aged below 18 years had their tooth extracted the previous year due to dental
problems (Telegraph.co.uk 2018). Hence, one major gap lies in the fact that although
Rochdale has formulated programs for improving oral health among the elderly, it needs to
take efforts for enhancing the same among primary school children.
Section B:
Among the prevalent health care issues, dental caries is a common health problem,
which mostly affects the children. As per the review that has been conducted, the percentage
of children suffering from dental caries among the early childhood and middle childhood
groups is close to more 80%. As per the statistical survey data, United Kingdom is topping
the charts for dental diseases and oral health issues, especially in children (De Leeuw et al.
2015). On a more elaborative note, it has been reported that 170 children have been identified
to be affected by oral diseases in UK. Moreover, data also suggests that the dental infection,
tooth decay and pain is the major contributing factor leading to 26% of the school aged
children having missed days in schools due to dental pain and infection. Hence, the need for a
large scale educational intervention is crucial, especially for the communities in North
Western England such as for Rochdale (Telegraph.co.uk 2018).
Challenges in implementation of the interventions:
The intervention chosen for this program is an education and counselling based
behavioural intervention pursuing the health behaviours of the target population. It has to be
mentioned in this context that for addressing any preventable health adversity, it is very

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
important to target behaviour change of the target population. Hence, the theoretical approach
of theory of planned behaviour is effective. However, it has to be mentioned that this
particular intervention will attempt to address and change the deep rooted self-care ideas and
perceptions of a considerably large scale population belonging to different socio-ecological
backgrounds, hence, undoubtedly it will receive difficulties and challenges in fruition
(Bertram, Blase and Fixsen 2015).
First and foremost, the most important implementation challenge that this project
might encounter is the resistance to change among the target population. Elaborating more,
this will be a primary school based intervention and it will target all socio-economic groups.
Now the level of health literacy and awareness differs drastically among different socio-
economic groups. Hence, the lack of participation will be an imperative challenge for the
program and its successful implementation. Another notable difficulty that we may encounter
while completing the project is the limited availability of resources and manpower. The
intervention will need to invest time, money and the skillset and expertise of trained
professionals, and the limited availability of such resources, especially in the remote location.
Lastly, a key challenge in the implementation of the intervention is the language barrier. It
has to be mentioned that ethnic minorities have higher prevalence of dental diseases in the
UK, and they have limited English language proficiency. Hence, the intervention program is
needed to be more culturally effective and safe however, it will be difficult to have translators
and language interpreters on a large scale for all different locations. These limitations also
might affect the effectiveness of the intervention program and can limit the success of the
program, hence care is needed to be taken beforehand to address if not completely eradicate
the possibility of these challenges stalling the progress of the project (Eldredge et al. 2016).

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
Evaluation of the intervention:
Along with successful implementation of the chosen intervention program, there is
also need for effective evaluation of the intervention programs to ensure that the program is
meeting the objectives set. There are various evaluation protocols that can be employed to
continuously monitor the effectiveness of such behavioural intervention programs. First and
foremost, I will use feedback survey as an evaluation tool. The feedback will be collected on
a monthly basis, and will incorporate both the children and their parents to observe the
pattern of change in the behaviours. The feedback system will also allow the capturing of the
individual behaviour change patterns which will in turn help increase the authenticity,
relevance and richness of the data. Another key evaluation technique that will be opted for
judging the effectiveness of the program is the bimonthly dental clinic audit (Pierce and
Kealey 2015). This will be carried out in the clinics closest to the school radius for the
selected schools where the interventions have been given. The audit will help discover the
change in the rate of primary school children visiting the clinic for dental issues after the
introduction of the intervention program and will help provide data to directly correlate the
impact of the behavioural intervention in preventing caries. Lastly, it is also important to
judge if the results of the intervention have been consistent in follow up to decide whether the
intervention had been sustainable in effectiveness or not. To address this objective, care will
be taken to implement a follow up oral health assessment after 3 months of completion of the
6 month educational intervention program. This evaluation technique will encompass an
interview of the target population to fill out a questionnaire of oral health and hygiene
behaviour of the target population. This will not only help provide an opportunity to conduct
a final assessment of the effectiveness of the intervention program and whether it has to been
successful to change or improve the behaviour of the oral care and hygiene children and their
parents (De Leeuw et al. 2015).

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A few examples of evaluation approaches for similar intervention programs can be
discussed extracted from previously published literature. For instance, Makvandi et al. (2015)
has stated that questionnaire based interviews as evaluation techniques have been used to
evaluate an educational intervention program for improving oral health young mothers with
children. Another article by Petersen et al. (2015) has discussed clinical audits to be effective
for evaluation of the oral health intervention programs to improve oral health. In this case
however, we will be taking the assistance of a RCT study to check the effectiveness of the
intervention. In this case, a small population from one primary school can be selected and a
pilot study design can be selected for the RCT to take a preliminary assessment of the
effectiveness of the intervention before applying it on the large populations. This will help
the researchers understand if there is any applicative issues associated with the intervention
and if there is requirement for any improvisations to the intervention and the chosen
technique to optimize the outcome. Although, time and financial constraint for an additional
pilot study can be a challenge to realization of this concept.
Section C:
Clear description or examples of the initiative:
The intervention program is designed taking the assistance of theory of planned
behaviour and it will encompass a few key strategic interventions. The first intervention will
be a thorough counselling of the children and their parents to understand the exact oral health
and hygiene. This will incorporate assessment of the existing dental hygiene behaviours of
the target group, the existing knowledge on caries and how to prevent it and then counselling
to improve the hygiene behaviour of the children. The counselling will be provided in a one
to one setting and will implement evidence based education so that the target group easily
identifies the benefits associated with proper oral hygiene maintenance and its positive
impact on improving the oral health and preventing caries or oral infection. Post the

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PRIMARY SCHOOL-BASED INTERVENTION FOR PREVENTING CARIES
counselling, the next part or the intervention program will be a demonstration based
education session where different preventive oral hygiene maintenance programs (Montano
and Kasprzyk, 2015). These educational sessions will include right teeth brushing techniques
and frequency, right tools for brushing teeth twice a day, flossing techniques, and use of
fluoride based mouthwashes as an added layer of protection against any infection or caries.
The intervention program will also include monthly workshops where the target children will
be involved in interactive sessions on adequate oral hygiene maintenance behaviour and
techniques. Quiz and practice sessions will also be arranged to ensure that the children are
understanding and retaining the education being provided to them and are implementing in
their day to day life. The program will continue for a period of six months and at the end of
the 6 month period, a follow up session will also be arranged to check the final outcome of
the program and how it affected the health promotional behaviour of the children.
Considering the target population for which the intervention program will be arranged, the
primary school children, aged 5 to 11, and their parents will be selected randomly from two
primary schools in Rochdale. Each school will have individual project team and the target
population will involve all different social and cultural backgrounds. The intervention
program will be designed in a culturally appropriate manner and a few dominant languages
other than English will be included in the informative flyers which will be distributed after
each educational intervention session to the target group for the ethnic groups. The session
will be arranged on the weekends and on a once a week pattern to ensure utmost participation
in the program (Eldredge et al. 2016).
Reach, uptake, channels and sources:
The reach of the project would not be limited to just the target children of primary
school, but the reach of the project is also extended to the families of the children as well.
One key concept of the theory of planned behaviour which had been chosen as the theoretical