Head teachers’ views of oral health education in schools in Tamil Nadu,India

Introduction

School-based oral health education is fundamental for oral health promotion. Schools provide a platform on which to promote oral health as more than 1 billion children are educated worldwide through them. In principle, good quality health education in schools could benefit school staff, parents and everyone in the wider community (Kwan et al., 2005). Many common oral health diseases are preventable through good quality health education in schools (Kwan et al., 2005); hence, schools have an important role to play in modifying children’s attitudes and behaviours towards health.

In Tamil Nadu, India, there are over 50,000 schools. Of these, about 68% are public schools with an enrolment rate of 99.4% and an attendance rate of 97%. The state government is responsible for school administration, and schools are divided into different types depending on the examinations available to students. All public and most private schools follow the Samacheer Kalvi curriculum or Uniform System of Education. A content analysis of this curriculum suggests that in the primary years of 1–5, the following oral health topics are included: basic information on parts and types of teeth, tooth decay and the importance of brushing (Geetha Priya et al., 2016). In the middle and high school curriculum, health education is taught through the subject areas of Ariviyal Tamil (Tamil language science) and environmental education, but neither of these subject areas addresses the issues of oral health. In 2007, a national rural health mission school initiated an oral health awareness programme in India. This included screening for the early identification and prevention of oro-dental problems (Ministry of Health and Family Welfare, 2005). In Tamil Nadu, as of 2016, only 360 of 1,421 primary health centres provided basic dental treatment, such as fillings, scaling and extractions.

In India more generally, the budget allocated for national oral health care in the most recent 5-year plan was USD2.31 million per year to satisfy the health needs of over 1 billion people. This budget for oral health care should be seen within the context of the annual total public health expenditure of USD16.569 billion for the fiscal year 2012–2013 (Grover, 2014), and this suggests that the allocation of public funding for oral health is very low (7,500 times lower) compared to general health allocations. By comparison, New Zealand, a country with a successful oral health care system, spends USD66 million per year on oral health (Ministry of Health, 2006) to meet the needs of a total population of over 4.6 million (Figure 1).

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Figure 1.

Public dental expenditure in Australia, New Zealand, USA and India (Grover, 2014; Ministry of Health, 2006; Ministry of Health and Family Welfare, 2005).

Oral health inequalities are a concern in India because dentists tend to work in urban areas, but only one-quarter of the country’s population live in urban communities. The dentist to patient ratio in urban areas is 1:10,000 and in rural areas is 1:250,000 (Singh and Purohit, 2013). Moreover, only 20% of primary health centres in India are equipped with dental units (Singh and Purohit, 2013). In this context, limited access to dental treatment requires the majority of the Indian population to depend on oral health education alone to prevent oral health disease.

Oral health education is frequently neglected in the Indian education curriculum (Bhardwaj et al., 2013). The effectiveness of oral health education in schools has been demonstrated in various studies (Bhardwaj et al., 2013; Freeman et al., 2016; Nakre and Harikiran, 2013). In India, children and adolescents make up 40% of the total population (Government of India, 2012), schooling is compulsory until 14 years of age in the state of Tamil Nadu and children are provided with free textbooks, a uniform, a free mid-day meal and free stationery supplies. Consequently, oral health education delivered through the school system would reach a substantial number of the population. Moreover, India’s diversity with respect to language, culture, religion and caste makes school a suitable environment for children to benefit from oral health education in an inclusive manner.

A literature review identified seven studies conducted in India assessing the effect of school-based oral health education on oral health outcomes (Ajithkrishnan et al., 2010; Bhardwaj et al., 2013; Chachra et al., 2011; Gambhir et al., 2013; Gauba et al., 2013; Grewal et al., 2009; Parkash et al., 2004). Because school-based oral health education is in the early stages of development, the majority of these studies focused on guideline development rather than on effective oral health education strategies. A few of the studies, however, comprised interventions to test the effect of oral health education on oral health status (Ajithkrishnan et al., 2010; Bhardwaj et al., 2013; Gauba et al., 2013).

School-based oral health education has been shown to have significant effects on knowledge, attitudes, oral hygiene practice and oral health status of adolescent populations. For example, Parkash et al. (2004) investigated the effects of school-based oral health education on children’s attitudes, knowledge and behaviours using a three-phase intervention study in New Delhi, India (Parkash et al., 2004). In the first phase, 1,500 students in the 6–8 and 12–14 year groups were evaluated for pre-intervention oral health status, together with their knowledge, attitudes and practices. In the second phase, oral health education was provided by teachers. In the third phase, a post-intervention evaluation was conducted using the same oral health survey instruments (Parkash et al., 2004). Average Decayed, Missing, Filled Teeth (DMFT) decreased from 1.62 to 1.51 per child as a positive outcome of the intervention, with results being statistically significant (p < .001). Among the sampled senior-aged children, the total number of filled teeth increased from 30 at baseline examination to 224 at the final examination, again seen as a positive outcome related to the intervention. There was also a marginal increase in knowledge, attitudes and practices scores in the final evaluation (Parkash et al., 2004). Hence, targeting children and adolescents using the existing infrastructure and human resources at school can be a clinically effective and economically efficient implementation option in the current Indian context.

Our initial study, conducted among the adolescent population in Tamil Nadu schools, investigated the oral health literacy of adolescents attending private and public schools in both rural and urban areas (Veerasamy et al., 2016b). Only 8% of adolescents had sufficient oral health literacy to understand the importance of protecting their oral health. The prevalence of dental caries was identified as 61.5%, with a mean DMFT of 2.03 (Veerasamy et al., 2016a). Hence, effective oral health education is essential to improve the oral health literacy of the adolescent population and in turn improve oral health outcomes in Tamil Nadu. This study was conducted to explore the views of head teachers regarding the implementation of oral health education in school curricula and to understand whether oral health policies are implemented in private and public schools of Tamil Nadu. The findings will be helpful towards developing school-based oral health education programmes.

Methods

A qualitative descriptive approach was chosen to examine whether policies relevant to oral health education exist and are being implemented, either directly or indirectly, in the Tamil Nadu school curriculum. Data collection involved gathering head teachers’ perceptions, opinions, knowledge and attitudes towards oral health policies and the implementation of oral health education in schools. To ensure the trustworthiness of the study, we followed the criteria for credibility, transferability, dependability and confirmability (Shenton, 2004). Prior to the commencement of the study, ethical approvals were received from the Human Ethics Committee, University of Canterbury, New Zealand, and from the Institutional Review Board, Sree Balaji Dental University, Tamil Nadu, India.

This study was conducted as a part of a larger oral health epidemiological study among an adolescent school population (Veerasamy et al., 2016a). Participants for the epidemiological study were randomly selected from two districts of Tamil Nadu: urban participants were recruited from Chennai city, and rural participants were from Thanjavur district. The Chennai city corporation is organised into 15 zones consisting of 200 wards. Five of the 15 zones in Chennai city were randomly selected. The wards within each zone were also randomly selected and private and public schools in each ward were listed; eight randomly selected schools were approached for permission to recruit participants for the study, and four schools accepted to participate. The Thanjavur district is divided into three revenue divisions, namely, Thanjavur, Kumbakonam and Pattukottai. Eight schools were randomly selected across all revenue divisions, and all selected schools accepted to participate in the study. A quota sampling system was then used to invite head teachers from all selected schools to participate in the study. Four urban (two from public and two from private) and six rural (three from public and three from private) school head teachers accepted this invitation. Two head teachers declined to participate in the study. Hence, the participants for the qualitative interviews were recruited from private and public schools in both rural and urban areas of Tamil Nadu.

In India, each school is administered by one head teacher who is solely responsible for institutional planning and management. He or she decides how to use the available resources and how to initiate steps to mobilise these resources and involve teachers, parents and other organisations to achieve quality education for students. Hence, head teachers were invited to participate in an interview and were given an envelope that contained the research information, consent forms and a list of the questions that would be asked in the interview.

Face-to-face interviews were held at each head teacher’s school, at their convenience. Written informed consent to participate in the interview was received prior to the interview. The interviews were audio-recorded with the permission of the participants and conducted in either Tamil or English depending on the participant’s preference. Only one head teacher opted to be interviewed in English. The interviews ranged from 15 to 25 minutes in duration and were recorded using Evernote software on an iPad. Data were transferred to a computer on the same day. Field notes were taken before and after each interview, and these were used during analysis of the data. These notes contained details needed to understand the school culture and infrastructure. Both the field notes and interviews were coded with pseudonyms to preserve the school and individuals’ anonymity. The interviews were transcribed and later translated into English by the lead researcher. Head teachers were given an opportunity to read their interview transcript and provide further comments. None of the head teachers who reviewed their transcript requested changes. Qualitative findings are reported below using recommended guidelines from the Standard for Reporting Qualitative Research (SROR) (O’Brien et al., 2014).

Analysis

Braun and Clarke’s (2006) thematic coding and analytical framework was utilised as follows. Interviews were initially analysed question by question in two phases. First, each interview transcript was coded and analysed to identify categories and themes specific to the original research questions, namely, what is the extent of oral health education occurring in schools? What are the head teacher’s views on implementing oral health education? And, what other challenges are there in implementing oral health education in Tamil Nadu schools?

The responses provided by the head teachers were organised and analysed through a sequence of organising, summarising and interpreting the data (Braun and Clarke, 2006). By reading and re-reading the transcripts, codes were identified. The codes were then categorised according to whether the respondent was from a private, public, rural or urban school to enable a description of differences and similarities between school type and location.

During the interviews, it was noted that head teachers displayed a lack of awareness of what oral health encompasses. In response to this, the interviewer was careful to identify whether any ‘hidden’ oral health–related policies were incorporated into the school curricula. For example, a sugar-free policy was incorporated into one school’s curriculum for health reasons, but the head teacher reported that he or she did not have any oral health policies.

In the second phase of the analysis, new ideas which did not specifically relate to the original research questions were identified from the data, analysed and coded separately. One of the new ideas that emerged during the second phase of the analysis was the lack of food and other basic needs in schools, especially for adolescent women.

Finally, in the verification phase, conclusions were drawn from combining all the categories in the first two phases of analysis. Four overarching themes were identified.

Findings

On completion of 10 interviews, it was evident that oral health education was not well recognised in any of the schools. A lack of awareness regarding oral health was repeatedly identified among head teachers’ responses, as was a lack of awareness for the need to implement oral health policies. Hence, it was concluded at this point that data saturation had been achieved.

All of the head teachers had more than 20 years of teaching experience, and all had worked as a head teacher for 5–22 years in their current school or in schools with a similar curriculum. The four key themes that emerged were lack of recognition, academic burden, prioritisation of other health needs and policy inequities.

Discussion

Our study aim was to identify the status of current oral health education in private and public schools in rural and urban areas of Tamil Nadu. Findings suggest that oral health education is generally ignored in both private and public schools. Most of the head teachers interviewed for this study believed oral health education should be mandatory for students; however, public school head teachers considered oral health education as less important because essential basic needs such as access to enough food were not being fulfilled.

This study revealed that private schools, which accommodate higher socio-economic populations, are gaining more access to both junk foods and nutritious foods. In contrast, public school head teachers indicated that classroom hunger was still a significant issue in their schools in Tamil Nadu. Recently, the Tamil Nadu Government launched a restaurant chain throughout the state, providing healthy and hygienic food to the public at low cost (breakfast: USD0.02; meals: USD0.08). This programme was initiated after data collection took place for this study. This initiative is now addressing classroom hunger, but the assumption that every student has access to, and is using, this programme requires further investigation.

The schools located closer to dental colleges had the advantage of frequent oral health screening together with follow-up for treatments. A few schools had dental screenings conducted by the IDA, but head teachers indicated these were insufficient because follow-up treatments were not provided, and oral health issues identified in the screenings were not treated. Janakiram and Taha (2016) argued that screening for dental decay and other oral health diseases without any follow-up treatment is unethical practice. This is particularly true for those who do not have affordable access to a dentist for further treatment as they, therefore, cannot benefit from routine oral health screening. Even though dental screenings are considered part of oral health awareness programmes, enabling policy could be implemented whereby follow-up treatment is made accessible for child and adolescent populations. Hence, the current practice of screening only to diagnose dental caries by dental universities for dental education purposes, and by the IDA for oral health promotion, should be reviewed.

This study revealed inequities with respect to health policies between private and public schools. Public schools received highly efficient health coverage, including eye checks, heart surgeries and also monthly blood tests for students, with the exception of oral care. Private schools did not have regular health educational training for the teachers about important health issues, such as tuberculosis and AIDS. Parkash et al. (2004) suggested that the oral health education provided by teachers was effective in reducing dental caries and also in improving oral health knowledge and attitudes. Hence, proper training should be given to teachers in Tamil Nadu to improve their oral health literacy so that they can provide oral health education to students. Private schools have generally ignored both health and oral health education; however, public schools provided efficient health coverage and general health education training to the teachers, with the exception of oral health education. Both private and public schoolteachers should be trained to provide oral health education. Local dental institutions and the IDA could concentrate on training teachers rather than simply providing a periodic screening. A report by the Director of the Central Board of School Education, which was based on a review of health education from 10 different states, indicated that priorities for health education were limited in actual practice (Nazar, 2011). Nazar (2011) was also critical about the lack of commitment by the Health and Educational Department for health promotion delivered through schools, which was also indicated by the head teachers in this study.

Head teachers indicated that a lack of awareness among policy-makers was a major reason behind the non-existence of oral health education-related policies in Tamil Nadu schools. Tandon (2004) suggested that one of the greatest challenges for the Indian oral health care system was the lack of qualifications and training among policy-makers and dental health planners in public health dentistry. Tandon (2004) identified an insufficiently qualified workforce as a major challenge for developing a better oral health care system in India. Difficulty in training teachers and appointing new staff or school nurses to promote oral health education was also repeatedly mentioned as a significant problem among head teachers in this study.

A systemic review on the effectiveness of oral health education on oral health outcomes reported that most successful oral health programmes are labour-intensive and received significant funding and additional support (Nakre and Harikiran, 2013). In this study, the majority of head teachers viewed implementation of oral health education as a difficult task in the current curriculum due to lack of resources and time constraints. Head teachers viewed the current education system’s focus on exams and achievement scores as a burden for students. Furthermore, adding oral health education to the curriculum would increase this burden to both teachers and students. Most of the head teachers identified that the current curriculum was designed in such a way that school subjects deemed less important were taught to students at the expense of more significant issues such as oral health. The Tamil Nadu Ministry of Education and Ministry of Health should implement policies to introduce oral health education in Tamil Nadu schools without increasing the burden to teachers and students. The Ministry of Education could review the Samachir Kalvi curriculum to accommodate sufficient time for health and oral health education. A limitation of this study was the general lack of oral health literacy and insufficient knowledge about oral health education among the head teachers. Although the primary researcher asked questions and provided examples of oral health education, most of the head teachers could not answer them beyond their knowledge about routine health check-ups provided at their school. Hence, future research with school teacher participants should include a health literacy knowledge assessment.

Conclusion

A significant issue identified in this study is the lack of effective oral health policies in Tamil Nadu schools, which has caused schools to ignore the placement of oral health education in the curriculum. The dental screenings conducted in some schools were considered ineffective. This study highlighted a considerable number of school students who were not eligible for the Tamil Nadu government’s mid-day meal policy and were still experiencing classroom hunger. Private schools were lacking in the provision of both health and oral health education, and hence, the Government should strengthen the current health promotion policy to involve private schools. The current academic curriculum, which mainly focuses on academic examinations to secure a place at university, was considered a challenge to the implementation of oral health education in Tamil Nadu schools. The Ministry of Education could review the current curriculum by prioritising oral health education without increasing the burden to teachers and students. Future studies should focus on framing an oral health education model for schools in Tamil Nadu by analysing current oral health education strategies in the schools of developed countries.