Muhammad Farid, Nurdin (2021) Process and impact evaluations preschool oral healthcare programme (POHP) in Selangor / Muhammad Farid Nurdin. PhD thesis, Universiti Malaya.
Abstract
Preschools provide an efficient setting to promote the oral health of young children as children attend preschools on daily basis, the structures and system at preschools are established, and vital facilities for conducive oral health environment such as clean water supply and sanitation are already in place. Because of these promising potentials, the Ministry of Health (MOH), Malaysia has introduced the Preschool Oral Healthcare Programme (POHP) in 1984. This programme aims to improve the oral health status of children aged 5 to 6 years who attend preschools. To date, there has been no evaluation conducted on the POHP in terms of its process implementation and potential impacts on the oral health parameters of preschool children. Such evaluations are important because the findings will inform policymakers on the extent to which the POHP has contributed towards preschool children’s oral health. The findings could also be used to address any shortcomings of the POHP in order to achieve the National Oral Health Plan (NOHP) targets for preschool children. Objectives: The study consisted of process and impact evaluations of the POHP. For the process evaluation, the specific objectives were: i) to explore the effectiveness, feasibility, and suggestions for improvement of the POHP in Selangor state from the perspectives of dental therapists (DT), ii) to explore the effectiveness, feasibility, and suggestions for improvement of the oral health-related activities (OHRA) and oral health-related facilities (OHRF) at preschools in Selangor as recommended in the Guidelines on Oral Health Care for Preschool Children (2003) using the perspectives of preschool teachers. For the impact evaluation, the specific objectives were: iii) to compare between preschools with POHP and preschools without POHP in terms of oral health and related behaviours of preschool children, oral health literacy (OHL) of preschool teachers, OHRA at preschool, and OHRF at preschool, and iv) to iii evaluate factors associated with preschool children’s oral health and related behaviours, and OHRA and OHRF at preschools. Methods: The study consisted of 2 phases; Phase 1 and Phase 2. Phase 1 was a qualitative study involving 2 sample populations; DT from 9 districts in Selangor state using focus group discussion (FGD) as method of data collection, and preschool teachers from 4 districts in Selangor state using in-depth interview (IDI) as method of data collection. Both FGDs and IDIs were conducted using an interview schedule developed by the researcher and a dental public health specialist (DPHS). The qualitative data were transcribed verbatim and analysed using the framework method analysis. Phase 2 was a cross-sectional study involving preschool children and preschool teachers as sample populations from preschools with POHP and preschools without POHP. Sample size for preschool children was 1082 (teachers were recruited using convenience sampling). Multistage cluster sampling method proportionate to size was employed to collect preschool children sample. Preschool children were randomly selected from 2 districts in Selangor, which were Petaling (urban) and Sepang (rural) districts. Study tools included a parent self-administered questionnaire (proxy) which assessed socio-demographic characteristics of parents and child, parent’s oral health knowledge (OHK), parent’s oral health behaviours (OHB), global self-rating items of oral health, and child OHB at home. Teacher self-administered questionnaire assessed socio-demographic characteristics, OHL using the Malay version of Dental Health Literacy Assessment Instrument (DHLAI), OHRA, and OHRF at preschools. Data were assessed using the SPSS version 23 software. Results: 114 DTs were involved in 13 FGDs. In terms of POHP effectiveness, DTs felt the POHP was effective to improve OHK of the children and teachers, promote oral health monitoring by teachers, promote healthy diet at school, inculcate toothbrushing habit in children, control caries, well accepted by children, promote oral health lessons in class, and provide toothbrushing facility at preschool. In terms of facilitators to implement POHP, the factors were good iv dental workforce teamwork, monitoring and support from dental administration, provision of financial aid, availability of transportation, sufficient time to implement programme, cooperation form school administration, cooperation from preschool teachers and preschool children, availability of dental materials, and training in dealing with preschool children. In terms of barriers to implement the POHP, the factors were lack of manpower, lack of support from dental administration, uncooperative preschool administration, availability of sugary food and drinks at school, lack of transportation and driver, lack of time, uncooperative teachers, uncooperative children, lack of space for OHRA, lack of dental materials, and uncooperative parents. For suggestions to improve the POHP, the DTs suggested to improve oral health education (OHE) materials and facilities, provide financial support, provide further training, involve parents in the programme, monitor OHRA and OHRF at preschool, include oral health in teacher’s training, increase number of DTs and assistants, introduce a dedicated team for preschool, provide additional dental equipment, collaborate with dental industry, use social media in OHE, and pay honorarium for dental visits to non-governmental preschools. With regards to IDI, 15 teachers were interviewed. In terms of effectiveness, the OHRA and OHRF were effective to instil positive attitudes among children and teachers, improve OHK of children and teachers, instil toothbrushing habit in children, and control caries. In terms of facilitators for OHRA and OHRF at preschools, the factors were good cooperation from school administration, provision of financial aid, availability of oral health-related materials, cooperation from parents, oral health seminar for teachers, helpful teacher’s assistant, good relationship with dental personnel, cooperation from preschool children, and good time management. In terms of barriers to implement OHRA and OHRF, the factors were lack of financial support, lack of oral health learning materials, lack of space, uncooperative children, environmental factors, extensive teaching duties, uncooperative parents, accessibility to sugary food and drinks at school, and insufficient number of v assistants. For suggestions to improve OHRA and OHRF at preschools, the teachers suggested to provide them with oral hygiene kit and OHE materials, improve oral hygiene kit storage and tooth brushing area, increase parental involvement, increase frequency of oral health seminar for teachers, reinstate dental treatment at school, provide financial aid for oral health, and conduct OHE exhibition at preschool. For impact evaluation of POHP, the response rate was 69.8% for preschool children and 76.5% for preschool teachers. A significantly higher proportion of children from the preschools with POHP used fluoride toothpaste at home than children from the preschools without POHP (p = 0.021).In terms of teacher’s OHL, a significantly higher proportion of teachers who worked at the preschool with POHP had a higher mean score of knowledge domain of the DHLAI than teachers who worked at the preschools without POHP (p = 0.033) and more teachers who worked at the preschools with POHP had good level of knowledge domain of DLAI than teachers who worked at the preschools without POHP (p <0.001) . In terms of OHRA and OHRF at preschools, a significantly higher proportion of teachers who worked at preschool with POHP taught oral health syllabus at preschool (p = 0.009), displayed oral health-related posters/pamphlets at preschool (p = 0.029), performed oral health-related role play at preschool (p <0.001), performed toothbrushing activity (p <0.001), performed toothbrushing activity everyday/alternate days (p = 0.042), brushed teeth using toothpaste (p = 0.001), used fluoridated toothpaste (p <0.001), examined children’s teeth (p = 0.046), examined children’s teeth ≥1x/6 months (p = 0.043), provided toothbrush storage at preschool (p <0.001), provided toothbrushing facilities at preschool (p <0.001), and provided a mirror for children to use after toothbrushing (p <0.001) than teachers who worked at preschools without POHP. In terms of significant factors associated with children having “more good” OHB at home when other factors were controlled were children living in urban location (p = 0.025), parents with good OHK (p = 0.001), parents who brushed ≥2/day (p <0.001), parents who visited dentist <6 months (p = 0.015), vi parents with no oral health problem in the past 3 months (p = 0.001), parents who had low perceived oral health impact on daily life (p = 0.006), and female children (p = 0.022). A significantly higher proportion of teachers who worked at the preschools with POHP implemented “more good” OHRA and OHRF at preschools than teachers who worked at the preschools without POHP when other factors were controlled (p <0.001). Conclusion: The DTs and preschool teachers perceived that the POHP, OHRA and OHRF at the preschools could help to control caries and suggested that parents should be involved in the programme. However, lack of financial support is a barrier for the DT to implement POHP and the teachers to implement OHRA and OHRF at the preschools. Nevertheless, the POHP in Selangor has positive impact in providing conducive oral health environment at the preschools. Further improvement of POHP to include parents should be considered as parents’ factors were significant factors for children’s OHB apart from location and child’s gender. Keywords: School-based oral health programme, preschool oral healthcare programme, children’s OHB, OHL, conducive oral health environment.
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