Daily brushing with fluoride toothpaste has shown promising results in the effort to improve the oral health of Filipino school-goers. (DTI/Photo Bella Monse)
The Fit for School initiative in the Philippines began in 1998 as a small-scale project in Mindanao, one of the southern Philippine islands, incorporating 20 schools and focusing on oral-health education and dental treatment. Dental Tribune International Group Editor Daniel Zimmermann spoke with Dr Bella Monse, a former dentist and now consultant of the German Development Corporation (GTZ) in the Health and Nutrition Section of the Department of Education in the Philippines, about the programme and how it is helping to improve the oral health status of children throughout the Asia Pacific region.
Daniel Zimmermann: Ms Monse, you are going to introduce your country’s Fit for School Health Programme at the World Congress on Preventive Dentistry in Thailand. Could you please explain what the programme does?
Bella Monse: The NGO Fit for School supports the health and education sector in the Philippines in institutionalising an Essential Health Care Package for Filipino Children. This package implements daily hand-washing with soap and tooth-brushing with fluoride toothpaste, as well as biannual deworming, as an integrated part of the public school system.
Children are the main actors as they carry out the activities in the same organised manner, like the daily flag ceremony, under the leadership of classmates as group leaders. This daily routine in schools is familiarising children with healthy habits and may induce long-term behaviour change in family life.
What are the main advantages of an integrated school health programme?
In countries where diarrhoea and respiratory tract infections are still the major cause of death amongst children, two-thirds of the children are infected with soil-transmitted parasites (common worms), and virtually all children suffer from untreated dental caries, improvement in personal hygiene, focusing on hand-washing and tooth-brushing is the base for any health-care programme. Integration of oral health care into general health care will mainstream advocacy, pool resources, avoid overlap and simplify health programmes.
The latest National Oral Health Survey has revealed that 97 per cent of first-graders in public schools in the Philippines suffer from tooth decay.
The oral-health status of children in the Philippines is in an alarming state, and this is true for other countries in Asia as well. In the Philippines, caries amongst public school children remains completely untreated, leading to unnecessary pain and intra-oral infections. The National Oral Health Survey revealed that six-year-old children had on average nine decayed teeth in their mouth with 40 per cent of these teeth presenting caries with pulp involvement.
Twenty per cent of six-year-old children also reported toothache during the time of the survey and the condition is the main reason for school absenteeism in the Philippines. We have developed an index to measure the consequences of untreated caries—the PUFA index—which will be presented during the World Congress on Preventive Dentistry in Thailand.
What are the reasons for the neglect of oral health care and are there regional differences?
The main reasons are an unhealthy diet and lack of access to appropriate levels of fluoride. Daily tooth-brushing with fluoride toothpaste is not yet a habit for the majority of Filipino children in their family life. The National Oral Health Survey found the highest caries levels in highly urbanised areas and easily accessible areas (near highways), where money for soft drinks and junk food is available, while caries levels in remote areas are lower, most probably owing to traditional nutritional habits.
The ‘Fit for School’ programme recommends simple interventions such as brushing teeth with fluoride toothpaste. Why can these measures not be implemented in children’s homes?
During the last decades, the Department of Education has run health-education programmes promoting a healthy diet and daily tooth-brushing and giving advice to visit the dentist twice a year. However, despite these efforts, children are eating junk food, not brushing their teeth and not visiting dentists. And how can children do so, if regular tooth-brushing is not a habit in family life, if toothbrushes and toothpaste are not available, and if there is no money to go to the dentist, even if children have toothache? Schools are the most effective places to introduce change, as children spend the majority of their day with their classmates and the teacher. Children are the best messengers for introducing behaviour change into family life.
The programmes are aimed primarily at school children. Yet, figures from watchdog organisations for children’s rights estimate that 16 per cent of young children in the Philippines work and thus do not attend school.
This is a sad fact and the real figures are even higher. Only about 60 per cent of children finish elementary school. All efforts have to be increased to achieve universal primary education, helping and encouraging parents to send their children to school.
You recently completed the first pilot programmes. What was their outcome?
These pilot programmes have already been scaled up to national policy and currently more than 630 000 children are enrolled in the programme. We expect that at the end of the school year 2009/10 more than a million school children will participate in the programme. With regard to the institutionalisation process, one of the most important outcomes of the pilot phase was the need for clear policies, mandating teachers to supervise the daily routine of hand-washing and tooth-brushing and integrate these into daily school activities. We also learned a lot concerning partnership with the parents and teachers’ association and community involvement, which is essential for the construction of hand-washing and tooth-brushing facilities.
With regard to the health outcomes of the interventions, hand-washing with soap has proven around the globe to be the most effective health-care intervention in halving the occurrence of infectious diseases (specifically diarrhoea and respiratory infections). Our research has shown that daily fluoride tooth-brushing reduces the caries increment by 40 per cent and progression into the pulp by 60 per cent, while international published data on mass deworming of children provides the evidence for improved nutritional status and academic performance.
Education Secretary Jesli A. Lapus has announced plans to extend the programme to six million children by the end of 2010. Is this a realistic target?
The Philippines Education Secretary is actively promoting this programme, and he is accorded much attention within the Philippines and in the Asian region, especially in light of the H1N1 pandemic, for which hand-washing is important as well. The compelling concept of the ‘Fit for School’ programme, addressing high-impact childhood diseases in a comprehensive, yet simple, and cost-effective package, provides the backdrop for high expectations for a fascinating public health success story. We aim to reach six million children, which is nearly 50 per cent of public school children, by the end of 2012. Backed by national and international health policies, ample evidence on effectiveness, clear implementation strategies and support from influential partners, this is a realistic target.
Dental hygiene has to be maintained throughout life. Do you expect the programme to have any long-term effects or is there need for further oral-health promotion programmes later in life?
Children are performing daily tooth-brushing in school and we expect that this will lead to lifelong behaviour change. It is known that children are the best messengers and agents of change for promoting and introducing behaviour change in family life. Limited data is available to answer this question, but promising results from research conducted in Scotland amongst high-risk children showed long-lasting effects, evidenced by a reduction in caries increment of 39 per cent compared with control children four years after the termination of a school-based fluoride tooth-brushing programme. We are just starting a comprehensive research project to evaluate the programme in terms of health outcomes, academic performance and behaviour change.
You said before that many countries in Asia demonstrate similar oral-health patterns amongst their youth. What lessons can your programme provide for countries that aim to implement similar programmes in their schools?
Countries that want to implement similar programmes have to focus on prevention and behaviour change. Only a few evidence-based interventions, which governments can afford for all children, are necessary for an essential school health package that answers to the demand and the local conditions of the public school system in their respective countries.
Thank you very much for the interview.
