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The impact of school-based oral hygiene education on the oral-health-related quality of life

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Catherine Bowden Milejczak
Abstract:
As the Wanji Tribe of the Southern Highlands of Tanzania faces urbanization, they are at risk for diminished quality of life related to oral health due to the introduction of sweet products and little access to preventive dental care. Previous research indicated that preventive oral hygiene care reduced the incidence of oral diseases. However, literature review and previous research have not indicated whether school based oral hygiene education programs have the potential to improve indices of quality of life related to oral health. The purpose of this quantitative, 4 week community intervention study was to determine if a school based oral hygiene program had an impact on the quality of life indices (Decayed, Missing, Filled Index; Community Periodontal Index; Simplified Oral Hygiene Index; Dean's Fluorosis Index) and the Child-Oral Impacts on Daily Performance Index for the children of the Wanji Tribe. The health belief model, social learning theory, and community organization theory provided the theoretical foundations for this study. The impact of the multistage, random selection, pretest/posttest intervention was evaluated using the t -test analysis comparing groups on the means of different indices. The overall results indicated that the school based oral hygiene program improved the knowledge and attitudes of oral hygiene and oral hygiene skills of the Wanji school children. This study contributes to social change by identifying a public health intervention that can improve oral hygiene skills and knowledge toward oral health, reduce oral disease, and improve quality of life among school children.

i Table of Contents List of Tables ................................................................................................................................ viii List of Figures ................................................................................................................................. xi Chapter 1: Introduction to the Study ................................................................................................ 1 Introduction ............................................................................................................................... 1 Rationale .................................................................................................................................... 4 Problem Statement .................................................................................................................... 8 Purpose of the Study .................................................................................................................. 9 The Nature of the Study .......................................................................................................... 10 Research Questions ................................................................................................................. 10 Hypothesis Statement .............................................................................................................. 11 Research question ............................................................................................................. 11 Sub questions .................................................................................................................... 12 Theoretical Base ...................................................................................................................... 14 Definition of Terms ................................................................................................................. 15 Assumptions, Limitations, and Delimitations of the Study ..................................................... 17 Assumptions...................................................................................................................... 17

ii Limitations ........................................................................................................................ 18 Delimitations ..................................................................................................................... 18 Significance of the Study ........................................................................................................ 18 Social Change Statement ......................................................................................................... 19 Summary ................................................................................................................................. 20 Chapter 2: Literature Review ......................................................................................................... 22 Introduction ............................................................................................................................. 22 Health-Related Quality of Life ................................................................................................ 23 Oral-Health-Related Quality of Life ....................................................................................... 24 Epidemiology of the Community’s Oral Diseases and Conditions ......................................... 26 Dental Caries ..................................................................................................................... 26 Periodontitis ...................................................................................................................... 31 Noma 34 Oral Cancer ....................................................................................................................... 37 Fluorosis............................................................................................................................ 40 Oral Systemic Disease Relationships ...................................................................................... 41 Diabetes Mellitus .............................................................................................................. 42

iii Cancer… ........................................................................................................................... 46 Heart disease ..................................................................................................................... 48 Respiratory Disease .......................................................................................................... 54 School-based Health Education ............................................................................................... 57 Oral Health Indices .................................................................................................................. 61 Simplified Oral Hygiene Index ......................................................................................... 62 Community Periodontal Index .......................................................................................... 63 Decayed Missing Filled Teeth Index ................................................................................ 63 Deans Fluorosis Index ...................................................................................................... 64 Child-Oral Impacts on Daily Performance ....................................................................... 65 The Intervention: A School-Based Oral Hygiene Education Program .................................... 71 Teacher’s Oral Health Training Program ................................................................................ 72 The Population: The Wanji ..................................................................................................... 73 Theoretical Perspectives .......................................................................................................... 74 Chapter 3: Research Method .......................................................................................................... 77 Introduction ............................................................................................................................. 77 Research Design ...................................................................................................................... 77

iv Setting and Sample .................................................................................................................. 79 Intervention ............................................................................................................................. 81 Instrumentation and Materials ................................................................................................. 82 Decayed, Missing, Filled Teeth Index (DMFT) ............................................................... 83 Community Periodontal Index (CPI) ................................................................................ 85 Simplified Oral Hygiene Index (OHI-S) ........................................................................... 86 Dean’s Classification of Dental Fluorosis ........................................................................ 87 Child-Oral Impacts on Daily Performances Index ............................................................ 89 Measurement Procedures ........................................................................................................ 92 Research Questions and Statement of Hypothesis .................................................................. 92 Hypothesis Statement ....................................................................................................... 92 Data Collection and Analysis .................................................................................................. 95 Participant’s Rights ................................................................................................................. 96 Chapter 4: Results .......................................................................................................................... 98 Introduction ............................................................................................................................. 98 Participants’ Demographic Characteristics ............................................................................. 98 Pre-Intervention Data Collection ............................................................................................. 99

v Research Questions Data ....................................................................................................... 101 Decayed, Missing, Filled Index ...................................................................................... 103 Community Periodontal Index ........................................................................................ 103 Simplified Oral Hygiene Index ....................................................................................... 104 Dean’s Fluorosis ............................................................................................................. 104 Child-Oral Impact on Daily Performance ....................................................................... 105 Training of Trainers Intervention .......................................................................................... 106 Post-Intervention Data Collection ......................................................................................... 107 Research Questions Data Collection ..................................................................................... 108 Decayed, Missing, Filled Index ...................................................................................... 108 Community Periodontal Index ........................................................................................ 108 Simplified Oral Hygiene Index ....................................................................................... 109 Dean’s Fluorosis ............................................................................................................. 110 Child-Oral Impact on Daily Performance ....................................................................... 110 Comparison between the Groups .......................................................................................... 111 Brushing .......................................................................................................................... 111

vi Using Sweets analysis ..................................................................................................... 128 Decayed, Missing, Filled Teeth Index ............................................................................ 135 Community Periodontal Index ........................................................................................ 136 Simplified Oral Hygiene Index ....................................................................................... 142 Dean’s Fluorosis Analysis .............................................................................................. 148 Child-Oral Impact on Daily Performance Index ............................................................. 149 Hypothesis and Research Questions ...................................................................................... 183 Hypothesis Statement ..................................................................................................... 183 Alternate Hypothesis Statement ...................................................................................... 183 Summary ............................................................................................................................... 188 Chapter 5: Discussion, Conclusions, Recommendation .............................................................. 190 Summary ............................................................................................................................... 190 Interpretation of the Findings ................................................................................................ 193 Brushing, Brushing Frequency, and Brushing Type ....................................................... 193 Using Sugar, Frequency, and Types ............................................................................... 197 Decayed, Filled, Missing Teeth Index ............................................................................ 199 The Community Periodontal Index ................................................................................. 200

vii Simplified Oral Hygiene Index ....................................................................................... 203 Dean’s Fluorosis Index ................................................................................................... 205 Child-Oral Impact on Daily Performance ....................................................................... 207 Recommendations for Action ................................................................................................ 215 Recommendations for Further Studies .................................................................................. 216 Implications for Social Change ............................................................................................. 217 Conclusions ........................................................................................................................... 217 References ............................................................................................................................. 219 Appendix A: Bright Smiles, Bright Futures Program ........................................................... 239 Appendix B: Data Collection Tool ........................................................................................ 244 Appendix C: Letter of Cooperation from a Teacher.............................................................. 246 Appendix D: Teacher Pretest/Posttest ................................................................................... 247 Appendix E: Data Summary Form ........................................................................................ 249 Appendix F: Confidentiality Agreement ............................................................................... 250 Appendix G: Participation Agreement/ Local Leader ........................................................... 251 Appendix H: Participation Agreement School Headmaster .................................................. 252 Curriculum Vitae ................................................................................................................... 253

viii List of Tables

Table 1. Research Indices .............................................................................................................. 78 Table 2. Nature of Research Indices .............................................................................................. 83 Table 3. Simplified Oral Hygiene Index ........................................................................................ 87 Table 4. Dean’s Fluorosis .............................................................................................................. 88 Table 5. Child-OIDP Recording Form ........................................................................................... 91 Table 6. Data Analysis Plan ........................................................................................................... 96 Table 7. Demographic Characteristics of the Study Sample .......................................................... 99 Table 8. Percentage Distribution Behavioral Characteristics of the Studied Population by Intervention ......................................................................................................................... 101 Table 9. Percentage Distribution of the Study Population by Intervention for the Indices ......... 102 Table 10. t-Test Data Analysis for Brushing................................................................................ 112 Table 11. Linear Regression Analysis for Brushing ................................................................... 116 Table 12. t-Test Data Analysis for Brushing Frequency ............................................................ 118 Table 13. Linear Regression Analysis for Brushing Frequency .................................................. 121 Table 14. t-Test Data Analysis for Brushing Type ..................................................................... 123 Table 15. Linear Regression Analysis for Brushing Type .......................................................... 127 Table 16. t-Test Data Analysis of Sweet Frequency ................................................................... 130

ix Table 17. Linear Regression Analysis of Sweet Frequency ........................................................ 134 Table 18. t-Test Analysis for the Community Periodontal Index ................................................ 137 Table19. Linear Regression Analysis of the Community Periodontal Index ............................... 141 Table 20. t-test Analysis for the Simplified Oral Hygiene Index ................................................ 143 Table 21. Linear Regression Analysis for the Simplified Oral Hygiene Index. .......................... 147 Table 22. Fluoride Water Samples ............................................................................................... 149 Table 23. t-Test Data Analysis Child-Oral Impact on Daily Performance for Eating Problems . 150 Table 24. Linear Regression Analysis for Child Oral Impacts on Daily Performance-Eating Problems .............................................................................................................................. 154 Table 25. t-Test Analysis for Child-Oral Impact on Daily Performance for Cleaning Teeth Problem ............................................................................................................................... 157 Table 25. t-Test Analysis for Child-Oral Impact on Daily Performance for Cleaning Teeth Problem ............................................................................................................................... 157 Table 26. Linear Regression analysis for Child- Oral Impacts on Daily Performance- Cleaning Teeth .................................................................................................................................... 161 Table 27. t-Test Data Analysis Child-Oral Impact on Daily Performance for Smiling Problems ............................................................................................................................................. 165 Table 28. Linear Regression Analysis for Child Oral Impacts on Daily Performance-Smiling Problems .............................................................................................................................. 169

x Table 29. t-Test Analysis for Child-Oral Impact on Daily Performance for Socializing Problems ............................................................................................................................................. 172 Table 30. Child Impact on Daily Performance- Socializing Linear Regression Analysis ........... 176 Table 31. t-Test Data Analysis Child Oral Impact on Daily Performance- Total Impact Score.. 178 Table 32. Linear Regression Analysis for the Child- Oral Impacts on Daily Performance for the Total Impact Score. ............................................................................................................. 182 Table 33. Goals and Objectives of the Bright Smiles, Bright Future program ............................ 241 Table 34. Student Lesson Plan ..................................................................................................... 242 Table 35. Teacher’s Training Program Lesson Plan Schedule .................................................... 243

xi List of Figures Figure 1. Layout of sampling frame………………………………………………….....81 Figure 2. Percent test scores for training the trainers test……………………………..107

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Chapter 1: Introduction to the Study Introduction Locker and Allen (2007) defined oral-health-related quality of life as “the impact of oral diseases and disorders on aspects of everyday life that a patient or person values, that are of sufficient magnitude, in terms of frequency, severity, or duration to affect their experience and perception of their life overall” (p. 409). Oral-health-related quality of life is associated with overall quality of life, and the two have common assessment factors: a person’s level of functioning; degree of psychological health; extent of social interaction; and their level of discomfort (Inglehart & Benjamin, 2002; Yusuf, Gherunpong, Sheiham, & Tsakos, 2006). In relation to oral-health-related quality of life, a person’s ability to function means they have the ability to chew, swallow, taste their food, and also speak (Inglehart & Bagramian, 2002). One psychological factor includes being happy with one’s appearance which includes teeth, face, and smile (Inglehart & Bagramian, 2002; Yusuf et al., 2006). Positive psychological factors are associated with a positive perception of one’s personal appearance and higher self- esteem (Inglehart & Bagramian, 2002; Yusuf et al, 2006). Social factors include the ability to have personal interaction with others including talking properly, kissing, and smiling (Inglehart & Bagramian, 2002; Naito, et al., 2006; Sheiham, 2005; Yusuf, et al., 2006). The level of pain associated with oral-health-related quality of life is associated with the psychological and social factors. It must be considered if level of discomfort prohibits the person from being able to function; does it hamper the psychological

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factors, or prohibit social interaction; is the level of discomfort altering the person’s lifestyle to the point that they cannot sleep, eat, talk, or perform normal tasks such as working, playing, or attending school. Oral-health-related quality of life is difficult to measure (Inglehart & Bagramian, 2002). Each person’s perception of her or his quality of life is different. For some, it focuses merely on the freedom from pain. Others are more concerned with biologically sound dentition, such as the ability to chew. Still others are more interested in a wholesome facial image, such as how they look (Inglehart & Bagramian, 2002; Yusuf et al., 2006). Oral-health-related quality of life is therefore different for each group or community of people. Cultural and ethnic practices also affect the beliefs and practices associated with oral-health-related quality of life. Groups have been known to place tribal markings on faces, reshape their teeth, or pierce body parts like noses, lips, tongues, and ears. These can be acceptable practices in one culture yet shunned in another. There are oral diseases and conditions that are detrimental to a person’s oral- health-related quality of life despite culture, race or ethnicity (Petersen, 2008). These include dental caries, periodontal diseases (gingivitis, periodontitis), oral cancer, Noma (a destructive infectious disease), and fluorosis. These diseases can result in discomfort and reduced functions related to the oral cavity. Impairment from these diseases can affect one’s daily activities (Inglehart & Bagramian, 2002; Kwan & Petersen, 2003; Petersen, 2005; Petersen, 2008). There are behavioral and lifestyle risk factors associated with these oral diseases, including sugar consumption, nutrition, smoking, hygiene practices,

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and alcohol consumption (Petersen, 2004). These risk factors are shared with other systemic diseases such as diabetes, heart disease, cancer, and respiratory disease (Petersen, 2008). The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well being and not merely the absence of disease and infirmity” (WHO, 1948, p.1). The impact and pathophysiology of these systemic diseases and their relationship to oral disease will be discussed more fully in chapter 2 of this study. The researcher used four standard dental indices to measure both reversible and irreversible diseases and a sociodental index to collect data that created a profile of the community’s oral health status. The reversible indices, the Community Periodontal Index (to evaluate periodontal conditions) and the Simplified Oral Hygiene Index (to measure oral hygiene and the presence of oral debris), evaluated those conditions that can be changed. The irreversible indices, the Decayed, Missing, Filled Index (to measure experience with dental caries), and the Dean’s Fluorosis Index (to measure the incidence of dental fluorosis), evaluated the presence of diseases that cannot be changed and have an impact on oral health. The Child-Oral Impacts on Daily Performance Index was used to evaluate the sociodental aspects of the community and provide an indication of the community’s oral-health-related quality of life. These indices are described in chapter 2 and the procedures for using them are described in chapter 3. Behavioral and lifestyle changes can reduce or eliminate the risk factors associated with both oral diseases and associated systemic diseases (Petersen, 2008).

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Oral hygiene education has the potential to change behavior and thus result in improved oral-health-related quality of life and improved quality of life in general (Petersen, 2008). Rationale The people of the Wanji Tribe live in an isolated area of Tanzania (South Western Diocese [SWD], 2000). They have limited health care services, which are provided at several small clinics (SWD, 2000). Until 2008 these people had little or no dental care services (F. Killewa, personal communication, July 10, 2008). Currently, the community has two trained dental care providers (F. Killewa, personal communication, July 10, 2008; S. Mwashiuya, personal communication, July 6, 2010). These dental technicians are primarily trained in providing services related to urgent care or the relief of dental discomfort (S. Msite, personal communication, November 2, 2008). Preventive dental services are rarely provided (S. Msite, personal communication, November 2, 2008). Periodontal disease and caries are oral diseases of concern for the Wanji Tribe (F. Killewa, personal communication, July 10, 2008; S. Msite, personal communication, November 2, 2008; O. Nkosya, personal communication, April 6, 2010; S. Mwashiuya, personal communication, July 6, 2010). Many people come to the clinics, which are general health clinics, with dental discomfort. There is one trained dental clinician in the area who works at the government health center and one who works in a faith-based clinic. Some have missing teeth and many are concerned with the way their teeth look, for example, color, shape, or alignment (F. Killewa, personal communication, July 10, 2008; S. Msite, personal communication, November 2, 2008). In the International

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Comparisons of Health Inequities in Childhood Caries Report, conducted by the World Health Organization’s Collaborating Center on Oral Health in Deprived Communities, it was reported in 2004 that 59% of the child participants from Tanzania had dental caries, 53% added sugar to their drinks, and 74% reported that they brushed their teeth at least twice a day (Petersen, 2005). However, Petersen reported that the Decayed, Missing, Filled Teeth Index, which details the prevalence of dental caries for Tanzania, is very low at <1.2 indicating an average of 1.2 teeth per person with caries, filled due to caries, or missing because of caries (Peterson, 2005). While this rate is low, there are still children whose caries that could affect their daily performance and overall health. In an outreach program study conducted in an urban area of Dar es Salaam by students attending the School of Dentistry in Muhimbili, Tanzania in April 2007, it was revealed that 206 students out of 302 had at least one carious lesion (68%) and 24 had spontaneous bleeding of their gums (7.94%) as a result of gingivitis (Scholander & Alfaro, 2007). Another study, conducted by Mwakatube and Mumghama (2007), evaluated the oral health behavior and prevalence of dental caries among school children in Dar es Salaam. This study indicated that 41.6 % of the study population had caries experiences, 64% consumed sugary snacks at home and 76.1% of the students had never seen a dentist Despite these reports, the prevalence of dental caries is said to be below the WHO’s Global Goal of a score of 3 or less on the Decay, Missing, Filled Index for 12- year-olds (Mwakatube & Mumghama, 2007; WHO, 2010). These studies, conducted in

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urban areas, showed the impact of sugar consumption. The Wanji people, once living in a remote area, are now being exposed to the influences of the more urban areas. Dr. Shila Mwashiuya, local dental officer, is concerned over the impact of sugar consumption as soda and sweets are becoming popular and the lack of oral health persists (S. Mwashiuya, personal communication, July 6, 2010). Sugar consumption levels in Africa have risen from 15 kg to 25 kg per person per year (Enwonwu, Phillips, Ibrahim, & Danfillo, 2004). Research has shown that dental caries is linked to social and behavioral factors (Petersen, 2005). Evaluation of the socio-cultural risk factors—such as education, occupation, income, ethnicity, lifestyles, and social network support; the measurement of behavioral risk factors such as oral hygiene practices and sugar consumption; and the evaluation of environmental risk factors such as drinking water (fluoride content), sanitation, hygiene, and nutrition against the prevalence of oral disease—will aid in developing a dental profile for the area (Petersen 2005; Petersen, 2008). This information can be used to establish an oral hygiene dental health education program specifically for the community as an intervention against oral disease and a means to improve oral-health-related quality of life. In discussion with the medical officer, the school officials, and local church leaders of the community, it was decided to target the school system to provide oral hygiene education. According to WHO, the ratio of dentist to inhabitants was a 1:220,000 in 2006 in Tanzania (2008e). Because there were limited numbers of dental health care providers, it was seen as more feasible to use the school system to deliver oral

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health education (Flanders, 1987; Kwan & Petersen, 2003; Petersen, 2008). Teachers could be trained to provide oral hygiene education and to monitor oral hygiene care practices at the school. In this rural environment, enlisting the help of teachers might be the only way to provide access to oral hygiene care. Primary school education is compulsory in all areas of Tanzania and the majority of the children attend school until the age of 12 (Ministry of Education, 2005). In many areas of Tanzania, the population ratio of the young is greater than the adult population (Ministry of Planning, Economy, & Empowerment, 2005). The Wanji Tribe has approximately 37,000 people (Mahali, 2002; National Board of Statistics, 2002). There are 20 primary and 2 secondary schools within the Wanji population area (F. Killewa, personal communication, May 16, 2007). One of the most important groups that can be reached in health education is in the school systems (Flanders, 1987). The effectiveness of school-based dental health programs on oral hygiene practices and the reduction of oral disease has been equivocal, but research needs to continue and programs need to be developed to find a method to help reduce the incidence of oral disease and improve oral-health-related quality of life (Flanders, 1987; Petersen, 2004; Petersen, 2008). Little research has been done to date to determine the effectiveness of school-based oral hygiene education on oral-health-related quality of life. This study included a community intervention. The participants were evaluated prior to and following the intervention. The researcher used five oral-health-related indices to gather the information needed for the study. Four of the indices were related to

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oral diseases and the fifth was a socio-dental index used to determine the oral-health- related quality of life. A description of the indices can be found in chapter 2; the methodology for the indices can be found in chapter 3. As the Wanji Tribe moves into the 21 st century and becomes more urbanized, it will face an increase in the detriments to oral health due to the influence of sugar-based products and the lack of oral hygiene knowledge and access to care. If the community is not aware of healthy oral hygiene practices—which include removal of dental plaque, flossing, and good dietary practices—then an increase in oral diseases could occur and thus reduce both the oral-health-related quality of life and the overall health-related quality of life for community members. Use of the school system is ideal because it can reach a large number of children at one time (Flanders, 1987; Kwan & Petersen, 2003). Children are eager to learn, they are fast learners, and they are a population at risk for oral disease (Flanders, 1987; Kwan & Petersen, 2003). These services could help them develop lifelong attitudes toward oral health and the skills to help maintain a good quality of life (Geurink, 2005; Petersen, 2008). Problem Statement The Wanji Tribe has little access to dental services, including preventive services and oral hygiene education. The tribe is moving toward urbanization in many village areas. Introduction of sugar products, including sweets and soda, has become popular amongst the community. The lack of oral hygiene knowledge and little access to dental care increase the tribe’s chances of acquiring oral diseases including caries and

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periodontal diseases. Additionally, it puts them at risk for the associated oral-systemic diseases such as cancer, heart disease, respiratory disease, and diabetes mellitus. A review of the literature has shown that school-based oral hygiene education has had an impact on reducing oral disease in some communities (Kwan & Peterson, 2003; Nyandindi, Milen, Palin-Palokas, & Robinson, 1996; Scholander & Alfaro, 2007; Flanders, 1987). In Tanzania, teachers have not been trained adequately to teach oral hygiene education (Thorpe, 2006). It is unclear whether school-based oral hygiene programs will have an impact on oral-health related quality of life. While school-based oral hygiene education has been successful with some populations, we do not know if it is unknown whether it will impact the oral-health related quality of life for the Wanji tribe. Purpose of the Study The purpose of this quantitative study was to evaluate the effectiveness of a school-based, oral-hygiene education program on dental disease and oral-health-related quality of life of students of the Wanji Tribe. Standard dental indices were used to collect data to determine the prevalence of oral disease; a sociodental index was used to collect data to determine the sociodental estimate of needs. Data was collected and evaluated in a pretest/posttest design. The prevalence of oral disease was then calculated and the perceived dental concerns, such as caries and gingivitis, were determined. Data was analyzed to determine if the school-based intervention was effective for improving oral-health-related quality of life by showing improvements in the oral health indices.

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The Nature of the Study The study was an experimental quantitative community intervention study to determine the effectiveness of implementing oral hygiene education programs in the primary school system for the Wanji Tribe. Data was collected using standard dental indices. A questionnaire was used to gather the demographic, behavioral, knowledge, and attitude information with respect to oral hygiene. A pre-test- post test analysis of the data was performed to determine if any significant differences occurred between the control group and the experimental group that received the intervention. A logistic regression analysis was conducted to predict which areas the intervention was most successful. Research Questions The study investigated whether a school-based oral health education program was effective in improving the oral health-related quality of life in the Wanji community. Effectiveness was measured by the differences in the key indices between a pre and a post test means. The research question is as follows: What is the impact of the oral hygiene education program on the oral health- related quality of life for the Wanji children following a 4-week intervention? The following sub questions were evaluated: 1. What was the impact of the school-based oral hygiene education program on the Decayed, Missing, Filled Index measuring dental caries following a 4-week intervention and evaluated using a t-test analysis?

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2. What was the impact of the school-based oral hygiene education program on the Community Periodontal Index measuring periodontal disease following a 4- week intervention and evaluated using a t-test analysis? 3. What was the impact of the school-based oral hygiene education program on the Simplified Oral Index measuring oral cleanliness following a 4-week intervention and evaluated using a t-test analysis? 4. What was the impact of the school-based oral hygiene education program on the Dean’s Fluorosis Index measuring enamel fluorosis following a 4-week intervention and evaluating a t-test analysis? 5. What was the impact of the school-based oral hygiene education program on the Child-Oral Impact of Daily Performances Index measuring oral health- related quality of life following a 4-week intervention and evaluated using a t-test analysis? Hypothesis Statement Research question What was the impact of the oral hygiene education program on the oral health-related quality of life for the Wanji children following a 4-week intervention? H 0 : Students who participated in the school-based oral hygiene education program did not have a significant improved oral health-related quality of life following a 4- week intervention.

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H A : Students who participated in the school-based oral hygiene education program had a significant improved oral health-related quality of life following a 4-week intervention. Sub questions 1. What was the impact of the school-based oral hygiene education program on the Decayed, Missing, Filled Index measuring dental caries following a 4-week intervention and evaluated by a t-test analysis? H 0 1 : Students who participated in the school-based oral hygiene education program did not have a significantly improved Decayed, Missing, Filled Teeth Index score following a 4-week intervention and evaluated by a t-test analysis. H A 1 : Students who participated in the school-based oral hygiene education program had a significantly improved Decayed, Missing, Filled Teeth Index score following a 4-week intervention and evaluated by a t-test analysis.

2. What was the impact of the school-based oral hygiene education program on the Community Periodontal Index measuring periodontal disease? H 0 2 : Students who participated in the school-based oral hygiene education program did not have a significantly improved Community Periodontal Index score following a 4-week intervention and evaluated by a t-test analysis.

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H A 2 : Students who participated in the school-based oral hygiene education program had a significantly improved Community Periodontal Index score following a 4-week intervention and evaluated by a t-test analysis.

3. What was the impact of the school-based oral hygiene education on the Simplified Oral Hygiene Index measuring oral cleanliness following a 4-week intervention and evaluated by a t-test analysis?

H 0 3 : Students who participated in the school-based oral hygiene education program did not have a significantly improved Simplified Oral Hygiene Index score following a 4-week intervention and evaluated by a t-test analysis. H A 3 : Students who participated in the school-based oral hygiene education program had a significantly improved Simplified Oral Hygiene Index score following a 4-week intervention and evaluated by a t-test analysis.

4. What was the impact of the school-based oral hygiene education program on the Dean’s Fluorosis score measuring enamel fluorosis? H 0 4 : Students who participated in the school-based oral hygiene education program did not have a significantly improved Dean’s Fluorosis score following a 4-week intervention and evaluated by a t-test analysis.

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H A 4 : Students who participated in the school-based oral hygiene education program had a significantly improved Dean’s Fluorosis score following a 4-week intervention and evaluated by a t-test analysis.

5. What is the impact of the school-based oral hygiene education on the Child- Oral Impact on Daily Performance score measuring oral health-related quality of life following a 4-week intervention and evaluated by a t-test analysis? H 0 5 : Students who participated in the school-based oral hygiene education program did not have a significantly improved Child-Oral Impact on Daily Performance score following a 4-week intervention and evaluated by a t-test analysis. H A 5 : Students who participated in the school-based oral hygiene education program had a significantly improved Child-Oral Impact on Daily Performance score following a 4-week intervention and evaluated by a t-test analysis. Theoretical Base The development of the program was based on the behavior change theory (Darby, 2010). Three concepts from this theory were used as guidelines: the intrapersonal (individuals) aspect was used with the health belief model; the interpersonal aspect (between people) from social learning theory (social cognitive theory); and the community aspect from community organizational theory. These theories will be address in chapter 2.

Full document contains 275 pages
Abstract: As the Wanji Tribe of the Southern Highlands of Tanzania faces urbanization, they are at risk for diminished quality of life related to oral health due to the introduction of sweet products and little access to preventive dental care. Previous research indicated that preventive oral hygiene care reduced the incidence of oral diseases. However, literature review and previous research have not indicated whether school based oral hygiene education programs have the potential to improve indices of quality of life related to oral health. The purpose of this quantitative, 4 week community intervention study was to determine if a school based oral hygiene program had an impact on the quality of life indices (Decayed, Missing, Filled Index; Community Periodontal Index; Simplified Oral Hygiene Index; Dean's Fluorosis Index) and the Child-Oral Impacts on Daily Performance Index for the children of the Wanji Tribe. The health belief model, social learning theory, and community organization theory provided the theoretical foundations for this study. The impact of the multistage, random selection, pretest/posttest intervention was evaluated using the t -test analysis comparing groups on the means of different indices. The overall results indicated that the school based oral hygiene program improved the knowledge and attitudes of oral hygiene and oral hygiene skills of the Wanji school children. This study contributes to social change by identifying a public health intervention that can improve oral hygiene skills and knowledge toward oral health, reduce oral disease, and improve quality of life among school children.