Using an Socio-Ecological Model to Improve Oral Health Equity in Schools

Introduction

Despite being largely preventable, dental caries (tooth decay) is the most common chronic childhood disease in Canada (Canadian Dental Association, 2017). The highest rates of oral disease are exhibited in children of lower socioeconomic status, racial/ethnic minorities, immigrants, and rural populations with limited or no access to quality oral health care. Data from the 2010 Canadian Health Measures Survey (CHMS) reported that 57% of children aged 6-11 years old have early childhood caries (ECC) (Government of Canada, 2010). As oral health is a fundamental component of general health and well-being, children suffer significant reductions in their quality of life on a functional, psychological, and physical level from ECC (Rowan-Legg, 2013). Trauma from ECC and other oral disorders can affect them into adulthood if not treated. The need for prevention and early intervention of oral health disorders and establishing positive oral health habits in at-risk children is critical for their health and long-term development.

Schools are in a unique position to reduce oral health disparities and promote oral health across the social and economic gradient (Gargano et al., 2019). Oral health education and programs can be initiated throughout the school years that target and influence the oral health status of disadvantaged populations. These programs can improve health and well-being, access to dental care, oral hygiene skills, and dental health education in children. Supported by the World Health Organization (WHO) Global School Health Initiative in 1995, a 'Health-Promoting School' strives to create a healthy setting for living, learning, and working, especially when it comes to advancing oral health equity and promoting social justice (WHO, 2013).

The Socio-Ecological Model

Social-ecological models (SEMs) are used to understand and intervene in individual, community, and population health when health disparities in chronic diseases are an issue (Gargano et al., 2019). SEMs take into account the interconnectedness between influential individual factors and upstream determinants of health. These models encourage simultaneous interventions by targeting multiple levels of influence in order to be more effective. Figure 1 is a SEM that looks at the individual, family, and community-level influences in regard to ECC.

Figure 1

Child, Family, and Community Influences on Oral Health Outcomes of Children

Note. From "Influences on Children's Oral Health: A Conceptual Model" by S.A. Fisher-Owens, S. A., Gansky, L.J. Platt, J.A., Weintraub, M.J. Soobader, M.D. Bramlett, and P.W. Newacheck, 2007, Pediatrics 120(3), p. e512, (/10.1542/peds.2006-3084). Copyright 2007 by AAP.

Interventions at these levels will look to induce change in:

Health behaviours and practices, knowledge, and use of dental care	Individual-Level Influences
Family health behaviours, practices, knowledge, socioeconomic status	Family-Level Influences
Characteristics of the Canadian dental care system	Community-Level Influences

This SEM can further be applied to school systems to better understand oral health disparities in children at each level and how schools can develop action plans to advance oral health equity.

Individual-Level Influences

The etiology for early childhood caries is multifactorial. At an individual level, a child developing caries is largely dependent on his or her diet, biology, and oral health practices (e.g. the act of toothbrushing and using fluoridated toothpaste) (Dülgergil et al., 2013). Because sugars are an etiological factor in the caries process, if a child has frequently high sugar consumption and poor oral hygiene, he or she is more at risk for developing ECC. There are numerous studies to support a strong link between higher rates of dental caries due to a high sugar intake (WHO, 2013).

Family-Level Influences

Individual-level behaviours of children are significantly influenced by family (parents), social (teachers and peers), and organizational (school) relationships. Parental influences govern a child's proximate environment. Low self-efficacy, education, dental knowledge, and skills of the parents or caregivers of children have a high association with how children develop cariogenic practices that lead to ECC. For example, parents with higher educational backgrounds were more likely to have children who consume vegetables and non-sugar sweetened beverages in contrast to parents with lower educational backgrounds. Hence, parents and role model figures are viewed as intermediary mechanisms through which societal and community influences affect children's health and well-being (Russo et al., 2020).

Socioeconomic factors such as status, ethnicity, culture, stress, education, household income, and access to dental care are significant family-level influences that affect a child's oral health status. As dental care is largely privatized in Canada, income and dental insurance are the two most important determinants of dental care utilization (Canadian Dental Association, 2017). For example, Locker et al (2011) found that only 19.3% of the lowest income groups had dental insurance, compared to the highest income groups having 80.5% dental coverage. Low-income families without dental insurance are less likely to access dental care due to cost. As the demographics of low-income families are largely immigrants and ethnic minorities, the children of these families are significantly more at risk for developing ECC than children from higher-income families.

Community-Level Influences

Canada ranks second-last in the public financing of dental health, among developed countries (Quiñonez & Grootendorst, 2011). The majority of public health programs occur at the provincial level. In Alberta, the Provincial Oral Health Office (POHO) is responsible for facilitating initiatives to improve the oral health status of Albertans (Alberta Health Services, 2016). Access to provincial community water fluoridation is one such population health initiative; however, those living in rural communities do not have access to fluoridated water, which puts these populations at an oral health disadvantage. As a preventative means for ECC, one of the POHO's objectives is to target disadvantaged school children and provide free dental services such as fluoride varnish and sealants (Huber et al., 2017). However, limitations to resources, providing adequate dental staff, and accessibility to vulnerable populations across the province remain an issue.

Summary of the specific causes of early childhood caries at each level of influence.

​Individual-Level Influences	Frequent and high sugar consumption Inadequate oral health practices
Family-Level Influences	Low self-efficacy, education, dental knowledge, and skills of parents and caregivers Socioeconomic factors such as low household income, dental coverage, and socioeconomic status create financial barriers to accessing dental care
Community-Level Influences	Lack of water fluoridation in rural areas Limitations to resources, dental staff, and accessibility to provide provincial oral health initiatives to prevent ECC in vulnerable populations

Strategies and Recommendations for Health-Promoting Schools

In Canada, nearly 6 million children attend elementary and secondary school each year (Statistics Canada, 2021). Since schools are integrated into community-level settings across the socioeconomic gradient, they can be impactful in oral health promotion to reduce the prevalence of ECC in vulnerable populations. Based upon the principles that the WHO has outlined for a 'Health-Promoting School', schools can implement a wide variety of oral health programs to improve oral health equity and reduce barriers to dental care access (WHO, 2013). They can significantly influence nutrition, education, and access to dental care at family and individual levels (Kwan et al., 2005).

Nutrition Programs

School-based oral health programs can target healthier nutritional initiatives that influence the individual level for ECC progression. Although the majority of health food initiatives in schools target the reduction of obesity, the reduction of sugar-containing foods and drinks also benefits the oral health cavity in children and reduces the risk of ECC (Jürgensen & Petersen, 2013; WHO 2013). Additional nutritional programs can include:

• Provision of healthier food options in cafeterias and vending machines

• Banning or reducing soft drinks and sweets sold at school

• Promotion of healthier food alternatives in school media

• Nutritional seminars

• Collaboration with neighbouring shops and supermarkets to influence healthier available food options

Education Programs

Sustainable health behaviours have been witnessed in school-based oral health education programs. Many studies consider incorporating sessions and activities for children, parents, and school staff that can be integrated early on in the curriculum (Jürgensen & Petersen, 2013; WHO, 2013). These educational programs can reduce oral health disparities due to socioeconomic factors and can include:

• Incorporating oral health into classroom lessons

• Daily tooth brushing and flossing exercises

• Seminars for parents and children on positive oral health behaviours

• Presentations and demonstrations of oral health self-care by dental care professionals

• Training staff (teachers and school nurses) on oral health promotion

Access to Dental Care Programs

Schools that have dental care programs are effective in increasing access to dental care, particularly for children in high-risk populations of dental decay such as low-income neighbourhoods and rural locations (Jürgensen & Petersen, 2013; WHO, 2013). The following dental services can be provincially funded and free for children as a means of promoting oral health at a community level:

• Administration of fluoride (varnish, rinses, tablets)

• Provision of toothbrushes and fluoridated toothpaste

• Administration of sealants

• Oral examinations

• Oral health screening

Conclusion

The socio-ecological model is an effective tool used to understand the factors that cause ECC in children at each level of influence and how it can be applied to develop school-based oral-health programs. Although many social determinants exist that affect ECC in Figure 1, the strongest indicators for the high prevalence of ECC include sugar consumption, oral health practices, family socioeconomic factors, and access to affordable dental care.

This literature focused on three main school-based programs (nutrition, education, and access to dental care) as outlined by the WHOs framework for a Health-Promoting School (WHO, 2013). Because schools are an efficient and effective way to reach children, families, and community members, examples of how these programs can affect multiple levels of influence - rather than targeting a single outcome on the individual level - were provided as a means for improving oral health equity in schools.

References

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