This study aims to evaluate the effects of an NGO (Non-Governmental Organization) -supported school-based oral health promotion program in primary schools of Iran.

This oral health-promoting program was conducted by the Barekat Organization (an NGO that supports the construction and equipment of schools in deprived regions) in cooperation with the Ministries of Education and Health and Medical Education in 2022. The program covered 3,000 schoolchildren in 32 schools. It included the education of schoolchildren, their parents, and their teachers using printed worksheets, face-to-face educations, and holding workshops by the school health educators from September 2022 to May 2023. The total mean score and the mean scores of sub-domains for students’ knowledge were compared using paired t-test after 9 months (α = 0.05).

The data of 576 schoolchildren including 261 (43.5%) boys and 315 girls (56.5%) were selected randomly for analysis. The total knowledge was improved significantly (from 9.1 ± 2.9 to 13.5 ± 3.1; p < 0.001; Cohen Effect Size = 1.4). At the baseline, female students had a higher baseline knowledge significantly (p = 0.001). The mean scores of knowledges increased in both genders after the interventions (p-value < 0.001). The most significant changes were observed regarding the knowledge of tooth eruption and tooth brushing, whereas the least significant changes were noticed in the healthy diet domains.

Educational interventions provided in primary schools proved to be effective in improving schoolchildren’s knowledge. Therefore, the findings can be considered convincing evidence for the implementation of a model for successful cooperation between the Ministry of Health and Medical Education and NGOs.

Dental caries is classified as one of the most common chronic diseases affecting children worldwide, with approximately 40–50% of schoolchildren experiencing tooth decay in their primary teeth [1]. In Iran, the dmft (decayed, missing, and filled teeth) of the primary teeth were reported to increase within the age group of 6–9 years gradually from 1990 to 2017 (4.34 and 5.06, respectively). The number of untreated decayed teeth was the major component of the dmft, with a value of 4.34 in 2017 and it has been reported that 76% of 6-year-old Iranian children needed dental treatment [2]. According to a meta-analysis study conducted in 2024 in Iran, the estimated prevalence of Early Childhood Caries has been 61.7% [3].

Untreated childhood dental caries can cause dental pain and an inability to eat or sleep, which in turn can adversely affect the child’s daily activities [4], e.g., school attendance [5]. Dental caries can also have negative impacts on their families by posing psychological stress (i.e. feelings of upset and guilt) and financial difficulties [6, 7]. In response to such complications, many countries have incorporated oral health education into their primary school curricula. In other words, oral health education in primary schools is aimed at providing children with the knowledge, skills, and attitudes required to maintain good oral hygiene practices and prevent oral diseases [8]. Effective oral health education programs have proven to improve children’s oral hygiene behaviors, mitigate the prevalence of dental caries, and enhance their knowledge about oral health. Based on the results of a systematic review, school-based oral health promotion programs have been effective in reducing 30–50% of the dental caries in elementary schools [9].

Many factors can contribute to the success of oral health promotion in primary schools. Firstly, parents and caregivers must be encouraged to be involved in the educational process. Research has shown that parental involvement can serve as a significant predictor of children’s oral health behaviors [10]. Parents who are educated in oral health are more likely to encourage their children to practice good oral hygiene habits at home [11]. Secondly, school-based programs should be integrated into curricula engagingly and interactively [12]. Such integration can be achieved through games, role-playing, and hands-on activities that make learning fun and enjoyable for children [9]. Finally, school-based programs should be evaluated and monitored regularly to guarantee their effectiveness and identify areas for improvement.

Despite the importance of oral health promotion in primary schools, several challenges must be addressed carefully. A major challenge is the limited resources available for the implementation of school-based oral health programs [13]. Schools may lack the necessary funds for materials and staff training, which can hinder the effectiveness of such programs. Therefore, sectors outside the Ministry of Education or the Ministry of Health and Medical Education, e.g., NGOs or charities, can play a pivotal role in supporting and expanding the coverage of such programs.

Regarding the economic status of Iran, as a low-middle income country, financial constrains might seriously hamper the development and implementation of preventive programs in targeted age groups including schoolchildren. Therefore, attracting the cooperation of other organizations out of the health sector and persuading them to invest in the health promotion programs could be an effective alternative for direct health sector financing. However, the methods and effectiveness of such cooperations needed to be evaluate. This study therefore is aiming to introduce an instance of this cooperation and evaluate the effects of school-based NGO-supported interventions on schoolchildren’s knowledge improvement.

This study was conducted to follow up our previous research endeavor entitled Implementing an Integrated Model of Oral Health-Promoting Schools in Isfahan. The previous work aimed to integrate the dental education curriculum with the principles of health-promoting schools, the details of which were published earlier [14, 15]. The previous study was conducted on 354 primary school students, their parents, and their teachers at six schools in the deprived regions of Isfahan. The results revealed that the program succeeded in improving schoolchildren’s knowledge, their parents’ and teachers’ knowledge and attitudes as well as the parental practice enhancement. It also expanded the coverage of professional preventive care at schools.

The project was implemented in an agreement between the Vice Chancellery for Research at Isfahan University of Medical Sciences and the Deputy of Health and Research of the Department of Education in Isfahan Province, Iran, as an action research plan (Ethics Code: IR.MUI.RESEARCH.1397.1.012) from 2018 to 2020. Interventions were based on the multidimensional PRECEDE-PROCEED planning model. Schoolchildren were taught oral health core messages in several ways based on the health belief model. Educational interventions included theoretically and practically face-to-face training sessions presented by dental students as well as two worksheets designed and validated by principal investigators (BT, IA).

Worksheet 1 included educational activities, e.g., puzzles, cluttered words, tables, painting, and crafting related to the oral health topics expected to be fulfilled in weekly art classes. However, Worksheet 2 included basic oral health-related messages integrated into various chapters of elementary textbooks. Furthermore, teachers were taught the worksheet education and supervision protocol at the designated schools. In addition to the designed educational packages for schoolchildren, parents were also considered the locus of attention. Therefore, two specific half-day workshops were designed for parents. The contents of the workshops were then provided for participants through printed pamphlets.

In 2022, the Barekat Organization [16] was informed about this project. It then proposed to expand the coverage of interventions at some primary schools. This NGO is mainly tasked with supporting the construction and equipment of schools in rural and deprived regions. As one of its missions, it is also involved in establishing and developing various health projects such as vaccination plans and health-related knowledge enhancement courses. This NGO is reported to have built nearly 2000 schools in different provinces of Iran.

In different meetings (held for more than 10 sessions) with the heads of its health sector, this NGO decided to redesign the worksheets in cooperation with a professional child graphics designer to enhance the quality of pictures. Based on the opinions of school teachers involved in our previous work, some more puzzles and paintings were added to Worksheet 1. Moreover, the quantities of pictures of boys and girls were deemed equal, and all puzzles and paintings were made pertinent to the core messages of oral health. In Worksheet 2, the pictures were all redesigned. Some pages were also dedicated to introducing famous Iranian characters with cultural backgrounds in mathematics, medicine, and literature. Parental pamphlets were also redesigned without any dramatic changes in the content.

The worksheets and pamphlets were then provided for the head of the Health and Wellness Chancellery at the Ministry of Education and the head of the Oral Health Bureau at the Ministry of Health and Medical Education for face validation and content validation. After their proposed small modifications were considered, the worksheets received the necessary confirmations. The logos of these two organizations were then approved to be placed on the front pages of publications.

In coordination with the Ministry of Education, the current project was set to be implemented in Varamin, Tehran Province, Iran. Varamin is a city with low-to-moderate socioeconomic status near Tehran. The project was conducted on approximately 3,000 schoolchildren (second-grade students aged 7–8 years) at 32 schools (15 boys’ primary schools and 17 girls’ primary schools) that had health coaches. Therefore, a day-long introductory educational workshop was conducted in September 2023 (two weeks before the beginning of the academic year in Iran) in coordination with the principals and administrators of the education chancellery in Varamin and in cooperation with the Health and Wellness Department of the Ministry of Education and the representative of the Barekat Organization for school health plans. All the school health educators of the designated schools were invited.

The content of the worksheets and parents’ educational workshops, the oral health core messages, the recommended oral health behaviors, facts about fluoridation, and the methods and protocols for training the schoolchildren in the worksheets were all presented during this workshop by the principal investigators (PIs) using PowerPoint-based lectures and discussion panels.

School health educators were expected to educate schoolchildren in the designed educational content during art classes and train the class teachers in Worksheet 2. They were also asked to implement at least two sessions of supervised tooth brushing practice in their schools and train children practically (Fig. 1). They were also responsible for organizing two workshops for parents to convey the oral health core messages, explain the educational interventions, and align participants with the educational environment at schools.

School children completing the designed exercises in their art classes under the supervision of their health coaches

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Based on our previous work, a ready-made and validated 17-item questionnaire was employed to assess schoolchildren’s attainment of knowledge before and after the interventions. This self-administered questionnaire included yes/no questions and some empty-space statements, covering six domains with at least two items in each part encompassing awareness about plaque biofilm, the role of fluoride, tooth brushing behavior, healthy foods, and the importance of healthy teeth as well as awareness about the pattern of tooth eruption (number and correct age). The questionnaires were also renovated to be colorful and attractive for schoolchildren and were distributed twice, once before the beginning of interventions and once after 9 months.

The educational objectives of oral health promotion for this age group were set based on the literature review and some items were designed for each objective. To ensure the face and content validity, the questions and educational objectives were given to 5 experts (3 oral public health.

and 2 dental pediatric professors). They were asked to rate the relevance of the questions based on a 3-point Likert scale (from 1: Completely relevant to 3: Not relevant). The reliability of the questionnaire was assessed by calculating the Guttman score (= 0.64) in a pilot study on 50 school children out of the project [14].

Inclusion criteria included schoolchildren studying at grade 2 in primary schools of Varamin city, that had received oral health educations at school setting and had completed the before and after questionnaire. Schoolchildren who were absent in the days of completing before/ after questionnaires were excluded.

The minimum sample size calculated based on the one-sample paired design (before-after) formula [17] was to be 546 by considering a standard deviation of 2.5 for changes in the knowledge based on our previous work [14], the expected minimum effect size of 0.3, the confidence interval of 95%, and the power of 80%. A multistage sampling method was adopted to recruit the participants; 14 schools were selected randomly (7 boys’ schools and 7 girls’ schools) using a systematic random selection from the list of the schools. Then, at each school, one or two classes that had completed before-after questionnaires were selected randomly (between 30 and 60 students at each school).

Data analysis was performed in SPSS 26 (powered by IBM). The Kolmogorov–Smirnov test was conducted to analyze the normal distribution of scores. The total mean score and the scores of sub-domains of students’ knowledge were determined. The mean scores were then compared through the paired t-test or its equivalent non-parametric test. The relationship between students’ knowledge and their demographic characteristics, e.g., gender, was analyzed through the t-test or its equivalent non-parametric test (α = 0.05).

The data of 576 schoolchildren including 261 (43.5%) boys and 315 girls (56.5%) were selected randomly for analysis. Table 1 presents the total mean scores of knowledge before and after the project in terms of gender. Accordingly, the total knowledge was improved significantly (from 9.1 ± 2.9 to 13.5 ± 3.1; p < 0.001; Cohen Effect Size = 1.4).

Comparing the mean scores in gender indicated that female students had significantly higher scores (p = 0.001) at the baseline, and the same pattern was observed after the educational interventions. The paired t-test revealed that the knowledge mean scores increased after the interventions in both genders (p-value < 0.001). However, the mean differences of knowledge scores were not different significantly between boys (4.37, 95%CI: 3.9–4.7) and girls (4.36, 95%CI: 3.8–4.8).

Table 2 reports the changes in the mean scores of the knowledge domains. The most significant and noticeable changes were observed in the domains of knowledge about tooth eruption (the number of primary and permanent teeth and the sequences of eruption) and tooth brushing (frequency and duration), whereas the least significant changes were noticed in the domains of healthy diet knowledge and fluoride. In addition, using the multivariate paired T² Hotelling test (Stata, StataCorp MP 17), the same results were gained (the differences were significant, Prob > f = 0.00).

Table 3 presents the changes in the percentage of correct responses to each domain of knowledge. Accordingly, in all domains, this percentage was increased significantly, especially the knowledge about the duration of tooth brushing and the best recommended time for brushing. In addition, the percentage of correct responses regarding the role of microbial biofilm in dental caries soared substantially. The multivariate paired T2 Hotelling test (Stata, StataCorp MP 17) also resulted in the same findings and the p-value remained < 0.001.

This study aimed to analyze the effects of a model for oral health promotion at schools in collaboration with an organization outside of the health sector. The results indicated that educational interventions affected schoolchildren’s oral health knowledge. The significant increase in the total knowledge scores (9.1 ± 2.9 to 13.5 ± 3.1) and improvements in specific domains, e.g., tooth eruption and tooth brushing, indicated that the project succeeded in educating the students. Other studies have also emphasized the effectiveness of oral health-promoting schools in shaping and enhancing schoolchildren’s oral health knowledge [18]. In our previous study conducted with the same educational package on schoolchildren in Isfahan, the mean score of knowledge was 7.8 ± 1.7 at the baseline and increased significantly to 9.4 ± 1.8 (p < 0.001) after the interventions [14]. The difference in the scores between the two studies can be due to the difference between the regions in the socioeconomic status or the difference in the sample size. However, the mean difference was nearly similar.

Another finding of our study concerned the observed gender differences. The fact that female students had higher baseline knowledge scores and maintained this trend after the educational interventions may raise concerns about potential disparities in access to oral health education or existing knowledge levels between boys and girls. This finding can also be explained partly by the fact that girls usually have higher positive attitudes and pay more attention to their appearance; therefore, they are more encouraged to attain more oral health [19].

Additionally, although there were significant improvements in certain domains of knowledge, e.g., tooth brushing techniques and the role of microbial biofilms in dental caries, there were less noticeable changes in other areas like healthy diet knowledge and fluoride use. This discrepancy highlights the importance of targeting all aspects of oral health education in detail.

The effectiveness of oral health education in school settings has been proven by many other studies [20,21,22,23] and found that oral health education programs at schools were effective in enhancing schoolchildren’s oral health knowledge, attitudes, and behaviors. The valuable, promising superiority of the present study may lie in its implementation method as an inter-sectoral health promotion program. Multi-sectoral partnerships for health enhancement are not unprecedented. These joint efforts are based on the principle that no individual organization or sector has the sole responsibility or sufficient capacity for population health enhancement [24]. We can only make the best use of available resources, skills, and talents through collaborative ventures; thereby reaching sustainable extended advancements in the prevention and control of chronic diseases, e.g., cancers, heart disease, and psychological disorders [25].

Nongovernmental organizations (NGOs) are the symbol of public participation, which is one of the major supporters of health promotion and mitigation of poverty and injustice across different societies. The experiences of both developed and developing countries have highlighted the necessity of developing and benefiting from such organizations more than ever [26]. This study presents how the commitment of such NGOs to public health promotion can be engaged with the objectives of oral health-promoting schools. This model of collaboration can help overcome the legal and financial obstacles within the framework of levers outside the Ministry of Health and provide preparations to normalize teaching oral hygiene permanently as a routine educational program at elementary schools. By collaborating with NGOs, schools can access the necessary support to establish and expand the coverage of these programs, ultimately boosting schoolchildren’s oral health.

The success of oral health promotion at primary schools can be attributed to a multifaceted approach that involves parents and caregivers, engages school-based programs, and encompasses regular evaluation. If educated in oral health, parents can successfully encourage their children to adopt good habits of oral hygiene at home, an essential predictor of children’s oral health behaviors [10, 11]. In school settings, interactive engaging activities, e.g., games, role-playing, and hands-on experiences, can make learning fun and enjoyable, thereby promoting healthy behaviors [9, 12]. Furthermore, the regular evaluation and monitoring of such programs can guarantee their effectiveness and help identify areas for improvement, ultimately leading to better outcomes of children’s oral health.

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BT has contributed in design, data collection, analyzing and drafting the article. AP has contributed in conception and design of the work, data collecting. IA and AG have contributed in design and drafting the article. All the authors have approved the paper prior to submission.

Correspondence to Bahareh Tahani.

The study protocol was approved by the Ethics Committee in the Vice Chancellery of Research at the Isfahan University of Medical Sciences (IR.MUI.RESEARCH.1397.1.012) and the study has been carried out in compliance with the Helsinki Declaration (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). addition, informed written consent from the parents and then verbal consent from the children were obtained.

While the photos of school health educators have been sent by themselves by consents, and inform written consent was gained from parents, the image presented in our study has no identifying images (the faces have been blurred).

The authors declare no competing interests.

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