Self-Perceived Behavior and Process Evaluation of Bocas Sanas Holanda-Maimón (BSHM, 2020): From the Past to the Future

Objective: To observe, register, report, interpret and evaluate the two weeks school-based Oral Health Education and Hygiene program of the Foundation Bocas Sanas Holanda-Maimón (BSHM) in the Dominican Republic in February 2020. Methods: 225 primary school children around Puerto Plata – a city in a poor region – were screened and treated by the BSHM 2020 team. Moreover, all children of the six schools that were visited, as well as the teachers, received oral health education. Results: Observational findings show that school-based tooth brushing was appreciated and effective, illustrating the importance of tailored oral health promotion and oral disease-prevention interventions specifically designed for every school context. Interprofessional support was necessary to develop an optimal working alliance among teachers and BSHM-volunteers in the school-based oral health interventions. Conclusions: On the basis of these observations and interpretations, the approach of BSHM will be drawn up and adjusted, especially regarding referrals for further curative dental care of the children and their parents to the CEPREDIMA in Maimón, to the NGO Fundacíon Clinicas Odotologicas Sonrisas or ideally, to the Centro Sanitario, a government agency that provides medical and dental care, and where specialist pediatric dentists work.


Introduction
The program involves an adequate application of evidencebased strategies in oral health promotion and prevention as well as in the treatment of oral diseases [3]. Normally, oral health education is provided mostly within dental practices; children and their parents receive individual attention from the oral care professional.
However, the WHO [4] recognizes that primary schools are the most adequate tool for providing information to people who do not visit clinics, because schools are easily accessible. Approaching schools can serve to improve the awareness of the importance of (oral) health and to pay attention to adequate tooth brushing during early childhood. Often it is difficult to determine the effectiveness of a one-time lesson on oral health care [5]. Moreover, there is little evidence that such a tooth brushing intervention actually results in a permanent behavioral change in the children.
However, the primary school period is a crucial stage of child development: health-related behavior that is practised routinely is more likely to become habitual, because the success of health education initiatives and programs lies in the ability to understand the differences in psychosocial factors, e.g., knowledge, attitudes, environment, and behavior both at individual and community level [6][7][8]. Also, oral health interventions need to be embedded within oral health systems that are financially fair for disadvantaged and poor population groups [9].

Participants and Procedure
During two weeks in February 2020, a team of 10 volunteers from the Bocas Sanas Holanda-Maimón foundation, including dentists, dental hygienists, dental assistants, a clinic manager and interpreters visited six schools in the Maimón region. Every day there was participation of one dentist and an oral health educator from the NGO Fundacíon Clinicas Odontologicas Sonrisas. Involvement of the primary schools was agreed, participation of the children and teachers present was on a voluntary basis, they were informed about what participation entailed and free to refuse the check-up and, if called for, curative care [1]. In total, 225 children who participated in the prevention program of BSHM and 220 children from five BSHM-schools were clinically examined.
If dental treatment was needed they were treated or referred to the government-run Centro Sanitario, with dentists specialized in treatment for children, to the private clinic CEPREDIMA in Maimón, which collaborated with the foundation BSHM, or to Clinicas Odotologicas Sonrisas in Puerto Plata. Seven teachers from the schools were clinically examined and dental cleaning was performed if necessary. In the sixth school visited, Escuela Paloindio, the five children in this very small school were not screened, but they did receive oral health education. In all schools, the emphasis of the oral health education was on tooth brushing; at least twice a day with a short horizontal tooth brushing method (precursor Bass-method).
Use of fluoride toothpaste was promoted and brushing conform the 'inside, outside, upside, backside' brushing order, starting in the lower jaw and continuing the same ordering in the upper jaw (10; Dutch BBBA-method -i.e., brushing order) (translated in Spanish the Adentro, Afuera, Arriba, Atras -system (sistema AAAA).
Using a helicopter view method, the BSHM 2020 program, including the different approaches of the tailored tooth brushing lessons (Table 1), were assessed using semi-systematic participatory observation, i.e., the observer -the last author of this paper-participated in the situation she was observing. In line with an earlier teachers evaluation (1) a meeting in the Escuela Basica La Colorada with the teachers present, the BSHM founder -the second author-and the other co-authors was arranged to gain insight in to what extent the provided oral health education and instructions on 'tooth brushing behavior' were understood, remembered and/ or implemented in this school (Table 1).

Discussion
The aim of this observation report was -after an evaluation in 2015 (1) showed that school-based tooth brushing should include tailored oral health promotion and oral disease-prevention interventions specifically designed for the target population at national level [11].
The long term benefits of this BSHM program and collaboration with other oral health care organisations, including mediumlongitudinal evaluation studies are recommended. This as basis for the BSHM approach to be transferred to the Dominican state and translated into national policy, so as to be formally adopted by the Ministries of Public Health and Education of the Dominican Republic [12].