Palestine - Integrating the WHO Health Promoting School Concept into National School Oral Health

Dr Lamis Abuhaloob WHO CC for Public Health Education and Training, Imperial College London, London, United Kingdom

Professor Poul Erik Petersen WHO Collaborating Centre for Community Oral Health Programmes and Research, University of Copenhagen, Denmark


The Palestinian Territories comprise two geographically separated areas (Figure 1): West Bank (WB) and Gaza Strip (GS). The WB comprise an area of 5,800 km2 west of the River Jordan. The GS is a narrow strip of highly populated land of 360 km2 lying on the eastern coast of the Mediterranean Sea1. The WB and GS contain 16 and 7 governorates, respectively2.

Figure 1. Map of Palestinian Territories

The long-term political instability in the Palestinian territories has caused serious deterioration of socioeconomic conditions. In addition, because of financial limitations existing health services are unable to meet the population’s oral healthcare3This is the first national oral health promotion study in Palestine applying the principles of the WHO Health Promoting Schools concept4 at the national level and involved representative governmental primary schools from all governorates.

Background and rationale

During the past 15 years, the burden of dental caries has been persistently high among 6-year-old children and a considerable increase in caries prevalence is now prominent among adolescents5, 6. In 2017, 83.4% of Palestinian grade 1 children suffered from dental caries in primary teeth and the average dental caries experience was dmfs 11.27.

'Research carried out in the Palestinian territories has identified substantial social risk factors important to children’s health including constrained economic resources of families, poor health-related quality of life, residing in refugee camps, poor nutrition status, the experience of governmental instability, and severe barriers to accessing healthcare services.

Although most recent research reported high dental care awareness among Palestinian mothers, the risk of dental caries remains high in Palestine because of irregular dental visiting practices, infrequent tooth brushing habits, low exposure to fluoridated toothpaste, and elevated sugar consumption7.

The School Health Programme was established in 1994 by the Ministry of Health and United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in order to provide dental care for children enrolled in governmental private schools in the Gaza Strip and the West Bank and refugee’s settings (UNRWA). This programme should include oral health screening, referral for dental care, follow-up services, oral health education and oral health promotion8. However, the existing school dental health programme does not match the oral health needs and an organized oral disease prevention programme would be important for tackling the poor oral health situation of Palestinian children.

Aims and objectives

This project aimed to develop and implement a demonstration programme for the promotion of oral health among primary schoolchildren in a representative sample of primary schools in Palestine. The project applied the principles of the WHO Health Promoting Schools concept4 which involves the creation of classroom-based health education to be carried out by schoolteachers coupled with family and community actions9.

Project Outline

A quasi-experimental study (2016-2018) recruited 3939 schoolchildren aged 5-6 years from 30 intervention schools (n=2333) and 31 comparison schools (n=1606). At baseline and post-intervention, mothers and schoolteachers completed WHO self-administered questionnaires about the oral health of children, oral health behaviour, and family factors. A total of 25 calibrated dentists examined the dental caries of children according to WHO criteria. Trained teachers in the intervention schools provided comprehensive oral health education to children in the classrooms, held regular oral health sessions for mothers, and supervised children's daily toothbrushing with fluoride-containing toothpaste (1,450 ppm F) at school.

The project implementation process is summarised in Figures 2, 3, 4, 5 and 6.

Figure 2. Chart describing Palestinian school oral health project implementation process

Figure 3: Teachers’ capacity building and dentists' training workshops in the Ministry of Health and Ministry of Education in Palestine

Figure 4. School oral health dentists examine Palestinian children’s oral health based on the WHO criteria

Figure 5. Trained teachers provide classroom-based oral health education to children and parents in Palestine

Figure 6. Trained teachers distribute fluoride toothpaste and toothbrushes free of charge and supervise children’s daily toothbrushing 


After 24 months of the programme implementation, the follow-up was completed for 75.8% of recruited children. The results showed that dental caries experience declined over the project, in both dentitions. The reduction in DMFT and DMFS was 23.3% and 23.2% (P<0.001), respectively. The drop-in caries experience indices in Gaza Strip were four to eight times higher than in West Bank and reached a 47.4% reduction in DMFT (Figure 7)

Figure 7. Reduction (%) in dental caries experience of schoolchildren in intervention collaborative schools compared to control schools (P<0.001)

In the intervention group, fewer children avoided smiling, fewer children missed classes because of toothache and 40% of children visited a dentist once or twice a year. The main reason for visiting the dentist was pain/troubles with teeth or gums. The percentage of children practicing toothbrushing at home two or more times a day increased, and 72.5% of the children used fluoride-containing toothpaste.

For 76.9% of 6-years old schoolchildren in the intervention schools, parents were the main source of information on oral healthcare. The contribution of teachers to oral healthcare facts raised to 43.3% in the intervention group by the end of the study (Figure 8). 

Figure 8. Source of knowledge for oral health care for 5-7-years old schoolchildren, at baseline and after 24 months

Mothers and teachers showed improvement in knowledge and positive attitudes towards dental care. The involvement of schoolteachers in oral health in schools and acceptance of dental health education materials significantly enhanced children’s oral health behaviour.

The WHO school oral health promotion programmes implemented in primary schools in Thailand10 and China11 showed a similar outcome.


Palestine has suffered from long-lasting political unrest for decades. The implementation difficulties observed in this study mostly relate to bureaucratic governmental procedures and political unrest. The field control of the project was better in the GS due to enhanced access to schools since there were no Israeli checkpoints. These checkpoints in the WB area were hugely delaying programme undertakings. Meanwhile, the Ministry of Health in Palestine was unable to support the entrance of the project Principal Investigator in regular travels from the GS to WB areas. Such obstacles emphasize the necessity of effective collaboration with WHO and UNICEF to facilitate the movements of researchers in occupied regions and to ensure the implementation of national health promotion projects appropriately.


The school-health intervention was effective in preventing up to 47.4% of dental caries incidents. However, the effectiveness varied between different geographic parts of Palestine because of differences in tap water fluoride concentration level (GS 1.38 and WB 0.24), field control, system administration procedures, and political unrest. Community support by international health associations may facilitate oral health programme implementation in politically distressed regions. In addition, this study confirmed the experience of empowered parents, schoolteachers and the community at large in disease prevention in poor settings. Finally, effective results in dental caries prevention are particularly obtainable when disease prevention programmes involve toothbrushes free of charge and fluoridated toothpaste.


Sincere thanks to the Borrow Foundation for having provided valuable funds for the project. Genuine thanks to the Ministry of Health and Ministry of Education in the State of Palestine for their significant help and contribution in implementing and running the projects.


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