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Table 1 Characteristics of included studies

From: Barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools: a systematic review

Author, year, (country) Study aims Study setting and methods Participants Outcome Limitations Funding source
Enablers Barriers
Dimitropoulos et al. (Australia) [30] Possible challenges and barriers in continuation of school tooth brushing program Primary schools; Focus groups School staff and oral health aide School staff level
-Positive attitude, acceptability, and adaptability
Organisational level
-Local school staff and oral health aides infection control training,
-Classroom-based toothbrushing activities,
-Authoritative school staff,
-Strong local school leadership,
-Peer support
-Flexibility of program implementation timings
Children level
-Program acceptability and children acceptance of lunchtime tooth brushing
Organisational level
-Whole school toothbrushing activity
-In-cooperation of the program in school daily routine (initial concern)
Children level
-Older age children program acceptability issues,
-Resistance of early morning toothbrushing
-Mishandling of toothpaste
-One school did not consent for focus groups
-Teacher’s response influenced by program supportive environment
-Increased local community participation (community collaborative implementation approach)
Not given
Yusuf et al. (England) [31] Identifying barriers and enablers in fluoride varnish and toothbrushing programs implementation Primary School; semi-structured interviews Health champions (volunteers), general dental practitioners, and school staff Children level
-Children’s participation in toothbrushing activities (79.2%)
Schools level
-Adaptation of various parental consent approaches
-Improve parents program engagement with the assistance of health champions (program Somali community volunteers’)
-Program protocol development aimed at schools for facilitation of implementation
-Program implementation flexible timelines
-Adequate sharing of information among school staff
-Program information translation in Arabic and Somali languages for parents
-Acceptability of health-promoting schools and by volunteers (Health Champions) and the dental team
-Some schools struggle with the return of the consent forms from parents
-Program communication issues with schools were highlighted by school staff
-Inadequate transfer of information from head staff to the school staff
School staff
-Frustrated due to internal organizational factors, time, and space issues
-It was a pilot study and results cannot be generalised to a wider population Not specified
Glaser-Ammann et al. (Switzerland) [32] Parents knowledge and attitude towards school dental health programs Early childhood setting, questionnaire-based surveys Parents-children’s dyads Parents level
-72% of parents accepted the importance of school dental programs in preschools
-72% attended the prophylaxis programs
-One fourth (25%) of the parents reported the dental health instructor as the best teacher for children toothbrushing learning skills
-One fifth (20%) believe school dental instructor is also the right person to teach a healthy diet
-Parents of children who were caries-free were more intended to participate in school dental programs (p = 0.11)
-The statistically non-significant association was observed between parents' attendance in school dental health program and their educational level (p = 0.11), country of origin (p = 0.07), and their income (p = 0.07)
Children level
-60% believes that their child has benefitted from the program and now brush their teeth better
-Just 36% reported that their child consumed healthy mid-morning snacks after the school dental health programs
Parents level
-Parents assumed that the kindergarten teacher’s role in teaching toothbrushing skills is not important
-Study design limits the study statistical analysis to be considered explorative, and regression analysis and Bonferroni corrections were performed Not given
Woodall et al. (UK) [33] Toothbrushing intervention effectiveness and process issues related to its coordination and delivery Early childhood setting; case studies, interviews, surveys Parents, children, school staff, oral health promotors School staff level
-Acceptability of the program
-Role of teaching support workers as the main contact point of program co-ordination with oral health promoters,
-Linking toothbrushing intervention with school educational curriculum,
-Training of school staff,
-Provision of adequate information to parents along with children's weekly oral hygiene updates
Parental level
-Program acceptability and participation
Children level
-Engagement and acceptability of program,
-Ripple effect
School staff level
-Increased workload,
-School committed staff frequent turnover,
-Role of teacher’s as pseudo-parent
Parents factor
-Lack of engagement and participation,
-Lack of awareness,
Toothbrushes storage and hygiene issues (initial concern)
-Participants sample size issue in each of the data gathering approach
-Survey didn’t include all schools
-Sample size of case studies was not representative of the school population
-Limited number of students participated in drawing activities due to lack of parental consent
Not given
Natapav et al. (Israel) [34] Factors associated with continuation of supervised toothbrushing program Early childhood setting; telephonic surveys School Teachers School staff level
-Teachers’ positive attitudes (70%)
-Program acceptability (96%)
--Willingness to teach toothbrushing skills (85%) and enjoying teaching toothbrushing skills (20%)
-Correlation between Teachers' willingness for the continuation of the program with their belief in program success (r = 0.73), acceptance of their role of teaching toothbrushing skills to children (r = 0.53), and enjoying teaching toothbrushing (r = 0.59)
-Statistically significant (p ≤ 0.05) association between teachers’ positive attitude towards the program sustainability and conduction of toothbrushing activities daily or several times a week
Children level
-84% of teachers reported that children like to learn toothbrushing skills
School staff level
-Teachers anticipated more barriers were associated with their unwillingness for the program continuation (r =  − 0.34)
-Thirty percent  of teachers think its parent's role to train children in toothbrushing skills
-Statistically significant (p ≤ 0.05) association was observed in teachers’ anticipated barriers of program sustainability and frequency of conduction of toothbrushing activities once a week or less
Not reported Ministry of Health (MOH)
Nyandindi et al. (Tanzania) [35] Assessment of teachers'-led factors in the oral health educational programs activities Primary schools, surveys and interviews, teachers’ oral examination and practical exercises Teachers Teacher’s level
-85% of teachers acknowledge the importance of health sessions in enhancing their personal hygiene
Teacher’s factors
-Teachers ranked health lessons in schools moderately important after reading, writing, and mathematics subjects
-Twenty-four percent  of teachers had taught about diet in the class, without mentioning the association between tooth decay and diet
-Most of the teachers prefer to teach toothbrushing theoretically and perceive it a parent’s responsibility to teach their kids toothbrushing skills
-Teachers claimed that the association between diet and tooth decay is not part of the health lesson curriculum of grade one class
-Teachers complained of insufficient material and time to teach health lessons in the overly packed class of children (mean [SD]: 65 +/− 27 students)
-Eleven percent of teachers perceived the need for further training in oral health education
-Only 26% of teachers had skills of making wooden toothbrush
Organisational level
-School administration rarely inquired about the health lessons conducted in schools
Not given Not given