Introduction
Introduction
1. Background......................................................................................................................................3
1.1. Problem statement..................................................................................................................5
Educational System..............................................................................................................................6
Health Situation in Northwest Syria....................................................................................................7
Oral health in Syria:.............................................................................................................................7
Justification of the study......................................................................................................................7
Objectives............................................................................................................................................8
Specific objectives...............................................................................................................................8
Hypothesis...........................................................................................................................................8
General information.................................................................................................................................9
2.1. Introduction...................................................................................................................................9
2.2. Oral Health System in Syria.........................................................................................................9
2.2.1. Historical Development of Oral Health Policies.................................................................10
2.2.2. Public vs. Private Dental Care Services...............................................................................10
2.2.3. Challenges in the Current Oral Healthcare Structure..........................................................10
2.3. Oral Health in Northwest Syria...................................................................................................11
2.3.1. Governance and Regulation of Oral Healthcare Services...................................................11
2.3.2. Availability and Distribution of Dental Care Facilities.......................................................12
2.3.3. Oral Health Personnel: Training and Workforce Distribution.............................................12
2.4. Literature Review.......................................................................................................................13
2.4.1. Oral Health Knowledge and Practices among School Children: A Global Perspective......13
2.4.2. Challenges in Delivering Oral Healthcare in Conflict-Affected Areas...............................13
2.4.3. Socioeconomic Factors Affecting Oral Health Among School Children............................13
2.4.4. Oral Health Education and Promotion Programs for School-Aged Children......................14
3. MATERIAL AND METHOD............................................................................................................15
3.1. Study Design...............................................................................................................................15
3.2. Study Location............................................................................................................................15
3.3. Study Population.........................................................................................................................15
3.4. Sample Size Determination........................................................................................................15
3.5. Sampling Techniques..................................................................................................................15
3.6. Inclusion and Exclusion Criteria.................................................................................................16
3.6.1. Inclusion Criteria.................................................................................................................16
3.6.2. Exclusion Criteria................................................................................................................16
3.7. The Questionnaire and Pre-Testing.............................................................................................16
1. Background
Oral health refers to the ability to maintain a clean and disease-free mouth and teeth, which
enhances daily functions such as eating, speaking, and smiling. Oral care includes several
basic elements, including brushing twice daily with a fluoride toothpaste, flossing to remove
food debris between the teeth, and avoiding foods high in sugar. In addition, attention to oral
health is closely linked to overall health, as oral diseases can affect the body in several ways.
For example, gum disease is associated with an increased risk of cardiovascular disease,
while excess sugar leads to tooth decay and an increased risk of diabetes (1)
Several studies have shown that the level of public knowledge about oral health varies based
on several factors. A study by "Bagramian et al." (2009) found that awareness of the
importance of oral care depends largely on the level of education, access to health care
information, and the effectiveness of public health campaigns. In this study, people who
received education about dental care methods, such as using fluoride and limiting sugar
intake, were more likely to adopt effective oral health practices (2)
Individuals' knowledge about oral health is influenced by several factors, including education
level, access to information about oral care, effectiveness of public health campaigns, and
cultural and social beliefs that shape individuals' perceptions of oral health. Individuals with a
higher level of education are often more aware of proper oral health practices, due to greater
exposure to health information in schools and through the media. A study by "Bourgeois et
al." showed that knowledge about oral health increases significantly with higher education
levels, as more educated individuals were more able to follow healthy habits such as regular
tooth brushing and visiting the dentist (3). In addition, public health campaigns affect the
level of oral health awareness. A study by "Petersen" (2005) indicated that health campaigns
focusing on the prevention of oral diseases, such as reducing sugar consumption and
increasing the use of fluoride, have significantly affected individuals' behaviors in several
countries, as tooth brushing practices improved and the rate of caries decreased among
individuals exposed to these campaigns (4). Cultural customs and beliefs also play a role in
shaping individuals' attitudes toward oral health; for example, in some societies, oral care is
considered secondary to general health care, leading to a low level of knowledge and interest
in oral and dental health (5).
Oral health behaviors include the practical aspects of dental and oral care, such as the
frequency of brushing, flossing, mouthwash, and regular visits to the dentist. Adherence to
these behaviors is an indicator of how much an individual cares about their oral health.
Studies have shown that these practices can be assessed by observing self-reported habits or
through clinical examinations. In a study by "Maes et al.", questionnaires were used to assess
oral health behaviors in adolescents, where the results indicated that 65% of participants
brushed their teeth twice daily, while the percentage of flossing was much lower (6).
Several factors influence individuals' behaviors regarding oral care. The most prominent of
these factors are: socioeconomic status, where a study by "Watt & Sheiham" (1999) showed
that individuals with low income and low educational levels are less likely to practice good
oral health behaviors due to lack of access to health care and dental care products (7). The
availability of dental care products, such as fluoride toothpaste and mouthwash, also plays a
crucial role in promoting oral health behaviors. In a study by Sakki et al. (1998), individuals
with better access to oral care products were more likely to brush their teeth regularly and
visit the dentist regularly (8).
Individuals’ knowledge and behaviors related to oral health are influenced by a range of
socioeconomic, cultural, and access to health care factors. Income, education, and
employment status are among the most prominent of these factors, with low income and low
education levels being associated with lower awareness of the importance of oral care and
difficulty accessing dental services. In a study conducted by Petersen (2005), it was found
that low-income and low-education groups are more vulnerable to oral diseases due to lack of
awareness and inability to afford preventive care (4).
Cultural customs and traditions also play a role in shaping oral health practices. Beliefs about
the value and importance of oral health vary from culture to culture, affecting the extent to
which individuals adopt preventive habits such as regular tooth brushing or visiting a dentist.
In a study conducted by Nash & Nagel (2005), researchers demonstrated how cultural
differences directly affect individuals’ perceptions of oral health and behaviors used to
maintain it (9).
Access to dental services is also a critical factor in the adoption of preventive behaviors such
as regular checkups. Difficulty accessing dental services due to lack of insurance coverage or
lack of nearby clinics leads to postponement of preventive care and exacerbation of oral
problems. According to Buchanan, individuals who lack insurance coverage were less likely
to visit a dentist regularly (10). Public health interventions such as health campaigns, school
programs, and community services also play an important role in disseminating knowledge
and promoting positive oral health practices. Evidence shows that programs targeting schools
and poor communities help improve population knowledge and dental care behaviors, as
demonstrated by Watt (2007), who confirmed the effectiveness of school programs in
improving children’s oral health behaviors (11).
Oral health is a significant predictor of personal health, well-being, and quality of life. Poor
oral health has a big influence on your overall health and quality of life. It has an impact on
your ability to speak, eat, and smile, as well as your social interactions, work, and academic
achievement. It is also connected to a variety of disorders, including diabetes, cardiovascular
disease, some malignancies, and poor pregnancy outcomes.
Oral disorders are among the most common noncommunicable diseases in the world,
impacting around 3.5 billion people. While the global burden of oral health issues is
expanding, particularly in low- and middle-income nations, three out of every four people
afflicted lived in middle-income countries in 2019. (12).
Oral diseases disproportionately impact the most vulnerable and underprivileged groups.
People with low socioeconomic position have a higher burden of oral diseases, and this link
persists throughout the life course, from early childhood to old age, independent of the
country's overall income level.
Most oral conditions and disorders share modifiable risk factors with the most common
noncommunicable diseases. Tobacco usage, alcohol intake, and poor diets high in free sugars
are all risk factors that are on the rise worldwide. There is a documented link between oral
and overall health. Diabetes, for example, has been associated to the development and
progression of periodontal disease. Furthermore, increased sugar consumption has been
linked to diabetes, obesity, and tooth cavities.
When oral health is compromised due to disease or injury, it negatively impacts overall
health. The pain and discomfort from oral diseases can hinder concentration, cause
individuals to miss school or work, and may even result in social isolation. These conditions
have a significant social and economic impact on both individuals and families, increasing
household expenses and significantly reducing quality of life and overall well-being (1).
Although largely preventable, oral diseases continue to impose a heavy health burden. They
are driven by a variety of modifiable or preventable risk factors such as high sugar intake,
tobacco and alcohol use, poor hygiene, and the broader social and commercial influences
behind these behaviors.
Educational System
The Syrian education system has been severely affected, leading to a shortage of qualified
teachers. From the beginning of the crisis in 2011 until 2015 alone, the syrian education
sector had lost 22% of teaching workforce. (15) At least 2.4 million children remain out of
school in 2021(number estimated to be higher) (16)
The COVID pandemic had an additional impact on schools, with attendance largely disrupted
for two school years in northwest Syria. In the absence of an organized structure for distance
learning, the disruption to attendance resulted in a real loss and a gap in education that was
not otherwise compensated for during that period.
Al-Bab city in northwestern Syria is one of the cities that has been greatly affected by the
conflict. Many schools have been destroyed and others have gone out of service for other
reasons. It also suffers from a severe shortage of qualified teachers. The city's population is
100,000 people, of whom 56% are forcibly displaced (May 2022) (OCHA).
Objectives
Assess oral health knowledge, behavior, identify factors affect the oral health knowledge and
behavior.
Specific objectives
Measuring students' knowledge of the importance of teeth
Measuring students' knowledge of fluoride
Measuring students' knowledge of signs of dental caries and oral and gum diseases
Measuring students' knowledge of habits necessary to maintain oral health
Measuring students' behavior towards oral and dental health
Identifying students' personal evaluation and satisfaction with the function of their
teeth
The impact of knowledge on oral health
The relationship between parental learning and students' knowledge and behavior
Hypothesis
H1. There is a significant lack of information among school students.
H2. Poor oral health behavior is a major problem among students in Al-Bab city.
H3. There is difference in oral health knowledge and behavior between resident and
internal displaced population.
H4. Oral health knowledge and behavior differ due to the educational level of parents.
H5. There is a difference in oral health knowledge between private and public schools’
children.
H6. There is difference in oral health behavior between private and public schools’
children.
General information
2.1. Introduction
**References**:
- Petersen, P. E. (2003). The World Oral Health Report 2003: Continuous improvement of
oral health in the 21st century–the approach of the WHO Global Oral Health Programme.
*Community Dentistry and Oral Epidemiology*, 31(s1), 3-24.
- Watt, R. G., & Sheiham, A. (2012). Integrating the common risk factor approach into a
social determinants framework. *Community Dentistry and Oral Epidemiology*, 40(4), 289-
296.
Since the start of the conflict, the situation has deteriorated sharply. The destruction of
healthcare infrastructure, the displacement of professionals, and the economic crisis have led
to a severe decline in the availability and quality of oral health services (OCHA, 2021). The
lack of cohesive policies and weakened governmental control in certain areas, particularly in
the northwest, has further exacerbated these challenges. This section aims to provide a
comprehensive overview of the current oral healthcare system in Syria, its division between
public and private sectors, and the impacts of ongoing conflict on service delivery and access.
The historical development of oral health policies in Syria reflects broader trends in the
public health sector. Prior to the conflict, efforts were made to improve oral health awareness
through school programs and public health campaigns (Petersen, 2005). However, these
initiatives were often limited in scope and did not reach rural or marginalized communities
effectively. Post-conflict, the focus on oral health policies has largely diminished, with
resources being redirected towards more immediate healthcare needs (UNICEF, 2019).
The division between public and private dental care services in Syria is stark. Public services,
though subsidized, have historically struggled with funding and resource allocation, leading
to long waiting times and limited treatment options (WHO, 2010). The private sector, in
contrast, offers higher quality services but is financially inaccessible for many, especially in
the current economic climate (Kronfol, 2012). The disparity between these sectors has
widened due to the conflict, as many private practices have shut down or moved to safer
areas, leaving public services to bear the brunt of increasing demand with fewer resources
(OCHA, 2021).
**References**:
- Kronfol, N. M. (2012). Historical development of health systems in the Arab region.
*Eastern Mediterranean Health Journal*, 18(11), 1157-1165.
- WHO (2010). Syrian Arab Republic: Health system profile.
- Petersen, P. E. (2005). The World Oral Health Report 2005: Continuous improvement of
oral health in the 21st century. *Community Dentistry and Oral Epidemiology*, 33(2), 118-
126.
- UNICEF (2019). Syrian crisis: Humanitarian impact and response.
- OCHA (2021). Humanitarian Needs Overview: Syrian Arab Republic.
- UNHCR (2020). Health and protection needs of displaced populations in Syria.
.
The situation of oral health in northwest Syria is a direct reflection of the region's complex
socio-political environment. This area, heavily impacted by years of conflict, has witnessed
significant challenges in maintaining basic healthcare infrastructure, including oral health
services. AlBab city, along with other regions in northwest Syria, has faced large-scale
displacement, a weakened healthcare system, and limited resources, exacerbating the already
fragile state of public health (OCHA, 2021). This section explores the current status of oral
health in northwest Syria, emphasizing governance, availability of facilities, and the
distribution and training of healthcare personnel.
In northwest Syria, governance and regulation of healthcare services, including oral health,
have been influenced by a mix of local councils, non-governmental organizations (NGOs),
and international humanitarian efforts (UNHCR, 2020). The lack of unified governance has
led to inconsistencies in service delivery and regulation. For example, areas under the control
of opposition forces often rely on NGOs and local initiatives to maintain basic health
services, including dental care (Save the Children, 2019). These efforts, while valuable, can
be fragmented and subject to funding limitations, leading to disparities in service quality and
availability.
Access to dental care facilities in northwest Syria is marked by significant geographical and
socio-economic disparities. Urban centers like AlBab may have more facilities, albeit still
limited, compared to rural areas where access is scarce or non-existent (OCHA, 2021). The
destruction of infrastructure and the displacement of healthcare professionals have led to a
severe reduction in available services. This has forced many residents, especially those in
rural or conflict-affected areas, to rely on makeshift clinics or travel long distances to seek
care (WHO, 2022). The uneven distribution of facilities remains a major barrier to achieving
equitable oral health care.
The shortage of qualified dental health professionals in northwest Syria is another critical
challenge. The displacement of trained personnel due to conflict has left the region with a
diminished workforce (UNICEF, 2021). Training programs for dentists and dental assistants
have also been disrupted, limiting the ability to maintain an adequately skilled workforce
(WHO, 2020). This shortage has contributed to longer waiting times for treatment and
reduced access to comprehensive care, particularly for vulnerable populations such as
children (Save the Children, 2019). The uneven distribution of the existing workforce further
compounds these challenges, with urban areas being better served than rural regions.
**References**:
- OCHA (2021). Humanitarian Needs Overview: Syrian Arab Republic.
- UNHCR (2020). Health and protection needs of displaced populations in Syria.
- Save the Children (2019). Impact of the Syrian conflict on health services.
- WHO (2020). Challenges in healthcare workforce training in conflict zones.
- WHO (2022). Syrian Arab Republic: Health system overview.
- UNICEF (2021). Effects of conflict on child health and access to care.
2.4. Literature Review
2.4.1. Oral Health Knowledge and Practices among School Children: A Global
Perspective
Research has consistently shown that children's knowledge and practices related to oral health
are influenced by a variety of factors, including education, cultural beliefs, and access to
resources (Petersen, 2003). Studies from different parts of the world indicate that school-
based education significantly improves oral health awareness and practices among children
(Marthaler, 2004). For example, research conducted in Europe demonstrated that children
who participated in oral health programs had better knowledge and engaged in more frequent
brushing and dental visits compared to those who did not (Sheiham & Watt, 2000). These
findings provide valuable insights for assessing the situation in Syria, where educational
disruptions and limited access to care may hinder similar positive outcomes.
Delivering oral healthcare in conflict zones presents unique challenges. Studies highlight that
conflict leads to the destruction of healthcare infrastructure, displacement of medical
personnel, and restricted access to essential services (Spiegel & Harroff-Tavel, 2010). In
contexts such as Syria, these challenges are further intensified by economic hardships and
security concerns, which limit the reach of aid organizations and the implementation of
preventive oral health programs (UNICEF, 2019). Research in similar conflict-affected
regions has shown that oral health often becomes a secondary priority compared to more
immediate healthcare needs, impacting the quality of life and overall health of affected
populations (Robinson & Hill, 2012).
2.4.4. Oral Health Education and Promotion Programs for School-Aged Children
Effective oral health education programs have been implemented in various countries to
improve children's dental care practices. For instance, school-based interventions that include
interactive lessons and practical demonstrations have proven successful in enhancing
students' knowledge and encouraging positive habits (Marthaler, 2004). These programs often
involve partnerships between schools, health departments, and community organizations to
ensure sustainability and reach. Adapting similar models to the context of AlBab could
potentially mitigate the challenges faced by school children in maintaining oral health amidst
difficult circumstances. The success of programs in regions with limited resources, such as
parts of Africa and South Asia, suggests that with proper adaptation and local involvement,
such strategies could be effective in northwest Syria (Petersen, 2003).
**References**:
- Petersen, P. E. (2003). The World Oral Health Report 2003: Continuous improvement of
oral health in the 21st century. *Community Dentistry and Oral Epidemiology*, 31(s1), 3-24.
- Marthaler, T. M. (2004). Changes in dental caries 1953–2003. *Caries Research*, 38(3),
173-181.
- Sheiham, A., & Watt, R. G. (2000). The common risk factor approach: a rational basis for
promoting oral health. *Community Dentistry and Oral Epidemiology*, 28(6), 399-406.
- Spiegel, P. B., & Harroff-Tavel, M. (2010). Health-care needs of people affected by conflict.
*The Lancet*, 375(9711), 372-380.
- UNICEF (2019). Syrian crisis: Humanitarian impact and response.
- Robinson, C., & Hill, C. (2012). Oral health in complex emergencies: Policy and practice.
*Oral Health and Dental Management*, 11(3), 107-114.
- Watt, R. G., & Sheiham, A. (2012). Integrating the common risk factor approach into a
social determinants framework. *Community Dentistry and Oral Epidemiology*, 40(4), 289-
296.
- OCHA (2021). Humanitarian Needs Overview: Syrian Arab Republic.
- Bourgeois, D. M., & Llodra, J. C. (2009). European Global Oral Health Indicators
Development Project. *Caries Research*, 43(5), 361-368.
3. MATERIAL AND METHOD
The questionnaire was pre-tested to ensure clarity, relevance, and comprehensiveness. Pre-
testing involved a pilot group from the study population to identify potential ambiguities and
make necessary adjustments before full implementation.
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