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Introduction

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Introduction

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AARAB Maryem
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© © All Rights Reserved
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Table of contents

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.

1.1. Problem statement


The worsening economic, social, and health conditions in Syria since the crisis began in
2011, coupled with a lack of health education on the importance of oral and dental care, have
intensified the problem and its consequences. In conflict zones and unstable regions like
Northwest Syria, oral hygiene is often deprioritized among affected communities due to the
pressing urgency of other survival needs.
The conflict in Syria has led to the displacement of millions both within the country and
beyond its borders, over 14 million Syrians have been displaced. 7.2 million internally
displaced persons (IDPs) and 5.5 million refugees registered in five countries neighboring
Syria—Türkiye, Lebanon, Jordan, Iraq and Egypt, while there are nearly a million refugees in
Germany (13).
Syria is presently divided into multiple spheres of influence controlled by mutually hostile
forces, as shown in the Figure 1 below. Northwestern Syria is an area outside the control of
the Syrian regime since 2012, under the control of opposition forces, and is currently divided
into two regions: the Euphrates Shield and Olive Branch operations area, an area under the
control of the Turkish-backed National Army, and the second area is the rest of Idlib
Governorate under the control of Hayat Tahrir al-Sham.
In Northwest Syria, 5.1 million people reside, including 3.5 million who have been forcibly
displaced. Among them, 2 million live in camps, and there are 1 million children who are not
attending school. (14). The destruction of significant portions of healthcare and other
infrastructure during the conflict has further deteriorated living conditions for the population,
especially for those who have been displaced.
Figure 1 Military control across Syria – end of 2022

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).

Health Situation in Northwest Syria


Since the start of the Syrian crisis ten years ago, the number of Syrians in need of
humanitarian aid has grown to 13.4 million. The crisis in northern Syria has been exacerbated
by hundreds of airstrikes and other attacks on health facilities, primarily carried out by the
Syrian government and its ally Russia, massive population displacement, severe economic
decline throughout the country, and the devastating effects of COVID-19 outbreaks. The
closure of the al-Yarubiya and Bab al-Salam border crossings in January and July 2020,
respectively, was caused by Russia and China's vetoes of draft resolutions to renew cross-
border operations. The Bab al-Hawa border crossing on the Syria-Turkey border is now the
sole way for UN humanitarian aid to reach people in northern Syria. (17)

Oral health in Syria:


Despite the presence of a good number of dentists in Syria, the lack of health awareness of
oral and dental health, in addition to the high costs of treatment compared to the income of a
large segment of the people and the lack of a free public alternative except on a very limited
scale, leads to a low level of health care in this field. The prevalence of untreated permanent
tooth decay among people aged 5 years or older reached 36.9 (%), prevalence of severe
periodontal disease in people 15+ years was 14.2 and prevalence of edentulism in people 20+
years was 10.4 %. (18)

Justification of the study


Oral health is an integral component of overall health and well-being, influencing the quality
of life from childhood through adulthood. While primary care has received attention by non-
government organizations in conflict zones like Northwest Syria, oral health have not
benefited equally from healthcare and public health education programs. This study is
justified by the urgent need to address oral health problems in vulnerable populations,
particularly children living in Northwest Syria. The combination of displacement, socio-
economic challenges, and a lack of access to healthcare exacerbates the prevalence of oral
diseases among children in these regions, with serious long-term consequences for their
physical and psychological development.
In conflict areas such as northwest Syria, children face additional challenges in maintaining
their oral health. These challenges include interrupted access to education and healthcare
services, poor hygiene conditions due to displacement, malnutrition, and poverty, all of which
can worsen oral health outcomes.

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

Oral health is a vital component of overall well-being, significantly influencing quality of


life, especially for children. Good oral health practices contribute to essential functions such
as speaking, eating, and social interaction, laying the foundation for better health outcomes
throughout life (Petersen, 2003). However, children are particularly vulnerable to oral health
issues due to factors such as inadequate health education, limited access to dental care, and
socio-economic challenges (Watt & Sheiham, 2012). In conflict-affected regions like Syria,
these challenges are further amplified. The city of AlBab, situated in northwest Syria, has
been deeply impacted by years of conflict, leading to the disruption of healthcare services and
educational systems (OCHA, 2021). This chapter outlines the general background on the oral
health landscape in Syria, focusing on systemic challenges and highlighting the specific
context of AlBab, where conflict has exacerbated existing barriers to maintaining proper oral
health among school-aged children.

**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.

- OCHA (2021). Humanitarian Needs Overview: Syrian Arab Republic.

2.2. Oral Health System in Syria


The oral healthcare system in Syria has experienced significant changes over the past
decades, particularly with the onset of the conflict in 2011. Before the crisis, oral health
services were available through both public and private sectors, with the government
providing subsidized dental care services in state-run clinics and hospitals (Kronfol, 2012).
However, the private sector dominated in terms of quality and accessibility, especially in
urban centers. Public dental care, though more affordable, was limited in scope and often
suffered from resource shortages and outdated facilities (WHO, 2010).

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.

2.2.1. Historical Development of Oral Health Policies

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).

2.2.2. Public vs. Private Dental Care Services

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).

2.2.3. Challenges in the Current Oral Healthcare Structure


The ongoing conflict has brought unprecedented challenges to Syria’s oral healthcare system.
The destruction of facilities, shortage of trained professionals due to displacement, and
economic hardship have severely limited access to care (UNHCR, 2020). Additionally, areas
outside government control, such as parts of northwest Syria, have faced difficulties in
maintaining regulatory standards and ensuring consistent delivery of dental services (OCHA,
2021). The lack of a coordinated approach has led to significant regional disparities in oral
health service availability, with rural and conflict-affected regions suffering the most.

**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.
.

2.3. Oral Health in Northwest 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.

2.3.1. Governance and Regulation of Oral Healthcare Services

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.

2.3.2. Availability and Distribution of Dental Care Facilities

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.

2.3.3. Oral Health Personnel: Training and Workforce Distribution

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

A thorough review of existing literature is essential to establish a foundation for


understanding the state of oral health among school-aged children in conflict-affected
regions, particularly in AlBab city. This section will analyze global and regional studies,
focusing on knowledge and practices, the impact of socioeconomic and cultural factors, and
successful educational programs aimed at promoting oral health.

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.

2.4.2. Challenges in Delivering Oral Healthcare in Conflict-Affected Areas

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).

2.4.3. Socioeconomic Factors Affecting Oral Health Among School Children

Socioeconomic status is a well-established determinant of health behaviors and outcomes,


including oral health (Watt & Sheiham, 2012). Children from low-income families are less
likely to receive regular dental care and are more prone to oral diseases due to limited access
to preventive measures (Petersen, 2005). In Syria, the economic impact of prolonged conflict
has exacerbated poverty levels, affecting children's ability to maintain proper oral hygiene
(OCHA, 2021). Additionally, studies indicate that parental education plays a critical role;
children whose parents have higher levels of education are generally more knowledgeable
about dental care and exhibit healthier oral practices (Bourgeois et al., 2009).

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

3.1. Study Design


This study utilized a cross-sectional design

3.2. Study Location


The study was conducted in AlBab city, located in northwest Syria. The geographic spread of
the schools included in the study covered the entire city, ensuring a representative sample.

3.3. Study Population


The target population consisted of students enrolled in the seventh and eighth grades, ranging
in age from 12 to 14 years, and included both male and female participants. This age group
was selected as it represents a critical period for developing health-related behaviors and
knowledge.

3.4. Sample Size Determination


A total of 367 students participated in the study.

3.5. Sampling Techniques


A random sampling technique was employed to select schools within AlBab city. Both public
and private schools were included to ensure variability in socio-economic backgrounds and
educational settings. This approach aimed to mitigate selection bias and enhance the
generalizability of the findings.

3.6. Inclusion and Exclusion Criteria


3.6.1. Inclusion Criteria
- Students aged 12-14 years.
- Enrollment in the seventh or eighth grade.
- Currently attending school in AlBab city.

3.6.2. Exclusion Criteria


- Students not meeting the age or grade criteria.
- Students not enrolled in school at the time of the study.
- Students with conditions that hinder their participation in oral health assessments.

3.7. The Questionnaire and Pre-Testing


The questionnaire used in this study was developed based on validated instruments from
previous research, specifically:
- Al-Darwish (2016) on oral health knowledge in Qatar.
- Bansal et al. (2016) on oral health attitudes in Chandigarh, India.
- Al-Omiri et al. (2006) on oral health behavior in North Jordan.

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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