The World Health Organisation (WHO) advocates using Health Promoting Schools/Healthy Schools (terms used interchangeably in this paper) to promote general and oral health [1
]. Healthy Schools are established worldwide as mechanisms for improving the health of school communities by supporting the health education curriculum through the school ethos and environment [3
WHO guidance on Health Promoting Schools has been translated into policy in many countries. In England, the National Healthy Schools Programme (NHSP) provides strategic leadership to local Healthy School programmes (LHSPs) by endorsing a whole-school approach focused on common risk factors (CRFs); risk factors such as diet, tobacco and exercise, which are shared by the major non-communicable diseases [5
]. Current thinking supports the promotion of oral health through this approach since some of the main aetiological factors of oral diseases such as dental caries (high frequency and amount of sugar intake) are well-recognised as also being implicated in other conditions such as diabetes [6
]. Risk factors for oral cancer are common to other types of cancer, and accident prevention programmes can prevent trauma to teeth and oral tissues.
The NHSP requires schools to achieve 'Healthy School' status by addressing the CRFs through focusing on four strands [7
• Personal, Social & Health Education (including drugs, tobacco, alcohol and sex and relationships education)
• Healthy Eating
• Physical Activity
• Emotional Health & Wellbeing
Oral health is not discussed within the NHSP, although the English oral health strategy suggests that oral health should be promoted using the CRF approach within settings such as Healthy Schools [8
]. LHSPs may not identify oral health as an important issue. Whether oral health is being promoted by the English NHSP has not been studied, although a small number of studies have been carried out in other national contexts.
A recent study in Scotland reported an association between Healthy School status and twice-daily toothbrushing for some children attending Healthy Schools in deprived areas [9
]. The authors analysed data from the Health Behaviour in School-Aged Children Questionnaire using multilevel logistic regression. Schools were classified into two categories: having/working towards a Health Promoting School award or not having/not working towards a Health Promoting School award. No attempt was made to determine which schools-based activities may have influenced this difference in behaviour.
A study in Brazil has also reported oral health benefits for children attending schools engaging with the Health Promoting Schools philosophy [10
]. Schools were categorised as being either supportive or non-supportive in terms of their engagement. Engagement was measured according to schools' implementation of health promoting strategies. Children in supportive schools had better and more homogenous health outcomes in terms of caries levels and dental trauma. Since none of the schools in the study had a formal dental health education programme, the differences observed could be attributed to the effect of a CRF approach in promoting oral health.
Whilst these studies point towards Healthy Schools having a positive impact on oral health, nothing is known about how the Healthy Schools programme translates into interventions influencing oral health. Therefore the research questions being addressed were:
What are the areas of the Healthy Schools programme which might impact on oral health? To what extent are these areas pursued within Healthy Schools programmes in the North-West of England? What are the barriers and drivers to the incorporation of oral health promoting activities within Healthy Schools programmes?