Introducction

Since 1970, the World Health Organization has developed strategies for health for all, whose main key is primary care, based on the promotion of a healthier lifestyle, with the joint participation of health and education professionals with the community. Today, comprehensive strategies are proposed, through programmes aimed at transforming conditions and lifestyles and the global environment, to facilitate healthy choices, which are key guidelines in the development of health promotion¹.

Accordingly, the National Centre for Health Promotion and Education in Cuba has drawn up a set of strategies aimed at achieving a greater impact on the health of the population. Specifically in the area of oral health, health promotion activities took on significant importance in 1992 when the National Programme for Comprehensive Dental Care began to be implemented in the population².

For the development of these programs and strategies, health professionals must learn to promote and lead individuals, families and communities towards changes in attitude that will provide healthy states³. Despite this, health promotion is carried out in an empirical manner, since university training in this area of knowledge is not developed specifically, but is implicit in the curricula of careers in the Medical Sciences, such as Medicine and Dentistry, among others.

Among the subjects that respond to the integrative discipline is Health Promotion in the first year of the career. Despite its existence, the student training process has not always achieved the necessary preparation to develop health promotion activities, especially to integrate them with the rest of the activities, which include comprehensive dental care. For different reasons, the knowledge and skills provided by the different disciplines and subjects are not systematized and interconnected for the development of health promotion, which does not favor the fulfillment of the objectives that the professional model proposes and brings with it a weak preparation of the graduates to develop this activity.

In all the units of the National Health System, professionals carry out health education activities; however, these are not always executed with the necessary quality to guarantee the modification of the population's attitudes and behaviors¹

All of the above expresses the contradiction that is established between the demands of society, the aspirations set forth in the normative documents of the higher education system as the starting point of the Cuban health system. From the political definitions of the health system and the pedagogical definitions formulated in the professional model, the need to emphasize the training of the dental student for the performance in the promotion of oral health of individuals, families and the community is evident. Therefore, the objective of this research is to determine the state of the educational policy of Health Promotion in the current curriculum of the Dentistry career.

Method

A literature review was conducted on the analysis of subjects in health promotion programmes in the medical sciences. The search was oriented towards research and published articles related to the topic. Thus, the study was limited to 36 articles. The databases of reference systems were consulted: SCOPUS, MEDLINE, PubMed and SciELO. The topics consulted in the revision were referred to studies of the previous and current Study Plan, an analysis of the teaching organization, the modes of action, instructional objectives and integrators per year.

The Study Plan for the Dentistry Career is designed based on the general guidelines for the curriculum, oriented by the Ministry of Higher Education, and is organized in a basic curriculum that contains the essential elements that guarantee the training of the professional in all its fields of action and in its own curriculum, which complements this training based on the characteristics of the higher education centers where the career is taught, the interests where these are located and the experience of its faculty.

It also contemplates a larger space for the basic curriculum due to the characteristics of the profession, where education in the workplace represents a high percentage, whose fundamental purpose is to form a stoma care professional who solves the problems and situations inherent to his or her professional profile, through the analysis and interpretation of reality, as an instrument for understanding the dynamics of stoma care problems⁴.

By analyzing the teaching organization, the course is organized in five academic years, in which the subjects respond to the year's integrating objectives, of growing complexity and which allow a greater degree of independence of the students in their training. The first four years of the course are structured in two semesters of 18 teaching weeks each and 4 weeks of exams, the fifth year is structured in two periods of 20 weeks each.

This allows the graduate to carry out actions, such as health promotion, which includes health education of the population and disease prevention with the timely detection of risks to carry out or indicate individual and collective prevention, among others.

Within the modes of action defined in Plan D, is to provide comprehensive dental care to individual and collective health. This describes among the functions of the graduate as a professional, identifying risk factors according to the health determinants that affect the basic mechanisms of oral diseases and uses as a permanent method of work, the Analysis of the Health Situation, as well as exercising health promotion and disease prevention actions through the use of work techniques and procedures⁴.

Results and discussion

As can be seen, this comprehensive care includes health promotion and disease prevention, which requires a professional with diagnostic, therapeutic, communication, training, administrative and research and innovation skills, capable of carrying out promotion, prevention, cure and rehabilitation actions in the individual, the family, the community and the environment; with the use of clinical, epidemiological and social methods; bearers of ethical, humanistic and revolutionary values; called upon to transform the oral health situation of the population, in accordance with the mandate of Cuban society today⁵.

Among the integrating objectives per year that make reference to the subject of health promotion, it is established for the first year of the career:

· To explain the importance of health conservation and care for healthy men.

· To apply the methods and techniques of health promotion and education.

· To carry out educational activities in the family, the community and the dental clinic, according to the characteristics of the beneficiary population, in accordance with their needs and interests in terms of oral health.

However, no related objectives appear for the second year, despite reference to hygiene standards for disease prevention in the dental office for both the dentist and the patient.

The third year of the course is planned:

· To carry out actions to promote, prevent and treat the different stomatological diseases that require surgical, endodontic and exodontic treatment.

In the fourth and five years:

As can be seen in most academic years, there are objectives related to the development of health promotion to be achieved through the subjects taught in those years. For the development of these subjects and the fulfillment of these objectives the career is organized through an integrative discipline.

The integrative discipline "Integrated Stomatology" is the guiding axis within the study plan of the stoma careers, promoting the interrelationship of knowledge from an interdisciplinary perspective, on a horizontal and vertical plane, that is, within the year or between years, that is, it seeks to achieve basic-clinical and basic-clinical-community integration, in different areas of knowledge to address the health-disease process from an integrated perspective^5,6.

This discipline is developed from the first year and concludes in the fifth year with pre-professional practice, being present throughout the training process through 20 subjects which are taught in different semesters, also supported by the contributions of the remaining disciplines and subjects of the career, and assumes them in their integration, thus achieving a multidisciplinary and interdisciplinary character, essential to address the health-sickness process from an integrated perspective to respond to the demands of professional work, ensuring mastery of the modes of action of the graduate⁶.

In the analysis made of the programs of the subjects that contribute to the integrative discipline, out of 20 subjects only 5 are declared to have health promotion content:

Health promotion in the first year: The student declares that his/her skills characterize the role of health promotion and its importance in health care. Develop educational materials. Prepare different health education techniques, giving priority to affective-participatory techniques. Carry out educational activities in the clinic and community institutions⁷.

Periodontics in the 3rd year: establish within the skills to be fulfilled, the development of health promotion actions aimed at eliminating risk factors of periodontal diseases⁸.

Family care in the second and fourth years of the course: where the student will learn health education techniques⁹.

Orthodontics in the 4th year of the course and its general objectives are: to carry out health promotion actions and prevent dento-maxillofacial anomalies in the population under 19 years of age¹⁰.

Integral attention to the population in the 5th year of the career: it proposes to develop health promotion activities in the community¹¹.

It is evident that the health promotion actions declared in the programs of the subjects are insufficient; in some cases, they are reduced to health education and as the contents advance by years they become scarcer, in spite of being expressed in the integrative objectives by year. The fact that no objectives related to health promotion are set for the second year and no subjects appear in this year that deal with the subject within its contents is noteworthy.

A critical analysis of the subject of Health Promotion, located in the first year of the career, shows that its design proposes as a purpose that students acquire the health approach, from the mastery of the work methods of Health Promotion, with a scientific conception in the health care of the population, linking with the community, applying techniques of information collection, which allow them to identify their conditions, ways and lifestyles, to develop educational strategies, aimed at solving their oral health problems⁷.

In its instructive objective it proposes the use of methods and techniques of health promotion and education, carrying out educational activities in families, the community and in dental clinics, according to the characteristics of the population, their needs and interests in terms of oral health⁷.

Their knowledge system includes topics such as: health promotion concepts, background, principles, global health promotion strategies. Conditions and lifestyles, Health education and its methods⁷.

In order to develop these skills, the student should characterize the role of health promotion in dental care, explain the importance of health promotion in health care, prepare educational materials, messages, posters, spots, prepare different health education techniques, emphasizing affective-participatory techniques, and carry out educational activities in dental clinics and community institutions.

Despite this, the course does not declare activities aimed directly at the formation of skills such as communication, diagnosis, development of educational actions and strategies, among others necessary to perform in the area of health promotion. Among the organizational forms of teaching the subject, there are fewer practical classes and education at work with 24 hours for its development, which reduces to repeating in a few actions content and messages aimed at health promotion, and then conclude with a written assessment, an educational proposal, which is not implemented.

In addition to the subject of Health Promotion, other subjects appear in later years, which in their analysis show possibilities for the development of health promotion through them.

Some aspects are detailed below:

Subject: Clinical propaedeutics and oral semiology in the second year of the course

It establishes the link of oral health as part of the individual's integral health with 102 hours of education at work. As instructive objectives, it proposes the execution of the clinical stomatological examination, by means of the application of the methods and techniques used in individual stomatological care, as well as interpreting the signs and symptoms collected by means of the interrogation, which may have repercussions on oral health¹².

Within its system of knowledge and as a potential for health promotion work, it treats the main symptoms, signs and syndrome of the different respiratory and circulatory, digestive, genitourinary and hydromineral, endocrine, metabolic, haemolymphogetic and nervous systems and their link with oral health. For these topics the student should develop among his/her skills: identify and describe the alterations found in the physical examination, especially from head to neck and emphasize the ganglionic groups and chains because of their importance to the stomatologist, perform the physical examination of the oral cavity, differentiate the most important symptoms and signs from the large syndromes treated in the content¹².

Subject: Comprehensive Care of the Family I.

It is taught in the 3rd year of the course where the student begins to be linked to the integral attention of the individual and families as the fundamental nucleus of society, with 119 hours of education in the workplace. One of the educational objectives is to provide comprehensive dental care to the population in the dental clinic, taking into account the biological, psychological and social factors involved in the health-disease process, using the methods and modes of action of primary care in the exercise of its promotion and prevention functions, recovery and rehabilitation, in accordance with the objectives of the national programme of comprehensive dental care in the area of primary health care, the student must work on the knowledge related to the Programme of Care for the Under-19s, their psychological behaviour and prevention in paediatric dentistry¹³.

Among the skills to be developed, students must determine priority groups within the population under 19 years of age, their emotional reactions to dental treatment, as well as identify the etiological and risk factors of dental caries, dental trauma, periodontopathies and malocclusions.

Subject: Comprehensive Care of the Family II

It is taught in the 4th year of the course with 99 hours of education at work and the objective is to provide comprehensive dental care to the population, using the methods and modes of action of primary care, when exercising their functions of promotion, prevention, recovery and rehabilitation in accordance with the objectives of the National Comprehensive Dental Care Program⁹.

In its system of knowledge, and as strength, are the actions of promotion, prevention, recovery and rehabilitation as part of the comprehensive care of the individual and the family. Among the skills that the subject proposes are, performing health education techniques as a tool for health promotion, applying preventive techniques for the different dental diseases and directed to geriatric and/or disabled patients. In other words, it takes advantage of the potential of working with priority groups⁹.

Subject: Comprehensive Care of the Population.

It is taught in the 5th year of the degree with a number of hours of education at work in the clinic where it is used not only for curative work, but also for promotion in the individual of 1200 hours and it proposes a total of 240 hours for work in the community¹⁴.

Its objective is to provide comprehensive care to the population with a community outreach, using the methods and modes of action of primary care, in the exercise of its promotion, prevention, curative and rehabilitation functions in accordance with the objectives of the National Comprehensive Dental Care Programme to achieve a greater impact on the oral health of the population¹⁵.

This subject does not have a system of new knowledge; rather, through academic activities, previous knowledge received from previous subjects is deepened, enriched and updated. Therefore, it is an ideal space for the systematization of contents and proposes, in its system of abilities, to develop and execute educational activities, of prevention and promotion of health, as well as to diagnose pre-malignant and malignant lesions of the oral cavity and neighboring regions according to P.D.C.B¹¹⁶.

In spite of the certain flexibility that Plan D has as a characteristic, which speaks in favor of the teacher enriching the educational teaching process by implementing materials and means with a greater degree of creativity and information, through the use of teaching aids and organizational forms of teaching, according to the characteristics and conditions of the scenarios in which the students are trained, health promotion is not developed within the curriculum, as the demands of these times and the profile of the professional demand; It is not integrated into the content of other specialties and related subjects, and much less is the space it has within Plan D used in the first year of the career.

From this analysis, it can be stated that the objectives, knowledge and skills established in the subject of Health Promotion are very ambitious to be achieved in the space occupied by the subject within the study plan, giving the greatest weight to the student's training for the activity of health promotion in the first semester of the first year. Therefore, it is difficult to achieve the general objectives and the system of skills set out in the subject, since the student has not acquired all the knowledge that is indispensable and for which he or she needs the integration of other subjects received in later years.

Likewise, the objectives of these subjects do not establish how these skills should be integrated and consolidated, since they incorporate contents that are indispensable for this purpose and that allow the student to complete the theoretical and practical preparation that he or she receives in the first year.

For the practice of the knowledge system, the student must develop skills to carry out the meticulous and ordered examination of the buccal-maxillofacial complex to different patients or among the students themselves, following the oriented methodology; as well as to identify by their clinical characteristics the lesions and pre-malignant states, and the causal factors associated to their appearance with the purpose of orienting the population towards the prevention of the same and the promotion of the buccal health¹⁷.

As for the attitudes necessary for performance in this area, the programs establish value systems that focus on the formation of qualities and characteristics of the future professional rather than on the formation of attitudes that the latter must assume in order to perform in this area. This does not allow the student to acquire attitudes that will foster a positive environment towards a healthy culture in the staff to whom he or she is directed^18,19.

It should be emphasized that carrying out health promotion activities requires knowledge, skills, and attitudes that are contributed and allow for their systematization from other subjects, which is not sufficiently defined in the curriculum and does not materialize in practice.

Among the conditions that have not favored such integration are the absence of objectives by year, and the definition of minimum skills from the second year onwards in subjects with a curative focus.

In order to guarantee that health promotion becomes the fundamental activity of the Basic General Stomatologist, this professional must have a solid medical-social vision. In primary care, he or she must interact directly with promotional, preventive, curative and rehabilitative actions of individuals. He or she must perform certain professional tasks that, when systematized and integrated, allow for the training of the functions to be performed in the area of promotion, during his or her professional performance¹⁹.

The training of students in this aspect should be the basic training axis in the academic, research and labour fields, starting from the beginning to the last year of the career. It is proposed to perfect this process through a system of activities for the integrative discipline in the most suitable modality, which is participation in the solution of real professional tasks, through education at work. In this way, the continuity, systematization, and integration of the knowledge, skills, and attitudes necessary for the student, once graduated, to work in the area of health promotion is guaranteed.

Conclusions

When carrying out an exhaustive review and an in-depth analysis of the curricula of the Stomatology career and the training in the services themselves, it is valued that although the contents have been updated and reordered, it is necessary to analyze how the transformations carried out will guarantee the quality in the training of this professional. Therefore, emphasis should be placed on the promotion of oral health as part of the general health promotion strategy, based on the promotion of healthy lifestyles through work with the community of health professionals.

The study of the programs of the subjects that contribute to the integrative discipline of the career, allow from the context of education in the work, an ideal space for the link of the theory with the practice, the formation in the students of the career, in knowledge, abilities and attitudes for their performance in promotion of health.

References

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Author notes

rhernandezv@usil.edu.pe