1. 1
The use of Road to Health Chart
(RtHC) in monitoring children’s oral health
Student NO: 3004123
Rugshana Cader

2. 2
Introduction
The problem was identified when my sister who has a two year old indicated to me that there
is an oral health section in her Road to Health Clinic Chart (RtHC) that has never been filled
in. As a young mother she reported that she had never been told to take her child to visit the
dentist before the age of one. In a subsequent enquiry at a local clinic parents were asked if
they were aware that there child’s teeth needed to be examined before the age of one. The
findings were that many parents did not know that children need their teeth to be examined
before the age of one. Parents at this local clinic were unaware that in their child’s growth
monitoring chart (RtHC) that there was an oral and dental section. At this clinic there was no
dental professional as part of the healthcare facility and this is something that needs to be
addressed. The criteria in the RtHC in the oral section is indicated to be filled by a dentist,
oral hygienist or dental therapist.
Childhood caries in South Africa is high. The highest caries indices are recorded in children
under five in the Western Cape (vanWyk, 2002). Healthcare in South Africa has unique
challenges. There are groups in the community who are affluent, however at the same time
there is a huge community that is marginalized and has little access to health care. There are
real limitations to resources, management, and staff available to service the large population
attending health care facilities. Dental and oral conditions are never addressed at the health
care facilities because it is not deemed important or a life threatening condition. This
literature review will consider the importance of the common risk approach to general health
and oral health.
Historical development of the RtHC
David Morley was a driving force for children's health worldwide for more than 50 years. He
spent his life advocating the importance of child health, the involvement of parents and
children in their own health care, and health-worker education (Independent, 2009). David
Morley started Under-Fives Clinics run by locals. He trained local women to immunise the
children and he devised the ‘Road to Health’ growth chart (Independent, 2009).
Development of the Road to Health Chart (RtHC)
The RtHC is a recommended tool or method of growth monitoring. It is an aid to discuss
health deviation and progress of the child. One of the strategies to improve the survival and
development of children as set out by World Health Organization (WHO) and United Nations

3. 3
Children Fund (UNICEF) is to monitor growth patterns, oral rehydration, and promotion of
breast feeding, food supply, family planning and female education (Madau, 2010).
Purpose and uses of the RtHC
World Health Organization (WHO) set up a global report specifically designed for
developing countries on child development. This policy identified best practice for child
monitoring in terms of measuring of growth, feeding practices, importance of nutrition,
immunizations. The emergence of this policy developed criteria for child monitoring that
health services can align themselves too.
The RtHC is a document in which the parent(s)/ caregiver have an accurate home-based
record of a child’s health and development, to promote the relationship between health
workers and the parent(s)/caregiver of the child and to improve the identification of children
needing extra care (Directorate Nutrition, 2011). Health workers are to record the following
information at each visit at the clinic. Weighing of the baby, plotting, interpretation and
feedback are recommended monthly during the first two years of life, and regularly after that
at three month intervals. This amounts to 36 visits or consultations the first five years of the
child’s life. This provides opportunity to promote a good relationship between health workers
with the parent(s)/caregiver and child, to detect problems early and to initiate intervention
(Directorate Nutrition, 2011). The critical issue regarding the oral health care component in
the RtHC nowhere is there any information for the healthcare workers to refer to the dental
clinic. Therefore, my assumption is that the oral section in RtHC is often overlooked by the
healthcare professional.
Road to Health Chart (RtHC)
The RtHC was updated and improved in 2011; the layout was developed by the National
Directorates for Nutrition, Child & Youth Health and Provincial contributions. The
researcher identified that very little communication happened between the developers of the
RtHC and dental directorates from Department of Health (DOH) or any dental institution.
The RtHC is made of Tyvek® paper that is tear- and waterproof to ensure that the chart will
not be easily damaged or soiled. Since this chart should be kept throughout the life of a child,
durability of the chart is important. The RtHC is issued to all children that are born in South
Africa, irrespective whether the birth delivery is at home, state or private institution. The
booklets are colour coded to identify pink for girls and blue for boys. It is compulsory that the

4. 4
booklet be presented by the mother or carer at the health facility that the child visits. The
RtHC is a monitoring system of the child’s development therefore, it is compulsory that the
healthcare professional records the correct information in this booklet (DOH, 2012).
Health care delivery in South Africa
In order to understand South African transformation in the health policies especially after
democracy in 1994, the researcher discusses the historical profile of the health delivery
system in South Africa. After the democratic elections in 1994 the healthcare system was
transformed into a single National Health Care system. This made access to healthcare more
available to the marginalized society (Mudau, 2010).
Integrated policy states that free health care will be provided in the public sector for children
under six, pregnant and nursing mothers, the elderly, the disabled and certain categories of
the chronically ill. Preventive and promotive activities, school health services, antenatal and
delivery services, contraceptive services, nutrition support, curative care for public health
problems and community based care will also be provided free of charge in the public sector
(ANC, 1994).
Oral and Dental policy document by ANC
This policy document states the importance of water fluoridation and that fluoride
supplementation should be introduced for children. Measures need to be incorporated to
diagnose and identify oral lesions early. Educational programmes to health workers can be
introduced to help them identify normal oral structure to abnormal oral manifestations (ANC,
1994).
Challenges of Health Care delivery in South Africa
Health service integration is the bringing together of different health activities that share
common health goals. Integration of health services is published widely in the South African
Health Policy document. However, actual translations of these policy statements into
implementable programmes are virtually non-existent. This is due to many factors such as
lack of support and guidance from health management, lack of resources, overburden staff
(Thema & Singh, 2013).
Global Policy of Health

5. 5
The South African health policy is based on the Primary Healthcare philosophy. This policy
was developed by the Alma Ata Declaration in 1976. This philosophy was adopted and
implemented globally which is supported by the WHO and UNICEF.
Health Promotion Philosophy
The health promotion framework within the health system indicates that health workers work
across different settings. Those working within the Department of Health may work in the
primary health setting, in preventative health care, in the acute setting or across the spectrum.
Action across the continuum must recognise interventions and be able to refer appropriately.
If health promotion philosophy is adopted by the Department of Health, this provides an
opportunity for all health workers to work collaboratively together (Carlisle, 2000) and
improving health for all.
Oral health professionals should advocate for better support from other health disciplines and
strive to adopt an interdisciplinary and multi-disciplinary approach to oral health (Carlisle
2000). Oral health has a direct link to general health, and the literature indicates of
relationship between poor oral health and a systemic link, therefore we should have multi-
disciplinary approach to oral health and general health (Petersen, 2005).
Global Policy of Oral Health
The WHO Global Oral Health Programme formulated policies for the improvement of oral
health. The policy is set out to reduce the burden of oral disease and disability, especially in
poor and marginalized populations; Promote healthy lifestyles and reducing risk factors to
oral health that arise from environmental, economic, social and behavioural causes;
Developing oral health systems that equitably improve oral health outcomes, respond to
people's legitimate demands, and are financially fair; Framing policies in oral health, based
on integration of oral health into national and community health programmes, and promoting
oral health as an effective dimension for development policy of society (Petersen, 2009)
Oral disease remains a global problem, particularly among underprivileged populations in
both industrialized and developing countries. Similar caries indices that were identified in the
(2002) Children’s Oral Health Survey of South Africa were identified in Philippines Oral
Health Survey (Bagramian, 2009).
Child Oral Health in South Africa

6. 6
The National Children Oral Health Survey (1999–2002) indicated the greatest need was
recorded in the Western Cape, where almost 80% of children needed oral health care (Thema
& Singh, 2013). There is little evidence to suggest that childhood caries is adequately
addressed through policy and service provision efforts in South Africa (Singh, 2011). Thus
there is a need for capacity building in oral health in South Africa. It is recommended that
strategies and interventions on oral health promotion need to be directed primarily at women
receiving antenatal care. A comprehensive approach to maternal and child health care,
involving efforts to encourage additional fluoride uptake, nutritional intake and safe breast-
feeding practices, could provide strategies to address early childhood caries (Singh, 2011)
Prevalence, Aetiology, and Prevention of Childhood Caries
Tooth decay is regarded as the most common chronic disease of childhood; it affects almost
50% of children. Dental caries is a multifactorial disease caused by bacteria, sugar,
carbohydrates which metabolize to form acids. These acids demineralize the tooth surface
causing dental caries. Cariogenic bacteria can pass from mother to child in the first two years
of the child’s life (Mouradian, 2000). Other causes of childhood caries can be contributed by
poor feeding practices and diet. It is recommended by American Academy of Paediatrics
(AAP) policy statement that dental caries risk assessment should be by the time the first tooth
appearance and no later than 12 months of age (AAP, 2011).
Integrated Approach to Dental Health
Health care providers at primary health care centres are generally the ‘first line’ of health
workers to meet basic health needs. Parents of young children take the children to visit
primary health care providers frequently for child monitoring that is for, weighing, growth
monitoring and vaccinations. The parents seldom see the need to visit oral health
professionals (Thema, 2012). If an integrated approach to health is implemented by all health
professionals, this can identify and detect dental caries and oral lesions early.
Methodology of a study conducted on growth monitoring
Assessing growth is common practice in the Paediatric world (De Onis, 2004). In a study by
De Onis (2004) which looks at using the growth monitoring practices worldwide in
preparation for a new international growth reference. The study was conducted in 178
countries all of which included the growth charts. A questionnaire was used and sent to 202
countries affiliated to the WHO. This was followed by a survey on the recording of the

7. 7
growth charts. This was crossed checked for consistency. Information was recorded on
Microsoft Access 97 along with the descriptive information.
Another study conducted on the ‘Utilization of Road to Health Chart’ the methodology
involved three methods of data collection. That was observation a structured interview and
check list (Mudau, 2010). The researcher intends using a similar methodology for the study,
the study will be based on the literature.
Conclusion
Many parents believe that the Road to Health Charts (RtHC) is required for the weight and
immunization of the baby only that these cards serve no other purpose (Tarwa, 2007). The
RtHC allows space for the recording of oral health issues and health workers should
encourage parents or direct them to the oral health clinic. However according to Mudau,
(2010) utilization of the RtHC by the parents and the primary health worker is not to the
optimum, often the parents do not understand the use of the chart, and primary healthcare
nurses do not fill in the chart correctly (Mudau, 2010: 2).
The literature indicates that RtHC is a recommended tool for monitoring child development.
However, there seems to be a gap in that to date no evidence has been found on the utilization
of the Oral and Dental section in the RtHC. Thus my problem statement is “How effective
and user friendly is the oral and dental section of the RtHC”. Is this section of the RtHC
administered and if so by whom? As presently it states in the book that this section must be
completed by a dentist, dental hygienist or dental therapist. At present the Western Cape has
alarmingly high rate of Early Childhood Caries (ECC). If the RtHC is used effectively it may
assist in early identification of oral childhood diseases. Health authorities may able to
implement in- service training for auxiliary health workers to identify oral conditions and
refer to the appropriate health professional.

8. 8
References
American Academy of Paediatrics (AAAP)., 2011. Policy of Early Childhood Caries (ECC):
Classifications, Consequences, and Preventive Strategies. [online]. Council of clinical
affairs: Washington USA. Available from:
www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf [accessed: 2 June
2014].
African National Congress (ANC).,1994. A National Health Plan for South Africa. [online].
ANC: Johannesburg: Available
from:http://www.africa.upenn.edu/Govern_Political/ANC_Health.html[accessed: 2 June
2014].
Bagramian, G, Garcia-Goody, & Volpe., 2009. The global increase in dental caries. A
pending public health crisis. American Journal of Dentistry, 3-8.
Coovadia, Jewkes, Barron, Sanders & McIntye., 2009. The health and health system of South
Africa: historical roots of current public health challenges. The Lancet, 817 - 834.
De Onis, Winhoven & Onyango., 2004. Wold Wide Practices in Child Growth Monitering.
The Journal of Pediatrics , 461-465.
DOH, 2012. The Road to Health Chart, [ online]Pretoria: Directorate Nutrition.
http://www.westerncape.gov.za/service/child-developmental-screening-and-growth-
monitoring [accessed: 2 June 2014].
Harrison, Heese, Harke., & Man.,1998. An Assessment of the "Road to Health" card based
on perceptions of clinic staff, SAMJ. 88 (11).
Garner, Panpanich, Logan., 2000., Is routine growth monitoring effective? Arch Dis Child,
197-201.
The Independent Times., 2009. Orbituaries. [Online]
Available at: http://www.independent.co.uk/news/obituaries/professor-david-morley-pioneer-
in-childrens-health-care-for-more-than-half-a-century-1779909.html
[Accessed 26 May 2014].
Malaudzi, 2012., Road to Health chart/ booklet. [online]. Available at: University of Pretoria
https://web.up.ac.za/.../file/.../UPdate%202012. [Accessed 26May 2014].
Mouradian, Wehr, Crall.,2000. Disparities in Children's Oral Health and Access to Dental
Care. JAMMA, 2625- 2631.
Mudau, 2010. Utilisation of the Road to Health Chart to improve the health of children under
five years of age,Masters of Arts. Pretoria: UNISA.

9. 9
Naidoo.,2012. The South African national health insurance: a revolution in health-care
delivery!. Journal of Public Health, 149-150.
Petersen, 2009. Oral health in the developing world,[online]. Geneva – Switzerland: WHO.
http://www.who.int/about/en/
Singh, 2011. Dental caries rates in South Africa:. South Afr J Epidemiol Infect, 259-261.
Singh, 2013. Integrated primary oral health services in South Africa. Afr J Prm Health.5(1),
1-14
Tarwa, 2007. The use of the Road to Health Card in. SA Fam Pract, pp. 15-20.
Thema, 2012. The role of the PHC nurse in providing oral health. [Online]
Available at: http://www.phcfm.org/index.php/phcfm/article/viewFile/413/538
[Accessed 26 May 2014].