Running head: ROSE HILL MIDDLE SCHOOL 1

Community Dental Health Project: Assessment, Diagnosis, Planning, Implementation, and

Evaluation Phases

Stephanie C.

Simone S.

Lauren Stevens

Community Dental Health IV

Winter Quarter, 2018

Date 02/22/2018
ROSE HILL MIDDLE SCHOOL 2

Assessment

Our target population is the 8th grade middle schoolers of Redmond, WA attending Rose

Hill Middle School. Adolescents at this age (13-14 years old) can have a high decay rate from

poor daily oral hygiene and increased diet of sugars and carbohydrates. Also, this population is

usually going through orthodontics and have a harder time cleaning around these types of

appliances increasing the likelihood of caries and gingivitis. The lack in knowledge in biofilm

removal makes our population a high risk for negative oral health outcomes making it important

for us to discuss these disparities with them.

Our data was collected using online databases available through the school library. We

focused on using PubMed to gather research articles to support our project. We also used

information from national research sites for statistical confirmation of their needs. Each group

member researched topics specific to their station during the presentation to support the need for

oral health education in the 8th grade student body.

The Rose Hill Middle School health teachers contacted Ms. Lindeman and asked if there

was a group of dental hygiene students who would come speak to their class like what was done

last year. Matt Laughlin and Chris Bradenfels are our contacts and the school address is 13505

NE 75th St., Redmond, WA 98052, and their telephone number is (425)-936-2460.

Community profile

The statistics on the demographics of Rose Hill Middle School were retrieved from

GRAPHIQ database (Startclass by GRAPHIQ Inc., 2017). The database states there are 750

students currently enrolled at Rose Hill Middle School which is higher than the state average of

602. Rose Hill Middle School is in Grass Lawn which is considered an upper middle class, well-
ROSE HILL MIDDLE SCHOOL 3

educated neighborhood (Startclass by GRAPHIQ Inc., 2017). Rose Hill has 444 students, or

59.2% that classify as Caucasian which is average in Washington state. Other races at Rose Hill

Middle are Hispanic, Asian, two races, American Indian or Pacific Islander. The gender

distribution is 55% male and 45% female (Startclass by GRAPHIQ Inc., 2017). The

socioeconomic status of students at Rose Hill Middle School is determined by National School

Lunch Program (NSLP). At this school, 15.7% of students qualify to receive free lunch meaning

the children’s family is $15,171. Also, 4.7% of students at Rose Hill Middle School receive

reduced lunch (Startclass by GRAPHIQ Inc., 2017). The student class at Rose Hill has a higher

than average scoring in the Washington Smarter Balanced Assessments/Measurements of

Student Progress (SBA/MSP). The Rose Hill school had scores of 79.9 % passing rate in Math,

English/Language Arts, and Science where the Washington average is 56.2% and the King

County average is 68.6% (Startclass by GRAPHIQ Inc., 2017). This shows the students at this

Middle School are well educated and have access to a proficient education. Also, 6% of students

are considered limited in English proficiency which is the average in Washington (Startclass by

GRAPHIQ Inc., 2017). Even though this is a small population it is important to still consider this

limitation while creating education material.

Needs Assessment

The needs identified by our contact, Mr. Laughlin, are brushing and flossing techniques,

drug use and how it effects the teeth, and the decay process. He said these children need to be

further educated in these fields because the health program does not have material on this topic

making it missed and forgotten. Mr. Laughlin said the best way to have this information retained

in long term memory is using “gross” pictures and hands-on activities. He said these children

are, in general, higher socioeconomic statuses so having the supplies to do proper hygiene is not
ROSE HILL MIDDLE SCHOOL 4

of financial restriction, but rather lack of motivation. This is supported in the demographic data

stating 20% or less are using the lunch services due to financial restraints from the GRAPHIQ

database (Startclass by GRAPHIQ Inc., 2017). Another statistic showing further need for

education in our target population is from the NCHS (National Center for Health Statistics)

stating “Among adolescents aged 12–19, nearly three in five adolescents had experienced dental

caries in permanent teeth, 15% had untreated tooth decay, and 43% had at least one dental

sealant present. Dental caries experience was not significantly different among Hispanic and

non-Hispanic white, black, and Asian adolescents” (Dye, Iafolla, Li, & Thornton-Evans, 2015, p.

2). This static demonstrates how common caries are among adolescents and the importance of

preventive treatment no matter their ethnicity. Our statistics show this population is in a wealthy

area of good socioeconomic status and easy access to resources, but their age and lack of public

education on dental needs puts this population at risk.

Literature Review

During our research for our target population, we discovered certain unmet needs found

among our adolescent age group. This research shows adolescents lack education on oral

hygiene, are at an increased risk of caries due to poor biofilm removal, how socioeconomic

status influences dental care and their dietary lifestyle affects their oral health.

During adolescence teens are not monitored on brushing habits or nutrition as much as

when they were children. An article by “Guideline on Adolescent Oral Health Care states”,

“Adolescence marks a period of significant caries activity for many individuals. Research

suggests that the overall caries rate is declining, yet remains highest during

adolescence… environmental factors such as diet, independence to seek care or avoid it,
ROSE HILL MIDDLE SCHOOL 5

a low priority for oral hygiene, and additional social factors also may contribute to the

upward slope of caries during adolescence” (2015, p. 152).

Even with this research there is little data to show what perceptions adolescents have on

oral health that causes an increased caries risk as described by Calderon and Mallory in their

literature review (2014, p. 369). Not having research on adolescents’ oral hygiene habits makes

deciding how to approach educational material difficult for this population. These difficulties can

explain why adolescents are not receiving the necessary education to improve oral health. Being

educated on proper homecare is important since it can affect their future general health as well.

There are direct links to poor oral health and reduced quality of life, low school attendance and

influences on growth and development (Calderon & Mallory, 2014, p. 369). This supports our

need to educate our population on proper brushing and flossing techniques and preventive

measures since it not only impacts their current health, but health in the long term as well.

Another unmet need for our population is untreated dental caries. Even though there is

fluoridated water and an increase of sealants being applied, percentages of dental caries are

prevalent in adolescents. In an article published of a survey from 2011-2012 from NCHS, they

found “Among adolescents aged 12–19, 58% had experienced dental caries in permanent teeth

in…The prevalence of dental caries experience was higher among adolescents aged 16–19 (67%)

compared with those aged 12–15 (50%)” (Dye et al., 2015, p. 191). It is important to make our

target population aware of this disease and educate them on the importance of caring for their

oral health. Our target population is within these age groups so making them conscious of dental

caries is important to help prevent them from occurring. By educating them we are allowing

them to make healthier choices and help prevent dental caries on their permanent dentition.
ROSE HILL MIDDLE SCHOOL 6

If dental caries or other treatment does occur, dental care is very expensive, so many

parents cannot afford to give their children the dental treatment they need. One study selected

1,000 children and adolescents from families of varying socioeconomic status and did an oral

exam to establish the correlation of dental caries to low socioeconomic status. Interestingly, in

one study it states,

“Though the socioeconomic status and dental caries had a weak correlation, the odds

ratio was high, indicating that the children of lower socioeconomic status or family with

both parents employed were at a higher risk for dental caries… Efforts are needed to

implement programs at the school level to enhance the oral and dental health among

children, as parental responsibilities toward this maybe inadequate due to economic or

time constraints” (Gokhale, 2016, p. 127).

The study highlighted that children and adolescents are at high risk for dental caries no

matter what financial circumstances they are in. This is important for our target population

considering the majority are within mid to high socioeconomic status but still need education on

dental caries risks.

It is also well-known America is facing an obesity epidemic with adolescents not being

an exception and this can direct effect their oral health. There is a study done by Zeigler et al.,

comparing the levels of subgingival bacteria in obese adolescents (average age being 14 years

old) with those adolescents who are within normal limits of BMI (2012). During their research,

they found obese adolescents had increased levels of 32 out of the 40 bacteria being tested, at

times being three times higher in the obese population (Zeigler et al., 2012, p. 159). This study

also found research showing links between adolescent obesity and “higher rates of prescribed
ROSE HILL MIDDLE SCHOOL 7

medications…lower frequency of toothbrushing as well as significantly higher VPI compared

with controls” (Zeigler et al., 2012, p. 159). At the other end of the spectrum, adolescents can

also be facing eating disorders due to social stress. A study done to show the prevalence among

adolescents with eating disorders states,

“The prevalence of risk behavior for eating disorders was 6%. Twenty adolescents

(1.7%) were identified with severe risk behavior for eating disorders and matched to 80

adolescents without such risk. Among the severe risk group, 45% of adolescents were

affected by tooth erosion and 80% by dental caries compared with 8.8 and 51.3%,

respectively, in the matched group” (Hermont, 2013, p. 680).

This study shows how eating disorders can cause increased risks for dental caries and

changes in normal oral pathology. These statistics are significant for our population because they

are now making more independent food choices and need to be educated on the impact those

choices can make.

In conclusion, our research justifies our populations’ need for our presentation to increase

their awareness of their oral health status. Since their socioeconomic status is not shown to

heavily influence their access to oral care, we decided to focus our presentation on their lifestyle

choices that can affect their health. These include their oral hygiene routines, caries risk and

nutritional choices. This information supports the importance of our oral health presentation to

the 8th grade population at Rose Hill Middle School.

Diagnosis

Our population is the 8th grade health class of Rose Hill Middle School. This means at

this age the population is going through changes in increased independence in their lifestyle
ROSE HILL MIDDLE SCHOOL 8

including nutritional choices and hygiene habits. Knowing this it allows us to prioritize oral

hygiene education at the top of their needs to decrease the risk of caries and biofilm retention.

This will be discussed during the presentation and demonstrated during stations for hands-on

techniques. Our other priority is discussing nutrition through examples of the decay process

when exposed to acidic or sugary foods.

The number of students we are presenting to is about 120 students separated into 4

classes of 30 students. They are in Rose Hill Middle School of Redmond, Washington in the

Lake Washington School District. During our initial conversation with our contact Matt

Laughlin, he discussed the lack of access to oral health education in the school health program.

He was aware of this deficient education and said it would be beneficial for the school to start

introducing oral health since it is a heavy influence on general health.

Other programs serving this population are DSHS offering state insurance allowing free

or less expensive preventive care to those in need. Also, The AAPD (American Academy of

Pediatric Dentistry) offers events to increase awareness of oral hygiene discrepancies in younger

populations. Through the Lake Washington School District there are links to clinics whom take

state insurance or patients without insurance which could be a good resource for some of the

students. These clinics include Center for Pediatric Dentistry for special needs patients,

Healthpoint Redmond Dental, Lake Washington Institute of Technology Dental Clinic, North

Public Health Center Dental for 1-18-year old’s, and Sea Mar Community Health Center (Lake

Washington School District, 2017).

ROSE HILL MIDDLE SCHOOL 9

Planning

Our strategy in planning our educational demonstration on oral health to our population is

focused on keeping it fast moving and engaging. Since our population is adolescents we know

they won’t be able to focus on a long presentation, so we decided to keep that portion short and

focus mainly on pictures to keep them engaged. For a more hands on experience, we decided to

do stations to reinforce the main topics of our presentation. At all times our strategy is to repeat

material to help retain information, and to present the material in a way relatable to the

population.

Project Goal and Objectives

Our goal of teaching at Rose Hill Middle School is to increase oral health knowledge in

8th grade students of Redmond, Washington. Our objectives are to increase knowledge of proper

nutrition in 8th graders of Rose Hill Middle School, to increase knowledge of proper oral hygiene

in 8th graders of Rose Hill Middle School, and to increase knowledge of decay process in 8th

graders of Rose Hill Middle School.

Timeline

May 31st: Contacted and confirmed with Matt Laughlin that we can do our community project

with his class

July 21st: Met at Starbucks in Bellevue to start planning presentation

September 18th: Meet with Matthew McLaughlin at Rose Hill Middle School
ROSE HILL MIDDLE SCHOOL 10

September 20th: Received and organized donated toothbrushes and toothpaste from dental offices

for the goody bags

October 31st: Group meeting to create PowerPoint presentation

November 10th: Final group meeting to practice presentation and organize supplies

November 17th: Date of presentation

Lesson Plan

Our plan is to show and explain to the students the way their habits influence their teeth

and how to properly care for them. First, we will distribute a pre-quiz handout, one per student

and allow for about 5 minutes for completion. Then we’ll teach using visuals in a PowerPoint

presentation. We’ll use the overhead projector in the classroom to present. The presentation will

include basic oral health information, brushing and flossing techniques, halitosis, and prevention

products such as xylitol and fluoride. We will also discuss the influence of smoking and drugs on

oral health and oral piercings. Then we will divide the students into 3 stations and spend 5

minutes with about 10 kids at each station. Stephanie will go over foods to eat sometimes or

always. She will be using a tri-fold board with sticky tape on pictures to put a selection of foods

on the board for the students to sort and discuss. Lauren will cover how to brush and floss using

Dentoform models, toothbrushes and floss. Simone will use eggs to demonstrate the decay

process from letting them soak in different kinds of fluids. Finally, we will distribute the post-

quiz handout, one per student, and allow for about 5 minutes for completion. We are estimating

roughly 120 students total, about 30 per class. We will be in Matt Loughlin’s health classroom in

Rose Hill Middle School for the duration of the presentation. Each class is about 50 minutes long
ROSE HILL MIDDLE SCHOOL 11

and we will present to four separate classes for a total of three and a half hours of presentation

time.

Budget

Our budget consists mainly of supplies for our table groups and means of transportation.

We estimated a total cost of roughly $55 relying heavily on donations. The actual cost was

$64.50 divided among the three of us (roughly $21.50 per person). Even though we saved money

on supplies, we spent far more on printing pre-and post-tests and fliers than originally expected

causing us to go above our projected budget plans.

Expected Estimated Actual

Purchase Budget Budget
Paper for printing Free $30
Toothbrushes Free Free
Toothpaste Free Free
Goody Bags Free Free
Lamination $5 Free
Gas $15 $20
Trifold board $10 $4
Eggs $4 $2
Juice/Soda $15 $4.50
"Thank you" card $5 $4

Summary

With our supported research on the needs of oral health education to the adolescent

population of Rose Hill Middle School, we were able to create a plan on how to give them this

instruction in a constructive way. By giving a PowerPoint presentation and doing hands on

activities we hope each child receives the material in a way that is understood to influence their

homecare. The next step is implementing our lesson plan to these 8th graders.
ROSE HILL MIDDLE SCHOOL 12

Implementation

Our objectives were to increase knowledge of proper nutrition in 8th graders of Rose Hill

Middle School, to increase knowledge of proper oral hygiene in 8th graders of Rose Hill Middle

School, and to increase knowledge of decay process in 8th graders of Rose Hill Middle School.

On November 17th, 2017 we implemented our oral health education presentation to the 8th grade

student body. We presented to a total of 99 students that day which was lower than the estimated

120 students we predicted. The first class consisted of 26 students, then 22 students in the second

and third classes and 29 students in the fourth class. The first class was from 8:39-9:23, the next

was 10:16-11:03, the next at 12:37-1:24 and lastly the fourth class at 1:28-2:15. The breaks

between the first couple of periods were due to a study break and then lunch. We were consistent

with our lesson plan having a PowerPoint presentation last 10 minutes, then three stations lasting

5 minutes each. Each station was very interactive allowing the students to ask questions and have

hands on experience implementing what was discussed during the presentation. The pre-and

post-tests lasted roughly 5 minutes including the time it took for them to settle down and get

ready for the class period. We stayed in contact with Matt Laughlin and Chris Bradenfels prior to

and during the presentation. We will use the pre-and post tests given during each class period to

determine the effectiveness of our presentations. We will also use any input from Matt Laughlin

or Chris Bradenfels if they contact us after the presentation.

Summary

To determine if our implementation was effective in increasing the education on oral

health in the 8th middle schoolers of Rose Hill we will evaluate the success rates between the pre-

and post-tests representing our summative evaluations. We will also have formative evaluations
ROSE HILL MIDDLE SCHOOL 13

through our personal experiences and what we felt could have been improved on during the

presentations.

Evaluation

To determine if our presentations were meeting our expectations, we did evaluations

during and after our project to establish our success. One way we achieved this was during our

breaks between classes doing formative evaluations. We would discuss time management,

classroom participation, and possible alterations to table stations to make the presentation more

effective for the students. We decided we were managing the time we had available well and it

didn’t need to be changed for future classes. Student participation varied between classes, so we

decided to try and present the material in an approachable way to make it more interesting. As

for changes to table stations, we needed to keep the students on topic by asking more questions

and making sure each group presents their information in the same amount of time.

As for the summative evaluation, we used our pre and post-test results to determine the

success of the program. The data from these tests is shown in Appendix E. From our results we

determined the students still did not have a full understanding of the cause of caries due to not

seeing improvement in test results. Our goal was to have the students understand bacteria is the

cause of decay, not just sugary foods. We feel this station may have needed more time compared

to the oral hygiene or nutrition stations to discuss the decay process more thoroughly.

Our goals on educating the 8th grade students on nutrition and oral hygiene were met as

seen by the improvement on pre and post-test scores regarding those topics. However, the goal of

educating the 8th grade students at Rose Hill Middle School on the decay process was not met

since there was little to no improvement on the question regarding this topic. Our results from
ROSE HILL MIDDLE SCHOOL 14

this presentation are not statistically significant due to the small population size and since the

student population is a convenience sample with little randomization.

One of the biggest limitations we faced was time. Having restricted time limitations made

it so some of the more complicated topics like the decay process was not elaborated on enough.

Another limitation was the budget. We were fortunate enough to have most of our supplies for

the goody bags donated, however personal expense was made when creating the table stations.

Since we wanted to keep spending to a minimum we couldn’t afford to buy enough supplies for

each student to have materials of their own which may have limited their learning experience. A

strength of our presentation is that we kept the audience engaged by using stations with hands on

activities. Another strength was being able to hand out homecare hygiene products through

goody bags with an informative flyer, so the students could utilize what they learned in class at

home. Lastly, we presented our material in different formats including PowerPoint presentation

and hands-on table stations which appealed to different learning styles.

Even though we felt the overall presentation was successful, it was not considered

sustainable to those whom we presented to. This is because the students live in a higher

socioeconomic area and have good access to oral care, so they have already been exposed to

much of the material we presented. This may have been why some of the test questions had such

positive results and why they became uninterested in the oral hygiene table station. To enhance

the success of future projects, it should be presented to a population with a greater need for oral

hygiene education. This could include children in low socioeconomic areas, adults with low

access to oral health care, and the elderly with limited access to dental care. Some modifications

to the presentation would be to allow more time, incorporate other forms of oral hygiene care so

the population could practice techniques with aids like rubber tip stimulators or interdental
ROSE HILL MIDDLE SCHOOL 15

brushes, and have dentoforms with mock braces to practice cleaning around orthodontia. Overall

the presentation was a positive experience for us on how to present oral hygiene education to

different populations.
ROSE HILL MIDDLE SCHOOL 16

References

Calderon, S., & Mallory, C. (2014). A systematic review of oral health behavior research in

American Adolescents. The Journal of School Nursing, 30(6), 369-403. Retrieved from

https://lmcproxy.lwtech.edu:2482/docview/1622667012/CFC0C8C19C8A4B92PQ/1?acc

ountid=1553

Dye, B., Iafolla, T., Li, X., & Thorton-Evans, G. (2015). Dental caries and sealant prevalence in

children and adolescents in the United States, 2011–2012. NCHS Data Brief. Retrieved

from

https://www.cdc.gov/nchs/data/databriefs/db191.pdf

Family Services. (2017). Lake Washington School District. Retrieved from

http://www.lwsd.org/programs-and-services/academic-support/family-services#Dental

Gokhale, N., & Nuvvula, S. (2016). Influence of socioeconomic and working status of the

parents on the incidence of their children’s dental caries. Journal of Natural Science,

Biology & Medicine, 7(2) 127-129.

doi:10.4103/09769668.184697

Guideline on adolescent oral health care. (2015). American Academy of Pediatric Dentistry.

http://www.aapd.org/media/policies_guidelines/g_adoleshealth.pdf

Hermont, A., Pordeus, I., Paiva, S., Abreu, M., & Auad, S. (2013). Eating disorder risk behavior

and dental implications among adolescents. International Journal Of Eating Disorders,

46(7), 677-683.

doi:10.1002/eat.22132
ROSE HILL MIDDLE SCHOOL 17

Startclass by GRAPHIQ Inc. Rose Hill Middle School in Redmond, Washington. (2017).

Retrieved from

http://public-schools.startclass.com/l/96682/Rose-Hill-Junior-High

Zeigler, C., Persson, G., Wondimu, B., Marcus, C., Sobko, T., & Modéer, T. (2012). Microbiota

in the oral subgingival biofilm is associated with obesity in adolescence. Nature

Publishing Group, 20(1), 157-164.

doi: 10.1038/oby.2011.305
ROSE HILL MIDDLE SCHOOL 18

Appendix A

Lesson Plan

TITLE: “Striving for healthy teeth”

TARGET GROUP: 8th grade Health Students of Rose Hill Middle School

ESTIMATED LENGTH: 40-minute classes, 6 classes per day

INSTRUCTIONAL METHOD: Lecture and Demonstration

EDUCATIONAL GOAL:
To increase oral health knowledge in 8th grade students of Redmond, Washington.

INSTRUCTIONAL OBJECTIVES:
1. To increase knowledge of proper nutrition in 8th graders of Rose Hill Middle School.
2. To increase knowledge of proper oral hygiene in 8th graders of Rose Hill Middle School.
3. To increase knowledge of decay process in 8th graders of Rose Hill Middle School.

INSTRUCTIONAL MATERIALS:
PowerPoint

LEARNING ACTIVITY:
Pre-and Post-test
PowerPoint Presentation (10 Minutes)
Sometimes foods and always foods for your teeth (5 minutes)
How to Brush and Floss (5 minutes)
Decay Process Demo (5 minutes)

Instructional Set:
We are here to show and explain to you the way your habits influence your teeth and how to properly care
for them.

Body
1. Distribute pre-quiz handout, one per student. Allow for about 5 minutes for completion
2. Introductions and PowerPoint presentation
a. Basic oral health information
b. Brushing and Flossing Techniques
c. Halitosis
d. Prevention Products (Xylitol, Fluoride)
3. 5 Minute Rotation per station
a. Always/Sometimes Foods and Drinks for your Teeth (Stephanie)
b. How to Brush and Floss (Lauren)
c. Decay Process Demo (Simone)
4. Distribute post-quiz handout, one per student. Allow for about 5 minutes for completion

Closure:
We’ve discussed basic oral health information, brushing and flossing techniques, bad breath, prevention
products and how the food you eat affect your teeth. By keeping your teeth clean you’ll be an overall
healthier person
ROSE HILL MIDDLE SCHOOL 19

Appendix B

Pre-test

1. If you drank a soda pop, how long does the sugar attack your teeth?
a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 20 minutes

2. Which kind of food is most likely to cause cavities?

a. Proteins
b. Carbohydrates
c. Dairy
d. Fruits and Vegetables

3. Does the health in your mouth effect the health in your body?
a. True
b. False

4. What motion do you make with your toothbrush to get the food off best?
a. Circles
b. Up and down
c. Back and forth

5. Can cavity causing bacteria be spread from person to person?

a. True
b. False

6. How do you think your teeth get cavities?

ROSE HILL MIDDLE SCHOOL 20

Appendix C

Post-test

1. If you drank a soda pop, how long does the sugar attack your teeth?
a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 20 minutes

2. Which kind of food is most likely to cause cavities?

a. Proteins
b. Carbohydrates
c. Dairy
d. Fruits and Vegetables

3. Does the health in your mouth effect the health in your body?
a. True
b. False

4. What motion do you make with your toothbrush to get the food off best?
a. Circles
b. Up and down
c. Back and forth

5. Can cavity causing bacteria be spread from person to person?

a. True
b. False

6. How do you think your teeth get cavities?

ROSE HILL MIDDLE SCHOOL 21

Appendix D

Goody Bag Handout

Ways To Maintain A Healthy Smile

Between Dental Visits

Brush 2x Daily For

2 Mins (morning
and night, circular brushing).

Floss 1x Daily

Brush Your Tongue To Avoid

Bad Breath

Drinking Lots of Water

Make Healthy Snack Choices Between

Meals
ROSE HILL MIDDLE SCHOOL 22

Appendix E

Data Results from Pre and Post Tests

Results are based on the questions answered correctly.

Class 1 Test Results

30
25
20
Students

15
Pre-test
10
Post-test
5
0
1 2 3 4 5 6
Question Number

Class 2 Test Results

25

20
Students

15

10 Pre-test
Post-test
5

0
1 2 3 4 5 6
Question Number
ROSE HILL MIDDLE SCHOOL 23

Class 3 Test Results

25

20
Students
15

10 Pre-test
Post-test
5

0
1 2 3 4 5 6
Question Number

Class 4 Test Results

30

25

20
Students

15
Pre-test
10
Post-test
5

0
1 2 3 4 5 6
Question Number