CHAPTER 11 ORAL HEALTH EDUCATION AND HEALTH PROMOTION
Results from a survey of the nation’s oral health indicate that, although caries rates have decreased in recent years, 45% of children and adolescents still have evidence of the disease.1 Another survey also found that 10% of adults are completely edentulous, and only one third have all 28 teeth.2 Periodontal disease indicators showed that one third of individuals 25 to 34 years old had moderate attachment loss, as did 63% of 45- to 54-year-olds and 80% of people more than 65 years old. More severe periodontal disease was found in 15% of those surveyed.3 These data indicate that oral disease remains a public health problem for Americans; one way this problem can be addressed is through oral health education.
Although the American Dental Association (ADA) recommends that individuals brush and floss their teeth twice a day in addition to having regular dental examinations, research suggests that many individuals do not adhere to this recommendation.4 In a survey of Detroit-area residents, Lang, Ronis, and Farghaly5 found that although more than 96% of the individuals surveyed did brush at least once a day, only 84% demonstrated adherence to their definition of “acceptable” brushing technique (e.g., brushing all teeth, including those that do not show when smiling). In the same study only 33% of individuals reported flossing daily, and only 22% demonstrated “acceptable” flossing technique (e.g., flossing all teeth). Because these data suggest a need for improvement in individuals’ oral self-care, the need for effective oral health education remains clear.
Oral health education for the community is a process that informs, motivates, and helps persons to adopt and maintain health practices and lifestyles; advocates environmental changes as needed to facilitate this goal; and conducts professional training and research to the same end.*6–10 Health education is any combination of learning opportunities designed to facilitate voluntary adaptations of behavior that are conducive to health.11 Health education programs are not isolated events but educational aspects of any curative, preventive, or promotional health activity. Comprehension of the multifactorial variables in dental disease and their interaction has increased the emphasis now placed on the educational process to assist in achieving desired health outcomes.
It has been well documented in dentistry and other health areas that correct health information or knowledge alone does not necessarily lead to desirable health behaviors.12 However, knowledge gained may serve as a tool to empower population groups with accurate information about health and health care technologies, enabling them to take action to protect their health.13 Both internal and external variables influence whether an individual or community will comply with recommended disease prevention, health maintenance, or health promotion procedures. Health promotion is any combination of educational, organizational, economic, political, and environmental supports for behavior conducive to health.11 Health promotion refers to actions that are intended either to alter the living environment of persons to improve their health (e.g., community water fluoridation) or to enable and empower individuals to take advantage of preventive procedures or services by reducing or eliminating access barriers. Other actions might include making available–or removing financial barriers to–procedures such as the appropriate use of fluoride supplements, use of dental sealants, supervised removal of dental plaque, and effective referral and follow-up services for individuals who need treatment.14 Education and promotion are intertwined to achieve long-term improved health for all populations within American society.
Procedures implemented through promotion can prevent a given disease or condition, but only education can foster informed decision making and maintenance of needed programs, services, or behaviors. Health education and promotion processes permeate all levels of individuals and groups and may include working with patients, parents, legislators, industry, and all other levels of influential policy makers, including health care providers.14
The oral health educator must be cognizant of available resources and demographic changes affecting social, economic, and health services environments. In addition, the educator must weigh internal and external variables in relation to clinical and behavioral research findings when designing a community program that will be effective in achieving long-term results.
Knowledge of program planning and community organization is essential, and skill development in these areas warrants inclusion in the professional preparation of the dentist and dental hygienist. To date, however, development of these skills has received little attention. The ADA and the American Dental Hygienists’ Association (ADHA) have responded to the expanding role of the dentist and the dental hygienist as health educators in the clinical practice setting and in the community by developing a variety of educational resources. Professional development products include guides, brochures, posters, flyers, and videos, many of which are available in English and Spanish for individual or group education during community presentations. ADA publications, such as Materials You Need for Your Effective Practice, have historically covered a wide variety of educational topics, including Educating Patients, Managing Your Practice, Controlling Infection, Posters and Plaques, and Videos That Teach.15 The ADA has developed a new two-part teaching guide called “Smile Magic” with lesson plans, activities, and activity sheets for preschool to grade 2 and grades 3 through 5. The ADA also offers a National Children’s Dental Health Month Planning Guide, starter kit, and supplemental materials to promote a successful annual February observance.15 The ADA website (www.ada.org) includes detailed information on these educational activities and provides a variety of online educational resources for children, parents, teachers, and those engaging in public speaking about dentistry.
The ADHA has developed continuing education programs and other professional development products that present the latest in theories and techniques intrinsic to successful dental hygiene practice. The ADHA also offers an array of practical guides for helping career-minded individuals and active program planners achieve success in community outreach programs and public relations and legislative action skill development.16 At the ADHA website (www.adha.org), additional information about current professional products for patient or consumer information is available, as well as oral health educational information for individuals of all ages.
Most professional training revolves around learning specific technical procedures and working with patients on a one-to-one basis. In this situation individual patient motivation is the primary objective of oral health education and unfortunately constitutes only a small component of the overall treatment plan.15 Ideally, the dentist’s or hygienist’s relationship with the patient allows the dental practitioner to tailor the preventive prescription to each individual patient’s needs, and patients can identify their own short- and long-term oral health goals. Through this process the dental professional is able to help those patients amenable to prevention to internalize the value of good oral health and to practice preventive measures. However, Chambers6 has concluded that strong evidence suggests that only a limited number of Americans are amenable to an at-home program of controlling plaque. A principal factor suppressing this number is that habits of healthy living are not supported by deep-seated cultural values. The role of the health educator becomes an essential component in the management of dental disease and in helping patients assume responsibility for their own oral health maintenance.
In most cases the same skills that were developed in working with patients on a one-to-one basis are carried over to the community setting. As a result, community oral health programs are usually conducted in much the same manner as individual patient education. Specific educational efforts focus on presenting oral health information and on trying to change an individual’s attitudes and behaviors with regard to oral hygiene habits and diet rather than on emphasizing an organized community approach to prevention and control of disease. Emphasis is placed on correct brushing and flossing techniques to help prevent, or at least control, periodontal disease and on nutritional counseling, sealants, and fluoride therapy for caries control, use of mouth guards in contact sports, emergency management of the avulsed tooth, and antismoking and antismokeless-tobacco education.
Success of these primary health promotion endeavors relies on the individual’s development of specific skills and their incorporation into the person’s lifestyle to reduce the prevalence of caries, periodontal disease, oral injuries, and oral cancer. Although popular, when it is used alone, this approach to disease prevention has had limited success in reducing oral disease and may not be an appropriate focus for public health education.14,17–19 Behavioral theories applicable on an individual level may not be directly transferable to solving group- and community-level health problems; theories of public health and epidemiology may be more relevant for societal change.13,20 In each case the health educator needs to choose the framework most appropriate for addressing the problem.21 Given Winslow’s definition of dental public health–the science and art of preventing and controlling dental disease and promoting oral health through organized community efforts–an alternative approach focusing on individual behavior change would be to target health education efforts to community leaders, as suggested by Frazier.22 This approach would redirect the educational processes to the selection of prevention and control programs that operate at the community level and do not require daily compliance on the part of the individual. Further, Frazier and Horowitz13 suggest that focusing health education and promotion efforts on a broader range of children and parents has a positive potential for a major impact on the oral health of future generations of families in different socioeconomic groups. All parents and infant caretakers–whether male or female, young or old–need to know how to prevent oral diseases. By imparting that knowledge to the children in their care and by reinforcing good daily oral health habits, the oral health of future generations could improve dramatically. School-based health education and promotion activities are viable ways of reinforcing healthy behaviors.
The purpose of this chapter is to present an overview of the current issues and concepts in oral health education and to discuss the transition in educational activities from the traditional approach to current and suggested approaches. By examining continuing community programs and examples of other organized community efforts, the student should be able to determine which program goals are appropriate for public health education and possible ways to accomplish those goals. Areas of recent and recommended educational research are highlighted. We hope that previously held beliefs will be challenged and that the extent, complexity, and importance of community oral health education will be better understood.
Although much progress has been made in the status of the nation’s oral health through oral health education efforts in the past, a number of important dental public health problems remain, and existing programs can benefit from giving special consideration to the unique needs of a variety of populations that may need such education. Many issues still need to be addressed by future oral health education efforts. A few of these are mentioned here to provide the reader with a general understanding of the types of problems that future oral health education should address.
The appropriate use of fluorides is the best method available to prevent the onset of dental caries. Interventions that used fluoride have been successful in preventing dental caries, averting pain and discomfort, and saving money. Water fluoridation serves as the cornerstone for community oral disease prevention and is the most cost-effective method to provide protection against dental caries for people of all ages.23,24 As stated in the Surgeon General’s Report on Oral Health in America: “Community water fluoridation is an effective, safe and ideal public health measure that benefits individuals of all ages and socioeconomic strata.”25 Approximately 300 million people in more than 40 countries worldwide consume fluoridated water. Water fluoridation costs between $.68 and $3.00 per person per year.25 Yet in the United States only 145 million people, or 62% of the population on community water supplies, are receiving this preventive measure. Approximately 100 million Americans (38% of those on public water systems) currently do not have access to drinking water with optimum levels of fluoride to protect their teeth. The Centers for Disease Control and Prevention (CDC) is collaborating with state and local health departments and water districts to address this issue.25,26 It is a challenge for all health care providers to reach the entire population with preventive interventions at the community level. Oral health educational efforts are needed to continue to inform community residents and legislators about the beneficial effects of fluoridation.
Oral self-care behaviors by individuals are still not at recommended levels.5,27 Educational efforts aimed at individuals and communities are still needed to increase the prevalence of such behaviors to improve their oral health status. Research is necessary to assess proposed theoretic models promoting oral self-care behaviors to determine if they are evidence based and appropriate for broad application. New theoretic models for study have been developed.28,29
The American Cancer Society (www.cancer.org) reports that the incidence of and mortality rates resulting from cancers of the oral pharynx and oral cavity are sobering and fortify the need for routine oral cancer screenings at each dental visit. In the United States, 30,200 people were diagnosed with oral cancers, and 7800 deaths were attributed to these cancers, in 2000. Oral cancers are more common than leukemia, melanoma, and cancers of the brain, liver, kidney, thyroid, stomach, ovary, or cervix. Possible sites include the tongue, lips, floor of the mouth, soft palate, tonsils, salivary glands, and nasopharynx.30 Risk factors include use of tobacco products and alcohol, exposure to the sun (lip cancer), dietary factors, and exposure to carcinogens in the workplace.31 Use of tobacco products has also been identified as a major risk factor for periodontal diseases relative to increased susceptibility, onset in young adults, severity and extent of disease, disease progression, and treatment failure.32 According to the American Cancer Society, 70% of adults who have smoked began before age 18 years.30 To reduce mortality rates from, and increase early detection of, oral cancers in accordance with the Healthy People 2010 initiative, oral care providers should ask patients about lifestyles and risk-taking behaviors and conduct screening examinations for oral cancer. Resources are available to assist health professionals in improving the health of their patients and students by implementing smoking and tobacco education, prevention, and cessation programs in their practices and in the school curriculum.33,34 The Internet provides wide access to current information and resources, which benefits professionals and laypersons alike. Websites are frequently linked to other sites for expanded searches. The American Cancer Society currently has three websites offering smoking cessation information and resources: www.cancer.org, www.quitnet.org, and www.cancer.org. With funds from the National Tobacco Settlement being dispersed to 22 states in the United States, many state health departments are benefiting from an infusion of needed funds, which may be used to develop comprehensive tobacco prevention, education, and treatment programs, media campaigns, and policy development and regulatory enforcement activities to reduce youth access to tobacco products and limit public exposure to secondhand smoke. The Massachusetts Tobacco Control Program has successfully developed such a statewide network using funds primarily generated in response to a voter referendum in 1992 to increase state excise taxes on tobacco products. Some funding from the settlement is also helping to fuel this ongoing initiative. In 2000 the U.S. Department of Health and Human Services updated the Public Health Service, sponsored Clinical Practice Guideline–Treating Tobacco Use and Dependence, incorporating new and effective clinical treatments, as well as a “quick reference guide” for clinicians.35,36
Several health organizations have taken action to institute tobacco control programs and recommendations. In 1995 the ADA established a new clinical service code, number 01320, “Tobacco counseling for the control and prevention of dental disease.” The Institute of Medicine took action to protect children and youth by adopting policy recommendations for communities, states, and the federal government.33
Tobacco use remains at epidemic levels, and young people still begin to smoke and use smokeless tobacco at alarming rates.37 Oral health education efforts by dental care practitioners, other health care professionals of all types, classroom teachers, and community health educators can help decrease these trends by emphasizing how tobacco causes oral disease and many physical health problems. Fried38 suggests that “interventions with adolescent girls may prevent initiation and habituation of tobacco use.” Children learn by what they see and how they live. Parents, caregivers, and health professionals who maintain healthy, tobacco-free lifestyles set an example that youngsters may choose to follow despite peer pressure to do otherwise.
Early childhood caries (sometimes referred to as nursing or baby-bottle caries) is a growing problem in the United States, increasingly affecting affluent members of the population in addition to the racial and linguistic minority groups that have previously been known to be affected.39 Oral health education efforts must be targeted to a wide range of the population, pediatric and family practice physicians, pediatric nurse practitioners, nurses, physician’s assistants, parents, and caregivers so that a broad-based understanding of the causes, effects, and methods of preventing this devastating condition can be effectively communicated.
The oral health effects of anorexia nervosa and bulimia may assist in the clinical diagnosis of these disorders. Health care professionals need to be aware of the oral manifestations so that they can make appropriate referrals for dental treatment. These are serious psychologic disorders that may lead to death as a result of physical complications or suicide. The National Association for Anorexia Nervosa and Associated Disorders reports that at least 8 million people in the United States suffer from eating disorders that last from 1 to 15 years. Only half of those diagnosed with long-term disorders are ever cured.40
Dental professionals may play a significant role in identifying patients with eating disorders on the basis of specific oral symptoms (enamel erosion, caries, periodontal disease, changes in the oral mucosa [i.e., contusions or lacerations of the soft palate associated with induced vomiting], dehydration, erythema, angular cheilitis, and swollen salivary glands).41,42 It is the responsibility of dental professionals to be familiar with the diagnostic criteria for eating disorders. Providing appropriate treatment in a supportive environment, information, and referrals for psychologic and medical help and follow-up could save a life.
The oral health effects of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) need to be recognized and addressed by health care professionals. Oral health educators should play a part in communicating information about the effects of the disease on oral health. Dental professionals, especially dental hygienists, should be familiar with the primary manifestations of HIV and AIDS: candidiasis (thrush), hairy leukoplakia, recurrent aphthous ulcers and herpetic lesions, Kaposi’s sarcoma, linear gingival erythema (formerly HIV-G), and HIV periodontitis.43 The initial diagnosis of AIDS or HIV may be made on the basis of oral lesions and symptoms.43 Although there is no documentation of HIV transmission from patient to dental care providers or from patient to patient, providers struggle with fears of HIV transmission. Passage of the Americans with Disabilities Act in 1990 has led to a number of lawsuits against dentists for refusal to treat patients with HIV. Federal courts have ruled consistently that people with HIV can be treated safely in private dental offices.44 Ideally, the hygienist and the dentist are members of a comprehensive care team working closely with the patient’s physician in the medical and support group caring for people with AIDS. These issues are discussed in greater detail in Chapters 9 and 10.
Because oral health education must take place within a cultural context, sensitivity to cultural issues may increase the efficacy of such efforts. Oral self-care practices, attitudes, and knowledge vary across cultural groups, and these differences are important to understand before educational interventions are designed.45 For example, if a particular cultural group has a fatalistic view that says that health cannot be influenced by any actions taken by the individual, the suggestion to brush or floss the teeth to improve oral health might go against this deeply held cultural assumption. Kiyak46 has suggested that several general factors may affect a particular group’s health care practices, including “cultural values, the socioeconomic status of a given ethnic group, language differences, misinterpretations of verbal and behavioral cues in the health care encounter, and the previous medical experiences of a given ethnic group.”
An important thing to recognize is that socioeconomic status is frequently intertwined with racial and cultural factors. In the United States members of racial minority groups frequently have lower incomes and less education than whites do. Although these socioeconomic differences are associated with different racial groups, it is important to understand that the effects of race are not the same as the effects of socioeconomic factors. For example, a recent study comparing oral self-care behaviors of African-Americans and whites found significant differences in the frequency of dental visits of the two racial groups, but when socioeconomic status was taken into account, these differences were reduced.47 Additional information concerning cultural issues is presented in Chapter 5.
The importance of preventive oral self-care behaviors may increase in later life with the advent of age-related comorbidities or medication usage that affects oral health (causing, for example, xerostomia and root caries). Negative changes in oral health may result in inadequate dentition, potentially leading to nutritional deficits, speech problems, or threats to social interaction because of related functional impairments or cosmetic factors. Given the declines in physical health and activities that some elderly people face, activities involving the oral cavity (e.g., eating, talking) may assume increased importance at this stage of life. The maintenance or preservation of oral health may therefore be more important in late life than at any other life stage. Thus the promotion of oral self-care behaviors and the assurance of their performance by elders are key issues in gerontologic health and must be addressed by oral health educators (see Chapter 6 for more detailed information about the dental needs of older adults).
With more than 53 million U.S. citizens physically or mentally impaired, dental professionals need the training to meet the challenge of accommodating and appropriately treating the special needs of patients with or without disabilities. Since the Americans with Disabilities Act was signed into law in 1990, many dental offices have been structurally modified to accommodate the disabled, yet little has been done to understand the psychologic needs of special patients. By eliminating discrimination against those with disabilities and impairments, standards of performance have been established that dental professionals may not be adequately trained to meet. The Americans with Disabilities Act affects our employment, the architectural design of our workplace, and the delivery of dental services. Casamassimo48 notes that more disabled people are seeking care and that this trend is likely to continue as the population ages and as health care reforms bring capitation, portability of benefits, and extended coverage to many more people. Many people in this segment of the population continue to experience difficulty in accessing dental services. For many, the attainment of adequate oral hygiene is difficult or impossible unless a caregiver is available to assist in daily care for the prevention of oral disease, especially among individuals with mild mental retardation who may lack adequate supervision. Preventive methods are available to meet the unique requirements of the person with special needs and may include the use of adaptive aids and chemotherapeutic agents that eliminate or control microbial organisms associated with caries, gingivitis, and periodontal and other oral diseases. These measures are particularly suited for persons for whom the usual mechanical hygiene procedures of brushing and flossing present difficulties. The oral health care of special patients is intimately linked with medicine and the larger health care delivery system. Appropriate oral care is an integral part of maintaining the health and well-being of people with disabilities.
Under the leadership of dental professionals, effective oral care programs in the many special care settings in which persons with disabilities are situated can be instituted with innovative approaches to staffing and the delegation of oral care tasks. Steifel49 states that “for no other group is the achievement of good oral health as important as for those with severe disability.” For many, the mouth takes on critical importance in terms of psychologic significance and physical function; it may be the only part of the body over which the individual retains voluntary control. In the event that the dentition is lost, the disabled person may be unable to wear a denture to aid in eating or to assist in verbal or device-activated communication. Also, the disabled person may often face negative consequences in appearance, self-esteem, social acceptability, and employability. In addition, dental disease and its consequences can place the individual at serious medical risk. A comprehensive team approach that includes a continuing program of education involving patients and their families, allied health professionals and direct care staff, administrators, and dental practitioners is necessary to improve the oral health of persons with disabilities. The National Institute of Dental and Craniofacial Research, one of the National Institutes of Health, maintains the National Oral Health Information Clearinghouse (NOHIC) as a resource that focuses on the oral health concerns of special care patients. Readers are encouraged to contact NOHIC at (301)402-7364 (voice), (301)656-7581 (TTY), or via e-mail at firstname.lastname@example.org.
An ethical obligation of oral care providers is domestic violence identification and referral, a situation that may be difficult for some providers to encounter. Domestic violence has been called a “horrifying epidemic” and declared a “public emergency” that occurs more often than any other crime.50 Domestic violence or violence in the family unit, with women and children as primary victims, is a major public health problem and is a worldwide epidemic. Domestic violence threatens the lives of millions of people each year, crossing all ethnic, racial, sexual orientation, religious, and socioeconomic lines. It is estimated that 90% to 95% of domestic violence victims in heterosexual relationships are women, according to www.drkoop.com/Wellness/Domestic Violence. In January 1992 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required all nationally accredited hospital emergency departments and ambulatory care facilities to implement a protocol to identify, treat, and refer victims of domestic violence to appropriate services.51 In 1995 President Clinton introduced the Violence Against Women Act to prevent domestic violence and assist victims. Oral care providers should become familiar with the physical signs of domestic violence, especially because 68% of battered women’s injuries involve the face, 45% the eyes, and 12% the neck.52 Dental professionals have an ethical duty to learn to recognize evidence of domestic violence or sexual assault. It is also important to be aware of the possibility of child or elder abuse. When abuse is suspected, skills in counseling and referral are necessary. For dental care providers to obtain such skills, there is a need to expand the educational curricula and continuing education to include strategies for dental professionals to address issues of family violence. Readers are encouraged to review the list of domestic violence national information centers and the suggested readings compiled by Gibson-Howell.53
The content and method of health education are derived from the fields of medicine and public health and from the physical, biologic, social, and behavioral sciences. Certain concepts and theories developed in these fields have influenced the efforts and practices of health educators. In the area of oral health education, many of the proven theories of behavioral scientists have been neglected, forgotten, or unaccepted. Given that the goal of oral health education is the prevention and control of dental disease, organized efforts aimed at achieving this goal should adhere to the proven theories and concepts relevant to health education activities. Current theories of health education that research has proven to be effective are reviewed so that future dental education efforts can incorporate them.
Research has shown that a fundamental error in many oral health education activities is the assumption that increasing a patient’s oral health knowledge will help change dental care behavior. This approach, based on a solely cognitive model, assumes the following sequence:
If this relationship were true, every oral health education program that increased the participants’ level of dental knowledge would have resulted in a behavioral change that improved the oral health status over a long period of time. To date, no evaluation of a oral health education program has produced such results.6–10
An error commonly made with this cognitive approach occurs when the educator fails to assess the learners’ level of knowledge before the educational encounter and treats the individuals as if they were void of any knowledge or past experiences at all. As Yacavone9 notes, it is important to realize “that the person is already ‘behaving’ when we encounter him–maybe not as we would like him to, but ‘behaving.’” To influence a person’s behavior through health education activities, an understanding of the dynamics of behavior is paramount.
A person’s behavior is the result of both internal and external forces. Beliefs, attitudes, interests, values, needs, motives, personality, expectations, perceptions, and biologic factors, plus the influence of family, peer groups, and mass economic factors such as occupation, education, and media, shape and affect actions.54 Sociodemographic factors such as age, race or culture, sex, occupation, education, and income have also been shown to have a strong influence on oral health practices and should be considered when designing and implementing health education strategies. The interaction of these forces has been illustrated in a model developed by Kressin (Box 11-1). Considering this model, it becomes evident that a straight-line relationship between the educator’s efforts and the learner’s behavior usually does not exist. To develop an effective oral health education program, the educator must be aware of the interaction of all the forces on the learner. The educator must first assess the learner or learners to develop and implement a rational educational program that will result in a sustained behavior change.
Courtesy N. Kressin, 2001.
This perspective on health behavior says that an individual’s behaviors are motivated by both beliefs (cognitive factors) and factors in the social environment (e.g., one’s community, friends, and family).55 The specific beliefs that are viewed as most important are concerned with an individual’s perceptions of self-efficacy, that is, beliefs that the individual can perform a particular behavior effectively and with good results. Aspects of the social environment important in this theory include learning how to perform a specific behavior by watching others do so and receiving support or reinforcement from others in the environment for practicing certain behaviors.
A number of studies conducted by Tedesco and associates56,57 have demonstrated that aspects of social cognitive theory are important in the development and maintenance of oral self-care behaviors such as brushing and flossing. Individuals participating in the educational programs designed by Tedesco and associates56,57 brushed and flossed for a longer period of time when they learned about these behaviors by practicing them as part of the educational process and when they received support and reinforcement from the dental educators about their capability to perform the behaviors. The findings from this research highlight the importance of actually practicing new behaviors as part of an educational intervention and of receiving positive feedback from dental educators for practicing the behavior correctly. Together, these factors increased the participants’ self-efficacy–their belief that they could successfully improve their oral self-care.
The theory of reasoned action states that an individual’s behaviors are primarily determined by intentions to perform the behavior.58 In turn, the individual’s intentions are determined by attitudes and beliefs about the behavior. Specifically, attitudes about what will result from performing a certain behavior (for example, that flossing will prevent periodontal disease and that retaining natural teeth is important) are thought to influence the likelihood that the individual intends to perform and actually performs a certain behavior. Also important to understanding attitudes are beliefs about how others will respond to the behavior (e.g., that others will notice and approve of cleaner-looking teeth and gums).
Oral health education efforts based on this theory should be directed toward increasing individuals’ intentions to care for their oral health by (1) emphasizing the importance and value of maintaining oral health and retaining the natural teeth, (2) educating and reassuring people that they can indeed effectively care for their oral health and prevent oral disease, and (3) changing community and societal norms so that more individuals are motivated to care for their own oral health and to support their friends and family in doing so.
Developed by Rosenstock,59 the health belief model considers a variety of factors thought to influence individuals’ health behaviors. The first factor is an individual’s readiness to act. Without this readiness, a person is unlikely to change a particular behavior, whether it involves quitting smoking or starting to floss the teeth daily. This readiness is considered a function of two things: the individual’s perceptions about the severity of the disease and the person’s susceptibility to it. If an individual does not think he or she is likely to get oral or lung cancer as a result of smoking or periodontal disease if he or she does not floss, the individual is less likely to stop smoking or start flossing.
The second factor that the health belief model considers is an individual’s consideration of the perceived costs and benefits of performing a certain behavior. If a person perceives a lot of difficulty in withdrawing from nicotine and perhaps gains weight as a result of quitting, he or she may conclude that the costs of quitting smoking are too great. Similarly, if a person feels that the time and energy required to floss daily are more than can be handled, that person might be less likely to do so. Alternatively, if a person’s views of the benefits of quitting smoking are strong and highlight the money saved, being able to breathe easier, and decreasing risks to physical and oral health, these perceptions might make it more likely that such individuals will quit smoking.
The last set of factors that the health belief model considers are referred to as cues to action. These cues prompt individuals to act by reminding them of the need to change their behaviors. These stimuli may be internal (such as pain or discomfort) or external (such as advertising campaigns reminding people of the harm done by smoking or a physician telling someone how much smoking hurts health).
From the perspective of the health belief model, a major obstacle to preventing dental disease through preventive behaviors may be the perception that the consequences of dental disease are not serious. In most cases dental disease is not life threatening, and a large portion of the population functions without their natural teeth. In a survey conducted by the Opinion Research Corporation for the ADA, the public’s chief barrier to prevention of dental disease was identified as the low value many Americans place on regular preventive dental care.60 Educational efforts designed with the health belief model in mind emphasize the fact that most individuals are vulnerable to the development of oral disease if they do not care for their teeth and that such disease may result in losing the natural teeth and that oral functions such as smiling and chewing are easier with natural teeth (emphasizing the severity of the disease and the individual’s susceptibility). Further, such educational efforts should emphasize that caring for the dentition through regular flossing, brushing, and preventive care will have the long-term benefit of retaining the teeth (emphasizing the perceived benefits) and that such efforts are relatively easy and require just a few minutes of time each day (emphasizing the low costs and the ease with which perceived barriers can be overcome). Finally, oral health education based on the health belief model provides cues to action that remind people about the need to take care of their oral health.
The stages of change model of behavioral change describes common stages of change through which individuals go when trying to change health-related behaviors.61 The first stage is precontemplation, which represents a time during which an individual is not actively thinking of changing a particular behavior. The next stage, contemplation, is when the individual begins to think about behavioral change. During this time he or she may think, read, or talk to others about changing a behavior and may become open to health education, in preparation for taking actual steps to change behaviors. The action stage is when an individual actually takes steps to change the behavior. Individuals are in particular need of support for their changed behaviors during this time, which may include specific training or education and social support from family and friends. Assuming that successful actions are taken, the individual moves into the maintenance stage, in which he or she attempts to continue the behavioral change. At this time it is helpful to identify factors that may tempt a person to relapse, so as to prevent, avoid, or learn how to deal with these factors. Relapse occurs when the individual is unable to continue to maintain the changed behavior; relapse is extremely common. The model and process is circular, however, so an individual can move on to another stage when ready to try again to change behavior.
Oral health education efforts should be mindful of the various stages of change that individuals can be in because these affect receptivity to educational efforts and the subsequent efficacy of the education. On the basis of this model, it is important to offer education to individuals who are ready to hear it (i.e., those in the contemplation, action, or maintenance stages). However, in community-based efforts where attendance is voluntary, it is likely that only individuals in these stages would attend educational programs.
The fourth and most current approach is the contemporary community health (or public health) model of health education, which takes into account social, cultural, economic, and other environmental factors that influence health. Rather than “blaming the victim” for noncompliant behavior and subsequent illnesses, the need for changes in influential variables such as the social, political, economic, and industrial environments is recognized. The community health model emphasizes the important role of public involvement in identifying individual and community health problems, setting priorities, and developing solutions to these problems, and it empowers population groups with accurate information about health and health care technologies. The utility of broad approaches to health education and promotion at the community level has been demonstrated in studies of other health areas.17,62–64 However, with few exceptions, dental professionals have not yet accepted many of the community-level methods used in these demonstrations. The World Health Organization has clearly stated the need for using sound community organization and community development principles of working with focus populations, such as sharing in decision making.65,66
The objective of community organization is to create awareness, interest, and desire to solve a problem while working with others to solve the problem. By involving people in making decisions about regimens or programs to improve their own health, people will tend to unite and maintain the level of commitment to, and motivation for, carrying out necessary actions to solve the problems.13,14 Readers are encouraged to review the Stanford Five City Project, which describes the communication-change framework; social marketing; the application of formative research in designing, modifying, and distributing printed educational materials; the use of mass media education; program planning; and evaluation.62 The Stanford Five City Project is an evaluation of a community-wide approach to the control of cardiovascular disease through healthy changes in behavior. This approach may be generalizable to dental disease prevention efforts as we continue to learn to unite a variety of medical, behavioral, communication, and social science theories with demonstrated applications to solve health problems.17
Social marketing is emerging as a new method for promoting desirable social change, by increasing the public’s acceptance of social ideas or practices among target groups. Social marketing combines the use of successful advertising and marketing techniques and applies them to changing people’s ideas and behaviors. In comparison with traditional marketing techniques, social marketing aims to change people’s attitudes about nontangible products, including ideas, services, and practices.67
How does social marketing work? The first aim of this method is to understand the “customer’s needs.” Through market research, the audience becomes known and understood by program planners. Second, the “product” must be made available through the media or other communication channels. Program planners need to selectively choose their communication channels based on their knowledge of the targeted community or population. Third, pricing must be considered. For example, if the aim is to increase rates of brushing and flossing within a population, the price of dental floss or toothbrushes may be lowered, or such products may be given away free of cost. Fourth, those involved in social marketing need to consider the opportunity costs of adopting a new behavior or idea. For example, time spent visiting the dentist or engaging in oral self-care could be spent in other activities, and individuals need to be persuaded that such activities are worth the time they invest in them.
Social marketing has been used to decrease tobacco consumption, increase health and safety, encourage improved nutrition and increased physical activity, and enhance the effectiveness of HIV/AIDS prevention programs, and it could be a useful device for oral health education as well.68–73
Silversin and Kornacki74 have stated that the media has a role in promoting behavioral change: “Media-based campaigns to promote oral health have been shown to be more effective if they continue over long periods of time, appeal to multiple motives, are coupled with social support, and provide training in requisite skills.” In addition, product advertising may influence public opinion and behavior.
Organizations such as Action for Children’s Television (ACT), the Center for Science in the Public Interest (CSPI), the National Congress of Parents and Teachers (National PTA), and the American Academy of Pediatrics (AAP) have expressed concern about the marketing of relatively nonnutritious foods to children.75–79 A nonprofit consumer-advocacy group based in Washington, D.C., CSPI has focused on nutrition and food safety issues since its founding in 1971.80
In 1992 the Children’s Television Act took effect, setting limits on the number of advertisements allowed during children’s shows and mandating that all broadcasters carry children’s educational or instructional programming as a condition for license renewal by the Federal Communications Commission (FCC). However, the FCC has concluded that this requirement can be met by citing public service announcements or short vignettes in fulfillment of the programming requirement. The American Academy of Pediatrics emphasizes that local oversight is necessary to monitor how stations meet these guidelines. The academy urged parents to take an active role in educating their children to become responsible and informed consumers and noted that media literacy should be taught to children in schools and in a variety of other settings.78,79
The increased use of tobacco products (smoking cigarettes and cigars and using chewing tobacco) in films and on commercial television is a cause for concern. Despite the tobacco industry’s agreement with the FCC to voluntarily remove tobacco advertising from television in 1969, the tobacco industry has paid stage and screen actors to smoke while acting, claiming that smoking is essential to the character or situation. In reality, performers who may serve as significant role models for our youth may by their actions be promoting dangerous and often deadly lifestyle behaviors for personal gain and tobacco industry profits. In a nation where an estimated 3000 youngsters begin smoking each day, the print, film, and advertising media are effectively influencing the actions and ultimately the health of our children. Surveys conducted by the National Center for Chronic Disease Prevention and Health Promotion indicate that brand choices of adolescent smokers were heavily concentrated on those brands with the largest advertising budgets.81,82 A 1991 survey in the Journal of the American Medical Association found that Joe Camel was as recognizable as Mickey Mouse to 6-year-olds. It is not surprising that, as a result of R. J. Reynolds’s Camel campaign, which was backed by a company research program, Camel’s share of the youth market jumped from roughly 3% in 1988 to 13% in 1993.83 Cigarette advertising is an important influence on the smoking behavior of the young, with advertising sensitivity being approximately three times larger among teenagers than among adults. Cigarette advertising puts children at greater risk by influencing and distorting their perceptions of the pervasiveness, image, and function of smoking within society.84 Media images are often blamed for children adopting risky behaviors. In March 2001 a study funded by the National Cancer Institute at the Pediatrics Department of Dartmouth Medical College was released that substantiated this relationship. Data from New England middle schoolers provided the first direct evidence linking movie exposure to smoking and alcohol use in children and adolescents. After researchers measured tobacco’s actual screen time in movies based on what the children had reported seeing, they found that the youngsters who had seen the most tobacco images were five times as likely to have used cigarettes as kids with the least exposure. This relationship prompted the suggestion that parents need to view movies as a potentially “toxic” exposure that could adversely affect children’s health behavior and in that respect may be little different from other environmental toxins such as lead or mercury.85,86
Dr. David Kessler, former Commissioner of the Food and Drug Administration (FDA), has referred to smoking as a “pediatric disease” because the average smoker begins by age 15 years and is a daily smoker by age 18 years. Although smoking levels among adults have been declining, smoking is on the rise among those under 19 years of age. Many children who start smoking every day end up as statistics a few decades later. According to Michelle Bloch of the American Medical Woman’s Association, “Fully half of all long-term smokers, especially those who begin in their teenage years, will be killed by tobacco. Of those half will die early in middle age.”83
In 1995 President Clinton announced that the FDA proposed to regulate nicotine in tobacco as a drug, despite the tobacco industry’s 100-year-old claim that tobacco is neither food, drug, nor cosmetic. The FDA launched a major initiative to strictly limit tobacco advertising to youth and other measures intended to curb youth access to tobacco products. The FDA’s goal was to reduce the number of children and adolescents who use tobacco products by 50% within 7 years by putting restrictions on the sale and distribution of nicotine-containing cigarettes and smokeless tobacco products and by limiting minors’ access to these highly addictive products. The ADHA has stood strongly in support of public policy and legislative efforts to curb underage smoking.87 In 1996 President Clinton signed an executive order that passed the final version of regulations proposed a year earlier. The FDA had planned to phase them in over a period of 6 months to 2 years. However, the tobacco industry, the advertising industry, and the wholesale and farm communities filed three lawsuits attempting to block the implementation of the rules. In 2000 the U.S. Supreme Court ruled that the FDA did not have the explicit authority to regulate nicotine in tobacco. Also in 2000 the historic $246 billion multistate tobacco settlement between the state attorneys general from 22 states and the major U.S. tobacco companies was enacted. This settlement was intended as restitution for state Medicaid funds expended for the treatment of citizens with tobacco-related illnesses and was intended to place restrictions on tobacco company marketing and advertising activities. However, the agreement failed to address the following matters: (1) need for comprehensive programs to prevent and reduce tobacco use in every state; (2) protecting people from secondhand smoke; (3) ban tobacco vending machines and self-service displays nationally, which would greatly reduce youth access to tobacco products; (4) need for more effective and more visible health warnings on tobacco products; (5) granting the FDA explicit authority to regulate tobacco products; (6) restriction of U.S. tobacco company marketing to youth overseas; and (7) assist U.S. tobacco farmers’ transition to other forms of income. The agreement has established several restrictions on tobacco company marketing and advertising. Restrictions include the following: (1) eliminates tobacco billboards and transit ads; (2) prohibits use of cartoon characters to promote tobacco products; (3) prohibits tobacco brand-name merchandise (e.g., hats, T-shirts), except at tobacco-sponsored events; (4) prohibits tobacco brand-name sponsorship of concerts, events in which any contestants are under 18, football, baseball, soccer, and hockey (except for Brown & Williamson’s continued sponsorship of the Kool Jazz Festival and the GPC Country Music Festival); (5) limits other tobacco brand-name sponsorships to one event or series per year per manufacturer (e.g., Winston Cup Race Tour); (6) permits free tobacco-product distributions only at locations where children are not permitted; (7) restricts offers of nontobacco items or gifts based on proof of purchase to adults; (8) prohibits the use of nontobacco brand names on tobacco products; and (9) reaffirms the previously agreed on prohibition on tobacco product placement in movies and on TV. Despite these concessions, the agreement still permits tobacco companies numerous opportunities to market and advertise their deadly products through unlimited advertising in newspapers, magazines, places that sell tobacco products, the Internet, and direct-mail advertising; permits unlimited tobacco-company sponsorship of events in their corporate name as opposed to brand-name advertising; and permits televising of tobacco brand-name, sponsored events. Tobacco companies can continue to advertise on buildings or property of places where tobacco is sold and at industry-sponsored events and can continue to use human images in tobacco advertising. Each tobacco company may continue single brand-name sponsorship of auto racing, rodeo, or other events, which may include an entire series of events (e.g., all NASCAR races).
Although President Clinton recommended that states receiving funds from the settlement target those funds for health-related purposes, the settlement says nothing as to how that money should be spent. During the 2001 congressional legislative session, several U.S. representatives proposed tobacco control bills to address several matters that the multistate tobacco settlement did not adequately address, as well as the authority of the FDA to regulate nicotine as a drug. If enacted, the bills will explicitly authorize the FDA to regulate tobacco products, impose financial penalties against tobacco companies if youth smoking rates do not decline, establish smoke-free indoor workplaces and public places nationwide (with few exceptions), and provide funding for tobacco control programs. For more information on tobacco-related legislation, issues, and resources, check the website developed and maintained by the CDC, www.cdc.gov/tobacco, with links to other useful sites such as www.tobacco.neu.edu (maintained by the Tobacco Control Resource Center at Northeastern University School of Law) and www.tobaccofreekids.org (maintained by the Campaign for Tobacco Free Kids).
Budgets for promoting preventive oral health interventions cannot compete with budgets for promoting products that are pushed and pulled into the marketplace with huge sums of money (e.g., tobacco, automobiles, cosmetics). The success of product advertising is based on linking personal satisfaction or enhanced self-esteem with the use of a product. Thus far, oral health promotion has not succeeded in linking preventive dental behaviors with motives other than health.74 However, promotional advertising of in-office tooth-whitening systems by organized dentistry for the purpose of enhancing personal appearance and sexual attractiveness may prove to have a strong appeal as a social marketing tool, effectively increasing demand for dental treatment among adult smokers and nonsmokers, as well as young adults.
Rubinson88 has identified parents as the most pervasive intervening variable in school oral health programs. Many program developers and evaluators do not consider enlisting the cooperation of parents.88 Rubinson88 further states that “the parents will certainly have a direct influence on oral health habits and should be involved with programmatic efforts.” The evaluation of oral health programs should be redirected to focus on efforts stressing skill acquisition and reduction of behavioral risk factors through an evaluation plan that is both plausible and realistic in the school setting. Perry and associates64 have demonstrated the effectiveness of combined school, parent, and community approaches to child health behavior in the Minnesota Home Team Project. This case demonstrated how sharing responsibility can be accomplished, and it established the superior impact of shared responsibility between the school and the home on children’s knowledge, skills, and practices with respect to dietary intake of more healthful foods.
The School Health Education Evaluation (SHEE), conducted in collaboration with the CDC from 1982 through 1984, suggests that exposure to health education curricula in schools can result in substantial changes in students’ knowledge, attitudes, and self-reported practices.89 The SHEE has provided evidence that school health education curricula can effect changes in health-related knowledge, practices, and attitudes and that such changes increase with the amount of instruction. The potential impact of these changes is significant.89 In response to this study, many school systems are reevaluating their health curricula and considering increased integration of health messages throughout the curriculum. Teachers will require additional training to develop greater competency on health issues. In view of budget limitations, teachers will continue to be the primary source for the dissemination of health education in our schools, with the assistance of health professionals in the community. Readers are encouraged to review the 10 basic elements that constitute comprehensive school health education as defined in the SHEE study.90
The complexity of the variables that must be taken into account in designing an oral health education program to motivate behavioral change for an individual has been briefly discussed. Greater detail and step-by-step procedures can be found in books devoted solely to the techniques of behavior modification and to the social sciences in dentistry.12,91,92
Oral health education programs for the community have gone through, and will continue to undergo, periods of transition as further study reveals educational methods that will produce desired preventive practices. Research has shown that behavior is not transmitted; behavior is learned. In health care, learning requires active participation on the part of the learner. For this reason the primary objective of most oral health education programs is to motivate individual students to seek the goal of disease prevention and tooth conservation.
Historically, oral health education for children has been a priority for the dental profession because of the high prevalence of dental caries in this age group. As a result, the school system has emerged as the most logical and practical setting to implement large-scale oral health education programs.93 The school-based oral health program provides an opportunity to reach the largest number of children during early stages of development when habit patterns can more easily be modified or changed. The school setting also provides an environment conducive to learning and reinforcement for a considerable period of time and allows the teachers to use various strategies for inducing children to participate in appropriate preventive oral health actions.94