WHAT IS HEALTH PROMOTION?

Community health promotion is defined as any combination of educational, social, and environmental actions conducive to the health of a population of a geographically defined area.³⁹ Another definition is that health promotion is a set of processes that can be employed to change the conditions that affect health, so that targets are not always the people whose health is in question.⁸³ Yet another simply states that health promotion is the process of enabling people to increase control over, and to improve, their health.¹⁰¹ These definitions all envision roles for the health professional, political leaders, society as a whole, and the individual in maximizing health status. Health education is an important part of health promotion, though it is just one part of the larger entity. Health education is defined as any combination of learning opportunities designed to facilitate voluntary adaptations of behavior that are conducive to health.³⁸ Health education and health promotion have been described as the mechanisms that connect prevention activities, policy development, and program implementation, maintenance, and evaluation.³¹

Although health is an elusive entity to define, we stated in Chapter 4 that it is more than the mere absence of disease and less than the idealistic definition of the World Health Organization (WHO). Greenberg refers to health as a quality of life with social, mental, emotional, spiritual, and physical functions,⁴¹ and he points out that too much emphasis is usually given to the physical function at the expense of the others. In effect, Greenberg is arguing for a “holistic” view of health. He defines wellness as a positive state, the degree to which a person has reached her potential regarding each of the components of health. Because it is the integration of social, mental, emotional, spiritual, and physical components at any level of health or illness, people can be healthy or ill and still possess a high degree of wellness.

At least among the better educated, the traditionally narrow view that equates health with the absence of disease has already given way to a broader, positive concept based on Greenberg’s definition. In day-to-day terms, attainment and maintenance of health are no longer just a matter of an annual medical checkup, but also include engaging in regular exercise, making sensible food choices, getting sufficient sleep, having some form of spiritual belief, maintaining friendships, and indulging in a diversity of interests. Society is much less tolerant of destructive behaviors like smoking and drunken driving than it once was, and interest in healthy eating has never been higher.

It is recognized, however, that this positive view has not permeated all strata of society to the same extent.^33,95 There are good reasons why. At the individual level, education results in greater access to knowledge and information, and it develops information-seeking attitudes and skills. In addition, better-educated people usually lead lives that give them more opportunities to develop healthy lifestyles than do those who have to spend more time and energy in just making ends meet. At the community level, the characteristics of the neighborhood and communities in which people live and work have become recognized as prime determinants of health status.^50,51

This concept of health promotion began to take root during the 1970s and was much influenced by a working paper put out by the Canadian Minister for Health at the time, Marc Lalonde. More of a visionary than many political leaders, Lalonde introduced the health field concept, a new idea at the time, as he tried to evaluate the impact of Canadian health policies.⁵⁷ Specifically, Canada had moved to a program of equal access to health care for all citizens through public financing, and Lalonde had observed that increased access to health care services did not by itself improve health status.

The health field concept, as Lalonde envisioned it, is a framework for the evaluation and analysis of community health needs that includes assessments of human biology, environment, lifestyle, and health care organization in more or less equal parts. Before Lalonde’s analysis, such assessments had usually been dominated by health care organizations (i.e., the view was that health services equal health), but today we are much more aware of the importance of the other factors as well. The cohesion and functionality of a community is often expressed as its social capital, which consists of features of social organization such as trust between citizens, norms of reciprocity, and group membership, that facilitate collective action.⁵² The wider concept of health promotion includes the investment of social capital, which can relate health status to availability of community amenities such as libraries, recreational facilities, biking and walking trails, public transportation, and employment opportunities, things that are provided by the community rather than by the individual. Factors that were seen by the influential Ottawa Charter as fundamental preconditions for health are shown in Box 5-1.

In an ideal world, governments would have policies in place that do not interfere with peoples’ lives but that give them the freedom to make informed choices on their health behavior. As a negative example, homeless people are preoccupied with fundamentals of day-to-day survival and live in a world that is deficient in many of the preconditions for health listed in Box 5-1. As a result, they have little opportunity to make rational choices on matters affecting their health. The first step in promoting health among the homeless, therefore, is to provide decent housing and adequate food, and do whatever else can be done to improve self-esteem. If we hark back to the definition of health promotion, we see that such steps represent the organizational, social-economic, and environmental supports that are basic to the development of healthy behaviors. Governmental action in this area often means legislation. In the high-income countries we are familiar with specific laws on matters like cigarette advertising, use of seatbelts and safety helmets, and immunizations for children. These laws, through which society accepts some constraints on absolute freedom in the interest of public health, are in addition to the public health codes covering water supplies, food preparation, and public accommodations. In the oral health area, legislation that mandates or permits water fluoridation, and the statutory basis in some countries for school dental programs, are both organizational aspects of oral health promotion.

COMMUNITY-BASED HEALTH PROMOTION

The principal community-based health promotion programs that have been conducted in the United States have been directed at reducing the risk for cardiovascular disease. Nothing on this scale has been carried out for oral health, though there are issues in these programs from which dentistry could well learn for implementation of its own health promotional programs.

Three major community-based programs aimed at reducing the risk factors for cardiovascular disease were implemented in the United States during the 1980s. All were focused on individual risk factors, because an appreciation of the role of social factors was still in its infancy at the time. These programs were conducted in Pawtucket, Rhode Island,⁸ the state of Minnesota,⁴⁶ and five cities in central California.²⁷ These projects were completed by the 1990s, and in retrospect they were all modestly successful, though not as conclusive as had been hoped.^2,28,35 Certainly a great deal was learned about the benefits and limitations of large-scale health promotion programs.

The projects had some features in common:

To assess the impact of community-wide health promotion, it is worth looking at one of these projects in detail. The purpose of the Stanford Five-Cities study, as an example, was to seek reductions in the cardiovascular risk factors of smoking behavior, high blood cholesterol level, and hypertension. The project began as the Stanford Three-Community study in 1972,²³ and promising results led to its expansion to become the Five-Cities study. The project was designed to test whether a comprehensive program of community organization and health education would produce favorable changes in risk factors, morbidity, and mortality in two treatment cities compared to three control cities over a period of 6 years. The methods chosen for comparative study were mass media health education in one city, and mass media education plus personal instruction for those at highest risk in the second.

This 6-year intervention was influenced by Bandura’s social learning theory.⁴ This theory states that reciprocal relationships exist between an individual’s behavior, cognitive processes, and the external environment, and that these relationships are mediated by self-efficacy: the individual’s belief in her competence to carry out specific actions. In practical terms, this theory states that the professional office environment is not conducive to learning and maintaining good health behavior; such activities are best carried out at home, at work, and in other community settings. The Stanford Five-Cities study was a sophisticated program, making use of community organization principles and social marketing methods.

The Stanford study design included biennial assessments of cohorts followed over the 6 years and assessments of independent cross-sectional samples at 2-year intervals. Results at the end of the 6 years showed that the treatment cities exhibited greater improvements with regard to most of the risk factors being measured (cardiovascular disease knowledge, blood pressure, smoking behavior, resting pulse) than the controls.^22,29 Mixed results were found for body mass index,⁸⁶ which suggests less than fully effective results. What were not expected were the improvements in the control cities, presumably due to the widespread media publicity given to cardiovascular risk factors.³⁰ Although findings overall were positive, the beneficial trends in the control cities made the net changes attributable to the program rather small.

A major question after such large-scale projects is whether the good results achieved are maintained after the project’s completion. To answer that question, participants in the Stanford project were followed up 4 years after the main project finished. Small net improvements in most risk factors measured were maintained in the treatment cities relative to the control cities, though trends in body mass index went the wrong way in both treatment and control cities.⁹⁷ This outcome was similar to the one found in the Minnesota Heart Health Program, in which strong efforts at obesity control ended in failure,⁴⁹ and in Pawtucket, where levels of physical exercise did not increase.¹⁹ The conclusion of the Stanford researchers was that the modest net differences suggested that new designs and forms of intervention are needed to better reach those at highest risk. Later reflections on the Stanford study in health promotion included the rather humble admission that the researchers had learned little about the factors which determine population-level change, and the lowering of risk factors in the control cities was clearly unexpected.²⁷

When the combined success of the interventions in all three of the cardiovascular health promotion projects was assessed, trends were in the favorable direction, although most differences between treatments and controls were not statistically significant.^64,96 There was agreement, however, that the success of community interventions of this type was linked to the community organization process.⁶⁸

Cardiovascular disease is a life-and-death matter, and the modest impact of these extensive and expensive health promotional interventions on such a serious disease is sobering. At the same time, most risk factors showed an overall secular decline in both treatment and control cities, which is good news. The conclusion that we really don’t know much about how to effect community-wide behavioral change seems the correct one here. For dentistry, it is worth reflecting on the lessons from these cardiovascular studies, given that apart from oral cancer we do not deal with life-threatening diseases.

PROMOTION OF ORAL HEALTH

Health promotion requires active interventions at different levels and by different organizations, and the health professional organizations are certainly important components. Campaigns conducted by professional organizations themselves, however, are often a mix of health promotion and public relations. Public relations exercises may have their place, but they should not be confused with health promotion. The American Dental Association (ADA), for example, launched a television campaign in the mid-1980s to increase patient visits among adults over age 30 years, mostly by presenting the health benefits of regular dental care.¹⁵ Although the ADA’s House of Delegates voted not to finance this campaign nationally, several state associations picked it up for local use. The success of this campaign, in terms of improving oral health, is uncertain because of its narrow focus. The same could be said about an institution like National Children’s Dental Health Month and special events in that month like Give Kids a Smile! Day. The activities aimed at getting dentists more involved in smoking cessation among their patients (see Chapter 30), although obviously focused on the individual patient, are also a contribution toward community health promotion.

Dentists and dental hygienists spend a lot of time in educating their patients, and the public, on the value of good oral health. Organized campaigns such as the ADA’s Children’s Dental Health Month have also been conducted fairly regularly. All this effort has probably had some impact, though we can’t tell just how much. There is little question that over the last few decades the status of the public’s oral health, and its standards of oral hygiene, have continued to improve. Once again, however, we do not know how much of this can be attributed directly to oral health education and how much to rising living standards and norms of personal cleanliness and grooming (i.e., the type of “external” influences that were noted earlier in the Stanford Five-City study: good things happening outside of our control). We can also accept that the rising utilization of dental services (see Chapter 2) is evidence of increasing public acceptance of the value of good oral health.

The mass media, especially television, are frequently used in promotional programs in oral health, but again the effects are hard to measure. For example, a national campaign in Finland in the early 1980s used the mass media to try to increase demand for dental services. Although the proportion of adults making an annual dental visit rose from 54% to 65%, the researchers concluded that the mass media were not effective in changing health behavior.⁶⁹ The value of the mass media in promoting dental visits and good oral health behavior was also questioned after a 1980s campaign in the Netherlands.⁷⁸ These findings were not really surprising, because researchers earlier had defined the limitations of mass media in changing health behavior.^9,32 The Stanford Five-City cardiovascular intervention program, described earlier, also reached ambivalent conclusions on intervention strategies that relied heavily on television and newspapers.

One problem in defining a role for mass media in oral health promotion is that evaluation carried out by market researchers, accustomed to dealing with commercial advertisements, is often “process” evaluation that stops short of detecting outcomes. An example is seen in the evaluation of a Michigan television campaign in the late 1980s. Correct description of the advertisements was given by 22% of a random sample of adults, up from 13% early in the campaign. Aided recall, meaning recall after some prompting, rose from 23% to 32%, and 12% of those interviewed said they were influenced by the commercials.⁵⁶ Recording whether the message was seen and understood is relatively cheap and easy to do by an experienced social research group, but measuring the actual impact of the campaign on oral health is more complicated.

An example of an oral health promotional campaign is a sealant program conducted by the Ohio Department of Health.⁸² Results of an oral health survey of children in Columbus, which showed that caries experience was greatest among poorer children, were used as the rationale for grant support, which permitted continuation, and even expansion, of the sealant program in the city schools. But the data served wider purposes as well. They were invaluable in “marketing” the program among influential legislators, in developing a supportive constituency among parents and school personnel, and in educating the public. The end result was a preventive program that not only directly improved the oral health of the children concerned but that had the solid support of the community because its purposes were well understood and accepted.

Oral health promotion is more encompassing than dental health education and takes a broader approach to closing the oral health gap between the social strata. Oral health promotional efforts today should include the common risk factor approach, which brings oral health into the health mainstream by recognizing that much general health promotion (e.g., concerning tobacco use, diet, and hygiene) is also related to oral health.⁸¹ The role of social capital in oral health promotion is still being worked out, though some role for it is generally accepted. The growth of interest in epidemiology across the life course, which addresses the question of how events and circumstances in childhood affect health in adulthood,⁹³ will also help give oral health promotion a stronger scientific basis.

GOALS FOR ORAL HEALTH

At the international level, global goals for oral health in the year 2000 were established by the Fédération Dentaire Internationale (FDI, now the World Dental Federation) in 1982 and are listed in Box 5-2. These goals were developed after a great deal of discussion and with the strong involvement of WHO. They have passed into history now but are shown because they pretty well did what they were />