The mission of public health is to “fulfill society’s interest in assuring conditions in which people can be healthy.”¹ Without public health, including community oral health, society as a whole suffers because of lost productivity, decreased learning among school-age children as a result of health-related absences, and increased health care costs. Surgeon General David Thatcher, in the May 2000 Surgeon General’s Report,² refers to dental disease as a “silent epidemic that restricts activities in school, work, and home, and often significantly diminishes the quality of life.” He further states:

To improve the quality of life and eliminate health disparities demands the understanding, compassion, and will of the American people. There are opportunities for all health professionals and communities to work together to improve health.²

This chapter discusses community oral health programs as opportunities to address the access to dental care problems for children and adults. Evidenced-based practices, those that have been scientifically proven to be effective, are offered in these programs as a means to achieve improved oral health and consequently, overall health for all populations.

National, State, and Local Programs: Role of the Health Department

Essential Public Health Services for Oral Health

The core public health functions of assessment, policy development, and assurance shape the basic practice of public health at state and local levels. These core public health functions and the essential public health services (see Chapter 1) provided input into the Essential Public Health Services for Oral Health developed by the Association of State & Territorial Dental Directors (ASTDD) (Box 6-1).³ These guidelines describe the roles of state oral health programs and have been used in the development and evaluation of public health activities at the state level.

BOX 6-1

Essential Public Health Services for Oral Health

Assessment

• Assess oral health status and needs so that problems can be identified and addressed.

• Analyze determinants of identified oral health needs, including resources.

• Assess the fluoridation status of water systems and other sources of fluoride.

• Implement an oral health surveillance system to identify, investigate, and monitor oral health problems and health hazards.

Policy Development

• Develop plans and policies through a collaborative process that supports individual and community oral health efforts to address oral health needs.

• Provide leadership to address oral health problems by maintaining a strong oral health unit within the health agency.

• Mobilize community partnerships between and among policymakers, professionals, organizations, groups, the public, and others to identify and implement solutions to oral health problems.

Assurance

• Inform, educate, and empower the public regarding oral health problems and solutions.

• Promote and enforce laws and regulations that protect and improve oral health, ensure safety, and ensure accountability for the public’s well-being.

• Link people to needed population-based oral health services, personal oral health services, and support services, and assure the availability, access, and acceptability of these services by enhancing system capacity, including directly supporting or providing services when necessary.

• Support services and implementation of programs that focus on primary and secondary prevention.

• Assure that the public health and personal health workforce has the capacity and expertise to effectively address oral health needs.

• Evaluate effectiveness, accessibility, and quality of population-based and personal oral health services.

• Conduct research and support demonstration projects to gain new insights and applications of innovative solutions to oral health problems.

Adapted from Association of State & Territorial Dental Directors (ASTDD). Guidelines for State and Territorial Oral Health programs. Sparks, NV: ASTDD, 1997.

Many states have developed programs that include the essential services for oral health. For example, in the state of Washington, the “Smile Survey” was initiated to provide statewide screenings for children to assess the status of their oral health and to identify gaps in access to care. Preventive programs, such as sealants and oral health education, have followed as an answer to the problem of tooth decay. In addition, the Washington State Oral Health Coalition was formed in 1993 to further support improvements in oral health. A coalition is a diverse group of individuals, organizations, and agencies that unite to reach a common goal. An oral health coalition is therefore a cooperative effort on the part of many individuals and organizations to build systems and develop programs that improve community oral health.

The Washington State Oral Health Coalition has proved to be an excellent means of bringing dedicated professionals together to resolve oral health issues through policy development. This coalition is also involved in continual assessment of oral health and in the assurance of oral health solutions. More than 20 different locations in Washington have established oral health coalitions, with representation from consumers, schools, community clinics, health care and dental providers, health departments, and agencies that come in contact with low-income and minority populations. Anyone interested in achieving the goal of optimal oral health for Washington residents is invited to join. The strength and unity of a coalition make this goal attainable. The Washington Department of Health and the DHHS have developed a document, Community Roots for Oral Health: Guidelines for Successful Coalitions, that is available to people interested in forming an oral health coalition to improve the oral health of residents in their community (Box 6-2).⁴

BOX 6-2

Oral Health Coalitions

• Provide public recognition and visibility.

• Leverage resources; expand the scope and range of services.

• Provide a comprehensive approach to programming.

• Enhance clout in advocacy and resource development.

• Enhance competence.

• Avoid duplication of services, and fill gaps in service delivery.

• Accomplish what single members cannot.

Adapted from Children’s Alliance: Washington State Oral Health Coalition. Available at www.doh.wa.gov/.

Assessment, Planning, Implementation, and Evaluation

Four components necessary in initiating an oral health program are assessment, planning, implementation, and evaluation. Dental hygienists in private practice and in the community use these components to deliver oral health care. Community health extends the role of the dental hygienist from the traditional private practice to the community as a whole.

In this setting, the community is viewed as the patient. The community survey is comparable to the patient’s examination for assessment. The program plan and implementation are similar to the treatment plan and treatment of the patient. Evaluation and review of the program can be compared to the evaluation of the patient’s treatment (Box 6-3).

BOX 6-3 Components Necessary for Initiating an Oral Health Program

Community				Private Practice
Community survey	→	ASSESSMENT	←	Patient examination
Plan the program	→	PLANNING	←	Plan patient treatment
Conduct the program	→	IMPLEMENTATION	←	Treat the patient
Review program/evaluate	→	EVALUATION	←	Evaluate patient treatment

With increased emphasis on improving public access to oral health care, the responsibilities of the dental hygienist to promote oral health in the community take on renewed importance. Therefore it is important that the dental hygienist understand the basic concepts of assessment, planning, implementation, and evaluation as they apply to oral health programs.

Definitions of the components of initiating an oral health program are as follows ⁵:

1. Assessment is an organized and systematic approach to identify a target group and to define the extent and severity of oral health needs present.

2. Planning is an organized response to reduce or eliminate one or more problems.

3. Implementation includes the process of putting the plan into action and monitoring the plan’s activities, personnel, equipment, resources, and supplies. This step should include feedback from personnel and participants as well as ongoing evaluation mechanisms.

4. Evaluation is the method of measuring results of the program against objectives developed during the early planning stages. This process is ongoing and should identify problems and solutions to assist in revising the program as needed.

a. Formative evaluation, or the internal evaluation of a program, is an examination of the processes or activities of a program as they are taking place.

b. Summative evaluation involves judging the merit or worth of a program after it has been in operation. This step is an attempt to determine whether a fully operational program is meeting the goals for which it was developed.

These components are portrayed in the planning cycle model in Figure 3-4. The model provides a continuous cycle of steps to assess, plan, implement, and evaluate.⁶

Assessment

Assessing the relative importance of needs can be a complex process. It depends on human values, some of which are universally agreed on and others are more controversial. For example, a need that involves life or death generally receives higher priority; however, a choice between a health need that might affect the lives of a few people and one that affects the lives of large numbers of people is less clear-cut. Although many would argue that the needs of larger numbers must take priority, others want to consider factors such as age and the future impact on society. For example, a community may need to decide about initiating a free influenza vaccine program for its older population, enhancing the immunization program for children, or adding a clinic offering reduced dental care for indigent families (see Guiding Principles).

Guiding Principles

Establishing Health Priorities

• What is the magnitude of the problem? (Does it cause death or disability?)

• How many people are affected (one person, small community, or entire country)?

• What types of resources are available (personnel, money, facilities, and technology)?

• What has already been done in the community?

• What are the prevailing attitudes toward the problem?

• Which groups are expressing the most interest in the problem?

• What are the legal constraints?

Compounding the problem of establishing the priorities of health needs is the fact that each community is unique, with its own values and ideas. If a community’s basic need for food and security are not being met, dental needs assume a low priority. An issue that often arises is the idea that if a community’s perception of needs is adhered to exclusively, actual clinical health problems may go untreated because the people are not knowledgeable about many areas of health care. The solution to this dilemma involves striking a delicate balance between negligence and overzealousness. Although it is unethical to impose one’s own perceptions on a community, it is the professional’s responsibility to inform people of existing problems and their consequences.⁷

A needs assessment can identify health care problems within the community. The assessment provides information not only about the problem but also about the community itself. The data collected can be used to develop a community profile that will assist in finding the appropriate solution. Conducting a needs assessment for a community can be expensive with regard to labor and time. If funds are not available, coordination with other agencies interested in obtaining similar health information on the given population may be the solution.

Another possibility is to investigate dental surveys that have been done by other organizations. Dental surveys are conducted by professionals at dental schools, local and state health departments, and community health centers. Coordination with other agencies and organizations to know what has been done and what needs to be accomplished can prevent duplication of services.⁸ Data can be obtained and analyzed by various methods (see Chapter 3). After the needs assessment is performed, developing the appropriate goals and objectives is the next step.

Planning

Developing goals, objectives, and program activities is part of the planning process. During this stage, it is essential to have community involvement and participation. The formulation of program goals and objectives is an active process, offering specific proposals for changes to be made in the community. These changes address the specific problems identified in the needs assessment.

Goals

Goals provide a broadly based statement of what changes will take place, from which specific objectives are developed. For example, the school-based fluoride mouth rinse program will improve the oral health of school-age children.

Objectives

Objectives are more specific than goals; they describe in a measurable way the desired end result of program activities. They should tell the learner what he or she needs to do to be successful.

The performance verb is the key to a measurable objective (Box 6-4); it is an action word, such as “write,” “demonstrate,” or “recite.” Other elements of the objective are the condition, which tells under what circumstance the activity occurs, and the criterion, which tells how well the activity must be performed. The performance verb is essential in writing a measurable objective. The inclusion of a condition and a criterion makes the objective more specific and useful to the learner. In summary, the objectives should include the following:

1. A performance verb tells the activity and outcome.

2. A condition tells under what circumstance the outcome will occur.

3. A criterion tells how well the action and outcome must be accomplished to be effective.

An example of an objective for the aforementioned goal would be as follows: On completion of today’s six-step demonstration of how to rinse, the children will demonstrate the six steps without error.

Performance verb: demonstrate

Condition: on completion of today’s six-step demonstration

Criterion: without error

Another example of a measurable objective: On completion of the calibration exercise, the three examiners will record their findings with 85% accuracy.

Performance verb: record

Condition: on completion of the calibration exercise

Criterion: 85% accuracy

Once the problem has been identified and program goals and objectives have been established with a description of a solution, the next step is to state how to bring about the desired results. This area of program planning, referred to as program activities, describes how the objectives will be accomplished.

In planning these program activities, one must carefully consider the type of resources available, as well as program constraints. For example, in planning a school fluoride mouthrinse program in which the chosen activity would be weekly rinsing, resources might include selecting (1) the site at which the rinsing is conducted, (2) personnel, (3) supplies, and (4) the financial means to pay for the supplies. Constraints might include (1) availability of dental personnel to conduct screenings, (2) negative attitudes from some parents, (3) the amount of time it takes to rinse, or (4) lack of funding.

Planning is a crucial element to a successful program. A community oral health program that is well planned, with specific activities and consideration given to resources and constraints, is usually successful in terms of implementation.

Implementation

The process of putting the plan into action, the implementation phase, is ongoing and should be supervised and evaluated to ensure program effectiveness. Implementation, like planning, involves individuals, agencies, and the community working together. The strategy should answer the following questions ⁸:

1. Why: the effect of the objective to be achieved

2. What: the activities required to achieve the objective

3. Who: the individuals responsible for each activity

4. When: the chronologic sequence of activities

5. How: the materials, media, methods, and techniques to be used

6. How much: a cost estimate of materials and time

For ease in addressing these questions, many community oral health programs begin on a small scale. Using a smaller population with the intent to expand later is called pilot testing. In a pilot test for a fluoride mouthrinse program, for example, only one school would be involved the first year and the program would be expanded to include two or more schools the following year. This implementation strategy allows for an opportunity to test the program’s effectiveness and provides ease in control and monitoring of the program activities. A pilot program provides useful information and enables decisions to be made about the future of the program. Piloting is a form of evaluating the implementation.

Evaluation

Evaluation is a judgment of merit or worth of the program. The first step is to review the program goals and then to examine the specific measurable objectives. To evaluate the effectiveness of health programs, specific measurement instruments must be set up for collection of data on the attainment of each program objective. The data that are obtained through measuring the objectives are called measurable outcomes. Each objective should be reviewed to determine how well it meets the program goals. The bottom line in evaluation is accountability—to consumers, providers, and all involved agencies. Evaluation determines whether the program accomplishes what it was designed to accomplish (e.g., were the objectives of this study or program successfully met? If not, why not?). Summarizing what went well and what did not, or drawing conclusions based on intuition, is not adequate; the objectives themselves must be specifically addressed.

Inherent in this approach is the possibility of attaining a negative outcome, that is, the conclusion that the objectives have not been met. At the same time, however, this does not mean that the program has been a failure. If a program is evaluated properly so that negative outcomes become learning experiences and indicators of future programming and research, in some sense it has been a success.⁷ Formative evaluation during the implementation process can point out problems and identify opportunities to correct program deficiencies early on. With ongoing evaluation and change, the summative evaluation (end result) may in fact measure a program with initial problems as successful.

Program evaluation is an example of applied research. Basic (clinical) research (see Chapter 7) involves inquiry into the truth about facts, behaviors, relationships, and principles. Applied research is concerned with these same concepts but emphasizes the application of the knowledge and developing solutions to problems. For example, a basic researcher would be concerned with the effectiveness of the fluoride mouthrinse on the teeth and which concentration to use. A program evaluator would be concerned with the effect of the program operation and its ability to meet the program objectives. The fundamental purpose of program evaluation is to assist in decision making on the effectiveness of the program in its entirety and to reassess the program and make necessary changes to make the program more effective.

Dental hygienists play a role in assessing, planning, implementing, and evaluating community oral health programs. The dental hygienists who have chosen careers as state dental directors, public health educators, or promoters have played an important role in the advancement of dental public health, but there is much more that can be accomplished by all of the dental hygiene profession. By knowing how to organize an effective community oral health program and becoming involved in its implementation, dental hygienists can have an impact in reaching the goal of optimal oral health care for all people.