HEALTH BEHAVIOR CHANGE EDUCATION
Key Points of This Chapter
- The development and integration of behaviorally based dental care within the clinical education of students has not been substantial since the middle of the twentieth century.
- Patient self-management strategies and interactive methods to encourage informed patient choice are rapidly developing areas in health care. In order for such changes to be implemented in dental practice, changes in both the professional training and cultural norms in dental care will be needed.
- To provide an educational environment that will allow students to independently provide behavior change strategies in the practice of dentistry, a specific curriculum must be created and implemented to encourage such strategies.
- In general, for health behavior change curricula, a knowledge base attained through lectures, Problem-Based Learning, or E-Learning and clinical skills attained through clinical instructions and practices are required.
- Assessment universally drives the process of learning. Whatever the circumstances, all educators must focus on what the graduate needs for optimum performance and lifelong self-development through active learning, while being accountable to the society they must serve as ethical clinicians.
As outlined in the previous chapters, motivating patients regarding behaviors associated with health and disease is a central part of the practice of all health professionals. From an educational point of view, these activities are supposed to be based on theoretical knowledge, evidence from research, and interactive skills learned and practiced during professional training.
Behavior change interventions for patients may be delivered during active treatments by health care providers as well as separate educational programs targeted at risk populations in communities (Redman 2007). The need for further health behavior content in the education of health professionals, particularly in medicine and dentistry, has been well documented. The ability of the oral health care team to successfully guide behavioral change in patients is one of the most important factors for long-term oral health maintenance in the population. Health professionals’ perceptions of their patients, communication with patients, and effective models of professional interaction were identified more than 50 years ago as critically relevant to professional practice and thus appropriate targets for education (Gochman 1997).
Hundreds of years ago, societies began systematically caring for their citizens by promoting their health and welfare. Early in the twentieth century, the Carnegie Foundation for the Advancement of Teaching funded a series of reports on professional education in the United States. The fourth report, Abraham Flexner’s 1910 study of medical education, was a highly influential example of this effort. Preceding the report, medical education was largely an informal, unregulated “apprenticeship” experience based in a relatively larger number of small schools of varying quality. The Flexner report emphasized specific themes or innovations in medical education, including (1) the mobilization against proprietary medical schools, (2) the importance of the relationship between universities and professional schools, (3) the creation of higher standards for medical school admissions and for highly qualified, fulltime faculty, and (4) the movement toward education grounded in scientific research and thinking (Flexner 1910). To this day, the Flexner report still shapes medical as well as dental school curricula.
Increased attention was given to behavioral education in U.S. medical schools as soon as it was recognized that medical care without this element would be inherently less successful (Miller 1955). Despite this realization, the strongly biomedical, scientific educational focus that has been typical in the training and professional socialization of physicians has remained relatively unchanged (Gochman 1997). There is growing recognition of the value of providing a behavioral emphasis in medical and dental education. This change is being incorporated into ongoing reforms of medical curricula in both Europe and the United States (Piko and Kopp 2004).
In Europe, where modern dentistry began, the dentists were primarily trained by apprenticeship, learning by watching and assisting an established dentist. Although self-educated, Pierre Fauchard (1678–1761) exerted a powerful influence to move dentistry forward. During the early 1800s, dental leaders became convinced that dentistry required an enhanced knowledge of science. They further believed that the apprentice method of training was no longer adequate because no one person was both competent to teach all scientific subjects and instruct students in the mechanical techniques of dentistry. This growing understanding subsequently led to the establishment of dental education programs (Fales 2007).
In the United States, 16 years after the aforementioned Flexner report on medical education, the tenth Carnegie report on professional education focused on dentistry (Gies 1926). The Gies report, like the Flexner report, also supported a strong basic science education and almost certainly encouraged dental schools to strengthen this aspect of their curricula. Gies maintained that medicine and dentistry had a common biomedical bond and should be closely aligned. However, he also expressed that the two professions should remain separate since the cultures of physicians and dentists were already well established in the United States and Canada with little interest on the part of either profession to integrate. He further argued that service to the public could best be achieved through a separately organized dental profession; one that he cautioned needed to reform itself in order to elevate dentistry into a respected position in society equal to medicine. Gies also concluded that pre-doctoral education should emphasize general practice and primary care, a focus that still remains strong today.
The development and integration of behaviorally based dental care within the clinical education of students has not been substantial since the middle of the twentieth century.
In the United States, by the middle of the twentieth century, dental caries and periodontal diseases were widespread, with high percentages of patients experiencing rampant caries, abscesses, and advanced periodontitis, all of which created a high rate of edentulism. Because physical removal of caries and tooth extraction were the treatments available, the primary foci of the dental school curriculum were teaching students the skills to extract teeth, physically remove decay, replace the excavated tooth structure with various materials, and create prosthetic devices to replace missing teeth. In the past 60 years, however, the benefits of fluorides have substantially reduced tooth loss and the incidence of caries in all age groups.
Subsequently, more recent observations of curricular practices and needs in dentistry were reviewed (Tedesco 1995) as groundwork for the historic Institute of Medicine report on the future of dental education (Field 1995). Since the 1930s, behavioral sciences have been included among the essential elements in dental education. Yet the growth, development, and integration of behaviorally based dental care within the clinical education of students has not been substantial since that time. Lack of focus and time spent on health behavior does not result from a lack of guidelines. Professional associations and some dental schools have issued guidelines over the past 2 decades. These guidelines provide competency expectations and curricular goals for a wide range of topics, including the dynamics of dentist-patient interactions and the characteristics of patient behaviors (Plasschaert et al. 2005; Tedesco 1995).
In dental hygiene
It was recognized early that providing individual preventive care in dentistry could be time consuming. In 1911, Alfred C. Fones was the first dentist to formalize a role for auxiliary dental personnel in educating and instructing their patients. Fones also developed the first formal educational program for dental hygienists in 1913. Prevention, patient education, and behavioral guidance have always been central and defining roles for dental hygienists. In the United States, many of the early community health education programs that utilized dental hygienists focused on children in schools. The literature provides little information about the specific activities of early dental hygienists in private practice (Fales 2007).
Today, the roles of dental hygienists are many and varied (Mueller-Joseph et al. 2 005), but in brief, among them are
- educator/health promoter: use educational theory and methods to analyze health needs, develop health promotion strategies, and deliver and evaluate the results of attaining or maintaining oral health for individuals or groups; and
- change agent: analyze barriers to change, develop mechanisms to effect change, implement processes and evaluate successes of programs that promote health for individuals, families, or communities, and promote lifestyle for individual changes.
Although the strength and importance of creating and maintaining a productive professional alliance between dentists and dental hygienists may seem obvious, it was not until 1992 that behavioral objectives for dental education were developed recommending that dental students be taught to “consult with and refer to dental hygienists those patients needing nonsurgical periodontal therapy and supportive periodontal treatment” (Fales 2007).
During the last 30–40 years, there has been a substantial improvement in oral cleanliness in many countries. For some, oral hygiene “exercises” are as much part of routine health behaviors as weight control, exercise, smoking cessation, and other modification of lifestyle. All of these interventions are aimed at an improved quality of life, a healthier body, and increased lifespan. In Europe, behavioral medicine has traditionally been most strongly emphasized in the Netherlands and the Scandinavian countries (Piko and Kopp 2004), with considerable differences in the oral hygiene emphasis between and within countries, mainly explained by traditions, cultural traits, and social ambience (Löe 2000).
There is a great diversity in the methods, standards, and outcomes of dental education systems throughout the world. The “straight from secondary school to dental school” model, so common in parts of Europe and the ex-colonies, is very different from the post -baccalaureate system of dental education (Reed et al. 2002). The “odontological” approach to dental education, with little or no attachment to medicine, has historically been most prevalent in the Americas, much of Africa, the Western Pacific, certain Asian countries, and some European countries, particularly those in the north and west. Conversely, the “stomatological” approach to dental education, which incorporates dentistry into medical education in a way similar to that of other specialty medical subjects, has been prevalent elsewhere, including the countries of eastern and central Europe.
With the development of the European Union (EU), the directives of the European Commission (EC) required dental education in some areas (for example, Austria, Spain, Portugal, and Italy) to change from a stomatological educational model to an independent, odontological educational process. Paradoxically, however, while some dental curricula taught in the stomatological model have reduced the scope of the medical instruction in their schools, many traditionally odontological dental schools have been striving to bolster the “medical” elements of their programs. Little objective evidence exists regarding the extent to which the use of the stomatological or odontological approach to dental education may be beneficial or otherwise in reducing oral health disparities or increasing access to care (Hobdell et al. 2002).
Voluntary efforts among European dental schools to perform self-assessments ultimately aimed at creating common educational standards for European dental education (the DentEd thematic network project) revealed persistent educational disparities (Shanley and Nattestad 2002). Postgraduate vocational training programs for new graduates under the supervision of established clinicians to assist in the transition from the relatively sheltered environment of dental school to the pressures of independent practice have been required in some EU countries (Scott 2003).
In the United States today, the traditional external outcome measures reflecting the success of training in dentistry have been both state and national dental board exams. Often curricular emphasis has been justified in terms of the content included in these licensing examinations. Unfortunately, however, these exams include little focus on evaluating behavioral aspects in patient care, thus, this educational focus remains under-represented in many dental schools’ curricula (Gift and White 1997).
Traditional technological approaches to dental education must give greater expression to the psychosocial imperatives of health care while adapting to new and rapidly emerging research findings (Shanley and Nattestad 2002) and reflecting cultural, demographic, financial, and environmental circumstances of each individual school and country (Manogue et al. 2002).
Public health goals and responsibilities
Traditionally, the goal of health care interventions has been to “cure” the patient. However, since chronic and behaviorally based diseases have become so prominent in modern society, this narrow criterion of success is no longer sufficient. As outlined in chapter 1, cure is neither essential nor necessary in order that the patient may benefit from health care interventions. Training of dental professionals has also traditionally been focused on clinician-rendered treatment for disease rather than assisting people to change their behavior. Assisting patients in developing and practicing favorable health behaviors may constitute the more meaningful role in many aspects of health care (Mann and Stuenkel 2006).
Patient self-management strategies and interactive methods to encourage evidence-based informed patient choice, on the other hand, are rapidly developing areas in health care that may hold both economic and philosophical advantages (Redman 2007). In order for such changes to be implemented, changes in both the professional training and cultural norms in health care will still be needed.
Patient self-management strategies and interactive methods to encourage informed patient choice are rapidly developing areas in health care. In order for such changes to be implemented in dental practice, changes in both the professional training and cultural norms in dental care will be needed.
New educational initiatives and methods