Health Promotion and Health Communication

Upon completion of this chapter, the student will be able to:

• Apply various health promotion strategies and theories to situations for promotion of oral health.

• Follow a sequence of steps in the health communication process when developing a health communication project.

• Discuss the distinctions among “generic,” “targeted,” “personalized,” and “tailored” health messages.

• Discuss ways to assess needs of diverse populations before designing health communication strategies.

• Identify strategies for delivering health information to consumer groups by using materials, activities, and evaluation methods that are culturally sensitive and linguistically competent.

• Outline the basic components, advantages, and limitations of poster presentations, oral papers, and roundtable discussions as methods for communicating scientific information to health professionals.

• Identify and take advantage of opportunities for personal growth and development in health promotion and health communications.

Opening Statements

Challenges to Promoting Oral Health

• Despite years of research on prevention of oral diseases, very little is known about how best to promote oral health.¹

• More community-based participatory research, in which community members are involved at all stages, and more interdisciplinary research, with nondental behavioral scientists, might shed more light on effective strategies.

• More evidence is needed to document that changes in attitudes and beliefs about oral health lead to improved oral health outcomes.

• Improved knowledge levels alone rarely translate into healthy behaviors, so approaches need to be designed around proved behavioral theories.

• Most behavioral change that occurs after oral health education or promotion is short term and not sustained without periodic reinforcement. What does it take to create sustainable changes?

• Today, dental hygienists have unique and unlimited opportunities to become involved in community health activities and research and to contribute to the development of a better understanding and application of effective oral health promotion and communication approaches.

The main goal of this chapter is to help dental hygienists incorporate a thought process for assessing needs, forming evaluation questions, and planning communication strategies before jumping to implement what seems like a “good idea.”

The World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health is a personal resource that permits people to lead productive lives.² Health promotion is a broad concept that refers to the process of enabling people and communities to increase their control over various determinants of health (see Chapter 3) and therefore to improve their own health. Health promotion introduces the role of behaviors, not just attitudes and knowledge, into the health equation and goes beyond a focus on individual behavior toward a wide range of social and environmental interventions. Health promotion goes beyond health education and links oral health to other health issues. Thus this chapter focuses on the concepts of oral health promotion, strategies to effect behavioral and community changes, and the dental hygienist’s role in communicating health messages to other health professionals and the public.

The Ottawa Charter, a global health promotion imperative, identifies three basic health promotion strategies: (1) advocating for health, (2) enabling people to achieve their full health potential, and (3) mediating different societal interests in pursuit of health. The following five action steps can help achieve these strategies:

• Build healthy public policy (e.g., tobacco-free restaurants and bars)

• Create supportive environments for health (e.g., exercise rooms in work places)

• Strengthen community action for health (e.g., support for local farmers markets)

• Develop personal skills (e.g., healthy meal planning and cooking)

• Reorient health services (e.g., provider incentives for keeping people well)²

All of these steps have direct relevance to oral health, the health promotion theories enumerated in this chapter, and health care reform efforts in the United States and other countries.

Oral health promotion efforts can increase use of oral health and wellness services and preventive self-care measures. The anticipated outcome of these efforts is a reduced incidence and severity of oral diseases with improved oral health and overall health. Yet, as we see in the challenges in the Opening Statement, applied research relating to oral health promotion is still in its infancy and not yet well integrated or coordinated with research and theories developed by other health disciplines.

Health Promotion Theories

When promoting health and preventing disease, theories help us analyze and interpret health problems and then plan and evaluate interventions. What is a theory? A theory is a set of interrelated concepts, definitions, and propositions that present a systematic view of events or situations by specifying relations among variables to explain and predict the events or situations.³

A theory is an abstract notion that comes to life only when it is applied to specific topics and problems. Sometimes, theories are called conceptual frameworks or models. The best way to remember each theory is to focus on key concepts such as readiness to change, susceptibility to health risks, or how innovations are adopted.

How can theories be applied to dental hygiene practice and public health practice? Every day, dental hygienists face challenging situations that result in oral health problems such as families who feed their babies cariogenic liquids in baby bottles, athletes who sustain oral injuries because they refuse to wear a mouth guard, adults who say they are too busy to follow oral care recommendations, or administrators who eliminate school-based dental sealant programs but retain orthodontic screening programs. Theories can help us analyze these situations and apply solutions that have been effective in similar circumstances.

Traditionally, dental hygienists have viewed oral health problems primarily as the “patient’s” problem and have proceeded to “educate” the patient about how to improve oral health. This approach is doomed to failure because it skips directly to a generic intervention and does not assess or validate the patient’s point of view or health beliefs and does not consider the environmental, literacy, or cultural circumstances that have influenced the person’s attitudes, beliefs, or health practices. It is important to analyze oral health problems from more than one perspective and to understand how each perspective affects the others.

Behavior that leads to improved oral health can be affected at three levels:

• Intrapersonal (within the individual)

• Interpersonal (between people)

• Community (including institutional or organizational change and public policy)

The following section describes selected health promotion theories that relate to these three levels and that have the most relevance to oral health issues. An overview of the six selected theories is provided in Box 8-1. A narrative of each theory, including an oral health example, is accompanied by a table that contains key concepts, definitions, and general applications. For easier reading and to select theories that are most relevant to situations you may encounter, there is an overview table of additional theories with their focus and key concepts in Glanz and Rimer, which is available online.³

Intrapersonal Level

Stages of Change Theory (Transtheoretical Model)

Initially developed by Prochaska and DiClemente, the Stages of Change Theory views change as a process or cycle that occurs over time rather than as a single event. This theory allows the dental hygienist to assess a person’s readiness to change a behavior toward a more healthful lifestyle such as daily brushing to prevent gingivitis. The theory assumes that at any point in time everyone is at a different stage of readiness to make lifestyle changes and that people cycle through the various stages over time, depending on the behavior to be changed and whether the environment is supportive. The major stages of this model with definitions and applications are outlined in Table 8-1.

Table 8-1

Stages of Change Theory (Transtheoretical Model)

Concept	Definition	Application
Precontemplation	Being unaware of problem; not having thought about change.	Increase awareness of need for change; personalize information on risks and benefits.
Contemplation	Thinking about change in the near future.	Motivate and encourage to make specific plans.
Decision/determination	Making a plan to change.	Assist in developing concrete action plans or setting gradual goals.
Action	Implementing specific action or plans.	Assist with feedback, problem solving, social support, and reinforcement.
Maintenance	Continuing desirable actions or repeating periodic recommended steps.	Assist in coping, using reminders, finding alternatives, avoiding slips or relapses.

Adapted from Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Institutes of Health; 2005.

Oral Health Example

The cycle starts by increasing one’s awareness of a problem (e.g., a person has gingivitis) to initiating behavior change (brushing effectively and using antimicrobial rinses) and progresses to maintaining motivation to continue preventive actions (returning in 3 months to check progress). To be effective in changing behavior, health messages and programs should be matched to an individual’s current stage of readiness to change.

Health Belief Model

Originated by Rosenstock and others in the 1970s to explain people’s use of preventive health services, the Health Belief Model allows us to assess perceptions of how susceptible one is to a health risk and whether one believes that recommended preventive behaviors will result in less susceptibility.

One application of the Health Belief Model is to develop messages that are likely to persuade people to make decisions to improve their oral health. The components of the model and some applications are shown in Table 8-2. The primary hypothesis is that increased perception of severity and susceptibility to a disease results in an increased probability of taking action. Perceived ability to take action and cues to action are important factors.

Table 8-2

Health Belief Model

Concept	Definition	Application
Perceived susceptibility	One’s opinion of chances of getting a condition	Define population at risk and risk levels; personalize risk based on a person’s features or behavior; heighten perceived susceptibility if too low.
Perceived severity	One’s opinion of how serious a condition and its sequelae are	Specify consequences of the risk and the condition.
Perceived benefits	One’s opinion of the efficacy of the advised action to reduce risk or seriousness of impact	Define action to take: How, where, when; clarify the positive effects to be expected.
Perceived barriers	One’s opinion of the tangible and psychologic costs of the advised action	Identify and reduce barriers through reassurance, incentives, and assistance.
Cues to action	Strategies to activate readiness	Provide how-to information; promote awareness, send reminders.
Self-efficacy	Confidence in one’s ability to take action	Provide training and guidance in performing action.

Adapted from Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Institutes of Health; 2005.

Oral Health Example

Does your father think that he is at risk for development of oral cancer because he smokes a pipe? Does he believe that limiting use of the pipe would reduce his oral cancer risk? The model also looks at perceived severity of a disease threat, benefits of taking a particular health action, and barriers to completing the action. Does your father believe that the effects of quitting pipe smoking are worse than the effects of oral cancer? Does your father believe he can quit smoking his pipe? What types of support does he need to succeed?

Interpersonal Level

Social Learning Theory

The Social Learning Theory posits that people learn primarily in the following four ways:

1. Direct experience

2. Vicarious experience such as reading or viewing or listening to various forms of mass media

3. Judgments voiced by others such as testimony or promotions by experts

4. Inferred knowledge

The basic premise of this theory, developed by Bandera and sometimes known as the Social Cognitive Theory, is that people learn through their own experiences, by observing the actions of others, and by the results of these actions. Behavioral change is accomplished through the interaction of personal factors, environmental influences, and individual behaviors. Self-efficacy and self-confidence are important concepts. Table 8-3 lists the relevant definitions and applications of the major concepts.

Table 8-3

Social Learning Theory (Social Cognitive Theory)

Concept	Definition	Application
Reciprocal determinism	Behavioral changes result from interaction between the person and the environment; change is bidirectional	Involve the individual and relevant others; work to change the environment, if warranted.
Behavioral capability	Knowledge and skills to influence behavior	Provide information and training about action.
Expectations	Beliefs about likely results of action	Incorporate information about likely results of action in advance.
Self-efficacy	Confidence in ability to take action and to persist in action	Point out strengths; use persuasion and encouragement; approach behavioral change in small steps.
Observational learning	Beliefs based on observing others like oneself and/or visible physical results	Point out others’ experience and physical changes; identify role models to emulate.
Reinforcement	Responses to a person’s behavior that increase or decrease the chances of recurrence	Provide incentives, rewards, praise; encourage self-reward; decrease possibility of negative responses that deter positive changes.

Adapted from Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Institutes of Health; 2005.

Oral Health Example

Consider helping a single mother to feel confident about performing toothbrushing for her young child by using techniques such as demonstration, watching a video, providing ongoing encouragement, and giving periodic feedback. When the mother gains some confidence in her skills, she can then assist the child care workers and other parents at the day care center in learning these skills so that they can support each other and so that oral hygiene care becomes a daily activity for all of the children.

Community Level

Community Organization Theory

Community Organization Theory is the process of involving and activating members of a community or subgroup to identify a common problem or goal, to mobilize resources, to implement strategies, and to evaluate their efforts. People usually refer to this process as empowerment. This is a grassroots approach to health promotion, rather than an effort that is initiated and conducted by health professionals. Table 8-4 outlines the key components.

Table 8-4

Community Organization Theory

Concept	Definition	Application
Empowerment	Process of gaining mastery and power over oneself or one’s community to produce change	Give individuals and communities tools and responsibility for making decisions that affect them.
Community competence	Community’s ability to engage in effective problem solving	Work with community to identify problems, create consensus, and reach goals.
Participation relevance	Learner should be active participant and work starting “where the people are”	Help community set goals within the context of preexisting goals, and encourage active participation.
Issue selection	Identifying winnable, simple, and specific concerns as focus of action	Assist community members in examining how they can communicate the concerns and whether success is likely.
Critical consciousness	Developing understanding of root causes of problems	Guide consideration of health concerns in broad perspective of social problems.