Journal of Behavioral Medicine, VoL 4, No. 3, 1981

Community Oral Health Promotion Alfred L. McAlister I and Robert O'Shea 2

INTRODUCTION Health promotion is a concept combining and expanding the traditional areas of health education and preventive medicine. In the past, it has tended to reflect the structure and economics of the medical care system and has focused on changing individual behaviors in quasi-clinical settings (McAlister et al., 1976). Currently the level of analysis is widening and shifting toward a concern with the community and the influence of its social and physical environment on health and behavior (Farquhar, 1978; McKinlay, 1975). No longer restricted to educational strategies which emphasize information transmission or to limited preventive screening measures, health promotion pursues broad objectives for behavioral and environmental change designed to promote wellness and to prevent disease and injury (Department of Health, Education and Welfare, 1979b; Somers, 1976). Activities have included the promotion of education and self-help groups to aid adults to stop smoking (McAlister et al., 1979b), encouraging young people not to start smoking (McAlister et al., 1980), providing community education and training for cardiovascular health (Maccoby et al., 1977), and advancing community control in environmental issues (Caldwell et al., 1976). Adequate promotion of oral health does entail the community as well as the individual. This has been evidenced in the past 35 years of successful dental public health action for community water fluoridation and, more recently, in the spread of school-based fluoride rinse programs. The importance of the community as the site and target of promotion becomes magnified when one examines the current armamentarium against caries. Frazier (1978) has recently published a policy argument questioning 'Department of BehavioralSciences, Harvard University,Cambridge, Massachusetts02138. 2Department of BehavioralSciences, Universityof Buffalo, Buffalo,New York. 337 0160-7715/81 f0900-0337 $03.00 9 1981 Plenum Publishing Corporation

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the efficacy of interventions with individuals via health education, such as teaching of toothbrushing and flossing, or stressing instruction in diet and plaque control. She advocates substituting these interventions with measures that are passive to the individual, yet exert some amount of group control over the individual, such as water fluoridation, school-based supervised rinsing, and other self-applied fluoride programs. The general thrust of the literature on compliance with medical regimens would certainly reinforce Frazier's view. Passive group control measures are implemented chiefly at the community level through one or more of its systems. This paper provides a framework for community oral health promotion. Community systems and objectives necessary for increasing positive oral health behavior action at the community level are discussed. The four main oral diseases are mentioned in relation to suitable preventive behaviors. Theoretical disciplines of communication research are examined. Finally, a clearinghouse for propositions relevant to oral health promotion is suggested.

COMMUNITY SYSTEMS Warren (1978) defines the community as a local combination of people, organizations, and systems which performs functions of economic exchange, socialization, control, participation, and social support. Modern communities are composed of a large number of interacting systems and organizations. The following community systems are relevant to health promotion: (1) governmental offices and agencies, (2) commerce and business, (3) medical-care institutions and practices, (4) educational institutions, (5) voluntary associations (churches, clubs, unions), (6) neighborhoods, (7) families (8) informal networks of association, and (9) communications media. The community's social and physical environment is formed by the relationship among these component groups, and their actions ultimately contribute to guiding individual behaviors.

OBJECTIVES

Health promotion efforts have several objectives, the most timehonored being the provision of preventive services. Governmental health

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agencies or medical-care institutions, for example, may conduct blood pressure screening programs which are provided within industries, churches, or neighborhoods (Breslow and Somers, 1977). This represents a broader application of the conventional activities of individual-oriented providers and institutions. In addition to providing preventive services, health promotion has four other objectives: education and persuasion, training, social support, and environmental change. Education and persuasion are designed to influence intentions. A person concerned with promoting health might educate smokers about the inherent hazards, urging them to stop smoking. Ways to improve oral health behaviors, such as teaching proper brushing and flossing techniques, might be well received by individuals interested in preventing dental caries. The education and persuasion often found necessary to overcome ignorance and firmly held beliefs may require considerable ingenuity on the part of the health promoter. A vast body of theory and research exists, however, which can guide the planning and design of educational and persuasive communications (McGuire, 1969; Zimbardo et al., 1977). Training helps translate intention into maintained action. A person may be convinced of the virtues of optimum oral hygiene but find it difficult to adhere consistently to such a regimen. Many people may need some degree of training in skills of self-management. Such skills, ranging from the use of simple reminders and organized planned routines to the use of complex methods for managing impulses or stressful situations, can be found in the theoretical and practical discussions of self-control and self-management training (Mahoney and Arnkoff, 1979; McAlister et al., 1976). Social support provides valuable reinforcement for desired actions. Without some sympathy or encouragement, few individuals can achieve difficult behavioral changes. Social support traverses the gamut from a formal self-help group to an informal smile or compliment from a stranger. Although censure or disapproval is essentially the opposite of social support, they have a similar potency. Reviews of phenomena such as conformity and group dynamics illustrate the importance of social support to behavior change (Collins and Pancoast, 1976; Kiesler and Kiesler, 1969). Environmental change is aimed at improving access to and opportunity for positive behaviors, thus protecting members of the community from threats to their health. Heakhy physical exercise is promoted by the availability of appropriate facilites. The fluoridation of community water supplies is the outstanding example of environmental change for dental health. Lower consumption of sugared candies by schoolchildren may be advanced by removing sweets and substituting healthier foods in school vending machines. Environmental change is generally a matter of politics and economics, most reliably accomplished through organized

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action and advocacy. This social change often involves the activities of special-interest voting blocs, consumers' associations, and public interest organizations (Guskin and Ross, 1971; Perlman, 1976). In the past, traditional dental health education focused on the first two objectives only, stressing preventive services for schoolchildren or dental patients and educating and persuading them through the use of pamphlets, films, and talks presented by teachers, dentists, and hygienists. The current promotion of oral health properly widens in scope to add three objectives which are not traditionally found in the domain of the health provider. All five objectives (preventive services, education and persuasion, training, social support, and environmental change) are employed to bring about behavior changes and emphasize primary prevention of oral diseases. Each organization or system must be examined as an appropriate setting for each possible objective. Certain particularly promising combinations become obvious, e.g., private business as a source for environmental change, family as a source of social support, and communication media as tools for education and persuasion. Many novel combinations also become apparent, raising several questions. Are churches, clubs, and other voluntary organizations useful sites for training community members in self-control skills? What is the social support role of the neighborhood? How might informal networks be utilized to extend education and persuasion? Let us begin to examine this issue by discussing some of the characteristics of the community systems found within the United States. The "community" stands for a large number of widely varied and constantly changing locality-based groups. The Fluoridation Census 1975 (Center for Disease Control, 1977) counts 33,561 "places" in the United States. The Statistical Abstract (United States Department of Commerce, 1978) counts 64,688 local governments, including 3042 counties, 18,862 municipalities, and 16,882 townships. In addition to being numerous, communities vary in several important ways. For the purposes of this paper, six sources of community variation may be identified: (1) independence, (2) resources, (3) demographic composition, (4) power and leadership of organizations, (5) value placed on oral health, and (6) history of dental and oral health activities. The "community that contains most of its members' activities-work, leisure, education, trade, services" (Coleman et al., 1966), currently represented by the large metropolitan areas and geographically isolated towns only--is recognized as a community of independence. The remaining communities are interdependent parts of other areas, regions, and counties.

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It is important to understand the degree of independence found in a community when defining the unit being targeted and used for change. Community resources vary greatly, not only in wealth and per capita income, but also in quantity and type of professional dental health manpower. How many American communities have health departments that offer active and strong dental components? How many have no health departments at all? The resources likely to be given to oral health promotion are scarce. Of the $13 billion now spent each year on oral health, only a tiny fraction goes to the part of the dental institution that might be expected to lead a large effort at the community level. I should also be noted that in 1972 there were 116 board-certified public health dentists in the United States (National Center for Health Statistics, 1974). If large-scale promotion at the community level of action is to be brought about, it will certainly have to mobilize borrowed resources, man/womanpower from the community's other subsystems. The demographic composition of communities varies according to age, sex, and distribution of educational levels. All of these factors are important, since the tactics required in health promotion for small suburban bedroom communities with high proportions of children vary greatly from those required by central cities with large geriatric populations. Communities differ with respect to power and leadership, regarding their formal and informal organizations. They vary in power bases and in the ways that power is wielded. The history of fluoridation has shown that when there is more continuity of associational membership among major community groups, there is less chance for fluoridation to erupt in conflict and meet defeat (Coleman, 1957). Another study has shown that the greater the degree of power centralization, the more often fluoridation is adopted; the greater the degree of public participation, the less often fluoridation is adopted (Crain et al., 1969). Some water fluoridation campaigns fail because they rely heavily on the established leaders of the community and ignore the power of less obvious formal social structures (Kornhauser, 1950). In general, participation in and control of formal organization is distributed in the community according to socioeconomic status (Hollingshead and Redlich, 1958; Warner and Lunt, 1941), and those holding the majority of power tend to be both formally and informally associated with one another (Hunter, 1953). Usually, community power lies among many people and is found in many ways: in those who control wealth and other resources, in mass media, in solidarity and organized groups (ethnic-group spokesmen or civic leaders), in values (clergymen), and in prestige (social

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elite) (Rossi, 1960). Many of these power bases overlap, clearly establishing that power is shared. Reputed power is not necessarily equal to delivered power; much power is potential, yet goes unused (Rossi, 1960). One additional major community source of power lies with the professionals whose occupations serve the various community subsystems (Rossi, 1962). Another community variable might be described as the value placed on oral health. It is presumed that this value is partly a product of the composition, class, and resources of the population, but this does not necessarily have to be so. In the United States, oral health is given a relatively low priority. Despite the fact that oral disease is ubiquitious, it is perceived as minor (Kegeles, 1974). the fact that 30 million adults are edentulous is testimony to the low importance placed on oral health and is a reminder that the prosthetic dental arts have succeeded all too well. At any rate, this relative lack of importance placed on oral diseases results in consequences for all facets of oral health behavior and promotion. It is hard to overstate the importance of this fact, since it largely affects the willingness of any community system to become involved in promoting oral health. Fluoridation has certainly been greeted in a manner very different from that received by the Sabin vaccine. If the financial cost of community fluoridation were not so low, its present level of success probably never would have been achieved. In most communities there is a particular history of dental and oral health activities. For example, today American communities vary as to whether they have endorsed, fought over, or rejected fluoridation. They also vary in the priority given to dental-care programs and methods for teaching dental health. The community history of public opinion about dental health and of the role of particular leaders with regard to oral health may set rigid limits on their promotion, at least in the short run. This history may also establish precedence for a community, helping its members to decide the importance of oral health. The term community generally is used in referring to a city, town, or village, yet one must be cognizant of the fact that in the United States today considerable autonomy has passed from the local community to higher levels of power that involve regional, State, and Federal systems. The relevance of these political groups becomes important in regard to health promotion. The major initiatives in promoting oral health in both water fluoridation and school-based fluoride rinse programs have come from the state and federal levels (Department of Health, Education and Welfare, 1979b). If a national health insurance program with an oral health component is ever adopted, the entire structure of the dental institution will be changed radically, affecting patients, providers, and care.

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Before focusing on community-based objectives for promoting oral health, two additional dimensions must be considered: specification of both the four main oral diseases being attacked and the preventive behaviors being promoted. Oral health promotion is aimed at preventing caries, periodontal disease, malocclusion, and oral cancer. The behaviors being promoted are nicely described by Kegeles (1974) and may be subdivided into the usual three public health levels of prevention: Level I, specific protection and health education (i.e., brushing and flossing regimens, fluoridation, sealants); Level II, early detection and prompt treatment (regular dental checkup s); and Level I I I, rehabilitation (prosthetic appliances). In examining the relationships . . . . . these behaviors and the four main oral diseases, issues of policy or strategy become obvious, as do tactics applied in allocating promotional effort. Each separate objective is not necessarily of equal importance. Each particular disease requires different behaviors, which in turn are appropriate to various means of intervention. Environmental changes, so attractive in promoting the prevention of caries through fluoridation, for example, might not be appropriate for preventing oral cancer. Given the magnitude of dental problems associated with caries and periodontal disease, both of which are universal and chronic, it seems as if the objectives would almost have to include environmental change and required preventive services where possible. The utility of a community-based oral health promotion model may be illustrated via a hypothetical project aimed at preventing caries. This program should consider the specific disease (caries), an armamentarium (the behaviors being promoted, discussed earlier), a set of community subsystems (i.e., government, business, family), and an array of objectives or general change techniques (i.e., training, social support, prevention). For instance, programs attempting primary prevention of dental caries (specific disease) may use the family (community subsystem) as a means of training (objectives) in brushing and flossing techniques (armamentarium). Perhaps the major problem in promoting health is finding the coalition that will put the project in motion. Let us assume that the dentists and dental auxiliaries in a community are all involved in fee-for-service private practice. Their salaries are not paid by public funds and, as a result, they may avoid or even resent activity occurring outside the private office. They may have very little time and energy to devote to community oral health promotion. If we turn to the local dental society, we may find that the members may be neither interested nor equipped to deal with the promotion of oral health. For argument's sake, let us also assume that the community has a local health department which has a public health

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dentist who is interested in implementing our objectives. What is needed is knowledge of how best to go about identifying, recruiting, organizing, motivating, and equipping groups and individuals from among the various community systems which are likely to cooperate in such a combined effort. Applied research findings in these areas that are specific to dentistry do not exist, but perhaps valuable insight may be gained from work done in other disciplines, particularly from the area of communication research.

COMMUNICATION RESEARCH PROPOSITIONS

Communication research, a diverse field of study concerned with how ideas and influences are imparted, consists of four branches: mass communication effects, opinion leadership, diffusion of innovations, and communication technology. The research studies of mass communication effects (Flay et al., 1980; Griffiths and Knutson, 1960; Maccoby and Sheffield, 1961; Schramm, 1975) generally conclude that mass media are powerful agents of education, persuasion, and training only when their messages are supported by a social group and confirmed by their experience. Media can profoundly influence specific opinions when its general content reinforces cultural norms. When the media message can be translated easily into action, behavior can be powerfully affected. Communications are most persuasive when they are transmitted by a credible source and received in the context of a cohesive and conforming group. The communications that most effectively provide training are received in combination with a structured learning experience that provides opportunities for subsequent practice, feedback and encouragement. Another important branch of communication research is concerned with the phenomenon of opinion leadership (Coleman et al., 1966; Katz and Lazarfeld, 1955). Community systems have chains of hierarchical opinion leadership which present levels of dominance and exposure to new information. Within the small social groups of the subsystem there tend to be opinion leaders who are the first to adopt new habits of thought or action and whose behavior serves as a model for the rest of the group. Any given individual may follow several different opinion leaders in several different areas of expertise and may simultaneously act as the leader for others. The study of the diffusion of innovations is a branch closely related to opinion leadership that examines the networks through which innovation and influence are communicated in communities and organizations (Rogers, 1973; Rogers and Shoemaker, 1971). Diffusion tends to follow

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hierarchies of opinion leadership. It also tends to move from higher toward lower socioeconomic groups. Early adopters of new products or practices tend to be affluent and well educated. Change agents who most effectively promote diffusion are similar to members of the groups in which they hope to create change. A fourth branch of communication is concerned with communication technology (Parker and Dunn, 1972). New technology may eventually unify the functions of the telephone, television, and daily newspaper into one comprehensive utility. This would lead to creative ways of educating and organizing the community and has the potential for feedback that could guide learning and decision making.

SOME NEEDED RESEARCH ON COMMUNITY HEALTH PROMOTION

' It becomes clear that organizing a community for health promotion is a very complex task. A natural inclination is to turn to the literature to learn more about the past experiences of health promotion in this country, yet we find a scarcity of research studies. In oral health promotion, in particular, there has been very little reported. Amid the general dental research explosion that began in the 1950s, Galagan (1963) decried the absence of support for research in dental public health practice, and more than two decades later the situation has barely improved. What does exist is "experience" of dental public health administrators, and the clinical folklore produced by that experience. There is also a body of findings from the fluoridation research of the 1950s and 1960s, and this information should be codified. A narrower area for research which might be productive would include studies of the potential found within various segments of the dental profession: the organized practicing dentists and auxiliaries; the schools of dentistry, dental hygiene, and dental assistant training. Other community subsystems need to be studied for their oral health potential. Certain voluntary associations, such as the Jaycees and the PTAs, have been prominent in promoting fluoridation efforts. Other organizations should be explored to see if they could be natural allies. Nearly one-quarter of the school systems in the United States are currently offering a school-based fluoride program. The study by Siversin et al. (1980) will be useful in identifying some of the attributes and limits of subsystems in promoting oral health. The Health Systems Agencies are nationwide. What is their potential for promoting oral health?

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In addition to studying ways to mobilize the particular systems of the community, there is need for a series of applied action studies that examine the operation of various consortiums established to solve one or more o f the oral disease problems. The time is appropriate for an applied social science initiative to support social movements for oral health promotion and, specifically, national caries prevention programs. The Center for Disease Control has already announced a 10-year goal of country-wide community fluoridation aimed at reaching an additional 67 million people by 1990. One research contribution that might prove to be very beneficial would be the establishment of a clearinghouse for the compilation of propositions on community-level phenomena relevant to oral health behaviors. This codification could be similar to Williamson's (1977), but in this instance propositions would be stated, organized, and buttressed by referenced research studies. Propositions would be theoretically based when possible; descriptive, empirical generalizations would also be welcomed and necessary. Theoretical propositions without findings v~ould be collected but carefully flagged as hypotheses. As mentioned previously, some examples are readily available from past fluoridation research; Crain et al. (1969) give propositions which are concrete and specific enough to be of use to community practitioners: (1) The proponents have solid support from the health professions. (2) Opponents tend to be of lower status. (3) High-status opponents and proponents who are politically active are most effective. (4) The fluoridation issue typically generates considerable controversy. Kegeles' (1975) propositions regarding public acceptance o f dental preventive measures illustrate more theoretic and generalized statements: (1) No matter what preventive is developed for mass usage, it will probably be used less by persons with less education and lower incomes, blue-collarworkers, Negroes, Puerto Ricans, Mexican Americans, males and those over 45. (2) Perhaps the best means for achieving acceptance of a dental inoculation is to include it with the routine diphtheria, pertussis, tetanus, polio inoculation. Ideally these dental public health propositions would be somewhat akin to a human relations area file, a body of research materials available in several centers with addendums on an ongoing basis. The system would feature a provision for feedback by administrators and community practitioners who were attempting to put the propositions to work in actual programs. Such feedback would be precious, even when anecdotal, as it not only would test validity but would provide accountability for researchers.

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We must explore all of the opportunities for contact, participation, and change offered by the community in order to influence behavioral and environmental factors in an effort to stimulate community promotion of oral health.