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

Institutions and Oral Health Behavior J a c o b B. S i l v e r s i n 1 a n d J e a n n e A . C o o m b s 1

INTRODUCTION AND BACKGROUND The adoption of dental preventive behaviors requires that individuals take specific actions on a daily or periodic basis throughout life to prevent conditions they perceive as non-life threatening. Improving oral health behaviors, consequently, is difficult. There are numerous reports of discrete dental health education programs that have failed to modify dental health habits (Young, 1970; Nikias, 1976), indicating the need for a more comprehensive approach. Efforts targeted to reaching people where they spend many of their waking hours, in situations that provide continual opportunities for daily personal interaction, might succeed in stimulating and sustaining improved dental health preventive behaviors. More than two-thirds of the population of the United States can be found in either schooF or work settings and spend a large portion of their lives interacting with others (United States Department of Labor, 1979a; United States Department of Commerce, 1979; Project Head Start, 1979); thus, reaching people through these institutions is an approach which merits evaluation. In order to explore their potential role in improving oral health behaviors, schools and industry have been selected for consideration as sites for conducting behavioral research. Reasons to consider focusing efforts on these institutions as channels for positively influencing dental behavior, however, go far beyond their merely providing ideal sites for reaching large populations. There is a concern, a readiness, and a precedent on the part of both schools and industry to assume increased responsibility in this area. 'Department of Dental Care Administration, Harvard School of Dental Medicine, Boston, Massachusetts 02115. 2The word "school" is used to describe the preschool level (i.e., day care, Head Start), as well as grades kindergarten through 12. 297 0160-7715/81/0900-0297~03.00 9 1981 Plenum Publishing Corporation

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Schools have a long history of interest in dental health. Health education programs oriented to increasing students' knowledge about oral health and their oral hygiene habits have been widespread (Cohen and Lucye, 1970; Rayner and Cohen, 1971; Young, 1970). In addition, schools' commitment to improving oral health has been further evidenced by the finding that nearly one-quarter of the school districts in the United States are currently offering a fluoride rinse and/or tablet program to their pupils (Silversin et al., 1980). Even restorative dental services are available to pupils in a small number of schools (Cronin and Young, 1979; University of Connecticut Health Center, School of Dental Medicine, 1978). Whereas the school sector has a tradition of commitment to improving oral health, industrial settings have more recently become involved in promoting oral health and, hence, are fertile ground for research. During the past decade companies of various sizes have begun to offer dental benefits to their employees. In 1980 it is estimated that 60 million Americans will receive dental insurance as an employment-related benefit (American Dental Association, 1979a). Industries have a vested interest in preventing the need for restorative treatment among employees, since premiums for dental insurance are based on projections of the utilization of specific services. The potential role of industry in offering preventive dental programs was examined recently at the National Conference on Health Promotion Programs in Occupational Settings by leaders of labor, management, and the academic community. They viewed preventive dental programs as rdatively inexpensive to implement and apt to receive high employee participation (McGill, 1979). Both schools and industries appear willing to support dental health promotion programs as part of their legitimate role. This paper focuses on the potential for improving oral health behaviors at these institutionally based sites. Although it is clear that the dental profession can play an important role in the success or failure of such programs, and that its role merits thoughtful consideration, it will not be discussed here. W h a t Are the Preventive D e n t a l H e a l t h Behaviors?

The phrase "preventive dental health behavior" is used as a generic term for the purposes of this discussion, yet one should note that epidemiologic and basic science studies have led investigators to recommend that individuals take four specific actions to reduce the amount and severity of dental disease they might experience. These researchers suggested that people reduce the amount and frequency of sugar in their diet (Bibby,

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1975), thoroughly remove plaque from their teeth each day (Sheiham, 1977a), take daily fluoride supplements during childhood if not exposed to fluoridated water (Margolis et aL, 1975), and seek professional dental services on a regular, prescribed basis that varies with age (Sheiham, 1977b). Research documents that individuals' adoption of one of these behaviors does not automatically result in their adoption of the others (Williams and Wechsler, 1972). As Nikias (1976) suggested, each of these behaviors may not be influenced by the same set of variables or, in any case, each variable may not be equally important for promoting each action. The variations in required frequency, as well as differences in the investment of time and money related to each action, suggest that they are very separate behaviors. While the term preventive dental health behavior is used for convenience, we do not mean to suggest that a particular intervention shown to promote one preventive dental health behavior will necessarily affect any other dental health behaviors. Further empirical research is needed to examine the degree to which personal behaviors for preventing dental disease are interrelated. Theoretical Framework

Several behavioral and social science researchers have studied determinants of individual preventive dental behavior (Antonovsky and Kats, 1970; Kegeles, 1974; Kriesberg and Treiman, 1960; Newman and Anderson, 1972; Nikias, 1976; Young, 1970). This research focused mainly on the relationship between individuals' preventive dental health actions and their socioeconomic status, age, and sex, as well as their attitudes, beliefs, and values about dental disease, dental health, and preventive dental health actions. Although these variables were found to be somewhat related to an individual's oral health practices, researchers have also discovered that it is difficult to modify these variables to increase the likelihood of improving oral behaviors. This early research provided a foundation on which to develop a broader theory of how institutions can best have an impact on individual oral health behavior. According to a functional model developed by Green et al. (1978, 1980), these internal predictor variables that determine health actions are the predisposing factors--the internal or personal factors (knowledge, attitudes, beliefs, and values). Berkanovic (1976) clearly stated that information alone, regarding these predisposing factors, is not a sufficient diagnostic tool for designing an effective strategy for changing an individual's dental health behavior. Green et al. (1978, 1980) included

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two other categories of variables external to the individual that also significantly contribute to personal preventive actions. One of these, the enabling factors, is related to the opportunities that make it possible for a person to take the preventive action. Availability and accessibility of needed instruction, skills, and services are examples of these factors. The remaining set of external variables, the reinforcing factors; is related to the amount and consistency of support and encouragement from others who influence the individual to adopt and maintain the behavior. Green et al. (1978) emphasized the necessity to consider all predisposing, enabling, and reinforcing factors when analyzing approaches for changing health-related behaviors. "The failure to assess some of these factors and to develop a programme addressed to all three sets would seriously limit the impact of the programme" (p. 9). To date, little research has systematically explored the potential of applying all three concepts simultaneously in an effort to change dental health behaviors. Institutional settings provide an ideal research climate for investigating the relative importance of enabling and reinforcing factors on personal dental health behaviors. There is daily interaction among pupils and among employees in both formal and informal groups. It is now possible to study the effect of employing various combinations of these interventions on personal dental preventive health actions, because many schools and industries provide some dental services and/or dental education. The following literature review demonstrates the role of interpersonal reinforcing factors in promoting dental and other preventive health actions. Several research questions concerning the function of reinforcement in stimulating preventive dental health actions in schools and industries are considered. Approaches for investigating the impact on preventive behavior resulting from efforts by schools and industries to reduce barriers to receiving dental services and education (enabling factors) are discussed. Finally, in order to identify methods that will encourage institutions to adopt effective oral health programs, there is a focus on research questions regarding the diffusion and adoption of preventive health programs by schools and industries.

REINFORCING FACTORS A n O v e r v i e w of the Literature

It has been proposed that "the public is interested in dental services largely for their social and mental health benefits rather than because of concerns over physical health. The impact of dental health on social and

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job relationships is more important than its contribution, if any, to longevity. It contributes to the quality of life by enhancing freedom to engage in conversation, smile, dine, kiss, and to seek and retain jobs without the inhibitions of handicapping or disfiguring dental c o n d i t i o n s . . . " (Knutson, 1979, p. 648). Given this relationship between the need for acceptance by others and the desire for dental health, a systematic exploration of the role of interpersonal reinforcement in determining oral health behaviors seems warranted. A review of research on interpersonal reinforcement documents the importance of social relations to both dental and nondental preventive health actions. One fundamental observation derived from research about healthrelated actions is that, as in most other aspects of human behavior, individuals tend to conform to the values and practices which characterize their social and cultural milieu (Homans, 1950). Many researchers have noted that an individual's psychological or nominal membership in informal groups and reference groups, as well as their relationships with significant others, play a potent role in shaping that person's health behavior (Green, 1970b; Haggerty, 1977; Henderson and Enelow, 1976; Jenkins, 1979; McDill, 1975; Straus, 1961). Evidence of the influence of reference groups and social relations on individual health actions is primarily derived from studies of differential acceptance of preventive health measures among populations (Gray et aL, 1966; Johnson et aL, 1962; Merrill et aL, 1958; Neill and Bond, 1964; Rosenstock et al., 1959). Investigations of poliomyelitis vaccine acceptance during the 1950s and 1960s identified the degree of social participation and the expectations of others as important influences on adults' decisions as to whether they and their children should be vaccinated. Merrill et al. (1958) observed that relative to polio vaccination, individuals tend to hold beliefs and act in accordance with perceptions of peer group expectations. Rosenstock et al. (1959) suggested that the decision to seek vaccination was determined partly by social pressures applied by persons important to the individual. They hypothesized that situational factors and social support were critical determinants of action when personal readiness was low. Gray et al. (1966) further demonstrated the important role of social interaction and friends' expectations in influencing behavior. While a direct relationship between social class and immunization rates was confirmed in their study, beliefs regarding friends' expectations of immunization behavior accounted for these differing immunization rates across all social classes. In a study of vaccine acceptance in Dade County, Florida, Johnson et al. (1962) hypothesized that the variables of increased involvement in both formal and informal groups would relate positively to vaccine acceptance. Collected data supported the contention that each of these social

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interaction variables function independently as a predictor of taking vaccine. Perceptions of actions by friends " . . . was more highly associated with acceptance of oral vaccine than was any other variable used in this study" (p. 42). (Other variables used in the study include knowledge about the vaccine program, beliefs about polio and the vaccine, sociodemographic attributes, and personality factors.) The authors interpreted their findings in terms of reference group theory; persons who believed their friends took the vaccine could be assured of support for their own decision. Moreover, when important others were believed to have refused the vaccine, the individual was provided with psychological support for nonacceptance. The strength of group influence was weakened in cases where some friends were thought to be takers and some nontakers. In the absence of clear-cut expectations from friends, variables such as fear, knowledge, and personality factors became more important influences. Neill and Bond (1964) attempted to use the apparent relationship between polio vaccination acceptance and social relations in terms of expectations of others during a community-wide vaccination campaign. Using the reference-group concept, efforts were made to maximize participation among the low income, "hard-to-reach" groups by utilizing informal channels of influence. After conducting interviews in the community, public health nurses identified the health opinion leaders. These individuals became actively involved at neighborhood meetings, educating and motivating their friends and neighbors to take the vaccine. Although this study did not represent a rigorous scientific investigation, the results were impressive. While previously only 22~ of the community responded positively to the more traditional media-based campaign, the group membership influence approach resulted in an 87~ acceptance. The influence of group membership on utilization of dental services has also been demonstrated. When Lambert and Freeman (1967) investigated the role of social interaction on children's utilization of a public dental clinic, they found that 73% of families with one or more clinic goers also had friends, neighbors, or relatives who attended the same clinic. The researchers concluded that the mothers' evaluations of their friends' dental behavior apparently were associated with their use of dental clinics. The potential role of social forces in influencing oral health behaviors has been discussed further by Antonovsky and Kats (1970). After attempting to explain the dental health behaviors of a group of hospital employees and their dependents by using predisposing factors, including perceptions about dental disease and treatment, an unexpected conclusion was reached. The authors stated, "there is good reason to think that it might be wiser to allocate resources more along the lines of persuading people that 'everyone

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you think is important' is taking the desired action; or that 'if you wish to be a good person (mother, citizen, worker, etc.) you had best take this action'. This approach might well be more effective than persuading people that having healthy teeth should be of major importance to them" (p. 378). In addition to effects of membership in peer, friendship, worker, and other primary reference groups, a vast social psychological literature has developed concerning the effect of membership in a group formed for the express purpose of altering behavior (Cartwright and Zander, 1960; Hare, 1962; Lieberman, 1975). This group approach to health behavior change has theoretical underpinnings based on the pioneering work of Lewin (1958), whose experiments with changing the food purchasing habits of housewives during World War II established the effectiveness of group discussion on influencing an individual's actions. Bond's (1958) study, comparing group lectures to group discussions as a means for motivating actions for early cancer detection through breast self-examination, provided further empirical evidence of the potency of group reinforcement. Green et al. (1977) provided another example of the effect of informal peer relations on a group to change their individual actions. Their study illustrated the efficacy of group discussion in reducing asthmatic patients' dependence on emergency department facilities. Additional research concerning the effectiveness of the group approach to modify health behaviors was summarized by Green (1978). Undoubtedly, there are a variety of social and psychological processes operating in groups that affect members' actions. As Green stated, "The effectiveness of bringing together individuals who share common health problems appears to be based not only in the tendency to trust and conform to the judgment of others who have the same problem, but also in the quality of pertinent, relevant, and understandable discussion and mutual reinforcement that occurs among participants in such groups" (p. 48). Given what is already known regarding the influence of social reinforcement on individual health behavior, it seems warranted to investigate targeting interventions to existing reference groups in order to establish and reinforce individual dental health actions, or to form groups with the intent of developing expectations and norms for appropriate dental behaviors. Additional research is necessary, however, before strategies applying these constructs can become operational.

Schools

Prior to exploring the potential applications of the literature concerning the significance of social influences on health behavior for school-

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based dental health activities, the past history and current status of these programs should be brought into perspective. To date, school-based dental health programs, depending on their orientation, can be divided into two broad categories: informational and behavioral. The majority of programs generally have tried to change dental health behaviors by providing information about the disease processes and by stressing the relationships between good behaviors and disease prevention. In view of the extensive documentation concerning the limited role information plays in changing health behaviors (Young, 1967a, 1967b), it is not surprising that most of these programs have failed to alter children's dental health habits (Cohen and Lucye, 1970; Haefner, 1974; Young, 1970). School-based programs that have tried to change children's dental habits by employing a behaviorally based approach (Kaplis et al., 1979; Albino, 1978) have also had disappointing long-term results. Several extensive critical reviews of this school-based dental health education literature have concluded that regardless of the educational approach, and in addition to teacher-pupil interaction, reinforcements appear necessary if the program is to develop behavior that becomes integrated into the child's daily life at home (Cohen and Lucye, 1970; Haefner, 1974; Rayner and Cohen, 1971). There is evidence that the behavior of school-aged children can be influenced by two significant reference groups: parents and peers. While parents have the strongest influence during early childhood, as children grow older, conformity to peer group norms tends to increase in importance (Hamm and Hoving, 1971; Patterson and Anderson, 1964; Utech and Hoving, 1969). The period of adolescence represents a transition from childhood to adulthood, and it is widely recognized that both increased risk-taking behavior and challenges to parental authority are characteristics of this period. Although parental influences do continue to play an important role in matters pertaining to future life goals (Brittain, 1963, 1967), a strong need for peer acceptance has been shown to affect adolescent behaviors relevant to current life-style, such as smoking cigarettes (McAlister et al., 1979a; McKennell, 1969; Newman, 1970) and marijuana (Kandel, 1973). The strength of peer-group influence during adolescence complicates efforts to motivate youth to initiate health-related behaviors not supported by peers (McDill, 1975). Recognizing this shift in primary reference groups and source of social support, discussion concerning the potential role of interpersonal reinforcement in school-based dental health programs is presented in two sections that reflect this dichotomy.

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Young Children and Parents Based on studies that demonstrated the direct relationship between the dental habits of mothers and those of children (Freeman and Lambert, 1965; Metz and Richards, 1967; Rayner, 1970), Haefner (1974) called for research designed to explore methods for involving parents in school-based dental programs targeted to younger children. To date, however, little research has been conducted in this area and, with an occasional exception (Lee, 1978), progress has not been made in involving parents. Rather than view this failure to involve parents in school programs as unique to dental health promotion efforts, one should consider that this situation may be a reverberation of a national trend of decreasing parental participation. With the exception of rural schools (Friedman, 1979), parents have become less and less involved with their children's education. Lightfoot (1978) suggested that this lack of communication and cooperation between families and schools is a reflection of a growing conflict that exists between the two groups. She contended that this discord centers around issues of control, territoriality, and teachers' perceptions of parents and parent groups. Considering the prodigious growth in the number of two-parent working families and single-parent working families during the last four decades, involving parents in future school programs seems even less likely. From 1940 to 1970 the proportion of working mothers rose from 9.0 to 42.0%o (United States Department of Labor, 1971). As of 1977, 50.7% of all mothers aged 16 years and older worked; and of this group, 3.4 million or 22.0% were single parents (United States Department of Labor, 1979b). The inherent pressures in such living situations suggest that parents might relegate their involvement in a school-based dental education program to a low priority. There is some evidence that parents do want schools to play an active role in securing dental heakh for their children (Jenny and Frazier, 1974). Rather than perceiving themselves as partners with the school, however, one study demonstrated that when schools assumed a portion of the responsibility, parents perceived the school as having taken over the whole job (Shory and Sanford, 1964). This does not imply that parents can or should be excluded from involvement with their children's dental health behaviors if the children are to develop appropriate dental health habits. Consideration should be given to alternative channels for reaching and involving parents since, except in selected situations, the school may no longer be the best channel.

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The trend toward an increasing proportion of working mothers suggests that research should focus on the potential of the work site as a suitable place for reaching mothers to motivate and involve them in helping their children develop appropriate dental health habits. As fathers continue to become more involved in parenting functions, the potential to reach parents at the work site gains an even greater importance. Schools have already attempted to establish channels of communication with parents and, therefore, we will consider which selected types of school-based situations seem most conducive to the successful involvement of parents in dental health programs. If parents frequently enter the school and talk with teachers there is an opportunity for a good rapport to be established between school and home. Day-care and Head Start programs provide unique situations for involving parents in assisting and motivating their children to adopt improved oral health behaviors. In these preschool settings parents interact with teachers and other school personnel on a regular basis: while dropping off and picking up their children, during eligibility reviews, and during child progress conferences. In addition to the increased interaction between parents and teachers found in preschool programs, there is also the advantage of reaching children at a very early age. It might be of value to concentrate research efforts on exploring ways in which parents can be most effective in reinforcing what is taught in a school-based program. Research efforts also should explore ways to maximize the effectiveness of teachers working directly with parents, since teachers would be asked to work with parents as well as with children. Several areas need to be investigated: the extent to which teachers are convinced of the relationships among dental health, the overall welfare of pupils, and the need to involve parents in dental health programs; how best to motivate teachers to become actively involved in dental health programs targeted to both parents and children; and how to maximize teachers' self-confidence and comfort in working with parents while teaching them to reinforce dental health. One could reason that encouraging teachers to share with one another their ideas, goals, and frustrations regarding dental health programs would produce a support system and motivate them toward a more effective effort. Norms could become established concerning the role of a "good teacher" in motivating students and parents toward improving oral health. Another approach that has been tried in schools is the use of extrinsic rewards to reinforce positive oral health behavior in children. While one study showed that children's improved oral hygiene behavior continued after rewards were withdrawn (Martens et al., 1973) and others have demonstrated that extrinsic rewards motivated children to participate in

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topical and self-applied fluoride programs (Kegeles et al., 1978; Lund et al., 1977), the general literature regarding this behavior change technique has suggested that subjects tend to return to the baseline or to become more recalcitrant to improving their behavior once the rewards have been withdrawn (Deci, 1971; Lepper et al., 1973; Levine and Fasnacht, 1974). Rewards to children may be effective in influencing some of their dental health behaviors, but the scope is limited. Several important oral health behaviors require the involvement of parents. Children need supervision at home to reinforce proper eating habits and to see that they receive professional dental services periodically. Parents need to be reached at another site. Suggestions have been made for evaluating approaches for maximizing the effectiveness of efforts targeted to involving parents in preschool situations. A variety of research topics concerning the potential of involving parents at industrial settings is discussed later.

Adolescents

and Peers

Perhaps the school setting can be utilized to achieve greater success in changing dental health behaviors of adolescents, since it is during this stage of development that acceptance by peers strongly influences lifestyle and appearance-related behavior (Brittain, 1963; Kernan, 1973). Given the strength of adolescents' desire to conform, it is surprising that there has been little investigation of dental health norms among this group. One study by Albino and co-workers (1977) raised important issues regarding the relatively unexplored area of the role of peer reinforcement in the formation of dental health norms. In order to determine if brushing and flossing habits could be influenced positively, a 3-year study followed three groups of students from the sixth grade through the eighth grade in 33 Buffalo schools. One of the three groups received "an innovative program of instructional and motivational activities" (p. 288) which included values clarification exercises, parent-monitored rewards for cleaning their teeth, photographs of their own mouths after staining their teeth, and group competitions with small prizes. In addition, peer-group leaders were utilized. All three groups received traditional classroom dental health education talks, as well as referral to care. One of the two traditional groups, as well as the innovative approach group, received preventive services including topical fluorides and plastic sealants to reduce the incidence of caries. Evaluation measurements were taken after 30 months. While the three groups showed no clinical differences in terms of gingival scores (health of gums), the group receiving the social reinforce-

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ment approach did achieve significantly improved plaque scores. The authors perceived that the group competition did not function to provide incentive because of the prizes awarded, " . . . but rather to strengthen the group identity of individuals through providing a group goal. Evidence of rivalry among certain groups and the intragroup solidarity which goes along with such competition were observed" (p. 287). Furthermore, members within the group receiving innovative treatment who were identified by their peers as leaders achieved significantly greater improvements in dental health scores than did the nonleaders (Albino et aL, 1980). Further studies are needed to explore the questions raised by this investigation. It does appear that the motivational approach created a social milieu where oral hygiene behaviors were important in and of themselves, independent of any dental health benefits. It is of value to examine which interventions might be most useful for generating positive dental behaviors within an adolescent group. Another worthwhile area of research based on peer reinforcement and development of group norms is the use of peers to educate and motivate their friends. This approach has been successfully used in school health education programs targeted to both the promotion of oral hygiene (Morris, 1975) and the prevention of smoking among adolescents (McAlister et al., 1979a). The THETA Program (Morris, 1975), developed by the Division of Dentistry of the United States Public Health Service, has been promoted by the National Foundation for the Prevention of Oral Diseases. THETA is an acronym for Teenager Health Education Teaching Assistants and, as the name implies, the program uses peer education techniques. The prescribed procedure utilizes high-school students to educate and motivate primary-school children. The formal program evaluation was conducted without benefit of a control group; as a result, conclusions regarding its effectiveness are unclear. The initial results showed a significant reduction in plaque scores among the primary-school subjects at the program's termination, but no long-term evaluation has been described. Preliminary data from one study showed that when several of the principles of the THETA program were incorporated into a dental health project targeted to adolescents, the results were promising (Verity et al., 1979). These programs stimulate several research questions regarding the potential for employing the peer approach, or modified versions, which might include using students closer in age to the target group they were teaching. While one might assume that using adolescents to teach younger children is effective, in that younger pupils often view adolescents as role models and strive to emulate them, using students close in age to those they were educating might reduce the psychological and social distance sometimes found between educator and learner. Such

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distance has been hypothesized as one of the major barriers to communication with, and motivation of, target populations (Roberts et aL, 1963). Another aspect of the peer approach worth evaluating is that of using older students to teach younger students of the same sex only, as the opportunities for identification and discussion of appearance-related issues might be maximized. The effects of peer education should be investigated for possible changes in the behaviors of the student teachers, as well as the student learners. For the adolescents, involvement in the teaching might be a powerful motivation for behavior change. The influence of these student teachers on the behavior of their classmates should also be explored, as it is possible that they could serve as norm-setters among their own age group. It is clear that the peer education method holds promise for improving dental health behaviors Additionally, this approach has the potential for creating a sense of group and group norm around dental health behaviors. Several important questions concerning the role of norms and peer influence in changing dental health behaviors of adolescents still remain unanswered, Other research areas of interest might include the extent to which norms for dental health exist, the possibilities for school programs to create a widely accepted norm for dental health, the identification of dental health outcomes with the highest saliency for adolescents (e.g., good breath or white teeth), the evaluation of various methods of creating dental health norms, and the extent to which dental norms can motivate youth to adopt the desired behaviors. Furthermore, additional information about prevalent norms operating at various age levels would allow for improved targeting of motivation programs.

Industry While numerous studies have investigated the value of various dental health education approaches in the school setting, with the exception of studying the impact of offering financial incentives (EBPR Research Report, 1978), virtually no research has explored how the work setting can best be used for improving the oral health behaviors of employees and their dependents. Given that adults interact with their co-workers on a daily basis, the social milieu at work might provide a context within which to set dental health norms. Although the influence of social relations and informal group norms on individual work behavior at the work site has been observed (Katz and Kahn, 1966; Mayo, 1960; Miller and Form, 1964; Whyte, 1969), the influence of these relationships on dental health behavior has not been studied.

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Social scientists have investigated norms of dental health behavior of adults according to socioeconomic status (Haefner et aL, 1967; Koos, 1954; Kriesberg and Treiman, 1960; Nikias, 1968), yet no effort has been made to study the extent to which these norms are communicated among employees in formal or informal groups at work. As a preliminary step one might ask if employees, while at work, talk about their concerns regarding their own or their children's teeth, or if they discuss their own dental health habits. If this discussion occurs, does the frequency of shared topics concerning these personal habits vary according to workers' status vis-h-vis blue collar/white collar? As the work site becomes more involved in health promotion and employee assistance programs in a wide variety of areas ranging from physical fitness, hypertension, and weight control to alcoholism prevention programs and mental health promotion (Barrie et al., 1981; McGill, 1979; Washington Business Group on Health, 1978), the opportunities to introduce discussions about dental health will increase. The feasibility of establishing reinforcing norms should be investigated, in terms of both informal groups (communication among friends at work) and formal groups which could be specifically designed to deal with dental health issues. As previously mentioned, the formal- and informal-group approaches have demonstrated positive effects on health behavior. The potential role of formal support groups in setting norms regarding dental health behaviors has been explored in one army-based study concerned with oral hygiene practices (Durlak and Levine, 1975). Perhaps this group reinforcement approach should be applied specifically to several employees who share a common dental problem, for example, workers who have had or are about to undergo extensive periodontal treatment. The role of homogeneity among members of support groups, in terms of increasing the communication, trust, and consequent behavior change, has been investigated with nondental behaviors (Green, 1975). The hypothesis that homogeneity would similarly influence the effectiveness of dental support groups merits investigation. It appears that an increasing number of industries will be offering dental health education programs which train their workers in brushing and flossing skills (McGill, 1979). One might consider studying the effectiveness of educating workers on an individual basis, scheduling the intervention so that employees who work in close proximity are educated in succession. This approach might stimulate both communciation and support. One could examine the extent to which such communication and support is spontaneous, as well as explore methods for increasing opportunities for these to occur. Given that a high proportion of workers are receiving prepaid dental health benefits which are often extended to their families, and that pre-

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miums paid by employers relate to services used, one also might speculate that companies would be interested in motivating all members of workers' families to adopt preventive dental behaviors. It is within this context that companies might be persuaded to attempt to motivate employees to become involved in educating and influencing their children to adopt preventive dental health actions. There are two clear advantages of reaching parents at the work site. First, there is the simple issue of access, as parents can be reached where they already are. Second, parents can have continued support and reinforcement on a daily basis while at work, whereas at schools parents become isolated from one another once they leave the building. The work place provides several opportunities to investigate the feasibility and effectiveness of industry-sponsored parent education programs and of motivating parents to serve as role models for their children by improving their own dental heath. An increasing number of employers are offering workers parent education programs which include both physical and mental health components. Since parents are being brought together in the work environment to discuss these family health issues, an opportunity exists to introduce dental topics in a variety of ways and measure the effectiveness of each approach. In this context, one could evaluate the approach suggested by Antonovsky and Kats (1970) which proposed that efforts in the work setting should be designed to create the norm that to be a good parent entails being involved with the dental health of one's child. As McKinlay (1975) pointed out, the advertising industry appeals to the norm of being a good parent by suggesting that to be a good mother requires buying Twinkies for one's child. Blinkhorn (1978) demonstrated, however, that no clear norm presently exists among women regarding the appropriate role of mothers in training their children to care for their teeth. Using value clarification exercises with parent groups might help employees examine their role and responsibilities in terms of their children's dental health. Such an exercise could be followed by opportunities to learn about activities which would promote oral health. Support among group members who are trying to affect their children's dental health behavior could prove to be an additional powerful reinforcer and should be investigated. As parents at work are receiving health information, dental health educators might use this contact as an opportunity to discuss how parents can serve as role models at home to motivate their children toward preventive dental behavior. The practical strategy of getting mothers motivated to become involved with their children's dental health in the context of improving their own oral health habits reflects the findings of several studies. Rayner (1970) reviewed the literature on the relationship between mother and child oral health behaviors, concluding that a child's dental health

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habits are determined more by what a mother practices herself than by what she instructs or urges the child to do. Since it is probable that the relationship is similar between a father and child's dental health behaviors when the father assumes child-rearing responsibilities, both fathers and mothers should be involved in health education/motivation programs. Studies should explore how best to involve workers in designing and developing these programs. As Green (1970a) aptly stated, "When groups are allowed to participate early and actively in the collection of information and the making of decisions upon that information, they become more committed to the actions decided upon" (p. 38). The degree to which involvement could be used as an opportunity to create dental health opinion leaders should also be explored.

ENABLING FACTORS Schools

In addition to one's personal beliefs and attitudes about dental disease (predisposing factors) and the extent to which one interacts with people who reinforce preventive actions (reinforcing factors), it has been suggested that enabling factors, those variables that relate to the accessibility and availability of dental services, also affect an individual's preventive dental health behaviors. A growing number of schools are sponsoring dental-care programs, presenting researchers with opportunities to investigate the relationships between several care delivery options and individual preventive behaviors. Many schools have increased accessibility to specific dental services such as fluoride programs (rinse, tablets, gels, pastes), daily brush-ins, and dental screenings by offering them on the school premises. Clinical evaluations have shown that both fluoride rinses and fluoride tablets have substantially reduced dental decay (Driscoll, 1974). Nonetheless, the ability of schools to deliver these services effectively and the degree to which education and service are linked require investigation. Brush-ins should be evaluated in terms of their effectiveness in helping children develop the manual skills for cleaning their teeth. The provision of these services (enabling factors) affords us the opportunity to study their impact on other specific dental preventive health behaviors of children. One could compare the effect of a school-based motivational program targeted to improve home care, dental visits, and nutritional behaviors that did include a weekly fluoride rinse program with one that did not. In addition, offering services within the schools may present a viable opportunity to increase

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parental involvement in school dental health education programs. Further investigation should explore the extent to which service programs can be used to involve parents and the ways of maximizing such involvement. One might assess the effectiveness of providing services for children contingent upon parental involvement, as well as the degree of parental involvement on both parent and child dental health behaviors. During their regular hours, schools can also foster improved nutritional habits in children by limiting the availability of sweets or by making only noncariogenic food options available. When a suburban Boston elementary school simply replaced ice cream with fruit for dessert, it was found that virtually one-half of the students ate fruit with their lunch. Prior to offering fruit, about one-half of the students ate ice cream (Wells, 1979). While this experience in no way represents a research effort, it does suggest that schools can affect student diet during school hours. In England, Craft and Croucher (1979) demonstrated some success in improving dietary habits of young children by exposing them to an educational program that provided them with the opportunity to choose between"safe" a n d " u n s a f e " foods. Research focused on the long-term effects of these approaches to nutrition education seems warranted. In addition to preventive services, there has been a resurgent interest in delivering restorative services in school-based clinics. The Robert Wood Johnson Foundation, as well as the federal government, have been examining the feasibility of this approach. The government has recently lent financial support to two new school dental clinics in Hartford, Connecticut (University of Connecticut Health Center, School of Dental Medicine, 1978). The goal of any school-based restorative dentistry service should be not only to provide needed services, but also to develop the desire and skills in children to seek professional dental services in the community when they are no longer eligible for the school program. Evaluations of several school-based dental service programs, however, have documented that many young adults do not make a satisfactory transition from the schools' services to those available in the community. A study designed to evaluate the oral health of adolescents who received dental care in a school clinic in Brookline, Massachusetts, showed that "teen-agers accustomed in childhood to receiving such services from a public clinic are unlikely to turn to a private practitioner when denied the clinic's attentions because of age" (Lambert and Freeman, 1967, p. 174). This finding has been confirmed by additional studies conducted in New Zealand (Cohen, 1978b), Denmark (Christensen, 1981), and Finland (Ainamo and H01mberg, 1973), where children are eligible for school-based restorative dental services. One might hypothesize that care without adequate educational supplements

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may lead to a dependency on school-based curative services, rather than a self-reliance on seeking dental care. Recognizing the potential growth in the number of school dental clinics in the United States, researchers need to investigate systematically the barriers to seeking care when one no longer qualifies for school services. The effectiveness of various approaches toward motivating this appropriate action also needs evaluation. In Denmark, for example, the government is evaluating the efficacy of lectures, leaflets, postal reminders, and financial incentives designed to motivate young people to seek professional dental care once they become ineligible for school-based services (Christensen, 1981).

Industry

As in the school setting, the relationship between the availability of services to industry-based populations and their preventive dental health behavior demands close scrutiny. Almost all industry-sponsored dental prepayment programs provide full payment for preventive services and partial reimbursement for restorative and prosthetic services. Dental prepayment packages for the auto, steel, and telephone industries reflect this structure (American Dental Association, 1979b). One might assume that full coverage of preventive services would motivate employees to utilize them, yet companies and labor unions are finding that improving workers' oral health requires more than simply spending money. A number of investigators have concluded that industrial sponsorship of dental prepayment programs does not ensure utilization of professional services by all those who need treatment (Leverett et al., 1977; Mulvihill et al., 1972; Nikias, 1968). In fact, an analysis by age, sex, and socioeconomic status of the percentage of insured employees who make use of professional dental services does not vary substantially from the utilization figures for the nation as a whole. Other barriers, in addition to economic factors, are involved in the decision to seek dental care. It has been documented that access represents one such barrier (Kegeles, 1963). An insured employee may be able to afford dental services, but may lack an ongoing relationship with a dentist, may live in a community with a shortage of dental personnel, or may lose wages for time spent seeking dental care. Why might industry encourage utilization of dental insurance plans, since premiums are based on the assumption that utilization will be low? Users of the plan currently are subsidized by nonusers (Block and Hill, 1977). Increased participation in these prepayment programs initially would raise the price of premiums, causing a reluctance on the part of management to promote program use. A restructuring of benefit schedules, however, could make support of preventive programs financially more

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advantageous to industry. Bailit et al. (1979) documented that more than 30% of the dollars spent by dental prepayment programs represent reimbursements for expensive prosthetic services that are used by only 10%0 of the insured population. The authors suggested that management could discontinue payment of these expensive services without significantly reducing the employees' oral health status and could use these saved dollars for reaching the nonusers with basic preventive services. This strategy could significantly improve the dental health of an expanded number of workers without increasing company costs. The possibility that management may have incentive to increase utilization of the dental prepayment program in the future should lead researchers to focus current efforts on investigating how best to motivate these nonusers to become users. Additional research efforts could concentrate on measuring the effects of improving access to various combinations of curative and preventive dental services on the utilization of preventive services as well as on employees' oral health habits. Companies have begun to offer dental services at or near the work site, creating new opportunities for conducting such research. Several firms in England, including Gillette and Marks & Spencer, have introduced dental clinics at the work site (Anonymous, 1974). Gillette offers comprehensive services and Marks & Spencer provides screening, consultation, and referral services. In Winston-Salem, North Carolina, R. J. Reynolds Industries, Inc., has recently developed a comprehensive dental clinic near the work site for employees and their families (Plachy, 1980). Over 85% of the employees and their dependents have elected to join the closed panel dental clinic and 90% of those who did join are utilizing the services. The American Dental Association Council on Dental Care Programs is currently identifying other industry-based dental clinics (Beacham, 1979). Alternative combinations of dental services which could be provided at the work site require piloting and evaluation. One could envision, for example, an industrial on-site clinic that offered only preventive services and health education programs. Such a clinic could be an integral part of a broader dental health program within the company, reflecting the variety of motivational strategies previously discussed. It would be of interest to compare the effectiveness of an industry-sponsored education/motivation program that also offered on-site preventive services with the effectiveness of one that did not. Furthermore, it is necessary to investigate the relationship between the effect of on-site clinics and the mix of services offered. If industry-based clinics do cause desired changes in utilization and in personal health habits, it would be important to know what minimum mix of services is capable of producing favorable effects. If simply offering preventive services, education, and referrals produced similar results to those obtained by offering comprehensive services, industry might be more

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likely to adopt fewer measures because of the minimum cost, rather than to develop a full dental service. Industry-based clinics need to be evaluated in terms of their effect on worker and family personal oral health habits, utilization of preventive services, and utilization of other professional dental services. Their effect should also be measured on employee absenteeism due to toothaches and dental appointments. Gillette has calculated that since the introduction of their on-site clinic, there has been a substantial reduction in the amount of time employees spend receiving dental care during work hours (Anonymous, 1974). Full-time employees of the Woodward Governor Company in Rockford, Illinois, are required to use the company's on-site dental clinic and demonstrate that they are dentally fit (Gondela, 1979). The services of the clinic, in fact, are utilized by 99~ of the employees. "By eliminating both cost and access barriers to dental care, the Woodward Governor Company feels its workers' overall health is enhanced and, therefore, the company's productivity and profitability increased" (p. 10). There is also a very important opportunity for industries to affect the dental health behaviors of workers' children via enabling factors. Several industries currently offer on-site day care for the employees' preschoolers. The prospectus describing Boston-based Stride Rite's daycare program states, "Dental care is strongly stressed" (Stride Rite Corporation, 1976, p. 8). In addition to daily brushings, the children are taken to the pedodontic department of a local hospital for preventive and restorative care. The extent to which other industry-based day-care centers offer such a service, or the readiness of these day-care centers to assume such a role, is still unknown. Industry-sponsored day care provides great opportunities for parental contact with preschool administrators, teachers, and aides, as well as direct contact among parents, children, and staff during lunchtime. Such day-care programs provide researchers with the opportunity to explore the effectiveness of dental health education programs for preschoolers whose parents are readily available for daily involvement. In addition to paying for preventive services, dental prepayment policies can be structured to financially reward individuals for taking actions that promote their own oral health. Washington Dental Service Corporation, for example, has over 120,000 subscribers who are rewarded financially for making annual visits to their dentist (EBPR Research Report, 1978). The plan is structured so that the insurance company pays 70% of the fees for preventive and restorative services (excluding cast restorations) during the first year and, if the subscriber goes to the dentist at least once each year, the plan pays an additional 10% annually until he is fully covered. Failure to visit a dentist in any one year results in a penalty

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to the patients; they must pay an additional 10% of their bills for each year they miss, with a maximum penalty of 30%. According to in-house studies, plan utilization rose from 60 to 75% over a 5-year period. Further study is needed to confirm these findings, as well as to identify the optimum incentive system for other population groups. Clearly the effect of such an incentive plan could be investigated in combination with on-site preventive services and/or the types of motivational programs previously discussed.

DIFFUSION AND ADOPTION: INSTITUTION-BASED DENTAL HEALTH PROGRAMS

In addition to research related to understanding the determinants of oral health behaviors and evaluating the applications of these findings, investigations should be conducted to determine which factors are important for encouraging the diffusion and adoption of preventive dental health measures to schools and industry. In 1972 the National Institutes of Health, recognizing the need for this type of research, sponsored a Conference on the Diffusion of Medical Innovations for government policymakers, biomedical experts, and social scientists. Panelists stated that research about the diffusion of medical innovation is important " . . . to provide baseline data for policy planning on the part of the NIH as well as other government agencies" (Gordon and Fisher, 1975, p. 27). The conference concluded " . . . that a great deal of information about this country's medical needs, medical innovation availability, and the benefits as well as costs of diffusing various technologies are important if rational decisions are to be made regarding medical diffusion" (p. 177). Very little research has been conducted on the diffusion or adoption of dental preventive measures, in particular, or preventive measures, in general; studies reported have dealt with innovations that diffuse to public health officers or private practitioners (Becker, 1970; Cohen, 1966; Miles 1975) rather than to schools or industries. Within the past few years, exploratory research has led investigators to suggest that one should differentiate between preventive innovations where results are long-term and nonpreventive innovations where results are more immediate. This basic difference has led Rogers (1977) to suggest that research specifically directed at preventive innovations is needed. Some educators hold implicit the value of delayed gratification and long-term benefits (Miles, 1975); therefore, one may hypothesize that preventive health activities may be seen as appropriate activities for schools if they share the attribute of delayed benefits. On the other hand, since many companies finance a great

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share of the health care-related costs for employees and dependents, management's motivation for adopting preventive health measures may be related primarily to controlling these costs. Research on the factors that are involved when institutions consider adopting a dental preventive educational and/or service program would provide valuable information to those concerned with developing new educational and/or biomedical preventive measures that necessarily depend on acceptance by institutions for implementation. A few ongoing studies are exploring issues concerning the diffusion and adoption of preventive programs and, in so doing, are providing groundwork for continued research. For example, the National Institute of Dental Research is funding a 3-year study designed to assess the factors contributing to the current adoption and diffusion of fluoride rinse programs among United States schools (Coombs et al., 1980). In addition, the study is designed to assess whether the adoption of fluoride rinse programs represents a broad interest by schools in the larger issue of prevention or whether it is the result of isolated events. Data are being collected on who makes and influences the decisions about the adoption or discontinuance of health programs such as fluoride rinsing, as well as on the barriers and problems involved in implementing and maintaining similar preventive programs. In another example of research regarding the adoption and diffusion of preventive programs, the Bureau of Health Education of the Center for Disease Control is funding the National Center for Health Education to study the dissemination of one popular school-based health education teaching package, the School Health Curriculum Project (Green et al., 1981). By working with committees of educators and curriculum experts, the investigators plan to develop a national strategy for diffusing this curriculum to schools. As a final example, the Washington Business Group on Health, an organization supported by member corporations, is principally concerned with controlling health-care costs. They have conducted several informal surveys to identify the types of health education and other preventive programs based at the work site which are available to employees (Barrie et aL, 1981; Washington Business Group on Health, 1978). While their studies are not exhaustive, they provide preliminary data for anyone interested in investigating factors involved when industries decide to offer employees a prevention program. Innovative dental prevention programs suggest other stimulating research possibilities. Due to their concern for curbing the cost of insurance premiums by controlling health-care costs, the insurance industry is a particularly appropriate source for promoting prevention programs in

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institutional settings. The Dental Service corporation of California currently is offering funds to any school in their state that wants to provide a fluoride rinse program in grades kindergarten through 6 (Hoeschen, 1979). Research might explore other ways in which the insurance industry can maximize its impact on the adoption and maintenance of institutionally based prevention programs and determine if the acceptance of such programs is affected by the availability of private sponsorship. Research designed to explore how institutions make decisions regarding dental health programs should proceed only insofar as programs of proven efficacy exist. It might be useful to explore schools' receptivity to offering frequent supervised plaque removal programs for pupils, as such programs have been shown to be effective in foreign-based clinical trials (Axelsson et al., 1976; Axelsson and Lindhe, 1977). Investigating the willingness of schools to house and finance such a program would be useful to policy-makers and planners. It has been demonstrated that fluoride tablets and drops are useful for preventing tooth decay in preschool populations as well as in schoolaged populations (Andersson and Grahnen, 1976; Margolis et al., 1975). Research could be designed to explore factors that relate to whether physicians who work in industry-sponsored health maintenance organizations prescribe fluoride for child patients when appropriate. This information could help in planning approaches to motivate these physicians to routinely prescribe fluorides when applicable. In addition to researching institutions' receptivity to delivering effective oral health prevention services and education programs, investigators should explore the willingness of target groups to obtain services in institutional settings. While there is some evidence to suggest that a majority of parents are in favor of school-based dental programs (Jenny and Frazier, 1974), no published research studies describe the willingness of workers to accept industry-based dental health education or service programs.

SUMMARY

Two institutions have been cited as potentially rewarding targets for research regarding dental health promotion efforts. Schools and industries provide settings where over two-thirds of the population of the United States can be reached, and both these institutions have demonstrated their interest in improving the oral health status of their population groups. Research is needed to discover how these institutions can maximize the effectiveness of their efforts.

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Evidence has been presented regarding the relationship among social support, norms, social milieu, and preventive health. A number of specific research questions have been considered concerning the role of these reinforcing factors in motivating young children, adolescents, and working adults to improve their dental health behaviors. Further questions are posed regarding the relationship between the availability of institutionallybased/sponsored dental services (enabling factors) and individual preventive behavior among children and adults. Finally, a discussion of the need to study factors that relate to the diffusion and adoption of institutionally based dental health programs is presented. We have postulated that researchers who focus on these institutions are in the unique position to explore the effect of interpersonal reinforcing factors and enabling factors on individual oral health behaviors. The existence of a variety of ongoing institutionally based dental health programs, as well as evidence that many schools and work sites are already committed to improving oral health, suggests that opportunities are available to gain institutional cooperation to conduct such research. It is envisioned that answers to the research questions posed will build on and complement what has already been learned about the relationship between predisposing factors and preventive dental health behaviors. This holistic approach will increase our understanding of the complexities of the determinants of individual dental health behaviors and improve the likelihood of designing and diffusing institutionally based dental health programs that will lead to dental disease prevention and long-term behavior changes. While the research suggestions are directly related to current dental health issues, answers to these questions should also serve to improve our understanding of the potential for institutions to impact on the prevention of many significant nondental health problems.

ACKNOWLEDGMENTS The authors wish to express their gratitude to Carol G. Bikofsky, Mary Jane Kornacki, and Alison Ulrich for their help in the preparation of this manuscript.