Chapter 7. Public Education and Media Advocacy

Chapter Description

Oral health promotion strategies need to be comprehensive, and consistent, as well as culturally and linguistically appropriate. Key concepts of health communication, public education, health promotion, media advocacy, health literacy, and cultural competence are discussed. Tips and resources are given for framing oral health messages. Key oral health messages to convey to improve the oral health of young children and pregnant women are included. These generally coincide with those of the new statewide First 5 Oral Health initiative. Multiple media formats are needed to disseminate the information. 

Chapter Overview                                                                

Traditionally, most oral health education efforts have been conducted by dental professionals during dental office visits, in schools by teachers or dental hygienists, or by dental products manufacturers who were trying to sell products such as toothpaste or toothbrushes. February is considered Dental Health Month in the US by many national dental groups, so that oral health messages and volunteer efforts are targeted to various community groups throughout the month. Health communication researchers, however, have shown that one-time efforts do not generally change behaviors or affect oral health status. Reinforcement of key messages and provision of incentives are needed at regular intervals. People also learn in different ways and selection of the most effective media modality is important. Recently, researchers also have discovered that the US public does not generally understand 1) the importance of oral health and its interaction with general health, 2) the range of methods available to prevent and treat oral diseases, or 3) roles and responsibilities for self-care and professionally delivered oral care and follow-up. This situation sometimes creates friction and misunderstanding between dental professionals, health professionals, policymakers and the public, as well as missed opportunities for prevention, early detection and early care for oral diseases. Improving health communication among these groups is the focus of this chapter.

Self-Assessment

Many communities have struggled to develop effective oral health promotion strategies that will be meaningful and motivating to various community members, especially those who are not benefiting from available preventive measures and dental care. Occasionally efforts have been targeted to policymakers to raise their awareness of oral health issues and to suggest specific courses of action. All these efforts are well-intentioned but often fragmented and not generally evaluated. The new California First 5 Oral Health Initiative and other First 5 statewide public education campaigns present much needed opportunities to coordinate, strengthen and better tailor oral health messages to various sectors of the population. Rural communities can participate in these efforts in a number of ways that are meaningful to local programs. Use the self-assessment for this chapter to analyze what oral health activities and efforts your community has attempted in the past and how successful they have been. Then proceed to look at what resources are available to your community to pursue new strategies using a framework to measure outcomes.

Definitions and Concepts

• Health Communication

“Health communication is the study and use of communication strategies to inform and influence individual and community decisions that enhance health.”(USDHHS, Healthy People 2010, 2000.)

• Public Education

This chapter defines public education as the various communication methods that are used to convey oral health messages to members of the public who are not health professionals or dental professionals, e.g., parents, childcare workers, Head Start staff. Public education is then a subset of the broader field of health communication.

• Health Promotion

Health promotion is defined by the World Health Organization as “the process of enabling people to increase control over and to improve their health” (WHO, 1998). Health refers not only the absence/control of disease, but also the self-perceived quality of one’s life. Health promotion is accomplished through public education, media advocacy, changing policies, and other strategies. It relies on the principles of self-help, social support, empowerment and taking responsibility for actions. A number of health promotion theories will be mentioned in subsequent sections of the chapter.

• Media Advocacy

Media advocacy has been particularly useful in California in changing health behaviors such as tobacco use and getting annual mammograms, as well as influencing public policies, laws and funding streams. Current efforts are targeted to enrolling children in early childhood education programs and linking families with health services. Extensive and effective media campaigns, however, are often too expensive to develop on a community level. Rural communities can build on statewide efforts by putting a local or rural spin on the issues or using local personalities as champions. Community members also can play key roles by serving as focus group participants for media campaigns to make sure the messages are culturally relevant, easily understood and sufficiently motivating.-

• Health Literacy

The National Literacy Act of 1991 defined literacy as “…ability to read, write and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.”

Health literacy is an important element of oral health communication. Nearly one-half of all American adults have difficulty understanding and acting upon health information. Health literacy means enabling people to obtain, process and understand basic health information and services and then act in their own interests. Analyses of oral health education materials produced over the past 20 years shows that most materials are written at a college literacy level. Recent recommendations are for materials to be visually appealing and written at about the 3^rd to 5^th grade level, using “plain language” rather than technical terms. People with limited English proficiency or limited education may have less knowledge of oral disease prevention and management, and limited use of oral health service, thus resulting in poor oral health status. Health literacy needs to be addressed in the context of culture and language, and is crucial to quality health care.

• Cultural Competence

The term “culture” includes shared ideas, meanings and values acquired by members of a society. Culture influences health beliefs and health practices.

Cultural competence is a developmental continuum that ranges from cultural destructiveness to cultural blindness to cultural proficiency, with various stages along the way.

How to “Frame” Oral Health Messages

Marketing research conducted by the Frameworks Institute shows that oral health issues need to be “reframed” to help people 1) connect oral health to general health, 2) prioritize oral health as an important health issue, 3) assign responsibility for the development of dental problems to systems rather than primarily to parents, and 4) believe that there are systemic solutions to the problems. The researchers feel that messages need to:

• emphasize prevalence of the problem
• explain severity of the problem
• identify consequences of the problem
• underscore the efficacy of prevention in solving the problem
• mainstream the issue.

View examples of messages for each of these characteristics. The First 5 Oral Health Initiative and efforts in other states build on this research, but also emphasize oral health in relation to school readiness. View anticipatory guidance messages as well as oral health messages for health professionals, the early childhood education team and parents on the First Smiles website.

The same concepts of framing messages also apply to the field of media advocacy. Media advocacy activities are generally organized around two concepts:

1. framing for access: shaping the story to get attention and gain access to the media
2. framing for content: telling the story from a policy or advocacy perspective.

The Berkeley Media Studies Group provides the following “framing” tips for media advocacy.

The Center for Health Improvement’s Health Policy Guide pro vides a brief but useful overview of techniques for working with the media to get your message out. It covers media interviews, press releases, press conferences, letters to the editor, op-ed pieces, and radio. A section in Chapter 5 of the Healthy People 2010 Oral Health Toolkit also provides tips for working with the media.

Citizens Watch for Kids’ Oral Health, funded by the Washington Dental Service Foundation, was formed to “respond to the Surgeon General’s challenge to make oral health a priority.” It seeks to identify opportunities to prevent oral disease and to advocate for increased levels of prevention, primarily by engaging large constituencies to support policies to improve oral health. This is a good example of merging public education and media advocacy. Thecoalition is comprised of labor, business, medical, public health, education, dental and children's advocacy groups. It publishes opinion columns, editorials, news articles and letters to the editor, and runs print and radio ads to coincide with the legislative session. Examples of their materials and an overview of “framing the issue of oral health for the public” can be viewed at http://www.KidsOralHealthWatch.org. Citizens Watch produced the Watch Your Mouth campaign by the Citizens Watch for Kids’ Oral Health, with support from the Washington Dental Service Foundation and the Annie E Casey Foundation. The campaign has chosen the following key messages:

• Oral health is part of overall health
• Poor oral health affects quality of life
• Oral disease is linked to other health problems
• Oral disease is an infectious, progressive disease that can be prevented
• Prevention is cost-effective
• Fluoride is the best way to prevent oral disease
• When oral disease is left untreated, we all end up paying more
• Ensuring good oral health is a blend of community responsibility and personal action.

Increasing Oral Health Literacy

• An Institute of Medicine study on health literacy (see references) recommends:
• “People have opportunity to use reliable, understandable information about health
• Include health and science as part of the K-12 curriculum
• People can assess credibility of health information
• Cultural contexts of diverse people should be integrated into health information
• Health practitioners communicate clearly with patients during health encounters
• There is ample time for discussions between health care providers and patients
• Patients feel free and comfortable asking questions
• Rights and responsibilities in relation to health and health care are presented in clear, understandable language
• Informed consent process and forms are understandable to patients.”

All of these concepts are important when designing programs and materials for public education and provision of oral health services. For more information on health literacy, view the following website: http://www.hsph.harvard.edu/healthliteracy and see the Designing Program and Materials Resources at the end of this chapter.

One way to increase oral health literacy in young children is to acquire developmentally appropriate books that touch on oral health subjects. The Maine Oral Health Program has assembled a categorized and annotated bibliography of children’s books on oral health that notes the targeted age levels. Family Resource Centers, Head Start programs, local libraries, and other programs should acquire a variety of such books to make available to teachers and families. A variety of other interesting learning activities for educational settings and for parents to use are included in the Cavity Free Kids curriculum, developed by the Washington Dental Service and adapted for use in California (see the Resources section.) A number of other educational resources for children are also included in the Resources section.

Using Health Promotion Theories

A variety of health promotion theories have been researched to explain how people make decisions to adopt or change certain health behaviors. A useful reference that provides an overview of the theories is Theory at a Glance: A Guide for Health Promotion Practice by Glanz and Rimer (2003). The following table from that document summarizes the focus of these theories.

Theories are useful as frameworks for organizing your health promotion efforts in a way that has been proven successful in other situations. They also allow analysis of how effective the approach was and what side effects may have occurred.

Summary

In this chapter you learned important concepts of health communication, public education, health promotion, media advocacy, health literacy and cultural competency. After completing the self-assessment of community resources and efforts, and using the information in this chapter, use the Worksheet: Planning Public Education Efforts to select a few strategies to try in your community. This chapter also references many new materials being used in California communities through the First 5 Oral Health Initiative.

Resources

  For Public Education

• ABCD A Manual for Dental Providers: available through http://www.mchoralhealth.org/HeadStart/hsmaterials.html. Includes a section on Family Oral Health Education and handouts for parents (your baby’s teeth, fluoride varnish, and lift the lip).

• A Place of Our Own: Dental Care is a resource section of a broader website (http://www.aplaceofourown.org) for early childhood educators in California.

• Bright Futures in Practice: Oral Health Pocket Guide, 2004: available through http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf to download or can also order multiple copies. This pocket guide is designed to help dental professionals and others implement the oral health-related guidelines published in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Chapters cover oral health supervision guidelines, risk assessment, screening, examination, anticipatory guidance, measurement of outcomes.

• California Dental Association maintains a website (http://www.smilecalifornia.org) that has a section for the public. It includes fact sheets on various preventive measures and one on “Information for moms and moms-to-be”.  Their main website (http://www.cda.org/public) includes a “patient’s bill of rights”.

• Cavity Free Kids: Oral Health Education for Preschoolers and their Families. 2003. Washington Dental Service Foundation. This curriculum is being adopted by California First 5 to provide training for Head Start staff and parents, WIC staff and childcare staff. Other states such as Oregon, Washington, and Hawaii are also using this curriculum.

• CDA Foundation. Easy Steps to Oral Health. 2002. Three packages are tailored toward a specific age group and are available in both English and Spanish. Each package contains an educational video with corresponding mail-back evaluation postcard, a take-away brochure and a narrowcast display. Package One “Cavity Free Families” is for pregnant mothers and families with infants. Package Two “Look at My Teeth” is for families with children of ages one through three. Package Three “ My Trip to the Dentist” is for families with children ages three through five. A DVD with all three packages is available for providers to use in waiting rooms and was distributed to all CDA members with the March 2003 CDA Journal. Ordering information is at http://www.cdafoundation.org/news_dvd.htm.

• First Smiles Oral Health Education & Training Project is the California statewide First 5 oral health initiative. Materials to be shared with parents, caregivers, early childhood educators and health professionals are featured on the website. Many useful resources will be placed on the project website at http://www.first5oralhealth.com, so check the site often.

• Mestman SS and Herman AD. What To Do For Healthy Teeth. La Habra, CA: Institute for Healthcare Advancement. 2004. Order from http://www.iha4health.org. Easy to read, easy to use reference book for parents and others on oral health topics for all age groups. Written by a dentist and a childcare educator. Includes pages for notes and health related phone numbers.

• Healthy Smile, Happy Child: Early Childhood Caries Prevention. Maternal and Child Health, Nevada Bureau of Family Health Services, 2002. This training aid/kit contains materials on early childhood caries prevention and fluoride varnish, including a brochure, anticipatory guidance curriculum, and presenter manuals. The 74-page anticipatory guidance curriculum includes schedules (prenatal to 24 months) and resources for oral health care. The accompanying presenter manual includes class objectives, an outline, and participation notes, as well as camera-ready copies for making 43 Power Point slides and a post-training evaluation form. Download most materials from http://health2k.state.nv.us/oral/.

• National Maternal and Child Oral Health Resource Center Fact Sheets. Download from http://www.mchoralhealth.org/pubs1.html. 

  Inequalities in Access: Oral Health Services for Children and Adolescents with Special Health Care Needs, 2^nd ed being released in early 2005.
  This illustrated fact sheet highlights the inequalities in oral health care for children and adolescents with special health care needs. The fact sheet presents data on conditions and disabilities affecting the oral health of these children and adolescents, barriers that make it difficult for them to access oral health care, and programs to help them gain access to such care.

  Oral Disease: A Crisis Among Children of Poverty, 1998.
  This illustrated fact sheet documents the problem of dental decay and other oral diseases in children from families with low incomes. The fact sheet presents data on access to care for vulnerable children, the percentage of children enrolled in Medicaid/EPSDT who receive a preventive dental service, the incidence of dental decay in culturally diverse populations, and the costs of care in terms of both national economic priorities and personal pain and suffering.

  Oral Health and Learning: When Children’s Oral Health Suffers, So Does Their Ability to Learn, 2001.
  This illustrated fact sheet highlights the connection between oral health and learning. It addresses topics such as lost school time, inability to concentrate, decreased school performance, impaired speech development, inadequate nutrition, and reduced self-esteem.

  Oral Health and Health in Women: A Two-Way Relationship. 2004.    This illustrated fact sheet discusses how women can maintain their own oral health, which will in turn help to keep their baby’s mouth healthy.

  Preventing Tooth Decay and Saving Teeth With Dental Sealants, 2^nd ed. 2003.
  This illustrated fact sheet highlights the benefits of using dental sealants as a preventive oral health measure. It discusses what dental sealants are, how they can be used to prevent tooth decay, and programs to increase their use. The fact sheet also provides data on the cost-effectiveness of dental sealants and the number of children and adolescents who have used them.

  Promoting Awareness, Preventing Pain: Facts on Early Childhood Caries, 2^nd ed, 2004.
  This illustrated fact sheet describes the problems associated with early childhood caries (ECC) and provides suggestions on how to prevent or stop the progression of this infectious disease. It also presents data on the number of children with ECC and the cost, both financial and in terms of a child's overall well-being of ECC.

  Trends in Children's Oral Health, 2001.
  This illustrated fact sheet highlights available data on key issues affecting the oral health of infants, children, and adolescents. It presents information on early childhood caries, oral injuries, tobacco use, the protective role of fluoride and dental sealants, children with special health care needs, and access to care.

  Head Start: An Opportunity to Improve the Oral Health of Children and Families, 2003.

  This illustrated fact sheet highlights an overview of children in Head Start, data on access to oral health services and oral health status, and promising strategies to improve oral health in these children.

  Oral Health Tip Sheet For Head Start Staff: Working With Health Professionals To Improve Access To Oral Health Care. 2003.
  and
  Oral Health Tip Sheet For Head Start Staff: Working With Parents To Improve Access To Oral Health Care. 2003.

These two tip sheets were created to help Head Start staff deliver consistent messages to promote good oral health and help them strive for successful dental appointments.

• New Parent Kit Brochures. Brochures on a variety of topics are available in English and Spanish on the California Children and Families Commission website at http://www.ccfc.ca.gov/parentinfo.htm. Oral health information is integrated with general health information.

• Oral Conditions in Children with Special Needs: A Guide for Health Care Providers: available at http://www.nohic.nih.gov is a teaching tool for health professionals that includes color photos of oral conditions and anticipatory guidance messages.

• Oral Health Information for the Early Care and Education Community. http://www.kdhe.state.ks.us/ohi/download/early_care_and_edu.pdf. Kansas Head Start Association. 2001. This website includes core information and resource materials focusing on early childhood.

• Oral Health…From Pregnancy Through the Toddler Years: An Oral Health Education Program for Health Professionals: available through http://www.colgatebsbf.com/par_oral_preg.asp. This kit for health professionals, produced by Colgate-Palmolive Company, provides a teaching module on oral health education for four key stages of life: pregnancy, birth to 6 months, 6 to 18 months, and 18 to 24 months. The booklet discusses topics such as eating, brushing, and flossing during pregnancy; care of the infant's gums; use of bottles and pacifiers; and tips on snacking and brushing. Also provided are common questions and answers from families, reproducible brochures (in English and Spanish), and a poster.

• State of California, DHS, Maternal and Child Health Branch. Stop the Spread of Tooth Decay. 2003. Pamphlets and posters promoting oral health care for families with children from birth to five years. Written in English and Spanish. County health departments or MCH programs can order for free in packages of 100 pamphlets. http://www.mch.dhs.ca.gov/documents/pdf/oralhealthpstr_eng.pdf.

• Washington Dental Service Foundation: Oral Health Focus http://www.deltadentalwa.com/oralhealth/o_1.htm) includes short paragraphs about many topics in a “did you know?” format.

• WIC and Head Start Lesson Plans and Bulletin Boards on Oral Health. Maryland Dept. of Health and Mental Hygiene. http://www.fha.state.md.us/oralhealth/html/wicplan.html.

• ZATA Zoo Animal Teaching Aids (http://www.teachingaid.com): Fuzzy puppets (about 15 inches high when seated), come in 5 animal characters that have large mouths with flossable teeth, water squirter, and oversize toothbrush. Web site also includes stories, plays and poems, coloring sheets, and a user group board to post ideas. Good for use with young children. Cost about $85 each on the website.

For Designing Programs and Materials

• Centers for Disease Control and Prevention. Scientific and Technical Information. Simply Put. 2^nd ed. Atlanta, GA: CDC, 1999. Available in pdf format at http://www.cdc.gov/od/oc/simpput.pdf.

• First 5 California Implementation Tools for School Readiness Series. Health and Social Services. 2004. Oral health is included in this document and PowerPoint presentation at http://www.healthchild.ucla.edu/First5CAReadiness/materials.

• Freimuth VS and Quinn AC. The contributions of health communication to eliminating health disparities. AJPH. 94(12):2053-55, 2004.

• Health Communication Partnership has an online Field Guide to Designing a Health Communication Strategy; this can be accessed via http://www.hcpartnership.org. Although the guide doesn’t have an oral health focus, it is still a valuable resource.

• Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academy Press. 2004. Order from http://www.iom.edu/report.asp?id=19723.

• National Cancer Institute. Making Health Communication Programs Work: A Planners Guide. Bethesda, MD: NCI, 2002. (order online for free from https://cissecure.nci.nih.gov/ncipubs/details.asp?pid=209)

• The Partnership for Clear Health Communication is committed to offering free and low-cost resources and programs that deliver information, medical education and practice management tools to health care providers and groups that provide information to patients. Visit the website at http://www.AskMe3.org for more information about the partnership or their Ask Me tool to help improve health communication between providers and patients.

• UCSF Center for the Health Professions. Toward Culturally Competent Care: A Toolbox For Teaching Communication Strategies is available in CD-ROM format. The curriculum focuses on teaching clinicians to recognize cultural differences in patient interactions and use specific communication skills to improve patient care. For more information visit http://futurehealth.ucsf.edu/cnetwork/index.html.

• USDHHS. Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies. Baltimore, MD: HCFA, October 1999. (fax to 410-786-1905 to order for free—in process of being updated)

• Wallach L et al. Media Advocacy and Public Health: Power for Prevention. Newbury Park, CA: Sage Publications. 1993.

Evaluation

What did you learn or accomplish as a result of reading this chapter? Did it help you to organize your thoughts about what strategies for public education and media advocacy would be most effective in your community? Were the resources and examples helpful? Complete the feedback form and tell us what was useful or not useful for you.