Time for America to Brush Up on Oral Health Among the Elderly: A Critique of the Delta Dental ‘Senior Dental Health’ campaign in NJ – Gretchen Sminkey
Although oral health has recently been correlated with health outcomes such as cardiovascular disease and diabetes (1-2), there has not been a significant amount of change present to promote oral health among Americans. In 2007, 19.5% of children between the ages of 2-5 years had untreated dental caries (3). This percentage grows to 26.8% among people between ages of 20-64 years (3). As the population of America ages, the importance of oral health must be emphasized as national public health issue. Proper oral health maintenance is especially important for the elderly population because they are often afflicted with other ailments and are therefore at high risk for malnutrition (4). The complete loss of natural teeth (endentulism) is a major health problem for elders (5). According the Center for Disease Control and Prevention, between 1997 and 2008, the overall prevalence of endentulism in those 65 and older was 25.9 percent (3). There are significant disparities that exist across poverty levels when investigating this burden, with 38.9% of poor people suffering from edentulism (3). Another important factor when considering oral health among the elderly is access to quality dental care. In 2007, only 58% of adults 65 years and older had reported a dental visit within the past year (3).
In 2003, the Surgeon General called for national attention to the oral health problem in the United States (6). The report highlighted the need for policy modification and improvement, burden of oral health disease, and closing the existing disparity gap. In response to this call for action, states began to develop campaigns to address the growing problem of oral health (7). The Delta Dental insurance company launched a campaign in New Jersey in 2010 called “Senior Dental Health” awareness campaign. The campaign was directed at senior citizens and consisted of public service announcements that aired on the radio and television. The campaign offered an informational website and also reached out through the social network, facebook. The commercial announcement was sixty seconds long and narrated by a periodontist who is present during the ad. The announcement begins by stating some issues associated with oral health and aging such as the result of dry mouth from certain prescription medications and the link between oral health and 120 possible diseases, including heart strain. The message then consists of advice for seniors to ‘stay on top of their oral health’ by brushing and flossing their teeth regularly, drinking fluorinated water, cleaning their dentures, and visiting their dentist. The ad concludes with the slogan, ‘it could save your life’, followed by the Delta Dental of New Jersey Foundation website. Although the senior dental health campaign was created through good intentions, there are several areas where improvements could be made to enhance the outcome of the campaign. The goals of this critique are to identify inadequate behavioral theories utilized in this campaign and offer an intervention design incorporating alternative behavior models to improve this campaign.
Critique One-The campaigns use of the Health Belief Model
One major flaw in the ‘Senior Dental Health’ campaign is the use of the health belief model (HBM) to initiate oral health behavioral change among the target population. The HBM is based on the premise that determinants of health result from a cognitive process and therefore does not account for the impact of social determinants (8). The model emphasizes the individual and not the environment or social status of the individual. Poor oral health is a progressive status that is reached through multiple social determinants such as income level, insurance status, and living situations (8). Under the current basic Medicare plan, senior citizens do not receive coverage for routine dental care such as cleanings, fillings, tooth extractions, and dentures (9). Socioeconomic status and financial burden are major contributing factors behind poor health decisions related to dental care (10). Elderly patients residing in long-term care facilities have poor oral health (11), and may not have access to the required resources to change their situation. The campaign does not account for these social, economic, and environmental influences on health behavior that the target audience may experience.
Furthermore, the campaign does not offer resources available to elders whom may not have access to any dental care. They assume that those who see or hear the announcement have a toothbrush, floss, and fluoridated water. In 2000, there were still eleven states where less than 50% of the residents had access to adequately fluoridated water, the majority of which are in the Pacific-Northwest region (12). By excluding these factors, the campaign places the blame on the individual and relies exclusively on the individual to resolve these issues. This can result in a negative response from the target population, who may feel the campaign message is directly blaming them for having poor oral health. This understanding is known as victim blaming and can cause negative outcomes rather than proactive outcomes (13).
A major component of the HBM is that an individual makes decisions based on a perceived personal threat of a certain disease (14). Attempting to reach older adults in this manner is extremely difficult since the majority of them are dealing with other major health conditions that take precedence over dental health (15). They may not perceive themselves as being susceptible to oral health problems that would require them to visit their dentist. The perceived benefits of getting to see a dentist must outweigh the perceived barriers, which are plentiful for the elderly (10). Transportation is a major issue for older adults that can influence their ability to get to dental services. Older adults often rely on others to transport them to and from medical appointments. If older adults feel that they have sufficient oral health, they will not perceive that asking for a ride is worth the hassle to get to the dentist. The cost of dental coverage is another barrier that must be addressed when thinking about perceived susceptibility risk (16). A final barrier to be considered is the prevalence of dental anxiety and its affect on seeking dental health (17). The context in which health behavior occurs through these social determinants cannot be ignored if health promotions are to be successful.
Lastly, the HBM model is based on the assumption that humans are rational and use a cognitive process to make informed decisions (14). According to Dan Ariely, author of Predictably Irrational, humans are irrational beings and we make predictable decisions based on emotions and previous experiences. Health decisions do not occur in a vaccum, but within a complex network of various social, economic, and environmental factors (18,p.20). The intention of changing a certain behavior does not always lead to action and this irrationality must be acknowledged when promoting public health behaviors.
Critique Two-The Campaign Fails to Address Core Values
Cultural core values vary greatly among different populations across states, nations, and continents. According to the social market theory, in order to reach a specific target audience and influence health behavior change, the campaign must appeal to a societies core values or interests (19). The social market theory (as applied to public health) is a process that applies marketing principles and techniques to create, communicate, and deliver value in order to influence target audience behaviors that benefit society as well as the target audience (20). The senior dental health campaign utilized only a small portion of the marketing theory through integrating public service announcements to older adults. One major component of the social market theory is consumer orientation (21). This encompasses the needs and interests of the target audience. The older adult population places high value on maintaining control and independence of their lives for as long as they can (22). The campaign fails to recognize the importance of these values and the major influential power they could have on oral health behavior change. Campaigns using health as the motivational factor have failed to produce significant outcomes, while others that address sex, hunger, and freedom have proven to be extremely successful (23). The anti-smoking TRUTH campaign to fight youth smoking in Florida used the high value teens place on rebellion to have them realize that tobacco industries are essentially taking away their freedom (24). The senior dental health campaign assumes that health alone is the highest priority for older adults, when in fact the desires to remain independent and in control drive health behaviors.
Another major component of the social market theory is branding (25). Branding refers to the set of associations linked with the market outlet, in this case the public service announcement. The purpose of the brand is for the consumers to view a particular product as the best method of dealing with an issue (26). The brand is also part of the ‘promise’ offered to older adults. The campaign fails to clearly state what exactly older adults will get for maintaining oral health. Rather, the message orders senior citizens to brush, floss, clean dentures, and visit their dentist or they could die. This type of direct and authoritative command could result in the opposite intended behavior (27). In general, people do not like to be told what to do by someone that does not relate to them on some level (27). The use of fear in public health campaigns has a history of failure (28). For example, the ‘this is your brain; this is your brain on drugs; any questions?’ campaign did not deter teens from using drugs (28).
Lastly, the social market theory has aspects that must include the importance of visual and verbal cues (26). These verbal and visual cues are the often the first aspect of a campaign that the public interacts with. The brand is reinforced through these cues. The public senior dental health service announcement that aired over the television had no logo, featured small print, offered no phone number, and did not highlight key words or points to be taken away from the message. The voice of the narrator was monotone through the entire narration, making it very easy to ignore and categorize it as ‘just another commercial’. Since the campaign is directed at older adults that may suffer from visual or hearing impairments, these cues must be clear and understandable.
Critique Three: The campaign ignores the issue of stigmatization
The social stigma theory developed by Erving Goffman in the early sixties proposes that stigma is an “attribute that extensively discredits an individual, reducing him or her from a whole and usual person to a tainted, discounted one” (29). Stigmatization usually results from a societal label placed on certain mental, physical, or emotional characteristics, diseases, socioeconomic status or race and/or ethnicity. Those with poor oral health may keep themselves isolated in order to avoid social situations where they must communicate with others, revealing the poor state of their mouth. When people interact socially with one another, one of the first physical attributes noticed is the mouth and judgments may be inferred based upon what they notice. These are then transferred into certain negative beliefs that are consequently attributed to everyone that has poor oral health. The campaign fails to acknowledge that some senior citizens may have a knowledge base about good oral health, but encounter psychological barriers that deter them from seeking dental care.
The impact of stigmatization on oral health seeking behavior has shown to be a significant barrier (30). A major consequence of stigma is the negative effect on an individual’s self-esteem (31). This has implications for oral health among the elderly who delay seeking treatment because they feel that they no longer have control over their health. Older adults tend to think that once they reach a certain health status or are diagnosed with a chronic condition, there is nothing they can do to change that. This introduces the variable of self-efficacy and it’s critical role behavior change. An individual must believe that they have the power and knowledge to change their health behaviors. Self-efficacy is at the core of cognitive theories. The senior dental health campaign aims to increase awareness about seeking oral health treatment, but fails to address the fact that many older adults feel helpless about their health (32).
To summarize, the senior dental health campaign is rooted through well meaning intentions, but fails to consider some important behavioral and social factors that affect oral health behavior among older adults. Utilizing the health belief model for behavior change ignores the major influences of social, economic, and environmental networks. Older adults place high priority on maintaining independence, and the campaign fails to recognize this core value and use it to their advantage in ‘selling’ oral health. Lastly, the stigmatization of oral health cannot be ignored in light of the huge influence it has on health seeking behavior.
Proposal of techniques to improve the Senior Dental Health campaign
The following intervention proposal utilizes various alternative models to improve oral health awareness and behavior change among older adults in the United States. The methods address the flaws encountered in the previous senior dental health campaign critique and how the new approach will account for these flaws. The major driving force behind these methods of improvement is the application of the social ecological model, which recognizes the importance of an individual’s social, economic, and environmental networks on health behavior and health outcomes. The flaw demonstrated due to the health belief model is addressed through use of a comprehensive needs assessment that creates the foundation for the intervention. The second flaw regarding core values is addressed through empowering older adults to retain independence and control of their lives by acknowledging oral health. The final flaw surrounding the issue of stigmatization is addressed through changing social norms within the community about oral health and increasing self-esteem among the elderly.
Utilizing Group-Level Models to Improve the Oral Health of Older Adults
In order for public health campaigns and interventions to be successful, they must include models that account for outside influences on health behavior. The ecological model accounts for the importance of individual factors as well as interpersonal, institutional/organization, community, and policy level that influence individual behavior (33). The first step towards implementing a socio-ecological model is conducting a needs assessment of the target population to gather information about what they feel is affecting their beliefs and attitudes towards oral health (34). This type of qualitative data collection is essential in creating a strong foundation. Qualitative data is collected through various methods such as (a) interviews with older adults from all income levels, health levels, races, and ethnicities, (b) focus groups with target audience members and their families as well as key stake-holders within the community (c) observation of community and inventory of physical environment as it relates to oral health (35).
Another element of the ecological model is the impact that policy has on individuals. By starting at the community level, dental health advocates can push for small changes that have large results. Through this type of information gathering, researchers gain the knowledge base to create an intervention that older adults in a particular community feel directly meets their needs. Blindly addressing the target audience through assumptions that all their desires and barriers are the same will not evoke behavior change. Since an intervention using this method involves multiple social levels within a community, it is important to include them during the formative period. An example of a successful intervention that works on multiple levels is the Apple Tree program in Minnesota (36). This mobile dental clinic provides dental health to those who encounter various forms of access barriers from transportation to disability (36). This program is an example of an ‘upstream’ model of prevention that accounts for underlying social determinants (8). This type of program also helps to ease the anxiety associated with going to the dentists because the care is brought directly to them (37). The senior dental health campaign should first implement these types of strategies to determine what older adults in the community want in order to maintain their oral health.
Overall, by utilizing the socio-ecological model to influence behavior change rather than the health belief model, the senior dental health campaign will launch from a much stronger starting point. A powerful needs assessment creates an interactive environment among community members and oral health advocates and researchers. Older adults affected by the campaign are given the opportunity to help create an intervention that will later help them. This sense of involvement helps build connections to the program and aid in sustaining health behavior change in the long-run (34).
Empowering Older Adults to Retain their Independence
In addressing the second flaw of the original campaign, the use of the social market theory must be improved by appealing through core values, rather than health. The main premise of the marketing theory is that the sellers make a ‘promise’ to the consumers and show support for this ‘promise’ (38). The value that older adults place on maintaining their independence is directly correlated with quality of life (32). Older adults feel that their independence is one aspect of their life that they have control over since they cannot control what happens to them physically (32). By orienting the oral health campaign to integrate this core value, the older adult population would more likely to acknowledge the importance of oral health. The senior dental health campaign must therefore advertise the promise that good oral health can help them retain their independence and then show support. One method of doing this would be to have older adults in the public service announcement living independently and enjoying their golden years, while at the same time referencing the importance of oral health in relation to specific conditions that may render someone dependent. This would reinforce the correlation, but in a non-threatening way and from an individual who relates to the target audience rather than an authoritative figure. Older adults also place high value on social relationships (32), so the campaign could appeal to them on this level as well.
As mentioned in the critique, another important aspect to consider is the use of branding in public health promotion. The brand of the market theory is the association made between the senior dental health campaign and oral health. The market theory does not just sell a certain behavior; rather it defines a behavior through branding (25-26). The senior dental health campaign did not demonstrate any brand that older adults could associate the campaign message with. Another way of looking at branding is how this campaign is distinguished from others; that is, how is it different from other oral health campaigns (39). The senior dental health campaign must create a logo, key phrase, or even a song that would be strongly associated with oral health for the elderly. A successful example of branding is the ‘swoosh’ Nike logo that is associated with athleticism and physical fitness (40). Consumers do not just purchase shoes, they work towards owning a pair of ‘Nike shoes’. The brand can also become part of the visual or verbal cues of the campaign, making it more aesthetically appealing for the consumers. The website did not mention the use of any pamphlets, brochures, or handouts that senior citizens could take home as reminders.
Changing the social norms surrounding oral health
The third and final critique is the most challenging to remedy because of the difficulty of changing public opinion to eliminate the stigma associated with oral health. The social expectations theory can help to explain how mass media influences social norms and sets guidelines that people consciously or unconsciously follow. According one source, the theory is based on the idea that “the media convey information regarding the rules of social conduct that the individual remembers and that directly shapes overt behavior” (41). Through mass media communication, individuals observe how to acceptably interact with others in certain social situations. This theory, therefore, has valuable implications for addressing the stigmatization of oral health. The negative public opinion held about those with poor oral health (42) can be changed through mass media outlets that reach the target audience. In the case of this campaign, primarily through television and radio, but also the internet for younger aging adults. Although these outlets were used, they were not used to their maximum potential. The campaign did not have any variety as far as scripts and information and the website had a poor layout and not enough educational information. Different levels of public service announcements could broaden the scope of the campaign to include influential people acknowledging the importance of oral health and encouraging older adults that their health is in their control. Ideally, social norms within the older adult community would begin to change. The major driving force here is the goal to make proper dental care the easy choice, rather than the difficult one. The social expectations theory successfully changed social norms surrounding the use of designated drivers, so that it transformed into a socially acceptable behavior (43).
As stated above, the senior dental health campaign was created with the idea of improving oral health among older adults. However, as this critique made evident, there were aspects of the campaign that could be changed to emphasize how people perceive health behavior. The field of public health is slowly beginning to recognize alternative theories that help to explain human behavior towards health and implementing them into interventions and policies.
1. Meurman, JH, Sanz M, Janket S. Oral Health, Atherosclerosis, and Cardiovascular Disease. Critical Reviews in Oral Biology and Medicine; 2004 15(6): 403-413.
2. Moore PA, Weyant RJ, Mongelluzzo MB. Type 1 Diabetes Mellitus and Oral Health: Assessment of Periodontal Disease. Journal of Periodontology; 1999 70(4): 409-417.
3. Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data Interactive. www.cdc.gov/nchs/hdi.htm. [Accessed 12/01/2010].
4. Friedrich, Liz. Nutrition for the Elderly. 7th ed. Talent, OR. Nutrition Dimension, 2010. Print.
5. Sheiham A, Steele JG, Marcenes W, Lowe C, Finch S, Bates CJ, Prentice A, Walls AWG. The Relationship among Dental Status, Nutrient Intake, and Nutritional Status in Older People. Journal of Dental Research; 2001 80 (2): 408-413.
6. U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institute of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, Spring 2003.
7. Keep American Smiling: Oral Health in America (2003). The Oral Health America National Grading Project, Campaign for Oral Health Parity. Available at: www.oralhealthamerica.org (accessed 12/08/2010).
8. Watt RG. Emerging theories into the social determinants of health: implications for oral health promotion. Community Dentistry and Oral Epidemiology; 2002 30: 241–7.
9. Department of Health and Human Services: Official US Government Medicare handbook: Medicare and You. Centers for Medicare and Medicaid, 2010-1011.
10. Kiyak HA, Reichmuth M. Barriers and Enablers of Older Adults’ Use of Dental Services. Journal of Dental Education; 2005 69(9): 975-986.
11. Kiyak HA, Grayston MN, Crinean CL. Oral Health Problems and Needs of Nursing Home Residents. Community Dentistry and Oral Epidemiology; 1993 21(1): 49-52.
12. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. Morbidity and Mortality Weekly Report, 2001; 50(No. RR-14):[pg 10].
13. Watt RG. From Victim Blaming to Upstream Action: Tackling the Social Determinants of Oral Health Inequalities. Community Dentistry and Oral Epidemiology; 2007 35(1): 1-11.
14. Rosenstock I, Strecher V, Becker M. Social Learning Theory and the Health Belief Model. Health Education & Behavior; 1988 2(15): 175-183.
15. Atchison KA. Percieved Oral Health in a Diverse Sample. Journal of Dental Research: Advances in Dental Research; 1997 11(2): 272-280.
16. Stoller EP. Patterns of Physician Utilization by the Elderly: A Multivariate Analysis. Medical Care; 1982 20:1080–1089.
17. Sohn W, Ismail A. Regular Dental Visits and Dental Anxiety in an Adult Dentate Population. The Journal of the American Dental Association; 2005 136(1): 58-66.
18. Ariely, Dan. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper Perennial, 2009.
19. Cronin JJ, Brady MK, Hult GT. Assessing the Effects of Quality, Value, and Customer Satisfaction on Consumer Behavioral Intentions in Service Environments. Journal of Retailing; 2000 76(2): 193-218.
20. Kotler P, Lee N. Social Marketing: Influencing Behaviors for Good. Thousand Oaks, CA: Sage Publications, Inc., 2008 (pg.21).
21. Lefebvre R, Flora J. Social Marketing and Public Health Intervention. Health Education Quarterly; 1988 15(3): 299-315.
23. Siegel M, Lotenberg LD. Marketing in Public Health: Strategies to Promote Social Change 2nd ed. Sudbury, MA: Jones and Bartlett Publishers, Inc., 2007 (pg. 56).
24. Hicks, JJ. The Strategy Behind Florida’s “truth” Campaign. Tobacco Control; 2001 (10): 3-5.
25. Evans WD, Blitstein J, Hersey JC et al. Systemic Review of Public Health Branding. Journal of Health Communication; 2008 (13): 721-741.
26. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, 25-41.
27. Soames, RF. The Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health; 1988 78(2): 163-167.
28. Witte, K. Putting the Fear Back into Fear Appeals: The Extended Parallel Process Model. Communication Monographs; 1992 59(3): 329-348.
29. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Prentice Hall, 1963.
30. Persson RE, Persson GR, Kiyak HA, Powell LV. Periodontal effects of a Behavioral Prevention Program. Journal of Clinical Periodontology; 1998 25:322–329.
31. Major B, O’Brien LT. The Social Psychology of Stigma. Annual Review of Psychology; 2005 (56): 393-421.
32. Bowling A, Gabriel Z, Dykes J et al. Let’s Ask Them: A National Survey of Definitions of Quality of Life and Its Enhancement Among People Aged 65 and Over. International Journal of Aging and Human Development; 2003 56(4): 269-306.
33. Bethesda MD. Part Two: The Ecological Perspective: A Mulitlevel, Interactive Approach. Theory at a Glance: A Guide for Health Promotion Practice, National Cancer Institute; 2005 9-21 (NIH publication no. 05-3896).
34. Reifsnider E, Gallagher M, Forgione B. Using Ecological Models in Research on Health Disparities. Journal of Professional Nursing; 2005 21(4): 216-222.
35. McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly: 1988 15(4): 351-377.
36. Apple Tree Dental: Improving the Lives of People with Special Access Needs. Available at: http://www.appletreedental.org/DentalServices/Mobile/default.aspx (accessed: 12/09/2010).
37. Kvale G, Berggren U, Milgrom P. Dental Fear in Adults: A Meta-analysis of Behavioral Interventions. Community Dentistry and Oral Epidemiology; 2004 32(4): 250-264.
38. Grier S, Bryant CA. Social Marketing in Public Health. Annual Reviews of Public Health; 2005 (26): 319-339.
39. Kohli, Chiranjeev. Branding consumer goods: insights from theory and practice. The Journal of Consumer Marketing; 1997 14(3), 206-219.
40. Goldman R, Papson S. Nike Culture. Thousand Oaks, CA: Sage Publications, Inc., 2000.
41. Defleur M, Ball-Rokeach S. Chapter Eight: Socialization and Theories of Indirect Influence: Theories of Mass Communication 5th ed., New York, NY: Longman, 1989 (p. 406).
42. Sanders AE, Spencer JA, Slade GD. Evaluating the Role of Dental Behavior in Oral Health Inequalities. Community Dentistry and Oral Epidemiology; 2006 34(1): 71-79.
43. Winsten JA. Promoting Designated Drivers: The Harvard Alcohol Project. American Journal of Preventative Medicine; 1994 10(3): 11-4.