Tuesday, May 4, 2010

Americans may wait to seek oral healthcare due to serious flaws in the “Oral Healthcare Can’t Wait” campaign – Leah Fico

In the year 2000, the US Surgeon General issued a report stating that oral health is an integral and essential component of general health for all Americans (1). Oral health is so important to overall health because links have been established between poor oral health and other systemic diseases, such as diabetes, cardiovascular disease, adverse pregnancy outcomes, and osteoporosis (2, 3). Poor oral health may not only result in an increased risk for systemic diseases for an individual, but an increase cost of dental care, loss of self-esteem, lost productivity, and in extreme cases, death (4). Because of all the possible negative outcomes associated with poor oral health and untreated oral diseases, poor oral health significantly impacts quality of life (4). Despite the increased evidence supporting the importance of oral health, dental utilization declined for most adults between the years 1988-1994 and 1999-2004 (2).

It seems likely that dental utilization may decrease in response to economic downturns. In the spring of 2009, the Dental Trade Alliance (DTA), a non-profit trade association, and Oral Health America, a national campaign to promote oral health, conducted a survey of Americans to find their views on oral health care issues. The survey found that economic uncertainty played a significant role in individuals not seeking dental care (5). In response to these findings, the DTA launched the “Oral Healthcare Can’t Wait” campaign. The campaign’s goal is to sustain and improve oral healthcare in America (5). The campaign message communicates that maintaining optimal oral health is important to everyone, despite the state of the economy, and raises awareness about the risks of postponing regular dental check ups and recommended treatments (6).

“Oral Healthcare Can’t Wait” is a multifaceted campaign designed for both dental professionals and consumers. The campaign’s marketing materials include dental trade and consumer print and online advertisements, a professional and consumer public relations program, public service announcements, patient education brochures and posters, and an online video. The campaign also has websites for dental professionals (www.oralhealthcarecantwait.com) and for consumers (www.visityourdentistnow.com), The campaign relies heavily on dental professionals to help relay its message to consumers and utilizes a dental practice marketing toolkit to promote “Oral Healthcare Can’t Wait” in local markets.

The campaign communicates the risks of ignoring dental care and how “ordinary” people are susceptible to dental problems. For example, the posters for the campaign show a person with a sticker over his or her mouth that reads “Hello. My gums bleed. A lot”, “Hello. I keep putting off dental appointments”, or “Hello. So what if I loose all of my teeth?”. The public service announcement and online video show a series of “ordinary” looking people engaged in daily activities like working, cooking, and shopping. Each person stops, smiles, and a voice explains the dental issue that the person is experiencing like gums bleeding, jaw pain, or bad breath. The voice then explains the risks of ignoring dental problems and that people should visit their dentist now.

The campaign uses the Health Belief Model (HBM) to change people’s behavior about seeking dental care. The HBM of behavior change assumes that people will engage in a healthy behavior if they feel that the perceived benefits outweigh the perceived barriers (7). The perceived benefits are characterized by the person’s feeling of the susceptibility to a condition and the severity of a health problem (7). The “Oral Healthcare Can’t Wait” campaign aims to increase a person’s feelings about the perceived benefits of oral healthcare by showing that everyone is susceptible to dental problems and by detailing the risks and severity of those oral problems. The campaign also tries to downplay barriers to oral healthcare, such as cost, to tilt the weight in favor of the perceived benefits of oral healthcare. While the campaign does an excellent job of highlighting the importance of oral health, there are several flaws in its design. These flaws may limit the effectiveness of the campaign’s goal to improve oral healthcare in America.

Critique Argument 1 – The “Oral Healthcare Can’t Wait” campaign targets the individual

As stated by poet John Donne in his 1624 poem, Devotions Upon Emergent Occasions, “No man is an island, entire of itself; every man is a piece of the continent, a part of the main” (8). “Oral Healthcare Can’t Wait” targets the individual to make the decision that oral healthcare is important and to seek dental care. The “Oral Healthcare Can’t Wait” campaign fails critically by targeting the individual without regard to the complex system of influences that shape behavior. Because the campaign is based on the HBM, it focuses on individual decisions and does not address social or environmental factors, which are an important component of decisions (8). For example, the campaign does not address such problems as the inability to access dental care, cultural differences in attitude towards oral health, social inequalities or other environmental and social factors. Individual level theories ignore the wider social context within which an individual operates, such as family and communities (9).

The “Oral Healthcare Can’t Wait” campaign neglects to account for social influences that effect behavior change. In fact, critics of individual level models propose that neglecting the importance of social influences on health and disease promotes a “victim-blaming ideology” (10). It does seem as though the “Oral Healthcare Can’t Wait” blames the individual for not seeking dental care instead of addressing any social reasons, such as policy or socioeconomic factors. This type of approach, which ignores the interactions between cultural, sociopolitical, and economic conditions, fails to put individual health experience and behavior into context for a target audience (11). What good is it to tell someone that waiting to see a dentist may cost more in the long run, when that person doesn’t have $20 to buy dinner that night for his or her family? Or what good is it to warn a person of the risks of periodontal disease, when it is very common in his or her community to have missing teeth?

Alternative behavior change models have been developed to address these social and environmental influences. These newer models show that a multidisciplinary approach at a community level may provide more effective interventions (11). For example, the ecological model for health promotion addresses the importance of interventions to change interpersonal, organizational, community, and public policy factors which support and maintain unhealthy behaviors (10). Unfortunately, the “Oral Healthcare Can’t Wait” campaign does none of these things. Similarly, the campaign fails to incorporate some of the most recent evidence of social network theory. Recent studies have demonstrated that health behaviors such as smoking cessation and behavioral traits such as obesity are spread through social networks and depend on the nature of social ties (12,13). Again, the campaign focuses solely on the individual and does nothing to address that behavior is largely dependent on social networks.

Likewise, the “Oral Healthcare Can’t Wait” campaign does not account for herd behavior, which is when many people take the same action, due to some people mimicking the action of others (14). The theory of innovations suggests influential members of the social system can spread change within a whole social system (15). The campaign could take advantage of this phenomena and target the right people to steer the masses of people to seek dental care. Instead, the campaign targets dental professionals and all consumers with blanket statements about risks of poor oral health.

The “Oral Healthcare Can’t Wait” campaign clearly focuses on the individual as the key decision maker in regards to health. While this may hold some truth, research does now suggest that social and environmental factors play a critical role in the decision. Because the “Oral Healthcare Can’t Wait” campaign fails to account for these social and environmental factors and focuses solely on individuals, it is less likely to be effective in promoting oral healthcare for all Americans.

Critique Argument 2 – The “Oral Healthcare Can’t Wait” campaign assumes behavior is rational

Another flaw in the “Oral Healthcare Can’t Wait” campaign is that it assumes that people’s behavior is rational. Because the campaign is based on the HBM, it assumes that behavior is determined by an objective, logical thought process (16). The campaign assumes that telling people of the serious risks of poor oral health will result in people taking action to seek dental care. In the same manner, the HBM has been criticized because it assumes that people will do a cost/benefit analysis on the facts given to them and act in manner of their own self-interest (9). However, people have biases and emotions which may hamper rationality (14). The campaign fails to account for this fact. These emotions and biases may, in part, account for why dental utilization rates have not increased over the last fifteen years. In this time period, much research has shown the importance of oral health to overall health and that information has been offered to the public. However, people have not responded rationally by seeking dental care. In fact, dental utilization rates declined for most adults (2).

For this reason, the campaign’s effort to drive people to seek dental care by promoting the importance of oral health may be futile. Research has shown that decisions and behavior appear to be irrational (17, 18). When studying the biological basis of decision making, researchers have found that the brain’s decision making process is influenced by biases and framing effects and that decisions are not always rational (19). The “Oral Healthcare Can’t Wait” campaign neglects to account for this irrationality. In his book Predictably Irrational: The Hidden Forces that Shape our Decisions, Dan Ariely states that “we are not only irrational, but predictably irrational – that our irrationality happened the same way, again and again” (20). There are certain elements of this “predictable irrationality” that could have been leveraged in the campaign to increase the likelihood that people would seek dental treatment.

One element that may influence irrational behavior is people’s expectations. Expectations and priming, which is trait concepts and stereotypes, have been shown to impact the logical, rational decision making process (21, 22). In fact, one study shows that physical warmth or cold can influence a person’s decision on another person’s personality traits (21). Another study shows that expectations about the taste of beer, influences the actual experience of drinking beer (22). These studies suggest that expectations play a real role in influencing behaviors and decisions regardless of what seems logical or rational. Therefore, expectations about dentists may influence a person’s decision to seek dental care even if it seems rational to do so. The “Oral Healthcare Can’t Wait” campaign does nothing to address people’s expectations about dentists. The campaign also fails to take into account that because of expectations, people may act irrationally.

Critique Argument 3 – The “Oral Healthcare Can’t Wait” campaign sells oral health

The “Oral Healthcare Can’t Wait” campaign sells an important product to its consumer – health. But is health really what people want? Critics of the HMB have argued that a serious limitation of the model is the assumption that health is highly valued by most people (16). A similar argument can be made for this campaign. While health may be important, personal freedom, personal liberties and individual rights are values which may be of greater importance (23). While health may ultimately be what the campaign is trying to offer, the issue could be reframed to offer something more compelling.

Framing is a way to redefine a product or an issue to convey a certain meaning (24). Marketing theory is based on this idea and marketers have been reframing their products for years. Marketers use the frame to provide the perspective they want others to adopt, a rational for the evidence presented, and the sequential pattern for presenting the evidence (25). Marketing theory’s greatest asset is the intense concentration that is placed on the consumer by identifying and meeting their needs and problems (26). Thus, marketers frame their product based on customer needs, instead of on what the organization wants to sell. The “Oral Health Can’t Wait” campaign unfortunately did not use marketing theory in its strategy as it appears oblivious to consumers’ needs. Had the developers of the campaign framed oral health in a way in which was compelling to its target audience, it could prove to be quite effective.

Message framing has been shown to influence individual health behavior (27). For example, by reframing a teen anti-smoking campaign into an anti-manipulation campaign, the Florida Department of Health was extremely successful in declining youth smoking rates (28). An important part of framing a public health issue is to show the benefits of the “product” as fulfilling a powerful need or desire, called a core value (29). A key feature of Florida’s anti-smoking campaign was that it sold something much bigger than health to those teens, it sold control. In a similar fashion the “Oral Healthcare Can’t Wait” campaign could have sold control, independence, or even sex to meet the desires of its audience instead of the risks and benefits associated with oral health.

The “Oral Healthcare Can’t Wait” campaign clearly gets its message across – oral health is important. However, the message does not appeal to people’s core values because campaign failed to consider what those core values might be. By using marketing theory in its design, the “Oral Healthcare Can’t Wait” campaign may have developed a product that fulfills people’s wants and needs. However, the designers of the campaign failed to do so and, thus, may have limited its effectiveness at improving oral healthcare in America.

Proposed Intervention: The Sexy Smiles for America Campaign

The Sexy Smiles for America campaign is designed to encourage Americans to seek regular dental care. The campaign design addresses some of the weaknesses in the “Oral Healthcare Can’t Wait” campaign. The Sexy Smiles for America campaign accomplishes this through various strategies. First, it is intended to appeal to people’s core values, specifically sex and control. Second, the campaign will address social and environmental factors and attempt to change behavior of whole groups of people. Third, the campaign will try to create social change by impacting policy. And finally, the campaign will try to change people’s expectations of going to the dentist and of oral healthcare. The campaign will have four components to help pull through these different strategies. The four components of the campaign include media advertising, a website, a political action committee, and community outreach. These four components will work synergistically to motivate people to seek dental care, as well as, create a sociopolitical environment which enables them to do so.

The campaign’s media advertising and website will be designed to appeal to people’s core values. In doing so, the campaign will not sell oral health, but instead, sex and control over one’s appearance. The media advertisements will feature beautiful people with sexy smiles. The advertisements will be placed on television and in print. Possible locations for the print media may be magazines and also posters in subway stations. The focus of the advertisements will be sexy smiles. There will be no statistics or facts given about oral health. In fact, the advertisements will not mention health at all. The television ads will not have any speaking, but rather sexy sounding music. The only text that will appear is “Sexy Smiles for America” and then give information about the website or a phone number to call for more information. Again, the goal is for the advertisements to sell sex and control, instead of oral health.

The website will aid with this goal. The website will feature pictures of people smiling, like the advertisements. The website will also have a part for people to upload pictures of themselves smiling and people can vote for the sexiest smile in America. There will also be merchandise like t-shirts, hats, and stickers which will help create the Sexy Smiles for America brand. The website will also try to change the expectations people have of the dentist by posting stories and dental profiles. The website will also have portions dedicated to oral health information and links to various dental organizations. Information on how to become involved in community outreach and the political action committee will also be available on the website.

The community outreach component of the campaign will help bring the campaign’s message into local communities. The campaign will train local community leaders to talk about oral health and the importance of dental care with in local communities and within social networks. The goal of this component is to influence whole groups of people to find the importance in seeking dental care. The community outreach will be a forum to discuss social and political issues regarding oral health and dental healthcare. The outreach may aid to organize the community to become involved in a political movement. The political action committee will be a grassroots effort to mobilize dentists and the public to influence government policies regarding dental healthcare.

Defense of Intervention Section 1 – The Sexy Smiles for America campaign targets groups and the social environment

One of the main problems with the “Oral Healthcare Can’t Wait” campaign is that it focuses on the individual without regard to the social and environmental factors that influence behavior. The “Sexy Smiles for America” campaign is design to influence multiple levels of influence that shape behavior. Social and environmental factors are often extremely important components of decisions (8). The campaign addresses these social and environmental factors in various ways. First, the campaign’s political action committee will try to create social change through the government. The committee will work on issues such as racial disparities in oral health, access to care, and cost of care. The campaign will also have information about these social issues on its website and provide a forum for discussion at community outreach programs. Addressing cultural, social, economic conditions will put help place individual health into context with the realities of a person’s life (11). The strategy for this campaign was based on the ecological model for health promotion because it addresses the importance of interpersonal, organizational, community, and public policy factors on health decisions (10).

The “Sexy Smiles for America” campaign is not only designed to address social and environmental factors related to oral health, it also designed to change behavior of whole groups of people at one time. Social network theory suggests that social networks influence health behaviors (12, 13). In addition, the theory of innovations suggests that change can spread among a population as a result of a few opinion leaders adopting the change (15). Research in health behavior change has shown that interventions are extremely successful when opinion leaders within a community endorse and informally spread that intervention (9). The community outreach portion of the campaign was developed based on these theories and research. The campaign will look to identify community leaders to train on the oral health initiative. The goal is for these leaders take the information back into their communities in whatever way they feel is best. The hope is that the behavior to seek dental care will spread throughout social networks and communities.

Defense of Intervention 2 – The Sexy Smiles for America campaign assumes that people are irrational

A weakness in the “Oral Healthcare Can’t Wait” campaign is that it assumes people act rationally. However, simply telling people of the risks of poor oral health will not necessarily motivate them to seek dental care. People have biases and emotions that interfere with rationality (14). The Sexy Smiles for America campaign accounts for irrational behavior in a few ways. First, the media portion to the campaign does not even mention oral health. The issue is reframed to be about sexy smiles. The issue was reframed because of the research which shows that framing effects can cause irrational decisions (19). In addition, decisions can be irrational because they can be influenced by the behavior of others (30). Therefore, a second way in which the campaign accounts for irrational behavior is to leverage the interactions between people through the community outreach initiative.

Behavior and decisions can also be irrational due to expectations and priming (21, 22). People may not seek dental care because of negative expectations about dentists and dental treatments. Research will be done through surveys to determine what those negative expectations are among the population. The Sexy Smiles for America website will feature a section dedicated to trying to change the negative expectations associated with going to the dentist. The website will post user stories and dentist profiles to try and influence expectations. In addition, the community outreach program will leverage community leader’s interactions with community members to change expectations. Changing the expectations or at least addressing the expectations that people have regarding dental healthcare, accounts for another way in which people may make irrational decisions.

Defense of Intervention 3 – The Sexy Smiles for America campaign reframes oral health into an issue of sex and control

One of the critical flaws in the “Oral Healthcare Can’t Wait” campaign is that it sells oral health. The campaign is limited because the strategy was based on the HBM, which assumes that health is highly valued by most people (16). The Sexy Smiles for America campaign strategy is based on marketing theory and does not make this assumption. Marketing theory places the customer at the center of any campaign by meeting their needs and desires (26). The Sexy Smiles for America campaign will try to meet these needs and desires by reframing the issue of oral health. Although the Sexy Smiles for America campaign is also ultimately trying to promote oral health, the issue is reframed to sell sex appeal and control.

Studies have shown that message framing can influence individual health behavior (27). The reason for selling sex appeal and control is to frame the issue around people’s core values. In framing a public health issue, it is important to show benefits that fulfill a powerful need or desire (29). Sex and control seem to naturally fit the bill. Sex appeal will be sold through the campaign through the advertisements which will include sexy people, smiles, and music. The goal is for viewers of the ads to feel that they have control over their appearance and “sexiness”. People can control their sex appeal by having a sexy smile and the way to a sexy smile is through good oral health. Unlike, the “Oral Healthcare Can’t Wait” campaign, there will be no risks of poor oral health mentioned in the ads. In fact, the only benefit showed during the ads will be the sexy smiles. By reframing the issue around sex and control, the Sexy Smiles for America campaign should be successful in promoting good oral health.


Although the “Oral Healthcare Can’t Wait” campaign should be applauded for its goal of improving oral healthcare for Americans, its serious flaws may limit its effectiveness. The campaign was designed narrowly for the individual without regard for social and environmental influences or group behavior. The campaign assumes that behavior is rational. And finally, the campaign sells health. The campaign was based on the traditional model for behavior change, the HBM. The developers of the campaign failed to incorporate findings and contributions in social and behavioral sciences for public health, which have been shown to increase the effectiveness of public health interventions.

To address the flaws identified in the “Oral Healthcare Can’t Wait” campaign, the Sexy Smiles for America campaign was designed. The strategy for this intervention was based on alternative models of behavior change, including the ecological model, social network theory, the theory of innovations, and marketing theory. The campaign tries to change group behavior and accounts for social and environmental factors influencing decisions. The Sexy Smiles for America campaign assumes that people are irrational. The campaign is also reframed to sell core values to the American consumer. The strengths of The Sexy Smiles campaign should make it effective in its goal to improve oral healthcare for Americans.


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