Oral Health promotion

Oral Health Promotion
Dr VAIBHAHAV BANSAL
Reader
Dept. of Pulic Health Dentistry
Rama Dental College Hospital & Research Centre

• CONTENTS:
• Introduction
• Historical development of health promotion
• Definition and principles of health promotion
• Oral health promotion in action
• Differing approaches to health promotion
• Scientific basis for oral health promotion
• Conclusion
• References

• Health promotion is distinct from disease prevention and
health education in both its aims and its strategies.
• It is a comprehensive approach to enhancing the health of
families, communities and populations which both
complements and challenges the approach on which formal
health care systems are based.
• From its perspective, health is both an individual and social
responsibility that is best secured by collaborative actions at
all levels of society.

• Dental diseases affect a large number of people and cause
much discomfort and pain. Their impact is therefore
considerable, both to the individual and wider society.
• With escalating costs and wider acceptance that doctors and
dentists are not able to cure most chronic conditions,
increasing interest has focused on alternative means of
dealing with health problems.

HISTORICAL
DEVELOPMENT OF HEALTH
PROMOTION

early 19th
century
Industrialization
& urbanization
Densely
populated
cities and
towns
Infectious
diseases
Social reformers began to investigate the link between
the unsanitary living conditions and public health

• After the Second World War, the governments of most
industrial nations began to invest heavily in health
• Focus have shifted from the envoirment to health care,
prevrentive inteventions and health education
• Green and Kreuter have referred to this period as one of
resource development and redistribution.

• it was recognized that the major health problems of modern
populations, particularly the poor, which were expensive to
manage but could not be cured.
• As the costs of medical services continued to rise,
governments began to turn their attention to cost
containment finding ways of reducing or stabilizing costs
while continuing to secure improvements in health.

• However many of these disorders could be prevented by
changes in personal behaviors or the social and physical
environments in which people lived (Lalonde, 1974).
• In this he argued that the major causes of death and disease
were due to environmental causes, individual behaviors, and
life styles rather than to biochemical characteristics.

• These provided the first step in the development of a new
approach to population health – that of health promotion.
First WHO conference on Health Promotion :-
Ottawa 1986

DEFINITION OF
HEALTH
PROMOTION

• ‘The process of enabling people to increase control over
and to improve their health’ (WHO, 1984)
• Health promotion policy combines diverse but
complementary approaches including legislation, fiscal
measures, taxation and organizational change. It is
coordinated action which leads to health, income and social
policies that foster greater equity. Joint action contributes to
safer goods and services, healthier public services and
cleaner, more enjoyable environments (WHO 1984).

• Health promotion has three important
elements
1. Focus on tackling the determinates of health
2. Working in partnership with a range of agencies
and sectors
3. Adopting a strategic approach utilizing a
complementary range of actions to promote the
health of population.

PRINCIPLES OF
HEALTH
PROMOTION

The Ottawa Charter (WHO, 1986) outlined five
key areas of action as:
 Creating supportive environments
 Building healthy public policy
 Strengthening community action
 Developing personal skills
 Reorienting health services

Determinants of health:
• Socio-economic and environmental factors, plus the
individual health – related behavior determinants.
• In the past health professional have ignored the complex
array of factors that influence the humman behaviour
• A major emphasis in health promotion is therefore to
make the healthy choices, the easy choices by focusing
attention upstream. (millo 1986)

Working in partnerships:
• Community participation is an essential element of health
promotion.
• The active involvement of the local community in all
aspects, from the identification of the health issue to ways
of initiating change, is a central principle.
• One of the key roles of professionals is therefore in enabling
and nurturing health promotion within communities.

Partners in oral health
1. Health professionals
2. Education services
3. Local authority staff
4. Voluntary Sectors
5. Commerce and industry; food producer,
advertisement industry
6. Government, local, national & interntional

Strategic action:
• A strategic approach is required for the development of
effective health promotion policies.
• based on an appropriate assessment of local needs and
resources,
• Health promotion strategies should be based on the common
risk factor approch.
Health promotion strategies based on common risk factor
approach therefore offer the potential for effective dealing
with a combination of health problems together.

Diet
Stress
Control
Hygiene
Injuries
Exercise
Alcohol
Smoking
Cancers
Diabetes
Obesity
CVD
Respiratory disease
Mental illness
Dental caries
Periodontal
diseases
Skin diseases
Trauma-teeth &
bones

ORAL HEALTH
PROMOTION IN
ACTION

• Health promotion seeks to improve and protect health
though a diverse variety of complementary strategies.
• The five areas for action outlined in the Ottawa Charter
provide a useful structure to explore options for promoting
oral health. (WHO, 1986)

1.Develop personal skills
• Supporting personal and social
development through health
education.
1. Cognitive
2. Affective
3. Behavioral
Essentially health education aims
to equip individuals and
community with necessary
knowledge , attitudes and skills to
maintain and improve health

2.Strengthen community action
• This can be achieved through
developing a community
development approach.
• It is a process in which the
community defines its own health
needs, decides how these can be
best tackled, and then takes
appropriate action.

Examples for community actions
Advantages: it is starting with
people’s concerns and is
therefore likely to gain support;
Problems: the time consuming
difficulty of evaluation, and the
potential conflicts that may arise
within communities on setting
priorities and identifying
possible solutions.

3.Re-orient health services
• The responsibility for health promotion in
health services is based among the many
health professions and at the various levels of
health care.
• There is a need to shift resources away form
the dominant treatment and curative services
towards those that promote health and prevent
disease.

4.Build healthy public policy
• Legislative and regulatory policy passed at
either national or local level can have a very
powerful influence on health by creating a
social environment which protects or
improves health.
• key element of health promotion is placing
health onto the policy agendas of influential
decision-makers

• Healthy public policy requires the coordinated use of all policy
levers available, including ‘legislation, fiscal measures, taxation,
and organizational change.
• Fiscal measures that reduce the costs of healthy products enable
a larger number of people to select healthy options.

5.Create supportive environments
• This aspect of health promotion recognizes the
impact of the environment on health and seeks
to identify opportunities to make changes
conducive to better health.
• Healthy public policies can of course provide
a legislative framework for environmental
change, water fluoridation being a prime
example.

Healthy environments
change at local level. For
example, developing policies
within local organizations
such as schools, workplaces,
and hospitals which seek to
promote the health of clients
and staff is an important
aspect of health promotion.
This is termed as
‘organizational change’.

DIFFERING
APPROACHES TO
HEALTH PROMOTION

Five different approaches to health promotion are
discussed to illustrate the diversity of ways of
working within health promotion.
1. Preventive
2. Behavior change
3. Educational
4. Empowerment
5. Social change

1. Preventive approach
• The aim of this approach is a reduction in disease levels, in
which medical / dental professionals take the lead.
• This approach adopts a very top-down authoritative style of
working, with the health professional acting as the experts
and the patients being recipients of preventive care.
• Interventions such as screening tests or clinical activities
such as immunization are used.

• Oral health examples could include preventive measures
such as fissure sealants or the establishment of screening
programme for oral cancer detection and prevention.
• Limitation: it does not address the underlying causes of the
disease. Therefore new cases will constantly arise and
require attention.

2. Behavior change:
• This approach aims to encourage individuals to take
responsibility for their health and adopt healthier lifestyles.
• It is largely based upon the assumption that provision of
information will lead to a sustained change in behavior.
• It is an expert – led approach utilizing a range of methods
including one-one advice and mass media campaigns.

• The desired changes in lifestyle are determined by the
professional and largely imposed on the patient.
• Health education advice provided by dentists within
surgeries aimed at improving oral hygiene practices is an
example of this approach commonly adopted by dental
profession.

3. Educational approach:
• To make informed choices about their health-related
behavior, people need not only knowledge but also the skills
and attitudes that support this information.
• The educational approach aims to provide individuals with
these.
• However, unlike the behavior change approach, it does not
set out to persuade a person to change in a particular
direction; rather, it is attempting to provide individuals with
choices, which they are then able to act upon as they
choose.

• This approach may use a range of methods to help
individuals make an informed choice about their health
related behavior.
• In addition to provision of information, opportunities to
explore and share beliefs and attitudes towards health
concerns may be very important.
• Although attitudes may be very difficult to change, having
been developed throughout the person’s life, group
discussions or on-to-one counseling may be useful
experiences to enable individuals to explore the basis of
their beliefs.

• Limitation: although educational approach seeks to enhance
an individual’s overall ability to choose a healthy lifestyle,
this approach is still largely led by the expert and ignores
the wide range of factors that determine whether an
individual has the opportunity to change.

4. Empowerment:
• This aims to assist people in identifying their own concerns
and priorities, and in developing the confidence and skill to
address these issues.
• Unlike the other approaches, empowerment is essentially a
bottom – up approach in which the health professional acts
as facilitator.

• Rather than being the expert, this role involves helping
individuals or communities identify their problems and seek
appropriate solutions to move things forward.
• Skills in negotiation, advocacy, and networking are essential
requirements for health professional working in this way.

• This approach can be adopted at both an individual and
population level.
• Within clinical settings no-directive counseling techniques
can be used to increase people’s control over their own
lives, although this technique is infrequently used in clinical
dentistry.
• At a population level, community development is a way of
empowering groups to become more actively engaged in
improving their health and well-being.

5. Social change:
• This approach acknowledges the importance of socio-
economic and environmental factors in determining health.
• It therefore aims at changing the physical, social, and
economic environments to promote health and well-being.
• To achieve this requires changes in policy, and political
support.
• Lobbying and policy planning are key elements.

• Many health professional often feel uncomfortable working
in such a political arena, but influencing policy-makers at an
international, national, or local level is essential to secure
good health.
• For example, in oral health, water fluoridation is largely a
political issue which requires political action for its
implementation.
• Only by working closely in a skillful manner with local
government and national politicians will progress with this
proven public health measure be secured (Evans and Lowry
1999).

• Each of the approaches described has certain strengths and
weaknesses, so a combination of approaches is probably the
best way to promote oral health.
• Clinical dentistry has mainly focused upon the preventive
and behavior change approaches.
• Based upon Beattie’s (1991) typology, fig presents a useful
framework for analyzing health promotion approaches:

Educational
approach
Individual focus
Behavior
change
Preventive
approach
Empowerment
Lay led
Social change
Collective focus
Professionally laid

PLANNING ORAL
HEALTH PROMOTION
INTERVENTIONS

Form planning group
Identify resources
Assess needs
Agreeing strategic aims
Set goals
Plan action
Plan evaluation
Implementation
Review

• Dental services have traditionally been concerned with
treating and to a lesser extent, preventing two major
diseases – caries and periodontal disease.
• Other conditions such as mucosal disorders, oral cancer,
TMJ disorders, salivary problems such as xerostomia and
trauma to the teeth and mouth have also been a focus of
dental practice.

• The main factors related to these disorders are dietary
sugars, inadequate fluoride intake, poor oral hygiene,
smoking, alcohol, stress and accidents.
• Since most of these factors are implicated in other chronic
disorders, promoting oral health and general health are one
and the same thing (Sheiham 1992).

Sheiham (1995) has identified the following six policy
areas as being essential to improving the oral health of the
population:
1. A food and health policy to reduce sugar consumption
2. A community approach to improve body and oral hygiene
3. A smoking cessation policy
4. A policy on reducing accidents
5. Policies on water fluoridation
6. Ensuring access to appropriate preventive dental care

• If the dental team is to convince their patients of the
importance of effective self care, then they must agree a
practice policy between team members.
• Teamwork is the key to effective and efficient health
education while dentists are best placed to diagnose, the
health education needs of particular patients or groups of
patients, it may be more cost effective for an auxiliary to
actually give the advice.

• Kickbusch (2003) had called health
promotion as “the third public health
revolution”
• Nutbeam (1998) had provided a useful
summery
The new public health is distinguished by its basis
in a comprehensive understanding of the ways in
which lifestyles and living conditions determine
health status, and a recognization of the need to
moblize resources and make sound investments of
policies , programes and services which create,
maintain and protect health by supporting healthy
lifestyles and creating suppotive envoirement for
health.”

• Treatment services alone will never successfully alleviate
the causes of dental diseases.
• Health promotion offers the potential to tackle the
underlying determinants of health and thereby improve
the oral health of all sections in society.
• The success of health promotion largely depends upon
developing partnerships across agencies and, most
importantly, actively involving local people in the whole
process of health promotion.

• Daly B, watt R, Batchelor P, Treasure E. Essential dental public Health;
133 – 152.
• PINE CM, COMMUNITY ORAL HEALTH; 291 -306.
• Marya CM . A Textbook of Public Health Dentistry; 224-235
• Kickbush I. the contribution of the world health organization to a new
public health and health promotion. Am J Public health; 2003; 93: 383-8
• Nutbeam N. Health promotion glossery. Health Promot Int. 1998;13:349-
64.
• WHO ( World Health Organization) (1984). Health promotion: a
discussion document on the concept and principles. Copenhagen, WHO.
• WHO ( World Health Organization) (1984). The Ottawa charter for health
promotion 1. iii-v. Geneva. WHO.
• Seiham A, Watt RG. The common risk fector approch for promoting oral
health.community Dent Oral Epidimiol. 2000:28: 399-406.

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