Chapter 5: Promoting HP 2010 Oral Health Plans and Activities

Any Healthy People 2010 plan is meant to be a "living entity"--an active plan for involving anyone who wants to play a role. It is not meant to be just a written document that sits in a bookcase or is used by only a few individuals. To infuse a plan with life requires making it interesting, relevant to people’s lives, understandable, doable, and capable of motivating people to action. Capturing the public’s attention in an era of information overload and global coverage, however, is a major challenge. The ideas discussed in this chapter are meant to be starting points that trigger innovative ideas to use in your own community, tribe, territory or state.

Health Communication

Communication can be thought of as the "conveyor belt of interaction." As noted in Chapter 2, communication strategies and the speed of information dissemination are constantly changing with advances in technology. Information is a critical element of informed participation and decision making. Health communication, media advocacy and social marketing strategies are becoming more sophisticated and are assuming a greater role in efforts to improve health outcomes. Health communication has emerged as a separate Focus Area (#11) in the national Healthy People 2010 objectives (view chapter online at www.health.gov/healthypeople/Document/tableofcontents.htm#volume1.) Before embarking on designing and implementing health communication strategies to disseminate your HP 2010 plan and activities, however, you will need to develop a promotional/marketing plan.

"Health communication encompasses the study and use of communication strategies to inform and influence individual and community decisions that enhance health… Communication occurs in a variety of contexts; through a variety of channels with a variety of messages; and for a variety of reasons. One of the main challenges in the design of effective health communication programs is to identify optimal context, channels, content and reasons that will motivate people to pay attention to and use health information."

Developing a Promotional/Marketing Plan

Increasingly, health professionals are turning to the field of social marketing to develop and implement health promotion plans. Social marketing is a technique that has been used since the 1970s to increase public awareness of the relationship of behaviors to diseases and to influence people to take action. This is an important mechanism for emphasizing the link between oral health and general health, and how certain health behaviors can prevent oral diseases.

According to Edmonds and Fulwood (see reference on page 25 of the Resources section for this chapter), the goals of a social marketing strategy are to 1) increase awareness of a problem; 2) convey a message that the problem can be solved; and 3) describe the solutions. Social marketing uses five basic public health steps:

• learn about your target audience
• plan your health messages, communication channels and timeline
• shape your messages so they are relevant to your audience, and pretest them
• implement your plan -- deliver the messages
• evaluate the effectiveness in trying to change behavior.

These steps can and should be reinforced by other strategies such as policy initiatives, legislation, funding and programs.

A recent study by Sorien and Baugh (see reference on page 25 of the Resources section for this chapter) of almost 300 government policymakers (legislators, legislative staff, and executive managers of health agencies) found that these officials are inundated with information that they must review and digest to make funding and policy decisions. The researchers estimated that about one half of this information is not relevant to their current work. All policymakers did not have the same information needs, but most preferred that information be presented in a concise 1-2 page format that summarizes in non-technical terms the main issues or research relevant to legislative policy and recommendations. Preferred format was short bulleted lists with explanatory tables, charts or graphs. Staffers, however, needed more detailed information appended to the summary. In general, older policy officials preferred printed materials, while younger ones were comfortable accessing electronic information.

Information resources and studies such as these are valuable for creating a HP 2010 marketing plan. The following marketing tools from the chapter on Communicating Health Goals and Objectives in the Healthy People Toolkit are included in the Resources section and also can be downloaded from the Healthy People Web site:

• Simple Market Research Strategies
• Sample Market Research Questions
• How to Develop a Marketing Plan
• Evaluate Your Marketing Plan.

Healthy Delaware Marketing Objectives is available online in the State Healthy People 2010 Tool Library at www.phf.org/HPtools/state.htm.

An excellent CD ROM and training course produced by the Centers for Disease Control and Prevention and facilitated by trainers from the Society for Public Health Education, is CDCynergy. This is a multi-media CD ROM used for planning and managing health communication programs. This tool can assist teams in generating comprehensive health communication programs, placing them within a larger public health framework, and incorporating accountability and evaluation. There is no specific tailored version for oral health yet, although there is for cardiovascular disease, diabetes, immunization, tobacco use prevention, and micronutrients. For more information see http://www.cdc.gov/std/HealthComm/cdcynergy.htm.

All of these tools will help you gather additional information and use the information to develop a promotional/marketing plan. They provide a general framework that can be adapted for oral health plans.

Specific Strategies to Communicate About HP 2010 Plans

One-dimensional communication approaches are ineffective for achieving HP 2010 oral health goals and objectives. Successful initiatives rely on multi-dimensional interactions to reach diverse audiences. Although diversity usually is defined by social and demographic variables such as race, ethnicity, age, gender and socioeconomic status, behaviors within groups using these classifications often are as heterogeneous as those among the groups.

Involving individuals from the community who have specific knowledge about cultural characteristics, health behaviors, language preferences, and preferred media channels of community members is crucial when developing messages and marketing plans. Public-private partnerships and collaboration can help identify and leverage appropriate resources and strengthen the impact of your efforts. Various channels used for disseminating or acquiring HP 2010 information will be discussed in detail before giving tips on creating specific messages. An excellent summary of the pros and cons of various communication channels and activities is presented in the National Cancer Institute publication, Making Health Communication Programs Work, (Downloadable from www.cancer.gov/pinkbook. Print or CD-ROM copies can be ordered online at http://cancer.gov/publications or by calling 1-800-4-CANCER (1-800-422-6237)).

Web Sites

The Internet is an excellent vehicle for communicating information to a broad audience, providing regular updates, highlighting activities, linking users to other resources, and gaining feedback on proposed activities or plans. Research is needed in each community, however, to determine if information should be provided in more than one language, and which groups will be missed by using an electronic communication medium. Do not assume everyone has Internet access. Some people are intimidated by, prefer not to use, or cannot afford electronic forms of communication.

All of the national Healthy People materials published since 1995 are available on the national Healthy People Web site at www.health.gov/healthypeople.

A number of states have posted their Healthy People 2010 Plans on their state health department Web site or a separate Web site dedicated to Healthy People activities. An updated list of the state Web sites is maintained on the Healthy People Web site. Examples of ways that some of these sites are formatted or used follow.

• North Carolina’s Web site, Healthy Carolinians, includes the following items in its site map:
  • NC 2010 Health Objectives
  • County Profiles
  • Certification Process
  • Governor’s Task Force
  • Office of Healthy Carolinians
  • Community Assessment
  • Training and Resources
  • Conference Information
  • Web Links.
  The Web site’s User’s Guide provides an overview of the process, criteria, and definitions used for developing the objectives, describes the difference between measurable objectives and developmental objectives, includes notes on the standard data tables and sources of data, and discusses target-setting methods. The six health goals are described, and chapters for the individual focus areas are accessed separately from a dropdown menu.
• Maryland’s Health Improvement Plan includes a useful section that discusses the question, "What is public health?" Data and other information are presented by state and county for each focus area, including oral health. Objectives and action steps are also presented.
• Vermont uses a concise format to highlight its oral health objectives (see pages 6-7 of the Resources section for this chapter). In addition to the HP 2010 Plan, Vermont’s Web site includes a personal letter to Vermonters from the Commissioner of Health, emphasizing that HP 2010 is everyone’s plan and thanking all of the volunteers who continue to contribute to its success.
• Alaska has a large chapter on oral health that discusses oral health status and disparities related to dental caries, periodontal disease, edentulism, cleft lip and palate, oral cancer, fluoridation and fluorides, and sealants, as well as provider issues, strategies and resources for addressing needs, and data issues. Volume II of Alaska’s strategic plan addresses the targets and indicators in Volume I through 14 stories of community-based efforts for public health improvement.
• Minnesota uses charts and examples of strategies, discusses evidence for each strategy and potential benefits of reaching the objectives. Minnesota uses a Q & A (question and answer) format.
• People and organizations in two counties where Fargo, North Dakota and Moorhead, Minnesota are located have formed a collaborative known as Healthy Communities Without Borders. They have launched a health data/education Web site using HP 2010 as the information framework. The Web site is administered from North Dakota’s state data center.

The Internet is a visual medium, so writing for Web sites is different than writing reports that are primarily narrative text. Reading on-line is not as easy as reading printed text. Web site users are more likely to scan documents quickly, so the Web site needs to be graphically interesting and easy to navigate. Anything that helps people scan quickly also improves readability. Too many graphics, however, will increase the time it takes to access each page.

The primary language of population groups you want to reach will affect how useful information presented on an English-only Web site will be. Some Web sites allow users to select language options, while others are created entirely in a specific language such as Spanish. Data from the 2000 US census indicate that Hispanics are now the largest minority group in the United States, and many recent immigrants or older individuals still do not read English. A recent analysis of reading levels of Web sites devoted to presenting health information to the public showed that those in English were written at a collegiate level, while Spanish language sites were geared to a 10^th grade reading level (see Berland citation on page 25 of the Resources section for this chapter). Both of these are far above the levels of 6^th-8^th grade recommended by many professionals who work in the field of health literacy. Some Web sites have addressed this problem by creating a "public" area and a separate area for "health professionals," with the information written and tailored differently.

Excellent resource for writing on the Web:

• www.usability.gov/design/writing4web.html covers methods for designing readable Web sites.

Conferences

Conferences are an excellent method to bring a diverse group of people together to present information and discuss strategies. Such meetings are conducive to a variety of formats such as oral presentations, keynote addresses, panels, roundtable discussions, posters, brainstorming sessions, workgroups, and informal networking. Some states use satellite conferencing technology to enable people in rural or geographically dispersed communities to participate. Town hall meetings are another useful method for gaining community input in a number of sites. When planning conferences, consider the special needs of some attendees, such as accessible facilities for disabled attendees, sign language interpretation and translation services.

Many states have launched their draft or final HP 2010 Plan or their Oral Health Plan with kick-off events or conferences.

• Alaska held a kick-off event, Healthy Alaskans 2010: Hitting the Targets, in December 2000 with over 120 people attending. Attendees received an update on the status of the target-setting process, gave feedback on the draft indicators and targets selected by chapter leads and committees, and identified priorities and strategies to improve the health of Alaskans in the upcoming decade. As individual chapters were posted on their Web site, the public could provide additional feedback via the Web site.
• Illinois held a number of community input sessions and a brief dental summit to present its draft statewide oral health plan. The state has have since created follow-up strategies to implement the plan.

A number of states hold Healthy People conferences annually or periodically.

• North Carolina marketed its 10th Annual Carolinians Conference for October 12, 2001 on its Web site with on-line registration.
• Iowa periodically holds Barn Raising conferences that focus on different aspects of keeping people in Iowa healthy. Barn Raising II held in June 1999 brought together 700 public health and community leaders to solicit input into the state HP 2010 plan and to assist participants in developing local plans. Barn Raising III in June 2001 paired national experts with local health practitioners and consumers who had been successful in initiating programs with positive, measured outcomes. This conference was also available nationally and internationally via Webcast.

Many national and regional health conferences have sessions devoted to HP 2010 or weave the HP 2010 theme into a variety of sessions.

• The annual National Oral Health Conference (sponsored by ASTDD and AAPHD) and the American Public Health Association annual meeting generally include sessions on HP 2010.
• In December 2001 an oral health workshop, Building Healthy Communities, States and a Nation through Partnerships, was held in Washington DC. Numerous states and communities highlighted their collaborative efforts to accomplish HP 2010 oral health objectives.
• Community-Campus Partnerships for Health holds annual conferences, with a number of sessions devoted to HP 2010 projects and use of the new curriculum planning guide Advancing the Healthy People 2010 Objectives Through Community-Based Education (see reference on page 25 of the Resources section for this chapter).

Listservs

Listservs are an excellent way to disseminate information in a timely manner to a large target group. They also are useful for distributing minutes, announcing meetings, sharing resources, discussing issues and soliciting feedback. Listservs can easily be expanded to include new members. Someone needs to be responsible for maintaining and monitoring any listserv for it to be credible and current. One listserv that sometimes includes discussions or announcements regarding HP 2010 oral health activities is the dental public health listserv. Individuals can join this listserv by sending an email message to: Majordomo@list.pitt.edu. In the BODY of that message (not the subject line) type the following message: subscribe dental-public-health (The message must be typed exactly as shown here, including the hyphens between the words).

Newsletters

Newsletters provide a regular mechanism for reaching a defined audience and are relatively inexpensive to produce, but require maintenance of mailing lists if the newsletter is not just posted on a Web site.

• CDC’s Office of Disease Prevention and Health Promotion publishes a quarterly newsletter on the Healthy People Web site for HP 2010 Consortium members to share news about their prevention activities related to achieving the nation’s health objectives.
• Maryland publishes a quarterly oral health newsletter that discusses HP 2010 plans and other oral health activities; it is available on Maryland’s Web site.
• North Carolina publishes Communities in Action, a newsletter for members of Healthy Carolinians, and produced through a partnership with the State Center for Health Statistics and the Office of Healthy Carolinians. It is posted on North Carolina’s Web site along with regional news and monthly email news.
• Some statewide oral health newsletters may not be available on Web sites but programs will add individuals or agencies to the mailing list. Check the state oral health Web sites on the ASTDD Web site.

Media Coverage

A variety of public media channels are available to disseminate information about HP 2010 and oral health.

• Local TV or radio stations offer public affairs talk shows, some of which may be specifically focused on health issues. Try to contact a producer at least one month in advance of when you would like your piece to air, and prepare a short written summary of the main points you would like to make.
• Public Service Announcements (PSAs) for TV or radio can be effective for delivering messages if aired at the time when the target audience is listening. Paid PSAs versus those aired for free usually have better placement. PSAs generally are one minute or less, so choosing the words and visuals is crucial. Field-testing each of the planned PSAs with members of the target audience is extremely important. Bill Cosby has been featured/cast in a number of PSAs for Healthy People 2010, including one on oral health.
• Press conferences often are scheduled to draw attention to a major conference, successful programs, or release of a report. The downside of using this method is that reporters may chose not to attend, or there may be many competing stories that day.

• If you do not want to stage a press conference, press releases are a good alternative. Press releases can be used to announce an upcoming meeting and its importance or to report on health disparities or progress made in achieving objectives and reducing disparities. More details about formats of press releases are included in the Resources section.

• Another option is to write letters to the editor. Remember that editors receive hundreds or thousands of these, and the impact of the letter may be limited. It is much more effective to write a letter directly to reporters, columnists, and news managers to get their attention about your HP 2010 or oral health issues. Some suggest being cool, astute, professional, succinct and persistent in this type of letter.

Media Advocacy

Media advocacy is a useful strategy for advancing HP 2010 objectives to the implementation and policy stages. Media advocacy moves the focus from health behaviors of individuals to the behaviors of policy makers who make decisions that affect the environment in which actions occur. Media advocacy organizes activities around two interrelated concepts:

• framing for access: shape the story to get attention and gain access to the media
• framing for content: tell the story from a policy advocacy perspective.

The Watch Your Mouth Campaign, produced by the Citizens Watch for Kids' Oral Health with support from the Washington Dental Service Foundation and the Annie E. Casey Foundation, is a good example of a media advocacy program focused on oral health. This campaign was based on marketing research conducted by the Frameworks Institute that showed how to "reframe" oral health issues to make 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 campaign has chosen key messages and media channels that:

• 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.

Examples of their materials and an overview of "framing the issue of oral health for the public" can be viewed at www.KidsOralHealthWatch.org. Evaluations to date have shown such success in increasing access to preventive and restorative services. Other communities are replicating this model.

To create a strong media plan, invite people who are connected to the media to participate in the HP 2010 planning committee or an oral health coalition advisory committee. For more information on media advocacy see the Reference list (see Wallach citation on page 26 of the Resources section for this chapter).

Options for Formatting Information

The way that information is formatted is crucial to how people will see and understand the messages. Not everyone wants to read a detailed report, especially if most of it is text and complicated graphs. Even highly educated readers appreciate formats that are concise, easy and quick to read, colorful, and include a variety of photos and graphics. Computer software programs and Internet access to "public use" graphics have made it easy and inexpensive to design materials that fit these criteria.

Research in the area of health literacy has provided valuable information about ways that people learn and apply information. Interesting findings from the 1992 National Adult Literacy Survey showed that about one-half of adults in the U.S. have difficulty:

• reading graphs and tables
• interpreting instructions
• reading and comprehending health information
• completing medical history, informed consent and insurance forms.

Other research findings show that people with low literacy skills, in comparison to those with higher literacy skills:

• have poorer overall health
• are less likely to make use of screening services
• present with later stages of disease
• are more likely to be hospitalized
• have poorer understanding of treatment needs
• have lower adherence to medical regimens. (Source: Rima Rudd, presentation at APHA, Oct 2001)

All of these findings suggest that we need to get the HP 2010 information to diverse groups in the population, especially the "underserved and uninsured" populations, many of whom are recent immigrants and experience language or literacy problems. For more information on health literacy and creating easy-to-read materials, go to the Web site at www.hsph.harvard.edu/healthliteracy.

Other resources for designing and formatting materials include:

• Scientific and Technical Information, Simply Put, published by the Centers for Disease Control and Prevention (see reference on page 25 of the Resources section for this chapter). Selected pages from this booklet are included in the Resources section to highlight tips for the following areas:
  • text appearance
  • visuals
  • layout and design
  • translation.
  *Also included is a checklist for easy-to-read print materials.
• National Cancer Institute, Making Health Communications Work, is a comprehensive approach to planning, conducting and evaluating health communication programs. It includes resources, tips, worksheets, and samples, and reviews planning frameworks, social science theories, and models for change. This publication is available online in Adobe PDF file format at http://cancer.gov/pinkbook and also can be ordered as a CD ROM from https://cissecure.nci.nih.gov/ncipubs/details.asp?pid=1138
• HRSA has created a number of fact sheets on oral health that serve as information and advocacy pieces. Many of these can be downloaded from the Web site www.mchoralhealth.org.
• For those who want to understand and present data and statistics in a valid way using charts and graphs, Web sites such as the Pennsylvania Department of Health’s Health Statistics Technical Assistance, Tools of the Trade at www.health.state.pa.us/stats/ are extremely useful.

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