Analysis of Boston Public Health Commission’s Boston BestBites Restaurant Program to Fight Obesity – Lindsay Flaherty

Introduction to Obesity and BestBites
As public health practitioners are very aware of, obesity is a major problem in the United States. In Massachusetts, the obesity rate for 2007 was 21.3 percent, which is lower than most states in the country (1). The obesity problem persists in the city of Boston as well, and five years ago, the Boston Public Health Commission created the Boston Steps program to address it, along with diabetes and asthma in eight Boston neighborhoods with the highest prevalence of these conditions. In this focused area including Chinatown, Dorchester, Hyde Park, Jamaica Plain, Mattapan, Roxbury, South Boston, and the South End, 33 percent of residents are overweight, while 20 percent are obese (2). One of the programs created as part of Boston Steps is called the Boston BestBites program.
Boston BestBites is designed to help Bostonians make healthier food options when dining out in the city. With all of the tempting restaurant choices in Boston, it is not surprising that that 40 percent of residents’ food dollars are spent while eating away from home (3). Restaurants that are interested in participating in BestBites submit potentially healthy recipes to nutritionists from Brigham and Women’s Hospital for analysis. The hospital nutrition department has developed guidelines constituting a healthy meal, outlining total calories, saturated fat, trans fat and sodium. Maximum allowances in these categories are outlined for an appetizer, entrée and a dessert. The guidelines fit in with the Dietary Guidelines for Americans 2005, which recommends a 2,000 calorie per day diet for the average American adult (4). Restaurants then work with the nutritionist to meet the guidelines, if they do not pass originally. Once the recipe meets the criteria, participating restaurants are given window decals, coasters, and table tents branded with the BestBites logo and are included in campaign advertising. Healthy menu items are designated in some way so diners know what they are choosing (5).
Boston BestBites launched in August of 2006 with 12 participating restaurants. It sent out 600 packets of information to garner restaurant participation (6). As of April of 2007, there were 21 participating restaurants, spanning some of the targeted neighborhoods, but not all. Information about the program after April of 2007 is difficult to find. It appears as though the program is no longer running, or doing so with minimal support. This could be due to a number of reasons, from lack of funding, to lack of restaurant support, or even poor outcomes.
This approach to fight obesity in restaurants taken by Boston BestBites is not unique. There have been other similar approaches developed. I developed a program that precluded BestBites called The Boston Heart Party Restaurant Program in which we garnered local Boston restaurants to develop heart-smart dishes to complement our free CVD screenings. Some national chain restaurants have created healthier options on their menus for those individuals who are dieting. One example of this was when Applebee’s teamed up with Weight Watchers in 2003 to create a menu that fit the Weight Watchers criteria and was offered alongside other menu choices (7). It is easy to understand the logic of such programs. By providing healthy options on a menu, it allows people to participate in the dining experience of eating out while staying true to their diet. It could even encourage non-dieters to choose healthy, good-tasting options. In reality, the people who have obesity issues may not have the willpower to make the healthy choices when they eat out, or else they may eat and drink other things along with the healthy option that wipe out the positive effects after all.
Critiques of the Intervention
While the Boston BestBites campaign and those like it are innovative and logical, this paper will examine how this program and others like it are flawed for three main reasons. The first is that the campaign as it stands is focused on the individual and does not account for several other options that affect dining choices. Second, it does not take into account social and cultural influences on changes in behavior that can be explained through sociology and anthropology’s influences on the field of public health. Finally, while the campaign had visually appealing collateral materials, it was not supported by a strong communications program, which could have helped to solidify consumer awareness adoption.
Argument #1: Insufficiency in an Individual-Based Model
The Boston BestBites campaign is based on the Health Belief Model (HBM). In the HBM, health behavior is motivated by the following thought processes: perceived susceptibility to an outcome, perceived severity of the outcome, perceived benefits of an action, perceived barriers of taking that action, cues to action and self-efficacy (8-10). When patrons take their seats in a restaurant with a menu to decide what to order, they are presented with an array of choices. They essentially go through the thought processes presented by the HBM as they decide what to eat. Specifically, some of the questions they may consider are:
· Should I choose the lasagna or the baked chicken BestBite option?
· Would the enjoyment of the lasagna be worth breaking my diet for the day?
· If I get the lasagna, will I have time to put in an extra long session at the gym tomorrow?
· Will the BestBite option make me feel good enough to pass up my favorite meal?
Unfortunately, the limitations to the HBM apply to the Boston BestBites campaign as well. One of the main limitations of the HBM is that it is an individual-based model and assumes that people make decisions in a vacuum. However, it is important to consider that other people may be part of the decision-making process and experience of dining in a restaurant. In reality, most people seldom dine out alone. When dining out in a group, people most likely discuss options of what to get with others at their table. Besides engaging others in their decision-making process while eating out, people often share food with others they dine with. Even if they order the healthy dish, they may still be going over their allotted caloric intake for a “healthy” meal because of sharing, sampling, or ordering appetizers and drinks.
Another limitation of the HBM model is that it is based on the assumption that people make rational decisions. The idea of ownership as it relates to rational behavior is discussed by Dan Ariely in his book Predictably Irrational. He uses an example of highly coveted Duke basketball tickets to show that if a person owns something, he puts a higher value on it than a person who does not own it but would like to (11). This concept can be applied to the experience of dining out for new dieters. For people who have been accustomed to unhealthy eating habits, their entire lives, then it will be more difficult for them to give up what they are used to and choose the healthy option. Consider the hypothetical example of a man named Joe. Joe is overweight and grew up in an Italian household that traditionally ate homemade lasagna every Sunday. This lasagna was not a new-fangled version of the dish containing low-fat, soy-based cheese, an abundance of vegetables and whole wheat noodles. Joe is accustomed to gooey, cheesy lasagna with ground beef and sausage loaded into it. Lasagna is comforting and nostalgic to Joe, as well as delicious. When he dines out at an Italian restaurant for the first time and sees the lasagna on the menu next to the BestBites baked chicken, he will think about how enjoyable and comforting lasagna is to him. The decision to choose the chicken would be more difficult for him than someone who has never eaten lasagna before, in the same way that the Duke basketball tickets are more valuable to someone who possesses them. The man in the example will be strongly focused on what he is losing when choosing the chicken over the lasagna, as opposed to the health benefits of the chicken and may act irrationally.
Argument #2: Lack of Consideration for Social and Cultural Influences
Boston neighborhoods are extremely diverse and different from one another. A comparison of the demographic make-up of two of the neighborhoods focused on in the Boston Steps program shows this. According to 2000 Census data, Roxbury has 63 percent black people, 24 percent Hispanic people, and five percent white people. Twenty-two percent of people speak Spanish at home (12). In contrast, South Boston 85 percent white people, 7 percent Hispanic people, and two percent black people. Only six percent of people speak Spanish at home (13). In the Boston BestBites program, a simple solution was applied to a range of ethnic restaurants in neighborhoods with culturally and ethnically diverse backgrounds. But addressing the needs in Boston’s diverse neighborhoods cannot be met by a one size fits all solution.
By considering and applying sociological and anthropological theories and research methods in the development of the BestBites program, a more effective program could have been created. Sociology incorporates a focus on social groups, hierarchies, structures and the nature of social interaction into public health programs. Anthropology emphasizes the role of culture in human behavior and public health problems and takes into account a holistic approach to behavioral decisions (14).
As described above, dining out is highly social and culturally unique. Companions, surrounding, and a person’s background can have a strong influence on the decision-making process at a restaurant and needs to be considered in the BestBites program. Additionally, a person’s cultural background and beliefs might play an important role in how he or she views dining out and what types of dining choices are typical. This must be considered in order to understand how to best influence behavior in a restaurant setting.
It is unclear what, if any, research was done to develop this intervention. Research methods common to sociology and anthropology could have been helpful in developing a successful program. Sociology typically utilizes both qualitative and quantitative research methods, while anthropology focuses mostly on using highly qualitative methods alone. Some of the research tactics that would have been helpful in the development of the program, include surveys, observation, one-on-one interviews, focus groups and experimentation. Data collection could then be used to generate theories about behavior and inform an intervention that could be more effective (15).
Argument #3: Failure to Support Program with Extensive Marketing Program
Finally, the Boston BestBites campaign did not thrive, because it was not supported by strong communications tactics resulting in visibility for the campaign. Even though the campaign had strong collateral materials, they could not serve to hold up the campaign’s success alone. As has been described in this analysis, the BestBites public health intervention is built in a setting that is greatly influenced by social factors. In order to have a greater impact on people’s decision-making, the campaign needs to be accompanied by a higher volume of social marketing, advertising and public relations. When searching for resources about BestBites, there are a couple of pages on the Boston Public Health Commission (BPHC) website, a press release for the launch, a couple of news articles from the launch, and a couple of website commentaries on the program. Other than that, it is impossible to find information about the program before walking in the doors to one of the few participating restaurants.
There are various studies and papers that outline how advertising and marketing can affect people’s actions. One such model is William J. McGuire’s Information Processing Model (IPM) (16). The IPM culminates in a communication/persuasion matrix including the thirteen steps in information processing. They are: exposure, attention, liking, comprehension, cognitive elaboration, skill acquisition, agreement, memory storage, retrieval, decision making, acting on a decision, cognitive consolidation, and proselytizing (16). The IPM model has received criticism that it reduces the decision-making process to a succession of steps which is too orderly. However, it outlines the importance of reaching audiences with messages in various ways and at various times in order to get the consumer through this long list of thirteen steps. The BestBites program is accompanied by clean and practical collateral materials (i.e. table tents and coasters); but if a person has not heard of the program before walking in the door to the restaurant, he or she will most likely not make it past steps one and two (exposure and attention) on the matrix hierarchy. This would most likely not be enough to choose to make a behavior change and order a healthy dining option.
Other communications theories also underscore the effectiveness of using message dissemination as a means to influence consumer thought and opinion. Diffusion of Innovation Theory says that the media can be used to influence and encourage people to help further a message (17). The Agenda-Setting Theory similarly contends that the media can be used to help and direct people on what topics to think about (18). Through better utilization of message distribution by the media and other means, the BestBites program may have been a higher priority in the minds of Bostonians. By hitting audiences with the BestBite messages in various ways – even low budget ones – the campaign could have gained more energy and momentum. This may have helped to influence more people to make the healthy menu item choices and encourage more restaurants to sign on to participate.
Conclusion
In summary, the Boston BestBites program that was developed as part of the Boston Steps program by the BPHC seems like an innovative and catchy idea on the surface. However, by considering the campaign through the lens of a knowledgeable public health practitioner, it is clear that it contains flaws that might limit its effectiveness. Restaurant patrons do not make their decision of what type of food to order while dining out on their own. They are influenced by their companions, surroundings, and cultural background. Such influences need to be taken into consideration in the development of an effective intervention. In addition, a program with flashy collateral materials cannot stand on its own without a full scale communications program to help disseminate messages repeatedly to restaurant patrons so they are more likely to make healthy choices while dining out.
A New Intervention
On the surface, the Boston BestBites program is a fun and innovative way to fight obesity in the Boston neighborhoods with the biggest disparities. In order to create a new and better intervention to help Bostonians make healthier choices while dining out, it will not be necessary to completely overhaul the program. Instead, I propose to renovate it using what we know about more effective – and often unconventional – methods of addressing public health problems. The revamped BestBites program will need to incorporate social and environmental factors into the decision-making process; be constructed based on sound qualitative research so that it will uniquely meet the needs of patrons who live in certain neighborhoods and frequent certain restaurants; and be supported by a strong communications program to not only build awareness, but also supplement the decision-making process.
The revised program will be called Boston BestBites Nites. The campaign will run for a year, and will offer two unique BestBites Nites per month, each at a different restaurant located in one of the neighborhoods targeted in the Boston Steps program. There will be a total of total of 24 “nites.” The restaurant participating at each BestBites Nite will be required to have two appetizers, two entrees and two desserts pass through the nutritional analysis developed by Brigham and Women’s Hospital. In addition to this requirement, restaurants will be given autonomy to add additional elements to their Nite in order to help to customize it to their own patrons. Public health professionals will be available to help develop these ideas based on both traditional and nontraditional models for behavior change. Examples of activities unique to a specific restaurant include offering the meals at a discounted price as a way to entice lower income patrons; a physical activity component such as dancing that is typical in a particular culture and could help garner attendance; or the development of “mocktails” to help teach people how to adopt other healthy lifestyle changes.
All of the Nites will incorporate an educational component as well. The BestBites collateral materials will be expanded to include educational materials. A nutritionist from Brigham and Women’s Hospital Department of Nutrition will be present to answer any questions that patrons have about healthy eating and meal creation. Restaurants will also be free to suggest and develop other educational components based on their customer base. Following a certain restaurant’s BestBites Nite, it will be required to leave at least one of the healthy options on its menu for the future, and continue to distribute educational materials and other campaign literature throughout the duration of the program.
Counter-Argument #1: Moving Beyond an Individual-Based Model
Dining out at a restaurant is not an individual experience, and so an intervention that is based on an individual-based model simply will not have the intended impact. There are several ways that BestBites Nites is more incorporative of social factors. First, the BestBites Nites program is based on the ecological model. This model considers that individual factors are only a small contributor to a person’s behavior. Other factors that affect behavior include social/cultural/group, socioeconomic and structural, political and environmental factors. All of these factors would work together to influence behavior, not work individually (19).
In the BestBites Nites program, the decision-making process shifts from one that is individually focused, to one that is group focused. Family and friends will decide together that they want to attend the BestBites Nite at a certain restaurant, and so one person will not be isolated in trying to choose a healthy menu option amid other temptations and social pressure. Social, cultural, socioeconomic and group factors are already built into the experience. The individual need only decide which of the healthy options he or she wants to eat when after arriving at the event. An evening shaped around healthy restaurant dining and fun removes the pressure from an individual to make a healthy choice while under the influence of environmental surroundings or social pressures. Dancing or entertainment will make the evening more appealing as a group activity. The educational component will arm diners with ideas on how to maintain healthy eating habits in everyday life or while dining out in the future. Since at least one of the healthy menu items will stay on the menu after the BestBites Nite at that location, diners will be more likely to choose it on an individual basis in future visits to that restaurant now that they have experienced it in a group they are comfortable with.
The BestBites Nites also take into account that people do not always make rational decisions. As discussed above, diners know what they are giving up when they choose a healthy meal. For example, patrons at Poppa B’s in Dorchester are accustomed to traditional soul food dishes such as BBQ ribs, fried chicken and sweet potato fries (20). The BestBites Nite at Poppa B’s should not exclude these soul food favorites, but update them into healthier options. Patrons who may be tempted to make an irrational decision will remember how good these items are and not necessarily be satisfied with a menu that does not include them. An example of a renovated, healthy, soul food menu could include BBQ chicken, oven fried chicken and oven baked sweet potato fries. The patrons will not feel like they are giving anything up.
Counter-Argument #2: Strong Consideration for Social and Cultural Influences
As mentioned above, Boston is an extremely diverse city, and it is hardly possible to create a one size fits all obesity intervention that would have an impact on the city’s diverse population. Since BestBites Nites will take place at one location at a time, it will allow the program to be more tailored to accommodate the unique diners who typically frequent those restaurants, based on common characteristics of local residents. In this way, a BestBites Nites held at Poppa B’s in Dorchester will be very different from a BestBites Nites at Centre Street Café in Jamaica Plain.
The public health practitioners who are tasked with development and implementation of the BestBites Nites program will be instrumental in helping restaurants to develop a unique evening at their restaurant that will specifically help to encourage healthy dining among their patrons. By utilizing data collection methods more typical in the fields of sociology and anthropology, a more precise and focused understanding of each restaurant’s customer base can be gathered. Therefore, for each of the 24 restaurants that participate in BestBites Nites, two customer focus groups, at least 200 surveys, and at least five one-on-one interviews will be conducted with restaurants and patrons. Some of the questions that can be posed through these qualitative research methods include:
· Why do you dine at this restaurant?
· What is your favorite menu item at this restaurant, and why do you choose it?
· Who do you typically dine at this restaurant with?
· Do you maintain a healthy diet at home?
· What do you think of when you hear “health food”?
· What does eating a meal with family and friends mean to you?
· How is the food at this restaurant different or similar from the food you eat at home?
· Are there any activities – such as dancing, games, or demonstrations – that you would find entertaining while dining at this restaurant?
The research will be compiled into a report including recommendations for unique tactics to meet those patrons’ needs. The public health professionals will then meet one-on-one with the restaurant owners to design the evening.
Counter-Argument #3: Development of a Strong Communications Program
As mentioned above, Boston BestBites is a creative idea accompanied by a strong base of sharp collateral materials. The campaign’s development of restaurant-friendly items such as coasters and a recognizable logo is an important first step in building recognition of the campaign. However, the program received practically no media attention, has an outdated website, and seems to have fizzled out soon after its inception. In order to drive attendance to BestBite Nites and provide education to people that will hopefully have a longer term impact on people’s dining choices, the campaign will need to be supported by a strong communications program. The existing materials should be used as a basis for this, and additional materials should be developed to build upon and expand them.
The communications program will need to include public relations, advertising and community relations components. It should be creative and wide-reaching. By repeatedly getting the BestBites message in front of residents of target neighborhoods, it should follow that the campaign will have greater adoption based on William J. McGuire’s Information Processing Model (IPM) (21) and the Agenda Setting Model. More specifically, some or all of the following tactics could be included in the communications campaign:
· Advertising in community media publications, such as the Roslindale Transcript, Brighton Tab, South End News, and Jamaica Plain Gazette.
· Hanging flyers at neighborhood libraries, coffee shops, book stores, grocery stores, etc.
· Working with a local healthy food store (such as Trader Joe’s) to have them distribute flyers for BestBites when bagging groceries or giving receipts to customers.
· Generating feature stories in regional, local and community media about participating restaurants.
· Place a news story in Brigham and Women’s weekly newsletter, as well as other Partners institutions – possibly even offering a promotion for all Partners employees.
· Scheduling a “chat” with one of the nutritionists from Brigham and Women’s on Boston.com, where users can write in questions about the program.
· Signing on a campaign “spokesperson” to help educate and influence consumers to eat healthy while eating out with the BestBites program.
In addition to these communications tactics, a strong and up-to-date website should be developed as a core information source of campaign information in addition to collateral materials. A catchy web address can appear on collateral materials, in advertising, or in news articles. When a user visits the website, it will have a detailed schedule and description of upcoming BestBites Nites and participating restaurants. Healthy dining tips and a blog by a Brigham and Women’s nutritionist could also be strong additions to the website. The online communications strategy could even incorporate the use of social media, where appropriate. For example, a Facebook group could be created for BestBites Nites to build buzz. For communities that do not have a high usage of the Internet, extra collateral materials and community relations tactics will be utilized to reach audiences in the most appropriate way.
In conclusion, Boston BestBites is an innovative program with a strong and established base. By tailoring and renovating the program to be more in tune with all of the factors that affect the decision-making process for diners at participating restaurants specifically, the intervention can have a greater impact. An improved intervention that is built around an individual-based decision-making model should also be strongly supported by a highly visible communications campaign that will help to foster a greater participation rate and, with hope, ultimately help improve the health of residents in the Boston neighborhoods facing the most disparaging obesity statistics today.
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Abstinence Only’s Alienation of Developmental Psychology, Social Psychology, and Public Health Basics - Joanna Matwiejczuk

Over the last several decades, sexual education has been incorporated into high school classrooms across the country. While policies over comprehensive sexual education versus abstinence only education vary state by state and classroom by classroom, it is also evident that the political climate over this distinction has been in the eye of controversy. The federal government fiscally supports an abstinence only curriculum for adolescents and due to various factors, many schools have accepted the money from the government to teach abstinence only and thus have adopted an abstinence curriculum while forsaking comprehensive sexual education. However, not only is an abstinence only curriculum a close minded approach to sexual health education, but it is also unrealistic for the target audience, as well as irresponsible from a public health perspective. From the 2007 Centers for Disease Control Youth Risk Behavior Surveillance System, it has been found that 48.7% of adolescents have self-reported to being sexually active (1). An abstinence only curriculum therefore is virtually lost on almost half of its target population, statistically speaking. You can’t tell me what to do! What developmental psychology has to say. It comes as no surprise to parents, teachers, the general public and even adolescents themselves that the teenage years have been classified from a behavioral science perspective as a time to rebel, to break rules, to push limits and to act in exactly the opposite way that society would like them to act. This is not to say that all teenagers disobey their parents or the law, but it is inherently natural for them to engage in risky behaviors, especially behaviors that they are told not to engage in. Rebellion is a tool used by adolescents to begin establishing a sense of self and to gain independence. According to Erik Erikson's work in developmental psychology, "adolescence is a period of time in which a young person can take time to explore identity so as to work out conflicts and establish a secure sense of self" (2). Abstinence only teachings rely only on highlighting all the negative aspects of sex, such as the risks of unwanted pregnancy, the risks of contracting sexually transmitted infections, as well as the emotional harm that could result when one begins having sexual contact before they are mentally ready. However, from a developmental perspective, "youth may view abstinence as a developmentally appropriate stage, which precedes the equally appropriate stage of becoming sexually active when they are 'ready'" (3). Abstinence only education does not teach safe sex nor does it point out resources where adolescents can turn to if they do indeed choose to have sex. This absolutist curriculum is unrealistic given what we know about the psychological development of young people. They are essentially being told "do not have sex" which could only further fuel the need to rebel and thus engage in sexual activity. Our country's "just say no" attitude towards adolescent risky behaviors including alcohol consumption, substance use, tobacco use, and sex has not changed the fact that youth across the United States experiment with substances AND with sex on a daily basis.
Adolescence is also a time when young people seek greater freedom and when they hone their abilities to make positive choices. However, oftentimes, young people make many negative choices before they realize what the "right" choice is, but from a developmental perspective, they must be allowed (within reasonable means) to make various choices and recognize the repercussions of their actions. This is what learning and growth is about and this is what teenagers need in order to grow into healthy, balanced adults. "Teenagers’ identification of themselves a people committed to abstinence could keep them from considering situation in which they might someday choose to engage in sexual behavior and from learning how they might then protect themselves against unwanted pregnancy and STDs" (4).
As educators of adolescents, schools as well as the federal government, should create an atmosphere of learning where young people can be presented with many options and receive explanations of the various consequences (positive and negative) of sex before making an educated decision about how they choose to proceed in their own sexual lives. This is similar to various parenting styles in psychology developed by Diana Baumrind, in which there is strong evidence to show that authoritative parenting where children are allowed more freedom and decision making leads to better youth development outcomes, as opposed to authoritarian parenting which demands strong adherence to set rules and stunts psychological development (5). "Strong abstinence intentions may be linked with a view of sexual behavior that minimizes the role of personal choice and agency in making sexual decisions" (6). Restrictive statements and scare tactics about sex education will not foster positive youth development nor will it equip young people with the personal negotiation skills they will need for the more difficult choices in their futures. "Young people...need to be prepared to negotiate and renegotiate...[and] be treated in ways that encourage meaningful decision-making including in relation to sexuality, from a much earlier age" (7).What about your friends? Will they be around? Perspectives from social psychology. A very important aspect that is neglected in abstinence only education is the influence and power of the social environment of adolescents. In general, society is very influenced by community, peers, the media, etc. (8). This influence is heightened for our society's very impressionable teenager. Abstinence only education fails to factor in the everyday environmental exposures into the classroom curriculum. It does not account for what is already out there in the world and merely preaches a single answer (no) to a very complex issue like sex. Many (47.8%) of youth are already engaging in sexual activity and while 52.2% may not be, they are in contact with their peers daily and oftentimes intimately. Abstinence only teachings do not address the power of peers and social groups as a teenager seeks social approval and engages in conformity. Personal and group attitudes towards sex can often be much stronger than messages to simply not have sex. Young people will not only encounter sex as an issue among their peer groups, but will also be confronted with it on a much more personal level in their intimate relationships. A curriculum that incorporates the possibility of such situations and provides tools to navigate such situations would be much more appropriate given the national statistics concerning sex and adolescents and the social climate that youth live in. "They live in a largely peer-defined world easily accessible through communication technologies" (7). Another extremely powerful influence on young people is the media. Sex is not only on television, but in movies, on the radio and in music, in magazines, billboards, advertisements, news, commercials, etc. countless times each day. "The mass media are an increasingly accessible way for people to learn about and see sexual behavior. The media may be especially important for young people as they are developing their own sexual beliefs and patterns of behavior, and as parents and schools remain reluctant to discuss sexual topics" (9, 10). Adolescents are heavily exposed to the media and while they view others (adults and their celebrity peers) engaging and negotiating sexual situations in their "on screen lives," it is unrealistic to expect them not to be considering it in their own lives. Abstinence only education fails to acknowledge all of the publicity sex is gaining in our society's media and instead chooses to voice the same message of simply saying no to sex before marriage. Instead of addressing and perhaps utilizing examples of sex in the media as an avenue for a lesson plan about safe sex, abstinence only delivers the same messages today as it did decades ago. Just as Trojan condom commercials can highlight the positive consequences from engaging in safe sex, sexual health education should be able to do the same. I didn’t do it because I thought you were…Well I didn’t because you were supposed to…A stance on public health and education responsibility As educators and public health professionals, we need to consider the repercussions of an abstinence only curriculum. While it may seem "best" to encourage young people to wait until marriage or a long term relationship to have sex, in reality many youth are not taking this course of action. However, even those who do choose to wait will eventually need information, resources, and support to inform their decisions and judgment about sex. Unfortunately, an abstinence only curriculum does not equip these youth for their "next step." Abstinence only education alienates the sexually active as well as the homosexual youth population. Since these groups have either started having sex, or may not see sex in a heterosexual framework (i.e. at risk for pregnancy or for intercourse), these young people are not included and given no resources to protect their own sexual health (11).
As a center of learning, schools should take responsibility for teaching their students about sex, about the risks and benefits, about safe and protected sex, and guide young people to resources that can be utilized to help make decisions, to facilitate safe sex, or resources to turn to in a time of need following sex. "Ironically, the very methods aimed at protecting children often contribute to their abuse...[by] underminding their potential of being aware, knowledgeable, and competnet individuals" (12). Indeed we are doing a disservice to young people by not sharing the facts with them and allowing them to develop and make healthy decisions based on their individual needs. It is disturbing to think that sex education has been forced to exist only outside the classroom for so many young people. As educators, there is an opportunity to shed light, accurately inform, and spread a message but, instead abstinence only educators are just saying no. "This approach captures only negative consequences of sexual activity, ignoring potentially positive aspects, such as developing a sense of intimacy, achieving social skills and goals, and experiencing sexual pleasure" (3). For the public health world, where disease prevention and health promotion are key goals, sex in and of itself is not the public health problem. Unsafe and unprotected sex is what causes of the spread of STDs and unwanted pregnancies. Of course abstinence would solve the issues, but since that is not realistic in the long term, the focus needs to remain on the promotion of safe sex to all those at risk, including and especially, adolescents. "Sex education is intended to serve a very practical public health purpose...[but] the growing prominence of the abstinence only approach will likely have serious unintended consequences by denying young people access to the information they need to protect themselves" (11). Ignoring the issue, as abstinence only education does in a way, will not eradicate the problems associated with unsafe sexual activity.
It is also dangerous to assume that those adolescents engaged in sex and those thinking about initiating sex are armed with the facts they need in order to do it safely. Their information may not come from parents or other educational sources, but rather the internet, media, and peers which can be much less reliable and send unclear, mixed, inaccurate messages. What abstinence only education has taught us
In conclusion, abstinence only education fails to deliver what adolescents need at this developmental stage in their lives and ill equips them for skills needed to engage in positive decision making. Adolescents will eventually, if they aren't already, become a part of the sexually active population and when they reach that point, they must have some information about safe sex, as well as options and resources to turn to. "Society must recognize that a majority of adolescents will become involved in sexual relationships during their teenage years" (13). Abstinence only education has failed to account for the dynamic influence of social environment, especially media and peer groups. Instead, it has focused on a static, close minded approach to address a complex and ever changing issue that faces our teens. Above all else, abstinence only education has failed the public health community by bypassing the real issue at the heart of sex which is the prevention of disease. By not taking the curriculum to the next level, the ignorance of safe sex can lead to very negative and unfortunate outcomes for our young people. Abstinence only supporters are failing our young people by not providing them with the information they need to protect their health and well being. So it's our responsibility, but what can we do?
Given all this information, we should start to consider what a more ideal approach to achieving safe sex amongst adolescents should actually look like. We have learned that abstaining from the abstinence only educational approach may prove to be beneficial if executed properly. A comprehensive sex education program needs to be developed in order to address the multifaceted issues that adolescent sexuality raises. And, not only developed but implemented and mandated by government as the most responsible approach to sexual health education. Although "comprehensive sex education" curricula are in place in schools across the country, we must examine what that really means. I do believe that a comprehensive approach is necessary, but there are crucial, key elements missing from many of the current comprehensive programs. We must specifically address what is known about adolescent psychological development and factor that into every feature of the program. We must also carefully consider adolescent psychology from a social perspective and be aware of the social climate of our society. Lastly, in order to address the issues outlined prior, we must always keep in mind that it is the duty of educators and public health professionals to design programs that effectively incorporate information and strategies specific to adolescents when considering the features of a comprehensive sex education curriculum.
Comprehensive sex education, unlike abstinence only education, acknowledges that adolescents may already be engaging in sexual activity, or may be considering beginning engagement in sexual activity. It incorporates abstinence into the curriculum, but does not solely focus on abstinence as the only option for preventing unwanted pregnancy or the transmission of STIs. It also points out and encourages safe sex practices, such as using birth control and condoms as well as teaches communication skills to assist adolescents in negotiating sexual activity. This education should ideally be happening in the classroom, either at the middle school or high school level when a large percentage of adolescents are starting to initiate sexual activity or thinking about it. I strongly believe that a classroom setting is the most effective way to reach many young people because school is mandatory. They have to attend. School is also where youth learn everything from math to science, and sexual health should be another course that they need to complete. As an epicenter of learning in their communities, schools must take on this responsibility and intentionally address sexual health in order to fully serve the students, as well as their parents, the community members, and society as a whole. It is a public health responsibility to teach complete (comprehensive) sex education that addresses all topics and considers all members of a population. This responsibility can be achieved very effectively in a classroom setting. It is harmful to employ an abstinence only education as it falls short of information dissemination. Information that is essential to making safe, healthy decisions.But, won't they just do what they want anyway?
In order to address the complexity of adolescent psychological development it is important to acknowledge that adolescent rebellion exists and that there may not be an effective way to combat it, nor should we try to. Comprehensive sex education would be charged with needing to work around this issue and find a way to successfully incorporate strategies that can work in such an atmosphere. The message of "no sex" as abstinence only education sets forth is very absolutist and casts a rule out for adolescents to follow. Not only would this be ineffective knowing what we know about adolescent rebellion, but it also would not allow for adolescents to naturally develop cognitively. Adolescents will be faced with difficult situations throughout their lives, and "no" will not always be the answer. From a youth development standpoint, comprehensive sex education needs to allow for healthy decision-making, both encouraging the navigation of options available and also equipping adolescents with skills to be able to critically think through a decision in order to make a positive one. I propose incorporating into the comprehensive sexual education curriculum a unit on healthy relationships and decision-making strategies. This may involve interactive lesson plans that allow youth to practice skills and also must include posing situations to them about sexual scenarios that they may need to navigate. Healthy relationships will need to cover everything from friendships, "hooking up," and dating, to long-term relationships, homosexual relationships and unhealthy (abusive, etc.) relationships. Some of these topics may be sensitive and it may be difficult for teachers to talk about, but creating an open environment where frank discussion is not only allowed but encouraged may make all the difference.
Comprehensive sex education needs to exist on a continuum. In other words, information dissemination is only the first step, other supports and reinforcements need to be in place in order for the information to be fully processed and utilized. I propose supplying "sex goody bags" during sex education which include resources and samples of many commonly used contraceptives. Items can include male and female condoms, spermicide, a condom carrying case, and tangible "dummy" examples of prescription contraceptives such as the vaginal ring, the patch, etc. as well as information accompanying each piece in the bag. The bag can also include a resource list of health centers, or a business card with important information that can be kept with them at all times. This way, adolescents have a chance to experiment with the various options they have and may more effectively find one that suits them. This approach factors in adolescent development because it allows for experimentation in a controlled environment and also acknowledges that not all young people may be comfortable approaching an adult with questions about sex. This way, youth have the chance to explore various methods to prevent unwanted pregnancy and STIs, and truly get a feel for their options.They won't listen...there's too much competition...
It is critical to realize that there are many societal influences upon young people. Comprehensive sex education may have to compete for attention. Or, there may be a way to utilize and incorporate social influences (peer and media especially) into sex education. Not only are communication skills necessary for adolescents, but a reliable medium of communication is necessary. As previously discussed, young people may not be comfortable enough to raise questions about their own sexual health. I propose the creation of a text message network ("Sext me!") that can provide resources, answers to questions and support for teens thinking about sex, experiencing the emotional aftermath of sex, or needing to know where to go for help. This two-way, anonymous form of communication could be a relatively easy, non-judgmental, non-confrontational way to get questions answered and resources supplied. It goes beyond just supplying information and text messaging is a medium that adolescents communicate through a lot. Such a network and program can be established through community resources, not necessarily exclusively schools. To address staffing issues, resources can pooled through the community, or city, county, state, etc. in order to create an extended network. Also, incorporating youth into the development of the "sext network" as well as employing young people in the infrastructure can add to the legitimacy as well as the approachability that other young people will experience when they consider sending a text message to obtain sex information.
It may seem nearly impossible to counteract with media influence in the lives of young people. And although it would be extremely difficult to monitor or change what is shown in the media about sex, there is a way to counteract the messages that are conveyed about sex. I propose that classroom curricula devote time to digesting and discussing the week's, for example, media activity. Whether it be the latest episode of a popular teen sitcom, or the release of a controversial song, teachers should intentionally designate classroom time to view, discuss, demystify, and engage young people in talking about any questions that could arise. It is also important to address details that may be missing from the staged situation, or address what follow up to a scene may look like in reality. Incorporating humor and open-mindedness into the classroom discussion is essential in order for this approach to be effective. Although this does not eliminate inaccurate, unrealistic information from reaching a very impressionable audience like teenagers, it does provide a solution so as to not ignore that this indeed does exist as a very real and powerful influence in their lives. This approach also grants an opportunity for educators to remain at the forefront of current youth sex culture and remain informed. This information and experience can also help mold their classroom curriculum to be more relevant, current and timely for teenagers.In conclusion, abstinence only education barely scratches the surface of what is a complex, involved, and multifaceted issue like adolescent sexual health. Comprehensive sexual education is a primary step in the right directions. There are obviously many other interventions that can be incorporated at an after school level, or within the community, or in a young person's home. However, I believe that sex education needs to heavily involve educators who spend day after day with the same young people and who are expected to teach. And they must teach. All the options and uncover all the resources that are available. Comprehensive sex education as laid out in this discussion must incorporate creative and current strategies in order to be effective. As times change, curricula must as well. However, three facts that will not change is that adolescent sex education is the responsibility of the public health and education community. Also, interwoven into all aspects of a comprehensive sex education curriculum, must be principles seeped in what is known about adolescent psychological development and what positive, healthy youth development looks like. And finally, educators must never ignore the strong effects of peer groups and the media on our society's young people. Education need not combat these effects, but rather find meaningful ways to use social psychology principles to create a strong, all encompassing curriculum that will reach adolescents and ultimately shape their decision-making skills and capacities.

REFERENCES
1. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health, 2007.
2. Erikson, E. Identity: Youth and Crisis. London: W.W. Norton & Company, Inc., 1968.
3. Ott, MA, Pfeiffer, EJ, and Fortenberry, J. Perceptions of sexual abstinence among high-risk early and middle adolescents. Journal of Adolescent Health 2006; 39(2):192-198.
4. Masters, N, Beadnell, B, Morrison D, Hoppe, M, and Rogers Gilmore, M. The opposite of sex? Adolescents' thoughts about abstinence and sex, and their sexual behavior. Perspective on Sexual and Reproductive Health 2008; 40(2):87-93.
5. Baumrind, D. Parental disciplinary patterns and social competence in children. Youth and Society 1978; 9:238-276.
6. Fine, M. Sexuality, schooling, and adolescent females: the missing discourse of desire. Harvard Educational Review 1988; 58(1):29-53.
7. Lehr, V. Developing sexual agency: rethinking late nineteenth and early twentieth century theories for the twenty-first century. Sexuality & Culture 2008; 12:204-220.
8. Kirby, D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 9. Brown, JD. Mass media influences on sexuality. Journal of Sex Research 2002; 39: 42-45.
10. Brown, JD, Steele, JR, and Walsh-Childers, K (eds.). Sexual Teens, Sexual Media: Investigating Media's Influence on Adolescent Sexuality. Mahwah, NJ: Lawrence Erlbaum Associates, 2002. 11. Collins, C, Alagiri, P, and Summers, T. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? Policy Monograph Series, 2002.
12. Robinson, KH. Childhood and sexuality: adult constructions and silenced children (pp. 66-78). In: J.Mason, J.Mason, & T. Fattore (eds.). Children taken seriously: Theory, practice, and policy. London: Jessica Kingsley Publishers, 2005. 13. Sexuality Information and Education Council of the United States. Adolescent Sexuality Fact Sheets. New York, NY: Sexuality Information and Education Council of the United States. www.siecus.org.

First 5 Education Training Initiative: Preaching to the Choir – Jessica Kissen

Oral hygiene is very important to children for various reasons. “Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social well-being.” (1) Children especially can be affected by bad oral hygiene. Dental caries, or tooth decay, can affect a child adversely. Children can experience severe “pain, discomfort, disfigurement, acute and chronic infections, and eating and sleep disruption.” (2) Dental problems in childhood could result in health problems in adulthood and/or could be signs of serious illness. (3) Unfortunately, across the world, maintaining good oral health is a big problem
Dental caries are an epidemic in the United States, although many in the United States don’t acknowledge it. According to research, many call the prevalence of dental caries a “silent epidemic.” This is due mostly because tooth ailments, although widespread, are not deadly and usually will just cause pain and discomfort that people can deal with until it is too late. (4) Unfortunately, it is more prevalent than people realize. Between the ages of 2 and 11, 42% of these children have dental caries. (5) What is worse is that Black and Hispanic people who live in poverty have the largest disparity of tooth decay. (6) But recently, because of an increased awareness to this epidemic, the United States has started to take notice and recognize oral health as something to focus on and has started to create different initiatives and interventions to help combat this growing epidemic.
In a study done in 2000, which was designed to assess a pediatrician’s knowledge of oral health and hygiene, the results show that pediatricians need more training in this area. (7) Stemming from this important study, a recent initiative was established called The First 5 Education Training Initiative; this intervention was piloted in California in February 2004. (8) The goals of this initiative is to educate and train dentists, medical professionals and early childhood educators about new scientific procedures and practices that can be used to promote oral health in children in their very early childhood (0 to 5 years). This intervention plans on eliminating the epidemic from the inside out. By educating the educators, this initiative is believed to provide more dental health care to children and better dental health care for children.
Unfortunately, this is not the case. This is obviously a very flawed intervention that doesn’t address the core problems with dental care and oral health. Although the study mentioned above recommends that pediatricians be educated in dental procedures and technology, this intervention does not address key elements to dental care. First 5 Initiatives do not address problems with the Medicaid Dental Care system. Although every single child who is enrolled in Medicaid has the right to dental services, only about 18 percent of these children have even come in for a check up. (9) Since the service is provided, why is there so small a number of children actually going to the dentist regularly? The other flaw deals with the target. Are we educating the right people with this program? Should we be educating the professionals or parents, teachers, and care-givers? The general public does not realize the severity of this epidemic, but professionals do. Why are we trying to educate people who already know that bad oral health is a major problem? The problem that might be hardest to combat is the social norms about dental care and oral health. Dental care is strongly viewed as an elective procedure for those who can afford it. Most people don’t believe the oral hygiene is very important. This program does not address how to make a change in the social norms about oral health. The program is ending its four year agenda in December 2008, and reports already show that it has been a failure. Failure to address the real problem with dental care and oral health made this initiative a waste of 7 million dollars.

First 5 Initiative Does Not Address How to Pay for Dental Procedures
Unfortunately, confirmed by the low percentage of Medicaid beneficiaries going to the dentist regularly, Medicaid’s plan does not seem to be attracting parents to send their children for regular check ups. “Medicaid programs face a myriad of difficulties, from low levels of participation by dentists to difficulties in teaching beneficiaries how to negotiate the dental care system.” (9) First 5 Initiatives tried to address the low participation through dentists. The program’s goal is to educate dental and medical professionals about the importance of dental care and oral health, and eventually these dentists and medical professionals will take Medicaid patients more often. Unfortunately, this could never be the case.
It has already been established that dental care for children is crucial to their overall health, but having a dental procedure takes time and money, and not many dentists or medical professionals are working for Medicaid. When a family has dental coverage, the dentist will be alert to the dental problems in the family and he will be reimbursed by that family’s dental insurance plan. Research shows that families who are in a higher socio-economic status (SES) go to the dentist regularly compared to mid to lower SES. (10) What does that tell us? People who are in the low SES range usually have Medicaid as their insurance. Medicaid families also have the State Children’s Health Insurance Plan, SCHIP, for their children, which is insurance coverage for mothers and their children. (11) SCHIP’s dental coverage is controlled on a state by state basis. There are still out-of-pocket fees, and other costs that apply to the program. As with many low-income families these fees may deter a mother from taking her child to the dentist. Not only are their fewer dentists that accept Medicaid and SCHIP, there are other constraints such as “inflexible work hours [and] distances to providers.” (10) These barriers do not help with dental care in children. And as the children age, these barriers don’t get any easier. Just because more professionals know about the problem, doesn’t mean that people are actually getting help. In conclusion, just by educating professionals about oral health does not help with payment and improvement in oral health.
First 5 Initiatives Does Not Target the Right People
The First 5 Initiative is a great plan addressing problems with knowledge about oral health in a professional community, but this professional community already knows about the dangers of dental caries and the need for regular visits to the dentist. The training that is instituted by this program is not even hands on. There are no patients on which they are performing procedures and check ups on. Many of the training sessions are even online through webcasting. How does this support a community of people who need to get dental care?
So who really needs the education? In an older study done in Romania that showed although many mothers knew about the dangers of poor oral hygiene, there was still a prevalence of tooth decay in many children. “On one hand, most of the mothers knew about the negative effect of sweets and candy; nevertheless, the consumption of various sugary foods was relatively frequent.”(12) This shows that although most mothers understand that some foods may cause a problem, they would rarely do anything about it. Translating this to First 5, shouldn’t we be training mothers to be more careful about what they feed their children? First 5 will do a great job educating professionals so that when a mother does bring a child in for a dental procedure or check up, the dentist will be able to talk to the mother. But, as we have discussed, many mothers don’t even take their children to the dentist. It is a waste of valuable training time.
When we look at this intervention in the perspective of a model, First 5 is trying to increase the amount of children going to the dentist from the inside out; meaning that the outcome we want to have is an increase in the number of children that get regular dental check ups. The exposure that we are using is educating professionals. Where is the link between professionals and children? Early educators are targeted by First 5. Unfortunately, this program targets children between the ages of 0 and 5 and this is before children have a chance to go to kindergarten. There is a missing link between the education of professionals and getting children to get dental care.
First 5 Ignores the Social Norms about Dental Care in the Community
Is dental care viewed as an essential and crucial part to a child’s health? Aside from the hassle and the money it takes to get a child to go to the dentist, do parents feel that it is so important that their children receive dental care? “Some parents mistakenly believe that younger children do not need to visit the dentist because the young children’s teeth are not permanent.”(10) Overall, the public doesn’t see dental care as very important to children who don’t have permanent teeth. Dental care seems to be put on a shelf until the children grow up. The barriers for dental insurance only get worse as children become older. Unfortunately, this can have some major consequences. What is the worst part about it is the fact that dental problems are easily preventable and treatable if the problem is diagnosed earlier. (13) This creates a rift between social norms and the consequence of not having dental care.
The questions to answer are how are any of the First 5 initiatives addressing the fact that people do not think dental care is important. This intervention fails to address the fact that the general public believes that dental care is a luxury. Mostly it is because parents do not realize that tooth decay is a real problem which is very preventable. In a report done by the Dental Health Foundation, the public opinion about “tooth decay [is that it] is a natural and minor occurrence that deserves little attention or dollars.”(14) Some parents can consider children caries as a minor inconvenience since they think that children’s teeth are temporary and the problem will go away when they have permanent teeth. (10)
Since dental care seems relatively unimportant to some people, people who can’t afford to take their children to the dentist for a regular check up will chose to avoid it. Having a co-pay or even gas on the trip may be more costly. In an important study published in the Journal of Community Dentistry and Oral Epidemiology, the author states that there is a need for educating mothers of a preschool age children about the importance of brushing teeth because mothers had no interest and no information about teaching their children how or why to brush their teeth daily. (15) Mothers had no interest to teach and monitor their children’s brushing habits because dental health isn’t as important to them as physical health. As stated above, evidence shows that it is just as important.
In conclusion, the First 5 was a complete disaster. It had the wrong target, the wrong approach, and the wrong idea. Educating people who were already educated was a waste of 7 million dollars. After looking at the data (16) we can even see that this was a failure. This pilot program did nothing but help us understand where First 5 went wrong. Although, from this intervention we will be able to create a better more effective initiative that targets the right people and puts money in the right places.

Learning from the First 5 Mistakes: First 5, Part 2 – Jessica Kissen

The First 5 Initiative piloted in California in 2004 didn’t work for many reasons. The initiative did not address key problems in dental health care delivery, coverage, and ignored the norms about dental health care. From the failure of First 5 we can learn from the mistakes and devise a new plan that has more potential to work because this new initiative focuses more on areas in health behavior that target the community and people to change attitudes and behaviors towards dental health. This plan is an extension of the First 5 Initiative and combats all the flaws that this initiative had.
The First 5 Free Dental Plan
The first problem to be addressed with First 5 deals with money. The First 5 initiative does not address how to pay for dental procedures. Not many people have dental insurance and dental procedures can be very expensive. As we have seen from previous research, much of the lower Socio-Economic Status population does not go to the dentist regularly. The government has tried to combat this by including some dental coverage in Medicaid and SCHIP. Unfortunately, this has not been working because even though there is a plan, the costs and premiums are still too high. In the First 5 Part 2 Initiative, these kinds of barriers will be eliminated with the First 5 Free Dental Plan. The First 5 Free Dental Plan (F5Plan) will be a government sponsored nationwide dental insurance plan. Families must apply for the plan and applicants will be chosen on the basis of their SES status and adherence to the First 5 Motherhood Training Program (to be discussed later). All applicants must have either Medicaid or SCHIP. They must also apply within the first year of the birth of their child. After enrolling in the program, the child will have bi-annual check-ups with dentists that are provided by the program. Dentists who are enrolled in the program will get subsidized for the check ups and can apply for an extra tax cut for providing more expensive procedures. This plan is based on a Political Economic model. (17) By addressing the monetary barriers that are faced by the mothers of the children, the mother will be more inclined to have dental coverage for their child. This will be done in conjunction with a plan that will educate the mother about the importance of oral health and the affordability of the F5Plan, called the First 5 Motherhood Training Program.
The First 5 Motherhood Training Program
Ideas about education are very important when it comes to dental health. Many people don’t understand the importance of oral health and the risks of poor oral hygiene, especially in children. In First 5, education is strongly emphasized in the professional community. Although the idea about education is the right way to go, medical professionals are already educated in the benefits of oral health. Parents don’t understand the importance of dental health for their children, especially at an early age. In Part 2, education will be geared towards the mothers of the children. Prenatal care is given to all expectant mothers enrolled in Medicaid and SCHIP. Part 2 will be included in this prenatal care and postnatal care.
In Part 2, there will be three training sessions during the last term of the mothers’ pregnancy. They will be free and will last between one to one and half hours. These training sessions will be designed specifically to educate mothers about the prevalence of poor oral hygiene, the severity of the problem, the consequences of poor dental care, and also about affordable dental care plans and the F5Plan. These sessions will be led by trained professionals, such as dentists and nurses. They will be able to answer questions that the mothers might have and also will provide brochures with even more information. If the mother attends all three sessions during the last term of her pregnancy, the mother will get a free dental exam and also be eligible for the Five Year Free Dental Program. Not only does this provide information to the mother about the oral health of their soon-to-be-born child, but it also gives the mother incentive to complete the program.
This program builds on the idea that most people don’t understand the health risks of having poor oral hygiene. As previous research has shown, much of the general population doesn’t understand the severity and importance of dental health. (18) The Health Behavior Model is one of the best ways to target these mothers with this program. (19) A mother sometimes doesn’t think that their child is susceptible to bad oral health. By showing that every child is at risk for dental caries and tooth decay, the mother will realize that their child is susceptible. The next step would be to help the mother understand that risks of poor oral hygiene. It can affect the child adversely and can damage their teeth and health for the rest of the child’s life. The mother can then learn about how easy it is to obtain dental insurance and get dental care for their child. This increases the self-efficacy of the mother because she now believes that she will be able to afford a dental plan. An increase in enrollment in dental insurance plans may spark more community involvement and a change in the social norms about dental coverage and care. The First 5 Community Incentive Program will help to further this change.
The First 5 Community Incentive Program
The next, and possibly the most important missing part of the First 5, is addressing the social norms about dental care. Although the First 5 Motherhood Training Program helps an individual understand the consequences and need for oral hygiene, the general population doesn’t understand the severity. This Community Incentive Program will be based in lower SES communities and is state-by-state sponsored. Here, the target is families in these communities and is less based on the oral hygiene of children, but more based of basic oral hygiene for everyone in that community. The idea behind this is to change the ideas about dental care to the parents of the children so that they will continue having dental insurance and coverage throughout the child’s life. Each state must sponsor a community education program that relates to teaching about dental health along with providing some form of dental services. Because this is a statewide program, every state may sponsor as much or as little as they would like, and can sponsor any program they see as best for the community. But the incentive part if the most important. At the end of each year there will be an assessment done by the government on the overall success of programs done in each state. The most successfully implemented plans and projects will be rewarded with a very large subsidy. Seventy percent of the subsidy must be used to expand the project to the next year and 30% can be used to the state’s discretion. Another perk of this program is that the most successful plans will be implemented nationwide in the third step of the First 5 Initiative’s overall plan.
This program builds on changing the community perspective on dental health care, coverage, and availability. Although plans may vary state to state, there are suggestions that can be rooted in the First 5 Community Incentive Program. There are so many ways a state may sponsor a program that can socially affect the community. Using the Social Networking Theory, a state can sponsor programs that target groups and then use those groups to outreach to other communities. (20) A state can sponsor dentists to come talk to a local community at a church and answer questions about dental care. Another way to help a community understand the importance of oral health is with the use of marketing and commercials. Community Access Television stations can be used to broadcast interviews with dentists. Dentists and nurses can be brought onto radios to answer questions in the community about dental insurance, coverage and care. Here, with the use of the communications theory, a state can fund the diffusion of information through public access. (21)
Overall, like most incentives, money is a huge issue. Without it, dentists don’t get paid, patients don’t get the treatment, children will have poor oral hygiene, and communities will still see oral health as something that isn’t important. By starting with this issue, the First 5 Initiative can build further onto other issues that deal with education and community involvement. This initiative has the potential to be very important and very beneficial to helping children get the dental care they need and helping parents understand the important of oral health.

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