Steve Martino
Oral health behavioral and social intervention research concepts and methods
Yale University
oral health affects many aspects persons functioning overall health wellbeing including speaking eating maintaining ones appearance selfesteem physical comfort activity level quality life 1 behavioral social factors significantly impact oral health nutrition feeding oral hygiene practices pain management treatment adherence dental anxiety oral health knowledge literacy parenting corporate advertising access healthcare dental insurance well socioeconomic factors many behavioral social oral healthrelated issues primary secondary tertiary prevention behavioral social interventions needed target issues reduce incidence oral health problems improve rates people recover behavioral interventions educate instruct individuals good oral health disease management practices handle psychological social challenges impact oral health behavior examples include prenatal education assessment expectant parents decrease primary caregivers mutans streptococci levels risk transmission infants 2 b motivational interviewing mothers prevent early childhood caries 35 adolescents reduce dental avoidance behavior 6 c 5as ask advise assess assist arrange routine dental care increase tobacco quit rates 7 dental officebased weight control interventions children adolescents reduce dental caries prevent obesityrelated systemic diseases eg diabetes negatively impact oral health 8 social interventions target groups people organizations communities improve oral care examples include schoolbased interventions promote preadolescents gingival health 9 b social marketing campaigns increase awareness screening oral cancer african americans 10 11 c providing dental homes pregnant women medicaid improve access utilization dental care 12 training dentists detect methamphetamine users dental comorbidities refer patients substance abuse treatment programs 13 developing testing behavioral social interventions promote oral health effectively treat diseases disorders represent important parts national institute dental craniofacial research nidcr strategic plan 14 exploring piloting innovative behavioral social interventions testing efficacy clinical trials establishing effectiveness used within community public health settings complex processes require wellconsidered executed research plans investigators fields steeped behavioral social intervention research traditions mental health addiction public health developed conceptual models theories methodologies statistical cost analysis approaches could aid intend conduct kind research oral health field special issue gathers together stateofthescience guidance leading experts behavioral social intervention research means advance inclusion best research practices oral health field investigators interested studying oral health behavioral social interventions capitalize existing research concepts methods rather recreating proverbial research wheel special issue aims provide investigators critical concepts tools need conduct intervention research highest standards ultimately improve oral health outcomes topics special issue emerged nidcrsponsored meeting behavioral social intervention research held july 2009 attended behavioral social science investigators within outside oral health field see httpwwwnidcrnihgovresearchderbssrbbehavioralinterventionresearchhtm detail articles contained volume address core areas discussed meeting collective group investigators felt needed attention psychosocial oral health research applied could improve quality scientific contribution articles written respective experts area addition special issue includes expert commentaries expand upon notions raised authors article first article richard crosby seth noar 15 encourages investigators plan longterm program research developing behavioral social interventions improve oral health article highlights precedeproceed socioecological approach example one planning model used health promotion model describes move intervention earliest stages planning development steps 1 5 empirical testing evaluation community settings steps 6 9 course would like see oral health innovative ideas improving health translated behavioral social interventions interventions established efficacious successfully implemented variety community clinic settings commentary ralph diclemente emphasizes precedeprocede provides blueprint systematically drawing investigators attention multiple individual social environmental factors influence oral health behavior 16 russell glasgow notes importance integrating activities used identify factors step information gained related actions reinforce one another well involve stakeholders entire planning process 17 lisa onken briefly describes stage model alternative planning approach guiding development innovative efficacious sustainable oral health behavioral social interventions 18 second article kay bartholomew patricia dolan mullen 19 describes five ways health behavior theory essential behavioral social intervention research authors suggest theory identifies behaviors relevant particular health problem describes causal relationships behaviors identifies ways behavior change made clarifies successful behavior change assessed highlights methods data reported intervention trial authors use framework called intervention mapping ensure interventions draw available relevant studies maximize public health impact interventions developed commentators suggest ways enrich framework henrietta logan emphasizes broad theoretical understanding oral health problems needed comprehensively elucidate many pathways behavior change occurs instead taking narrow focus excludes invisible populations increases health disparities 20 donald chi reminds us theory crucial guiding intervention development empirical evidence effectiveness practitioners experiences using interventions develop theory used conceive new interventions refine existing ones 21 bidirectional process might best build behavioral theoretical foundation oral health field provide commented sarah kobrin coherence understanding intervene within interplay behavioral social factors create positive change 22 third article david mackinnon linda luecken 23 gives stepbystep tutorial conducting mediation analyses behavioral social intervention research mediation analyses viewed statistical representation investigators health behavior theory words health behavior theory specify hypothesized important behaviors related one another sort outcome expected particular intervention mediation analyses meaningful without theory theory cannot tested without mediation analyses addition theorytesting sake knowledgebuilding purpose mediation analyses understand active ingredients mechanisms action within behavioral social interventions fully explore nuanced ways interventions produce outcomes commentaries james sheppard expands upon points using hypothetical example intervention designed increase flossing 24 alexander rothman notes understanding mediators may especially important efficacious interventions begin move controlled settings diverse community ones interventions effectiveness may vary depending implementation situation targeted population 25 mark litt underscores need investigators measure potential mediators first place promoting mediation analyses behavioral social intervention investigations would minor revolution oral health field 26 fourth article belinda borrelli 27 describes methods ensuring behavioral intervention delivered intended ie fidelity article states theory also crucial establishing fidelity procedures theory specifies essential elements behavioral social intervention also potential mediators moderators intervention essential elements become aspects fidelity important monitor allow confidence essential elements delivered intended susan czajkowski remarks dr borellis model fidelity brings focus often neglected areas extent participants receive make use essential intervention elements b future funding initiatives require investigators explicate methods monitoring maintaining fidelity 28 barbara campbell james neff note interventions move efficacy controlled conditions effectiveness reallife conditions testing establishing procedures maintain fidelity interventions becomes challenging nonetheless argue diverse samples providers participants offer unique opportunities study practicelevel variables influence fidelity relationship multiple factors intervention outcomes 29 30 another essential element psychosocial intervention research ensuring intervention acceptable target population target interventionists fifth article guadalupe ayala john elder 31 describes qualitative methods ensuring acceptability behavioral social interventions including conducting interviews focus groups article also describes importance developing appropriate acceptable measures target population highlighting methods ensuring reading level clarity measures appropriate intended participants article introduces idea may tension interventions suggested theory interventions considered acceptable target population interventionists mediation analyses identify active ingredients behavioral social interventions may help resolve tension distinguishing aspects interventions essential aspects interventions tailored target participants helen meissner daniel mcneil expand discussion advocating mixed methods qualitative methods used together quantitative ones approach could provide insights oral health disease go beyond one approach might offer increase chance public accept use interventions 32 33 amid ismail cautions investigators also include acceptability analyses final intervention rather interventions development careful conduct acceptability research manner biased simply tell researchers want hear 34 acceptable behavioral social intervention developed demonstrated efficacy compelling clinical trial logical next step researchers implementing intervention new settings sixth article dwayne simpson 35 describes model implementing evidencebased interventions taking account preparation needed organization level training required interventionists factors facilitate adoption implementation intervention create longterm practice improvements implementation research health fields especially addiction treatment highlights important aspects implementation commentaries jane weintraub catherine demko recommend expanding simpsons model include broader public health perspective eg conditions larger system consideration consumer needs community input strategies maintaining new dental practices using change management processes 36 37 david chambers highlights challenges studying intervention sustainability noting lack consensus appropriate definitions sustainability eg level intervention fidelity timeframes determining sustainability occurred methods capture improvements made evidencebased practices time 38 research dissemination implementation including sustainability needed oral health field final article joan oconnell susan griffin 39 provides primer conduct cost analyses behavioral social intervention research surprisingly costs interventions assumptions reasonable costbenefit ratios important consideration implementing sustaining interventions richard manski comments perspective taken individual patients without insurance community society metric used dollar value qualityadjusted life year averted caries tooth years gained opportunity costs affect determination meaning cost analyses 40 tackling complex landscape costs requires specific expertise often associated health economics frequently included curricula behavioral social intervention researchers merging areas expertise may important step toward developing efficacious costeffective behavioral social interventions improve oral health sarah duffy advocates oral health field unique position capitalize advances made economic evaluations within disciplines use standardized methods across studies approach would allow efficient comparison findings wellreasoned decisions behavioral social interventions best meet oral health needs society 41 special issue concludes discussion topics addressed issue inform nidcr behavioral social intervention research program 42 conceptual framework presented integrates six topics special issue following intervention planning model appropriate use health behavior theory conducting mechanisms action analyses monitoring fidelity ensuring acceptability working toward intervention sustainability building economic analyses intervention studies conceptual framework also acknowledges relative emphasis research activities vary stage intervention development research conducted oral health disease involves interplay complex processes including many behavioral social factors incumbent upon oral health field understand factors develop highquality empirically supported interventions address improve oral health nation special issue meant serve primary resource oral health research community well researchers health fields foster movement direction articles within issue provide many conceptual methodological tools needed develop test deliver potent psychosocial oral health interventions diverse communities special populations moreover engaging type research collaborating behavioral social science experts disciplines oral health investigators raise quality relevance oral health research poised uniquely contribute knowledge base behavior social change support preparing article provided grants national institute drug abuse p50da09241 u10 da015831 contents solely responsibility author necessarily represent official views nida author acknowledges invaluable support melissa riddle phd david clark drph national institute dental craniofacial research behavioral sciences social research branch producing special issue author received honorarium nidcr writing editing manuscript