Oral Health in Appalachia
The Appalachian region faces oral health disparities that require continued attention to address a “silent epidemic,” where over 98% of the population suffers from tooth decay by age 44 and more than 50% of adults have destructive periodontal disease (Ebersole, Souza, Gordon, & Fox, 2012. More recently, the Appalachian Regional Commission (2014) contextualized these findings within the rural regions of Eastern Kentucky and concluded that indicators of poor oral health remain at alarming rates in this part of Appalachia. Rural, low-income, Appalachian residents are less likely than urban, wealthier residents to visit a dentist, are more likely to have no dental insurance, and suffer disproportionate rates of missing teeth (Office of Oral Health, 2003). Residents of rural areas in Kentucky go to the dentist significantly less often (Heaton, Smith, & Raybould, 2004) and have significantly higher incidence of periodontal disease, oral cancer, and pharynx cancer (Huang, Valentino, Wyatt, & Gal, 2008) than residents in urban areas. These incidence rates among adults are consistent with studies of oral health among children in Eastern Kentucky (e.g., Hardison et al., 2003; Stone, 2014). Clearly there is a need for further applied health communication scholarship investigating oral health disparities in Appalachian regions of Kentucky.
Oral Health Behaviors
According to the American Academy of Periodontology, brushing teeth after meals, flossing at least once a day, and seeing the dentist at least once a year are the three main prevention drivers to obtain good dental health (American Academy of Periodontology, 2014). Fear and anxiety is the most usual reaction that is popularly referred to when the topic of dentists or dental visits are brought up (Finch, Keegan, Ward, Sen, 1988). Dental anxiety and fear plays a role in explaining delayed dental care and the underuse of dental services (McNeil & Berryman, 1989). Those who delay dental care often forego preventive care, which is less intensive, expensive, and severe than corrective care (Crego et al. 2014). Many patients with dental fear seek treatment only when orofacial pain is unbearable (Armfield et al., 2007).
Nemeth et al. (2012) conducted a study in rural Appalachia and found that residents are knowledgeable about proper dental care but are discouraged to act on their knowledge due to stereotypes that already exist about their oral health. The media often selects stereotypical representations of Appalachians that include images of people with broken, damaged, or missing teeth (Zschaebitz & Gordon, 2013).
Some factors affecting oral health are personal health-related behaviors, such as the use of smokeless tobacco, smoking, drug abuse, soda consumption, and a high-sugar diet. At the interpersonal level, the lack of prioritization of oral health amongst friends, peers, and family members plays an important role in the perspectives of young adults about the state of oral health in their community. Communication between dentists and patients on an interpersonal level affects belief systems too, given that participants reported feeling blamed at times, and excused at other times, by dentists for poor oral health (Sorenson et al., 2004).
The interrelatedness of the tobacco use and oral health disparities in Appalachian regions should not be underestimated. In 2015, approximately 171,000 of the estimated 589,430 cancer deaths in the U.S. were caused by smoking tobacco (American Cancer Society, 2015). Nemeth (2012) found that Appalachian residents are knowledgeable about the adverse outcomes of nicotine dependence, but given that tobacco farming is a staple of the Appalachian economy, they have little encouragement to put forth effort into prevention and maintenance behavior. Poor attitudes about and distrust of healthcare providers combined with a strong sense of personal pride and an inability to pay for healthcare costs contribute to the neglect of healthcare in general, particularly maintenance and prevention related to tobacco use (Deskins, 2006; Gorsuch, 2014; McDaniel, 2006).
Schoenberg et al. (2013) studied perceptions of healthy eating among Appalachian residents and found that many participants identified gaps in nutrition knowledge as a persistent problem as well as problematic influences from family, friends, and media on perceptions of healthy food choices. These choices impact oral health and reveal a longstanding norm of Appalachian regions that women are in control of domestic duties, including the oversight of family healthcare (Welch, 2011).
Fatalism plays a large role in the refusal of oral treatment; Welch (2011) reported fatalism in Appalachia becoming so synonymous with attitudes towards healthcare that professionals no longer question its validity, but rather accept it as inevitable. Research demonstrates that in Appalachia many residents may feel it is too late to begin properly caring for their teeth (Royse, 2011).
Theory of Reasoned Action
One of the theories used in health communication campaigns is the theory of reasoned action. The theory of reasoned action explains volitional human behavior, proposing that one’s intention to perform or not perform a behavior is the most critical determinant of human behavior. Behavioral intention is dependent on the individual’s attitude toward the specific behavior, and his or her perception of the evaluation of the behavior by important others. The attitude of the individual, in turn, results from his or her salient beliefs about the outcomes of the behavior. Similarly, the individual’s motivation to comply with salient others in his or her social network accompanied by the normative beliefs regarding the target behavior ascribed to these salient others produce his or her subjective norms (Fishbein, 1990; Fishbein & Ajzen, 1975).
Loss vs. Gain Framed Messages
When creating a health campaign, researchers have to create messages to disseminate to their population. Several researchers play with the idea of loss vs. gain framed messages when creating ads. A loss-framed persuasive appeal emphasizes the disadvantages of failing to comply with the communicator’s recommendation. The contrast is a gain-framed appeal, which emphasizes the advantages of compliance (O’Keefe & Jensen, 2009). Research suggests that potential losses are more motivating than potential gains when risky actions are contemplated, whereas gains are more motivating than losses for low-risk behaviors (Kahneman & Tversky, 1979).
Block and Keller (1995) discussed how a Harvard study recommends that messages designed to change behaviors should avoid message executions that evoke negative emotions and instead use upbeat tactics. The implication of this study is that public service campaigns using negative language to frame their message are less effective than public service messages using positive frames. Maheswaran and Meyers-Levy (1990) state that when someone is already motivated to change a behavior, negative frame messages are more effective, since they are considered more informative than positive framed messages. Meyorowitz and Chaiken (1987) state that if someone has low self-efficacy negative framed messages are more effective than positive framed messages. Several studies, (e.g., Meyerowitz & Chaiken, 1987; Rothman et al., 1993) found that women are more likely to change a behavior when presented with a negative framed message.
Self-efficacy Theory
Bandura (1977) claims that perception of self-efficacy is an important factor in determining human behavior. A person self-efficacy determines whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences.
McCaul, O’Neil, and Glasgow (1988) tested the self-efficacy model for oral hygiene behaviors and compared the usefulness of self-efficacy expectations with theory of reasoned action. In his study, McCaul et al. found that self-efficacy added significantly to the prediction of intentions, beyond the attitude and subjective norm components of the theory of reasoned action. Bandura’s self-efficacy theory establishes that humans are going to perform behaviors they feel they can cope with and avoid behaviors they feel they cannot manage. In addition to good self-efficacy perception, appropriate skills and incentives are also needed if an activity is going to be performed (Bandura, 1977).