The Integral Role of Behavioral and Social Sciences in a Systems Approach to Oral Health Research
C. Yolanda Bonta DMD, MS, MS
Lois K. Cohen, PhD, was the founding director of the Office of International Health for the National Institute of Dental and Craniofacial Research (NIDCR). When she retired from the NIDCR in June 2006, she had served the federal government for 42 years. At the NIDCR for 30 years, she advised five NIDCR directors and two interim directors about the relationship between oral health and the social and behavioral sciences. Early on, she directed the NIDCR Office of Planning, Evaluation, and Communications. In 1989, she became director of the NIDCR Extramural Research Program. At the same time, she was named the first NIDCR associate director for international health, a position she held until her retirement.
A tribute symposium was held in honor of Dr. Cohen on December 11, 2006, at the National Institutes of Health (NIH) campus in Bethesda, Maryland. The symposium was titled, “The Integral Role of Behavioral and Social Sciences in a Systems Approach to Oral Health Research.” Dr. Cohen spoke with Inside Dentistry about how the oral healthcare community’s adoption of behavioral and social science research led to an international coalition focused on oral health systems research.
Inside Dentistry (ID): How do the behavioral and social sciences help inform oral health research?
Dr. Lois K. Cohen (LC): The theoretical perspectives as well as the methodologies developed by such disciplines as sociology, psychology, anthropology, economics, epidemiology, public health, political science, psychopharmacology, and related fields have all been used successfully to address a variety of issues related to dental, oral, and craniofacial health. The list of examples would be too long for this article but there is well-documented literature on subjects as diverse as the social aspects of water fluoridation issue, who becomes a dentist, and what are the professionalization processes, to studies of personal oral hygiene practices of the public and the impact of those practices on the use of oral health services. Most oral health phenomena can be better understood by examining the social, economic, and even cultural environment in which those phenomena occur. Once the whole range of determinants of oral health are identified and understood, health providers can better focus their energies and resources on reinforcing the positive effects of some of those determinants and counteracting the negative effects of others.
ID: What tools have been typically used to study these issues?
LC: Questionnaires, interviews, social surveys, [and] standardized tests of various types have been used for evaluation research and field or community-based trials, to cite just a few. They can be used to measure the public’s and/or the profession’s attitudes, knowledge, and practices. Such measures can be used to ascertain the impact of interventions employed to create changes along any of these desired dimensions. Psychologists have measured orofacial pain perception and the impact of facial appearance on self-esteem. Sociologists and health service researchers have measured how lifestyle practices, reimbursement practices, and organizational arrangements influence the use of oral health services. They have also examined how days lost from school or work because of dental reasons effect productivity for a given society.
ID: How did your own research lead to your current international focus?
LC: Initially, my own research for the federal government focused on national programs of interest to the public health service, such as early detection of oral cancer, the prevention of dental caries through the appropriate use of fluorides and oral hygiene, and issues related to the training and education of an adequate supply of dental personnel to meet the needs of the US population. In the late 1960s, under President Richard Nixon’s administration, there was national debate about how the United States could improve the delivery of all health services. In preparing for these discussions, we realized we had very little in the way of standardized data about the relative effectiveness and efficiency of our own predominantly fee-for-service delivery system in comparison to other systems for delivery of oral health services around the world. With the assistance of the World Health Organization [WHO] and the cooperation of organized dentistry globally, namely the Fédération Dentaire Internationale [FDI], we identified experts knowledgeable about measuring health systems, as well as oral epidemiologists, health economists, social scientists, and statisticians to design a common research protocol that eventually was applied to samples within more than a dozen nations. Those nations represented systems of oral health delivery that had been operational for at least 25 years and, consequently, had the potential for affecting the oral health of their respective populations. The goal of that effort was to identify structural characteristics of delivery systems that seemed to work well with respect to the oral health outcomes of their populations. Interdisciplinary teams were constituted in each country as well as centrally at WHO in Geneva, and two monographs and many journal publications resulted in the peer-reviewed literature over a couple of decades. Our national issues could not be answered completely by looking only within our geographic borders. The elements for innovation often come from looking outside the proverbial “box” and the globe becomes the necessary laboratory.
There are many other research questions that benefit from a global perspective. The NIDCR has funded studies of diseases and disorders that may exist in this country but are more prevalent elsewhere in the world. By studying cleft lip and palate where cases are more plentiful, new insights are possible and in a quicker time than could be accomplished by studying these birth defects only in our own country. Oral cancer, noma (cancrum oris), oral manifestations of HIV/AIDS, and Sjögren’s syndrome are all examples of oral problems that might best be approached by international teams of scientists who can share data and resources, increasing the probability of valid and reliable results. These days, scientific talent to address such issues may not necessarily be available in a single country and there is a need to bring together interdisciplinary scientists from different parts of the world. The challenge is a global one; one that is reflected in the title of a video we made, “Science Knows No Country.”1
No sooner did Dr. Cohen announce her retirement after an illustrious career at the NIDCR than she was recruited as a National Ambassador for the Paul G. Rogers Society for Global Health Research Program. Twenty-seven of the nation’s foremost experts in global health will advocate for greater US investment in global health research. These prominent scientists include a former Centers for Disease Control and Prevention director and experts in malaria and other infectious diseases, child health, dentistry, nursing, geriatrics, psychiatry, and economics.
These individuals will comprise the inaugural class of Ambassadors in the Paul G. Rogers Society for Global Health Research. The Society is named for the former Florida Congressman, a renowned champion for research to improve health, and is currently the Research!America chair emeritus. Research!America launched the Society this summer to increase awareness of—and make the case for greater US investment in—research to fight diseases that disproportionately affect the world’s poorest nations. Research!America is the nation’s largest not-for-profit public education and advocacy alliance working to conduct research to make improving health a higher national priority. Founded in 1989, it is supported by more than 500 member organizations, which represent more than 125 million Americans. For more information, visit www.researchamerica.org.
ID: And, if there is time, what else are you doing in retirement?
LC: On a part-time basis, I’ll serve as a consultant to the NIDCR in the areas of both behavioral and social science research as well as global health. Also on a part-time basis, I serve as a consultant to the Canadian Institutes for Health Research, primarily in my role on the Advisory Board of their Institute of Musculoskeletal Health and Arthritis [IMHA]. The Institute has the responsibility to strategically fund oral and dental research and knowledge-exchange projects, as well as those in arthritis, bone, skin, muscle, and musculoskeletal rehabilitation. My prior experience as the director of the NIDCR’s division of extramural research from 1989 to 1998 provided some background that might be helpful to this Canadian government counterpart to the NIH as it grows its national health research funding agency.
In my spare time, I try to contribute to an organization close to my heart, the Friends of the NIDCR [FNIDCR]. This relatively new organization, founded in 1998 on the NIDCR’s 50th anniversary, is focused on advocating for and complementing NIDCR programs. The FNIDCR is a coalition of individuals, organizations, and associations that bring together patients and consumers of oral health services with the providers of those services, researchers, educators, and the oral-health–related industries. Together they form a critical mass of talent, expertise, and outreach potential that can serve to facilitate the work of the NIDCR.
Another activity that has just begun to potentially enhance the outreach to larger communities is the development of Friends of the Organization of Safety and Asepsis Procedures (FOSAP). This group focuses on oral infection control, and could help extend good oral infection control practices and integrate those with good general infection control procedures in other health settings both nationally and globally.
I also continue to work as called upon and, of course, as time permits, with WHO, the Pan American Health Organization, the FDI, the International Association of Dental Research, the American Dental Education Association and its international counterpart, the International Federation of Dental Education Associations, the American Dental Association, and the Fogarty International Center of the NIH. These are all entities with which I have worked before and these continue to be essential partners as global health networks are developed and sustained.
To be honest, in the short time since my official retirement from federal civil service, I find myself continuing to engage in activities that brought me pleasure and satisfaction before retirement. This probably reflects that I loved what I was doing and now have the opportunity to continue those activities as a private citizen. The only downside is that there is not any time, so far, for my love of the arts, particularly the crafts of ceramics and glass. Those “hands-on” pursuits are clearly not receiving any attention and I can only dream that one day, there will be time for those as well!
References1. Dr. Cohen’s video, “Science Knows No Country,” is available from the NIDCR. For a copy, contact Dr. Cohen through the NIDCR: Lois.Cohen@nih.gov
|From left to right: Dr. Ruth Nowjack-Raymer, Dr. Maria Canto, Professor Samuel Dworkin (holding poster), Professor Richard Watt, Professor Judith Albino, Professor Helen C. Gift, Dr. Lois K. Cohen, Professor Peter Davis, Dr. David Abrams, Professor Ronald Andersen, Dr. Alice Horowitz, Professor Asuman Kiyak, Dr. Patricia S. Bryant, Professor Debra Roter, Dr. Dushanka V. Kleinman.|
|About the Author|
|C. Yolanda Bonta DMD, MS, MS |
Somerset, New Jersey