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Abstract
This article uses the social learning theory (SLT) and the theory of planned behavior (TPB) to demonstrate important tenets of an effective health education program for the prevention of oral cancer. Findings demonstrate that both models can be used to develop a health education program that will be effective in reinforcing health-seeking behaviors and increasing the knowledge of oral cancer in the community. SLT can be used to not only underscore the significance of social norms, environmental influences, and self confidence (self-efficacy) in addressing the risk factors associated with oral cancer, but also to change the health behaviors of individuals towards participating in more oral cancer screenings. TPBs constructs of attitude, subjective norm, and perceived control can be used in the health education program to motivate individuals towards performing specific health behaviors that are likely to reduce the incidence of oral cancer in the community.
Introduction
Oral cancer continues to attract less attention than other forms of cancer despite the fact that it has been well documented as a public health challenge with high incidences of mortality and morbidity (Lopez-Jornet, Camacho-Alonso, Minano, & Sanchez-Siles, 2013). These authors acknowledge the inability of most health professionals to diagnose oral tumors during the early phases of their development due to insufficient knowledge of the signs, symptoms, and risk factors associated with oral cancer in the general population. As such, there is a mounting need to develop effective health education programs that can impart knowledge and facilitate early detection based on the fact that oral cancer is treatable if diagnosed early (Lopez-Jornet et al., 2013; Kumar & Suresan, 2012; Kumar et al., 2015). This article uses the social learning theory and the theory of planned behavior to demonstrate important tenets of an effective health education program for the prevention of oral cancer in a multicultural community setting.
Problem Description
Most oral tumors that lead to oral cancer are associated with modifiable and non-modifiable risk factors such as cigarette smoking, heavy alcohol consumption, increasing age, occupational exposure to carcinogens, poor dental hygiene, exposure to the sun, poor dietary behaviors (e.g., low consumption of fruits and vegetables), and infection with human papillomavirus (Kumar & Suresan, 2012). Although primary prevention has been cited as the most cost-effective prevention program due to its capacity to reduce the prevalence of potentially malignant disorders through the modification of some of the mentioned risk factors, research is consistent that most people are poorly informed about the risk of oral cancer and ways to prevent this disease (Kumar et al., 2015). Additionally, although early detection of oral cancer is critically important in increasing survival rates, dental care services remain underutilized in most countries as most people are yet to develop oral health-seeking behaviors (Howell, Shepperd, & Logan, 2013; Vernon, Demko, Webel, & Mizumoto, 2014). Based on these considerations, it is important to use behavioral models such as the social learning theory and the theory of planned behavior to drive health promotion interventions for oral cancer with the view to modifying unhealthy behaviors and reinforcing routine screenings (Schwarzer & Luszczynska, 2008).
Using the Social Learning Theory to Develop an Effective Health Education Program
Albert Banduras social learning theory (SLT) can be used to develop an effective health education program for oral cancer by addressing the underlying determinants of health behavior as well as methods of promoting change (Tittle, Antonaccio, & Botchkovar, 2012). The main elements of SLT include reciprocal determinism (the way in which behavior and the environment continuously interact and influence each other), observational learning (the capacity to learn by observing the behavior of others), expectations (the value a person places on the outcomes resulting from different behaviors), and self-efficacy (a persons belief and level of confidence in his or her own ability to successfully make a change or perform a behavior) (Sharma & Romas, 2010).
Taken as a whole, SLT not only identifies but also underscores the significance of social norms and cues, environmental influences, and self confidence (self-efficacy) in addressing the risk factors associated with oral cancer and changing the health behaviors of individuals towards participating in more oral cancer screenings. Indeed, SLT can form the basis for an effective health education plan intended to educate community members about the mentioned risk factors by developing social contexts that encourage learning through observation or direct instruction (Haleem et al., 2016). For example, reciprocal determinism can be used to modify social norms that show smoking and alcohol consumption as cool , hence promoting cessation and alcohol moderation among populations most at risk for oral cancer.
An effective health education program for oral cancer should contain information and materials that reinforce the expectations of the targeted audience to modify health behaviors. Such materials should aim to demonstrate the harm caused by cigarette smoking, heavy alcohol consumption, and poor dietary habits. Popular personalities within the community can be used to modify health-seeking behaviors through observational learning, as community members are more likely to visit dental clinics for oral cancer screening if they know their preferred role models also visit the clinics. Following the SLT, such role models can be used to generate attention about the importance of oral cancer screening and reinforce the retention of this health behavior (Sharma & Romas, 2010). Additionally, brochures and community newsletters can be used to ensure the repetition and reinforcement of instruction messages aimed at ensuring appropriate intake of fruits/vegetables and keeping good dental hygiene.
Finally, it is important to develop ways that could be used to enhance the self-efficacy of individuals most at risk for oral cancer to reduce risky behaviors and develop health-seeking behaviors. Available literature demonstrates that self-efficacy beliefs can be developed through direct mastery experiences (previous personal accomplishments and successes), vicarious experiences (situations in which an individual increases his or her own self-belief by watching a similar person achieve success in certain situations), verbal persuasion (leading a person using feedback and verbal cues to believe that he or she can be successful in a specific situation), and arousal state (how an individuals physiological state and his or her interpretation of that state affects whether an experience is empowering or disempowering) (Zhang et al., 2014).
To enhance the self-efficacy of individuals in minimizing the risk factors associated with oral cancer and visiting dental clinics for oral checkups, an effective health education plan should incorporate the key elements of mastery, vicarious experience and verbal persuasion. For example, the education plan should provide community members with the means to participate in oral cancer screening and enhance their capacity to take care of their oral health through self-management techniques. Such an education program should also facilitate communication and interaction by providing individuals with the opportunity to raise questions and concerns relating to oral cancer symptoms and disease management. Additionally, an effective education plan for oral cancer must provide community members with access to advice for their problems and concerns through available means (e.g., telephone and email) and also encourage them to take an active role in reinforcing healthy behaviors that reduce the risk factors associated with oral cancer. Lastly, it is important for the education program to provide positive reinforcement (e.g., free rides to the health facility, live telephone follow-up support, and social support groups) for community members to continue visiting dental clinics for oral cancer screening as such reinforcements will go a long way to modify their negative health behaviors through strengthening their self-efficacy beliefs.
Using the Theory of Planned Behavior to Develop Effective Health Education Program
The theory of planned behavior (TPB) proposes an association among beliefs, attitudes, social influences (social norms), and perceived abilities to perform the expected behavior (Gross, Anderson, Busby, Frith, & Panco, 2013, p. 76). This section demonstrates how an effective health education program for oral cancer can incorporate TPBs theoretical constructs of attitude, subjective norm, and perceived control to motivate individuals toward performing specific health behaviors that are likely to reduce the incidence of oral cancer in the population.
Available literature demonstrates that, although the prevention of oral cancer through risk factor reduction and early detection is critical in minimizing incidence and mortality, little progress has been achieved so far due to inadequate knowledge about oral cancer and associated risk factors (Powe & Finnie, 2004). Individuals are likely to change their attitude and beliefs about oral cancer screening when they become more knowledgeable on the risk factors involved and the benefits of obtaining oral cancer screening on a routine basis (Asare, 2015). Owing to the fact that the attitude construct in TPB is determined by the individuals beliefs about outcomes or attributes of performing the behavior (behavioral beliefs), it is important for health education programs for oral cancer to attempt to change the beliefs of individuals by demonstrating how smoking cessation, alcohol moderation, and consumption of fruits and vegetables result in positively valued outcomes such as good overall health and reduction of risk factors for oral cancer. Such programs should contain simple, ethnic-specific, and well-illustrated information on oral cancer to not only increase peoples knowledge about the risk factors and symptoms of oral cancer, but also to reinforce their participation in oral cancer screening through attitudinal change (Montano & Kasprzyk, 2008; Powe & Finnie, 2004).
An effective health education program must include information on secondary prevention strategies for oral cancer. Although these strategies include visual and tactile examinations of the oral cavity as well as the head and neck areas, they can only be undertaken when community members form a habit of visiting dental clinics on a regular basis (Kumar & Suresan, 2012). Here, TPB can be employed to not only guide aspects of the education program intended to encourage regular dental visits, but also to facilitate culturally-sensitive care that appeals to vulnerable populations in the community. For example, stakeholders in the health industry can use ethnic-specific role models within the community in campaign messages that demonstrate the need to visit dental clinics on a regular basis for visual and tactile examinations. According to the TPB, such role models (e.g., TV, movie, and sports personalities) are more likely to shift the normative beliefs of community members to perform the behavior of visiting dental clinics (Schwarzer & Luszczynska, 2008). Specifically, the role models approval of visiting dental clinics on a regular basis is likely to change the subjective norm of affected populations and motivate them towards developing health-seeking behaviors for oral cancer.
Another important construct in TPB is perceived behavioral control, which relates to factors or issues that are beyond the control of individuals but nevertheless influence their intentions and behavior (Brein, Fleenor, Kim, & Krupat, 2015). Perceived control, according to Schwarzer and Luszczynska (2008), is determined by control beliefs concerning the presence or absence of facilitators and barriers to behavioral performance, weighted by their perceived power or the impact of each control factor to facilitate or inhibit the behavior (p. 71). Although available literature demonstrates that oral cancer affects more African Americans than Whites (Kingsley, OMalley, Ditmyer, & Chino, 2008), the former are less likely to seek medical help than the latter due to barriers such as low access to care, low socioeconomic status, lack of insurance coverage, and negative attitudes on treatment facilities (Asare, 2015). Drawing from these concerns, it is important for health education programs for oral cancer to include a facilitation component for vulnerable populations to enhance their behavioral performance. For example, stakeholders should consider including information on free oral health facilities and ethnic-specific oral dental clinics to minimize control beliefs and facilitate health-seeking behavior among the most vulnerable populations.
Ethnic Considerations in Health Education Programs
Owing to the fact that oral cancer affects more African Americans than Whites (Kingsley et al., 2008), an effective health education plan should include subjective elements that reinforce the attitudes and beliefs of African Americans to undergo more visual and tactile examinations in healthcare settings. For example, African Americans should be exposed to more media campaigns to heighten their concern about oral cancer and encourage them to visit dental clinics on a regular basis for medical checkups. Additionally, an effective education program must encourage seamless interactions between community members and professionals in healthcare delivery. It is therefore important to develop media campaign messages (e.g., posters, flyers, posters) that are easily understandable and have the capacity to appeal to community members to modify their lifestyle and dietary habits, particularly in terms of increasing their daily intake of fruits and vegetables, smoking cessation, and consuming alcohol in moderation (Lopez-Jornet et al., 2013). It is important to develop these messages using cultural-specific value systems and subjective norms to encourage adherence and also to remove any barriers to communication.
Conclusion
This article has used SLT and TPB to demonstrate important tenets of an effective health education program for the prevention of oral cancer in a multicultural community setting. From the discussion and analysis, it is clear that the behavioral models can be used to develop a health education program that will be effective in reinforcing health-seeking behaviors and increasing the knowledge of oral cancer in the community. SLT can be used to underscore the significance of social norms, environmental influences, and self confidence (self-efficacy) in addressing the risk factors associated with oral cancer and modifying health behavior to encourage more oral cancer screenings. TPBs constructs of attitude, subjective norm, and perceived control can be used to motivate individuals towards performing specific health behaviors that are likely to reduce the incidence of oral cancer in the population. The program should contain simple, ethnic-specific, and well-illustrated information on oral cancer aimed at not only increasing peoples knowledge about the risk factors and symptoms of oral cancer, but also reinforcing their participation in oral cancer screening through attitudinal change.
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