Fluoridation advocacy: Pew's contributions and lessons that emerge

The Children’s Dental Health Project (CDHP) was commissioned to prepare this report by The Pew Charitable Trusts. It is intended to summarize Pew’s efforts over six years to support and strengthen advocacy for community water fluoridation. CDHP is among the more than 100 local, state and national organizations that comprise the Campaign for Dental Health, a coalition that Pew launched in 2011. CDHP thanks the 26 individuals who work for state health departments, health and medical organizations, foundations or other institutions who participated in lengthy interviews for this report [see Endnotes]…

… The Pew Charitable Trusts created a children’s dental campaign in 2008 with a broad mission to improve the oral health of low-income children, focusing on financing for care, oral disease prevention and expanding the dental workforce. Pew is a public charity that has launched dozens of policy initiatives in a variety of fields where there is a clear evidence base, bipartisan support and an opportunity to make a difference…

This report examines the impact that Pew’s work has had in advancing community water fluoridation and the lessons that have emerged from these experiences…

Appendix: Campaigns to Initiate or Reaffirm Water Fluoridation

Overarching lessons

Don’t assume that “sharing the science” behind fluoridation will ensure a campaign’s success. It’s important to connect the scientific evidence to a community’s values.

Monitor traditional media and social media. Many attacks on local fluoridation policies initially appear as Facebook pages or manifest themselves through a series of anti-fluoride letters to the editor.

Identify individuals who can be effective, passionate public spokespersons and tap into the community’s values.

Recognize that every campaign is comprised of different phases requiring careful planning and execution. No campaign to initiate fluoridation should be undertaken without allowing ample time for coalition-building, fundraising and the other critical phases.

Ensure that campaign roles are appropriately aligned with individuals’ skills and knowledge. A particular dentist might be a great choice to brief the campaign on new or existing studies, as well as to review content for scientific accuracy. But this same dentist might not be the ideal spokesperson to engage in media interviews.

City/State

Key lessons that emerged

Arkansas

Type of Campaign: State Legislature

Estimate number of people affected: 640,000

Identify a highly respected and committed legislator as the bill’s chief sponsor.

Cite a negative health ranking or report card to instill a sense of urgency, rally supporters and build momentum.

Seek and secure funding sources to defray the capital costs of initiating fluoridation.

Consider hiring a government affairs firm that has good relationships with legislators of both major parties.

Build a strong, diverse coalition of stakeholders to strengthen advocacy efforts.

San Jose, CA

Type of Campaign: Local water board vote

Estimated number of people affected: 285,000

Inform public officials and key stakeholders of the typical arguments that critics use so they are “inoculated” and are far less susceptible to the myths that they will hear as the public dialogue intensifies.

Communicate the need for fluoridation in ways that connect with residents’ values, such as the “social justice” impact of fluoridation.

Allow ample time for key pre-campaign activities, such as meeting with potential partners and choosing the best data for illustrating the community’s oral health challenges.

Wichita, KS

Type of Campaign: Public referendum

Estimated number of people affected: 450,000

Don’t over-rely on health professionals as spokespersons. Identify parents, teachers, civic leaders, business leaders and other nontraditional stakeholders who can help deliver key messages to target audiences.

Reach an understanding on funding commitments or vehicles before moving into a public referendum.

Ensure that the campaign’s structure and governance enable it to be nimble and to direct funding or resources where they are needed without delay.

U.S. Department of Defense (DOD)

Type of Campaign: Memorandum from senior DOD official

Estimated number of people affected: 125,000(b)

Recognize the important role that data can play in helping to establish the need for policy action or reaffirmation.

Connect the importance of oral health and fluoridation’s benefits for adults to the organization’s mission—in this case, military readiness.

Portland, OR

Type of Campaign: City Council, Public referendum

Estimated number of people affected: 900,000

Set 60 percent support (in public opinion surveys) as a minimum threshold before proceeding with a fluoridation campaign that could go to a referendum. This threshold recognizes that support tends to erode for virtually all ballot proposals—regardless of the issue—in the months leading up to Election Day.

Lay the groundwork for a “flip the switch” grassroots field operation if there’s a chance that the fluoridation proposal could be referred to voters.

Use data to demonstrate the need for cavity prevention and consider carefully whether “crisis” or similar terms are accurate ways to describe the community’s challenge.

Consider citing one or two glaring examples of deceptive messages to illustrate why opponents lack credibility

b. This includes active-duty personnel and their dependents.

… First, Pew provided various forms of direct assistance—such as survey research, communications training, strategic guidance and financial support—to several state and local campaigns that sought to expand fluoridation. Three of these five campaigns were successful in enacting or reaffirming policies to implement this proven health practice.

… Marjorie Stocks, a consultant with the California Dental Association Foundation, said Pew’s entry into the field was welcomed by local advocates who were campaigning to pass or preserve fluoridation policies. “When Pew stepped onto this stage, it gave us all a real boost,” she said. “Something has congealed nationally that wasn’t there before.” Stocks has supported local fluoridation campaigns in San Jose and other California communities. She said the network that Pew created has been invaluable to local advocates.

… Second, Pew formed a coalition called the Campaign for Dental Health (CDH) that has grown to include more than 100 children’s, medical, dental and community-focused organizations at the local, state and national levels that care about improving oral health. The CDH was created after Pew had lengthy discussions with four foundations—the Washington Dental Service Foundation (WDSF), the United Methodist Health Ministry Fund, The Health Trust and the Bower Foundation.

In 2009, Pew and these foundations sought an analysis of fluoridation by William Smith, a social marketing expert and the former executive vice president of the Academy for Educational Development. The following year, SalterMitchell Inc., a social marketing firm, conducted a communications scan to better understand how the topic was being framed in news stories and how it was being discussed online and in social media.

The CDH has established a website (ilikemyteeth.org) that includes a blog, bilingual fact sheets and resources, and numerous pages that explain community water fluoridation in consumer-friendly, nonclinical terms. Smith and SalterMitchell advised the initial development of the website’s content. Through the CDH, Pew has sponsored annual conferences that enable public health advocates and practitioners to share information and insights on fluoridation advocacy.

… Jane McGinley, manager for fluoridation activities at the American Dental Association (ADA), cited the CDH’s fact sheets and leaflets as some of “the best things that Pew has brought to this issue.

… Robin Miller, who works in Vermont’s Office of Oral Health, said the CDH’s [ Campaign for Dental Health] web portal has filled a gap. “I always refer to the ‘I Like My Teeth’ website, and that’s where we direct selectmen and other officials who have questions about fluoride,” she explained. “I like the plain language that the website uses to explain what fluoridation is and the evidence showing its benefits.” (15)

… Judith Feinstein, who served as Maine’s oral health director and was the longtime chair of the American Association of State and Territorial Dental Directors’ Fluorides Committee, said the network that Pew formed is very important. “Through webinars and conferences, we have become better connected than we used to be,” she said. “Pew provided the venture capital for this network.” (16)

… “I have appreciated the way Pew has reached out to reporters, editorial writers and others in the media to share accurate information about fluoridation,” said Laura Smith, WDSF’s president and CEO. “Without that information, these stories could be written in ways that confuse or mislead readers. We have needed that kind of proactive media approach.” (17)

… Pew’s accomplishments were facilitated by the generous support offered by a number of foundations, including The Bower Foundation, California Dental Association Foundation, Delta Dental of Minnesota Foundation, DentaQuest Foundation, Kansas Health Foundation, New York State Health Foundation, United Methodist Health Ministry Fund, and Washington Dental Service Foundation. Foundations helped provide much of the fuel to support Pew’s entry into this field. Moreover, some of these foundations shared valuable insights with Pew that were drawn from their own experiences of working to advance community water fluoridation.

… As part of this effort, Pew funded message testing and focus group research to gain a better understanding of the public’s views of water fluoridation and to identify effective strategies for reaching key demographics in the fluoride debate. This research has greatly informed local campaign strategies and altered the manner in which pro-fluoride advocates discuss the issue of water fluoridation. (For example, advocates recognized the need to stress the consequences that tooth decay can have on children and adults.)

… Hollis Russinof, a program manager for the Campaign for Dental Health at the American Academy of Pediatrics, said that Pew filled a gap. “There really wasn’t a national message or national frame around this issue before Pew entered the field,” she said. “They created the framework that helped to change the way we do this work.”

In particular, Russinof praised Pew for engaging experts in social marketing who had experience developing award-winning anti-smoking campaigns that could help inform strategies for promoting fluoridation. After consulting with these experts, Pew took several steps, including:

Connecting and convening oral health leaders and advocates throughout the country, both in online forums and through annual conferences.

Creating a Rapid Response Team to alert public health activists who are willing to review online articles and, when appropriate, provide scientifically accurate comments about the benefits of water fluoridation.

Launching the Fluoride Responders listserv where advocates share research and other information, advise one another on advocacy strategies, and collaborate on responses to anti-fluoride efforts.

“The Rapid Response Team was the most helpful thing that Pew created because it connected me with so many oral health advocates and experts who could brief me on new studies and offer other insights,” said Dr. Johnny Johnson, a Florida dentist. (19)…

… Over a three-year period, Pew consulted with advocates in dozens of communities who were fighting to defend local fluoridation policies against attacks. Most of these policies were preserved. Matt Crespin, associate director of the Children’s Health Alliance of Wisconsin, said Pew’s assistance aided a local coalition’s efforts to preserve Milwaukee’s fluoridation policy in 2012. “It was helpful to have people at Pew who could give us an idea of what to expect and how to handle each of the anti-fluoride arguments,” Crespin said. (88)

Columbia, Mo., Bradford, Vt. and Pinellas County, Fla., are among numerous other communities in which fluoridation was successfully defended or reinstated with Pew’s assistance. In fact, since 2011, Pew has assisted more than 40 communities in defeating rollback attempts, effectively protecting water fluoridation for more than 5 million people…

Read this 27-page report