Applying an Ecological Model to Social Marketing Communications: A Case Study Analysis

The paper discusses the application of an ecological model to social marketing communications. It highlights the need to address the inter-relationships within an individual's environment to achieve behavior change. The Social Ecological Model (SEM) is presented as a theoretical framework to understand the influences on health-related behaviors. The paper explores the limited research on applying the SEM to social marketing and emphasizes the importance of incorporating social, institutional, and policy approaches in health promotion. The aim of the paper is to investigate how a SEM can be used in social marketing communications to achieve behavior change, addressing questions related to institutions' involvement, inter-related influences, and the achievement of empowerment and social justice. The study analyzes a case study of a social marketing communications strategy implemented by NHS Health Scotland and Childsmile, focusing on children's oral health. The paper concludes by discussing the components of the SEM (microsystems, mesosystems, exosystems, and macrosystems) and the methodology used in the research, including documentary review, interviews, and observations.

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Lindridge,Andrew;MacGaskill,Susan;Gnich,Wendy;Eadie,Douglasand Holme,Ingrid (2013).Applying an
ecologicalmodelto socialmarketing communications.European Journalof Marketing, 47(9) pp.1399–1420.
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Applying a social ecological model to social marketing communications
1. Introduction
Social marketing aims to encourage behaviour changes for the greater good of the
population and has been shown to positively affect knowledge, awareness, attitudes and
behaviour in a number of areas (Gordon et al., 2006; Stead et al., 2007). However, although
recognition of the importance of consumer-community oriented and evidence based public
health approaches has increased, those interventions that predominantly rely upon
communication and education have failed to reduce the gap in health status between different
socio-economic groups (Ram, 2006; Zimmerman and Bell, 2006). One possible explanation
for this disparity lies in the increased awareness of economic, environmental and social
influences in determining an individual’s health (Andreasen, 2002).
Wymer (2011) argues that social marketing practitioners and scholars have failed to
consider the effects of the environment and appropriate institutions in delivering positive
behaviour changes. Hence, for social marketing programmes to achieve the aim of delivering
behaviour change, there is a need to address an individual’s inter-relationships within their
environment. Yet these inter-relationships remain unclear and difficult to act upon (Noar and
Zimmerman, 2005), despite calls for an increased research focus on contextual and social
influences on health (Koh et al., 2010; Marmot et al., 2008).
The Social Ecological Model of health behaviour (SEM) addresses these criticisms, by
providing a theoretical framework to understand environmental inter-related influences
affecting an individual’s health related behaviours (Sallis et al., 2008). Such is the prevalence
of the SEM in public health discourse that its application is recommended by the World
Health Organisation (Blas and Kurup, 2010), whilst the Institute of Medicine and the
Association of Schools of Public Health calls for the SEM to be taught to students as an

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effective means of achieving health behaviour change (Gebbie, Rosenstock and Hernandez,
2003).
Considering the importance of the SEM and its application to inter-related influences that
affect health related behaviour, research into their application in social marketing is limited.
For example, Golden and Earp (2012) reviewed the application of the SEM to health
behaviours over the period 1989 – 2008 and noted that despite calls for a more comprehensive
approach to understanding how use of the SEM can help solve public health problems, their
practical application remains uncertain. Furthermore “calls for multilevel interventions that
better incorporate social, institutional, and policy approaches to health promotion have gone
largely unheeded” (ibid, p. 397). For example, SEM studies into community and policy
related involvement in health behaviour change accounted for only 20% and 6% of published
papers, whilst only 39% reviewed related institutional level activities. Instead, previously
published research has tended to focus on individual level activities within the SEM (ibid).
Consequently, SEM applications have broadened our understanding of health problems,
without identifying specific influences or providing guidance on improving health
interventions (Glanz, Rimer and Viswanath, 2008; Golden and Earp, 2012).
Application of the SEM to social marketing communications is appropriate where the
emphasis lies in encouraging people to take greater responsibility for health related decisions.
This encouragement is facilitated through bottom-up and top-down approaches to deliver
health behaviour change. The former involves the individuals and their communities
understanding their behaviours and being empowered through alliances to change their
behaviours (Oetzel et al., 2006). For example, the importance of parents and schools in
providing social support (Coker et al., 2002) and positive opinion leaders, such as peers and
spouses, in promoting good health (Durantini, 2006). This is an approach that Dempsey et al.
(2011) argue encapsulates the essential aspects of health promotion: empowerment, equity,

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inclusion, respect and social justice. In contrast, the top-down approach relies upon changes in
policy and institutions to deliver behaviour change. Incorporating both these aspects appears
to deliver effective health promotion campaigns (Jackson et al., 2007). Yet, considering the
widespread recognition of these approaches, there is a lack of clarity regarding the concepts of
social marketing communication and their relevance to public health (McDermott, Stead and
Hastings, 2005; Maibach, Rothschild and Novelli, 2002).
The aim of this paper is to investigate and explore how a SEM of social marketing
communications could be used to deliver behaviour change. In doing so we aim to address
criticisms of the SEM and its application to social marketing communications by attempting
to answer the following questions:
Q1: How can institutions’ involvement in developing social marketing communications
influence behaviour changes to reduce the health status gap between different socio-
economic groups?
Q2: How are social, institutional, and policy inter-related influences that affect health related
behaviours incorporated into social marketing communications?
Q3: By applying a SEM to health orientated social marketing communications, how can
empowerment, equity, inclusion, respect and social justice be achieved?
The aim and questions of this paper are addressed through a case study that analyses the
development and implementation of a social marketing communications strategy to bring
about health behaviour changes. The case study reviews a health behaviour change campaign
undertaken by NHS Health Scotland in partnership with Childsmile, an evolving childhood

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oral health service delivered across Scotland. Using, the development and implementation of
Childsmile’s social marketing communications strategy as a case-study affords exploration of
how a SEM of social marketing communication can be used to deliver behaviour change.
Childsmile aspires to provide access to care for every new-born, combining a targeted and
universal approach to children’s oral health improvement through four programme
components (Core, Practice, Nursery and School). This ‘Integrated Programme’ provides a
comprehensive pathway of care including: supervised nursery tooth-brushing for all 3 to 4
year olds with extended supervision to Primary 1 and 2 classes in disadvantaged areas and
distribution of oral health packs (Childsmile Core); tailored oral health promotion and clinical
prevention in dental practices from 6 months of age with additional support to those families
most at risk of dental caries in the home and community setting from birth (Childsmile
Practice); and clinical preventive (fluoride-varnish) programmes in priority nurseries and
primary schools (Childsmile Nursery and School). Childsmile not only involves programme
staff and other dental and oral health providers, but requires the support of a range of
professionals working with children and families.
2. The Social Ecological Model and its components
Originating in the 1950s (Hawley, 1950), the SEM aims to identify the inter-relationship
and influence of economic, environmental and social influences on the community, inter-
cultural and inter-personal, and institutions within. Developing the SEM further,
Bronfenbrenner (1977, 1979) categorised the SEM as consisting of four inter-related systems:
micro, meso, exo and macro. Recognising how these systems interact with each other offers
opportunities to address them leading to the desired behaviour change, illustrated here by
examples of supporting children’s oral health.

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Microsystems represent aspects of the individual and their social group’s self-identity
affecting their behaviours. For example, the uptake of health orientated behaviours can be
inhibited, or enhanced, by personal motivation, intentions and demographic profile
(O’Donnell, 2005; Ryan and Deci, 2000), such as the parents’ level of education, and attitudes
towards oral health (Grembowski et al., 2008; Holme et al., 2009; Saied-Moallemi et al.,
2008). Consequently, such factors can inhibit parents taking their children to the dentist,
leading to anxiety towards visiting a dentist (Soulliere, 2009), mistaken oral health beliefs and
perceived low importance of primary teeth (Kelly et al., 2005).
Mesosystems represent social structures, including laws (enforced change, such as higher
taxes on cigarettes to discourage smoking), and Government policies (such health orientated
marketing communications) through to encouraging service development, such as child
orientated dental services. For example, in a study of dentists from former East and West
Germany, West German dentists, unlike their Eastern counter-parts were not trained in the
levels of stress that children aged 3-6 years old experience from a visit to the dentist (Splieth
et al., 2009).
Exosystems reflect the importance of the community in developing collective efficacy
(Cohen et al., 2006). For example, a British study, involving 268 mothers of young children at
high-risk of dental cavities found gaps in knowledge, and weak community and family
support regarding oral health (Blinkhorn et al., 2011). Yet health orientated social marketing
campaigns may challenge community social norms that the individual exists within.
Consequently, well intentioned interventions may produce resistance to change from the
targeted community.
Macrosystems represent the cultural context that the individual exists within, including
society’s cultural expectations of the individual. For example, a positive cultural belief
towards oral health can mitigate structural barriers, such as a lack of accessible transportation,

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school absence policies and discriminatory treatment (Kelly et al., 2005). However, this
assumes that the target audience are health literate, i.e. have the ability to understand and
comply with the required healthy behaviour (Nutbeam, 2000; Kickbusch et al., 2008). A lack
of health literacy has been identified as a significant barrier in educating a population to
undertake healthy behaviour changes (Nielsen-Bohlman et al., 2004).
3. Methodology
The aim of this paper is to investigate and explore how a SEM of social marketing
communications may achieve behaviour change. A reflexive, mixed methods case study
approach was used, which provides opportunities to examine the rich variety of primary and
secondary data collected, and to evaluate policies and interventions and their impact on inter-
related environmental influences affecting children’s oral health.
A triangulation of methods was employed, including documentary review, observation at
meetings, in-depth telephone interviews with those involved in developing Childsmile’s
social marketing communications strategy and a review of Childsmile’s use of findings from
a needs assessment (undertaken by the Institute for Social Marketing) and commissioned to
inform the development of its marketing communications campaign. Firstly, the documentary
review included Childsmile and Scottish Government’s oral health documents to assess policy
decisions and objectives, and internal Childsmile planning documents, processes and
monitoring data made accessible to the authors:
Insert Table 1 here
Secondly, supporting these documents, two members of the NHS Health Scotland/
Childsmile marketing communications team were interviewed twice. These interviews, using
open-ended questions, explored the planning and information-gathering, and its subsequent
use and delivery in Childsmile’s marketing communications. Thirdly, complimenting this,

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one of the authors observed key meetings to progress initial planning of Childsmile’s
marketing communications campaign allowing further insights into Childsmile’s programme
constraints and opportunities.
Finally, the needs assessment approach undertaken by the Institute for Social Marketing on
behalf of Childsmile was critically reviewed alongside Childsmile’s use of the findings, in
order to plan their social marketing communications strategy.
This needs assessment comprised18 stakeholder focus group interviews. The focus groups
aimed to identify core issues surrounding oral health care and related communications in
relation to young children from the perspective of parent/carers and professionals involved
with early years. Stokols (1992) argued that the premise of the SEM required understanding
of how target audiences interact with their environment, and focus groups were chosen as an
effective way to gain rich data and ‘real life’ understanding from a range of stakeholders,
within the research resources (Petty et al 2012). A topic guide, used to ensure coverage of key
issues, was developed from the research questions, a literature review including oral health
and behaviour change papers, and input from the programme steering group (refer to
Appendix 1). Respondents were also encouraged to raise any additional issues they thought
were relevant. Interviews were digitally-recorded with participants’ permission, transcribed in
full, annonymised and analysed thematically.
One set of focus group participants consisted of first time parents/main carers with one
child aged 0-3 years, or parents/main carers with more than one child who were eligible for
the nursery and school-based Childsmile programmes. The sample was drawn from lower
socio-economic groups (C2DE) living in disadvantaged areas in Scotland, reflecting key
targets. Ten focus groups were recruited (n=53, groups comprising 3-8 respondents each):
Insert Table 2 here

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Eight mini-focus groups representing professionals were also recruited consisting of
Childsmile oral health workers and other related health professionals such as Public Health
Nurses/Health Visitors and Midwives; and Nursery Staff:
Insert Table 3 here
Analysis of the triangulated case-study data used an evaluative approach. Rossi et al
(2004, p.28) describe this as an approach which uses "...social research methods to
systematically investigate the effectiveness of social intervention programmes.” Such an
evaluation requires an objective assessment and appraisal of the social marketing activity to
reach relevant conclusions for future research and programmes (World Health Organisation,
2001). This was achieved for this paper through applying Naidoo and Wills (2000) evaluation
criteria:
• Effectiveness – the extent to which the health promotions aims and objectives were met
• Appropriateness – how relevant was the intervention to the needs of the target audience
• Acceptability – was the promotion carried out in a sensitive, appropriate manner
• Efficiency – were time, money and resources used to maximum effect, and
• Equity – did the promotion have sufficient resources equal to the target audience needs
4. Findings
The findings are presented using Naidoo and Wills (2000) evaluation criteria outlined
above.
Effectiveness – the extent to which the health promotions aims and objectives were
met. The World Health Organisation (2001) argue that the evaluation of any marketing
communications campaign must commence with evaluating the clarity of the concept, i.e.
were the aims clearly expressed and were they met. This is particularly relevant to
Childsmile’s marketing communications and the SEM as it infers a response to the influences

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of: (i) the target population’s demographics, (ii) the nature of the environment that the
population exists within, such as their community and social networks, and (iii) how people
engage with various health related institutions (Brug, 2006).
Childsmile summarises its vision as combining targeted and universal approaches to
tackling children’s oral health improvement through the four programme components (Core,
Practice, Nursery and School) as mentioned above. Focussing on the communication strategy
the goal is ‘to drive uptake of Childsmile within each local Health Board, with a focus on the
early years’ (Moore et al, 2010).
Considering the environment’s effect on children’s oral health and Childsmile’s vision and
goals, Childsmile’s marketing communications addressed two themes: (i) the need to educate
parents about children’s oral health and Childsmile, and encourage early registration with a
dental practice, and (ii) the need to support dental practices and related professionals in
providing friendlier service encounters, and in encouraging oral health behaviours. Childsmile
developed a marketing communication campaign that addressed these themes whilst
addressing wider environmental influences identifiable with SEM. Table 4 describes the
marketing communications materials for the public and Table 5 materials for professionals:
Insert Table 4 here
Insert Table 5 here
Childsmile’s vision and objectives were a response to Scotland having one of the highest
rates of childhood dental decay in Europe, coupled with significant inequalities in oral health,
low rates of dental registration for young children (35% of 2 year olds in 2004), limited
preventative activity, and oral health problems being the most common reason for children to
have an elective general anaesthetic (Macpherson et al 2010).

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Indeed, although inequalities in oral health persist (Macpherson et al 2011), improvements in
children’s oral health are evident and, encouragingly, national targets calling for 60% of
school-aged children to be caries free by the year 2010 have been met. A national loner-term
assessment of Childsmile impact, led by Glasgow University will deliver further insights into
the effectiveness of the marketing communications, although the natural, roll-out of the
programme and resultant non-experimental study design will not afford assessment of the
unique contribution of Childsmile’s social marketing activity (over and above other
programme interventions).
Although assessment of more proximal measures is subject to the same cautions with
regard to attribution as longer-term health outcomes, it can be argued that shorter-term
outcomes (in terms of Childsmile’s over-arching theory of change) such as the number of
nurseries and schools participating in the programme, or the number of children enrolled at a
dental practice, provide a more timely measure of the communication strategy’s impact at this
relatively early stage of programme delivery. Childsmile monitoring activity provides some
support for the suggestion that the marketing communications programme is having some
success in engaging its target audience. In the period 2006-2010, the proportion of socially
deprived schools, (identified by the Scottish Index of Multiple Deprivation), participating in
the Childsmile tooth-brushing scheme increased from 52.7% (n=482) to 94.7% (n=540),
whilst the percentage of all nurseries participating remained around 94% during this period
(Childsmile Evaluation and Research Team, 2011). A similar improvement is the increase in
the number of children attending a Childsmile dental practice rising from 1,142 in 2006 to
28,164 by 2010 (Childsmile Evaluation and Research Team, 2011).
Appropriateness – how relevant was Childsmile’s marketing communications programme
to the social, institutional, and policy needs? In response to, Childsmile’s focus on socio-

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economically deprived communities, issues of empowerment, equity, inclusion, respect and
social justice within the SEM framework are considered.
Childsmile actively involved key social, institutional, and policy stakeholders in the
development of their marketing communications. This was achieved through a variety of
approaches, including: clinical guidelines and working with policy makers, previous
experiences of Scottish child orientated oral health programmes, and commissioning The
Institute for Social Marketing to undertake a needs assessment exercise to identify the target
audiences’ core issues surrounding oral health. This needs assessment comprised two
complimentary methods. First, secondary data identifying oral health problems amongst
Scottish children was collected and reviewed. Second, focus group interviews were
undertaken in order to facilitate stakeholder participation during Childsmile’s marketing
communications initial design stage. Focus groups were deemed appropriate for exploring the
views and shared experiences of participants. Importantly, this approach benefits from
respondents' interaction with one another as well as the moderator (Webb and Kevern, 2001),
promoting reflection on the experiences of particular services or activities, and generating
further insights and ideas for potential improvements, perhaps more than one-to-one
interviews may achieve.
The key findings from the first set of focus groups (first time parents/main carers) and how
the various SEM systems affected children’s oral health are presented below:
Insert Table 6 here
A key aspect of social marketing communications and their appropriateness is that the
communities Childsmile targeted experience the communication materials as empowering,
equitable, inclusive, respectful and offering social justice. The issues raised from these focus
groups were partially addressed through existing programme interventions, on a face-to-face
basis, through health professionals either in the parents’ home or other community venues,

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with frequency and duration tailored to individual needs. Materials developed as part of
Childsmile’s marketing communications campaign, were designed to support (and be
delivered within) existing programme interventions. For example, mistaken oral health
beliefs, low importance of primary teeth and perception of need balanced in relation to costs
have all been attributed to parents not attending to their child’s oral health needs (Kelly et al.,
2005). Following the focus group findings, attention was given to how Dental Health Support
Workers (DHSWs), lay workers trained and employed by Childsmile, who work alongside
professionals (e.g. Public Health Nurses and teachers), communicate the Childsmile message
to families. Delivery was enhanced through distribution of revised Childsmile marketing
communication materials to advise parents on what foods and drinks were suitable for their
baby, as well as encouraging discussions regarding teeth cleaning, toothpaste and oral health.
However, the appropriateness of some aspects of Childsmile’s marketing communication
materials can be questioned. For instance, Childsmile’s parents’ website aims to provide oral
health information. The extent that parents from socio-economic deprived groups’ access this
website is uncertain. Even though Childsmile made considerable attempts to ensure the
language was user friendly, issues of literacy needs to be considered. For example, a study by
McInnes and Haglund (2011) found that text used in websites often became increasingly
complex and prohibitive for those with low levels of health literacy. Childsmile’s use of
websites then may be more relevant to increasing their visibility to a wider audience and
addressing wider political concerns (such as be seen to being seen to involve parents) rather
than actually increasing reach to socio-economic deprived groups.
Following the parent focus groups, eight mini-groups of health professionals and those
involved in pre-school education were recruited through relevant management structures.
Involvement of a range of professionals and their commitment to delivering and contributing

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to Childsmile’s objectives was deemed as essential. The findings from these focus groups are
summarised below:
Insert Table 7 here
The professional’s focus groups’ data indicated that any social marketing communications
needed to overcome cultural, personal and structural boundaries manifesting in all aspects of
the SEM systems. The findings indicated how the environment was affecting children’s oral
health through lack of support and access to dental services (top-down effects). Only a few
examples of bottom up effects in the form of community alliances regarding oral health were
evident, typically involving a lack of parental and school support.
Acceptability – were Childsmile’s marketing communications carried out in a sensitive,
appropriate manner? The roles of various SEM systems, identified from the focus groups,
were supported through Childsmile’s existing programme of intervention activity, much of
which involved direct involvement with dental practices engaging with the communities they
existed within. This approach aimed to address issues of acceptability. These interventions
aimed to achieve collective efficacy through communicating and promoting Childsmile oral
hygiene activities and addressing previous calls for greater community involvement (Cohen et
al., 2006).
Dental anxiety identified from the focus groups and already recognised and targeted as an
issue by the wider Childsmile programme was further addressed by the development of a
variety of marketing communication tools aimed at supporting dental practices to turn a
potentially fearful encounter into a positive one. This included: offering children a tooth
brushing wall chart, a food diary (to monitor sugar intake through foods and drinks) and
stickers, which allow the child to be rewarded for correctly tooth brushing or having
successfully received a fluoride based covering (varnish) on their teeth.

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Marketing communication materials were also delivered and administrated by Childsmile
related professionals through nursery and primary school orientated programmes. This
engagement with children via their nurseries and schools, and indirectly their wider
community, was described by the Childsmile interviewees as highly effective in delivering
oral health. The Childsmile related professionals were trusted and the school represented a
nurturing, neutral space for the message to be heard, trusted and acted upon.
Efficiency – were time, money and resources used to maximum effect in Childsmile’s
marketing communications? Childsmile’s vision was to improve oral health amongst young
children in Scotland, with an emphasis on socio-economic deprived communities. Whilst
Childsmile’s marketing communications can only be fully assessed within the context of
wider Childsmile results, an efficiency review of Childsmile’s marketing communications can
be attempted.
Nurseries, schools and dental practices extensive use of marketing communication tools
encouraging positive oral health, such as tooth brushing sessions, is likely to be a cost
effective means of achieving Childsmile’s vision and objectives. Cost effective in terms of
providing a health intervention that encourages positive health behaviour changes that may
reduce future oral health problems. Perhaps the most efficient aspects of Childsmile’s
marketing communications appears to be the greater cooperation between oral health
professionals achieved through coordination in jointly delivering Childsmile’s marketing
communications.
Yet this reliance on health professionals to deliver Childsmile’s marketing communication
message is problematic. A central aspect of Childsmile’s marketing communications was the
reliance on Health Visitors (HV) in liaising between families and oral health care
professionals. The extent to which this method of communication has increased uptake from
Childsmile’s target groups is uncertain. During Childsmile’s initial demonstration phase (July

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2006 to December 2009) 22, 684 children were referred to a DHSW, 18,227 children
subsequently had an appointment made with a dental practice and 15,310 attended an
appointment (Kidd, 2012). However, this trajectory may be influenced by multiple issues.
Equity – did the promotion have sufficient resources equal to the target audience needs? A
number of factors impacted on the intended delivery of the initial Childsmile’s
communications strategy, with a much more limited set of activities implemented than drawn
out in the strategic plans (Moore et al., 2010).
First, the evolving nature of the programme and the changing external context in which it
operates necessitated an early review and modification of planned communications activities.
Several planned activities were deemed no longer relevant, whilst others would benefit from
re-scheduling owing to programme mainstreaming. To illustrate, by the end of 2010, it
became evident that Childsmile delivery within dental practices would be mainstreamed via
changes to the national payment system for dental practices across Scotland. This
government-led (and Childsmile driven) change meant that practices, rather than ‘signing up’
to Childsmile, were automatically required to deliver in accordance with its guidance. This led
to a decision to postpone proposed activity aimed at engaging dental practices and instead to
produce resources to communicate new expectations to dental practices and support delivery.
Second, a changing economic climate and the time taken awaiting approval for Childsmile
marketing communication expenditure from the Scottish Executive witnessed the
postponement of several activities intended within the 2010-12 communications strategy.
Two examples of community programmes which have not yet been implemented as originally
planned are: 1) a proposed touring road show, targeted at pregnant women and children under
the age of four, and 2) the establishment of community partnerships and champions: for
example, targeting libraries, local bookshops and supermarkets, based in targeted
communities, which would then run Childsmile related activities, such as dedicated story-

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telling sessions. Consequently, the resulting communication activities appeared to be top-
down, with little encouragement towards forming community alliances to deliver oral health,
as prescribed by Oetzel et al. (2006). The postponement then of these communication
activities suggests that equity was not achieved.
5. Discussion
The premise of this paper was to assess the role of the SEM through three inter-related
questions applied to Childsmile’s marketing communications.
Question 1 asked “To what extent can institutions’ involvement in developing social
marketing communications influence behaviour changes to reduce the health status gap
between different socio-economic groups?” Childsmile and the institutions they collaborated
with are identifiable with the SEM’s mesosystems (such as social structures, laws and
policies). Involving various stakeholder institutions appears to be central to delivering a
coherent and relevant marketing communications that delivered behaviour change. Certainly,
initial evaluation results indicate an increased uptake of dental services and improving oral
health, even though certain target audiences remained unmotivated to access appropriate
health services. Supporting dental practices through appropriate marketing communication
materials appear to have contributed towards improving oral health figures. However, these
interventions, whilst designed to address individuals’ concerns inherently represent a top-
down effect. However, the involvement of nurseries and schools within the Childsmile
programme, including distributing appropriate marketing communication materials to
children, is reflective of aspects of Coker et al.’s (2002) bottom-up effects in providing social
support. Indeed, institutions such as nurseries, schools and the Childsmile DHSWs and Dental
Nurses that work with them, were instrumental in building oral health confidence in parents.

17
This approach develops further Blinkhorn et al.’s (2011) observation regarding children’s oral
health and parent’s knowledge gaps.
Yet the importance of institutions within the SEM for Childsmile appears to be secondary
to the role of community. Nurseries and schools, an aspect of any community, appeared to
represent a cross-over, an intersection between top-down and bottom-up effects, perhaps
contributing towards Childsmile’s marketing communications impact. Consequently,
nurseries and schools represented a trusted information source, within the community that
Childsmile, parents and the wider community engaged through and with each other. In this
respect, we would argue that educational establishments undertook a variety of roles within
Childsmile’s SEM, including helping to achieve collective efficacy – exosystems (Cohen et
al., 2006) – and encouraging change within the local cultural context – macrosystems.
Future SEM social marketing campaigns then should focus their efforts on identifying the
central nexus that links institutions to their target audience, such as nurseries and schools.
This identification process may then lead to greater marketing communications receptivity
amongst target audiences in delivering behaviour change.
The second question posed was “How are social, institutional, and policy inter-related
influences that affect health related behaviours incorporated into social marketing
communications?” From a social perspective, social marketing programmes and the
application of the SEM have been criticised for their failure to consider the environment’s
influence on individual’s behaviour (Glanz, Rimer and Viswanath, 2008). By applying the
SEM to Childsmile, we identified how the various systems within the SEM affected
children’s oral health. Childsmile’s marketing communications were dependent upon support
from various stakeholders, tacit knowledge from similar programmes, and extensive
marketing research. The merits of using SEM drew upon identifying the systems and in the

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effective collection and analysis of the data, from document and publication research and
interviews establishing ‘real life’ issues that supported their marketing communications.
Our findings endorse the need for closer collaboration between social, institutional, and
policy approaches. Indeed, whilst Scottish Government policy called for improvements to
children’s oral health, this was also reflective of the structural barriers that existed within the
communities Childsmile’s marketing communications were attempting to reach. Indeed,
Childsmile’s marketing communication materials were designed to address these structural
barriers (identified through focus groups), effectively challenging the community social
norms. Social marketers applying the SEM should therefore consider the need for extensive
and wider communication between social, institutional, and policy interests.
The third question asked “By applying a SEM to health orientated social marketing
communications, how can empowerment, equity, inclusion, respect and social justice be
achieved?” Empowering socio-economic deprived groups to change their behaviour was a
central tenet of Childsmile’s marketing communications as behaviour change is only possible
if individuals and their communities understand their behaviours. This was achieved through
identifying and involving a range of stakeholders in the empowerment process, including,
parents / children and dental practices, health professionals and educationists. This
recognition suggests that coordinated communications concepts that understand the
environmental needs of the target audience, and deliver appropriate marketing
communications through ‘life-contact points’ (Lefebvre and Flora, 1988) can achieve clarity
and relevance.
Perhaps most important was the issue of health literacy being compromised by socio-
economic conditions. Whilst Nutbeam (2000) and Kickbusch et al. (2008) note how health
illiteracy affects healthy behaviours, the findings of the communications needs assessment
undertaken on behalf of Childsmile indicated a willingness amongst the parental target

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audience to improve their children’s health. In this instance, marketing communications
focussed on providing suitable materials to support health professionals in gaining trust from
the community, allowing the oral health message to be heard; a finding that develops further
Kelly et al.’s (2005) observations regarding parents mistaken oral health beliefs and perceived
low importance of primary teeth.
This paper, however, is not without its limitations. Perhaps the most noteworthy is the
inability to evaluate the impact of the full marketing communication strategy as originally
developed to support the Childsmile programme. At present, a more limited amount of
communication activity has been delivered than set out within this strategy (Moore et al.,
2010). This is compounded by the reality that, while Childsmile’s monitoring provides an
indication of programme roll-out and uptake, understanding the relationship between
Childsmile activities and improvements in children’s oral health requires further longitudinal
follow-up. In addition, it is not possible to completely isolate the impact of Childsmile’s
marketing communications campaign from other activity within and outwith the wider
Childsmile programme. Childsmile’s marketing communications was an aspect of a wider
health programme, and it was not envisaged would be evaluated as a separate entity from the
wider programme.
Finally, our findings were dependent upon the quality of the data that was gathered to
identify these environmental influences. For example, due to resource constraints, the use of
focus groups, whilst providing rich data, was not complemented by additional individual
interviews which may have identified further insights. In addition, we were only able to
interview two of the five people involved in the development of Childsmile’s social
marketing campaign, with the remaining people employed in other NHS posts or on maternity
leave.

20
6. Conclusion
The aim of this paper was to investigate and explore how a SEM of social marketing
communications could be used to deliver behaviour change. By identifying the need for SEM
systems to be addressed and incorporated in the campaign, we showed how various personal
influences, along with economic, environmental and social influences need to be considered.
This is particularly important amongst socio-economic deprived groups who may suffer from
low levels of health literacy (Nielsen-Bohlman et al., 2004; Nutbeam, 2000) and are harder to
engage with through appropriate ‘life path points’ (Lefebvre and Flora, 1988).
Through identifying these intervening variables, Childsmile developed a social marketing
communications campaign that was implicitly designed to bring about behaviour change.
However, our paper illustrates the impact of the changing environmental context that well
developed social marketing communication campaigns exist within. Although Childsmile
undertook extensive data gathering exercises to inform its marketing communications, the
realities of economic and political pressures restricted what could actually be delivered. This
highlights the importance of understanding, and responding to, the interacting SEM
influences and stakeholder perspectives in delivering behaviour change.
Nonetheless our paper supports the potential for well planned social marketing
interventions to overcome environmental forces that can lead to positive behaviour change.
Future research should explore in greater depth individual aspects of the SEM systems and
their influence on social marketing interventions. Increased understanding of how these
systems influence behaviours will ultimately support the delivery of more effective social
marketing campaigns.

21
References
Amin, M. S. and Harrison, R. L. (2009), “Understanding parents’ oral health behaviours for
their young children”, Qualitative Health Research, Vol. 19 No. 1, pp. 116-127.
Andreasen, A. R. (2002). “Marketing Social Marketing in the Social Change Marketplace”,
Journal of Public Policy and Marketing, Vol. 21 Spring, pp. 3-14.
Blas, E. and Kurup, S. A. (2010), “Equity, social determinants and public health
programmes”, World Health Organization: Geneva.
Blinkhorn, A. S., Wainwright-Stringer, Y. M., and Holloway, P. J. (2011), “Dental health
knowledge and attitudes of regularly attending mothers of high-risk, pre-school children”,
International Dental Journal, Vol. 51 No. 6, pp. 2435-2438.
Bronfenbrenner, U. (1977). “Toward an experimental ecology of human
development”. American Psychologist, Vol. 32, pp. 513-531.
Bronfenbrenner, U. (1979). The Ecology of Human development. Cambridge, MA: Harvard
University Press.
Brug, J. (2006), “Order is needed to promote linear or quantum changes in nutrition and
physical activity behaviors: a reaction to 'A chaotic view of behaviour change’ by
Resnicow and Vaughan”, International Journal of Behavioral Nutrition and Physical
Activity, Vol. 3 No. 1, pp. 29.
Childsmile Evaluation and Research Team (2011) Unpublished Headline Report, Annual
Process Evaluation Report, December. University of Glasgow.
Cohen D., Finch B., Bower A., and Sastry N. (2006), “Collective efficacy and obesity: the
potential influence of social factors on health”, Social Science & Medicine, Vol. 62 No. 3,
pp. 769–778.

22
Coker A, Smith P, Thompson M, McKeown R, Bethea L, and Davis K. (2002), “Social
support protects against the negative effects of partner violence on mental health”, Journal
of Women's Health & Gender-Based Medicine, Vol. 11 No. 5, pp. 465–476.
Dempsey, C., Barry M. M. Battel-Kirk, B. and the CompHP Project Partners (2011),
“Literature Review : Developing Competencies for Health Promotion “, IUHPE, Paris.
Durantini M., Albarracin D., Mitchell A., Earl A., and Gillette J. (2006), “Conceptualizing the
influence of social agents of behaviour change: a meta-analysis of the effectiveness of HIV
prevention interventionists for different groups”, Psychological Bulletin, Vol. 132 No. 2,
pp. 212–248.
Gebbie, K., Rosenstock, L. and Hernandez,L. M. ( 2003), Who Will Keep the Public Healthy?
Educating Public Health Professionals for the 21st Century. Washington, DC: National
Academies Press.
Glanz, K., Rimer, B. and Viswanath, K. (2008), Health Behaviour and Education, John Wiley
and Son, London: UK.
Golden S. D. and Earp, J. A. (2012), “Social ecological approaches to individuals and their
contexts: twenty years of health education and behavior health promotion interventions”,
Health Education Behaviour, Vol. 39 No. 3, pp. 364-372.
Gordon, R., McDermott, L., Stead, M. and Angus, K. (2006), “The effectiveness of social
marketing interventions for health improvement: what’s the evidence?”, Public Health,
Vol. 120 No. 12, pp. 1133-1139.
Grembowski, D., Spiekerman, C., and Milgrom, P. (2008), “Linking mother and child access
to dental care”, Pediatrics, Vol. 122 No. 4, pp.805-814.
Hawley, A. H. (1950). Human ecology: A Theory of Community Structure. New York: Ronald
Press.
Holme, I., MacAskill, S. and Eadie, D. (2009), Research to Develop a Communications

23
Campaign to Promote Childsmile within Local Communities - Stage 1: Literature
Review. NHS Health Scotland, Edinburgh, available at:
http://www.healthscotland.com/documents/3534.aspx, accessed 31st August 2011.
Jackson, S. Perkins, F., Khandor, E., Cordwell, L., Hamann, S. and Buasai, S. (2007),
“Capacity Building. Integrated health promotion strategies: a contribution to tackling
current and future health challenges”, Health Promotion International, Vol. 21 , pp. 75-
83.
Kelly, S. E., Binkley, C. J., Neace, W. P., and Gale, B. S. (2005), “Barriers to care-seeking for
children’s oral health among low-income caregivers,” American Journal of Public
Health, Vol. 95 No. 8, pp. 1345-1351.
Kickbusch, I., Wait, S. and Maag , D. (2008), Navigating Health: The Role of Health
Literacy, Alliance for Health and the Future, London.
Kidd, J. B. R. (2012), Factors that influence the on-going retention of pre-school children
aged 0-5 within Childsmile, the national oral health improvement programme for
Scotland, MSc(R) thesis, University of Glasgow.
Koh, M. D., H. K., Oppenheimer , S. B., Emmons, K ., Geller, A. C., and Viswanath, K.
(2010) , “Translating Research Evidence Into Practice to Reduce Health Disparities: A
Social Determinants Approach”, American Journal of Public Health, Vol. 100 (s1), pp.
S72–S80.
Lefebvre, R. C. and Flora, J. A. (1988), “Social Marketing and Public Health Intervention’,
Health Education Quarterly”, Vol. 15 No. 3, pp, 299-315.
McDermott, L. Stead, M. and Hasting, G. (2005), “What is and what is not social marketing:
the challenge of reviewing the evidence”, Journal of Marketing Management, Vol. 21
No. 5-6, pp. 545-553.

24
McInnes, N. and Haglund, B. J. (2011), ‘Readability of online health information:
implications for health literacy’ Informatics for Health and Social Care, Vol. 36 (4), pp.
173-89.
Macpherson, L. M. D., Conway, D. I., Goold, S., Jones, C. M., McCall, D. M., Merrett, M. C.
W., and Pitts, N. B. (2010a), National Dental Inspection Programme of Scotland Report
of the 2010 Survey of P1 Children, Scottish Dental Epidemiological Co-ordinating
Committee, Edinburgh, UK.
Macpherson, L.M.D., Ball, G.E, Conway, D.I., Edwards, M., Goold, S., McMahon, A.,
O’Keefe, E., Pitts, N.B., Watson, S. (2011), ‘Report of the 2011 Detailed National Dental
Inspection Programme of Primary 7 children and the Basic Inspection of Primary 1 and
Primary 7 Children’, Scottish Dental Epidemiological Co-ordinating Committee.
Maibach, E., Rothschild, M., and Novelli, W. (2002), “Social Marketing”, in Glanz K.,
Rimer, B. and Marcus L. F., Health Behaviour and Health Education, 3rd Edition, Jossey-
Bass, San Francisco.
Marmot, M., Friel, S., Bell, R., Houweling, T.A., and Taylor, S. (2008), “Commission on
Social Determinants of Health, 2008. Closing the gap in a generation: health equity
through action on the social determinants of health,”Lancet , Vol. 372 (9650), pp. 1661–
1669.
Moore, A., Backler, N. and Fairclough, C. (2010) Communications Strategy: Promoting
Childsmile within Local Communities 2010-2012, Childsmile, Edinburgh, UK.
Naidoo, J. and Wills, J. (2000), Health Promotion: Foundations for Practice, Edinburgh:
Bailliere Tindall.
Nielsen-Bohlman, L., Panzer, A. M. and Kindig, D. A. (2004), Health Literacy: A
Prescription to End Confusion, Institute of Medicine of the National Academies of
Sciences, Washington, D.C.: National Academies PressSallis.

25
NHS Health Scotland (2008), Getting it Right for Every Child ,
http://www.scotland.gov.uk/Resource/Doc/238985/0065813.pdf, accessed on 17th March
2011.
NHS Health Scotland (2007), Better Health, Better Care,
(http://www.scotland.gov.uk/Publications/2007/12/11103453/0 accessed on 17th March
2011.
NHS Scotland (2005), SIGN 83 Prevention and management of dental decay in the pre-
school child, http://www.sign.ac.uk/pdf/sign83.pdf, accessed on 17th March 2011.
Noar, S. and Zimmerman, R. (2005), “Health Behaviour theory and cumulative knowledge
regarding health behaviours: are we moving in the right direction”, Health Education
Research, Vol. 20 No. 3, pp. 275-290.
Nutbeam, D. (2000), “Health Literacy as a public health goal: a challenge for contemporary
health education and communication strategies in the 21st century”, Health Promotion
International, Vol. 15 No. 3, pp. 259-267.
O'Donnell, M. P. (2005), “A simple framework to describe what works best: improving
awareness, enhancing motivation, building skills, and providing opportunity”, American
Journal of Health Promotion, suppl 1–7 following 84, iii, Sep-Oct.
Oetzel, J. G., Ting-Toomey, S., Rinderle, S. (2006). Conflict communication in contexts: A
social ecological perspective. In J. G. Oetzel & S. Ting-Toomey (Eds.), The SAGE
Handbook of Conflict Communication. Thousand Oaks, CA: Sage.
Petty, N. J., Thomson, O. J., Stew G. (2012) “Ready for a paradigm shift? Part 2: Introducing
qualitative research methodologies and methods”, Manual Therapy, Vol. 17 No. 5, pp.
378-384.
Ram R. (2006), “Further examination of the cross-country association between income and
inequality and population health”, Society Science Medicine, Vol. 62 No. 7, pp. 779-791.

26
Rossi P., Lipsey M.W. and Freeman H. (2004) Evaluation: A Systematic Approach. 7th
Edition. Sage Publications, Thousand Oaks, California.
Ryan R, and Deci, E. (2000), “Self-determination theory and facilitation of intrinsic
motivation, social development, and well-being”, American Psychologist, Vol. 55, pp. 68–
78.
Saied-Moallemi, Z., Vehkalahti, M. M., Virtanen, J. I., Tehranchi, A., and Murtomaa, H.
(2008), “Mothers as facilitators of preadolescents’ oral self-care and oral health”, Oral
Health and Preventive Dentistry, Vol. 6 No. 4, pp. 271-277.
Sallis J. F., Owen, N., Fisher, E. B. (2008), “ Ecological models of health behaviour”, in
Health Behavior and Health Education: Theory, Research, and Practice (4th ed), ed. K
Glanz, B., Rimer, B. and Viswanath, K. pp. 464-85. San Francisco: Jossey-Bass.
Scottish Government (2005), An Action Plan for Improving Oral Health and Modernising
Dental Services in Scotland,
http://www.scotland.gov.uk/Resource/Doc/37428/0012526.pdf, accessed on 17th March
2011.
Soulliere, J. (2009), “High barriers to dental care exist for 12 million children”, in Mot, C. S.
(Ed.), Children’s Hospital National Poll on Children’s Health. Available:
http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1043, accessed 3rd
August 2011.
Splieth, C. H., Bunger, B. and Pine, C. (2009), “Barriers for dental treatment of primary teeth
in East and West Germany”, International Journal of Paediatric Dentistry, Vol. 19 No. 2,
pp. 84-90.
Stead, M., Gordon, R., Angus, K., and McDermott, L. (2007), “A systematic review of social
marketing effectiveness”, Health Education, Vol. 107 No. 2, pp. 126‐191.

27
Stokols, D. (1992), “Establishing and maintaining healthy environments: toward a social
ecology of health promotion”, American Psychologist, Vol. 47 No. 1, pp. 6–22.
Webb, C., and Kevern, J. (2001), "Focus groups as a research method: a critique of some
aspects of their use in nursing research", Journal of Advanced Nursing, Vol. 33 (6), pp.
798-805.
World Health Organisation (2001), “Evaluation in health promotion: Principles and
perspectives’, eds: I. Rootman, M. Goodstadt, B. Hyndman, D. V. McQueen, L. Potvin, J.
Springett and E. Ziglio, WHO Regional Publications European Series, No. 92.
Wymer, W. (2011) "Developing more effective social marketing strategies", Journal of
Social Marketing, Vol. 1 (1), pp.17 – 31.
Zimmerman, F. J. and Bell, J. F (2006), “Income inequality and physical and mental health:
testing associations consistent with proposed causal pathways”, Journal of Epidemiology
and Community Health, Vol. 60 No. 6, pp. 513-521.

28
Appendix 1: Focus group topic guide
Parents’ Topic Guide
Introduction
Theme 1: Early-years health services
Range of general health care services related to young children in this area.
Ways in which parents/carers hear about them.
Member of the family/household likely to take the child/ensure the child attends.
Factors and issues that help and hinder attendance.
Theme 2: Dental care awareness
Respondents’ practice and perceived importance of routine oral care/toothbrushing.
Experiences and issues in registering with a dentist.
Dietary issues and perceived relevance to oral care/general health.
Key sources of information and opinion formers regarding oral care.
Theme 3: Awareness of services and understanding of the Childsmile programme
Awareness of any local services for young children relating to oral health (establish context
vis. a vis. Childsmile).
Explore awareness and response to key elements:
Childsmile Practice elements (e.g. services, materials, recruitment, registration)
Childsmile Nurseries and Schools elements (3-8 year olds) (e.g. activities, materials,
perceived children’s responses).
Theme 4: Experiences and responses to other oral health and other child related social
marketing campaigns and services
Response to health communications in general (e.g. channels, messages, sources, likely
response).
Response to Childsmile promotional/informational materials (e.g. understanding of topics,
routes, tone, formats, volume, language, additional non-print resources).
Response to other campaigns to explore alternative channels and formats for communicating
with parents/children (e.g. personalised calendar, play items, websites, mobile vans,
incentives, events/activity days).
Additional service factors to enhance engagement and on-going participation (e.g. practical
support, location).

29
Table 1: Documents reviewed
Data Format Scope
Communications
strategy
Communication reports Two reports (2009)
Childsmile -
National Headline
Data
Monitoring reports Reports - March / September
2011, March 2012)
Service
improvement
activity
Documenting work undertaken
as part of the Central Evaluation
and Research Team’s formative
activity
Six reports (2009-11)
Academic papers Papers that discuss and analyse
Childsmile activities
Six papers (2009-11)
Childsmile Website Parents and carers / Professional Various webpages
NHS Health
Scotland
Health initiatives 5 reports including: (1) SIGN 83
Prevention and management of
dental decay in the pre-school
child (2005); (2) Better Health,
Better Care (2007), and (3)
Scotland Getting it Right for
Every Child (2008)
Scottish Executive Health initiatives Report - An Action Plan for
Improving Oral Health and
Modernising Dental Services in
Scotland (2005)

30
Table 2: Parents/carers sample
Child Age Group Location
1 One child; 0-3 years West1 Urban
2 Children ages 0-3 years and 4-8 years West1 Urban
3 One child; 0-3 years West1 Urban
4 Children ages 0-3 years and 4-8 years West1 Urban
5 BME group (at least one child 0-8 years) West1 Urban
6 One child 0-3 years and 4-8 years East2 Urban
7 Children ages 0-3 years and 4-8 years East2 Urban
8 One child; 0-3 years North3 Rural
9 Children ages 0-3 years and 4-8 years North3 Rural
10 Children ages 0-3 years and 4-8 years East2 Urban
1 Areas where Childsmile Practice established
2 Areas where Childsmile Nursery and School established
3 Areas where Childsmile components were not yet rolled out

31
Table 3: Sample of key professionals
N Professional group Administrative area (main
Childsmile component at the
time)
Geographical
area
1 Public health nurses/health visitors East (Childsmile Nursery and
School)
Urban
2 Public health nurses/health visitors West (Childsmile Practice) Urban
3 Public health nurses/health visitors North (Early roll-out
Childsmile unknown in
interview areas)
Rural
4 Nursery/nursery school staff East (Childsmile Nursery and
School)
Urban
5 Nursery/nursery school staff North
(Early roll-out
Childsmile unknown in
interview areas)
Rural
6 Community midwives West (Childsmile Practice) Urban
7 Childsmile Extended Duty Dental
Nurses (EDDNs) & Dental Health
Support Workers (DHSWs) 2
East (Childsmile Nursery and
School)
Urban
8 Childsmile Extended Duty Dental
Nurses (EDDNs) & Dental Health
Support Workers (DHSWs)
West (Childsmile Practice) Urban

32
Table 4: Childsmile marketing communication materials – public
Promotion type Relevance to
focus group SEM
findings
Target audience Relevance to target audience
DVD ‘How to
protect your
children’s teeth’
Microsystems:
addressed low
oral health
knowledge
Distributed through nurseries,
schools, dental practices and
local libraries. DVD aims to
combat negative norms held by
the community to accessing
dental care. The DVD
communicates, through young
children themselves, the
vulnerability of young children
to oral hygiene problems.
Information
leaflets,
including:
‘Drinks for
babies and young
children’ and
‘Tooth brushing
standards’
Macrosystems:
offered support
and guidance for
parents, indirectly
addressing
pressure from
family relatives
for children to eat
unhealthy foods
Leaflet aims to promote
parental uptake of
breastfeeding, milk and water
as safe drinks for their
children’s teeth and other
advice on encouraging healthy
teeth amongst children up to
five years of age.
Website
(www.child-
smile.org)
Macrosystems:
Parents fears of
attending a dentist
and poor oral
health knowledge
Parents
Website provides information
on access to Childsmile
activities (up to the age of 12).
Website aims to also reassure
the parent about Childsmile
intentions.
Tooth brushing
charts
Encourages children to record
when they brush their teeth,
reminding children of the need
to brush regularly.
Comic
Microsystems:
encouraging
positive oral
health habits
amongst children
Children
Educational tool aimed at
informing children about oral
health.

33
Table 5: Childsmile marketing communication materials – professionals
Promotion type Relevance to
focus group SEM
findings
Target audience Relevance to target audience
DVD, ‘Tooth
brushing
programme’
Nurseries,
schools, dental
practices and local
libraries
Educates and supports staff in
establishing a tooth brushing
programme in preschool
environments. Important as
parents from socio-economic
deprived groups may be more
likely to be employed in jobs
with unfriendly child hours.
Posters Nurseries,
schools, dental
practices and
health care centres
Aims to encourage dental
attendance, by allaying fear of
visiting the dentist.
Stickers
Microsystems:
need for dental
practices to
encourage
children’s visits to
dentists, and
overcome parental
fears
Dentists / children Offered to children visiting the
dentist
Booklet - ‘First
teeth, healthy
teeth’
Macrosystems:
addressed parents’
shame regarding
own oral health,
consequently
encouraging
uptake of oral
health amongst
children
Health visitors and
nurses offering an
accessible
information
source for
professionals to
engage with
parents
Aims to offer support “in
delivering oral health promotion
advice with confidence, and
provides easy access to
information on subjects
including oral health in
pregnancy, registering with a
dentist, teething, tooth brushing
and nutrition” (Childsmile,
2011).
Food diary Macrosystems:
supporting parent
in recognizing
unhealthy foods
eaten, and
indirectly
resisting extended
family pressures
for children to eat
unhealthy foods,
Dentists / parents Given to parents to monitor
sugar intake through foods and
drinks. Parents often felt
pressurized by extended family
members to let their children eat
sugary foods. Food diary
increased awareness and
potential oral health
implications, thereby
encouraging reduction of sugary
foods.
Website
(www.child-
smile.org)
Booklets
Mesosystems:
aims to inform
dental practices
about Childsmile
and how to
support clients
Dental practices Provides specific information on
engaging with clients and how
to introduce and facilitate
Childsmile interventions for
community partners (e.g. Public
Health Nurses and nursery and
school teachers) as well as for
Childsmile staff.

34
Table 6: Focus group findings: Parent/carers from socio-economic deprived communities
SEM system
identified
Participant narrative Relevance to SEM Relevance to soc
communications
I would rather not take him because I could
feel myself, as soon as I go in to a dentist the
sweat runs off me and I don’t want to pass
that on to him… I could be sitting smiling
and the tears are streaming down my face
you know, and I really don’t want him to see
me like that and I don’t want him to feel any
of that from me.
Parent, East (Fife), Children 0-3 & 4-8
years
Individual and their social
group’s sense of self-
identity affected
participants’ oral health.
Identifying personal
motivations, intentions and
demographics can serve to
either encourage or
discourage oral health.
Parental psychol
manifesting throu
identified, reflect
observations (Gr
2008; Saied-Moa
I was told the next time I ever go to the
dentist I was to make an appointment for the
little one, and that way he can get his teeth
checked out. But I don’t go to the dentist
regularly myself.
Parent, West (Glasgow), BME at least
one child 0-8 years
Low importance placed on
children’s oral health,
supporting Kelly et al.’s
(2005) findings.
Parents may have
knowledge and a
consequently like
similar behaviou
children.
Micro-
systems
Mother (M) , and her mother (GM):
My mum’s determined, he loves lollipops
and it’s just, it makes you cringe. ‘Don’t
give him a lollipop, his teeth are trying to
grow, leave him alone [M].
But he loves it [GM].
No, he doesn’t. You give him a worm and
Participants’ cultural
context affecting oral
health.
Grandparents, au
encourage unhea
undermine oral h
Blinkhorn et al.’
observations.

35
he’ll love that too [M].
Parent, East (Fife) Children 0-3 & 4-8
years
I made an appointment but they said that it
was too full and they’d get back to me, so
I’m still waiting.
Parent, West (Glasgow), One child 0-3
years
Parents unable to
services or to obt
or finance the tra
NHS services, re
Soulliere’s (2009
I’ve actually got false teeth due to being too
scared of the dentist. And now I regret
losing all my teeth … And I keep saying to
them [her children], ‘You don’t want these.
They’re horrible. They’re really horrible.
Parent, West (Glasgow), Children 0-3 &
4-8 years
Participants’ sha
own poor oral he
societal expectati
them to seek den
children. This fin
Amin and Harris
identified poor p
a barrier to engag

36
Table 7: Focus group findings - oral health workers and other professionals working
with young children and families
SEM
system
identified
Participant narrative Relevance to
SEM
Relevance to social marketing
communications
Micro-
systems
I think with our parents,
some of them have got
such poor dental
hygiene themselves, we
need to start educating
them.
Preschool/ Nursery,
North
Individual and
their social
group’s sense of
self-identity
affected
participants’ oral
health.
Dental practices need to
recognize client fears and
encourage healthy behaviours
amongst parents, who will then
socialize their own children.
…and they’ve got other
problems, so oral
health seems maybe
like … it’s low down in
their estimations.
DHSW and EDDN1,
West
Children’s non-attendance at
dental services attributable to:
dental visits in response to pain
rather than preventive care, with
decay happening ‘all of a
sudden’; lack of motivation in
part linked to competing
parental priorities among
vulnerable families; and lack of
cultural awareness of importance
of tooth brushing/oral health.
Narratives reflected Amin and
Harrison’s (2009) recognition of
low expectations amongst the
socio-economically deprived.
Meso-
systems
Commenting on a child
with an abscess:
…of course, you’d go
up there [dentist
surgery], waiting until
the doors open. But,
even that is not a
priority for them,
because their priority
was, ‘I got a crap sleep
last night’, they’re not
thinking, ‘My poor
child’s in pain with an
abscess’ so priorities
are [different].
DHSW and EDDN2,
West
The social
structures that
represent and
provide oral
health services.
Subtle indications of negative
perceptions towards the socio-
economically deprived,
reflective of Kelly et al.’s (2005)
research.

37
Macro-
system
It’s going into the
dentist, getting people
to actually attend, make
appointments and
actually go there, and
it’s cultural, it’s going
to take a long time to
shift it.
Public Health
Nurse/Health Visitor,
North
Participants’
cultural context
affecting oral
health.
Recognition that oral health is
not culturally important in
contrast to wider challenges of
coping with disadvantage.
Exo-
systems
It’s your grandmothers
and your great grans
you’ve got to
get through to. I’ve had
patients coming in and
it’s like you’re speaking
to the wife, but the wife
speaks to the husband
and then the husband
speaks to the gran, so it
really is the
grandparents you’ve got
to speak to, especially
within that sort of
community.
DHSWs & EDDNs,
West
Community’s
influence on
participants’ oral
health and
macro-systems,
the participants’
cultural context
that affected oral
health.
Parents often felt disempowered
in resisting wider family
pressures to allow their children
high sugar foods. Partially
affected by low education levels
regarding oral health.