Chapter 1. Oral Health Needs Assessment for Rural Communities

Chapter Description

This chapter highlights the importance of performing a community needs assessment to look at significant oral health issues. Various situations can either be assets or potential barriers to improving the oral health of young children in rural communities. Resources and tips for assessing community perceptions and gathering data are included, as are examples for developing a "statement of need." Links are provided to models that help guide planning and evaluation efforts to address oral health problems in rural communities.

Chapter Overview

How familiar are the following scenarios in your community?

Three communities out of twenty in the county have small town water systems, while the rest of the communities have wells or families have individual wells. None of the town water systems are fluoridated, and the natural fluoride content of individual wells varies from 0.1ppm (negligible) to 1ppm (the recommended level for prevention of dental decay). Dental exams of children over the past 10 years indicate consistently high decay rates. Dentists have recommended fluoridating the 3 town water systems, but the town councils have always said it was too expensive.

Mrs G. has 3 children under the age of 5. They already have dental decay that requires extensive treatment. The family lives in an isolated area in a frontier county and is currently enrolled for Medi-Cal benefits. There are no dentists in any nearby towns who will accept new Medi-Cal patients. There are no pediatric dental specialists within a 3-county area, so the family will have to travel at least 2 hours over mountain passes that often are closed in the winter months. Both parents work full-time and a grandmother takes care of the children.


Jean is a new public health nurse for a small local health department. Upon analyzing how she has spent her time during her first 4 months at work, she discovers that an average of 20 hours per week are spent trying to find dental care or funding for children referred by physicians, preschool teachers, child care workers, or parents who have asked her for assistance. Her supervisor is complaining that she is neglecting her other duties.


All of the people in these scenarios are experiencing frustration with lack of resources or situations they perceive as insurmountable. Most of these situations cannot be solved by individuals but require collaborative efforts, communication, advocacy, and changes in systems.
It does take at least one passionate and committed individual, however, to start the process.


The needs assessment process can foster constituency building and collaborative efforts.


Self-Assessment: Potential Barriers to Oral Health and Dental Care

What oral health issues create challenges or frustrations in your community? Use the self-assessment tool-- a worksheet with examples of potential barriers, with space for you to add additional ones specific to your community. Perceptions of issues and potential barriers may differ among parents, health professionals, public health staff, the business community, and other groups. Or there may be differences based on ethnicity, socioeconomic status, age or gender. Where is your community in the process of identifying, prioritizing and addressing the issues outlined in the self-assessment?

Community Needs Assessment

It is important to assess the range of perceptions in a community, not just listen to one group or the most vocal people. This allows analysis of commonalities, differences and reasons for the perceptions.

Various methods can be used to get input from a variety of individuals or groups. Surveys, focus groups, SWOT analysis, and brainstorming are a few methods that have been used successfully. An overview of needs assessment methods is provided that compares purpose, cost, time involved and advantages. Sometimes a neutral person who is not a member of the community can collect and analyze people's perceptions in an objective way. On the other hand, trusted and respected members of the community may be able to elicit more meaningful information After opinions have been documented, the focus of the analysis and presentation of information should be an acknowledgment that there are differences of opinion but everyone's opinion is of equal importance.


Focusing on commonalities rather than differences will help move people forward toward solutions.


Needs assessment also includes collection and analysis of data, e.g., numbers of children who have dental decay and are not receiving care, or the number of dentists who are enrolled as providers in the Denti-Cal program. It is important to validate the perceptions you have gathered with actual facts so you can discuss the issues using qualitative and quantitative information. This can be accomplished through secondary data collection (locating and summarizing existing data from various sources), or primary data collection (collecting new data). A number of resources are available to help you do both. An excellent "how to" manual is Assessing Oral Health Needs: ASTDD Seven Step Model, available to view or download and print at (click on publications).

One of the worksheets in the Seven Step Model asks you to look at your goals for doing a needs assessment. For example, do you want to:

  • establish baseline data?
  • update existing data?
  • document the extent of oral health needs in a community or subgroup?
  • show the gaps in services?
  • demonstrate the need for more service providers?
  • demonstrate the need for collaboration and coordination of efforts?
  • show the changing demographics of the region?

One of the keys to collecting data and information is to be clear on your goals. Spend time collecting the information you need, not extraneous information that is "nice to know" but won't be useful for documenting your needs. Needs assessment information also serves as a baseline for evaluating your outcomes.

Developing a Statement of Need

Once you've collected and analyzed the information, the next step is using it to address the identified problems.


Presenting a concise, compelling description of the major oral health issues in a community is a crucial step for enlisting partners and resources to address the problems. A common mistake is to know that problems exist but not be able to document their importance to decision makers or funders who could help provide resources and solutions. When writing a "statement of need", don't make the situation appear hopeless-it needs to appear challenging, but not insurmountable.


Compare the following three ways to make a point in a statement of need.

1. The mean dfs for Head Start children ages 3-5 in rural areas is 4.5. Prevalence of early childhood caries is 40% of 5-year-olds. Treatment costs range from $400 to $4000.


2. By the time they reach age 5, 40% of Head Start children in rural areas will have dental decay. Treatment for severe cases can cost almost $4,000 per child if hospital anesthesia procedures are needed.


3. Show a photo of a child being treated in the hospital, with caption of "Up to 40% of 5-year-old Head Start children in rural areas may incur costs of $4000 each to treat their dental decay."

When writing a statement of need, consider the audience. The first statement is written with epidemiologists and oral health researchers in mind as part of a research application or journal article. Statement 2 is more appropriate for a grant application. Option 3 is useful for newspaper or other advocacy pieces where you want to create a memorable visual image and an emotional response. Important elements to consider in presenting information include the literacy level of the audience, their potential interest in the topic, and knowledge of oral health issues. Your goals for writing the statement of need will determine what information to include.

View an example of a statement of need. Note--some funders expect you to include a description of your proposed solutions in the Statement of Need section of a grant proposal, while others request that type of information in a Proposed Methods section.

Planning for Change

Once you have identified issues and potential barriers-"defined the problem"--you will need to step back and prioritize which ones you can realistically tackle, and what strategies you will use. Ask these questions:

  • What do you really want to accomplish?
  • What can you accomplish in the immediate future, versus a year from now or in five years?
  • What are the community's assets?
  • Who can help you make your ideas a reality?
  • What resources will you need?
  • How can you mobilize people to rally around the cause?
  • Do you have people in the community with the knowledge and skills that are needed, or will you have to look for help from experts or other communities?
  • Are other communities having similar problems?
  • Would it be beneficial to join with other communities to leverage resources?

These are important questions to ask when planning an effort to improve the oral health of a population. Chapter 2 addresses ways to mobilize community assets for collaborative planning. A variety of planning and evaluation models are available to help you develop goals, objectives, activities, and desired outcomes.


Don't become frustrated with the planning process and jump right into solutions. It will cost you time, money and more frustration if the solutions are not appropriate or if you can't mobilize the needed resources. Take the time to create a vision of what you want to do, who can help you, and the paths you can take to accomplish your goals.


Healthy People in Healthy Communities, a booklet available on the Healthy People website at uses a MAP-IT approach to planning that is based on achieving Healthy People 2010 objectives for the nation. MAP-IT stands for:


Mobilize individuals and organizations that care about the health of your
community into a coalition.

Assess the areas of greatest need in your community, as well as the resources
and other strengths that you can tap into to address those areas.

Plan your approach: start with a vision of where you want to be as a
community; then add strategies and action steps to help you achieve that vision.

Implement your plan using concrete action steps that can be monitored and will
make a difference.

Track your progress over time.


Mobilize individuals and organizations that care about the health of your community into a coalition. Assess the areas of greatest need in your community, as well as the resources and other strengths that you can tap into to address those areas. Plan your approach: start with a vision of where you want to be as a community; then add strategies and action steps to help you achieve that vision. Implement your plan using concrete action steps that can be monitored and will make a difference. Track your progress over time.

A similar approach called MAPP (Mobilizing for Action through Planning and Partnerships), promoted by the National Association of County and City Health Officials (NACCHO), is available at Nine communities/counties are implementing the MAPP process to show how it can be used in a variety of settings:

  • Amherst, MA
  • Hartford, CN
  • Columbus, OH
  • Lee County, FL
  • Mendocino, CA
  • Nashville/Davidson County, TN
  • Northern Kentucky District, KY
  • San Antonio, TX
  • Taney County, MO.

Federal agencies and many foundations use "logic models" to assist in the planning and evaluation process. Logic models link program resources and activities to program products and outcomes, while communicating the logic and rationales behind the program. Faulty logic can lead to ineffective and inefficient programs. United Way uses logic models that are focused on local communities. Some of the county First 5 Commissions in California use this model for writing their requests for proposals. See the Resources section of this chapter for websites and references on logic models or similar planning models. View a logic model related to oral health.

Options for Solutions

A number of national and state conferences have addressed oral health issues and barriers to dental care; some have specifically addressed rural issues. Electronic versions of reports from some of these meetings can be viewed at (look under state or regional reports.) They might provide ideas for ways to assess and address specific problems.

The Children's Dental Health Project has summarized problems experienced by 15 states as well as some potential strategies to address dental access problems ( look under state surveys of oral health needs.)

UCSF Center for the Health Professions published a report, Improving Oral Health Care Systems in California (, funded by the California Healthcare Foundation. Chapter 3 highlights some of the barriers, disparities, and factors influencing the probability of persons seeking dental care.

View an overview table of some strategies to reduce five different types of barriers. Some of the columns have been left blank to enable use as a worksheet. The next few chapters of this manual provide descriptions and examples of specific strategies to use for various problems.


This chapter has prompted you to ask the following questions:

  • What oral health issues create challenges or frustrations for your community?
  • Have a variety of people been asked to voice their opinions and concerns to gain a broad perspective on the issues?
  • Have the issues been analyzed? How?
  • Are there data to document the problems?
  • Has the community identified its strengths/assets/resources?
  • Has all of this information been developed into a statement of need?
  • Have broad goals and strategies been discussed?
  • Has a comprehensive planning process been designed to address the oral health issues?


Community Catalyst, Inc. A Guide to Organizing Community Forums. July 2002.

Gamm LD et al, eds. The state of rural oral health. (In Rural Healthy People 2010: A Companion Guide to Healthy People 2010. Vols 1 and 2, 2003.

Lees DH. Operational application of a county wide oral health needs assessment. Abstract. J Public Health Dent. 63(Suppl 1):547, 2003.

State of Washington Department of Health. Community Roots for Oral Health: Guidelines for Successful Coalitions. Olympia, WA, 2000.l Also includes the following Appendix under Evaluation. Selecting and Evaluating Outcomes for Oral Health Coalition Efforts.

United Way of America. Measuring Program Outcomes: A Practical Approach. Alexandria, VA, 1996. (To order, call Sales Service/America, 800-772-0008, item # 0989.)

View for help in designing a simple logic model for a prevention program.

A more detailed description of logic models with checklists and examples is available through the WK Kellogg Foundation website at


What did you learn or accomplish as a result of reading this chapter? Did it help you to organize your thoughts about oral health issues in your community? Are you planning a community needs assessment or already writing a statement of need? Were the resources and examples helpful? Complete the feedback form for Chapter 1 to tell us what was useful and not useful for you.