By Nelle Gregory, RN, MPH

Many chronic health conditions and most dental diseases are preventable if we eat healthy foods, exercise, get good sleep, limit our stress, and practice good oral hygiene. Many of us have the information we need to make good decisions, so why do we sometimes

fail to follow our healthcare providers’ recommendations? To make changes in our behaviors, we must have the desire to act and move towards a goal…we must be motivated. For healthcare providers, it can be discouraging when patients fail to comply with their treatment recommendations. Research has shown that most of us have a hard time following our healthcare provider’s recommendations; knowledge is not enough to change behavior.  It requires that healthcare providers move from simply sharing health information to building mutual respect that allows the patient to articulate his or her own solutions.

At community listening sessions conducted by The WNC Children’s Oral Health Initiative, parents said they do not know what good oral health looks like, when they should take their child to the dentist, where they could get care, what the standard care is, and how much it should cost. They do not have the basic information they need to make good oral health decisions… and it is impacting their ability to get their children into care. Many parents shared stories of feeling shamed and talked about being ‘blamed for their kids poor oral health.’  They discussed how this made them less likely to want to go back to the dentist.

The American Dental Association (Health Literacy in Dentistry, 2009) encourages the creation of a respectful and ‘shame-free’ dental environment. By helping patients identify their own reasons to change their behavior, they build trust in and respect for their healthcare provider and are more motivated to change. Motivational interviewing is one tool that helps healthcare providers support and encourage their patients’ readiness to change.

Motivational Interviewing (MI)

Motivational interviewing (MI) is an evidence-based approach to behavior change that is grounded in a respectful conversation between provider and patient to identify a patient’s readiness for change, and that helps the patient come up with ideas about how they can strengthen their motivation to change.  Making MI the foundation of anticipatory guidance assures that providers listen to the concerns of parents and children, understand their ambivalence to change, and support their ideas about change and what they think would work.  In a dental setting, MI shifts the conversation from a one-way monologue about brushing their teeth and cutting down on sugar to a conversation about the parent and child’s experiences, challenges, and ideas about what needs to change and how the provider can support them in making the needed changes.

The American Dental Association research has shown that the main reason people do not get dental treatment is due to cost and perceived need.  The way providers counsel impacts their patients’ perceived needs.  At one of the community listening sessions a parent shared that her dentist told her to ‘just do a better job brushing her daughter’s teeth,’ but the parent, whose child is autistic, said that she has a hard time getting her daughter to open her mouth, and brushing her teeth is the least of her worries.  She left frustrated that her dentist had no understanding of autism, and her perceived need for dental services was low.

Research has shown that using MI in dentistry can lead to more lasting behavior change and improved oral health outcomes (Kay, 2016). Positive behavior change occurs more readily when healthcare providers connect the change with what the patient values – people are motivated to change when it impacts what they value rather than what someone else determines they need.  Confrontational styles or persuasion are likely to build resistance and mistrust. When health providers try to persuade or give advice, patients often feel guilt or shame.  Healthcare providers must abandon the impulse to solve their patient’s problems and allow them to articulate their own solutions. Our motivation is impacted by our culture, family norms, and the multitude of other issues we deal with in our daily lives.  The parent of the autistic child shared that she just needed her dentist to listen to her, hear the challenges she faces when trying to care for her daughter’s oral health, empathize with her, give her suggestions the dentist had heard from other autistic parents on how to get her daughter to open her mouth, and work with her to figure out a better solution.

Learn More
The WNC Children’s Oral Health Initiative is partnering with MAHEC to develop MI training for dental professionals.  If you want to get more information about the project or MI training, contact

About the WNC Children’s Oral Health Initiative

The Western North Carolina (WNC) Children’s Oral Health Initiative, with funding from The Duke Endowment, is working to improve children’s oral health.  The project is coordinated by Mission Children’s Hospital and  WNC Health Network and overseen by a Steering Committee of dentists, dental hygienists, physicians, public health providers, and community partners.  The group completed an assessment of children’s oral health in 18 western counties in NC in 2017.  They held parent listening sessions to hear concerns parents in WNC had about their children’s oral health.  A strategic plan was developed that prioritized the concerns voiced by parents.



American Dental Association. Health Literacy in Dentistry: Strategic Action Plan 2010-2015. Council on Access, Prevention, and Interprofessional Relations. Chicago, IL, 2009.

Achison KA, Rozier RG, Weintraub JA. Integrating Oral Health, Primary Care, and Health Literacy: Considerations for Health Professionals Practice, Education and Policy. Commissioned by the Roundtable on Health Literacy, Health, and Medicine Division, the National Academies of Sciences, Engineering, and Medicine.  Prepublication copy, 2018.

Kay EJ, Vascott D, Hocking A, Nield H. Motivational interviewing in general dental practice: A review of the evidence. British Dental Journal 2016; 221: 785-791

Beth Booth, originally from the coast of NC, became health director of Graham County, NC in November, 2017. Since landing in her leadership role with Graham County Department of Public Health, she has led the agency in bringing back primary care and in streamlining services, working creatively to leverage auxiliary and support staff in the face of a rural nursing shortage.

Image by Nik Shuliahin

The health department is also strengthening their work in the community and has reestablished a previously dormant substance use coalition. In addition to Beth and Amber Williams, Health Educator at the health department, the coalition includes resource officers, principals, preachers, nonprofit leaders, the leader of Celebrate Recovery (a local faith-based recovery program), and the director of a local thrift store who is a minister and does work with substance use.

As Beth was getting the coalition back in action, she determined that she wanted to conduct a listening session (or focus group), with people in recovery to both help inform the community health assessment process, and to also avoid taking on issues not viewed as high priority by those most affected by substance abuse.

Beth and Amber worked with WNC Health Network before the listening session. “Support from WNC Health Network was crucial,” says Beth. “We attended their WNC Healthy Impact training on how to convene community listening sessions. Then they worked with us

Photo of Graham County by Patrick Williams, Ecocline Photography

one-on-one to develop the script and give us pointers, including how to pay attention to body language of people in the group, how to ask people to speak up without being obtrusive, and how to sit quietly and not overpower the group or sway them in any direction.”

Beth had built a relationship over the previous year with a team leader at Celebrate Recovery, and he was able to schedule an evening for Beth and Amber to come to meet with participants in the program. Beth and Amber arrived early so that they could participate in the sermon and group dinner prior to their session. “I didn’t just walk in during the middle of the sermon and disturb everything. Staying for the whole event is crucial for building mutual trust and respect,” says Beth.

Beth and Amber started their listening session by letting participants know that the session would be recorded, and how they were planning to use the information. When the session started they had six participants – by the time it ended they had about 10 in attendance.

“I told the participants – you are the experts in this. I want to know what you’ve experienced, how you got where you are, and  how you got yourself out,” says Beth. “At one point when our tape recorder stopped running the participants let us know that it had stopped and waited to continue talking until the recorder was running again. Oftentimes public health is afraid they’re going to offend someone by asking targeted questions, but it’s not a sensitive issue to them, it’s their life. They want you to hear what’s coming out of their mouth and to give a darn about what they think.”

The listening session participants gave Beth and Amber feedback on where to locate syringe drop boxes, and how to best structure youth prevention programming. They also spoke to the challenges posed by stigma: “The group told me that there are plenty of people who have trouble getting help because people don’t think they’re worth the help.” Eventually, the team leader had to come in and stop the lively session because it was past 9 pm.

Because of feedback and insights gained from the listening session, the health department is now working on reopening the domestic violence shelter that shut down in 2017. They are exploring what can be done to expand transitional housing, and to increase prevention for youth, including resiliency education in the schools. They are looking at starting a support group for adults in recovery that is not faith-based, as well a support group for children located in the schools.

The experience – in addition to holding listening sessions with other segments of the community – has driven home for Beth that there are still too many people who don’t realize what a huge problem substance misuse poses for their friends, family, and neighbors. Beth says: “That has been an awakening for me – I took it for granted that people knew we have a problem in our county, but when I present the data and the stories I’ve heard you can hear the murmur going through the room… they’re shocked. It has started coming down to community-wide education and bringing everyone to realize, yes – there’s a problem in the county. It might not touch you, but it exists.”

Beth Booth’s Thoughts on Successful Listening Sessions:

  • Be upfront when you go in to the listening session; know that participants are going to ask you what you plan to do with the information and that you will be held accountable for how you respond.
  • Don’t make assumptions; sit and listen with an open mind.
  • Don’t think that participants are going to be close-lipped. If you build relationships and mutual respect they will respond to your questions openly and generously.
  • Be honest about what you’re looking for: ‘I’m here for you and your opinion.’
  • Let the group know that they are the experts and that you’re looking to learn from them.
  • Take the time to sit through the entire session or event (provided that you have been invited into that space). Be respectful of the participants’ time and the time you’re taking from them.
  • Take the information given to you by the participants and understand that their story is valid data, as if you had asked a scientist.
  • When you acquire information from community members you must hear it and you must do something with it – you’re responsible for it.
  • Understand that the participants have just as much passion about the issue as public health does – probably even more passion.

If you are interested in learning how WNC Health Network could support you in conducting community listening sessions of your own, contact Emily Kujawa, Project Manager & Improvement Specialist (