In 2000, the U.S. surgeon general issued a report

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1 Developing Dental Hygiene Students as Future Leaders in Legislative Advocacy Ellen J. Rogo, R.D.H., Ph.D.; Leciel K. Bono, R.D.H.-E.R., B.S.; Teri Peterson, Ed.D. Abstract: The purpose of this investigation was to determine the effect of a legislative advocacy project on the knowledge, values, and actions of dental hygiene students enrolled in a leadership course. A quasi-experimental design was employed with a convenience sample of twenty-one undergraduate and seventeen graduate students. The data collection instrument was designed by the authors with three scales (knowledge, values, and actions), a section on barriers to future advocacy actions, and two open-ended questions. Content validity of the instrument was established before it was administered with an online survey tool. Students scored their pre-project and post-project status on the three scales. Cronbach s alphas revealed internal consistency of the three scales at 0.95 or higher. Pre-project scores and post-project scores were analyzed by parametric tests and confirmed using nonparametric tests. Knowledge, values, and actions statements were statistically significant; however, actions were rated the lowest. Multiple barriers for future advocacy actions were identified. Implementation of a legislative advocacy project in an undergraduate and graduate leadership course can positively influence the development of knowledge, values, and actions; however, mentorship in the professional association is needed after graduation to continue the development of future leaders. Dr. Rogo is Associate Professor, Department of Dental Hygiene, Idaho State University; Ms. Bono is Clinical Instructor, Department of Dental Hygiene, Idaho State University; and Dr. Peterson is Statistical Consultant, Idaho State University. Direct correspondence and requests for reprints to Dr. Ellen J. Rogo, Department of Dental Hygiene, Idaho State University, 921 S. 8 th Ave., Stop 8048, Pocatello, ID 83204; rogoelle@isu.edu. Keywords: dental hygiene students, dental hygiene education, legislative advocacy, public policy, leadership training Submitted for publication 6/26/13; accepted 8/27/13 In 2000, the U.S. surgeon general issued a report addressing oral health, oral health disparities, and limited access to oral health care. 1 This report, the first of its kind, acknowledged the systemic-oral health complications that can diminish quality of life for the U.S. population. The goals established for Healthy People 2010 and 2020 acknowledged the need to eliminate health disparities and increase the longevity and well-being of the nation by considering health determinants. 2,3 Three levels of determinants have been defined as constituting the ecology of health 4 (Figure 1). The micro level centers on an individual s health determinants related to healthy and unhealthy behaviors and biological and genetic factors. Health care professionals providing clinical care and self-care education have been responsible for improving individual health determinants. At the next level, the broader mesio determinants are family, community, and social factors. An expanded view of mesio health determinants includes income, social status, work environment, social support groups, education, employment, living conditions, and availability of health services. 5 Public health practitioners work to improve the community environment, thereby enhancing the oral health of a broader population at the local level. The macro level reflects the widest determinants of policies and systems that influence the health of populations at the state and national levels. Improvements to Medicaid reimbursement policy and alternative delivery systems have the greatest potential to expand access to oral health care to underserved populations. Changes implemented at the macro level have the ability to filter down and affect the mesio and micro levels of health determinants; 4 therefore, interventions at the macro level are considered an upstream approach to health care. Traditional oral health care has focused on a downstream approach at the micro level by providing individualized clinical care and changing patient behaviors. This approach has not been successful in maintaining or addressing population health concerns in the United States. 6,7 Interventions at the upstream or macro level are recommended to address the multiple factors involved in population health. 6-8 Incorporating a broad view of population health and understanding how multiple levels within the upstream/downstream paradigm interact and cascade into other levels allow health professionals to create multilevel interventions that can address downstream health disparities. 8 Although ecology of health and upstream/downstream approaches are valuable tactics when considering health changes at the macro level, it is the combination of these forces that successfully address the health of a nation. Collaboration across multiple disciplines along with support from April 2014 Journal of Dental Education 541

2 Figure 1. Population determinants of health Source: Committee on Assuring the Health of the Public in the 21st Century. The future of the public s health in the 21st century. Washington, DC: National Academy Press, governmental agencies and communities is essential for success. 5 Focus on health care determinants at the macro level is thus needed to address current U.S. inadequacies in addressing oral health care prevention and disparities. In order to implement such changes in populations and communities, health care professionals need to become advocates who have been educated to manage and improve the resources necessary for health. 9 Preparing dental health professionals to become advocates and leaders in macro-level legislation requires an understanding of political frameworks, the recognition that one can influence policy making, and implementation of these skills at the undergraduate, graduate, and professional levels. Advocacy is a fundamental element in the code of ethics for health care professionals 10 and is interwoven into dental health professions preambles committed to the promotion and improvement of public health As an integral component of any professional organization, advocacy recognizes an educated united voice as a valuable instrument in policy formulation; 10 as nursing educators have noted, health policy development and advocacy are quintessential exemplars of today s professional practice and particularly crucial in graduate nursing education. 15 This statement is applicable to the many facets of dental professionals education. Advocacy requires leadership skills, the courage to challenge the status quo and protect patients rights, and the ability to become an empowering link in policy change. With a population oral health focus, the call to teach and involve students in the political process is needed for the progression of legislative skills in professional development and for future involvement with advocacy initiatives. 16 However, research regarding dental professionals advocacy and involvement in health education curricula has so far been limited. 16,17 In an attempt to provide more insight into the process of educating dental professionals for legislative advocacy, a two-credit leadership course was introduced into a bachelor of science (B.S.) entry-level degree program and a three-credit leadership course in a master of science (M.S.) dental hygiene program at Idaho State University. The undergraduate course was delivered on campus, and students worked in groups of five or six to complete the activities. The graduate course was provided online, and students completed the activities and projects on an individual basis. The purpose of this educational intervention was to provide students with experiences to link leadership theory with practice, while developing our ability as educators to assess, plan, implement, 542 Journal of Dental Education Volume 78, Number 4

3 and evaluate a legislative advocacy project. Table 1 outlines the basic components of the assessment, planning, implementation, and evaluation phases of the project over a seven-week time frame. The aim of this study was to determine the effect of the legislative advocacy project on the undergraduate and graduate students knowledge, values, and actions. In addition, the students perceived barriers to future legislative advocacy actions were assessed. After an overview of nursing education that we used as a model, the methodologies of our study and its results are described. Using Nursing as a Model Advocacy has been woven into the rich history of nursing from the beginning with Florence Nightingale, and the nursing literature is replete with examples of leadership, political advocacy, and legislative instruction at the baccalaureate and graduate levels. The political advancement of nursing provides a framework to guide dental health professionals into future public health policy advocacy. Cohen et al. 18 discussed four stages that are important for political activism: the buy-in, self-interest, political sophistication, and leading the way. Dental health professionals have begun this political traverse into activism, and future leaders are needed. In order to create leaders with advocacy skills, education and empowerment become valuable assets in developing political awareness. Nursing has long recognized the importance of participating in macro-level legislation and the benefits of teaching advocacy as part of its educational curriculum, and the nursing education literature provides valuable insight into educational strategies for developing political competence. These courses have been implemented with the focus of preparing nursing professionals with the skills necessary to navigate the political arena. Providing advocacy experiences at the undergraduate and graduate levels helps students expand health care focus beyond the individual into the macro-level domain. 19,20 Facilitating students with legislative knowledge and strategic collaborative skills aids in future public policy transformation and creates a foundation for future leadership. 15,20 Numerous nursing advocacy courses have applied active learning strategies to familiarize students with the legislative process. Students have experienced increased political awareness and empowerment and have developed critical thinking skills needed for political competence Relationships formed with coalitions, interest groups, and state Table 1. Phases and components of the Legislative Advocacy Project Legislative Advocacy Phases Components Assessment Assess legislative efforts of your state dental hygienists association Assess the role of the state association s lobbyist Assess your state s legislative system Assess your legislators as policy makers on health care legislation Assess health bills being considered during the current legislative session Assess supportive collaborators for the legislation Assess opponents for the legislation Planning Create a professional mission, vision, and values for the project Complete a SWOT analysis related to the project Complete a strategic plan for the project Develop an evidence-based fact sheet to support or oppose the health care legislation Write a letter to legislators to support or oppose the health care legislation Implementation Send letter and fact sheet to legislators Follow the progress of the bill through the current legislative session Extend knowledge of being a change agent and advocate Evaluation Evaluate the strategic plan outcomes for Assessment phase Planning phase Implementation phase Evaluate the effectiveness of the project Reflect on the positive and negative aspects of the experience Explain changes for future endeavors April 2014 Journal of Dental Education 543

4 legislators have been reported to positively impact students and influence the legislative process. 21,22 Students have acknowledged the power of a political voice in population health, their own professional development, and the ability to sharpen advocacy skills as key components in developing political awareness Advocacy is not without barriers. Lack of interest and apathy regarding macro-level politics have been explored as they affect the nursing profession. The main deterrents in nursing macro-level legislation involve lack of knowledge and advocacy skills. 25 Students often fail to recognize their actions as being political or worthwhile, and they frequently view public policy as an impediment to health issues rather than an avenue for change. 26 Free time, resources, and personal efficacy have also been identified as barriers for organized political participation in professional associations. 25 In spite of these findings, research following nursing activists and legislators reveals that nurses have the ability to influence legislative action. Various legislative strategies and decision modus operandi developed by state legislators and nursing political experts have been studied and recommended for lawmaking action regarding population health These strategies, along with supportive networks for nursing advocacy efforts, suggest a provision of collective strength to the profession and the ability to influence the political arena With the rapid changes in the definition of public health policy to include social health determinants, nursing has recognized the need to educate students and professionals to utilize advocacy skills and strategies beyond the traditional health policy intervention to formulate broad health policies. 31,32 Mentoring and collaborations with faculty and professional associations are recommended to foster student advocacy efforts. 24,33-35 Nursing advocacy efforts have provided a rich array of political examples and leadership for dental health professionals. As we politically traverse our own advocacy road, nursing research involving education, legislators, nursing activists, and students has constructed a legislative road map for us to follow. With this road map in hand, investigations regarding dental health professional political advocacy begin. Multiple approaches can be utilized in designing a dental health professional advocacy course that introduces students to the legislative arena and empowers them to become involved in macro-level legislation and population oral health. Methods A quasi-experimental research design was employed for this study. Data were collected using a survey based on several instruments from the nursing literature and the components of our current legislative advocacy project. The pre-project and post-project data collection instrument consisted of three scales related to knowledge, values, and actions of legislative advocacy. The post-project survey also contained a section on barriers to future legislative advocacy actions and two open-ended questions asking 1) what would encourage you to increase the probability of participating in legislative advocacy efforts, and 2) is there additional feedback you want to share? The knowledge variable and barrier variable were scored using a seven-point Likert scale ranging from 1=strongly disagree to 4=neutral to 7=strongly agree. The values variable was scored using a sevenpoint scale based on level of importance from 1=extremely not important to 4=neutral to 7=extremely important. The final variable, related to legislative advocacy actions, was based on a seven-point scale, which reflected the probability of engaging in these actions from 1=not very probable to 4=neutral to 7=very probable. After Institutional Review Board approval was granted for exempt status from Idaho State University (HSC #3594), a content validity activity was conducted. Two undergraduate students and four graduate students applied a content validity index to the data collection instrument. Students were selected to establish content validity instead of dental hygiene faculty because of their experience with this project. Although faculty members were considered professional experts in research methodology and survey design, they lacked experience with the legislative advocacy project. Using participants from the research population is one method for establishing increased relevance of a data collection instrument. 36 All questions and statements on the survey were scored on a four-point scale: 1=not relevant, 2=somewhat relevant, 3=quite relevant, and 4=highly relevant. 37 Content validity was established for each statement in the knowledge, values, and actions sections of the instrument when a score of 3 or 4 by 80 percent was received from the participants. Wording changes were suggested, and revisions were made to the survey. The final survey was created in SurveyMonkey. A convenience sample of undergraduate students 544 Journal of Dental Education Volume 78, Number 4

5 enrolled in the leadership course in the 2011 spring semester (n=24) and graduate students enrolled in the course in the spring semesters (n=26) were invited to participate in the study. The link to the survey was sent to these students using their addresses; however, no personal data such as IP addresses or addresses were collected to maintain confidentiality and anonymity. The first screen accessed on the SurveyMonkey site contained an overview to the study and a consent statement. Those students who volunteered to participate continued to complete the survey. The participants retrospectively scored their knowledge, values, and actions before they were engaged in the legislative advocacy project and then scored their post-project knowledge, values, and actions; they also responded to the barriers section and open-ended questions. The survey remained open for two weeks, and two follow-up reminders were sent. After the survey was closed, the data were downloaded from the SurveyMonkey site into an Excel document, and all incomplete data were removed before analysis. Cronbach s alphas were calculated for each of the three variables (knowledge, values, and actions) for both the pre-project and post-project responses. Six scale scores (three scales for before and three scales for after) were calculated by averaging responses on individual items within each variable. Descriptive statistics (means and standard deviations) were calculated for each of the six scale scores. Average scale responses were compared from pre-project and post-project for both undergraduate and graduate students using a Repeated Measures Analysis of Variance (RM-ANOVA). The RM- ANOVA established the variance within the same subjects measured at two points in time to determine whether differences were found. The assumption of normality was tested using the Shapiro-Wilk test. The assumption of homoscedasticity was tested using Box s M test of equality of covariance matrices. When the assumptions were violated, nonparametric tests were conducted to assess the robustness of the RM-ANOVA to the violations. If the results differed between the parametric and nonparametric tests, the nonparametric results were used. Results One hundred percent of the participants were female. Twenty-one B.S. (87.5 percent) students and seventeen M.S. (65.4 percent) students completed the survey. The majority of undergraduate students were between the ages of twenty-one and twentyfive; the majority of graduate students were in the forty-plus age category. All of the B.S. students were members of the Student American Dental Hygienists Association (n=19, 90.5 percent) or leaders in this organization (n=2, 9.5 percent). While some M.S. students were members of the student organization (n=4, 23.5 percent), the majority were members of the American Dental Hygienists Association (n=8, 47.1 percent), some were leaders in this organization (n=4, 23.5 percent), and one student (6 percent) was not a member of either association. The majority of B.S. students were registered to vote (n=17, 81 percent) and voted in the last election (n=11, 52.4 percent). Likewise, the majority of M.S. students were registered to vote (n=16, 94.1 percent) and voted in the last election (n=13, 76.5 percent). Cronbach s alphas in each of the knowledge, values, and actions scales before and after the legislative advocacy project ranged from to 0.973, indicating a high level of internal consistency among the scales (Table 2). Means and standard errors for each of the scale scores broken down by B.S. and M.S. level and before and after the legislative advocacy project are shown in Table 3. These scores were represented on a seven-point scale. Low scores on the knowledge scale represented low self-reported knowledge regarding the legislative process, and high scores indicated a high level of knowledge. On the values scale, low scores indicated a low level of importance of the values associated with legislative advocacy, and high scores indicated a high level of importance on this scale. For the actions scale, low scores indicated a low likelihood of action, and high scores indicated a high likelihood of action. The neutral point on all scales was a value of 4. B.S. and M.S. students had an average score in the low range for both the knowledge and actions variables before the advocacy project. In terms of values, the average score before the project was at neutral for the B.S. students and at slightly important for the M.S. students. In all cases, the average ratings after the legislative advocacy project were higher than before it. The results of the RM-ANOVA for the knowledge, values, and actions variables are shown in Table 4. The knowledge scale demonstrated a significant main effect of before versus after (F=124.79, DF1=1, DF2=36, p<0.001) and B.S. versus M.S. students (F=8.07, DF1=1, DF2=36, p=0.007). There was no significant interaction between before versus after and student level (F=0.059, DF1=1, DF2=36, April 2014 Journal of Dental Education 545

6 p=0.810). This finding indicated that all students increased in their self-reported level of knowledge and that B.S. students reported lower levels of knowledge than did M.S. students. The lack of a significant interaction indicated that the amount of change was not significantly different for the two student levels. The assumption of normality was met for the before knowledge scale (p=0.260), but it was violated for the after knowledge scale (p=0.010). In addition, Box s M test indicated a significant violation of homoscedasticity (p=0.022). The Wilcoxon signed-rank test indicated a significant increase from before the legislative advocacy project to after the project for both student levels (p<0.001 for both B.S. and M.S. students). However, a Mann-Whitney U test indicated no difference between the undergraduate and graduate students on the before knowledge scale (p=0.189) and a significant difference on the after knowledge score (p=0.004). This finding was consistent with the increase in self-reported knowledge as demonstrated by the RM-ANOVA. However, this result indicated a greater increase for the M.S. students than for the B.S. students. Table 2. Cronbach s alphas for knowledge, values, and actions variables Variable Before After Knowledge Values Actions The results of the RM-ANOVA for the values scale demonstrated a significant main effect of before versus after (F=57.67, DF1=1, DF2=36, p<0.001) and B.S. versus M.S. students (F=9.25, DF1=1, DF2=36, p=0.004). There was no significant interaction between before versus after and student level (F=0.148, DF1=1, DF2=36, p=0.703). This finding indicated that all students increased in perceived level of importance of legislative advocacy and that B.S. students reported lower levels of importance than did M.S. students. The lack of a significant interaction indicated that the amount of change was not significantly different for the two student levels. The assumption of normality was met for the before values scale (p=0.170), but it was violated for the after values scale (p=0.010). In addition, Box s M test indicated a significant violation of homoscedasticity (p<0.001). The Wilcoxon signed-rank test indicated a significant increase from before the legislative advocacy project to after the project for both student levels (p<0.001 for B.S. and p=0.001 for M.S. students). However, a Mann-Whitney U test indicated no difference between the undergraduate and graduate students on the before values scale (p=0.121) and a significant difference on the after values score (p<0.001). This finding was consistent with the increase in perceived importance of legislative advocacy as demonstrated by the RM-ANOVA. However, this result indicated a greater increase for the graduate students than for the undergraduates. The results of the RM-ANOVA for the actions scale demonstrated a significant main effect of before Table 3. Mean (M) and standard error (SE) for knowledge, values, and actions variables B.S. Students M.S. Students Before After Before After Variable M (SE) M (SE) M (SE) M (SE) Knowledge 2.9 (0.32) 6.0 (0.16) 3.7 (0.35) 6.6 (0.17) Values 4.0 (0.34) 6.1 (0.14) 5.0 (0.38) 6.8 (0.16) Actions 2.5 (0.38) 4.2 (0.29) 3.4 (0.42) 5.9 (0.32) Note: Scores ranged from 1 (lowest) to 7 (highest). Table 4. RM-ANOVA results Significant Main Effect Significant Main Effect No Significant Interaction Variable Before vs After B.S. vs M.S. Before vs After and Student Level Knowledge F=124.79, p<0.001 F=8.07, p=0.007 F=0.059, p=0.810 Values F=57.67, p<0.001 F=9.25, p=0.004 F=0.148, p=0.703 Actions F=68.035, p<0.001 F=8.50, p=0.006 F=1.942, p= Journal of Dental Education Volume 78, Number 4

7 versus after (F=68.035, DF1=1, DF2=36, p<0.001) and B.S. versus M.S. students (F=8.50, DF1=1, DF2=36, p=0.006). There was no significant interaction between before versus after and student level (F=1.942, DF1=1, DF2=36, p=0.172). This finding indicated that all students increased in perceived likelihood of action and that B.S. students reported lower levels of likelihood of action than did M.S. participants. The lack of a significant interaction indicated that the amount of change was not significantly different for the two student levels. The assumption of normality was not met for the before actions scale (p=0.004) or for the after actions scale (p=0.003). Box s M test indicated the assumption of homoscedasticity was met (p=0.100). The Wilcoxon signed-rank test indicated a significant increase from before the legislative advocacy project to after the legislative advocacy project for both student levels (p<0.001 for both B.S. and M.S. students). However, a Mann-Whitney U test indicated no difference between the B.S. and M.S. students on the before actions scale (p=0.268) and a significant difference on the after actions scale (p<0.001). This finding was consistent with the increase in perceived likelihood of legislative advocacy as demonstrated by the RM-ANOVA. However, this result indicated a greater increase for the M.S. students than for the B.S. students. Barriers to legislative advocacy are shown in Table 5 for the participants. No statistically significant differences were found between the two groups related to any of the barriers (p= ). Table 6 Table 5. Mean (M) and standard error (SE) for barriers to legislative advocacy B.S. Students M.S. Students Barrier M (SE) M (SE) Lack of time to be involved 5.0 (1.4) 5.1 (1.5) Lack of comfort testifying before legislators 5.0 (1.7) 4.9 (2.1) Lack of comfort speaking personally with legislators or staff members 4.6 (1.7) 4.2 (2.4) Lack of priority to be involved 4.9 (1.3) 3.8 (2.0) Lack of mentorship in the state dental hygienists association 3.9 (1.7) 3.7 (2.6) Lack of interest 4.0 (1.6) 3.1 (2.2) Lack of belief that my legislative advocacy actions can make a difference 3.9 (1.6) 2.9 (2.4) Lack of knowledge of the legislative process 3.0 (1.6) 2.6 (2.3) Note: Scale was 1=strongly disagree to 4=neutral to 7=strongly agree. Table 6. Responses to open-ended questions by B.S. and M.S. students What would encourage you to increase the probability of participating in legislative advocacy efforts to improve health? Nothing; it was a great project, but it is not my personality type to do this sort of thing. (M.S.) I m not a very vocal person, so this would be very hard for me. (B.S.) I think being involved in private practice for a bit would increase the probability of my participating, as well as my state association having enthusiasm for participating in legislative advocacy. (B.S.) This course was instrumental in increasing my awareness about legislation and the need to become involved in advocating for oral/general health issues. I have already made a commitment to become involved in these issues after taking this course. (M.S.) More experiences and exposure to the process within the group efforts of ADHA. I would like our local ADHA branches to have advocacy awareness days: updating local hygienists and demonstrating the process and progress of all health or general legislation that has importance to our profession. (M.S.) Is there additional feedback about the Legislative Advocacy Project that you wish to share? I did learn a great deal about the process, which was great! (B.S.) The focus of this course should be on the advocacy project, which is the most important aspect. (B.S.) This course provided a great opportunity to learn how one can become an advocate and made one aware of the health disparities that exist in our nation. I wish everyone could have the opportunity to participate in this course because the information is invaluable. (M.S.) This is an excellent project that will instill confidence in dental hygiene professionals to become involved and stay involved in the legislative endeavors of their professional associations. (M.S.) April 2014 Journal of Dental Education 547

8 provides representative comments from the M.S. and B.S. participants. Discussion Results from this study suggest the students knowledge, values, and actions significantly increased after completing a legislative advocacy project. Although there was not a significant difference between the B.S. and M.S. students prior to taking an advocacy course, both demonstrated a significant increase in these three variables. These findings suggest that a legislative advocacy assignment was a worthwhile experience for both groups of students in helping them become familiar with the legislative process, recognizing the value of a political voice, and developing skills needed for political awareness. In a similar study, Faulk and Ternus 24 utilized active learning strategies in an online advocacy course to engage students in the legislative process. Their data from online postings and a survey demonstrated a paradigm shift from beginning perceptions to ending perceptions with an increase in knowledge, values, and future advocacy actions. A greater overall increase in knowledge, value, and actions for M.S. students in our study was noted when compared with B.S. students. M.S. students completed the advocacy project by themselves in an online course, suggesting active individual involvement with a vested interest in political awareness as practicing professionals. B.S. students completed the project in the traditional classroom setting in groups of five or six students. A suggestion for future advocacy courses at the B.S. level would be to decrease group size to two or three students in order to actively engage each student in the assessment, planning, implementation, and evaluation phases. Helping students recognize their personal values and gain political confidence are important educational objectives for a legislative advocacy instructional unit. In our study, assessment, planning, and implementation strategies were employed to assist students in extending their knowledge of being a change agent and becoming a health professions advocate. Students were encouraged to follow a health care bill through the legislative process. Active learning strategies were used to create a professional mission, vision, and values statement for the project, conducting a SWOT analysis, completing a strategic plan, developing an evidence-based fact sheet, and contacting the legislators with written cor- respondence. B.S. students worked in small groups in a classroom setting to engage in these activities, whereas M.S. students created and then shared their work with each other through weekly online postings. The key elements in the effectiveness of this legislative advocacy project were the engagement of students in the learning process and focusing on the highest cognitive level, that of creating. Other active learning strategies that could further enhance development of political awareness include attending a legislative session, participating in a professional association s Lobby Day, personally interacting with state legislators or lobbyists, viewing a legislative session on the Internet or television, or providing testimony at a hearing for a health bill. Suggestions for onsite classroom instruction might include role-playing or a political debate regarding a health bill. Cramer 35 suggested additional strategies for creating political experiences such as researching issues pertinent to individual concerns or health care topics, as well as monitoring state and national legislation that could affect health care policy or patients. This author also noted that, to cultivate political confidence, such experiences need to be introduced early in education and continue past graduation into professional associations. While classroom experiences are important, it is the opportunity to experience advocacy in action that fosters experiential learning and shifts the focus from a cognitive sphere to the affective domain. Affective experiences can foster a political awakening in which desire and beliefs that one can make a difference are realized. It is important that students have the opportunity to observe legislative action. Byrd et al. 22 designed an advocacy course in which nursing students interacted with public health officials and state legislators. Anecdotal student conclusions from their study suggested increased political awareness along with recognition of the value of a political voice in population health. Because our study encompassed both the traditional classroom setting and online learning to actively involve students in various advocacy projects, critical thinking, and leadership skills, the significant findings suggest the advocacy course content was effectively delivered in both settings. In a similar study with nursing students, Rains and Carroll 15 demonstrated the positive impact of a health policy course on graduate students self-perceived political competence in four advocacy areas: political skills, political knowledge, understanding political context, and political motivation. Their course was 548 Journal of Dental Education Volume 78, Number 4

9 taught onsite in a classroom setting with additional students participating via teleconference locations. Both groups exhibited a significant increase in selfperceived political competence suggesting both methods of delivery were effective. Even though our study indicated a significant increase in knowledge, values, and actions after completing an advocacy assignment, some students expressed concerns or personal apprehension regarding advocacy. Perceived barriers and limitations to future advocacy were the lack of time and lack of comfort testifying before legislators. Both levels of participants tended to disagree regarding lack of knowledge of the legislative process as a barrier, thus supporting the effectiveness of the instructional unit. M.S. participants slightly disagreed with the barriers of lack of interest and lack of belief that their actions could make a difference, whereas B.S. students were more neutral about these two barriers. One plausible explanation is that B.S. students were focused more on clinical practice and becoming entry-level practitioners than their M.S. counterparts, who were already practicing and had experience and confidence interacting with clients. In a similar study in the nursing profession, Cramer 35 used a Civic Volunteer Model to determine factors associated with political participation of nurses and found the two best predictors of participation were free time and personal political efficacy. Cramer recommended fostering student efficacy through joint collaboration between faculty and professional associations. Anecdotal responses from B.S. and M.S. participants in our study reflected the importance of legislative advocacy efforts to improve oral health. The participants expressed increased political awareness and action after the educational intervention. Additional responses acknowledged the value of one s voice, increased personal efficacy, and the desire to have all oral health professions students complete a legislative advocacy instructional unit. The participants also considered an advocacy project to be a worthwhile investment. Due to our study s small sample size of convenience with one undergraduate class and graduate participants from classes, additional research is needed with a larger population to determine if a legislative advocacy instructional unit consistently increases knowledge, values, and actions in dental hygiene students. This study also employed a retrospective pretest analysis that might have influenced posttest answers. Suggestions for future studies include using a similar research design that uses a pretest prior to the instructional unit. Enhancements to this research design could include a follow-up survey to the participants who completed this study to determine subsequent actions and if there were any changes to perceived barriers after graduating from the program. Conclusion Educating future oral health professionals to participate in health advocacy at the macro level is necessary to address the oral health needs of the nation. Our current dental delivery system leaves a number of populations underserved, so the academic community, professional associations, and other stakeholders need to work with legislators to develop other models for delivery of care. 38 Advocacy to support legislation is paramount to make improvements including alternative models of care emphasizing interprofessional practice. The American Dental Education Association (ADEA) s Foundation Knowledge and Skills for the New General Dentist include the ability to contribute to and improve oral health beyond traditional practice settings. 39 Health care advocacy requires the ability to understand policy and its development by examining, identifying, evaluating, and participating in the legislative and regulatory processes involved in policy formulation. 40 The World Health Organization framework for addressing health inequities directs policy intervention to reduce social stratification, exposures to health risk factors, susceptibility of vulnerable populations, and differing outcomes of diseases. 41 These interventions also are applicable to improve oral health strategies through policy development. 42 Oral health professionals are called to engage in advocacy efforts to guide policy formulation that benefits the public s health and expanded access to care. Implementing advocacy projects for students can provide the foundation needed to address upstream and downstream legislative action, oral health disparities, advancement of the profession, and creation of future leaders. Educational workshops provide the opportunity to develop advocacy skills as educators and leaders. For students, a legislative advocacy unit during the professional curriculum can have a positive influence on creating and expanding political awareness. Even though the outcomes in our study suggested a positive experience for B.S. and M.S. students, these actions might not be continued. Engaging students April 2014 Journal of Dental Education 549

10 and professionals in advocacy does not guarantee political practice although active learning strategies can create a foundation for future professional and community involvement. 22 Educators and mentors form the cornerstone, empowering students with the legislative knowledge needed to create a foundation for future leadership. This foundation becomes the keystone for entering the affective domain and cultivating advocacy in action. REFERENCES 1. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, Healthy people 2010: understanding and improving health. Washington, DC: U.S. Government Printing Office, Healthy people 2020: understanding and improving health. Washington, DC: U.S. Government Printing Office, Committee on Assuring the Health of the Public in the 21st Century. The future of the public s health in the 21st century. 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