UCLA-Sesame Street Collaboration To Improve Children's Oral Health

James J. Crall, DDS, ScD, is a professor and chair of the division of public health and community dentistry at the University of California, Los Angeles, School of Dentistry. Conflict of Interest Disclosure: None reported.

David Cohen is the director of education, research and outreach at Sesame Workshop in New York. Conflict of Interest Disclosure: None reported.

Sofia Polo, MPH, is a research strategist at Fluent Research in New York. Conflict of Interest Disclosure: None reported.

Sylvia Rusnak, PhD, is a senior research analyst at Sesame Workshop in New York. Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: This paper describes a series of activities through which UCLA and Sesame Street collaborated to develop and use oral health resources as part of a children’s oral health awareness campaign.

Methods: Activities included producing five new Sesame Street oral health videos featuring Muppets, supporting a children’s oral health awareness campaign through social media, distributing child and parent educational resources and conducting focus groups of parents, caregivers and oral health professionals to assess their perspectives about children’s oral health, messages and strategies.

Results: The awareness campaign exceeded each of six preestablished goals, with the social media campaign generating impressive metrics within a month of the release of the fifth video. The five new videos generated over 687,000 views across UCLA’s More LA Smiles and Sesame Street websites.

Conclusions: Resources developed through the UCLA-Sesame Street collaboration for the children’s oral health awareness campaign were accessed by targeted populations at rates that exceeded expectations both during and after the campaign.

Practical implications: These new resources are available at no cost via the internet and can contribute to additional efforts aimed at increasing oral health literacy for young children, their parents and caregivers.

Keywords: Children; oral health; health literacy; Sesame Street; dental health education

__________

Dental caries is the most common chronic disease of childhood and affects high-risk children beginning in infancy and early childhood. [1] Chronic diseases are highly dependent on lifestyle and behaviors that increase or reduce disease risk, social determinants of health and health literacy. Chronic diseases also often share many common risk factors. [2]

Evidence indicates that disadvantaged children who participate in early childhood education programs with an emphasis on health and nutrition have significantly lower prevalence of risk factors for diet-related chronic diseases in their mid-30s. [3] The evidence is especially strong for males. Evidence also shows that tooth decay in early childhood is a risk factor for caries development in permanent teeth. [4] Accordingly, efforts to find effective methods to improve health literacy and establish healthy behaviors related to young children’s oral health are warranted from a life-course perspective. [5]

Sesame Street has been recognized as a trusted educational source for young children for over 50 years. In 2005, Sesame Workshop launched Healthy Habits for Life, a multi-year, contentdriven initiative to help young children and their caregivers establish an early foundation of healthy habits. [6] The vision of this initiative is to harness the power and reach of Sesame Street to make overall health and well-being as crucial to the healthy development of young children as learning to read and write — helping to establish habits that will last a lifetime.

Collaboration between UCLA and Sesame Street regarding oral health began in 2005 as part of planning for a UCLA-directed Health Resources and Services Administration (HRSA) National Maternal and Child Oral Health Policy Center national symposium on oral health and school readiness, which was convened in Washington, D.C. in November 2006. The collaboration served to heighten Sesame Street’s awareness of the extent and impact of early childhood caries and oral health disparities among U.S. children.

Sesame Street subsequently convened the Children’s Oral Health Expert Meeting in May 2008 to gather input for a new oral health initiative, “Healthy Teeth, Healthy Me.” [7] The initiative and necessary resources ultimately were developed with funding provided by the MetLife Foundation and Sam’s Club and was launched nationally in 2012 in New York City. [8] Included in the initial set of resources created for “Healthy Teeth, Healthy Me” is the “Elmo Brushy Brush” video, which has garnered over 1.6 billion views on YouTube, making it the mostviewed Sesame Street video of all time.

The UCLA-Sesame Street partnership reengaged formally in 2018 as part of the UCLA-led Medi-Cal 2020 Local Dental Pilot Project known as More LA Smiles (MLAS). MLAS partnered with Sesame Street in Communities (SSIC) to create a children’s oral health awareness campaign, including local events, installation of Sesame Street Comfy Cozy Spaces, production of new video resources, convening of focus groups comprised of providers and caregivers and updating and distributing 100,000 “Healthy Teeth, Healthy Me” education kits.

This paper highlights key resources developed through this partnership, describes how the resources were used as part of a recent children’s oral health campaign and provides perspectives regarding the value of these resources in efforts to improve oral health literacy.

Materials and Methods

As noted above, UCLA partnered with Sesame Street and its Sesame Street in Communities program as part of the UCLA-led Medi-Cal 2020 Dental Transformation Initiative Local Dental Pilot Project, known as More LA Smiles (MLAS). [9] Major activities included: production of five new Sesame Street oral health videos featuring various Muppet characters, supporting a MLAS Children’s Oral Health Awareness Campaign, printing 100,000 co-branded “Healthy Teeth, Healthy Me” child and parent education booklets. Sesame Street in Communities also organized focus groups comprised of diverse Los Angeles caregivers and oral health care providers to assess their perspectives about young children’s oral health and to gather feedback on messages and strategies.

Production of New Sesame Street Oral Health Videos

Key messages emphasized in the new Sesame Street oral health videos included:

■ Daily toothbrushing with fluoride toothpaste.

■ Recommended amounts of toothpaste for young children.

■ Making toothbrushing a part of regular nighttime routines (brush, read, sleep).

■ Eating healthy snacks and drinking water.

■ Taking children for their first dental visit by age 1 and having regular check-ups thereafter.

A list of the titles and links to internet locations for English and Spanish versions of the five new videos and additional Sesame Street oral health resources is provided in TABLE.

Production and Distribution of ‘Healthy Teeth, Healthy Me’ Resources

“Healthy Teeth, Healthy Me” is a bilingual (English and Spanish), multimedia outreach initiative motivating children ages 2 to 5, their parents and caregivers to care for children’s oral health. Original versions of “Healthy Teeth, Health Me” were formatted as printed multimedia resource kits that included a Sesame Street DVD and a family guide. In response to changes in information technology, an online toolkit was created. The online kit includes the Provider’s Guide (supporting health practitioners as they create partnerships with families), the Family Guide (with tips for parents/caregivers and children’s activities), an interactive “Brush Those Teeth” game for kids, printable oral health educational activities for children and families and a YouTube playlist of “Healthy Teeth, Healthy Me” initiative video clips. Resources available through More LA Smiles were used to update content using the five new Sesame Street videos and to produce 100,000 print copies of “Healthy Teeth, Healthy Me” booklets for distribution locally at various events in Los Angeles County.

More LA Smiles Children’s Oral Health Awareness Campaign

Sesame Street involvement in the MLAS Awareness Campaign also included helping develop and implement an overall educational campaign and marketing strategy, organizing and participating in local MLAS events in Los Angeles, producing cobranded educational materials and designing and supporting a social media campaign.

Local Events

Local MLAS Children’s Oral Health Awareness Campaign events in Los Angeles were conducted during December 2019 at three sites: Maple Primary Elementary School, Freemont High School and T.H.E. Clinic, a local community health center. The events were designed to be engaging educational activities tailored to the unique characteristics of different settings. At Maple Primary School, activities included participatory educational activities for students focused on tooth-friendly foods and drinks, toothbrushing technique (using interactive e-tablets) and creating their own customized toothbrushes. Additional elements of these local events involved “Sesametizing” sites by creating Sesame Street “Comfy Cozy Spaces” in school and clinic settings, having life-size Muppet characters interact with children and program staff, and distributing toothbrushes, toothpaste and oral health education materials (FIGURE 1). Local events also served as opportunities to engage local media in highlighting the importance of children’s oral health. A number of additional local events were planned for 2020 but had to be canceled due to the COVID-19 pandemic.

Social Media Campaign

From Aug. 25 through Sept. 22, 2020, MLAS conducted a children’s oral health awareness campaign in partnership with Sesame Street in Communities (SSIC) using UCLA social media channels and websites. The aim was to inform parents, caregivers and children about the importance of oral health using engaging Sesame Street educational videos produced with support from MLAS and featuring Muppet characters Grover and Elmo. For this campaign, MLAS communications and SSIC staff developed a partner toolkit that outlined the goal of the campaign, how partners and interested organizations could participate and some general messages (English and Spanish) that could be shared on social media. A campaign webpage was also created that provided premade social media graphics, easy access to UCLA social media channels, a social media calendar of the important dates on which each video would be released and other assorted SSIC resources. In support of MLAS marketing endeavors, SSIC posted the oral health videos and boosted them in two phases: Phase one posted three of the videos and targeted just the Los Angeles region; this phase was completed in Sept., 2020, and featured posts linked to the MLAS website. Phase two posted each of the five videos and targeted a more general audience and also featured links to the SSIC website; this phase ran from mid- October through mid-December 2020.

Focus Groups

Sesame Street organized a qualitative study using focus groups to examine dentists’, child care providers’ and parents’ current practices and perceptions of the barriers Chinese-speaking, Spanishspeaking, Korean-speaking, Black and Filipino families encounter with regard to the oral health of their young children. The focus groups also sought to solicit feedback on SSIC’s oral health resources. Research objectives included identifying stakeholders’ top priorities and concerns around the oral health of young children; exploring stakeholders’ current practices for promoting the oral health of young children and pinpointing where they learned about these practices; describing the challenges and barriers parents encounter in promoting the oral health of young children, including those unique to specific language/ethnic groups; and gathering feedback and recommendations on the SSIC resources and soliciting ideas for effective dissemination strategies to reach the specific language/ethnic groups. The focus groups consisted of 16 in-depth 45- to 60-minute individual interviews with dentists via Zoom and 13 90-minute virtual focus groups with mothers and child care providers conducted via Zoom.

Results: More LA Smiles Children’s Oral Health Awareness Campaign

During the lifetime of the campaign, the aim was to achieve the following goals across all platforms on social media:

■ Reach 10,000 users per video at minimum.

■ Achieve 25% engagement across all posts per video views.

■ Receive 20,000 views per Dentist Grover video.

■ Receive 50,000 views for Elmo’s Toothy Dance.

■ Increase followership by 50% across all platforms.

■ Recruit at least five local and/ or national partners.

Results of the awareness campaign exceeded each of the preestablished goals, with the social media campaign generating impressive metrics within a month of the release of the fifth video (FIGURE 2) [10] and a grand total of over 687,000 views of the five featured new videos across MLAS and SSIC websites by the conclusion of the project in December 2020. Followers increased across all social media platforms, with Facebook followers showing the highest percentage increase (112%) and Instagram having the greatest number of followers (204).

Focus Groups

High-level/executive summary findings from the focus groups organized by Sesame Street include the following:

■ Dentists’ top priorities: Helping families form habits and routines around brushing two times per day, visiting the dentist two times per year, eating healthy foods and taking care of primary (baby) teeth.

■ Mothers’ top priorities: Mothers’ primary concerns centered on their children having a good-looking smile so that they reflect well on them and their family. Mothers also see an attractive smile and good oral health as providing more opportunities to be successful in life.

■ Child care providers’ top priorities: Promoting good oral health by educating children and families and using videos and books to teach children about the importance of brushing to encourage good habits at home.

Participants in the focus groups identified several common barriers that are experienced by families, including financial constraints, time constraints, misconceptions about diet and the belief that dental visits are only for acute issues (when dental problems have been identified), rather than for prevention or a part of wellness. Parents reported that knowledge about oral health comes primarily from personal experiences, pediatricians’ advice and dentists’ advice. Participants felt that the most effective way to share information about children’s oral health is through child care providers and educators who share them with parents and having resources available in dentists’ and doctors’ offices. Chineseand Korean-speaking participants emphasized the need for all resources to be translated in order for them to be useful to members of their communities. [10]

Mothers also see an attractive smile and good oral health as providing more opportunities to be successful in life.

Distribution of Oral Health Supplies and Multimedia Resources

More LA Smiles distributed oral health educational content and oral health supplies through a variety of channels. As noted, the three local events held at local partner sites during December 2019 provided opportunities to distribute “Healthy Teeth, Healthy Me” educational booklets and oral health supplies (toothbrush, toothpaste, timer, oral health handout) to over 1,000 children in underserved areas. MLAS and SSIC also partnered with and participated in a large day-long community event at Dodger Stadium organized by The L.A. Trust for Children’s Health, a nonprofit organization that works to promote health for children enrolled in Los Angeles Unified School District (LAUSD) schools.

The onset of the COVID-19 pandemic resulted in the cancellation of many community outreach events during the final nine months of 2020. However, MLAS was able to distribute “Healthy Teeth, Healthy Me” booklets and oral health supplies to community partners to use during various community outreach activities (e.g., grab-and-go food distribution, local clinics and health fairs). MLAS also partnered with The LA Trust to facilitate incorporation of the MLAS- Sesame Street videos into educational programming for LAUSD students (280 televised spots with an estimated 2.1–2.8 million total views), which was broadcast by local television station KLCS during the prolonged period when school facilities were closed and schools were operating with remote instruction.

Conclusions and Discussion

This paper highlights collaborations between UCLA and Sesame Street to develop and utilize educational and motivational resources to improve the oral health of young children. The goal of these efforts was to increase awareness of behaviors that are recommended for reducing the prevalence, severity and impact of early childhood caries (ECC), including establishing a dental home by age 1 and having regular dental checkups, toothbrushing daily with fluoride toothpaste and reducing caries risk by substituting healthy foods and water for sugar-containing foods and beverages. [11]

Progress toward reducing the prevalence and impact of ECC and oral health disparities among young children has proved challenging. Despite significant research, ECC remains a significant public health problem. Recent systematic reviews have failed to establish evidence for the best way to prevent and manage the disease, but frequently suggest that, in addition to the traditional narrow focus on biological risk factors, greater attention be given to approaches that focus on social, behavioral and family factors and oral health literacy. [12] There also is growing recognition that the chronic disease management concept, focusing on self-care through identifying facilitators and barriers for healthy behaviors, is a promising approach.

Interest in behavioral interventions stems from the understanding that most preventive strategies require action on the part of the individuals who would benefit — action that may not occur naturally and therefore must be actively motivated in some way. [13] Emerging evidence suggests that web-based educational programs for increasing oral health and caries-related knowledge, attitudes and planned behaviors in young mothers can be an effective and low-cost strategy for promoting maternal and infant oral health. [14]

Clinical approaches used heretofore to educate mothers and young children about oral health have limitations stemming from oral health care not being initiated at an early age, especially in high-risk populations such as those covered by Medicaid. Despite recommendations for children to have their first dental visit by age 1, visits to dentists by children under age 3 — especially children from low-income households — remain relatively low. [15] Recent efforts have recognized the important potential contributions of primary care providers in improving the oral health of young children. However, despite growing interest and various initiatives to increase integration of oral health into primary care services, evidence from Medicaid program data shows that the impact remains relatively modest in most states. [16] These limitations underscore the need for additional approaches to educate parents and young children about oral health and help promote the development of healthy habits. Sesame Street is a trusted source of information for young children, with demonstrated positive effects of programming on cognitive outcomes (including literacy) and health and safety knowledge by children in the U.S. and other countries. [17–18] Resource and time constraints did not allow for assessment of these types of outcomes as part of the MLAS project.

Results from this pilot project did however demonstrate that resources developed as part of the UCLA-Sesame Street collaboration for the MLAS children’s oral health awareness campaign were accessed by targeted segments of the population at rates that exceeded expectations both during and after the campaign. By virtue of being accessible at no cost via the MLAS and Sesame Street internet sites, these resources have the potential to contribute to additional efforts aimed at increasing oral health literacy for young children, their parents and caregivers.

ACKNOWLEDGMENTS The UCLA-led local dental pilot project (More LA Smiles) was supported by the California Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services through the Medi-Cal 2020 Dental Transformation Initiative. The authors express appreciation to the DHCS program staff for their support throughout the project and to the following More LA Smiles project staff members who contributed to the collaboration with Sesame Workshop: Landon Celano, Mary Esser and Tanvir Kaur. We also acknowledge the support provided by Jasmin Williams, Rochelle Haynes and Jeanette Betancourt of Sesame Workshop to the More LA Smiles project

REFERENCES

1. Sheiham, A. Dental caries affects body weight, growth and quality of life in preschool children. Br Dent J 2006 Nov 25;201:625–626. doi: 10.1038/sj.bdj.4814259.

2. Egger G, Dixon J. Beyond obesity and lifestyle: A review of 21st century chronic disease determinants. Biomed Res Int 2014;2014:731685. doi: 10.1155/2014/731685. Epub 2014 Apr 7. PMCID: PMC3997940.

3. Campbell F, Conti G, Heckman JJ, Moon SH, Pinto R, Pungello E, Pan Y. Early childhood investments substantially boost adult health. Science 2014 Mar 28;343(6178):1478– 85. doi: 10.1126/science.1248429. PMID: 24675955; PMCID: PMC4028126.

4. Crall JJ, Quinonez R, Zandona A. Caries risk assessment: Rationale, uses, tools and state of development. In: Berg JH, Slayton RL, eds. Early Childhood Oral Health. 2nd ed. Hoboken, N.J.: Wiley-Blackwell; 2015:193–220.

5. Crall JJ, Forrest CB. A life course health development perspective on oral health. In: Halfon N, Forrest C, Lerner R, Faustman E, eds. Handbook of Life Course Health Development. Cham, Switzerland: Springer; 2018:299–320. PMID: 31314282. Erratum: doi.org/10.1007/978-3-319- 47143-3_27.

6. U.S. Department of Health & Human Services/NIH/NIEHS. Sesame Workshop Healthy Habits for Life — A great start to a lifetime of good health. Accessed Aug. 27, 2021.

7. Sesame Street. Healthy Teeth, Healthy Me. Accessed Aug. 27, 2021.

8. Sesame Street. Sesame Street: Healthy Teeth, Healthy Me Launch! Accessed Aug. 27, 2021.

9. UCLA Dental Transformation Initiative. More LA Smiles. Accessed Aug. 27, 2021.

10. Sesame Street in Communities (SSIC). More LA Smiles & SSIC Project Recap: 2019–2020. Project report prepared by Sesame Street for More LA Smiles, 2020.

11. World Health Organization. WHO Expert Consultation on Public Health Intervention against Early Childhood Caries: Report of a meeting. Accessed Aug. 27, 2021.

12. Twetman S. Preventing early childhood caries: Motivating families. Ann Royal Australasian Coll Dent Surg 2016;23:40– 42.

13. Albino J, Tiwari T. Preventing childhood caries: A review of recent behavioral research. J Dent Res 2016 Jan;95(1):35–42. doi: 10.1177/0022034515609034. Epub 2015 Oct 5.

14. Albert D, Barracks SZ, Bruzelius E, Ward A. Impact of a web-based intervention on maternal caries transmission and prevention knowledge and oral health attitudes. Matern Child Health J 2014 Sep;18(7):1765–71. doi: 10.1007/s10995- 013-1421-8.

15. Griffin SO, Barker LK, Wei L, Li CH, Albuquerque MS, Gooch BF; Centers for Disease Control and Prevention (CDC). Use of dental care and effective preventive services in preventing tooth decay among U.S. children and adolescents — Medical Expenditure Panel survey, United States, 2003–2009 and National Health and Nutrition Examination survey, United States, 2005–2010. MMWR Suppl 2014 Sep 12;63(2):54– 60. PMID: 25208259.

16. Centers for Medicaid and Medicare Services. Annual EPSDT Participation Report: Form CMS-416, Fiscal Year 2019. www.medicaid.gov/medicaid/benefits/early-and-periodicscreening-diagnostic-and-treatment/index.html. Accessed Aug. 25, 2021.

17. Mares ML, Pan Z. Effects of Sesame Street: A metaanalysis of children’s learning in 15 countries. J Appl Dev Psychol 2013 May–Jun;34:140–151. doi.org/10.1016/j. appdev.2013.01.001.

18. Kearney MS, Levine PB. Early childhood education by MOOC: Lessons from Sesame Street. National Bureau of Economic Research. Working paper no. 21229, June 2015; Cambridge, Mass. www.nber.org/papers/w21229. Accessed Aug. 25, 2021.

THE CORRESPONDING AUTHOR, James J. Crall, DDS, ScD, can be reached at jcrall@dentistry.ucla.edu.