Theory of Change

We understand the following root causes to be key barriers to the population-level condition we are trying to achieve, noted in the above Results Statement. Acknowledging these barriers informs both our long-term strategies and our shorter term objectives, and enables us to directly address the root of the problem rather than the symptoms.

• Oral health contributes directly to overall health. There is a pervasive misunderstanding of this critical interconnection, which has been reinforced by a legacy of siloing dental health from broader health care.
• Dental care delivery and financing systems must be reimagined to meet the oral health needs of Maine's population.
• The design of the traditional dental system exacerbates the impacts of systemic racism, discrimination, poverty, and other disparities in access to care and therefore oral health outcomes.
• We must use our better and more comprehensive understanding of dental disease to inform solutions for treating and managing it as a chronic disease.
• Expanding and diversifying the dental workforce will ensure delivery of community-based and minimally invasive care at the scale needed to serve all Maine children.
• There is insufficient infrastructure within state government to support strategies to address oral health as a public health issue.

In the process of developing the root causes and strategies, we realized that there were a number of unspoken assumptions that were guiding our collective understanding of the problem and the solutions. Thus, we recognized that it was important to explicitly state the following assumptions that underlie our theory of change and the network’s strategies:

• Relationship-building & funding (for both backbone support and for implementation partners) are essential to fuel network strategies.
• Increased access to care (the right kind of care in the right place at the right time) leads to better oral health outcomes (reduced dental disease). Tracking access and utilization measures is more feasible, while impact evaluation and tracking disease outcome measures requires a bigger investment of resources.
• A complete oral health workforce includes dentists, hygienists, dental therapists, primary care providers, school nurses, oral health navigators, community health workers, and other public health care partners working in teams with all providers working to the top of their scope/license produces a more efficient and effective workforce.
• Sustainable financing means that the new models or expanded workforce do not have to rely on grant funding, volunteers, or donations for ongoing routine operations, rather sufficient financing for the desired models is built into the way the system is designed and operates.
• Our vision is focused on children, but children live in families and families live in communities so the system changes we seek will impact beyond children, and need to be intentionally designed to work for everyone.
• This work is multi-generational and by focusing primarily on children we will hopefully see increased impact as today's children become the next generation of parents.
• Right now many kids CAN'T get any dental care at all and we are designing a transformed system in which it will be POSSIBLE for all kids to access the right care in the right place at the right time. If we get to the point where it is possible but people still aren't taking advantage of it, then we may need to evolve our theory of change to analyze what the root causes are for why people aren't utilizing the care that is universally available.
• Poverty, food insecurity, inadequate diet, and ineffective social systems for people facing systemic discrimination contribute to poor oral health, and while COHN may indirectly address these factors through promoting mouth-healthy habits, they are bigger issues beyond our zone of impact.