An overview of health behavioural change theories and models: interventions for the dental hygienist to improve client motivation and compliance.

ABSTRACT

Background: While striving to deliver optimal healthcare, dental hygienists must support their clients' progression towards health related behavioural changes. An understanding of the theory behind behavioural change can guide dental hygienists in recognizing clients' barriers to improved oral health practices and offer methods to overcome obstacles. Discussion: Dental hygiene education programs could apply behavioural change theories in clinical assessments. This overview discusses behavioural change theories and models which have been applied in a clinical setting for the purpose of assisting dental hygienists to enhance and support client behaviours. A common theme found in the literature was that in order to successfully improve clients' long term oral health, dental hygienists must identify barriers that prevent effective daily oral self care regimes. Dental hygienists can establish a respectful collaborative relationship with their clients by recognizing and responding to the clients' level of readiness for change. This can ultimately result in improvement of their oral health behaviours. Results: The findings included several techniques dental hygienists can utilize to become more proficient in investigating the client's rationale for non compliance. The techniques focused on using an individualized approach to integrate the clients' existing beliefs and values into the process of care. Conclusion: Good communication skills and a trusting supportive relationship are the fundamental keys to facilitating the clients' ability to improve oral health.

RESUME

Introduction: En s'efforcant de livrer les meilleurs soins de sante, les hygienistes dentaires doivent soutenir la progression de leur clientele dans l'evolution des comportements en matiere de sante. La comprehension de la theorie qui soutient cette evolution peut aider les hygienistes dentaires a reconnaitre les barrieres qui freinent l'amelioration des pratiques de sante buccale chez la clientele, et offrir des moyens de surmonter les obstacles. Discussion: Les programmes de formation en hygiene dentaire peuvent appliquer les theories de changement de comportement aux evaluations cliniques. Cette vue d'ensemble traite des theories et des modeles appliques en clinique pour aider les hygienistes dentaires a ameliorer et a soutenir le comportement des patients. La litterature indique communement que, pour reussir a ameliorer a long terme la sante buccale de la clientele, les hygienistes dentaires doivent reconnaitre les obstacles qui bloquent I'efficacite des regimes personnels de soins buccaux quotidiens. Les hygienistes dentaires peuvent etablir une relation de collaboration respectueuse avec leur clientele en reconnaissant le niveau d'empressement au changement. Cela peut ultimement ameliorer leurs comportements en sante buccale. Resultats: Les resultats comprennent plusieurs techniques que les hygienistes dentaires peuvent utiliser pour ameliorer leur competence dans I'investigation des raisons qui incitent la clientele a I'inobservance. Les techniques se concentrent sur I'approche individuelle pour integrer les croyances et les valeurs du client dans la prestation des soins. Conclusion: De bons talents de communication et une relation de confiance et de soutien sont les elements clesqui faciliteront la capacite de la clientele a ameliorer sa sante buccale.

Key words: motivational theories and models, behavioural change theories and models, health behavioural models, Transtheoretical Model, Health Belief Model, adherence, compliance.

Introduction

Up to 75 per cent of the United States adult population has periodontal disease. (1) Those affected must modify their oral health practices to improve their oral status or to inhibit the progression of their disease. (2) This adjustment includes adherence to an effective daily self care routine complemented by regular professional oral care.

The chief goal of dental hygienists is to improve the oral condition of their clients while promoting health and preventing disease. (3) The main detriments to oral health--dental caries and periodontal disease--are usually preventable and controllable if effective oral health behaviours are maintained. (4) It is necessary for dental hygienists to understand certain barriers that complicate a client's ability and motivation to adopt preventive oral health practices. (5)

Objective: This paper discusses the application of theoretical techniques for dental hygienists to assist their clients with overcoming barriers to oral health, and encourage motivation to make a positive change in their oral health.

Method: An overview of the literature from 1997 to 2010 was considered to evaluate the application of health behaviour models by the dental hygiene profession. The information was collected using the following search engines: National Centre for Biotechnology Information, PubMed Central, MEDLINE, EviDents Search Engine and Google Scholar. Searches were limited to full text publications in English. Several articles were recommended in a personal e-mail from Susan Isaac, RDH, MEd. A proposal to enhance dental hygiene education was suggested in personal communication with Dianne Gallagher, BGS, Dip-DH, PGD, EdAdmin, MEd. Information was obtained from two text books used in North American dental hygiene curricula. (2), (3) Articles were also retrieved from the Camosun College Dental Hygiene 151 course package, which accompanies a course intended to develop the dental hygiene student's understanding and the influence of evidence based research, statistics, professional standards, and ethics in providing oral healthcare.

Results and Discussion: Behavioural change has been defined as the progression of identifiable phases that ultimately result in the acquisition of a new behaviour. (2) "Compliance," or the client's level of obedience to the dental hy-gienist's recommendations, has been distinguished from "adherence," which is a behavioural change resulting from the client's educated choice. (2) For successful periodontal health, thorough daily self care practices must be followed as a complement to professional periodontal therapy. The client's homecare is a key for a successful outcome, so it is essential that clients reach a personal decision to alter their oral health practices. (2)

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Dental hygienists can encourage self efficacy and reinforce the potential benefits of the new behaviour to support clients make educated choices. A wholesome relationship between a doctor and a patient is founded on trust in the physician's opinion and empathy from them. (6) Compliance has been found to be high when doctors are emotionally supportive, reassuring, and treat patients respectfully as an equal partner (6)."These principles can also be applied to the efforts of oral health professionals. To enhance adherence, the client must believe that the dental hygienist's advice is sound, that the change will be beneficial, and that his or her opinions and choices are included in setting behaviour goals.

Discussion

Factors which may hinder clients' success of acquiring improved oral health practices

The ability of dental hygienists to foster motivation to change oral health behaviour can be hindered by determinants such as childhood upbringing, (3) age, gender, ethnicity, level of education, marital status, socioeconomic status, (4) and social support networks. (6)

People with low income levels, financially burdened by the cost of therapy, are less likely to obey their doctor's advice. (6) Socioeconomic status and cultural practices can influence a person's perception of oral health. (4) Some people may not expect to keep their teeth for life, and may perceive dental care solely as emergency care. Poverty can be considered a culture in which health attitudes, beliefs, and values are passed down through generations within families with low income. (3) Poverty is a key predictor of poor oral health. Low income earners perceived the benefits of health services as less valuable and utilized preventive services less often than higher earners. (3) People with low income were still reluctant to receive professional dental services even when the cost of dental treatment was eliminated. (4) This research reinforces the need for dental hygienists to advocate for increased public funding to improve access to preventive oral healthcare services.

Attitudes and beliefs shaped in childhood, (4) by family, media, cultural factors, and economics influence health beliefs and behaviours. (4) People with a strong social networks have higher rates of compliance." The dental hygienist can strive for cultural attunement and the knowledge of each client's familial values to better understand their perspectives and incorporate their beliefs into the personalized care plan.

Motivation is most effective when strategies are employed to encourage inspiration from within the client. (7) The best self care plan is the one the client makes for his or herself (personal communication with Gallagher D, 2011 Jan. 11). The following theories have been found to be effective in the oral health field, and offer techniques for dental hygienists to enhance the motivation for behavioural change.

Theories which explain cognitive barriers to behavioural change and offer motivational techniques

The following theories, compared in Table 1, include appropriate dental hygiene interventions for each theory.

Table 1. A comparison of theories which explain cognitive barriers to
behavioural change. Dental hygiene interventions to empower and
motivate clients are indicated.

  Theory/Model            Main Concept             Dental Hygiene
                                                    Intervention

Self-Efficacy     * Success reinforces        * Encourage achievable
Theory              success; clients who        goals; these will be
                    have overcome a             more likely reached,
                    perceived barrier will      thereby reinforcing
                    be more likely to           self efficacy.
                    strive further to reach
                    their goals because
                    they have experienced
                    feelings of
                    accomplishment.

                  * Relapses are a normal     * Reassure that
                    part of the learning        relapses may be
                    process.                    expected and do not
                                                indicate failure.

Locus of Control  Clients can be divided      * Tailor interventions
Theory            into two personality          to motivate clients
                  types:                        according to their
                                                personality type.

                    1. Internal focus of      * Offer feedback that
                       control clients          supports self efficacy
                       believe their own        to motivate external
                       actions dictate          locus of control
                       the outcome of a         clients by encouraging
                       condition.               a sense of
                                                responsibility for
                                                their oral health.

                    2. External locus of
                       control clients
                       believe the outcome
                       of a condition is
                       out of their control
                       and is determined by
                       another person, fate,
                       or God.

Attribution       Self perception is          * Find out about other
Theory            predictive of success         events in the client's
                  or failure:                   life where hard work
                                                has resulted in
                                                rewarding benefits and
                                                compare this with the
                                                desired behavioural
                                                change.

                    * If clients believe      * Use this comparison
                      they can reach the        to confirm that a
                      behavioural change        positive health outcome
                      goal, they will           can be achieved by oral
                      devote more effort        health actions the
                      to accomplishing the      client takes.
                      goal and be more
                      likely to succeed.

                    * Likewise, if clients
                      do not think they are
                      capable of carrying
                      out the dental hygiene
                      recommendation, they
                      will not try as hard
                      and be more likely to
                      fail.

Theory of         A client's attitude and     * Clients who
Reasoned Action   intention to change a         understand that reduced
                  behaviour is influenced       dentinal
                  by:                           hypersensitivity will
                                                follow consistently
                                                using a dentifrice with
                                                5% potassium nitrate
                                                will be more likely to
                                                use it as directed
                                                rather than
                                                occasionally.

                    * perceived risks         * Inquire about the
                                                oral health beliefs and
                                                practices of the
                                                client's family or
                                                social group. If a
                                                client is the only one
                                                at work who smokes on
                                                coffee breaks, the
                                                dental hygienist can
                                                ask if the client feels
                                                cast out by his/her
                                                work colleagues, and
                                                whether or not this
                                                might be a motivating
                                                factor for smoking
                                                cessation.

                    * benefits

                    * possible outcomes
                      (behavioural beliefs)

                    * expectations of
                      significant others
                      (normative beliefs)

Health Belief     Informed people make        * Educate clients on
Model             better decisions. In          the consequences of not
                  order to change their         modifying behaviours.
                  behaviour, clients must
                  believe:

                    1. They are at risk for   * Explain the benefits
                       a health condition.      of the new behaviour.

                    2. The condition is a     * Offer reassurance and
                       serious health risk.     correct misinformation
                                                to counteract perceived
                                                barriers.

                    3. There is a             * Explain how, where
                       successful               and when to take
                       intervention.            action, and provide
                                                verbal feedback to
                                                increase self-efficacy.

                    4. Barriers to
                       interventions can
                       be overcome.

Transtheoretical  * Tailor interventions      * Assess the client's
Model (Stages of    to match the client's       readiness to change and
Change Theory)      readiness to change. As     create a personalized
                    a client progresses         care plan to best suit
                    through the following       the client's individual
                    predictable stages, the     needs.
                    pros and cons of
                    changing a behaviour
                    are weighed, If the
                    pros outweigh the cons,
                    the client will
                    continue to the
                    subsequent stage.

                  * Stages of change:         * Table 2 provides
                    Pre-contemplation,          dental hygiene
                    Contemplation,              interventions for each
                    Preparation, Action,        stage.
                    Maintenance and
                    Relapse.

Conversational    * Clients will respond      * Prompt the client
Interviewing        more favourably to a        with open ended
                    dental hygienist's          questions to inquire
                    advice if the               about the client's
                    educational efforts         values, experiences and
                    complement the client's     knowledge.
                    stage of readiness.

                                              * To gather a better
                                                understanding of the
                                                client's desire to
                                                change a behaviour,
                                                observe non verbal cues
                                                along with verbal
                                                responses.

Motivational      * Similar to                Phase I: For clients in
Interviewing        conversational            precontemplation stage,
                    interviewing, but         interview to determine
                    incorporates the          the client's chief
                    Transtheoretical model    complaint and build
                    into the interview.       rapport and trust to
                                              establish a professional
                                              relationship. Phase II:
                                              For clients in
                                              contemplation stage,
                                              collaborate to find
                                              ways to identify and
                                              overcome perceived
                                              barriers which prevent
                                              their progression to
                                              preparation stage.

                  * Dental hygiene
                    interventions are
                    separated into two
                    phases to help
                    encourage clients to
                    progress from
                    precontemplation to
                    action.

Self Efficacy Theory

The Self Efficacy Theory offers an explanation of how self confidence is a determinant of oral health behaviour (4) and an accurate predictor of oral health status (5) Showing clients microbial slides from their plaque samples before and after self care routines is a motivator for clients with a low self efficacy. (4) Participants were more likely to practise plaque control by visualizing the outcome of their self care techniques. (4) Plaque disclosing agent was also a powerful means of increasing self efficacy because it made the result visible. (3) Another way is to verify to the clients that they have the skills to change a behaviour. Recognizing low self efficacy will also help dental hygienists enhance adherence by collaborating with their clients to set achievable, individualized goals. Achievable goals supplemented with ongoing encouragement are more likely to be met. (8) The cyclical pattern of an experience of success reinforcing further success can be initiated and maintained, consequently driving the client's self efficacy and motivation to improve their self care.

Locus of Control (LOC) Theory

The LOC Theory categorizes people's perception of how much their actions influence a health outcome. (5) Clients who believe their own behaviour determines their health status are considered to have an internal LOC (I-LOC), whereas clients who defer the blame of their poor oral health to family history or genetics are said to have an external LOC (E-LOC). This black-or-white categorization is not always realistic. (5) Clients may indicate an I-LOC regarding their overall health yet shift to an E-LOC when questioned about their oral health practices. Dental hygienists may encounter non compliance stemming from a sceptical I-LOC client who believes the dental hygienist's advice is motivated by the consumer market. (8) I-LOC clients tend to be highly motivated to comply if they are given evidence that a change will benefit them. An E-LOC client may retain the expectation that dentures are inevitable as one ages. (3) People living in poverty are more likely to acquire E-LOC expectations that restrict their perceptions of the value of seeking oral healthcare. Dental hygienists can motivate E-LOC clients by increasing their acceptance of responsibility for and ability to achieve oral health. One approach is to offer feedback that encourages self efficacy, (3) such as asking the client to recall previous behavioural change successes as a reminder that they are capable of accomplishing the newly desired change too.

Attribution Theory 

The Attribution Theory describes how self perception is predictive of success or failure. It relates the belief of accomplishment to the effort devoted to a task, as well as the actual level of success. (8) Dental hygienists can promote self efficacy by confirming a positive oral health outcome. When this occurs, clients are more likely to invest greater effort in achieving a goal (8) which will in turn increase their ability to reach their goal. (5)

Theory of Reasoned Action (TRA)

The TRA proposes that a client's attitude and intention to alter individual behaviour drives the desire to change. The intent to change is influenced by perceived risks, benefits and possible outcomes of the new behaviour, as well as normative beliefs that stem from the expectations and persuasion of significant others and social groups. Social norms are stable over time and can provide strong motivation for compliance. (5) This is advantageous in oral healthcare as long as the recommended behaviours coincide with the group's practices.

Two primary models have been adapted for application in oral health. The Health Belief Model (HBM) attempts to explain and predict health behaviours by considering beliefs and values. Using the Transtheoretical Model (TTM), dental hygienists can assess the client's readiness to change and create a personalized care plan to best suit the client's individual needs.

Health Belief Model (HBM)

The HBM describes how behavioural change depends on the perceived threat of a health condition, such as periodontal disease. Clients must believe they are at risk for tooth loss or periodontal disease, and that this would impact their overall health and quality of life. They must trust that recommended interventions may help prevent tooth loss or halt further disease progression. Clients must be optimistic that the temporal commitments of daily self care and financial investment in dental services are worth it for keeping their teeth. (4) The stronger these beliefs are, the more likely the client will comply. (9) The client must be confident that barriers to the proposed interventions can be overcome by following recommendations. (5) Potential dental hygiene change strategies for the HBM are: educate clients on the consequences of not modifying behaviours, explain the benefits of the new behaviour, offer reassurance and correct misinformation to counteract perceived harriers, explain how, where and when to take action, and provide verbal feedback on their efforts to increase self efficacy. (3)

Client education plays a very important role in behavioural change. A misunderstanding of the disease process can result in poor compliance. (8) Supplying information alone is not enough to establish permanent behavioural changes. (2), (5) It may be beneficial to supplement the HBM with efforts to identify a client's readiness to change. (9) This coupling, in combination with the previously discussed theories, holds potential for dental hygienists to encourage their clients towards a healthy oral self care routine.

Transtheoretical Model (TTM)

The TTM was originally developed from research on substance addictions (9) and has given rise to health promotion techniques which have been employed by oral health professionals. (10) The TTM describes how change is a non linear gradual process along a continuum which can be interrupted by relapses to old habits. This model appreciates how a client's decision making process involves weighing advantages and disadvantages. (11) The TTM relies on the support of a trusting relationship that demonstrates acceptance, caring and good listening skills, (11) of which one source is a dental hygienist.

The TTM stages are defined by various attitudes, beliefs, and actions characterized by certain motives. Dental hygiene interventions to promote success in behavioural change are indicated for each stage in Table 2.

Table 2. Dental hygience interventions tp promote a successful outcome
in behavioural changes, as propposed by the Transtheoretical Model and
based on the Stage of Change Throry.

       Stage       Assessment tools: Client       Dental hygiene
                       characteristics             interventions

Pre-contemplation  * Resistant and           * Avoid trying to force
                     unmotivated to change     into action

                   * Unaware of the health   * Validate their lack of
                     risk (e.g. periodontal    readiness
                     disease)

                   * Aware of the risk, but  * Acknowledge the
                     denies it applies to      perceived cons
                     them

                   * Defensive about the     * Encourage optimism and
                     problem                   self efficacy

                   * Considers the signs     * Respect their
                     (e.g. bleeding gums)      decision, clarify it is
                     to be normal              their decision

                   * Believes the outcome    * Encourage self
                     (e.g. tooth loss) of      exploration of present
                     action (e.g. not          behaviours
                     flossing) will not
                     have a significant
                     impact on personal
                     health

                   * Has accepted that       * Education: health
                     tooth loss is             risks of not changing,
                     inevitable as one ages    as it applies to
                                               client's individual
                                               situation

                   * Feels no control over   * Increase frequency of
                     the prognosis             professional care

                   * Has no intent to
                     change within the next
                     six months

Contemplation      * Acknowledges the        * Avoid trying to force
                     problem                   into action

                   * Begins to consider the  * Validate their lack of
                     benefits and costs of     readiness
                     behavioural change

                   * Reaches a point where   * Identify pros and cons
                     the pros and cons of      of changing behaviour
                     changing are equally
                     important

                   * Still resistant to      * Respect their
                     change                    decision, clarify it is
                                               their decision

                   * Takes an interest in    * Encourage self
                     the appearance and        efficacy
                     function of own teeth
                     and gingiva

                   * Asks for information    * Encourage small steps
                     about oral health,        towards desired change
                     disease and therapies

                   * More open to            * Inquire if client has
                     discussing personal       a suggestion for how you
                     oral health status        could help

                   * Intends to make a       * Education: long term
                     change within the next    benefits of change
                     six months

Preparation        * Decides the benefits    * Ask hypothetically:
                     of changing slightly      What would it feel like
                     outweigh the costs of     to have already made the
                     not changing behaviour    change?

                   * Plans to start          * Reinforce long term
                     changing behaviour        benefits
                     within the next month

                   * Inquisitive about own   * Encourage small steps
                     teeth/oral health         towards desired change
                     status

                   * Has a plan of action    * Offer support
                     (e.g. has set aside a     reminders via email or
                     time to floss each        phone
                     day)

                   * May write down or       * Identify barriers,
                     verbalize to              brainstorm to solve
                     significant others the
                     desire to change

                   * Becomes motivated and   * Encourage self-efficacy
                     confident in personal
                     ability to change

                   * Purchases the self
                     care aids (e.g.
                     fluoridated
                     toothpaste) required
                     for personal
                     new behaviours

                   * Sets a date when new
                     behaviour will
                     commence

Action             * Has been practising     * Discover how client
                     the new behaviour(s)      can create their own
                     for one to six months     reminders

                   * Benefits of the new     * Evaluate obstacles
                     behaviour are still as
                     important as in the
                     preparation stage, but
                     the costs of not
                     changing drop off

                   * Actively engaged in     * Encourage client
                     strategies to modify      problem solve, offer
                     their behaviour           ideas if needed

                   * Highly susceptible to   * Acknowledge the
                     discontinuing new         perceived cons
                     behaviour and/or
                     reverting to old ones

                   * Self efficacy to        * Identify social
                     maintain the new          support: friends,
                     behaviour may             family
                     fluctuate

Maintenance and    * Maintained the          * Address relapse
Relapse              behavioural change for    triggers
                     more than six months

                   * Results of maintaining  * Brainstorm to overcome
                     the new behaviour are     relapse triggers
                     much more advantageous
                     than the thought of
                     relapsing

                   * Highly motivated to     * Alternative strategies
                     making new behaviour a    may be needed
                     permanent habit

                   * Interrupted by          * Evaluate
                     regression to earlier     success/failures in
                     stages                    dealing with previous
                                               obstacles

                   * Increasingly more       * Encourage self
                     confident in personal     efficacy: "Look how far
                     ability to maintain       you've come!"
                     the behaviour

                   * Tempted to give up new  * Reinforce long term
                     behaviours in exchange    benefits
                     for the familiarity of
                     old ones

                   * May be discouraged by   * Reassess motivation
                     the lack of tangible      and barriers
                     long term benefits

                   * Negative self talk can  * Education: relapses
                     signal a relapse          are expected as part of
                                               the process

Adapted from Nield-Gehrig (2008) (2), Darby and Walsh (2010) (3),
Hollister and Anema (2004) (5), and Velicer et al. (1998). (11)

The TTM has been predictive of the decision to comply with interdental cleaning at least three times a week in participants who did not previously practise this habit. (12) Figure 1 illustrates how the data in this study were consistent with the model's predictions of stage assessment, indicated by the perceived pros and cons of adopting the new behaviour. Clients in the precontemplation and contemplation stages found that the drawbacks to cleaning interdentally, such as technique difficulty and messiness, outweighed the pros, which were improvement in appearance and oral health.

[FIGURE 1 OMITTED]

Twenty one per cent of the US population are in precon-templation for practising regular interdental cleaning. (12) A client may either be unaware oral self care is a problem, or aware of the problem but reluctant to modify behaviour. A client who has made unsuccessful attempts to change personal habits may become demoralized by failure. Clients in the precontemplation stage are often dismissed from health promotion programs as they are deemed unwilling to participate. (11) Rather, a common mistake is to presume that a client is ready for an instantaneous and permanent behavioural change. (11) It is estimated that few clients are in contemplation and action stages and more clients are in the maintenance stage for interdental cleaning. (12)- The authors attributed these data to including clients who obtained regular oral health services and who may have already been influenced by previous exposure to oral hygiene instructions. (12)

Studies in the early to mid 1990s found that although stage distributions for smoking cessation among European countries were similar, the sample populations vary markedly from US results (11) as summarized in Table 3. While stage distributions for smoking cessation have been established, the stage distributions for other behaviours detrimental to oral health remain unknown.

Table 3. A comparison of stage distributions for smoking cessation
behaviours between sample populations in the United States and three
European countries (Spain, the Netherlands, and Switzerland) as
reported by Velicer et al. (1998). (11)

                  United States  European Countries

Precontemplation       40%               70%
Contemplation          40%               20%
Preparation            20%               10%

The TTM recognizes that appropriate interventions must be developed for each client depending on their readiness to change. Relationship and communication are critical aspects for interactions between dental hygienists and their clients. From research on therapeutic compliance from the medical perspective, (2), (6), (7), (10) it was concluded that healthcare providers should involve their clients when designing a treatment plan. Involving the client in the process of care can be a worthwhile approach to enhance communication. It is not within the scope of this paper to review the extensive intricacies of human communication or learning styles; however, the following discussion draws attention to the value of strong communication skills in building rapport with clients.

Conversational Interviewing (CI)

A client will respond more favourably to a dental hygienist's advice if educational efforts complement the client's stage of readiness. (2), (9), (10) The CI method involves prompting the client with eight or ten open ended questions to gather information pertaining to the client's values, experiences, and knowledge of oral health. (4) The dental hygienist's ob servations of verbal and non verbal responses can reveal clues to the client's health beliefs. (9)

Motivational Interview (MI)

The MI approach is similar to CI in that it uses open ended questions to collect information before providing information and advice. Both CI and MI aim to create a supportive environment by the acceptance of clients' beliefs and the affirmation of their previous knowledge to help them reach informed decisions. MI differs from CI by applying the TTM to motivate a behavioural change. Within two phases, MI encourages people to progress from precontemplation into action. (10) The intention of the first phase is to determine the client's chief complaint and build rapport and trust to establish a professional relationship. Completion of this stage is reached when the client advances from precontemplation to contemplation, and this may take some time. Clients in the second phase are hesitant to commit to the new behaviour; they desire to change but are still hindered by perceived barriers.

While this method of interviewing has been used in the nursing profession, it can also be applied in many healthcare environments. (13) Table 2 provides further detail on additional stage specific dental hygiene interventions.

It is essential to learn how important a change is to a client (2) and what the perceived barriers to that change are. It is not the actual barriers which impede a client's motivation, but rather how they perceive the barriers. (7) For instance, a soccer player who presents with chipped anterior teeth and complains of dentinal hypersensitivity will likely not comply with wearing a sports mouthguard until her/ his primary complaint has been addressed.

The client can also be asked to rate how ready he or she feels to make a change on a scale of one to ten. Probing as to what made the client choose that number is a valuable tool for dental hygienists to help identify underlying barriers to change not previously accounted for. (14)

Often with periodontal disease several adjustments to behaviour need to be made. An approach to this is to present each of the desired goals as written statements for the client to fill in with other priorities which may develop as progression is made. Clients can identify which goal is their highest priority. Working on one goal at a time to create one small alteration to a regular habit can help make the behavioural changes less overwhelming, and is predictive of successful progression into the action stage and to increased compliance. (2), (6)

The upkeep of daily oral self care involves personal decisions that are chosen by the client. (2), (5) Rather than relying solely on the generic oral health education approach of "show-tell-do" to explain the consequences of resisting recommendations, dental hygienists must accept that there is often a gap between the self care instructions given and their actual practice. To avoid confrontation during interviewing, dental hygienists can be the secondary source of solutions (13) while the primary source is the client. It is important to remember that there is a concealed rationale behind all uncooperative behaviours. (14)

There are aspects of this report which may devalue the findings. The majority of articles were obtained from a limited number of electronic search engines. Only articles in English with full text available were included. Informative studies in other literature databases, paper copies, or in other languages may have been omitted. An emphasis of the HBM and TTM, both of which have been well established in oral healthcare, resulted from their use as key words whereas the other theories were not specified in the search. Based on a personal interest, the author focused on techniques for assisting clients with the progression from the precontemplation to the contemplation stage of the TTM.

Conclusion

It is essential to recognize that dental hygiene intervention is only one element in the goal to promote and maintain health and prevent disease; clients must also choose to practise an effective oral self care regime on a daily basis, and their general health must be considered. The challenge is to increase the client's motivation and facilitate adherence to evidence based recommendations for self care. A practical knowledge of health behaviour modification theories can provide dental hygienists with a basis of how to meet the unique needs of each client to better support their health. There are various techniques which dental hygienists can use to approach the client, including: establishing a respectful collaborative relationship, identifying the client's beliefs, priorities and interest in changing behaviours, addressing self efficacy and barriers to oral health, and encouraging progression through adequate monitoring to reach client centred goals. All of the findings in the cited literature support the need for dental hygienists to practise effective communication skills that are centred on a caring, non judgemental attitude. These methods of collecting information and incorporating it into a client centred care plan, applying motivational theories, and setting collaborative and realistic goals can facilitate the client's success at self care. If dental hygienists also recorded their client's stage of change and subsequently selected appropriately staged interventions, they could enhance movement towards compliance and oral health for their clients. Practising these methods in school would allow dental hygiene students to integrate their theoretical knowledge into dental hygiene practice. Reflection on the clients' responses would deepen the students' understanding of the rationale underlying client behaviours and enhance their proficiency in assisting clients to achieve optimal oral health. If applying behavioural change theories becomes routine through practice, graduates entering the field will exit with a repertoire of effective intervention strategies that could potentially reduce the gap between the dental hygienist's recommendations and the client's compliance.

Due to the lack of Canadian data on the effectiveness of the TTM for oral health related behaviour, there is a need for future qualitative research to add to our evidence base. In view of the notable difference between US and European tobacco users in the precontemplation stage of smoking cessation, it may be valuable to find out if there also exists a stage distribution for oral health behaviours. As it has been suggested for medical research (6), the extent of the impact of non compliance with oral health recommendations could be investigated to extrapolate the possible financial implications of a low compliance rate on healthcare systems.

Acknowledgements

The author is grateful to Dianne Gallagher, BGS, DipDH, PGD, EdAdmin, MEd, NDHCB Board of Governors; CDHA Education Advisory Committee, BCDHA Board of Governors, Camosun College Instructor; and to Susan Isaac, RDH, MEd, Professional Education Consultant; Instructor, Vancouver Island University; Philips Global Professional Education Team, for sharing their expertise and mentorship to enhance the contents of this paper.

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THIS IS A PEER REVIEWED ARTICLE. Submitted 26 Jun. 2010; Revised 12 Jan. 2011; Accepted 20 Jan. 2011

Correspondence to: Shannon Collins; [e-mail]

Final year, Dental Hygiene Program, Camosun College, British Columbia