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 dental hygiene
The practice of keeping the mouth, teeth, and gums clean and healthy to prevent disease. Also called oral hygiene. education programs could apply behavioural change theories Behavioural Change Theories attempt to give explanations as to what influences the decision to change their health.
Having or marked by an advanced degree of competence, as in an art, vocation, profession, or branch of learning.
An expert; an adept. in investigating the client's rationale for non compliance. The techniques focused on using an individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. 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.
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 chez
At the home of; at or by.
[French, from Old French, from Latin casa, cottage, hut.]
at the home of [French] 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 The introduction to this article provides insufficient context for those unfamiliar with the subject matter.
Please help [ improve the introduction] to meet Wikipedia's layout standards. You can discuss the issue on the talk page. and models, behavioural change theories and models, health behavioural models, Transtheoretical Model The transtheoretical model of change in health psychology explains or predicts a person's success or failure in achieving a proposed behavior change, such as developing different habits. It attempts to answer why the change "stuck" or alternatively why the change was not made. , Health Belief Model, adherence, compliance.
Up to 75 per cent of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. adult population has periodontal disease Periodontal Disease Definition
Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where . (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 caries
or tooth decay
Localized disease that causes decay and cavities in teeth. It begins at the tooth's surface and may penetrate the dentin and the pulp cavity. and periodontal periodontal /peri·odon·tal/ (per?e-o-don´t'l)
1. pertaining to the periodontal ligament or periodontium.
2. near or around a tooth.
1. 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 com·pli·cate
tr. & intr.v. com·pli·cat·ed, com·pli·cat·ing, com·pli·cates
1. To make or become complex or perplexing.
2. To twist or become twisted together.
1. 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 PubMed Central is a free digital database of full-text scientific literature in biomedical and life sciences. It can be reached at .
It grew from the online Entrez PubMed biomedical literature search system. PubMed Central was developed by the U.S. , MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. , EviDents Search Engine and Google Scholar This article or section contains information about computer software currently in development.
The content may change as the software development progresses. . Searches were limited to full text publications in English. Several articles were recommended in a personal e-mail from Susan Isaac, RDH RDH
Registered Dental Hygienist
n an abbreviation for registered dental hygienist. , MEd. A proposal to enhance dental hygiene education was suggested in personal communication with Dianne Gallagher, BGS BGS British Geological Survey
BGS Below Ground Surface (depth below the ground surface)
BGS Bundesgrenzschutz (German: Federal Border Guard)
BGS Bachelor of General Studies (degree) , Dip-DH, PGD PGD Preimplantation Genetic Diagnosis
PGD Postgraduate Diploma
PGD Phosphogluconate Dehydrogenase
PGD Policy for Global Development
PGD PhpGmailDrive (file sharing utility)
PGD Product Group (US Marine Corps) , EdAdmin, MEd. Information was obtained from two text books used in North American North American
named after North America.
North American blastomycosis
see North American blastomycosis.
North American cattle tick
see boophilusannulatus. dental hygiene curricula. (2), (3) Articles were also retrieved from the Camosun College Camosun College is located in Victoria, British Columbia, Canada. As of 2006 it has over 7,000 students between its Lansdowne and Interurban campuses. The Lansdowne campus serves students in university transfer and access programs, as well as career, technical and vocational 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)
Dental hygienists can encourage self efficacy and reinforce the potential benefits of the new behaviour to support clients make educated choices. A wholesome whole·some
adj. whole·som·er, whole·som·est
1. Conducive to sound health or well-being; salutary: simple, wholesome food; a wholesome climate.
2. 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.
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 marital status,
n the legal standing of a person in regard to his or her marriage state. , 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 health services Managed care The benefits covered under a health contract 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 Public funding is money given from tax revenue or other governmental sources to an individual, organization, or entity. See also
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 dental hygienist
A person trained and licensed to provide preventive dental services, such as cleaning the teeth, usually in conjunction with a dentist. can strive for cultural attunement Attunement is a process, similar to synchronization, wherein previously diffuse systems come into alignment, often spontaneously. It is distinct from synchronized dancing, swimming, or other human aesthetic activities that are preplanned, practiced and then performed. and the knowledge of each client's familial familial /fa·mil·i·al/ (fah-mil´e-il) occurring in more members of a family than would be expected by chance.
adj. values to better understand their perspectives and incorporate their beliefs into the personalized per·son·al·ize
tr.v. per·son·al·ized, per·son·al·iz·ing, per·son·al·iz·es
1. To take (a general remark or characterization) in a personal manner.
2. To attribute human or personal qualities to; personify. 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 determinant, a polynomial expression that is inherent in the entries of a square matrix. The size n of the square matrix, as determined from the number of entries in any row or column, is called the order of the determinant. of oral health behaviour (4) and an accurate predictor of oral health status (5) Showing clients microbial microbial
pertaining to or emanating from a microbe.
the breakdown of organic material, especially feedstuffs, by microbial organisms. 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 dis·clos·ing agent
A dye used in dentistry as a diagnostic aid, applied to the teeth to reveal the presence of dental plaque. 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 cyclical
Of or relating to a variable, such as housing starts, car sales, or the price of a certain stock, that is subject to regular or irregular up-and-down movements. 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 locus of control
A theoretical construct designed to assess a person's perceived control over his or her own behavior. The classification internal locus indicates that the person feels in control of events; external locus (LOC LOC - lines of code ) 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 Attribution theory is a social psychology theory developed by Fritz Heider, Harold Kelley, Edward E. Jones, and Lee Ross.
The theory is concerned with the ways in which people explain (or attribute) the behavior of others, or themselves (self-attribution), with something
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 The theory of reasoned action (TRA), developed by Martin Fishbein and Icek Ajzen (1975, 1980), derived from previous research that started out as the theory of attitude, which led to the study of attitude and behavior. (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 HBM Human Body Model
HBM Human Brain Mapping
HBM Hottinger Baldwin Messtechnik GmbH (German company)
HBM High Bone Mass
HBM Hybrid Bilayer Membrane
HBM Humming Bird Medal
HBM Her/His Britannic Majesty ) attempts to explain and predict health behaviours by considering beliefs and values. Using the Transtheoretical Model (TTM TTM
Trailing 12 months. Often used with Earnings Per Share. ), 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 op·ti·mist
1. One who usually expects a favorable outcome.
2. A believer in philosophical optimism.
op 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 mis·in·form
tr.v. mis·in·formed, mis·in·form·ing, mis·in·forms
To provide with incorrect information.
mis 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 Contemplation
Compleat Angler, The
Izaak Walton’s classic treatise on the Contemplative Man’s Recreation. [Br. Lit.: The Compleat Angler]
sculpture by Rodin, depicting contemplative man. 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 de·mor·al·ize
tr.v. de·mor·al·ized, de·mor·al·iz·ing, de·mor·al·iz·es
1. To undermine the confidence or morale of; dishearten: an inconsistent policy that demoralized the staff. 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 smoking cessation Public health Temporary or permanent halting of habitual cigarette smoking; withdrawal therapies–eg, hypnosis, psychotherapy, group counseling, exposing smokers to Pts with terminal lung CA and nicotine chewing gum are often ineffective. 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 per·tain
intr.v. per·tained, per·tain·ing, per·tains
1. To have reference; relate: evidence that pertains to the accident.
2. 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 motivational interview Substance abuse A nonconfrontational counseling technique that may be used by a primary care giver to evaluate a substance–alcohol, illicit drug–abuser's receptiveness to treatment (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 im·pede
tr.v. im·ped·ed, im·ped·ing, im·pedes
To retard or obstruct the progress of. See Synonyms at hinder1.
[Latin imped a client's motivation, but rather how they perceive the barriers. (7) For instance, a soccer player who presents with chipped anterior anterior /an·te·ri·or/ (an-ter´e-or) situated at or directed toward the front; opposite of posterior.
1. Placed before or in front.
2. teeth and complains of dentinal den·tin·al
Of or relating to dentin.
(den´tn hypersensitivity hypersensitivity, heightened response in a body tissue to an antigen or foreign substance. The body normally responds to an antigen by producing specific antibodies against it. The antibodies impart immunity for any later exposure to that antigen. 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 A scale of one to ten or scale from one to ten is a general and largely vernacular concept used for rating things, people, places, ideas and so on. It is the naturally most popular choice of scale used in ordinary speech, followed by scales of one to five and then one to . 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.
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 Qualitative research
Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections. 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 extrapolate - extrapolation the possible financial implications of a low compliance rate on healthcare systems.
The author is grateful to Dianne Gallagher, BGS, DipDH, PGD, EdAdmin, MEd, NDHCB Board of Governors; CDHA CDHA Capital District Health Authority
CDHA Canadian Dental Hygienists Association
CDHA California Dental Hygienists' Association
CDHA Center for Demography of Health and Aging
CDHA Connecticut Dental Hygienists' Association Education Advisory Committee, BCDHA Board of Governors, Camosun College Instructor; and to Susan Isaac, RDH, MEd, Professional Education Consultant; Instructor, Vancouver Island Vancouver Island (1991 pop. 579,921), 12,408 sq mi (32,137 sq km), SW British Columbia, Canada, in the Pacific Ocean; largest island off W North America. It is c.285 mi (460 km) long and c. University; Philips Global Professional Education Team, for sharing their expertise and mentorship to enhance the contents of this paper.
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(2) (PCI Mezzanine Card) A PCI-based mezzanine card that is widely adapted to VMEbus, CompactPCI and PCI cards. 2503662/?tool=pmcentrez
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TSI Trading Standards Institute (UK)
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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; email@example.com
Final year, Dental Hygiene Program, Camosun College, British Columbia British Columbia, province (2001 pop. 3,907,738), 366,255 sq mi (948,600 sq km), including 6,976 sq mi (18,068 sq km) of water surface, W Canada. Geography