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A Proposed Client Self-Care Commitment Model.

Introduction

One goal of dental-hygiene care is to effectively involve clients as cotherapists in their oral-health decisions. A client's commitment to oral health affects dental hygiene care outcomes, and dental hygienists are continuously trying new strategies to enhance clients' motivation for oral self-care. Identifying more effective approaches to client motivation improves the oral health of the public and dental hygiene care in the practice setting.

Over a decade ago, American Dental Hygienists' Association (ADHA) Prospectus for Dental Hygiene asserted the critical nature of understanding our clients' cultural, social, and economic contexts in the provision of quality oral health care. One of the purposes of ADHA is to promote the oral health of the public by improving dental hygiene practice and advancing dental hygiene science. For that reason, in 1993, the association adopted a theoretical paradigm developed by Darby and Walsh for the profession. The dental hygiene paradigm focuses on health/oral health, the client, the environment, and the dental hygienist.

Dental hygiene's professional literature and educational texts have emphasized the importance of communication between client and practitioner, as well as client interaction and involvement in behavior change.[2,4-6] In practice, clinicians have tried multiple approaches to increasing their clients' motivation for oral self-care. Concurrently, researchers have been developing and presenting models for new approaches to oral self-care education.

The changing climate within the health care system suggests that a new approach is needed to encourage active client involvement in health maintenance. The traditional biomedical model of disease diagnosis and treatment is limiting, and new health paradigms are emerging. Current literature places more emphasis on client involvement in the decision-making process.[7-9] Several models include the client as a cotherapist and/or identify client commitment as important to compliance; however, there is a need to identify specific strategies for improving clients' commitment to positive health behaviors.[10-16] A framework is needed from which to evaluate the client's perspective and determine the cultural processes used in the interaction that facilitate commitment. Therefore, the purpose of this paper is to introduce the client self-care commitment model, which can be used as a possible theoretical framework to guide applications during dental hygiene care, dental hygiene education, and research investigations. Currently, experienced dental hygienists have been applying concepts from the model, so it is possible to begin documenting its effectiveness.

Literature Review

Enhancing the dental hygienist and client interaction is one way to increase the probability that a client will commit to positive health behaviors. Models from related disciplines that study human behavior can be used to identify characteristics of client/practitioner interactions that encourage clients' involvement and result in their commitment to self-care. This literature review focuses on four selected models of client/health care provider interaction from the disciplines of medicine, medical anthropology, psychology, and dental hygiene. The unidirectional biomedical model--from which medicine and dentistry traditionally operated--provides a familiar framework in which the clinician's interaction includes diagnosing a condition and, on that basis, telling the client what needs to be completed for oral health to occur. Two other models that may increase our clients' commitment to oral self-care include the empowerment model, in which the client is an integral part of the interaction and is responsible for making decisions concerning their oral self-care behaviors, and the explanatory model, in which the client discloses his or her own perceptions of the disease process.[17-18] Additionally, the human needs conceptual model suggests that the approach to dental hygiene care be based upon an evaluation of each client's human needs.[2,19] Elements of each of these models have been used as foundations and integrated into a new model entitled the "client self-care commitment model." This paper is the first step in suggesting a new conceptual model that can be used to encourage clients' interaction and commitment to a self-care routine.

Biomedical Model

The biomedical model, depicts disease as caused by biochemical changes related to conditions or events such as aging; injury or stress; or environmental factors such as pollutants, cigarette smoke, or alcohol (Figure 1). The role of the health professional is to identify pathogens or processes responsible for the disease by means of a physical examination. Treatment is designed to destroy or remove the entities causing disease, or at least to modify or control their progression. Prevention of disease is achieved by either avoiding pathogens, chemicals, activities, or environmental agents, or maintaining behaviors that control or reduce these variables.[20]

[Figure 1 ILLUSTRATION OMITTED]

In the biomedical model, compliance indicates that standards and levels of authority lie outside the client who must perform the suggested behavior.[21,22] The dental hygienist who practices according to this model determines the behavior best suited to the client, and interacts with the client to persuade the client to comply. A dichotomy is established: those who comply (compliers), and those who do not comply (noncompliers).[3,24] If the patient is a complier, the clinician feels good about successfully convincing the client to comply; however, if the client is a noncomplier, frustration may result.[25] A study by Berndsen, et al. indicates that there are differences in opinion between dental hygienists and periodontists when assessing client compliance.[21] Compared to periodontists, dental hygienists are more likely to understand and determine effectively the client's level of compliance with oral hygiene instruction. Specifically, periodontists are more likely to provide all clients with the same information and self-care instruction, whereas dental hygienists are more likely to provide information and self-care instruction to the client based on the client's level of cooperation.[21]

The biomedical model defines disease as a deviation from the norm of measurable biological variables. Within this model, dental hygienists discuss the presence of disease and etiology from a physiological/biological perspective, and relay this information to clients. Sometimes, differences in terminology, concepts, or view points can affect the communication and interaction that occur. For example, "diseases" are what scientists study and "illness" is what people experience; health professionals describe the "inflammation process" and people talk about "blood" and "sores."[26,27]

Favorable components of the biomedical model are time efficiency and knowledge sharing. In dental hygiene practice, having adequate time to provide comprehensive care is a common concern.[28] The biomedical model primarily involves a one-way approach to communication; therefore, time-consuming two-way conversations are minimized. Consequently, using this model, dental hygienists could potentially be communicating and sharing information while providing treatment, limiting the time for patient participation, but increasing treatment time during an appointment. Another advantage of the biomedical model is that it allows the dental hygienist to share knowledge of disease progression, and to provide treatment, from a position of authority.

The biomedical model also has some disadvantages. For example, when considering modifications for oral self-care behavior, the dental hygienist decides the behavior that the client needs to adopt, informs the client, and expects compliance with the recommended behavior.[29] The usual approach to interaction with clients is persuasion, a form of interpersonal influence in which one person tries to change the attitudes or behavior of another by means of argument or reasoning.[31] This creates a situation in which the client is a passive partaker rather than an active participant in care and decision-making. Thus, the client is less likely to comply with the dental hygienist's recommendations, or to make a personal commitment to a new self-care routine.

As dental hygiene continues to define its professional role, new methods that encourage active participation between the practitioner and clinician are being developed. Clinicians might need to use two-way communication and negotiate with clients when they want to eliminate or enhance behaviors that may affect treatment or health.[27] As dental hygiene has moved away from the traditional biomedical patient care approach, the profession has embraced a more collaborative client care approach. A cotherapist relationship is essential because client needs, choices, and internal motivations are elements critical to success.[32]

Explanatory Model

Compliance also has been viewed from a medical anthropology perspective. The discipline of medical anthropology is concerned with relationships between culture and sickness, culture and the healing process, and, within those contexts, client and practitioner communications. In contrast to the biomedical model, medical anthropology considers the nature of health systems to be social and cultural, rather than purely biologic. Cultural beliefs (attitudes toward health/sickness) are relevant in Western as well as other societies.

The explanatory model focuses on the interaction that actually occurs between clients and practitioners (Figure 2). It is the process of interaction that discloses the real understanding and relevance of health beliefs and behaviors of each participant involved in health care communication.[18] The explanatory model is a method of understanding a client's preexisting health beliefs, attitudes, and behaviors as they relate to the client's disease or illness and its treatment. Clients have an explanation (perception) of their illness (disease) and practitioners have an explanation (perception) of the client's disease. According to this model, the interaction between the explanatory model of the client and that of the practitioner is a vital factor in health outcomes. The study of clients' explanatory models--how they view their own health and disease--tells us how clients make sense of a given illness, and how they evaluate and choose particular treatments. Studying the interaction between the explanatory models of practitioners and clients is one way to analyze and evaluate the effectiveness of clinical communication that takes place in the health care setting.[33]

[Figure 2 ILLUSTRATION OMITTED]

Structurally, explanatory models seek to define five major aspects of a given illness, disease, or episode. These are (1) etiology; (2) time and mode of the onset of symptoms; (3) pathophysiology; (4) course of sickness or disease; and (5) treatment. Frequently, practitioners' explanatory models are used in health care to define these five areas, while a client's explanatory model addresses only what is most important to the client.[33]

The explanatory model states that the client's understanding of his/her health status and treatment recommendations may differ from the perceptions of the health care provider, because the client comes to the appointment with prior health beliefs, attitudes and behaviors (Figure 2).

The model outlines an oral health process wherein the dental hygiene practitioner can identify the client's health beliefs, and also explain the professional's viewpoint. Neither set of beliefs is considered right or wrong, because both have value in the interaction. The explanatory model suggests that the dental hygienist uses a process of negotiation to identify and reconcile differences in the two sets of beliefs (explanatory models). Studies applying this model in medical anthropology have shown that the more two parties in the health care interaction can come to agree, the more likely a client will be to commit to positive health behavior changes.[18,27,33] The client makes a commitment to comply with self-selected goals formulated by negotiations rather than selected by the professional.

The main principle guiding the explanatory conceptual model is that it considers the client's goals and perceptions paramount to commitment and compliance--to the extent that the practitioner's perceptions may be less important. Therefore, the primary advantage of using the explanatory model in oral health care is that it allows the clinician and client to express their individual explanatory models of a disease such as periodontitis, thereby creating an environment that encourages collaborative interaction. For example, many patients believe that it is normal for "gums" to bleed, or for older adults to lose their teeth; dental hygienists know that these notions are not accurate. The approach is to bring the two view points closer together, because a client's understanding and subsequent behavior is based upon how that person understands his or her own health status. The main disadvantage of the explanatory model is the added time and effort it might take for a clinician to determine the client's perception of the disease, treatment, and self-care methods. Also, patients may not be comfortable disclosing beliefs or self-care information to the dental hygienist. To be successful, the explanatory model must effectively engage the client in oral health maintenance.

Client Empowerment Model

An empowerment approach to positive health outcomes is based on an individual's capacity to interact with others to improve the quality of his or her life, or in this instance, health. Empowerment emphasizes the critical importance of people's participation in any plan affecting their health and lives.[17]

The primary purpose of self-care education in the empowerment model is to prepare clients to make informed decisions about their own health care (Figure 3). Empowerment maximizes clients' knowledge, skills, self-awareness, and sense of personal autonomy so that they can take charge of their self-care.[34,35] One main task of education can be an invitation to people to believe in themselves, to believe they possess the resources that they need to acquire the skills necessary to maintain or improve oral health.[36]

[Figure 3 ILLUSTRATION OMITTED]

Key to the implementation of empowering communication and interaction are two-way dialogue rather than monologue, collaboration rather than coercion, and use of a dialogue problem-posing process.[36,37] According to this model, when participants design their own processes and objectives, the achieved accomplishment becomes their own, which in turn becomes an internal incentive. Using these concepts enables empowerment for both the professional and the client.[38]

The primary advantage of using the empowerment model in oral health care is that the dental hygienist role changes from expert to collaborator and facilitator. Rather than persuading the client to adopt professional-chosen goals, the dental hygienist interacts to help the client identify personal oral self-care goals and behaviors. Rather than focusing on designing programs "on behalf of" others, health care providers strive to "collaborate with" clients, enhancing the emotional and practical resources they already have.[39,40] Empowerment replaces compliance with the experience of continuous client improvement and commitment to self-care behaviors.[41] For example, when providing nonsurgical periodontal therapy, dental hygienists see the client during initial therapy as well as during periodontal maintenance appointments. Each appointment is an opportunity to evaluate the client's improvement and collaboratively negotiate self-care methods that may encourage motivation and continued improvement. The main disadvantages of the empowerment model is the added effort and time it might take for a clinician to institute a collaborative and facilitative role to encourage the sharing of information during dental hygiene care. As with the explanatory model, patients may not be comfortable sharing self-care information with the dental hygienist (Figure 3).

Human Needs Theory

The most widely known dental hygiene model is the human needs conceptual model (Figure 4), which suggests that the approach to dental hygiene care be based upon an evaluation of each client's human needs.[2,42,43] This model uses basic human needs theory to explain four major concepts within the dental hygiene paradigm: client, environment, health/oral health, and dental hygiene actions. The theorists further identify eight relevant human needs that should be considered when implementing the dental hygiene process of care; wholesome facial image, protection from health risks, biologically sound and functional dentition, skin and mucosa membrane integrity, freedom from head and neck pain, freedom from stress, responsibility for oral health, and conceptualization and understanding (Table I).[19,44]

[Figure 4 ILLUSTRATION OMITTED]

Table I. Dental Hygiene Care Form
Dental Hygiene Care Form                                    Deficit

1) Wholesome Facial Image                                   Yes
* express dissatisfaction with appearance of:               No

   * teeth * gingiva * facial profile * breath

2) Freedom From Anxiety/Stress                              Yes
* reports or displays:                                      No

  * anxiety about proximity of the clinician or
  confidentiality * oral habits * substance abuse

  * concern about:

  infection control, fluoride therapy, fluoridation,
  mercury toxicity, DH care planned, previous
  dental experience

3) Skin & Mucous Membrane Integrity of                      Yes
   Head & Neck                                              No

* extra-/intra-oral lesion      * pockets>4mm
* attachment loss>4mm           * xerostomia
* gingival inflammation         * swelling
* bleeding on probing

4) Protection From Health Risks                             Yes
* BP outside of normal limits                               No
* need for prophylactic antibiotics
* potential for injury

5) Freedom From Head 8, Neck Pain                           Yes
* extra-/intra-oral pain or sensitivity                     No

6) Biologically Sound & Functional                          Yes
   Dentition                                                No
* difficulty in chewing
* presents with:

* defective restorations        * missing teeth
* teeth with signs of disease   * rampant caries
* ill fitting dentures/         * erosion
  appliances                    * abrasion

7) Conceptualization & Understanding                        Yes
* has questions or misconceptions                           No
  associated with DH care
* does not understand factors
  associated with oral disease or
  rationale for Rx

8) Responsibility For Oral Health                           Yes
* inadequate plaque control (plaque &                       No
  calculus present & associated with
  disease)
* inadequate parental supervision of
  oral health care
* no dental exam within the last two years


[ILLUSTRATION OMITTED]

During baseline assessment, deficiencies in these eight human needs are identified and a dental hygiene diagnosis is made. Planning, implementation, and evaluation of dental hygiene care focus on the unmet needs identified at baseline. Recently, theorists have developed an assessment instrument to assist clinicians in summarizing and organizing the data gathered, which can then be used to formulate a dental hygiene diagnosis and comprehensive dental hygiene care plan (Table I).

The unique theoretical intent of this conceptual model is to encourage an environment that is more client than task-oriented. The main advantage of this dental hygiene care model is that clinicians provide care that is scientific, humanistic, holistic and client-oriented.[32] Although the human needs conceptual model accommodates individualized dental hygiene care and client participation in decision making, it does not entirely consider the clinicians' explanatory model of disease, or allow clients to design their own objectives for commitment based on their explanatory model.

Perhaps theorists can go a step further. Drawing from the biomedical, explanatory, and empowerment models, or after identifying a client's unmet needs using the human needs conceptual model, dental hygienists could use a new approach to help the client commit to a self-selected self-care routine.

Proposed Client Self-Care Commitment Model

Medical, dental, and dental hygiene ethics stress the importance of client involvement in decision making.[45] Traditionally, dental hygienists have based clients' self-care programs on information gathered during assessment of their medical, dental, and periodontal health. This type of data can be referred to as "scientific data." Within this approach, the client's perceptions have been missing, and can be referred to as "social or cultural data" (Table I).

The explanatory, empowerment, and human needs models recognize the client as the essential component in oral self-care education, and the biomedical model offers the advantage of time efficiency and knowledge sharing. The client's perspective on self-care behaviors and the explanatory model of periodontitis are fundamental components of the assessment phase of nonsurgical periodontal therapy. Interaction between the client and dental hygienist that encourages the exchange of perspectives and explanatory models, active client participation, and negotiation of self-care behaviors, is one possible approach to empowering clients in self-care, and is the basis of the proposed client commitment paradigm (Figure 5). Empowering clients as decision makers to enhance their own oral health through commitment and compliance is the goal of this paradigm. Table II shows how the suggested model incorporates components of the three models previously reviewed, and how it can be implemented during the dental hygiene process of care.

[Figure 5 ILLUSTRATION OMITTED]

Table II. Application of the Self-Care Commitment Model
Domain                     Client Action

Initiation                 Discloses explanatory model
                           Disclosed preexisting beliefs and values
                           Discloses chief concern established

Assessment
 (*) Dental hygiene        Discloses perceptions of self-care
     diagnosis              and disease
 (*) Care planning         Explanatory model of self-care
                           methods and disease is verbalized

Negotiation                Becomes cotherapist with dental hygienist
 (*) Implementation        Identifies differences in explanatory
     of care                Models
                           Differences are reconciled
                           Negotiates treatment options
                           Negotiates self-care behaviors
                           Negotiates recare interval

Commitment                 Client establishes self-selected goals
                           Makes a commitment for self-care
                            behaviors
                           Makes a commitment for recare interval

Evaluation                 Provides self reported compliance to
 (*) Evaluation of care    previous commitment
                           Assessment
                           Negotiation
                           Commitment

Domain                     Dental Hygiene Action

Initiation                 Discloses explanatory model
                           Discloses preexisting beliefs and values
                           Helps client disclose chief concern

Assessment
 (*) Dental hygiene        Establishes baseline information
     diagnosis             Completes human needs assessment
 (*) Care planning         Encourage client participation
                           Is sincere, attentive and respectful
                           Verbalizes explanatory model of disease

Negotiation                Dental hygienist becomes cotherapist with
                             client
(*) Implementation         Identifies differences in explanatory
    of care                 models
                           Differences are reconciled
                           Negotiates treatment options
                           Negotiates self-care behaviors
                           Negotiates recare interval

Commitment                 Acts as collaborator and facilitator
                           Assists client with establishing
                            self-selected goals
                           Accepts clients' self-selected
                            commitments

Evaluation                 Provides self reported compliance to
 (*) Evaluation of care    previous commitment
                           Assessment
                           Negotiation
                           Commitment


(*) Components of the dental hygiene process of care

Initiation Domain

The traditional or biomedical approach to health care has been providing educational services to clients about their conditions and then providing specific recommendations. The health care provider also advises clients as to the importance of compliance to provider-selected behaviors. This approach corresponds to Parry's perspective that health care providers regard the client as a "blank slate" waiting for instruction from the practitioner, a view that underestimates the depth of the client's health beliefs before contact with the health professional. Expecting clients to comply with recommendations chosen by the provider is part of the biomedical model that assumes the health professional is the expert on the client's health behaviors (Figure 5, Table II).[27]

Within the proposed client self-care commitment model, the initiation begins when the client enters the operatory and dental hygiene care begins. Clients bring their own explanatory model of self-care methods and disease processes, pre-existing beliefs and values that the dental hygienist must identify during the assessment phase. The dental hygienist's role during initiation is to accept the client's values and beliefs, and assist the client in disclosing his or her chief concern.

Assessment Domain

During the assessment phase, the client discloses perceptions of self-care behaviors, knowledge of biomedical facts, and illness experience (symptoms) based on questioning strategies used by the dental hygienist. The client's model of illness may be unorganized, unconsciously formulated, and subject to change? This model requires the healthcare professional to be sincere, attentive, and respectful, where all dialogue is considered legitimate even if previously judged to be "incorrect." Examples of questions used to elicit a client's explanatory model are outlined in Figure 6. Questions to determine a client's self care behaviors are shown in Figure 7. To elicit client responses, dental hygienists may ask one or several questions, or any combination of questions guided by the client's response. This process is not accomplished by controlling the clients' reactions toward behaviors or ideas that seem foreign to oral health care professionals, but by recognizing the individuality of the ideas and explanatory models, and trying to understand their usefulness.[46] Another component of this commitment process is the dental hygienist providing the client his or her explanatory models of periodontitis. Clients assimilate new information from health professionals when the information fits their established beliefs, or when they judge the information as more useful than old ideas.[18] In this new model, when differences are not reconcilable, the client's priorities become the dental hygienist's priorities (Figures 6 and 7).[47]

Figure 6. Explanatory Model of Periodontal Disease Adapted Question Guide

Etiology (Cause)

* Has anyone ever told you what causes periodontal disease?

* What do you think caused your gum disease?

* Do you believe that it will lead to problems in your mouth?

Risks and Consequences

* What do you think this condition can do to you?

* How does this condition affect the body? What are the risks of its progression?

Time and Onset of Symptoms

* Is anything bothering you in your mouth?

* When did you first start noticing problems in your mouth?

* Why do you think the problems started when they did?

Course of Disease

* Are you concerned about the health of your mouth?

* Do you think that periodontitis is a serious condition?

* Is it permanent?

* Can its progression be stopped?

* What bothers you most about your condition?

* Can periodontitis affect your overall health?

Treatment

* What kind of previous treatment have you had for periodontitis?

* Are you aware of other available treatments?

* How frequently have you returned for recare visits?

* What results do you hope to receive from treatment?

Adapted from: Kleinman A: Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med 1978; 12:85-93.

Figure 7. Self-Care Behavior Sample Question Guide

Current self-care behaviors

* How many times a day/week do you brush your teeth?

* What type of toothbrush do you use?

* How much time do you spend brushing your teeth?

* Do you feel as though you do a thorough job brushing?

* What type of toothpaste are you currently using?

* Does your toothpaste contain fluoride?

* How often do you clean between your teeth?

* What type of product do you use to clean between your teeth?

* How much time do you spend cleaning between your teeth?

* Do you feel like you do a thorough job cleaning between your teeth?

* Are you using any other products to care for your mouth?

Attitudes and beliefs with self-care behaviors

* What specifically do you like about brushing

* How do your teeth feel after you brush?

* What do you dislike about brushing?

* What do you like, about cleaning between your teeth?

* What do you dislike about cleaning between your teeth?

* Who or what has been most influential in teaching you to care for your mouth?

* Do you want to keep your teeth?

Commitment

* What results do you want to achieve in your mouth by your next visit?

* What long term results do you want to achieve in your mouth?

* What would you be willing to do to improve the conditions in your mouth?

* How frequently are you willing to brush your teeth? How frequently are you willing to clean between your teeth?

* What is your motivation for coming to this appointment today?

Compliance at re-evaluation visit

* How have you been doing with the self care practices you decided to try at your last visit?

* How often did you follow the routine that we discussed at the last visit?

* Do you remember what your commitment was?

* What factors have inhibited you from achieving your commitment?

* What factors have assisted you in achieving your commitment?

Negotiation Domain

Once the explanatory models are verbalized, the client and dental hygienist become cotherapists and negotiate self-care behaviors, treatment, and recare interval. While clients may prefer to make good choices, their choices are based on their personal experiences and values, which may be incongruent with those of the dental hygienist. Therefore, it is preferable that they collaborate honestly to determine the best choices, with the dental hygienist acting as a resource person with whom the patient can explore alternatives for treatment and oral self-care. While clients may not be qualified to pass judgment on technical aspects of health care they are capable of making astute assessments about potential outcomes and health behaviors, as well as about the processes to achieve them.[48]

Commitment Domain

After the differences between the clinician and client explanatory models are reconciled, and self-care behaviors are negotiated, the dental hygienist helps the client establish self-selected goals. The dental hygienist then facilitates decisions about self-care, treatment, and recare interval. The client makes the decisions; the dental hygienist supports them and assists in their achievement. At the end of the appointment or treatment, the dental hygienist can assess his or her own perceptions of the level of client commitment, and documents these perceptions. During the reevaluation or recare appointment, the dental hygienist can assess how well the client has upheld the self-selected commitment to oral self-care behaviors and/or recare recommendations.

An important element of the empowerment model that has been included in the new model is that new competencies are learned in the context of daily living, rather than through formal instruction.[30] Optimally, dental hygienists will continue to evolve from experts who select clients' self-care behaviors to cotherapists who facilitate clients' decisions.

Evaluation Domain

Oral self-care in combination with professional treatment improves the outcomes of nonsurgical periodontal therapy and prevention of periodontal disease.[49,50] Evaluation of a self-care educational program focuses on the client's commitment to self-selected oral hygiene goals.[35] During the last appointment, the client self-reports to the dental hygienist his or her compliance with the established self-care commitment. Self-care education may improve the outcome of nonsurgical periodontal therapy in clinical practice, and may result in clients being cotherapists responsible for daily self-care practices, if sufficient attention is paid to client-practitioner interaction.

By eliciting the client's explanatory model, analyzing the differences between client and practitioner explanatory models, sharing health beliefs, and negotiating self-care behaviors, dental hygienists can promote oral health using a model that may be better suited to current health and cultural conditions. The profession of dental hygiene is in a position to embrace a new health paradigm that recognizes and empowers the client's role in oral health.

Conclusions and Recommendations

Dental hygienists have tried historically to "motivate" clients towards positive behaviors by providing disease information and self-care instruction about what they "should" and "should not" do to take care of their mouths. The models described in this article make it clear that this method primarily follows the biomedical model with its advantages of time, efficiency, and reinforcement of the role of oral health care provider as expert. If this approach were truly successful, client compliance would be frequent and further research would not be needed.

The explanatory model provides a framework for the dental hygienist to discover clients' health beliefs, and to explain the rationale behind self-care recommendations. It is a viable model to nurture the conceptualizations and understanding of both client and dental hygienist.

The empowerment model and the explanatory model propose ways to fulfill section eight of the human needs model. The biomedical model provides the dental hygienist with a structure for informing the client of health parameters in a time-efficient manner. The strength of this proposed commitment model is that it combines the advantages of these two models.

The human needs model states that clients should be responsible for their own oral health and understanding.[42,43] The only way for clients to have responsibility for their health is for dental hygienists to forfeit that responsibility. If the client truly has responsibility, the dental hygienist needs to accept the client's informed decisions without passing judgment. The self-care commitment model obviates the need to "motivate" a client to accept the health care provider's definition of health and well-being.

The human needs model also states that clients need to conceptualize and understand their status.[42,43] The dental hygienist's role is to assess the client's oral health and successfully explain that information to the client. However, if the dental hygienist does not identify the conceptual framework the client is using, it will not be possible to verify that he or she understands.

A framework from which to evaluate the client's perspective and determine the cultural processes used in the interaction that facilitates commitment is needed. Both quantitative and qualitative research is needed to identify the aspects of client/dental hygienist interaction that facilitate the client's commitment to oral self-care. Factors that affect compliance with that commitment also should be investigated. Qualitative information should include characteristics displayed by the client and the dental hygienist during educational sessions that facilitate desired outcomes of commitment to oral self-care.

The dental hygienist's role is to assess the client's oral health, provide alternatives, match client self-care behaviors to client goals, and ask for client commitment. Negotiation is necessary when client goals and self-selected behaviors do not match; but does not involve matching client goals to the health care provider's goals. It may be difficult for the dental hygienist to honor a client's decision that he or she does not think is in the best interest of the client. Dental hygienists' perceptions of clients' commitment can reveal a need to alter the process by which such perceptions are drawn.

One goal of the National Dental Hygiene Research Agenda is to test theoretical concepts in dental hygiene. Once this proposed commitment model is qualitatively tested, certain elements may be redefined. Dental hygiene lacks empirical data to document specific elements of client/practitioner interaction most likely to foster client commitment to protective oral health behaviors. Dental hygienists lack a framework for negotiating self-care programs based on the unique perspective of the client, and have traditionally based such programs on information gathered during assessment of the client's medical, dental, and periodontal health; what might be called "scientific data." This approach fails to include the client's perception, which might be referred to as "social or cultural data."

Using the client self-care commitment model, which recognizes the importance of a client's perceptions and decision-making in oral health care, hypotheses can be formulated and empirically tested on special client populations with differing disease etiologies. This will help determine if dental hygiene care, provided within such a conceptual model, will lead to enhanced oral self-care behaviors and, eventually, desired changes in oral health outcomes. Upon replication and validation of research findings, dental hygiene practitioners can implement the model in their specific practice settings.

Acknowledgments

The authors thank Denise M. Bowen, RDH, MS, and Kathleen O. Hodges, RDH, MS, for assistance with model conceptualization and critical review of this manuscript. This theoretical manuscript was partially funded by grant #787 from the Faculty Research Committee, Idaho State University, Pocatello, Idaho.

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Kristin Hamman Calley, RDH, MS; Ellen Rogo, RDH, MEd; Deborah L. Miller, RDH, MS, MA; Gretchen Hess, RDH, BS; and Laurie Eisenhauer, RDH, BS, are clinical faculty; all at Idaho State University, Department of Dental Hygiene, Pocatello, Idaho.
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Author:Calley, Kristin Hamman; Rogo, Ellen; Miller, Deborah L.; Hess, Gretchen; Eisenhauer, Laurie
Publication:Journal of Dental Hygiene
Article Type:Brief Article
Geographic Code:1USA
Date:Jan 1, 2000
Words:6562
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