Chapter 16.

Understanding Human Motivation for Behavior Change - Mary

Kaye Sawyer-Morse Alexandra Evans

Objectives

At the end of this chapter it will be possible to

1. Define motivation.

2. List reasons why individuals may not be motivated to receive regular oral care.

3. Describe two different approaches to motivate individuals to change behavior.

4. Describe elements of three common behavioral health promotion theories.

5. Explain the importance of appropriate health provider communication.

6. Describe four common client-provider communication styles.

7. Describe motivational interviewing and FRAMES.

Introduction

The mouth represents an area of the body of special importance and value.
According to Horowitz and coworkers,1 the mouth is associated with the
development of (1) a healthy personality, (2) perceptions, and (3) the overall
experience of pleasure. Many areas of the mouth, especially the gingival tissues,
are easily accessible for self-diagnosis and primary preventive treatment.
Individuals can easily detect gums that are red or bleeding. In addition, the
tongue, with its highly developed neurosensory feedback system, can be useful in
helping people to assess their own plaque levels and resultant need for improved
oral hygiene behavior. As a result, dental professionals should devise strategies
for motivating oral self-care behavior by teaching clients how to recognize their
own signs of dental distress or neglect.

In this chapter the interrelationship of motivation, education, and behavioral

modification are consideredall with the objective of helping dental
professionals develop more effective interpersonal skills, thereby becoming more
effective health educators and counselors.2 The task of educating the client can be
greatly simplified by a knowledge of and the application of a few basic constructs
of educational and health promotion and human motivation. These same
constructs apply equally to either private or public health practices.

The Problem: Oral health is an essential component of health throughout life.

Poor oral health and untreated oral diseases can have a significant effect on
quality of life. The mouth is the entry point for food and the beginning of the
1
gastrointestinal tract. The ability to chew and swallow is a critical function
required to obtain essential nutrients for the bodythe building blocks of good
health.3 However, millions of individuals in the United States have dental caries
and periodontal disease, resulting in unnecessary pain, difficulty in chewing,
swallowing, and speaking, increased medical costs, loss of self-esteem, decreased
economic productivity through lost work and school days, and, in extreme cases,
death.4 The Healthy People 2010 document recognizes the importance of oral
health and includes 17 specific objectives related to the overall goal: To prevent
and control oral and craniofacial diseases, conditions, and injuries and improve
access to related services.5

Regular and timely dental visits provide an opportunity for the early diagnosis,
prevention, and timely treatment of oral diseases and conditions, as well as for the
assessment of self-care practices. However, approximately 66% of people in the
United States do not see a dentist regularly,5 and among specific subpopulations,
such as certain ethnic groups or low-income groups, the proportion not receiving
regular care is even higher.6 For example, the Medical Expenditure Panel Survey
in 1996 indicated that 44% of the total population visited a dentist in the past year,
while 50% of non-Hispanic whites, 30% of Hispanics, and 27% of non-Hispanic
blacks had a visit. In addition, 55% of those individuals with some college
education had a past-year visit compared to 24% of those with less than a high
school education.7

The reasons individuals may not be motivated to seek regular and timely care
include: high cost of dental care, lack of dental insurance, lack of providers from
underserved racial and ethnic groups, fear of dental visits, habitual personal
neglect, lack of knowledge, limited oral-health literacy, and negative feedback or
unflattering statements about dentistry received from friends or relatives.5 Other
factors that have contributed to people losing confidence in dentists include prior
negative experienced with dentists (poorly executed or ineffective treatment and
unnecessary or questionable extractions or other treatments), dental treatment that
did not last long enough, and lack of access to appropriate dental care. Previous
painful experiences and perceived negative dentist behaviors (e.g. arrogance,
sarcasm, or inconsideration) appear to be especially important to the anxious
individual who is mentally preparing for dental treatment.8 See Table 16-1. Most
of these barriers can be overcome by effective client education and motivation
programs and more effective interpersonal communication by the dental
professional.

Dental Education and Motivational Programs

In previous chapters, it is stated that primary preventive dentistry can be

effectively implemented by using the following five actions: 1) plaque control, 2)
reduction of sugar in the diet, 3) fluoride therapy, 4) use of pit-and-fissure
sealants, and 5) client education. The successful use of any of these actions
requires effective relations between dental professionals and clients to achieve and
2
maintain a maximum level of oral health. Three major enabl-ing factors are
necessary to perform the above listed actionsappropriate skill-based education,
client self-motivation, and appropriate psychomotor skills.

For any preventive dentistry program to succeed, information about what needs
to be done and how it is to be accomplished must be available to both the dental
professional and the client. For the client, this information (and sometimes
misinformation) is often learned through school-based health programs; the
dentist, media, and advertising; and from peers, friends, neighbors, or relatives.
On the other hand, dental professionals learn preventive dentistry as part of the
curriculum in dental and dental hygiene schools, through reading professional
dental journals, by attending professional meetings and conferences, and through
participation in continuing education programs. In some cases, the gap between
the information possessed by the clients and the dental professionals is great. This
gap in knowledge poses a problem because people tend to seek what they already
believe and avoid exposure to anything that mandates changes.

In general, the personality characteristics of dentists indicate that technical

proficiency and attention to detail may be more common than strong interpersonal
communication skills.9 For this reason dental professionals may need to cultivate
specific knowledge and expertise in the area of human behavior and motivation
techniques. Because the skills to accomplish these tasks are not commonly taught
in dental school, many dental professionals do not have adequate skills to provide
information to clients appropriately.

In addition, many dental professionals are taught that providing knowledge to a

client is sufficient to change the client's behavior. However, extensive research
indicates that information by itself is necessary, but not sufficient. Human
behavior is a product of the interaction of multiple factors such as attitude, self-
efficacy, knowledge, or perceived risk and benefits. Any one factor can be
powerful but none acts independently.10 Therefore, not only do many dental
professionals need to acquire or strengthen skills on how to provide information to
clients, they also need to learn how to appropriately motivate clients so that
behavior change can occur. Many health behaviors theories explain health
behavior and can guide effective behavior change. For further description of three
common health behavior theories, see section Health Promotion Approach to
Behavior Change.

Motivation

What is motivation? Everyone is motivated to action or inaction. To not be

motivated is to be dead. Some argue that humans are primarily instinctual in
nature. This argument is difficult to accept because of the varied nature of human
behavior. If the "instinct theory" was valid, all humans would show a uniformity
of behavior across all cultures.11 This, of course, is not the case. Others believe
that behavior is learned and that our environment determines our actions. Indeed,
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no one should downplay the importance of environmental forces on human
behavior. Motivation may be described as the interaction between the
environment, personal and behavioral factors.12 Despite the fact that human
behavior is highly variable and at times unpredictable, one thing is certain:
Individuals' performances or behaviors are based on the degree to which they are
motivated. Motivation makes the difference.

Human motivation is complex. It is based on a blending of expectations, ideas,

feelings, desires, hopes, attitudes, values, and other factors that initiate, maintain,
and regulate behavior toward achieving a given goal or outcome. Other factors,
such as previous adverse experiences, educational insufficiency, nonacceptance
by peers, a poor self-image, and impoverished socioeconomic circumstances can
significantly influence behavior. Motivation factors can change with the passage
of time. Humans are strongly goal-oriented and can demonstrate a tremendous
drive to achieve their personal ambitions. For some, however, a significant part of
the pleasure is derived from working toward a goal; after they have "arrived,"
their pleasure is somewhat diminished. For these individuals, getting there is not
only half the fun, it is possibly all the fun. For example, some individuals
periodically become intensely motivated to upgrade their oral health status.
Appointments are made with the dentist, all restorative work is completed,
preventive programs are developed with a great amount of client participation
until all dental care has been completed, at which time the individual appears to
lose interest until another sudden flurry of interest may occur at a later date.

Motivation then is seen not as a personality problem or trait but rather as a state of
readiness or eagerness to change. This readiness may fluctuate from one time or
situation to another and can be influenced by the dental professional.13

Question 1

Which of the following statements, if any, are correct?

A. The layperson who is undereducated in dental health readily accepts suggested

changes in preventive programs that are directed to better oral health.

B. Perceived negative dentist behaviors may deter patients from seeking necessary
dental treatment.

C. Primarily, human motivation can be explained and understood as being

instinctual in nature.

D. In general, providing patients with knowledge is sufficient to facilitate

behavior change.

Educational Approach to Behavior Change

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The Learning Process

Because information transmittal involves learning, it is desirable to turn to the

teaching profession for how information is best imparted to ensure long-term
retention. Ensuring that a client adheres with a home care regimen can be the most
difficult part of therapy.14 According to Bloom's taxonomy of educational
objectives, a hierarchy of six levels of learning attainment progresses from a
complete lack of information to goal attainment (see Figure 16-1).15 These
successive levels are knowledge, comprehension, application, analysis, synthesis,
and evaluation. Most teaching today is at the lowest knowledge stage. After
mastery of this stage, the learner can only define, repeat, or name facts; it is only
partial learning at best. Possible verbs used in stating cognitive outcomes of
teaching programs starting with the knowledge level up to evaluation are listed in
Figure 16-2. If material is only taught at the lower levels of the taxonomy,
learning is incomplete.

The implication of partial learning is apparent when applied to plaque control

methods. The average person knows and comprehends that brushing and flossing
clean the teeth. They can even demonstrate that they can brush their teeth in some
fashion. But how many people can evaluate the effectiveness of their efforts?
How many can analyze where problems lie, and how many can propose
innovations to their personal oral hygiene program that might make it more
effective?

Teaching at the higher levels of Bloom's taxonomy is necessary to accomplish this

type of learning. At each cognitive level the teaching should feature an
explanation of the subject, followed in sequence by demonstration, applications,
feedback, and reinforcement. The use of these sequential steps in all teaching
helps to ensure a mastery of the desired topic or skill. In moving from one level of
complexity to the next, the learner is exposed to an organized continuum of
interrelated facts. Even after successfully mastering all levels of Bloom's
hierarchy, however, it is very possible that a skill or subject area learned in an
academic or clinical environment is not applied at home, in a more informal
environment on a routine basis. Day-to-day application occurs only after an
individual has learned sufficient information to determine that a specific benefit
accrues to him or her from its use and thus has become motivated. Education
involves learning; practical application involves self-motivation.16 At this point,
the knowledge needs to be incorporated into the client's existing value systems.

Incorporating Knowledge into Value Systems

Personal belief systems and values strongly influence an individual's behavior.

Values are developed through the application of knowledge, which thus requires
that an individual has enough facts to develop concepts and then a sufficient
number of concepts to develop a value.17 This concept is portrayed graphically in
Figure 16-3. The base of the pyramid consists of facts, which are the building
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blocks of all learning. Sometimes great voids or even misinformation occur in this
body of information. Yet, regardless of its completeness or accuracy, this
substratum of information is where concepts are formed by use of one's reasoning
power. Concepts, less numerous than facts, represent the organization and
classification of facts into meaningful personal habits or patterns. The greater
number of correct facts arising from different inputs, the greater the possibility of
developing correct concepts. On top of these supporting facts and concepts rest
valuesbeliefs and bodies of knowledge important to the individual.

These values are only as strong as the supporting information. It should be noted
that not all dental values are positive. For example, for individuals living under
impoverished conditions who do not appreciate the value of teeth from a health or
social viewpoint or where the loss of teeth is considered as normal, facts,
concepts, and values are often negative. These negative perceptions can motivate
nonparticipation in dental programs.18 It has also been noted that a client's
relationship with the dental professional influences their anxiety level and
resulting compliance with suggested oral health-care practices.8 The dental
professional must carefully consider the possible myriad facts and concepts that
can make up this pyramid when trying to change a client's value systema value
system that is valid to only the individual client.

Values are not neutral but are held with personal feeling.17 When they are
challenged, they frequently generate an emotional, defensive response. Making
changes in one's behavior is often very difficult and involves dealing with
conflict. Hayakawa19 expands this idea when he writes, "the process of learning,
which is also the process of growth, is essentially a means of resolving conflicts . .
. a conflict must always be present before learning can occur . . . conflict then is a
necessary accompaniment of personality development, and the progressive
assimilation of disturbing stimuli is the only practical means by which a stable
organization can be obtained. Without conflict, no learning results."

Therefore it is necessary that the dental professional understand that because of

the client's value system, resistance is normal and permanent changes in some
forms of behavior are difficult to achieve. This same resistance is met from the
client in the dental office, or from many in the community, when new health
programs are proposed. For example, sugar discipline is difficult to instill because
of concepts and values shaped early in childhood by the media and candy-laden
shelves in the supermarkets; water fluoridation efforts have failed in some areas
because of a barrage of misinformation and distorted facts, leading to strongly
held values by those voting against fluoridation. Such resistance to change should
not prevent the continual education and pressure for more effective oral disease
control programs. In this quest, however, we must be careful how we approach the
value systems of our clients or of the community. We must respect the fact that
others have their own value systems tied to their own set of expectations that may
be quite different from ours.

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Can human values be changed? The answer is yes, but this statement must be
qualified. Values are slow to form and slow to change.17 Even if the factual
information is complete and adequate, time is required for concepts to evolve and
mature; even more time is required before other additional facts and concepts are
acquired to support a new value. Stated another way, a dental professional should
not expect dramatic and immediate changes in client behavior as a result of only
one or two counseling sessions. Thus to attain a behavioral change, a health
education program is often confronted with the imposing requirement to modify
or reconstruct completely the facts and concepts making up an existing value
structure. No wonder so many health education programs fail. A good example is
smoking behavior. Virtually all smokers have enough facts necessary to develop
the concept that the behavior, cigarette smoking, is harmful. Yet many have not
accepted this concept into their own value systems to the point of behavioral
change, namely of not smoking. It is also seen in caries and periodontal disease
control programs in which clients are unwilling to conduct lifelong programs of
plaque control.

Figure 16-1 Bloom's Taxonomy of Educational Objectives.

Figure 16-2 Some possible verbs for use in stating cognitive outcomes.
(Courtesy of Marybelle Savage.)
Figure 16-3 The interrelationship between values, concepts, and facts
using oral health as a positive end value. Learning on all three levels helps
individuals discern facts, make sense of them and, finally, to live by the
meaning they perceive.

Question 2

Which of the following statements, if any, are correct?

A. Different groups of individuals presented with the same facts can develop
different concepts.

B. Once facts and concepts are a part of an individual's life, values fall in place.

C. Most education results in the learner being able to attain the cognitive level of
evaluation on Bloom's hierarchy.

D. The dental professional must acknowledge that values are slow to change and
that resistance to changing values is normal.

Health Promotion Approach to Behavior Change

An alternative way of examining human motivation draws from the health

7
education and health promotion literature. Although many definitions for health
promotion exist, one of the more common ones states that health promotion is
"any combination of health education and related organizational, political, and
economic interventions designed to facilitate behavioral and environmental
changes conducive to health."20

Central to all health promotion definitions is the concept of health behavior.

Positive informed changes in health behavior are usually the ultimate goals of
health promotion activities. Health behavior refers to "those personal attributes
such as beliefs, expectations, motives, values, perceptions, and other cognitive
elements; personality characteristics, including affective and emotional states and
traits; and overt behavioral patterns, actions, and habits that relate to health
maintenance, to health restoration, and to health improvement."21 Specific to the
field of dental care, health behaviors include getting regular dental check-ups,
regular brushing and flossing, and reducing sugar intake.

Identifying the personal attributes most significant for certain health behaviors is
critical for the development of successful interventions. For example, to increase
the number of individuals who obtain regular and timely dental check-ups, dental
health-care providers need to be aware of the personal attributes, or the
predisposing factors, that contribute to people getting regular check-ups. This
information can come from two sources: empirical data and health promotion
theories. Empirical data can provide us with data obtained through
epidemiological studies. Health-promotion theories can explain and predict why
people behave the way they do.

Health Behavior Change Theories

Three prominent theories that will be discussed in the following sections include
the Health Belief Model (HBM),22 Social Cognitive Theory (SCT),12 and the
Transtheoretical Model (TTM).23 These theories share the central assumptions
that people are capable of forethought, planning, and rational decision making.
People are goal oriented and self-regulating beings. All of these theories explicitly
or implicitly recognize that people experience their decision making and self-
regulation as part of a dynamic social-learning process.12 While the HBM mainly
predicts behavior, SCT and TTM address the processes of behavior change and
allow for the identification of appropriate strategies to facilitate behavior change.

Individuals' motivation is central to most health behavior theories for either

prediction or behavior change purposes. As will be noted below, most of these
theories include the assumption that individuals are interested in planning and
controlling their actions and are not passive "lumps of clay."

Health Belief Model

The Health Belief Model (HBM) is a commonly used theory to predict

8
individual's behavior regarding preventive health care. Originally developed in the
1950s to explain widespread failure of people to participate in interventions to
prevent tuberculosis,24 HBM has been extended to apply to people's responses to
symptoms and to their compliance with medical regimens.22

HBM includes five main components: perceived susceptibility, perceived severity,

perceived benefits, perceived barriers, and self-efficacy. Perceived susceptibility
refers to a person's subjective perception of the risk of becoming sick, while
perceived severity refers to the person's feelings of the seriousness of becoming
sick or leaving the illness untreated (both medical and clinical and social
consequences). The combination of susceptibility and severity is often labeled
perceived threat. Before a person will take action and change behavior, the
perceived threat needs to high. For example, before a person will consider flossing
every day, he or she needs to believe that not flossing will lead to periodontal
disease and that periodontal disease can have serious negative consequences for
him or her.

When an individual has a high perceived threat, that person will analyze the
perceived benefits and barriers of performing a certain behavior. Perceived
benefits refer to the beliefs regarding the effectiveness of the available actions in
reducing the disease threat. Thus, a person who believes that flossing every day
will reduce the risk of developing periodontal disease will be more likely to
perform this behavior than a person who does not have this belief. Contrary to
perceived benefits, perceived barriers (e.g. painful, difficult, upsetting,
inconvenient, time-consuming) can act as impediments to engaging in the health
behavior. Thus a sort of cost-benefit analysis occurs when individuals decide
whether the perceived benefits override the perceived barriers. If they do, those
individuals will most likely perform the behavior. If the barriers outweigh the
benefits, the behavior will probably not occur. Thus, even if a person feels a high
threat for periodontal disease, he or she may not change his current behavior to
daily flossing when the perceived barriers for flossing every day (e.g., time-
consuming, painful, inconvenient) are stronger than the benefits.

Determining their client's perceived threat, perceived benefits, and barriers can be
very helpful for a dental professional who wants to encourage a client to change
behaviors. By asking the right type of questions, all health professionals can
obtain this information. The dental professional can then address any perceived
misconceptions and, consequently, facilitate behavior change.

Social Cognitive Theory

HBM, is a theory that focuses on psychosocial factors within the individual that
can affect behavior change. Social Cognitive Theory (formerly known as Social
Learning Theory) includes both individual as well as environmental influences.
Thus, SCT explains human behavior in terms of a triadic, and reciprocal model, in
which personal factors, environmental influences, and behavior interact
9
continuously.12 In addition to explaining why a person behaves in a certain
manner, SCT can facilitate behavior change by providing specific learning
strategies (e.g., modeling). For a more detailed description of the various SCT
constructs, please see Health Behavior and Education (1997) by Glanz et al.

Reciprocal determinism is the underlying assumption of SCT. It explains that

behavior, environmental factors, and individual influences are continuously
interacting and each one affects the other. For example, a person who has high
dental anxiety (a personal factor) and receives no reinforcement to see a dentist
regularly (environmental factor) is not likely to go for preventive dental check
ups. However, if this person receives positive feedback for seeing a dentist
(environmental factor), and has a role model who visits a dentist every 6 months
(environmental factor), her level of dental anxiety may actually decrease. As a
result, she may be more likely to go see a dentist. SCT underscores the importance
of avoiding simplistic "single direction of change" thinking. Behaviors do not
occur in isolation and interventions should focus both on the individual and the
environment.10

Modeling, one of the key learning strategies proposed by SCT, has been
successfully used with dental clients to decrease dental fear and anxiety. A study
performed by Bernstein (1982) looked at the effectiveness of different strategies
to reduce fear of dentistry in adult clients who had avoided dental treatment for
from 1 to 10 years. The strategies studies included participant modeling (a SCT
strategy), symbolic modeling, and graduated exposure. Results suggested that
even though the strategies were equally effective for the short-term, participant
modeling was most effective for reducing fear for long-term period.25

Stages of Change Model

Oral health care providers have sought to understand and create those conditions
that would lead to beneficial and helpful behavior changes for their clients. The
Transtheoretical Model (TTM), developed by two psychologists, Drs. Prochaska
and DiClemente23 is a powerful and widely accepted model for understanding
how and why people change, either on their own or with the assistance of others.
The model is based on the individual's state of readiness or willingness to change,
which may fluctuate from one time or situation to another.

The Transtheoretical Model is composed of three main constructs, one of which is

the Stages of Change. The stages of change construct describes a series of five
progressive stages through which individuals pass in the course of changing a
behavior. The "wheel of change" derived from the Prochaska-DiClemente model
(Figure 16-4) reflects the reality that in almost any change process, it is possible
for a person to go around the "wheel" or relapse several times before achieving a
stable change. For example, an individual who is willing and ready to start
flossing once a day may begin this practice receiving information from his dentist,
then relapse after several weeks, and then start the daily flossing routine again
10
after another dental visit. Thus, according to the Stages of Change, relapses or
slips to previous behaviors is normal and a realistic occurrence.

The five stages of change as linked to the development of health behaviors,

including optimal oral hygiene habits, are described below. Daily flossing will be
used as the specific example to illustrate this theory.

PrecontemplationIndividuals in this stage are not aware of the positive

consequences of daily flossing and have no conscious intentions of starting to
floss daily within the next 6 months.

ContemplationIndividuals in the Contemplation stage are aware of the positive

consequences of changing their current behaviors and plan to start flossing within
the next 6 months (near future).

PreparationIndividuals in this stage are making concrete steps to adopting oral

hygiene practices. They may have bought new floss or scheduled dental
appointments.

ActionIndividuals in the Action stage are actually flossing every day but have
done so less than 6 months.

MaintenanceIndividuals have flossed daily for over 6 months.

As discussed earlier, at any time an individual may relapse to a previous stage,

thus an individual in the Action stage could relapse to the Preparation or even the
Contemplation stage.

Corresponding to each stage are appropriate counseling techniques. Thus, by

understanding the specific stages of behavior change and the corresponding
emotions that may accompany them, oral health care providers can better
understand the actions, or inactions, of their clients. With a better understanding,
they will be more able to meet the immediate needs of their clients and counsel
them appropriately. For example, precontemplators are not ready to change their
behavior and they do not want to hear threatening messages. They have a very
strong preponderance of "pros" about their current behavior and have a poor
acknowledgement of the "cons." These individuals should be given balanced
information about the current behavior, handled with kindness and care, and left
alone. It is not reasonable to blame these individuals for being unmotivated to
change their current oral hygiene practices.

Individuals who are in the contemplation stage tend to have a balance between the
positive and negative feelings about their current behaviors. They are often still
ambivalent about changing. Even when contemplators move into the preparation
stage, when the strengths of the pros for changing behaviors have increased over

11
the cons, they may still have positive feelings about their current behaviors that
are strong.

The Stages of Change model indicates that the goal of the oral health care
provider is not necessarily one of action. Because many individuals tend to be in
the precontemplation or contemplation stages, it is very worthwhile to try to
"move" these individuals to the next stage.

Figure 16-4 Prochaska and DiClemente's six stages of change (as modified
by Christen, et al., 1994).

Question 3

Which of the following statements, if any, are correct?

A. Affecting knowledge is central to most health behavior theories.

B. The stages of change model suggest that there is a one-way, linear progression
through five stages: precontemplation, contemplation, preparation, action, and
maintenance.

C. SCT explains that behavior is reciprocally affected by personal and

environmental factors.

D. All health promotion theories can predict health behavior and address
processes of change.

Approaches for Different Levels of Client Motivation and Adherence

Plaque-control measures are difficult to accomplish and require considerable time,

skill, and perseverance. In fact, current measures of oral hygiene requiring
fastidious removal of all supragingival plaque may be beyond the average
individual.26 Thus a blend of education, motivation, and psychomotor skills are
necessary to ensure good personal oral hygiene measures. No good evidence
supports the fact that mass education alters individual behavior. Instead,
individualized approaches are usually necessary, and even these are not always
successful.

For a dentist entrusted with the preventive care of a moderately motivated

individual, the recall program should be at sufficiently frequent intervals to
compensate for lapses in client self-care routines. At the same time, the
educational and motivation phases of client education should be emphasized to
improve the participation and effectiveness in self-care programs. In this way, the
dental professional assumes the task of caring for the client to the extent that
compensates for the shortcomings of the client while preparing the client to adopt

12
a greater role in maintaining personal oral health status. Ultimately, it is the client
who must assume as much responsibility for self-care as possible and to seek out
the dental professional for evaluation (examination) and reinforcement when
deficiencies are noted or suspected.

Once an individual becomes sufficiently motivated and changes his or her

behavior, the next important issue is adherence. Adherence implies that people
choose freely to undertake behavioral plans, have input to them, and have
collaborative involvement in adjusting their plans.27 What makes an individual
continue to follow dental recommendations and adhere to practice oral hygiene?
Although there is a paucity of literature in the area of adherence to oral hygiene
practices, literature related to other health behaviors can provide some
information.

Although there are some common factors, potential determinants of adherence are
not consistently detected. A clinically-oriented framework by Meichenbaum and
Turk (1987) may be useful for oral health-care professionals. This framework
divides factors related to adherence into characteristics of the individual (e.g.,
knowledge, attitudes, beliefs, expectancies about health, treatment), disease (e.g.,
complexity, duration, side effects), the treatment regimen (e.g., complexity,
duration, type, cost), relationship to the health-care-provider clinic staff (e.g.,
client-provider staff), and clinic organization (e.g., staff enthusiasm).28

This framework can be used to provide order to a list of determinants and can help
identify categories of potential moderators of adherence to treatments. Thus, to
improve adherence to specific regimen, oral health care professionals can use this
framework to examine their clients and clinics to determine potential areas of
improvement.

Selecting Methods of Influencing Behavior Change

Client-Provider Relationship/Communication Styles

Determining the most appropriate type of client-physician relationship is

extremely important for the practicing dentist. While some health-care
professionals prefer to be the expert and authority, others understand that not all
clients respond well to this type of relationship. When a client does not respond
well to the type of relationship practiced by the health care provider, important
information may be lost. On the other hand, the positive benefits derived from
good doctor-client communication include both immediate effects during the visit
and long term effects following the visits and involve compliance with prescribed
regimen, pain experience, physiologic changes, speed of recovery, and functional
state.29

There are four archetypal forms of the doctor-client relationship: paternalism,

consumerism, mutuality, and default. Paternalism is regarded as the more
13
traditional and probably the most common form of the doctor-client relationship.30
The paternalistic model provides a social control function in that the health care
provider is seen as the expert and dominant, controlling figure, while the client is
passive and free from social responsibilities. The physician maintains emotional
detachment and acts only in his or her sphere of expertise. Although some may
view this type relationship as negative, some clients may actually draw comfort
and support from a doctor-father figure. The supportive nature of paternalism
seems to be very important when a client is in need of extensive services and
therefore is vulnerable. In times of emergency, when correct decisions must be
made quickly to avoid life-threatening events, the health-care provider must take
control and the paternalistic form is usually necessary.

The consumerism prototype is the opposite of paternalism. In this type of

relationship, the power relationship between the client and the physician are
reversed: the client or the consumer has more power or control than the
physician.10 Especially when trying to "sell" prevention to the client, the
physician's role is to convince the client of the necessity of non-curative services
such as regular dental checkups or daily brushing. Several authors have defined
consumerism as a client challenge to unilateral decision making by physicians
when reaching closure on diagnosis and treatment plans.31 In this prototype, the
health provider and client co-jointly explore the various options and planning
objectives. This type of relationship appeals to higher order means of acceptance,
including reasoning, nonthreatening persuasion, and rewards. The healthcare
provider typically talks less, listens more, questions, reacts, and synthesizes when
necessary.32

Compared to consumerism, the mutuality prototype offers a more moderate

alternative. The client still has a great deal of power but so does the physician. In
mutuality, both individuals (client and physician) bring recognized strengths and
resources to the relationship. In this model, the client recognizes his or her role as
part of a joint venture while the physician understands the centrality of the client
in his or her care.10

In some cases, the client and physician remain at odds and cannot negotiate a
change in the relationship due to poor fit. In this case, a total lack of control exists
and the default prototype occurs.29 Although the client and physician may still see
each other during regular visits, the client may fail to make a commitment to
prescribed regimens and the physician may cease to be engaged or try to educate
the client.

Motivational Interviewing in the Change Process

Motivational interviewing, introduced by Miller and Rollnick (1991) is a

particular method to help people recognize and do something about their present
and potential behavioral problems.33 It is particularly useful for those clients who
are reluctant to change and ambivalent about changing. This technique attempts to
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help resolve ambivalence and to move the individual along the path to change.
Ambivalence is a state of mind in which a person has coexisting but conflicting
feelings about some issue. This "I want to but I don't want to" dilemma is at the
heart of the problem of all change. Ambivalence is a type of conflict within an
individual that has the potential for keeping people "stuck" and creating stress.
Ambivalent smokers who have been told by their periodontist that tobacco use can
cause periodontal disease, might readily acknowledge that their oral health is
endangered, yet may feel equally concerned about their ability to cope with
stressful situations without smoking.

Oral-health-care providers must understand that ambivalence is not merely a "bad

sign." It should be regarded as normal, acceptable, common, and understandable
part of the change process. What is highly valued by some (e.g., having good oral
health) will be of little importance to others.

Five broad clinical principles underlie motivational interviewing.33 These

principles emphasize that the clinician should: 1) express empathy (through
skillful reflective listening, the clinician seeks to understand and accept the
client's feelings and perspective without judging, criticizing or blaming, and
realizes that ambivalence is normal); 2) develop discrepancy (help the client
understand the discrepancy between their present behavior and their ability to
reach their important goals; clients should discover and present their own
arguments for and against change); 3) avoid argumentation (a gently
persuasive/soft confrontation approach should be usedone that asserts that
clients have the freedom to do as they please; avoid sending the message that "I'm
the expert and I'm going to tell you how to run your life"; do not accuse clients of
being "in denial" or label their behavior); 4) roll with resistance (invite the client
to consider new information and offer new perspectives, without being imposing);
5) support self-efficacy (it is essential to support the client's self-esteem and their
general self-regard; the client is responsible for choosing and carrying out
personal change and the overall message is of hope and faith to the client; "You
can do it. You can succeed.").

The FRAMES Brief Counseling Elements

Miller and Rollnick34 have described six practical counseling elements that are
active ingredients in effective and brief counseling interventions. They are
summarized in the acronym "FRAMES."

 FeedbackThe client is given feedback of their current status. The importance

of conducting a thorough assessment provides the client an opportunity to reflect
in detail upon their situation.
 ResponsibilityThere is an emphasis on the individual's personal responsibility
for change. "It's up to you to decide what to do with this information. Nobody can
decide for you, and no one can change your habit patterns if you don't want to

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change."
 AdviceSimple, clear advice to the client to make a change in their lifestyle is
given.
 MenuBy offering clients a menu of alternative strategies for changing their
problem behavior, the clinician provides a range of options, which allows clients
to select strategies that match their particular needs and situations.
 EmpathyUnderstand another's meaning through the use of reflective listening,
whether you have had similar experiences yourself. Use of warmth, respect,
supportiveness, caring, concern, sympathetic understanding, commitment, and
active interest to convey this element.
 Self-efficacyReinforcing the client's hope or optimism in their ability to make
changes promotes self-efficacy. Remember that your belief in the client's ability
to change is often a significant determinant of outcomes.

Basic Philosophy

A basic philosophy of prevention is itself a value. One basic philosophy

concerning preventive dentistry is that clients deserve to know the cause of their
dental diseases and how they can prevent them. This is a responsibility for the
health educator. Once armed with the knowledge, however, the client reserves the
right to remain sick. This is a problem of self-motivation. Clients are ultimately
responsible for their own dental health. In the final analysis, prevention is a shared
responsibility between the practitioner and the client.

Summary

The maintenance of good oral health requires a partnership between the dental
professional and the patient. No preventive program can be a success unless the
patient participates in a home self-care program to supplement office care
programs, with the level of success being proportionate to the amount of
participation. Maximum participation can be expected when the patient knows
what to do, how to do it, and above all has the motivation to adhere to
recommended procedures. Educational strategies can be used to teach facts and
skills, but these are useless without motivation. Motivation can be initiated by an
individual based on some need or desire, or it can be facilitated by persuasion
from external sources. With or without motivation, learning is best achieved in
sequential steps, as described by Bloom's hierarchy of cognitive levels. As an
individual accumulates facts, the facts merge into concepts and ultimately into
values, which in turn engender motivation. At times motivation provides the drive
to alter lifestyle to attain habit patterns necessary to maintain good oral health.
The dental professional can exert a direct or indirect influence on such a change
by providing appropriate behavior modeling, by taking a more active role as an
authoritarian, or by participating as a nonauthoritarian in developing a program of
planned change with the patient. All health education requires learning, but the
successful application of all health knowledge requires motivation.

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Answers and Explanations

1. Bcorrect.

Aincorrect. The average layperson does not accept change without considerable
persuasion.

Cincorrect. Human motivation is complex in nature and best described as the

interaction between the environment, personal, and behavioral factors.

Dincorrect. Knowledge is rarely sufficient to change behavior.

2. A, Dcorrect.

Bincorrect. Facts and concepts represent unorganized and organized thoughts,

respectively; values represent the acceptance and personal application of facts and
concepts.

Cincorrect. Most education is directed to the initial levelfacts; very little

learning ends up at the evaluation level.

3. Ccorrect.

Aincorrect. Most health-behavior theories attempt to explain or predict

behavior.

Bincorrect. The stages of change model suggest that behavior change does not
typically follow a linear progression but rather is cyclical as an individual
experiences relapse and adopts new behaviors.

Dincorrect. Health-promotion theories attempt to explain or predict behavior

with varying degrees of accurateness.

Self-Evaluation Questions

1. Health promotion can be defined as __________.

2. An individual, through reasoning, organizes facts into __________; which in

turn are the basis for a(n) __________.

3. The central assumption underlying health promotion theories is __________.

4. The five main concepts of the Health Belief Model include: __________,
__________, __________, __________, __________.
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5. The six cognitive levels of Bloom's hierarchy of learning are knowledge,
_________, __________, __________, __________, __________, and
__________.

6. The one main difference between HBM and Social Cognitive Theory is
__________.

7. __________ is the underlying assumption of SCT.

8. __________ implies that an individual chooses freely to undertake behavioral

plans, have input to them, and has a collaborative involvement in modifying the
plan.

9. In the dentist-patient partnership, it is the __________ who must assume

responsibility for home care programs, whereas the __________ must assume
responsibility of identifying and correcting deficiencies that occur in a home care
program.

10. In the development of optimal oral hygiene habits, patients encounter five
progressive stages of change. They are: __________, __________, _________,
__________, and __________.

11. In the process of applying motivational interviewing, the clinician should

apply five principles, which are: _____, _____, _____, _____, and _____.

12. The process whereby the clinician seeks to understand and accept the patient's
feelings and perspectives without judgment, criticizing, or blaming is called:
_____.

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