Factors associated with orthodontic patient compliance with intraoral elastic and headgear wear
Rebecca d. Egolf, DMD, MS,* Ellen A. BeGole, PhD,** Harry S. Upshaw, PhD*** Chicago, IlL
Factors related to compliance with the wearing of headgear and intraoral elastics were explored in a sample of 100 university clinic orthodontic patients. Data were gathered by means of a questionnaire that comprised items presumed to be associated with orthodontic compliance. These items were not patient characteristics, but variables of beliefs, attitudes, perceptions, and reasons thought to be associated with compliance. The 58 questions were reduced through alpha factor analysis and the imposition of a coefficient alpha restriction to 12 factors. These 12 factors were named according to the questions they comprised. To assess whether these factors were indeed related to compliance, correlation coefficients were calculated between the factor scores (independent variables) and the criterion of compliance with headgear and elastics (dependent variable). Compliance was rated on a three-point scale. Four factors were found to be weakly, though significantly, correlated with compliance. These factors were combinations of personality type, negative motives (pain, inconvenience, and dysfunction), and positive motives (general health awareness, specific dental knowledge, and personal oral embarrassment). The findings were compared with existing theories of patient behavior. (AM J ORTHOODENTOFACORTHOP1990;97:336-48.)
A compliant or cooperative orthodontic patient may be described as one who practices good oral hygiene, wears appliances as instructed without abusing them, follows the appropriate diet, and keeps appointments so that the goal of a stable, functioning, esthetic dentition can be achieved expeditiously. The cooperative orthodontic patient has been described in many studies that identified the patient by demographic and personal characteristics, such as age, sex, social class, personality type, and severity of malocclusion. Since the sex of the patient is one of the easiest attribute variables to assess, it is frequently reported although it may not be the central question of the study. Of eight studies relating gender to various aspects of orthodontic cooperation, three t3 reported girls to be more cooperative than boys, and five4-8 found no difference between the sexes. Age, on the other hand, is consistently and significantly associated with patient cooperation in the studies
Based on research submitted by Dr. Egolf in partial fulfillment of the requirements for the Master of Science degree, Department of Orthodontics, University of Illinois at Chicago. *Orthodontic private practice; attending staff member, Michael Reese ilospital and Medical Center. **Professor of Biostatistics, Department of Orthodontics, University of Illinois at Chicago. ***Professor of Psychology, University of Illinois at Chicago. 811113886
reviewed. 4"7"9Patients 12 years of age or slightly younger are more compliant than older children. Personality tests have been used by a number of investigators, generally with the goal of being able to predict patient cooperation by identifying particular personality types. Both GabrieP ° andMcDonald 8 used the California Test of Personality. This test purports to measure a number of psychosocial domains, such as selfreliance, sense of personal worth, or social skills." GabrieP ° found a low correlation between the scores from items of the California Test of Personality and a posttreatment, subjective assessment of motivation. He believed this correlation was too low to be predictive. McDonald, 8 however, reported a significant correlation between scores on the California Test of Personality and patient cooperation. Using the Adjective Check List of 300 adjectives and 15 needs, Allen and Hodgson4 described the cooperative patient as 14 years of age or younger, enthusiastic, outgoing, energetic, wholesome, selfcontrolled, responsible, trusting, determined to do well, hardworking, forthright, and obliging. The uncooperative patients were pictured as more than 14 years old, of superior intelligence, hardheaded, independent, aloof, often nervous, temperamental, impatient, individualistic, easygoing, self-sufficient, intolerant of prolonged effort or attention, and disregarding the wishes
the patients' self-perception of their profiles is more important than the diagnostic criteria in their decision to undergo orthognathic surgery. The questionnaire items (independent variables) were taken from the literature and from existing tests 3""'~9'2° and were reformulated when necessary. when these traits plus age and sex were correlated with cooperation.Z~ The question remained whether the factors. Some dimensions of compliance. With respect to the decision to seek orthodontic treatment. exploratory field study. it may be more a reflection of the skill of the student orthodontist than the uncooperative behavior of the patient. The remaining questions assessed demographics. which were thought to reflect reasons patients comply. This was done by examining the variables of beliefs. These patients were characterized as being concemed with appearance. reasons. To verify this mathematically. This procedure mathematically reduces a
.7 reported that patients in the lower middle or lower classes are more cooperative. High-need achievers. The instrument was refined by deletion or rephrasing of questions and was subsequently readministered to another five subjects with the same objectives. and requiring the presence of authority to enforce ethical behavior. Kreit et al. depending on the
The purpose of this research was to explore reasons orthodontic patients comply with the wearing of headgear and elastics. and internally motivated patients were shown to be better cooperators. be due to excellent wear) ° The criterion was rated on a three-point scale: excellent. The correlation of questions with a rating of cooperation produced a description of the uncooperative patient. The orthodontist assigned the patient to one of these categories. such as keeping of appointments and payment. retrospective.Voh~me97 Number 4
Factors associated with patient compliance
of others. 25 observed that. EI-Mangoury. The response scale was of the Likert type as shown in Table I.
large number of variables to a smaller number of hypothetical variables or factors. or patient history. and perceptions thought to be associated with cooperative behavior. to identify ambiguous questions and overly technical language. Some would expect a relationship between the severity of the malocclusion and the amount of patient cooperation. high-need affiliators. These two treatment aids were selected because they are under the patient's direct control. average. the cooperation of the patient was rated and this criterion of cooperation was correlated with the factors. Additional questions were suggested by patients and by experts in the field. in the present setting (a university teaching clinic). studies differ regarding the severity of the malocclusion and its relation to the child's desire for treatment. the statistical technique of alpha factor analysis was used. They may have a variety of personality characteristics not adequately described by one personality theory and a wide range in severity of malocclusion. It was a nonexperimental. The dimension of oral hygiene was notincluded since it was not shown by Crawford 7 or EIMangoury u to be correlated with appliance wear. ~2 in a study of orthodontic patient cooperation. which therefore. and to measure completion time. Nor was appliance breakage chosen because. However.I constructed a personality inventory and administered it to 1386 patients. attitudes. patient characteristics. Socioeconomic status was found to be related to cooperation. having conflict with their parents. The foregoing studies sought to identify the cooperative orthodontic patient on the basis of immutable chracteristics or attribute variables. x5.
MATERIALS AND METHODS Independent variables
A questionnaire was constructed for data collection. had no hypothesis) 7 To discover meaning in such a multitude of variables. Two studies 2.
Dependent variable (criterion of cooperation)
The criterion chosen was subjective assessment by the clinician of the patient's cooperation in wearing headgear or intraoral elastics.~6Bell et al. The child is described as younger and in the lower middle socioeconomic class. are more under parental control. and poor. Both Grew and Hermanson ~4 and McDonald 8 found no correlation. The first portion of the questionnaire consisted of 36 questions regarding general beliefs. Furthermore. Albino et al) 3 reported patient cooperation was related to an external locus of control. However. were indeed associated with cooperative behavior. and concepts related to health. a broken appliance might be the result of material failure and. among orthognathic surgery patients. also constructed tests to assess patient personality. A pilot questionnaire was administered to five subjects to determine the appropriateness of the reading level. The second portion of the questionnaire was a combination of items concerning specific reasons for the patient's compliance or noncompliance with four or five statement choices presented. attitudes. in fact. only age was found to be a significant predictor.
Some patients cooperate better if their parents or the orthodontist gives them a reward. Strongly Strongly disagree Disagree Neither Agree agree 0% 3% 5% 50% 42% 2. Strongly Strongly disagree Disagree Neither Agree agree 4% 12% 31% 41% 12% 10. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 1% 0% 2% 52% 45% 12. Having braces can help you have fewer problems with your mouth later on. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 2% 10% 8% 54% 26% 6. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 1% 3% 8% 56% 32%
. People with nice smiles have more friends. R e s u l t s o f the q u e s t i o n n a i r e ( P e r c e n t a g e o f p a t i e n t r e s p o n s e is r e p o r t e d . Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 3% 5% 20% 57% 15% 13. Self-confidence) Strongly Strongly disagree Disagree Neither Agree agree 18% 44% 14% 23% 1% 9. (Factor II. J. It's easier to wear braces if your friends are wearing them too. Orthop. Strongly Strongly disagree Disagree Neither Agree agree 13% 35% 36% 11% 5% 7. (Factor I1. Strongly Strongly disagree Disagree Neither Agree agree 14% 37% 26% 22% 1% 11. Q u e s t i o n s c o m p r i s i n g factors w h i c h c o r r e l a t e w i t h c o o p e r a t i o n are n o t e d . Having a healthy body is very important. Straight front teeth are very important.Dentofac. April 1990
T a b l e I. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 0% I% 8% 64% 27% 3. Patients who understand their treatment are more cooperative. Straight teeth can help prevent gum problems. (Factor IX. Orthod. Internal/External) Strongly Strongly disagree Disagree Neither Agree agree 16% 36% 26% 19% 3% 5. (Factor II. BeGole. Some day most people probably will have false teeth. (Factor 1I. Strongly Strongly disagree Disagree Neither Agree agree 12% 47% 27% 11% 3% 4.338
Egolf. (Factor 11. Some people want braces because their friends have them. Parents and the orthodontist become more upset with broken braces than they should. Some people have braces to help their bite. Strongly Strongly disagree Disagree Neither Agree agree 11% 39% 12% 32% 6% 8. ) I. (Factor I. Pain/Dysfunction. People with pleasing smiles get ahead in life. Strongly Strongly disagree Disagree Neither Agree agree 8% 30% 21% 39% 2% 14. attd Upshaw
Am. Straight teeth are easier to clean.
Most people don't understand how uncomfortable and annoying braces can be. Internal/External. Some patients lose or break their headgear or appliances to annoy their parents or the orthdontist. and Factor III. Strongly Strongly disagree Disagree Neither Agree agree 34% 43% 11% 8% 4% 27. Internal/External. (Factor I. Internal/External) Strongly Strongly disagree Disagree Neither Agree agree 7% 34% 29% 25% 5% 17. (Factor I. Wearing braces can be worse than having crooked teeth. he/she should wait until the next appointment to mention it. (Factor I. Parents should reward a child for properly wearing headgear and rubber bands. and Factor IX. Speaking clearly with braces can be a problem. C o n t ' d
15. (Factor II. Pain/Dysfunction. Pain/Dysfunction. retainer or rubber bands. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 0% 0% 2% 38% 60% 20. Self-confidence) Strongly Strongly disagree Disagree Neither Agree agree
1i % i 8% i 9% 40% 12%
. A person can decide how much and when to wear headgear. (Factor III. If a patient notices something wrong with the braces. Health Awareness) Strongly Strongly disagree Disagree Neither Agree agree 0% 1% 5% 47% 47% 25. Strongly Strongly disagree Disagree Neither Agree agree 37% 48% 7% 5% 3% 23. Wearing headgear or rubber bands definitely helps straighten teeth. Strongly Strongly disagree Disagree Neither Agree agree 0% 1% 10% 56% 33% 24. Stoic/Sensitive) Strongly Strongly disagree Disagree Neither Agree agree 15% 46% 27% 10% 2% 21. Having regular medical and dental check-ups is very important. Strongly Strongly disagree Disagree Neither Agree agree 1% 5% 10% 50% 34% 22. Pain/Dysfunction. (Factors I.Volume 97 Number 4
Factors associated with patient compliance
Table I. or a retainer better than the orthodontist. A person is more willing to cooperate and follow directions when the orthodontist explains what's being done and why. Pain/Dysfunction. (Factor II. Some families argue more when a child wears braces. Strongly Strongly disagree Disagree Neither Agree agree 20% 54% 13% 11% 2% 18. A family should help the patient to remember to wear headgear. Strongly Strongly disagree Disagree Neither Agree agree 28% 49% 8% i 2% 3% 16. lnterual/External) Strongly Strongly disagree Disagree Neither Agree agree 2% 10% 1 I% 50% 27% 19. Stoic/Sensitive) Strongly Strongly agree disagree Disagree Neither Agree 2% 33% 34% 30% 1% 26. Parents should not make their children wear braces if they don't want to do so. rubber bands.
braces aren't painful. Straightening back teeth for a better bite is very important. Strongly Strongly disagree Disagree Neither Agree agree 16% 32% 32% 19% 1% 37. my speech isn't affected. pain often keeps me from wearing headgear and rubber bands.340
Egolf. Strongly . Pain/Dysfunction. C o n t ' d
28. (24%) Yes. Some kids can get along well at home and still be bad orthodontic patients. all of the time. If a patient has a problem with his/her braces. Pain/Dysfunction. most of the time. Pain-Dysfunction. Wearing braces can cause serious eating problems. Pain/Dysfunction. (45%)
. pain occasionally keeps me from wearing headgear and rubber bands. Stoic/ Sensitive) Strongly Strongly disagree Disagree Neither Agree agree 6% 27% 34% 30% 3% 30. (1%) 40. Internal External) No. If parents want their children to wear braces. BeGole. Straight teeth will help a person avoid gum disease and cavities. Does wearing braces affect your speech? (Factor I. Braces can be used to treat jaw joint problems. and Factor Ill.? (Factor I. Interual/Extemal) No. Internal/External. only once in a while. (15%) The pain doesn't keep me from wearing headgear or rubber bands. Strongly Strongly disagree Disagree Neither Agree agree 0% 7% 23% 65% 5% 32. Strongly disagree Disagree Neither Agree agree 4% 16% 27% 45% 8% 34. If your speech is affected. Is wearing braces ever painful for you? (Factor I. (Factor I. (46%) Yes. Internal/External) No. (4%) 38. Internal/External) Strongly Strongly disagree Disagree Neither Agree agree 0% 4% 7% 57% 32% 31. Strongly Strongly disagree Disagree Neither Agree agree 1% 3% 41% 42% 13% 33. I couldn't wear headgear or rubber bands because of the pain. Pain/Dysfunction. Kids cooperate better with an orthodontist who is stem. If braces are painful does the pain keep you from wearing headgear or rubber bands. Strongly Strongly disagree Disagree Neither Agree agree 2% 2% 12% 59% 25% 35. (3%) 39. J. does that keep you from wearing headgear or rubber bands? (Factor I. the children should do it. sometimes. (16%) Yes. (37%) Yes. Some kids who don't cooperate with the orthodontist are also problem children at home. (31%) Yes. (32%) Yes. he/she should call the orthodontist immediately. (Factor III. Orthod. Strongly Strongly disagree Disagree Neither Agree agree 4% 17% 35% 37% 7% 29. (56%) Yes. Stoic/Sensitive) No. but only several times. Orthop. Pain/Dysfunction. part of the time. Internal/External) Strongly Strongly disagree Disagree Neither Agree agree 9% 38% 27% 21% 5% 36. April 1990
Table I. and Upshaw
Am. Dentofac. (13%) Yes. (22%) Yes. (Factor I.
I was never sick. (6%) and that frequently keeps me from wearing headgear and rubber bands. Has wearing braces ever caused problems at home for you? (Factor I. (3%) 46. (25%) Yes. Did being sick ever keep you from wearing headgear or rubber bands? (Factor I. (41%) Yes. (3%) 47. Internal/External) No. (33%) Yes. it was a little problem. it was a big problem. (5%) Yes. it was a big problem. (48%) Chewing was a problem but it didn't keep me from wearing headgear or rubber bands. (9%) Yes. (20%) I was sick but it didn't keep me from wearing headgear or rubber bands. I'm always too lazy to wear my headgear or rubber bands. (79%) Yes. (44%) Yes. (79%)
. because I didn't wear headgear. I had to talk a lot to convince them. (10%) 42. (2%) and that always keeps me from wearing headgear and rubber bands. I had to talk a little to convince them. (34%) Yes. Pain/Dysfunction. (50%) Yes. Did moving keep you from visiting the orthodontist or wearing headgear or rubber bands? No. I have worn headgear and was embarrassed a lot. (2%) Yes. (0%) 49. I have worn headgear and was embarrassed most of the time. there were no deaths in my family. (27%) Difficulty chewing occasionally kept me from wearing headgear or rubber bands. (1%) Difficulty chewing always kept me from wearing headgear or rubber bands. (2%) Yes. (87%) I moved but it didn't interfere with my orthodontic treatment. Stoic/Sensitive) No. (83%) I had family problems but it didn't interfere with wearing headgear or rubber bands. chewing is often difficult. (10%) Yes. but it was a minor problem. Do you ever not wear your headgear or rubber bands because you are too lazy? No. (3%) Yes. Yes. Internal/External) Chewing was not a problem. (31%) I have worn headgear but was never embarrassed. Did family problem such as your parents getting separated or divorced ever keep you from coming to the orthodontist or wearing your headgear or rubber bands? No. it was a problem (0%). I had a great deal of trouble convincing them. Did a death in your family ever keep you from coming to your appointment or wearing your rubber bands or headgear? No. I have worn headgear and ~vas embarrassed sometimes. Pain/Dysfunction. (2%)
41. Does wearing braces make chewing difficult? (Factor I. I didn't have such family problems.Volume 97 Number 4
Factors associated with patient compliance
Table I. (21%) Difficulty chewing often kept me from wearing headgear or rubber bands. chewing is sometimes difficult. (28%) Yes. (0%) 48. I can chew OK. (5%) Yes. (0%) 45. being lazy is a reason once in a while. (15%) Yes. C o n t ' d
My My My My speech is speech is speech is speech is affected affected affected affected but that doesn't keep me from wearing headgear or rubber bands. but not much of a problem. (6%) 44. (2%) Yes. Has wearing headgear ever been an embarrassment to you? (Factor III. being lazy isn't a reason. braces have caused big problems. Did you need to convince your parents you needed braces? No. Internal/External) No. (19%) Yes. it has happened occasionally. Pain/Dysfunction. I didn't move. (87%) Yes. (45%) and that sometimes keeps me from wearing headgear or rubber bands. (56%) Yes. chewing is always a problem. Has difficulty chewing kept you from wearing headgear or rubber bands? (Factor I. it has been a problem. (1%) 50. Internal/External) No. (0%) 43. (10%) Yes. but it hasn't happened often. Pain/Dysfunction. it has been a big problem.
it was a big problem. chewing was a big problem for me. Did anyone else encourage you to get braces? No. BeGole. J. it was a problem. (20%) Yes. (13%) Yes. but it was a little problem. Stoic/Sensitive) No. (4%) Yes. Internal/External. (5%) 60. (19%) Very self-conscious. it was my decision alone. Were braces a money problem for your family? No. (19%) A little self-conscious. (47%) Yes. (6%) Yes. (43%) Yes. (7%) My parents. Stoic/Sensitive) Not at all self-conscious. April 1990
Table I. but not very much of a problem. (1%) 54. Self-Confidence) No. but it's a little problem. Do you always wear your headgear. chewing was a problem. Before you had braces did you have a problem chewing? No. (93%) Me. How self-conscious were you about your teeth before you had braces? (Factor I11. but it was not a big problem. (20%) 52. (2%) Yes. (41%) Somewhat self-conscious. (15%) No. but it was a little problem. Pain/Dysfunction. (29%) No. the cost of braces was a problem. I rarely wear it. (36%) Yes. (3%) 56. I miss once in a while. it was a major problem.342
Egolf. (63%) Yes. it was a problem. it's sometimes a problem. (35%) Somewhat crooked. I wear it about half the time. (4%) 55. others encouraged me. (45%) Not very crooked. (1%) 51. (79%) Yes. C o n t ' d
There was a death in my family but it didn't interfere with orthodontic treatment. (4%) 57. (22%) Yes. rubber bands or other appliances the amount of time recommended by the orthodontist? (Factor I. the cost of braces was a big problem. (1%) Yes. it was a big problem. (12%) Yes. Has wearing braces ever kept you from participating in sports or playing a musical instrument? No. (40%) Yes. Orthop. (0%) 58. (45%) No. (14%) Yes. (3%) 59. Did you have a problem with your jaw joint (TMJ) before you had braces? (Factor III. Orthod. I don't play sports or a musical instrument. (17%) Very crooked. its a big problem. How crooked were your teeth before braces? Not at all crooked. Is missing school or work because of orthodontic appointments a problem for you or your parents? No. (32%) Yes. it was sometimes a problem. and Upshaw
Am. (14%) Yes. braces didn't keep me from playing sports or a musical instrument. (17%) Yes. Dentofac. but there were only a few foods that gave me problems. (2%) 53. Who should decide how much to wear headgear. (5%) Yes. rubber bands or other appliances? The orthodontist. and Factor IX. (81%) Yes. Mother (64%) Father (44%)
. (60%) Please check those persons who encouraged you.
Pain (28%) Eating (4%) Other (14%) Speech (3%) Laziness (10%) Sports (2%) Forgetfulness (9%) Lost (2%) Embarrassment (6%) Sleep (2%) Nuisance (6%) Irresponsible (1%) No excuse (6%) Doesn't help (1%) No response (5%) Illness (1%) 70. or quantified treatment results were not feasible. chart notations. Reliability is the consistency
. uncles. Your name (mean = 15. All patients who were scheduled for adjustments and who met these criteria were asked to participate. What is your mother's occupation9 67. (24%) Over l year ago. They were wearing or had worn intraoral elastics or a headgear. How would you rate your cooperation in wearing braces? Poor (8%) Average (51%) Excellent (41%) 65. The purpose o f the study was briefly explained by the student orthodontist and further clarified on the face sheet o f the questionnaire. exhibited no reading difficulties. Your age. Only a few patients declined to participate and only one questionnaire was unusable. (46%) Between 6 months and a year ago. What is your father's occupation? 66. (27%) 62.
Sample selection and questionnaire administration
The sample consisted o f 100 orthodontic patients in active treatment at the University o f Illinois College o f
Reliability and validity of the instrument
For a test to be useful and have meaning. Do either of your parents wear false teeth? Yes (45%) No (55%) 63. and the radiographic changes. What would you say the biggest reason is for not wearing headgear or rubber bands. (2%) 64. Cont'd
My dentist (37%) My guardian (1%) Friends (22%) Husband or wife (0%) My family (brother.
Dentistry.3 yrs. (25%) Less than once a day. Do you or anyone in your family use dental floss? Yes (77%) No (23%) 66. When was your last check-up at your family dentist? Less than 6 months ago. A subjective assessment from patient examination.) 71. and memory was thought to be sufficiently accurate since the patient/practitioner relationship was longterm and well established. Data collection took approximately 1 month. Furthermore. What is you religion? Protestant (9%) Catholic (71%) Jewish (2%) Other (18%) 69. (73%) Once a day. aunts or grandparents) (29%) 61. headgear devices with timing mechanisms. rubber band counts. the tooth mobility. These changes are the observable results o f wearing headgear and intraoral elastics.Volume 97 Number 4
Factors associated with patient compliance 343
Table I. the changes in tooth relationships. patient reports. How many times a day do you brush your teeth? Twice a day or more. sister. it must be both reliable and valid. and had been in treatment a minimum o f 3 months. since the study was ex post facto.
previous rate o f tooth movement. The subjects were at least 10 years old.
(24) A person is more willing to cooperate and follow directions when the orthodontist explains what is being done and why. Validity is the extent to which an instrument measures what it purports to measure. (14) Patients who understand their treatment are more cooperative. questionnaire items were taken from the literature and were also suggested by experts and patients.672 0.0. as seen in Table II.22Content validity was established by the formulation of questions deemed relevant to the situation and subjects being examined and a critical review of these questions.011 0.32.91 ! 0.344 Egolf. For an item in the questionnaire to be included for consideration under a factor.460 0.4% of the variance. As stated. with compliance: Factor I (pain/dysfunction.206
*Factors significantly correlated with the criterion of compliance. 17. internal/external Health awareness Stoic/sensitive Social importance of beauty Acquiescence Well adjusted/insecure Fatalism/determinism Authority Self-confidence Importance of straight teeth for oral health Oral beauty and success Orthodontics/family relations
0. April 1990
Table II.033 . included questions that were both positive and negative. factor II (health awareness).22TO maximize reliability. the absolute factor loading value was required to be greater than 0.748 0. internal/external). This retained 12 of 21 factors.560 0. Factor I was an amalgamation of pain/dysfunction in speaking and chewing and internal/external personality questions.523
0. Orthod. The instrument was then examined by orthodontists and a psychologist.810 0. The names for the factors were developed through examination of the retained questions that constituted the factor.5.5.129
with which an instrument repeatedly measures an entity.241 -0.289 -0.912 0. and Upshaw
Am.762 0. The association between the factors extracted from the questionnaire and the ratings of patient cooperation was assessed with the use of Pearson's product-moment correlation coefficients.218 0.648 0. Intercorrelations of the item scores yielded a measure of reliability known as Cronbach's alpha. factor III (stoic/sensitive). underlying factors.025 .492 0.21.594 0. the more internally consistent are the items in the factor. As an example. BeGole.21.Dentofac. Reliability and validity of the instrument Not only was alpha factor analysis used for data reduction. (34) Straightening back teeth for a better bite is very important. Positive and negative values were considered since the factors were bipolar. (12) Straight teeth are easier to clean. Correlation between alpha factors and levels of compliance. i. it was also used as a measure of reliability or internal consistency of the factors derived from the questionnaire. accounting for 77.550 0.252 0. alpha values for each factor
1 2 3 4 5 6 7 8 9 10 11 12
Pain/dysfunction.715 0.070 0.735 0. The chosen cutoff point for factors was a coefficient alpha of 0.061 0.0.853 0. although most factors had higher alpha values indicating a greater degree of reliability.
. Orthop.0. DISCUSSION Four factors were found to be associated with cooperation in the wearing of headgear and elastics and accounted for 38% of the variance.017" 0. 22 The larger the value of alpha.012" 0. (19) Having regular medical and dental checkups is very important. Four factors were found to correlate weakly.621 0.076 .. the following are the statements to which the patients were asked to respond that made up factor II (health awareness): (2) Having braces can help you have fewer
problems with your mouth later on.701 0. Factors were retained with alpha values greater than 0.e. J. alpha factoring was used.374 0. 17. (11) Having a healthy body is very important.0002* 0. but significantly. and factor IX (self-confidence).004* 0. RESULTS Factors extracted from the independent variables Alpha factor analysis was used to reduce the 58 questions to more basic. (5) Some people have braces to help their bite.126 0.
Embarrassment and apathy Embarrassment about wearing a headgear was not a major reason cited for noncompliance. the externally motivated patient may be apathetic regarding elastic and headgear wear. The headgear embarrassment question did not correlate with compliance.0008). Factor IX was best termed self-confidence or self-assurance.0 . 6% of the patients gave embarrassment as the reason for not wearing headgear. or powerful others (parents and orthodontists). This internal/external or locus-of-control concept evolved from social learning theory and has been the focus of many studies. fate. forgetfulness.292. question 38 ("If braces are painful. Factor III was labeled stoic/sensitive and also contained questions regarding pain. This differs from the observation by GabrieF 6 that embarrassment is important in headgear noncompliance. Both the patients and the orthodontists agreed on which malocclusions were severe (r = 0. health awareness. in screening for potential cooperation. It is perhaps an oversimplification of the theory to describe an orthodontic patient's personality as simply internal or external. They suggested that the pain threshold was related to the variables of emotion. nuisance. many of them concerning patient compliance. the challange becomes one of motivating the patient with this personality orientation. cooperation was not correlated with severity. In the open-ended questions. specific dental infor-
. 3 3 2 . These reasons could be described as apathy. Observations concerning pain and psychological variables were also made by Jones and Richmond. At this point. supporting the findings of Lewit and VirolainenY + However. This was consistent with the 6% in question 43 who reported they were embarrassed most of the time while wearing headgear. an internally motivated patient perceives a causal relationship between results and his or her own behavior.Volume 97 Number 4
Factors associated with patient compliance
Factor II contained health questions. p < 0. As defined by Rotter 19and EI-Mangoury. Factor I confirmed the findings of EI-Mangoury 12 and Albino et al. This question. This is in agreement with Burns. As a clinically useful principle. As this relates to personality theory. 16% of the patients reported laziness. p < 0. attitude. this limited description does not include the personality characteristics contained in factors III and IX. when considered alone. or the characteristics of achievement and affiliation theory. In the openended questions. Factor III included question 51 ("How self-conscious were you about your teeth before you had braces?"). a meaningful question would be "How selfconscious or embarrassed are you by your teeth?" rather than a rating of the severity of the malocclusion. The importance of pain to the patient is frequently underestimated in the clinical setting. patients who are stoic or internally motivated will comply with the wear-
ing of headgear and elastics despite pain and problems in speaking and chewing. was correlated negatively with cooperation (r = . Health awareness Factor II. ascribing results to luck. SECONDARY OBSERVATIONS Self-perception Another clinically applicable finding deals with patients' self-consciousness regarding their perceived dental disfigurement. since pain was cited in the open-ended question as the most frequent reason for not wearing headgear or rubber bands. 13 that personality as described by the Rotter internal/external paradigm is related to particular aspects of orthodontic patient compliance. namely. appears to be related to cooperation with treatment. p < 0. and motivation. Therefore. 24 who found no correlation between pain and orthodontic force applied as reflected in the degree of crowding.~z internally motivated patients will act to better their environment and are in control. Furthermore. p < 0. self-assurance and stoicism.05). the single question of laziness (question 41) was significantly correlated with compliance (r = 0.0002). chance. PRIMARY OBSERVATIONS Personality/pain-dysfunction The seemingly unrelated variables of personality type and pain/dysfunction formed two nebulous factors. This means the degree to which the patient is embarrassed or self-conscious regarding tooth malalignment. Externally motivated patients feel powerless and believe they have little control over events. Other patients will require more preparation regarding the amount of discomfort they may expect and methods to reduce it. contained questions about general health attitudes. or no excuse as the primary reason for not wearing headgear. no matter how minor. does the pain keep you from wearing headgear or rubber bands?") was significantly correlated with compliance (r = 0.003).364.25. 23 who observed that the way one copes with the pain and oral dysfunction associated with braces is probably a reflection of that patient's personality orientation. Furthermore. Its importance should not be summarily dismissed. factors I and III. In addition.
Orthop. and Upshaw
Am. cues to action. Bad patients complain. and are suspicious of treatment. Furthermore. BeGole. Personality variables and barriers to action deserve equal ranking with the beliefs of general health awareness and susceptibility. factor II would tend to indicate that a high initial baseline of health knowledge and awareness may be related to increased compliance with the wearing of headgear and elastics. it may be difficult or unnecessary to separate the beliefs of susceptibility and severity. The present study did not find a significant relation between compliance with the use of headgear and elastics and history of checkups (r = 0. and a question related to the need to acquire information about treatment. 4 EI-Mangoury. 28 Kegles. whether healthy or acutely or chronically ill. They are not reasons for noncompliance with headgear and elastic wear but may affect other aspects of compliance. It may be concluded from the significant factors found that many components of the Health Belief Model are applicable to the orthodontic situation. formulated to express the various interactions involved in treatment-seeking behavior. as perceived by the patient. respectful. and chance health loci of control and renamed Multidimensional Health Locus of Control Scales. They may be type B individuals who have a high need for approval or a high sensitivity to social desirability. and modifying factors. Cues to action may include a general positive health orientation and specific dental knowledge. and IX (self-confidence). From the significant factors found in this research and the findings of Allan and Hodgson. the factors of pain/dysfunction and health awareness) must be included. Dentofac.."
Health Locus of Control
Wallston and Wallston 2° developed the Multidimensional Health Locus of Control from Rotter's Internal/External Scale. powerful others. p < 0.812). plus demographic and sociopsychological variables and cues to action or stimuli. "The health belief model. ~3 it can be stated that the Multidimensional Health Locus of Control Scale does not recognize all the personality traits necessary for a construct of orthodontic patient personality. such as tests for tuberculosis. found the belief of susceptibility to he weakly related to preventive dental visits of factory workers. are susceptibility. The loss of control in becoming an orthodontic patient is certainly not as extensive as it is when one becomes a hospital patient. It was further expanded and refined to include internal. A better predictor of the likelihood of making preventive visits was the history of previous visits. April 1990
mation. As applied to orthodontics. follow instructions. generally can be managed by the small number of patients affected by these concerns. insist on information. III (stoic/sensitive). J. The description of the good
.:9'3° in studying the Health Belief Model and its applicability to dentistry. It grew out of an effort by social psychologists in the early 1950s to formulate a theory and make recommendations for increasing compliance with screening tests.. and exhibit undemanding. demand attention.025. can with some modification and extension provide a reasonable framework for considering the utilization of orthodontic treatment. Today the basic beliefs or variables of the Health Belief Model. The belief of severity may be construed to be selfconsciousness about the dental deformity. beneficial actions. considerate behavior. Other elements of the Health Belief Model are bartiers.346
Egolf. severity. Originally it was validated by the study of attitudes concerning hypertension and obesity. These reasons for noncompliance did not form a single factor on the analysis. It is surmised that the differences in findings may be ascribed to the child's dependency on the parent in providing transportation and making appointments. The variable of beneficial action was supported by the positive correlations between cooperation and factor II (health awareness).
Good patient/bad patient behavior
Taylor3z theorized that hospital patients. Good patients are compliant. behave as either good or bad patients. They may be type A individuals who need to be in control. and barriers to action. The aspect of the Health Belief Model termed
modifying factors is seen here to include personality type as evidenced by factors I (internal/external).3~ concerning another orthodontic patient behavior. variables other than personality type (e. ~7 However. This is consistent with the observation of Tulloch et al.
CURRENT THEORIES OF PATIENT BEHAVIOR
Does the information collected from this exploratory study support existing theories of patient behavior?
The Health Belief Model
The first theory of patient behavior to be considered is the Health Belief Model.g. Other studies have shown that acquisition of knowledge concerning a disease does not increase compliance. Specific barriers to action. such as economics and family disruption. t2 and Albino et al. faced with loss of control and depersonalization. such as the keeping of appointments. Orthod.
Influenceofseverityofmalocclusion on the duration of orthodontic treatment.
Social learning theory
The Social Leaming Theory formulated by Bandura ~ claims that social behavior develops as the result o f observing others and of reinforcement. Kerlinger F. 11.35:327-32. A behavioral evaluation of patient cooperation in the use of extraoral elastic and coil spring traction devices.54:433-9. They also may play a very important role in accounting for other aspects of patient cooperation. 5. Fox RN. Psychologicaltiming of orthodontic treatment. Child Dev 1968. interference with oral activities. GreweJM. which is best supported by these findings..36 They essentially correlated brushing and flossing frequencies of 131 adults with variables thought to be appropriate to the social learning theory. Patient cooperation in wearing orthodontic headgear. specific knowledge o f dental disease. pain. New York: Holt. 2nd ed. 9. Highland Park. 3. Hodgson EW. The need-forinformation question contained in factor II supports her contention that patient education is important. and barriers (forgetting and inconvenience) were found to be correlated (r ranging from . such as finances. Conformity and independence in adolescents' motivation for orthodontic treatment. barriers. 13. and dysfunction). t2 This probably is because the orthodontic patient is given the opportunity to participate in therapy and to be in control. The theory of patient behavior. 2. Lawrence SD. 1964. 1974. the characterization of the bad hospital patient as one who reacts because his or her need to be in control has been thwarted may not apply to the orthodontic patient.measurements as a determinant of patient cooperationin an orthodonticpractice. AM J ORTHOD 1978. however. Farr SD. Patient cooperation in orthodontic treatment. J Am Coil Dent 1968. Kaplan A. which were not explored in this study. Burstone C.0. were found to be important. El-Mangoury NH. 4.36 appears to contain components accounted for in the Health Belief Model and omits personality variables. A conventionalassessment oforthodontic cooperation as compared to interrogation and polygraph testing [MS thesis]. A multiple regression analysis of patient cooperation during orthodontic treatment [MS Thesis]. Psychologyof the use of the headgear. Its value in developing a construct of orthodontic cooperation is limited. This agrees with the recommendation by Taylor 32 that self-care is important for both good and bad patients. Buros OK. specific dental knowledge.39:1189-200. supports the contention that internally motivated patients cooperate better with the orthodontic therapy involving headgear and elastics and is consistent with the research of EI-Mangoury.Volume 97 Number 4
Factors associated with patient compliance
hospital patient appears applicable to the orthodontic patient. Albino JE.80:604-22. behavior of significant others. Development and validation of a measure of attitudes toward malocclusion. The selfhelp/education combination was also identified by Powers and Wooldridge. It may be approprate. AM J ORTHOD 1981. and personal oral embarrassment).42 to + 0.75:517-24. self-assessment of brushing and flossing proficiency (self-efficacy expectations).61:!039-43. The Social Learning Theory. and dental behavior of significant others. negative motives (pain. Tedesco LA. Tedesco LA. McDonald FT. 12. 16.48) with oral hygiene frequency. J Dent Res 1982. AM J OR'DIOD 1973. 1973. namely.35:320-5. AM J ORTnOD1968. Kreit LH. The use of personality. 8. Examination of the questions in factor II.74:687. Angle Orthod 1975. is the Health Belief Model.45:141-5. and positive motives (general health awareness. Lewit DW. The question o f why orthodontic patients comply requires more than a single answer or variable. that may be rel-
1. 10. 17.
. 1972. Green LJ. Crawford PR. Northwestern University. Angle Orthod 1965. 15. AM J ORTnOD1979. There are other factors and variables.18:52. Lopes CE. disrupting personal events. for developing methods to address noncompliant behavior. AM J OR'mOP 1977. Clemmer EJ. New York: State University of New York at Buffalo. Dent Abstracts 1973. Buffalo. Eiser ttM. such as appointment keeping or oral hygiene. Delman L. School of Dental Medicine. and self-consciousness about the oral condition. actual skill in brushing and flossing. HermansonPC. Cooperation of adolescents in orthodontic treatment [unpublished manuscript 1989]. 35 The value of this theory to account for oral hygiene behavior was examined by McCaul et al. Profile of an excellent orthodontic patient.72:198-204. Orthodontic cooperation with wearing of headgear and intraoraI elastics appears to involve a combination of the nature of a person's personality. which in the present study. Albino JE. Stambach HK. 7. Tests in print. 33
evant on an individual basis and for short periods of time.
Major factors related to patient compliance with headgear and elastic wear are personality type. GabrielHF. Hayes EW. Rinehart and Winston. Weiss J. and social pressures. Orthodontic cooperation. health awareness. 6. belief in effectiveness of brushing and flossing (outcome expectations). NJ: Gryphon Press. inconvenience. 14. as presented by Bandura 34 a n d a d a p t e d for the dental patient by McCaul et a1. which is concerned With attribute motivation.63:533-6. Allan TK. Loyola University of Chicago. The variables of self-efficacy and outcome expectations. MannJG. The influence of age on orthodontic patient cooperation. Swetlik WP. However. Virolainen K. II. Foundations of behavioral research.
Calif. Generalized expectancies for internal versus external control of reinforcement. Glasgow RE. Kegeles SS.C. Ellen A..5:171-82. 22. May 12 to 15. J Am Dent Assoc 1963. April 21 to 24. Wash. Psychometrika 1965. 35. Research methods in social relations. 34. Gibson ES.1:1205. 30. AM J ORTIIOD 1970.88:323-32. 1979.. 27. Initial tooth movement: force application and pain--a relationship? AM J ORTHOD 1985. Health Educ Monogr 1978. Javits Convention Center
Reprint requests to: Dr. Bandura A. Bums MH. Harre R. Introduction to measurement theory. 19. 1977. Psychol Monogr: General and Applied 1966. Orthod. 33. St. 20. Predicting levels of preventive dental beahviors. The encyclopedic dictionary of psychology. Louis Convention Center 1993--Toronto. Wooldridge PJ.348
Egolf. 28.35:156-84. New Jersey: Prentice Hall. Social learning theory. 26. 1983. Smith A. WallstonBS. or control. 31. IL 60680
AAO MEETING CALENDAR
1990--Washington. Cambridge: Massachusetts Institute of Technology Press. Louis. Metropolitan Toronto Convention Center 1994--Orlando. 21. 36. Allen MJ. J Am Dent Assoc 1985. Sackett DL. 3rd ed. Motivation of the headgear patient.8:166-73. AM J ORTHOD1985.6:160-70. J Soc Issues 1979. AM J OR~tOD 1984. McCaul KD. Orange County Convention and Civic Center 1995--San Francisco. Hospital patient behavior: reactance. April 1990
29. 24. COOkSW. Jondeph DR. and Upshaw
Am. SelltizC. 32. New York: Holt. 1979. Richmond S. Caffrey J. Factors influencing knowledge. May 1 to 4. Lamb R. Baltimore: Johns Hopkins University Press. McNeill RW. Kiyak HA. Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. Haynes RB. Rotter JB.38:129-35.. Gabriel HF.. Dentofac. Mo. 85:253-9. 25. Gustafson C. helplessness. Underhill BDS.Y. Some motives for seeking preventive dental care. Jones ML.. J. eds. attitudes and compliance of hypertensive patients. BeGole Department of Orthodontics University of Illinois at Chicago PO Box 6998 Chicago. Orthop. Compliance in health care. Wallston KA.
18.I 11:601-5. May 5 to 9. Angle Orthod 1968. May 10 to 13. Washington Convention Center 1991--Seattle. A comparison of attitudes toward orthodontic treatment in British and American communities.30:1-14. Taylor SE. Lancet 1975. eds. Sackett DL. Yen WM. Monterey: Brooks/Cole. Shaw WC. N. D.80:1-28. Moscone Convention Center 1996--New York.88:111-6. J Health Hum Behav 1967. et al. Rinehart and Winston. Powers M J. Fla. Taylor DW. Bell R. Development ofthemultidimentional health locus of control (MHLC) scales. Seattle Convention Center 1992--St.57:418. Why people seek dental care: a test of a conceptual formulation. Wallen TR.. Res Nurs Health 1982. 1976. Use of a personality rating scale in identifying cooperative and noncooperative orthodontic patients. Wrightsman LS. Alpha factor analysis. May 16 to 19. Tulloch JFC.67:90-8. Englewood Cliffs. May 7 to 10. 23. Haynes RB. Canada. BeGole. Kegeles SS. Randomised clinical trial of strategies for improving medication compliance in primary hypertension. Jones M. Kaiser H. Jones G.