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Education Introduction Perhaps this scenario is familiar. L.S. has case type III chronic periodontitis. She completed nonsurgical periodontal therapy three years ago and was put on three-month maintenance. Despite several discussions about the need for shortened recall intervals, she routinely misses appointments and is often delinquent with respect to maintenance. Her home care is inadequate, and attachment loss is progressive. The dental hygienist is frustrated by the patient’s unwillingness to adhere to oral hygiene recommendations and maintenance intervals. The patient is frustrated with being “hounded” by office staff to make frequent appointments and brush and floss more. The dynamics of behavior change are among the most rewarding and most frustrating encounters for dental hygienists. Chronic dental diseases are largely preventable but require patient engagement and behavioral adherence to dental hygiene recommendations. Effective and routine dental plaque removal, adherence to regular professional dental maintenance or supportive periodontal treatment visits and healthy dietary and lifestyle habits are adherence issues hygienists often address in their patient encounters. Dental hygienists typically approach patient education in a persuasive authoritative manner, offering “knowledge” and prescriptive strategies to lead the patient in making required behavior change. When patients are not ready for behavior change, the aforementioned health education advice or overt persuasion not only will fail to motivate but will create defensiveness.[1-6] It’s no surprise that, despite our best efforts, many patients fail to change behaviors that contribute to disease progression. In addition, when defensiveness develops between clinician and patient, patients may avoid return for timely professional treatment, which can add to the burden of disease. Studies on adherence to health professionals’ recommendations have shown that approximately 30 percent to 60 percent of health information provided in the clinician/patient encounter is forgotten within an hour, and that 50 percent of health recommendations are not followed. DiMatteo determined that adherence is as important in achieving good outcomes as effective interventions.[7] Improved adherence has been demonstrated when knowledge and advice are combined with behavioral strategies. Much of the evidentiary support for adherence and behavior change came out of cognitive and health psychology. Cognitive psychology has provided insight into human memory, perception, learning, thinking and motivation through the development of various theories. In the area of health psychology, three behavioral theories in particular have provided insight into reasons why people engage or fail to engage in health behavior change: Self-Determination Theory, Theory of Planned Behavior, and Stage of Change Theory.
Self-Determination Theory Self-Determination Theory (SDT) is a theory of self-motivated behavior change and personality development that provides insight into how people adjust to changes and control and alter behavior in the social environment.[8] The theory hypothesizes that humans have three basic psychological needs: competence, autonomy and relatedness. Competence helps the individual explore and master the environment so that they can have confidence in their ability to affect desired outcomes. Autonomy is the need to feel self-regulating rather than controlled by expectations of others. It gives individuals the sense of ownership with respect to their behavior. Relatedness involves the need to feel connected with others in meaningful social relationships. Although people need autonomy, they also need close relationships in which their thoughts, beliefs and feelings are respected. The degree to which these needs are met can determine the likelihood of behavior change. This has implications for the clinician to recognize that without a clear demonstration of respect and recognition of autonomy, they can do little to engage the patient. SDT conceptually puts motivation along a continuum ranging from extrinsic to intrinsic motivation. Extrinsic motivation refers to behavior aimed at achieving some separate outcome, whereas intrinsic motivation refers to the behavior aimed at inherent satisfaction of the activity itself. Extrinsic motivation may temporarily affect behavior, but because the motivation is dependent on external controls, the individual will be adherent only when those external controls are present. There is a wealth of evidence demonstrating that intrinsically regulated health behaviors are more stable and result in better health outcomes.[7, 9-13]
Theory of Planned Behavior The Theory of Planned Behavior (TPB) explains behavior as a function of an individual’s behavioral intent or motivation to adopt a behavior. Intention to adopt a behavior is determined by behavioral beliefs (one’s attitude towards the behavior), subjective norms (the perceived views of other significant people regarding behavior change) and perceived control regarding the behavior.[14,15] Another important feature of the TPB is that it empirically identifies the behavioral, normative and control beliefs that most strongly relate to the behavioral intention of interest. This requires a first step of elicitation to identify the beliefs and values held by the individual. For example, L.S. may believe that she will lose her teeth no matter what she does because many family members have. She might see frequent periodontal maintenance as a waste of time and money. The power of the TPB is that once the patient’s beliefs have been elicited, their associations with engaging in the target behavior can be explored. This approach also helps to identify behavioral beliefs, perceived norms and control beliefs that may be unique to a particular individual. Critical beliefs that drive behavior intentions can be quite different depending on an individual’s age, culture, family and social norms, background experiences and ethnicity.[14] Oral health education has traditionally been prescriptive without exploring those facets and beliefs that influence intent to engage in behavior.
Stage of Change Theory The Transtheoretical Model, also known as the Stage of Change Model, was originally published by Prochaska and DiClemente in 1982.[16] This model has been used extensively in health promotion research and practice in medicine, smoking, diet counseling, exercise, obesity and oral care. This model hypothesizes that readiness for change exists along a continuum from pre-contemplation through contemplation, preparation and action, ending in successful maintenance. At the pre-contemplation stage, the patient is not aware of the need for change or simply not ready to change. When patients are at the pre-contemplation stage, the role of the clinician is to raise their awareness by having the patient express their feelings about their oral condition. In the contemplation stage, the patient has considered changing oral behaviors but has not yet acted on the change. In this stage, the clinician’s role is to encourage the patient’s understanding of their problems through elicitation. In the preparation stage, the patient is ready to change, and the clinician can provide targeted information aligned with the patient’s stated priorities, beliefs and values. The action stage is where patients at least engage in the desired behavior, whether it becomes a habit or not, and with the expectation that lapses will occur. The primary role of the clinician in the action stage is to encourage the patient to identify ways to structure their environment to support the change. The last stage is maintenance, when the patient has taken positive action. At this stage, the clinician’s primary goal in supporting the patient is to prevent relapse. A primary implication of this model is that clinicians must be aware of where the patient is along the continuum to effectively impact behavior change.[17] In other words, interventions or education that do not match the patient’s location on the continuum will not advance the desired behavior change. This model also posits that movement from one stage to the next is dependent on the patient resolving ambivalence about behavior change. Any change in behavior will be framed in the patient’s mind by associated pros and cons. When patients can resolve that ambivalence, they are more capable of moving forward along the stages of change continuum.
Motivational Interviewing Educational and therapeutic interventions consistent with theories of behavior change are more likely to succeed.18 Motivational interviewing (MI) is a well-accepted strategy aimed at behavior change and is consistent with the three theories outlined above. The spirit of MI is defined by collaboration, evocation and autonomy, which manifest themselves through specific techniques and strategies. The nonjudgmental encounter aims to encourage patients to express their own reasons for and against change, and to think about how their current behaviors and associated health status affect their core values and life preferences. MI was first described by Miller in 1983.[19] Through experience and working with people with drug addictions, Miller found that the therapist’s behavior has an impact on patients’ motivation for behavior change. This awareness led to the development of MI, a directed, client-centered counseling style for encouraging health-related behavior change by helping patients explore and resolve ambivalence. MI has been shown to positively affect health behavior change related to smoking, drug addiction, exercise, weight reduction, diabetes management, medication adherence, condom use and oral health.[6,11,20-25] When the clinician elicits arguments for change from the patients themselves, the likelihood for change is increased. This requires the clinician to assume the role of sensitive and supportive advocate rather than persuasive expert. Miller suggests that resistance results when clinicians use a style of confrontational or direct persuasion.[1] Patient education has traditionally been based on advice given by the clinician, in which facts and their interpretation are delivered in a unidirectional message to the patient. This approach is contrary to the spirit of MI in that the clinician is the expert and the patient is the passive recipient. Factors associated with change—autonomy, intrinsic motivation, competence, connecting change with values and norms, perceived control, and readiness for change—are given, at best, secondary consideration. This puts the patient in the position of either accepting or resisting the advice that is often unsolicited. Patients may perceive the advice as judgmental and intrusive, setting up for resistance to change.[1-2] In contrast, MI places the patient in the role of expert and supports their need for autonomy. It is based on allowing the patient to interpret and integrate the information if relevant to his/her own situation. It acknowledges that the patient is the expert in his/her own life. MI appears to be most effective for patients with low motivation to change behaviors as it encourages trust between clinician and patient and allows the clinician to focus on increasing readiness for behavior change.[2,26]
Components of MI The key components of MI include expressing empathy; developing discrepancies; rolling with resistance; supporting self-efficacy; and eliciting change talk. These elements are closely related to the three needs outlined in SDT (competence, autonomy and relatedness) and take into account modifiers of behavior and behavioral intent (TPB) and Stage of Change Theory. Expressing Empathy: In MI, the clinician’s expression of empathy and acceptance is critically important. In contrast to traditional patient education, this requires the clinician to ask open-ended questions and then listen to the response. Open-ended questions give the patient the opportunity to share any concerns they may have. Reflective listening allows the clinician to “get it right” by reflecting back what they think they have heard. It is through this process of open-ended questioning and reflective listening that the clinician can begin to shift the paradigm from clinician-centered to patient-centered engagement. Research has shown that the average health care provider interrupts patient disclosures after 18 seconds.[27] When this occurs, it sends a clear message that the patient’s input is neither respected nor seen as relevant. Affirming the patient’s efforts, interest or willingness to seek care increases the person’s sense of relatedness and trust. Once trust is established, the patient can honestly express himself or herself and begin to resolve openly ambivalence about change. Developing Discrepancies: Inconsistencies between the current health status/behaviors and valued goals/preferences create a rationale for change. Initial understanding derived from open-ended questioning and reflective listening provides the clinician with the basis for eliciting personal discrepancies held by the patient. For instance, the clinician can ask, “On a scale of 1 to 10 with 10 being most important, how important is your oral health to you?” Once the patient identifies their self-rated importance, the clinician can further clarify by asking, “What would it take for you to increase the importance two or three additional levels?” This approach can also be used to explore level of motivation, as well as confidence in engaging in a new behavior. Rolling with Resistance: The second key component is avoiding confrontation and argumentation by rolling with resistance. When the patient expresses resistance to change, this is an ideal opportunity to respond differently and explore the patient’s view. Rolling with resistance supports the individual’s need for autonomy and sends the message that they are important in finding solutions. Once again, this collaborative approach allows for negotiated solutions that are consistent with the patient’s stage of change. Support Self-Efficacy: Supporting self-efficacy gives the patient the belief that he/she is capable of change. Since only the patient can initiate behavior change, this component shifts “ownership” of the solution to the patient. In the language of SDT, supporting self-efficacy can increase the person’s sense of competence and increase the likelihood of successful change. Eliciting Change Talk: An integral component of MI is eliciting self-motivation statements or change talk. When patients hear themselves talk, this increases their commitment to what they are saying and reinforces autonomy. People have a natural tendency toward personal development and change. The task of the clinician is to evoke, facilitate and strengthen this tendency rather than attempting externally to drive the change. Using MI, the clinician focuses on the patient’s motivation and interest in oral health and moves them along the stages of change, thus stimulating readiness for change. Recognizing that clinicians aren’t the best judges of what matters to patients is necessary in order to become effective change advocates in the dental hygiene environment. Weinstein recently showed that when patient values and dentists’ perceptions were examined, the dentists’ perceptions were not closely matched to patient values.[23] Extensive literature clearly demonstrates that values/beliefs, perceived susceptibility, social and family norms, cultural differences, lifestyle values and current perceived needs are important factors in motivation.[24]
Implications for Dental Hygiene Practice In our opening scenario, the patient knows that poor home care and noncompliance with treatment recommendations are detrimental to her oral health but is ambivalent about making a change. If the hygienist continues to focus on the negative outcomes, the patient ceases to engage in the dialog and be part of the solution. Ironically, this can result in yet more directive advice-giving from the provider. Using MI, a more productive interaction might be to encourage the patient to examine what they like about longer intervals between appointments compared to more frequent appointments. By doing so, the patient can articulate and resolve their ambivalence themselves. Ultimately, this strategy elicits the patient’s ideas on change. The purpose of this article was to introduce these concepts to clinical dental hygienists. MI is gaining evidence as a successful means of dealing with chronic health issues including oral disease.[11,24,25] Two recent studies highlight the utility of MI for oral health. Almomani and colleagues showed that MI was significantly more effective in reducing plaque scores, improving oral health knowledge and increasing autonomous regulation over time than traditional oral health education alone in a population of individuals with severe mental illness.[11] Similar improvements in oral health were reported by Weinstein and colleagues with regard to reduction in caries in high caries risk children.[24,25] To gain additional knowledge and skills in MI, clinicians are encouraged to more thoroughly explore this exciting approach through training programs and the literature. Suggested readings follow.
References
Other Readings Kay EJ, Locker D. Is dental health education effective? a systematic review of current evidence. Community Dent Oral Epidemiol 1996; 24: 231-6. Millstein SG. Utility of the theories of reasoned action and planned behavior for predicting physician behavior: a prospective analysis. Health Psychol 1996; 15(5): 398-402. Montano DE, Kasprzyk D. The theory of reasoned action and the theory of planned behavior. In: Health behavior and health education: theory, research and practice, 3rd ed. San Francisco: Jossey Bass; 2002. Rollnick S, Kinnersley P, Stott N. Methods of helping patients with behavior change. Br Med J 1993; 307: 188-90. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing. Br J Clin Pract 2005; 55: 305-12. Wright JA, Velicer W, Prochaska JO. Testing the predictive power of the transtheoretical model of behavior change applied to dietary fat intake. Health Educ Res 2009; 24(2):224-36. Karen B. Williams, RDH, PhD, is a professor and director of the Clinical Research Center at the University of Missouri-Kansas City. She received her certificate in dental hygiene and BS in education at Ohio State University, her MS in dental hygiene education at the University of Missouri-Kansas City, and PhD in Psychology and Research in Education with an emphasis in evaluation, measurement and statistics at the University of Kansas. Kimberly Krust Bray, RDH, MS, is professor and director, Division of Dental Hygiene at the University of Missouri-Kansas City, School of Dentistry, Kansas City, Mo. This article is sponsored by an educational grant from:
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