Health behavior models

1

Health Behavior ModelsSwagat Kumar III MDSDepartment of Public Health Dentistry2

Introduction Health Belief ModelTrans Theoretical Model The Theory of Reasoned Action/Planned BehaviorSocial learning/ cognitive theoryLocus of ControlImplementation of Health behavior modelsConclusion

3

Certain terminologiesNorms : Something that is usual, typical, or standard. something deemed proper by the societyConstruct : A construct is the abstract idea, underlying theme, or subject matter that one wishes to measure using survey questions

Domain : Afieldorscopeofknowledgeoractivity

Belief : Trust, faith, or confidence in (someone or something).

4

The most common oral diseases, dental caries and periodontal diseases are preventable.

An informed, motivated patient practicing basic preventive techniques is likely to have good oral health for life.

Other risk factors such as medical conditions , history of disease and access to dental care can contribute to dental diseases, but lifestyle choices such as tobacco use, dietary choices are under patients control.5Introduction

Therefore , it is the dental professionals responsibility to assist the patient in adopting healthy lifestyle choices that will promote good oral health.

The most common method is through health education.

6

Traditionally health professionals have focused largely upon giving their clients information in an attempt to change their behavior.

Educational theory has identified that there are three domains of learning:CognitiveAffective Behavioral 7

The cognitive domain refers to the acquisition of factual knowledge and intellectual understanding of ideas.

The affective domain is concerned with attitudes, beliefs and values.

Behavioral refers to skills or actions performed.8

This representation of human behavior rarely exists in the real world.

In reality it is a very complex and dynamic relationship between the three domains of learning.

Behavior is largely determined by the opportunities and conditions in which individuals are placed. (Seiham 2000)9

Theories of changeMany models and theories have been proposed to explain behavior change.

Most have been developed by health psychologists who focus at an individual level and largely ignore the social context within which the behavior is enacted.10

Health belief modelFirst proposed in the 1950s by Hockbaum and adopted in the 1970s by the U.S Public Health Service.

It was one of the first attempts to view health in a social context.

The theory was a milestone in health education because it placed a high value on the attitudes of the learner and recognized the importance of the learners readiness to enact meaningful behavior change.

11

It is a psychological model that attempts to explain and predict health behaviors.

This is done by focusing on the attitudes and beliefs of individuals.

12

The Health Belief Model (HBM) has the longest history of all the theories reviewed.

It was originally conceived by social psychologists in the public health arena as a way of predicting who would utilize screening tests and/or vaccinations.

According to the HBM, the likelihood that someone will take action to prevent illness depends upon the individual's perception that:a) they are personally vulnerable to the condition;the consequences of the condition would be serious;13

the precautionary behavior effectively prevents the condition; and

d) the benefits of reducing the threat of the condition exceed the costs of taking action.

It implies that people with better information make better health decisions.

14

The HBM has been used for intervening with health screening, illness, sick role, and precautionary behaviors.

The model has undergone some modifications since its original formulation.

The model's four key components are conceptualized as, perceived:1)susceptibility, 2) severity, 3) effectiveness, and 4) cost.15

ConceptDefinition ApplicationPerceived SusceptibilityOnes opinion of chances of getting a diseaseDefine population at risk, risk levels; personalize risk based on a persons features or behaviors; heighten perceived susceptibility if too lowPerceived Severity Ones opinion of how serious a condition and its consequences areSpecify consequences of the risk and the conditionPerceived BenefitsOnes belief in the efficacy of the advised action to reduce risk or seriousness of impactDefine action to take; how, where, when; clarify the positive effects to be expectedPerceived BarriersOnes opinion of the tangible and psychological costs of the advised actionIdentify and reduce barriers through reassurance, incentives and assistance.

16

Cues to action Events or strategies that increase ones motivationProvides how-to information, promote awareness, remindersSelf efficacyConfidence in ones ability to take actionProvide training, guidance in performing action.

17

Perceived effectiveness refers to the benefits of engaging in the protective behavior.

Motivation to take action to change a behavior requires the belief that the precautionary behavior effectively prevents the condition.

For example, individuals who are not convinced that there is a causal relationship between smoking and cancer are unlikely to quit smoking because they believe that quitting will not protect against the disease.18

Perceived severity refers to how serious the individual believes the consequences of developing the condition are.

An individual is more likely to take action to prevent cancer if s/he believes that possible negative physical, psychological, and/or social effects resulting from developing the disease pose serious consequences.

The combination of perceived susceptibility and perceived severity constitute a threat.

19

Perceived cost refers to the barriers or losses that interfere with health behavior change.

Belief alone is not enough to motivate an individual to act.

Benefits have to outweigh the costs involved.20

Mediating factors (demographic, structural, and social variables) have also been explored in applying the HBM.

Mediating variables (e.g., educational level) are believed to indirectly affect behavior by influencing an individual's perceptions of susceptibility, severity, benefits, and barriers.

21

Cues to action involve stimuli that motivate an individual to engage in the health behavior.

The stimulus that triggers action may be internal or external. For example, angina may act as an internal cue to initiate action.

External cues such as a spouse's illness or the death of a parent may also trigger health behavior changes in an individual who was not otherwise considering them.22

HBM factors also interact to trigger action. For example, when perceptions of susceptibility and severity are high, a very minor stimulus may be all that is needed to initiate action.

However, more intense stimuli may be needed to initiate action if perceived susceptibility and severity are low.

23

24Nathe C. (2010), Dental Public Health and Research: contemporary Practice for Dental Hygienist (3rd edition)

More recent formulations of the HBM have included self-efficacy as a key factor.

Self-efficacy is influenced by mediating variables and in turn influences expectations.

In addition, some forms of the HBM refer to general susceptibility to illness as a key factor in the model.

25

The value of health, another variable which is sometimes included, refers to interest in and concerns about general health, the extent to which an individual values health.

According to this view of HBM, individuals concerned about being healthy in general are more likely to exercise regularly than individuals who place little value on health.26

Becker and Maiman added the concept of motivation to the HBM.

This has also been interpreted as readiness to change behavior.27

Oral Health ApplicationsMany cross sectional studies have found reliable correlations between oral hygiene behaviors and appropriate HBM stages.However there is not enough evidence that it will produce predictable changes.Two reasons can be thought of:Lack of longitudinal studiesChanging beliefs should also be taken into account. Only giving increased information might not be sufficient for behavior change. (Groner J.A, Grossman L(2000) the impact of a brief intervention on maternal smoking behavior. Paediatrics 105:267-71)28

Strength of the model:It acknowledges the patients values and attitudes towards health behaviors.

Limitations : Increased information and changing beliefs might not be sufficient to bring about behavior change and that behavior change rarely follows a logical, stepwise progression.29

The Trans-theoretical Model (Prochaska et al. 1992)The trans-theoretical model and stages of changes developed by Prochaska, Norcross and DiClemente is based on Individuals readiness to adopt a new health behavior.

The theory states that, as individuals move through a series of readiness stage , certain behaviors and attitudes characterize each staged. 30

Assessing an individuals stage allows health care workers and educators to tailor the intervention appropriate to the persons stage of readiness.

Individuals might skip over the stages or lapse to previous stages, but an awareness of the patients current stage of readiness allows the practitioner to provide appropriate assistance in moving towards healthier lifestyle choices.

31

The stages of change are:

Precontemplation ContemplationPreparation Action MaintenanceTermination

32Source : Grimley 1997, Prochaska 1992

Pre-contemplation describes individuals who for many reasons do not intend to change within the next six months.

Some of these individuals may want to change at some future time, but just not within the next six months.

Others may not want to change at all and, in fact, may be very committed to their problem behavior (e.g., a lifelong smoker or someone who regularly cultivates a deep tan).33

Contemplation describes individuals who are thinking about changing their problem behavior within the next six months.

They are more open to feedback and information about the problem behavior than their counterparts in Pre-contemplation.34

Individuals in the Preparation stage are committed to changing their problem behavior soon, usually within the next 30 days.

These people have often tried to change in the past and/or have been practicing change efforts in small steps to help them get ready for their actual change attempt.35

The Action stage includes individuals who have changed their problem behavior within the past six months.

The change is still quite new and their risk for relapse is high, requiring their constant attention and vigilance.36

Maintenance stage individuals have changed their problem behavior for at least six months.

Their change has become more of a habit, and their risk for relapse is lower, but relapse prevention still requires some attention, although somewhat less than for individuals in Action.37

Termination stage often not attained , represents a stage in which the change is permanent to the extent that it is as if the previous behavior never existed. 38

39

Individuals move through the stages using a process of decisional balance . They can weigh the benefits and costs or the pros and cons , of the change.

Benefits can include health, emotional or social gains.

Costs can be represented by obstacles such as social pressures, addiction that creates a physical dependence on the habit, or merely the desire to continue the behavior.

Self efficacy slowly begins to come into picture which provides confidence for the person to change.40

Many studies across problem behaviors have found that the ten most used processes of change are organized into two higher order clusters of processes:

The Experiential processes Consciousness Raising, Dramatic Relief, Self-Reevaluation, Environmental Reevaluation, and Social Liberation; and

The Behavioral processes Helping Relationships, Counterconditioning, Reinforcement Management, Stimulus Control, and Self Liberation. 41

The experiential set of processes are most often emphasized in earlier stages (Pre-contemplation, Contemplation, and Preparation) to increase intention and motivation;

Behavioral set of processes are most often utilized in later stages (Preparation, Action, and Maintenance) as observable behavior change efforts get underway and need to be maintained.

42

Processes of ChangeThe processes of change describe the ten cognitive, emotional, behavioral, and interpersonal strategies and techniques that individuals and/or change agents (therapists, counselors) use to change problem behaviors.

Research has demonstrated that successful behavior change depends upon the use of specific processes at specific stages.43

Decisional Balance

Decisional Balance, or the pros and cons of behavior change, describes the importance or weight of an individual's reasons for changing or not changing.

The pros and cons relate strongly and predictably to the stages of change.

44

These two dimensions have been consistently supported by studies across many different problem behaviors in TTM-based research.

Characteristically, the pros of healthy behavior are low in the early stages and increase across the stages of change, and the cons of the healthy behavior are high in the early stages and decrease across the stages of change.

45

Decisional balance is an excellent indicator of an individual's decision to move out of the pre-contemplation stage.

46

Situational Confidence and Temptations

The self-efficacy construct utilized in the TTM integrates the models of self-efficacy proposed by Bandura, and the coping models of relapse and maintenance described by Shiffman.

Confidence and temptation function inversely across the stages, and temptation predicts relapse better.47

Confidence is typically lowest in the Pre-contemplation stage, since individuals have little performance feedback and/or little interest in change.

Confidence is higher during Contemplation, outperforming demographic variables in its ability to predict movement into Preparation and Action stages.

Even in the Maintenance stage where subjects have successfully altered the problem behavior for at least six months, temptation is one of the best predictors of relapse and recycling to earlier stages of change.48

Usage The past 20 years of Trans-theoretical Model-based research has found some common principles of behavior change which have applied to a wide range of health behaviors.

These behaviors include: smoking cessation, exercise adoption, sun protection, dietary fat reduction, condom use, adherence to mammography screening, medication adherence, stress management, and substance abuse cessation, to name just a few.

49

These problem behaviors are important from both a clinical and a public health standpoint because they are strongly associated with increased morbidity, mortality, and with decreased quality of life.

The Trans-theoretical Model (TTM) is a model of intentional behavior change that has produced a large volume of research and service across a wide range of problem behaviors and populations.50

Oral health applications Research has recorded the validity of the stages of change and decisional balance in oral care behaviors.

More research is needed to test the accuracy of the model in predicting altered behaviors for oral health care.

Currently, tobacco cessation is the most frequently used application of the stages of change of change with regard to oral health and has been verified through longitudinal research.51

Health care providers can help learners move through the stages using multiple mechanisms.

Consciousness raising, vicarious learning and environmental evaluation are useful in pre-contemplation, contemplation or preparation phase.

Media campaigns, television programmes or celebrity illness may have a greater impact on publics consciousness of disease or condition which could affect a persons readiness to advance into higher stages of readiness.52

In the action and maintenance stages, strategies such as counterconditioning and contingency management can be useful.

Counterconditioning can empower an individual to develop a healthy alternative for an unhealthy habit.

Contingency management such as preplanning strategies for managing high stress circumstances and rewarding positive changes can be most useful for helping individuals who have reached these higher stages. 53

For example:When used in tobacco counseling, the clinician must first establish the patients readiness to change stage.

A person who has no intention of stopping tobacco use would be a pre-contemplator.

For this patient, a brief counseling session offering information on the health consequences of using tobacco and offering support at a future date should the patient decide to quit should be appropriate. 54

A person in this stage might not be willing to set a quit date or develop quitting strategies.

In the contemplation stage would be considered quitting and might be willing to set a quit date. Offering support through counseling, providing information and quit aides through identifying quitting resources such as classes or support groups would be appropriate.

At this stage constant encouragement and information regarding benefits might help tip the decisional balance in favor of progressing to the next stage. 55

The patient in the preparation phase is ready to make the change. This person should enroll in a cessation class or purchase a nicotine gum/ patch and should be willing to set a date and should be willing to come up with a contingency plan to overcome cravings.

Assistance for this patient can be writing the quit date in the oral health record, identifying plans for replenishing gums or patches, help overcome stressful situations through counseling. 56

A person in the action stage could be enrolled in a cessation class or during a pharmaceutical resource and would have stopped using tobacco products for 1 2 months.

For this patient, frequent contacting to encourage continued abstinence, providing additional quit dates, completing a dental examination and prophylaxis, to support current changes is beneficial.

Patients in maintenance who have continued the behavior change for more than 6 months might be willing to help others overcome tobacco addiction through peer counseling.

This would also be appropriate for for people in termination.

Strengths of the model

First, it describes behavior change as a process, as opposed to an event.

Then, by breaking the change process down into stages and studying which variables are most strongly associated with progress through the stages, this model provides important tools for both research and intervention development.58

Secondly, its explicit focus on measurement of constructs has provided a strong foundation for the model.

Across different problem behaviors and populations, different variables have been associated with stage movement for each stage of change

59

Limitations of the model include the following:

The theory ignores the social context in which change occurs, such as SES and income.

The lines between the stages can be arbitrary with no set criteria of how to determine a person's stage of change. The questionnaires that have been developed to assign a person to a stage of change are not always standardized or validated.

60

There is no clear sense for how much time is needed for each stage, or how long a person can remain in a stage.

The model assumes that individuals make coherent and logical plans in their decision-making process when this is not always true.

61

The Theory of Reasoned Action/Planned Behavior ( Ajzen and Fishbein 1980) The Theory of Reasoned Action (TRA) is a widely used behavioral prediction theory which represents a social-psychological approach to understanding and predicting the determinants of health-behavior.

Over the years, TRA has been applied to many diverse health-related behaviors including: weight loss, smoking, alcohol abuse, HIV risk behaviors, and mammography screening.62

The theory of reasoned action states that the intention to perform a particular behavior is strongly related to the actual performance of that behavior.

Two basic assumptions that underlie the TRA are: 1) Behavior is under volitional control,2) People are rational beings.63

Two typesIntention to perform the behavior

Subjective norms Self efficacyAttitudesBeliefsInfluenced bynormativebehavioral

64

Predicting behavior is the ultimate goal of the TRA.

According to the TRA, behavior is influenced by the intention to perform the behavior.

Intention is influenced by three major variables: subjective norms, attitudes, and self-efficacy.

Subjective norms involve an individual's perception of what significant others believe about his or her ability to perform the behavior.65

For example, whether or not someone intends to cut down on dietary fat by giving up bacon and red meat could be partly determined by what that person believes his or her spouse's opinion would be if s/he did.66

Attitudes can be conceptualized in terms of values.

That is, an individual develops particular values about behaviors.

For example, one attitude might be: eating a healthy diet is a good way to prevent heart disease and/or cancer.

Self-efficacy is the confidence an individual feels that s/he can successfully perform the behavior of eating a healthy diet.

67

Two of the variables that influence intention, subjective norms, and attitudes are in turn influenced by beliefs.

Two general types of beliefs are considered in TRA: normative and behavioral beliefs.

Normative beliefs are situationally based social expectations, which are considered the rule.68

Normative beliefs influence subjective norms while beliefs about the behavior influence attitudes.

69

From a TRA perspective, the likelihood that an individual will engage in health risk reduction depends upon how much s/he is convinced that healthy behaviors will prevent risk, and the degree to which s/he perceives the benefits will outweigh the costs.

70

71

Strengths :Social norms and community expectations are powerful predictors of individual behavior, according to this theory.

When used in a community intervention, the theory might be better able to predict the behavior of the community than an individual.

Social norms do not change as readily as individual choices.

72

Therefore, social norms are more stable and provide strong normative beliefs to those in a community.

This theory helps explain an individuals perception of normal and expected behavior.

It is the most successful in predicting behaviors that are completely within the individuals control and in which intentions remain stable, such as daily oral hygiene practices.73

Extraneous factors outside the individuals control such as fatigue or change in environment might quickly change intentions and therefore change behavior and outcomes.

74

Limitation

The majority of TRA research has focused on the prediction of behavioral intention rather than on the behavior itself.

Unfortunately, because the correlation between behavior and intention is not particularly impressive, research on attitudes and behaviors is often dismissed.75

Despite this shortcoming, Sonstroem has suggested that TRA can still be a useful perspective as long as situation-specific attitude and intention measures are employed that specify congruent action, target, context, and time, and that the interactions between personal determinants and situations are emphasized

76

Oral health applicationsFor example:

If severe caries is accepted as a normal part of childhood, caregivers cannot attribute personal actions to oral diseases.

The clinician must assess the patients/caregivers dental knowledge and values to devise an effective health education plan.77

This approach could be applied to a local head start daily tooth brushing program.

The dental professionals involved in these programs can apply the theory of reasoned action to encourage daily toothbrushing, thereby creating a behavioral norm for the family.

Social norms of daily toothbrushing and use of fluoridated toothpaste that become firmly established within a family can have lasting effects, long after the children leave the head start program.78

Social Cognitive Theory (Bandura A, 1986)This theory may be the most comprehensive model of human behavior yet proposed.

Bandura's Social Cognitive Theory (SCT),also referred to as Social Learning Theory, is a behavioral prediction theory that represents a clinical approach to health behavior change.

This theory has been widely applied to health behavior with respect to prevention, health promotion, and modification of unhealthy lifestyles for many different risk behaviors.79

SCT emphasizes what people think and its effect on their behavior.

It states that individuals do not learn or change behavior in a linear fashion.

SCT proposes that behavior can be explained in terms of triadic reciprocity between three key concepts which operate as determinants of each other. 80

This important concept states that there is a continuous, dynamic interaction between the individual, the environment, and behavior.

Thus, a change in one of these factors impacts on the other two.

As individual learns more, behaviors and environment change.81

Self efficacy, the main construct of the SCT, is the belief that ones personal action will have an impact on the outcome.

82

Key concepts associated with the person include:

Personal characteristicsEmotional arousal/copingBehavioral capacitySelf-efficacy, expectationExpectancies, self-regulation,Observational/experiential learning, and reinforcement83

Self-Efficacy :

The concept of self-efficacy is recognized as one of Bandura's most important contributions to psychology and the field of health behavior change in general.

Self-efficacy refers to the confidence an individual has in his or her own ability to successfully carry out a behavior.

The importance of self-efficacy for behavior change has been widely recognized across multiple behaviors relevant to health risk reduction.84

An individual with low self-efficacy is likely to have lower expectations of successfully performing the behavior and be more affected by situational temptations that are counter productive to promoting and maintaining behavior change.

In contrast, an individual who has high self-efficacy not only expects to succeed but is actually more likely to do so.

85

For example, the likelihood that an individual will successfully perform a behavior like exercise is strongly dependent upon how confident that individual is that s/he can actually do activities, such as walking, jogging, swimming, or doing aerobics on a regular basis.

Several factors influence an individual's self-efficacy, including persuasion by others, observing others' behavior (modeling), previous experience with performing the behavior, and direct physiological feedback.86

It is gained as information, behavior and environment interact in a reciprocal manner.Can be gained through :Experiencing successVicarious learning learning from others experiencesVerbal persuasion

87

Vicarious learning :

It allows learning through modelled behavior and developing expectations based on others experiences.

It allows patients to learn of poor outcomes without actually experiencing them.

For example:A patient who has lost a tooth because of severe caries can be motivated to change behaviors to prevent losing more teeth.Another patient who has not actually been in this situation can adopt healthy practices upon hearing of the other persons experiences88

Modeled behavior is not as powerful at changing behavior as in personal experience, so repeated encounters with the patient to encourage changes is needed.

Success:

When success is gained through repeated efforts by the model , it is more influential than getting the results with ease.The model will be more powerful if it has similar characteristics as the patient89

Verbal persuasion:

It is a necessary follow up for those attempting to sustain a changed behavior.

It will include assisting the patients to form goals, determine exposure of outcomes and formulate strategies for coping with challenging situations. 90

Example :A 42 year old male presents with severe generalized gingivitis and isolated 4 mm pockets. The patient had a family history of type 2 diabetes and hypertension although the patients has neither of them.

Upon questioning, the provider learns that the patients father experienced loose teeth, resulting in need for full dentures at an early age. The patients wants to keep his teeth.

91

So in this case the dental provider can use vicarious learning to explain about periodontal disease and to teach the patient about proper oral hygiene measures and treat the patient.

92

In the subsequent appointment , the patient experienced improved gingival health because of his oral hygiene efforts.

Verbal persuasion will attribute the improved oral status to the patients practices.

Thus, the provider here has allowed the patient to experience success through his own effort (enactive attainment), allowed him to learn of poor outcomes through his fathers experience (vicarious learning) and pointed out that the results are a direct result of his efforts( verbal persuasion)

93

Strengths:

Self efficacy has shown to be an accurate predictor of oral health in both cross sectional and longitudinal studies.

It is a significant predictor of behavior in conditions such as managing diabetes and oral health.

Dental self efficacy was found to be a determinant in oral health and oral hygiene among diabetes patients and for general oral health in adults and adolescents.94

Limitation :One limitation is studies have shown that it lasts for a short period of time.

It is very domain specific, and similar domains can influence one another.

For example : as a person gains knowledge about plaque control, self efficacy can improve in the areas of personal hygiene in general. However it cannot extend to other health domains.So, a patient maybe confident in his ability to practice daily oral hygiene but has little confidence in having regular professional dental care.95

Locus of control The locus of control is an extension of Social cognitive theory.

Developed by Wallston and Kaplan in mid 1970s.

Along with the three components of SCT, lifestyle choices come into picture in this model.

96

Unlike self efficacy which is domain specific, Locus of control tends to be more global.

Many scales have been developed in accordance with the model.

Oral health research commonly uses the multidimensional Oral health locus of control scale with items specific to oral health behaviors and influences.This model has been found to be predictive for personal health behaviors.

97

Implementation of the Health Behavior modelsThe challenge for the health professionals is understanding and implementing the theories.

Implementation would be different for children, teens, adults, communities or other groups.

The interventions setting can also affect the implementation scheme.

98

Adults have unique learning needs influenced by a wealth of experience and established practices that work.

So for them information should be presented in a results oriented manner, so that they have a valid reason to change behaviors.

The key point of adult learning is relevance.

The second important point is that the information must be practical.

This means that the information presented must meet the patients readiness to learn and can be put to immediate use.

To put these concepts to work, the provider must , through observing and talking to the patient, determine the patients interest, attitudes and current knowledge.

He must also assess what the patient is ready to learn and what information can be put to immediate use.

The counselor will have to interview the patient to determine the current level of knowledge, interest and needs.

100

Providers should empower patients to be partners in care in the dental field.

Discussing past dental experiences, oral health expectations and provider identify treatment goals.

This however is not for all the patients, understanding that all education given must meet their immediate needs and should be put into immediate use will encourage patients to be active participants in health care.101

Patient education can be more successful if the following principles of adult education are used :

The patients need to knowThe patient as a decision makerThe patients acknowledgement of previous experiencesProviders meeting patients at their level of readiness to learn and providing relevant and practical information. 102

For example:A patient with type 2 diabetes who presents with a draining abscess, but the tooth is not causing any pain.Because of the lack of pain or interfering with daily activities, the patient does not want to have the tooth treated.The provider can make education relevant by advising the patient on the impact of chronic infection on blood sugar. 103

The provider can make the education practical by addressing other issues of concern to the patient such as anxiety, cost of treatment and perceived barriers to dental care. The patient then becomes a full partner in setting treatment goals.

The patient in this case is more likely to follow comprehensive treatment recommendation.

104

Motivational InterviewingIt is a technique which is quite useful in bringing about the desired changes.

Its defined as patient centered counseling that helps the patient resolve conflicts and ambivalence.

105

Using the principle of MI, the patients current needs can be determined. Some possible questions would be:What concerns do you have about your mouth?Tell me about your past experiences with dental treatment?What methods have you used in the past to clean in between your teeth?What do you know about prevention of gum disease?106

Frequently individuals with severe dental disease report no dental problems.

If upon a brief look the patients oral cavity reveals dental disease and the patient reports nothing wrong, the clinician should stop after the first two questions and focus on the need for good oral health, possibly touching on the association between chronic oral infections and diabetes mellitus or cardiovascular complications.

107

Certain characteristics of counseling that are not MI:Argues that the patient has a problem and in need of changeOffers direct advice without determining the patients interest in changeAdopts a superior attitude to the patientDoes most of the talkingLabels the patient108

Limits of behavior modelsModels are concepts, not representations of behaviorThey show the factors influencing behavior, but do not explain the processes for changing behavior.

Behavior is complex, but models are deliberately simpleThey are concepts to aid understanding they are deliberately simplistic and do not capture all the factors that account for behavioral outcomes.109

There is a limit to how far models will stretch :They are developed in the context of a specific behavior, and tend to work best in that context although some do have wider applicability.

Models dont tend to differentiate between peopleThey tend to show the behavior of a statistical everyman and need to be adapted in order to cover different audience groups.

110

Factors dont always precede behavior

Most behavioral models present social-psychological factors as preceding behavior but there are instances where people are compelled to change their behavior first, which then leads to change in the social-psychological variables.111GSR behaviour change knowledge review

Barriers preventing changeLack of opportunity : cases of limited access

Lack of resources : unable to follow the instructions because of low financial status

Lack of support : for example, trying to quit when the person living with you is a smoker

Conflicting information on nature of change like, confusion over health education messages112

Long term nature of benefit : when the benefit to be gained is not in the near future. For example, lung cancer does not affect teenagers for another 40 years and smoking has immediate personal and social benefits.

Belief that change is not possible: when someone has failed in their attempt to change.

No clearly defined goals : for example, asking someone to stop eating sugar when so many processed foods have sugar added to them.

Lack of knowledge 113Jacob and Plamping, 1989

Conclusion Health behavior modelling is complex and challenging.

Providers must assess the learners knowledge , interest and values and then decide on the most appropriate learning approach and design a personal oral health plan for the patient.114

115

References Norman O Harris, Health Education and Promotion Theories, Primary preventive dentistry, 8th edition. Pg: 324-339.

Daly B, Overview of Behavior Change, Essential Dental Public Health, pg: 153- 167.

Theories and Models Frequently Used in Health Promotion, Riverside community Health Foundation.116

Sutton, Stephen (2001). Health behavior: Psychosocial theories. In N. J. Smelser & B. Baltes (eds.), International Encyclopedia of the Social and Behavioral Sciences . 6499--6506.

5) James O. Prochaska, Colleen A. Redding, Health Behavior Models, Int Electron J Health Educ. 2000; 3 (Special Issue): 180-193

6) An overview of behaviour change models and their uses, GSR behaviour change practice guide

117

118