a brief description of important health behavior models

1. 1

2. Health Behavior Models
Swagat Kumar
III MDS
Department of Public Health
Dentistry
2

3.  Introduction
 Health Belief Model
 Trans Theoretical Model
 The Theory of Reasoned Action/Planned Behavior
 Social learning/ cognitive theory
 Locus of Control
 Implementation of Health behavior models
 Conclusion
3

4. Certain terminologies
 Norms : Something that is usual, typical, or standard.
something deemed proper by the society
 Construct : A construct is the abstract idea,
underlying theme, or subject matter that one wishes
to measure using survey questions
 Domain : A field or scope of knowledge or activity
 Belief : Trust, faith, or confidence in (someone or
something).
4

5.  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.
5
Introduction

6.  Therefore , it is the dental professional’s 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

7.  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:
 Cognitive
 Affective
 Behavioral
7

8.  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

9.  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

10. Theories of change
 Many 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

11. Health belief model
 First proposed in the 1950’s by Hockbaum and
adopted in the 1970’s 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 learner’s
readiness to enact meaningful behavior change.
11

12.  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

13.  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;
b) the consequences of the condition would be serious;
13

14. b) 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

15.  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

16. Concept Definition Application
Perceived Susceptibility One’s opinion of chances
of getting a disease
Define population at
risk, risk levels;
personalize risk based
on a person’s features
or behaviors; heighten
perceived susceptibility
if too low
Perceived Severity One’s opinion of how
serious a condition and
its consequences are
Specify consequences of
the risk and the
condition
Perceived Benefits One’s belief in the
efficacy of the advised
action to reduce risk or
seriousness of impact
Define action to take;
how, where, when;
clarify the positive
effects to be expected
Perceived Barriers One’s opinion of the
tangible and
psychological costs of
the advised action
Identify and reduce
barriers through
reassurance, incentives
and assistance.
16

17. Cues to action Events or strategies
that increase one’s
motivation
Provides how-to
information,
promote awareness,
reminders
Self efficacy Confidence in one’s
ability to take action
Provide training,
guidance in performing
action.
17

18.  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

19.  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

20.  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

21.  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

22.  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

23.  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

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

25.  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

26.  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

27.  Becker and Maiman added the concept of motivation
to the HBM.
 This has also been interpreted as readiness to change
behavior.
27

28. Oral Health Applications
 Many 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:
1) Lack of longitudinal studies
2) Changing 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

29. Strength of the model:
 It acknowledges the patient’s 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

30. 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 Individual’s 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

31.  Assessing an individual’s stage allows health care
workers and educators to tailor the intervention
appropriate to the person’s 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

32.  The stages of change are:
 Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Termination
32Source : Grimley 1997, Prochaska 1992

33.  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

34.  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

35.  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

36.  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

37.  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

38.  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. 39

40.  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

41.  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

42.  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

43.  Processes of Change
 The 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

44.  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

45.  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

46.  Decisional balance is an excellent indicator of an
individual's decision to move out of the pre-
contemplation stage.
46

47.  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

48.  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

49. 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

50.  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

51. 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

52.  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 public’s
consciousness of disease or condition which could affect
a person’s readiness to advance into higher stages of
readiness.
52

53.  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

54.  For example:
 When used in tobacco counseling, the clinician must
first establish the patient’s 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

55.  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

56.  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

57.  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.

58.  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

59.  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

60.  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

61.  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

62. 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

63.  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

64. Two types
Intention to perform the behavior
Subjective
norms
Self
efficacy
Attitudes
Beliefs
Influenced by normative
behavioral
64

65.  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

66.  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

67.  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

68.  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

69.  Normative beliefs influence subjective norms while
beliefs about the behavior influence attitudes.
69

70.  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. 71

72.  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

73.  Therefore, social norms are more stable and provide
strong normative beliefs to those in a community.
 This theory helps explain an individual’s 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

74.  Extraneous factors outside the individuals control such
as fatigue or change in environment might quickly
change intentions and therefore change behavior and
outcomes.
74

75.  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

76.  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

77. Oral health applications
 For 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 patient’s/caregivers
dental knowledge and values to devise an effective
health education plan.
77

78.  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

79. 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

80.  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

81.  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

82.  Self efficacy, the main construct of the SCT, is the belief
that one’s personal action will have an impact on the
outcome.
82

83.  Key concepts associated with the person include:
 Personal characteristics
 Emotional arousal/coping
 Behavioral capacity
 Self-efficacy, expectation
 Expectancies, self-regulation,
 Observational/experiential learning, and reinforcement
83

84.  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

85.  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

86.  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

87.  It is gained as information, behavior and environment
interact in a reciprocal manner.
 Can be gained through :
 Experiencing success
 Vicarious learning – learning from others experiences
 Verbal persuasion
87

88.  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 experiences
88

89.  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 patient
89

90.  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

91.  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

92.  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

93.  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 patient’s
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

94.  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

95.  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

96. Locus of control
 The locus of control is an extension of Social cognitive
theory.
 Developed by Wallston and Kaplan in mid 1970’s.
 Along with the three components of SCT, lifestyle
choices come into picture in this model.
96

97.  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

98. Implementation of the Health
Behavior models
 The challenge for the health professionals is
understanding and implementing the theories.
 Implementation would be different for children, teens,
adults, communities or other groups.
 The intervention’s setting can also affect the
implementation scheme.
98

99.  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 patient’s readiness to learn and can be put to
immediate use.

100.  To put these concepts to work, the provider must ,
through observing and talking to the patient, determine
the patient’s 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

101.  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

102.  Patient education can be more successful if the
following principles of adult education are used :
 The patient’s need to know
 The patient as a decision maker
 The patient’s acknowledgement of previous
experiences
 Provider’s meeting patients at their level of readiness
to learn and providing relevant and practical
information.
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103.  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

104.  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

105. Motivational Interviewing
 It is a technique which is quite useful in bringing
about the desired changes.
 It’s defined as patient centered counseling that helps
the patient resolve conflicts and ambivalence.
105

106.  Using the principle of MI, the patient’s 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

107.  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

108.  Certain characteristics of counseling that are not MI:
- Argues that the patient has a problem and in need of
change
- Offers direct advice without determining the patient’s
interest in change
- Adopts a superior attitude to the patient
- Does most of the talking
- Labels the patient
108

109. Limits of behavior models
 Models are concepts, not representations of
behavior
 They show the factors influencing behavior, but do not
explain the processes for changing behavior.
 Behavior is complex, but models are deliberately
simple
 They are concepts to aid understanding – they are
deliberately simplistic and do not capture all the factors
that account for behavioral outcomes.
109

110.  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 don’t tend to differentiate between
people
 They tend to show the behavior of a statistical
‘everyman’ – and need to be adapted in order to
cover different audience groups.
110

111.  Factors don’t 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.
111
GSR behaviour change knowledge review

112. Barriers preventing change
- Lack 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 messages
112

113.  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
113
Jacob and Plamping, 1989

114. 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. 115

116. References
1)Norman O Harris, Health Education and Promotion
Theories, Primary preventive dentistry, 8th edition. Pg:
324-339.
2)Daly B, Overview of Behavior Change, Essential Dental
Public Health, pg: 153- 167.
3)Theories and Models Frequently Used in Health
Promotion, Riverside community Health Foundation.
116

117. 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
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