From Volume 49, Issue 3, March 2022 | Pages 233-237
Clinicians can use behaviour change techniques effectively in routine consultations in healthcare settings, including dentistry. Professional guidelines support their use for preventing and managing a range of dental diseases. Theory and evidence from behavioural science can inform effective behaviour change interventions. This article examines the relevance of these techniques to the whole dental team and how they can be implemented within routine dental consultations.
Health behaviour change plays an increasingly important role in preventive dental care. Psychological theories are important in understanding health behaviours and in developing effective interventions to support health behaviour change. Public Health England recommend that dentists introduce the topic of behaviour change with their patients, and this approach is supported in multiple NHS policies and initiatives. For example, the NHS ‘Making Every Contact Count’ initiative1 recommends that every opportunity to have behaviour change-related conversations with patients should be capitalized on. ‘Delivering better oral health: an evidence based toolkit for prevention’2 also contains guidance for dental teams from Public Health England and the UK Department of Health and Social Care. This publication describes the importance of behaviour change interventions within dental practices and identifies those behaviours that should be targets for change.
Routine dental check-ups in the NHS offer important opportunities for ongoing intervention, potentially occurring routinely throughout patients' lifespans. Our research3 found that behaviour change conversations are acceptable to dental professionals and patients, particularly if they are linked directly to oral and dental health outcomes.
Health behaviours associated with oral and dental health include:
Successful interventions addressing these behaviours can also impact on several other conditions, such as diabetes, heart conditions and mental health, because they share common risk factors.4
Interventions delivered within primary dental care have the opportunity to capitalize on the regular ‘teachable moments’ that occur routinely in clinical practice. Teachable moments are planned or opportunistic events in a person's life that coincide with an openness to new ideas or change, such as a child attending their first dental appointment, a diagnosis of a health condition or a referral to an endodontist.5 Importantly, many behaviour change interventions are brief and can be incorporated within routine dental consultations. For example, a study of an intervention based on implementation planning (making plans to overcome barriers to change), which was effective in reducing dietary acid intake, was additionally found to be acceptable and easy to implement. The clinician and the patient could quickly identify which behaviour to target, discuss obstacles and make tailored plans within a typical dental consultation.6
Healthcare practitioners may hold common misconceptions around what works when encouraging patients to change health behaviours.7 These common mistakes are not only unlikely to be ineffective, but may even lead to the patient disengaging with the content of the message.8
A common misconception is that people need to be sufficiently scared of the damaging effects of their behaviour on their health in order to motivate themselves to change. This might seem reasonable – if only people understood what damage they were doing then they would stop it. Over the years this type of reasoning has led to many healthcare professionals (and public health campaigns) putting out fear-inducing messages, such as ‘smoking kills’. These have largely been ineffective because, unfortunately, people do not always behave this rationally and can disengage with the health message behind the scare tactic. In fact, increasing people's fear can actually increase the unhealthy behaviour through comfort-seeking.9,10
Another related misconception is that, if only patients knew more about a condition or illness then they would change their behaviour to avoid making things worse. However, many people already know that activities, such as smoking, drinking and leading a sedentary lifestyle, can cause health conditions or make them worse and, for a number of complex reasons, do not change their behaviours. In this case, simply giving people more information doesn't make them more able or motivated to make changes.
A growing body of research has explored the usefulness of behavioural science in understanding oral hygiene-related behaviours. A Cochrane review11 concluded that the Capability, Opportunity and Motivation model of behaviour change (COM-B)12 has the strongest support of all theoretical frameworks for oral health intervention. The model proposes that, for a behaviour to be performed successfully, individuals need to have sufficient Capability (physical or psychological ability), Motivation (conscious and automatic mechanisms that activate and inhibit behaviour) and Opportunity (physical and social environment that enables the behaviour). For example, in order to perform a target behaviour of tooth brushing, the patient would need to: be able to hold a toothbrush and know how to use it (capability); have a toothbrush and toothpaste and time to use them (opportunity); want to appear socially acceptable with clean teeth and fresh breath (motivation) (Figure 1).
There are opportunities for health professionals to intervene in each of the COM areas by supporting their patients using behaviour change techniques.12 A behaviour change technique is a strategy that helps an individual to change their behaviour to promote better health, for example, being provided with free toothbrushes and toothpaste and planning to brush teeth before going to bed.
Researchers have identified that goal setting, action planning and monitoring are particularly effective behaviour change techniques for improving oral health behaviours in adult patients.6,11,13 These conclusions are part of a broader evidence-base, which suggests that helping individuals identify and plan for potential barriers to a health-related behaviour facilitates behaviour change.
Observational work of clinical consultations across medical specialities shows that patients do offer cues and opportunities to talk about lifestyle behaviours, but that these are not necessarily picked up by clinicians. Behaviour change discussion is relatively rare in consultations (occurring in less than 20% of primary care consultations) and is typically initiated by patients rather than the clinician.14 Conversations with patients about behaviour change are perceived by health professionals to be sensitive. Consistently, the research finds that multiple barriers operate to prevent discussion of behaviour change occurring during routine practice, for example primary care practitioner skills and concerns about jeopardizing relationships.15.
Despite this, patients expect and want clinicians to initiate discussion about health behaviours if they are: relevant to a medical problem,16,17 or explicitly linked to prevention and treating oral health.3
Identifying stages of motivation is important. The following questions could be considered during consultations:
The advice provided by ‘Delivering better oral health’2 has been summarized and adapted to produce the strategies shown below.
The seed for a future intervention can be planted with unmotivated patients. For example, ‘Sounds like you aren't looking to [stop smoking] at this time. If you would like help with this we can talk about it again’. The next section may help you to support those patients who fall in the amber and green columns of Figure 2.
In order to give helpful advice to patients, dental practitioners need to have effective conversations about behaviour change with patients. Active listening involves not only being alert to cues patients offer about behaviour change, but also making it very explicit to patients that you are listening and want to understand their experiences. This way of listening improves behaviour change conversations.
In summary, practitioners who want to have acceptable and effective behaviour change conversations with patients should listen for cues in the conversation, decide what level of intervention is appropriate and then tailor their approach based on the guidance and examples given above. Table 1 describes these stages chronologically.
| Listen out for … | Examples | |
|---|---|---|
| Target behaviours | Behaviours that the patient wants or needs to change | Giving up smoking, cutting down on drinking alcohol or eating a better diet |
| Cues | Things that patients say that offer an opportunistic segue into behaviour change conversations | ‘I know I eat too many sweets’ ‘My children want me to stop smoking’ |
| Identifying barriers and facilitators | What does the patient say about their capability, opportunity and motivation to compete the target behaviour? | ‘I'm stuck in a rut’ |
Given that goal setting, planning and monitoring are the behaviour change strategies (BCTs) that have found to be the most effective in dentistry, we focus on these three techniques. Some further examples are included in Table 2.
| BCT | How to use | Example |
|---|---|---|
| Goal setting (behaviour) | Through active listening, you will have identified a target behaviour. For example, your patient might want to reduce the amount of sugar they consume. You can help the patient to set a goal to help them to achieve their aim. This should be specific, relevant to the individual, clear and easy for them to achieve | Goal: To have a biscuit once per day, after my lunch only |
| Action planning | During conversation, you may have worked with your patient to identify some barriers (eg ‘I work from home and I'm always snacking sweets on and biscuits’) and facilitators to changing the target behaviour (eg I feel annoyed at myself when I do this). These insights can be used to develop an IF/THEN plan that can be used to help overcome the barrier as it occurs |
If I want to snack outside lunchtime |
| Feedback and monitoring | Dental practitioners can capitalize on opportunities provided by regularly attending patients by reviewing goals and actions plans, giving praise and feedback, for example where there is improvement in oral health and building on past successes through setting new goals and making revised action plans | ‘I can see that you have reached your goal to brush twice a day, you don't need any further treatment. Well done. How do you feel about making a new plan to cut down on cigarettes? ‘ |
You may have identified a potential target behaviour through listening for cues, for example the patient might have mentioned wanting to cut down on sugary snacks. Goals should relate directly to the behaviour, be specific and relevant to the patient. It is also important for the goal to be achievable. This may help to increase patients' self-confidence in making behaviour changes, and subsequent goals can be set that build on previous achievements (see Feedback and monitoring).
Patients will often describe barriers to behaviour change during consultations, for example ‘I would love to stop snacking, but I have a sweet tooth.’ You can also work with your patient to identify one or two barriers to achieving their goal. You should encourage your patient to also identify facilitators to changing the target behaviour (eg ‘I like fruit … I could have strawberries instead of a biscuit on Tuesdays and Thursdays and keep snacks for mealtimes’). These insights can be used to develop an IF/THEN plan that can be used to help overcome the barrier as it occurs (see Table 2).
Dental teams have a unique opportunity for building relationships with patients who are regular attenders. Making a note of patient goals and the extent to which they have been achieved, setting new goals and reviewing and developing action plans can strengthen this relationship and allow practitioners to build on previous successes. It is worth taking a minute to note down goals and plans on patient records so that they can be referred to at the next consultation. You can also use some of these chairside techniques to encourage patients to attend their next appointment.
The following are links to further behaviour change resources. The Toothpicks training for dentists was designed by researchers at the University of Manchester while the other two links lead to further training in using the behaviour change taxonomy and COM-B model.
Behaviour change techniques and the COM-B model can be used to support useful behaviour change conversations between dental practitioners and patients in routine dental consultations. This approach makes these conversations easier to initiate and is more likely to result in patients engaging in behaviour change conversations, and ultimately changing health behaviours in ways that could lead to improvements in a number of oral and general health conditions and illnesses. Moreover, our research has shown that this approach to behaviour change is aceptable to patients.
There is also scope to tailor CPD, training and patient-facing behaviour change conversations to focus on specific areas of dentistry that may be particularly problematic, such as intervention with parent/child dyads, oral cancer prevention and discharge from surgical settings, to equip the workfore with a the skills to take a multi-faceted approach to supporting patients' behaviour change.
