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Randomized Controlled Trial of a One-minute Intervention Changing Oral Self-care Behavior
1 University of Aberdeen, College of Life Sciences and Medicine, King’s College, William Guild Building, Aberdeen, AB24 2UB, Scotland, UK; Correspondence: * corresponding author, f.sniehotta{at}abdn.ac.uk
Non-compliance with oral self-care recommendations, despite education and motivation, is a major problem in preventive dentistry. Forming concrete if-then action plans has been successful in changing self-care behavior in other areas of preventive medicine. This is the first trial to test the effects of a brief planning intervention on interdental hygiene behavior. Two hundred thirty-nine participants received a packet of floss, information, and a flossing guide. They were randomly assigned to a control or an intervention group. The intervention took 1.16 minutes and consisted of forming a concrete plan of where, when, and how to floss. Baseline measures and two-week and two-month follow-ups included self-report, residual floss, and theory of planned behavior variables. The intervention significantly affected flossing in that group at two-week and two-month follow-ups, as compared with the control group. This study provides evidence for the effects of a concise intervention on oral self-care behavior.
Key Words: self-care • prevention • behavioral intervention • oral hygiene • theory of planned behavior
Considerable progress has been made toward our understanding of the pathophysiological determinants of oral disease. Efficacious techniques for preventing caries and periodontal disease include self-performed oral hygiene measures (e.g., flossing), vaccination, and fluoridation (Nyvad et al., 2004). Although these measures are efficient under optimal conditions (i.e., fully controlled clinical trials), their effectiveness under everyday circumstances can be improved. Non-compliance with oral self-care recommendations attenuates potential effects of preventive dentistry, representing a key problem in the prevention of periodontal disease (Ciancio, 2003; Widstrom, 2004). The public’s participation in their oral health is entirely behavioral (flossing, brushing, seeing a dentist, dietary behaviors, etc.). An understanding of individual self-care behavior in preventive dentistry will be paramount to facilitating control of caries and periodontal disease (ten Cate, 2004; Sniehotta et al., 2005a). Evidence indicates that regular flossing reduces interdental plaque (Bauroth et al., 2003; Bellamy et al., 2004). Despite a lack of conclusive evidence for clinical effectiveness, flossing is considered an important method of preventing periodontal disease (Warren and Chater, 1996; Bellamy et al., 2004). Both the British (2007) and American Dental Associations (2005) recommend daily flossing, and yet flossing is infrequent (Bader, 1998; Rimondini et al., 2001). In Europe, from 30% to 60% of the adult population have medium to severe periodontitis (Petersen, 2003). Previous research on oral self-care has predominantly investigated how determinants of motivation affect behavior. Several studies have applied the Theory of Planned Behavior (TPB; Ajzen, 1991) and related theories in predicting oral self-care behavior (McCaul et al., 1988; Tedesco et al., 1991a,b; Rise et al., 1998; Syrjälä et al., 2002; Lavin and Groarke, 2005). According to the TPB, individuals form intentions to perform a behavior based on their attitudes, subjective norms, and perceived behavioral control (PBC), i.e., the perceived ease/difficulty of a behavior. Behavior is determined by behavioral intentions and PBC. The likelihood of flossing increases with higher intention and PBC. Evidence supports the theories’ assumptions, but, despite good intentions and sufficient perceived control, many people fail to act on their intentions, especially concerning regular self-care regimens. This indicates an intention-behavior gap (Orbell and Sheeran, 1998). Moreover, there is no evidence that interventions lead to sustainable changes in oral self-care. An intervention study based on Social Cognitive Theory (Bandura, 1997) found limited evidence for the efficacy of three interventions, including motivational strategies (like social and professional support), and varied rigidity of goals (McCaul et al., 1992). Motivational interventions seeking preventive self-care behavior must therefore be augmented by interventions that enable behavioral intentions to be successfully translated (Abraham et al., 1998; Sniehotta et al., unpublished observations). Forming a concrete action plan (implementation intention) detailing where, when, and how to act, is a simple technique proposed to facilitate intention-realization. Individuals are more likely to recognize situations and perform intended actions when they have formed a cognitive link between situational cues and concrete behavioral responses. These cognitive effects have been shown to possess automatic features that proceed without conscious intent (Gollwitzer, 1999). Compelling evidence suggests that forming if-then plans facilitates the performance of intended self-care behaviors (see Gollwitzer and Sheeran, 2006, for a meta-analysis). In dentistry, a longitudinal study found planning and past behavior to be a significant predictor of adherence to a daily flossing regimen (Schüz et al., 2006). This is the first intervention study to test the effect of the sole formation of simple if-then action plans on oral self-care behavior. We aimed to test whether a planning intervention would increase the use of dental floss in a sample of individuals who flossed infrequently, while having knowledge and motivation to floss (as addressed in a preceding lecture). Intervention participants were hypothesized to show a significantly greater increase in dental flossing than control individuals.
A 2(intervention) * 3(time) RCT was conducted with baseline measures and two-week and two-month follow-ups. This study received ethical approval at the University of Aberdeen.
Participants
Interventions Participants in the intervention group received the following instructions at the end of the online questionnaire: "You are more likely to adhere to a daily oral flossing regimen if you plan in advance where and when you want to do it. Please decide now where and when you will floss your teeth during the next two weeks. You may find it useful to floss just before or just after something else that you do regularly. Please write below where and when you will floss your teeth for the next two weeks (e.g., at 10.00 p.m. in the bathroom after brushing my teeth). I will use dental floss at _______________(WHEN) at or in _______________ (WHERE) before/after ______________(activity, e.g. washing my face)." The time from when the participant started the Web-based questionnaire to when he/she submitted it was measured automatically. This intervention took an average of 1.16 min, as measured by a comparison of average completion times of both groups (control. 4.21 min; intervention. 5.37 min).
Control Measures
Outcomes Primary outcome was a self-reported 7-day recall of dental flossing, validated in previous research against residual floss measures (Schüz et al., 2006) and diary methods (Lavin and Groarke, 2005). Residual floss was also used as a secondary outcome and for validation of self-reports. Outcomes were assessed 2 wks and 2 mos after the intervention.
Randomization
Blindness
Statistical Methods
Recruitment The flowchart is presented in the Fig  .
Drop-out Analyses Independent-sample t tests indicated that participants who discontinued to Time 2 did not differ from those who continued participation with regard to age [t (1.233) = 0.582; p = 0.56], gender (  2 = 2.308; p = 0.13), previous flossing behavior [t (1.237) = 0.091; p = 0.93], or baseline TPB measures (all p > 0.35). Likewise, no differences were found between participants who did/did not complete Time 3 measurements in terms of age, gender, previous flossing behavior, and TPB variables (all p > 0.15). Differential loss to follow-up did not occur. Hence, the longitudinal sample is representative of the baseline sample. The drop-outs did not systematically bias the longitudinal dataset.
Randomization Check
Baseline Data
High mean values for TPB variables (all means > 5 on scales ranging from 1–7) showed that participants held positive cognitions about flossing and were highly motivated to floss. Intercorrelations supported the TPB, since behavioral intentions were significantly correlated with attitudes, subjective norms, and PBC. Intentions and PBC showed substantial correlations to self-reported flossing at all time-points and to the floss used in the first 2 wks (Table 1
Initial flossing levels were low (1.5 times per week), supporting the rationale for sampling Scottish university students (Table 1
Intervention Effects
At Time 2, the intervention effect was highly significant. Participants in the intervention group showed a greater increase of flossing compared with the control group (adjusted means: intervention group = 5.2; control group = 4.2). The  2 statistic indicates a small-to-medium intervention effect size. Furthermore, ANCOVAs revealed that the intervention did not affect intentions to floss [F (1.192) = 0.357, p = 0.59] or PBC [F (1.192) = 0.772, p = 0.38].
At Time 3, 2 mos after the intervention, the effect was still significant (intervention group = 2.7; control group = 1.9), and the effect size was only slightly reduced. This indicates that this simple and brief action planning intervention affected flossing behavior over a period of 2 mos (Table 2 Three groups were formed when the measures of consumed floss were analyzed. Participants who returned unused floss packets or failed to return them were classified as "floss not used" (n = 135). Participants who had returned empty floss packets were classified as "floss finished" (n = 38), and all others as "floss not finished" (n = 66).
The frequencies of all three groups in the intervention and control groups are shown in Table 3
This is the first study to provide evidence that a simple, theory-based, one-minute intervention can facilitate changes in oral self-care behavior. The formation of an if-then plan—specifying when, where, and how to act—can increase the salience of the target situation and enhance the prospective memory for intended action. This encourages individuals to act in accordance with their intentions. In this study, changes in flossing behavior were found 2 wks and 2 mos following the intervention. Individuals in the inter ventions group showed a higher increase in flossing of 1.1 (Time 2) and 0.7 (Time 3) times a week compared with the control group. These results corresponded to evidence in other areas of preventive self-care behavior and showed similar effect sizes (Gollwitzer, 1999; Gollwitzer and Sheeran, 2006). It is noteworthy, however, that very few previous studies have tested planning effects over durations greater than a month. The intervention did not affect motivational TPB factors, but increased flossing directly. A previous study involving a similar sample failed to find planning effects on dental flossing (Lavin and Groarke, 2005). This might have been due to confounding effects of behavioral measurement, since participants were required to record flossing in a diary over a three-week period. Keeping a diary has been found to be a strong self-monitoring intervention that enhances oral self-care when the diary is kept (Sniehotta et al., 2005b). Even with participants keeping a daily diary, however, the formation of action plans will not foster additional effects regarding flossing frequency. Conversely, planning processes have been shown to include automatic effects that help individuals to recognize critical situations even when they do not self-monitor, to remember and initiate intended actions (Gollwitzer, 1999). This study shows that, unlike diary techniques, planning has effects that endure after the initial intervention. The results of this study need replication with other samples, to gauge the generalizability of the findings and obviate potential sources of bias caused by drop-outs and the use of a student sample. Young adults are a focal group for interventions, because it is at this stage of life that self-regulated self-care behaviors are developed. In Scotland, about half of all young adults pursue a university career, and, given oral self-care’s poor baseline data, this makes the utilized sample of particular importance. Future research should investigate the efficacy of action planning in dental consultations and as part of dental hygienist treatment, and focus on factors that facilitate long-term maintenance and habit-building (Sniehotta et al., unpublished observations). In summary, this study provides evidence for the effect of simple action plans on oral self-care behavior, and corresponds to findings in other areas of preventive medicine.
This research was funded by the University of Aberdeen. The authors thank Oral-B Gillette for providing the floss packets, and Caroline Rowlings for her assistance during data assessment. Received for publication January 18, 2006. Revision received February 21, 2007. Accepted for publication March 14, 2007.
Journal of Dental Research, Vol. 86, No. 7,
641-645 (2007) This article has been cited by other articles:
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