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Abstract

Regular dental attendance is a key oral health behaviour. Behaviour change interventions are increasingly being used to promote positive oral health behaviours. A systematic approach to understanding behaviour has led to the development of frameworks which aim to guide the process of designing behaviour change interventions. One such framework is the Behaviour Change Wheel (BCW). This article aims to explore and identify barriers to regular dental attendance which may be targeted using behaviour change interventions based on the Capability, Opportunity and Motivation Behaviour model (COM-B) and the BCW, and suggests potential behaviour change techniques which could be utilised into a behaviour change intervention with the aim to promote regular dental attendance.

Keywords

Dental care health behaviour attitudes models psychological

Learning Objectives

To understand biopsychosocial factors behind urgent only dental attendance

To appreciate the theoretical basis of the Behaviour Change Wheel and COM-B Behaviour model

Introduction

Regular dental attendance is a key oral health behaviour.^1,2 A regular attender is defined as someone who attends for routine dental check-ups, regardless of their dental needs.^3,4 The National Institute for Health and Care Excellence (NICE) recommends all adults should have dental recalls between three months and two years, based on their oral health risk.^5,6 Urgent only or non-regular attenders are those who attend for dental care when they have a specific dental problem.³ In the UK, 39% of adults are not regular dental attenders, which means a significant proportion of the population do not receive preventative advice, regular oral cancer screenings or timely intervention of dental disease.^6,7,8 Non-regular dental attendance is associated with poorer oral health compared with those who do regularly attend.^3,4,7,9 Dental attendance patterns have been shown to vary by factors such as age, gender and socioeconomic status^6,10,11,12 but the most common reasons provided for not attending the dentist regularly are concerns over the cost of treatment, anxiety and a lack of perceived need.^9,13

Behaviour change interventions have been used to promote positive oral health behaviour changes^14,15 and have been shown to be more effective when the underlying theory is understood and applied.^16,17,18 Behaviour models aim to provide an understanding of behaviour, and with the provision of oral health care shifting towards a biopsychosocial model, the relationships between individual and environmental factors behind an urgent only attendance pattern need to be understood to assist dentists and dental care professionals in the development and implementation of targeted behaviour change interventions to promote regular dental attendance.¹⁵

Behaviour change interventions

Historically, oral health promotion has relied on education alone in the form of giving information to patients on oral diseases, but this has not been shown to change behaviour.¹⁹ Oral health promotion has shifted towards the application of behaviour change interventions to promote positive health behaviour changes.^14,20,21,22 Traditional behaviour models such as the Health Belief Model or the Transtheoretical/Stages of Change model have been shown to be unreliable in guiding behaviour change.¹⁷ There are many different theories of behaviour change but little guidance on how to choose an appropriate theory for a particular behaviour. This has been cited as a reason why theory is underused in intervention design and implementation of behaviour change techniques.²³ A systematic approach to understand the individual components or barriers to change a behaviour has led to the development of frameworks, which combine multiple and often overlapping theories on behaviour change and aim to guide and simplify the process of developing evidence-based behaviour change interventions. One such framework is the Behaviour Change Wheel (BCW) (Figure 1), which is based on the COM-B model of behaviour (Figure 2).^17,23,24

Figure 1

Behaviour Change Wheel

Figure 2

COM-B Model of Behaviour

Behaviour Change Wheel (BCW) and the COM-B model

The BCW is a tool used to design behaviour change interventions based around the COM-B model, which explains that behaviour consists of three interrelated factors – capability, opportunity and motivation (Figure 2). Before the desired behaviour can take place the person must feel they are psychologically and physically capable, they must have the social and physical opportunity to carry out the behaviour, and they must have a desire or motivation to carry out the behaviour (Table 1). Any attempt to change behaviour should aim to address one or more of these components.²⁴ The second layer of the BCW links the three COM-B factors to ‘intervention function’ groups with suggested evidence-based behaviour change techniques to consider. Seven ‘policy categories’ make up the outer layer of the BCW, and are used to identify the method of delivering the behaviour change intervention on a wider population level.²⁴

Table 1

Conditions of the COM-B Model (Adapted from Michie et al.²⁴)

		What needs to happen for the target behaviour to occur?
CAPABILITY	Physical capability	Have the physical skills and strength/ability to perform behaviour
CAPABILITY	Psychological capability	Knowledge of the behaviour and skill to carry it out and knowing when and how often to carry out desired behaviour
OPPORTUNITY	Physical opportunity	Have access and time to carry out desired behaviour
OPPORTUNITY	Social opportunity	Support from peers, family, healthcare professional(s)
MOTIVATION	Reflective motivation	Hold beliefs that behaviour will lead to improved health and self-regulation of behaviour, planning and decision making
MOTIVATION	Automatic motivation	Have established routines and habits, management of anxiety

Behaviour change interventions in dentistry

Within dental research, there has been an uptake in the application of behaviour change models and frameworks (such as the COM-B model and the Theoretical Domains Framework²⁵) to help in understanding the antibiotic prescribing behaviour of dental clinicians,²⁶ the promotion of oral health advice among professional athletes²⁷ and in the design of interventions to promote positive oral health behaviour in patients with periodontal disease.^19,20,21,28 However, there has been little research, to date, on the use of behaviour change interventions to promote dental attendance. Behaviour change techniques such as ‘action planning’ and ‘coping planning’ have been shown to increase dental attendance in patients with low dental anxiety levels.²⁹ The provision of written material to reinforce verbal advice has also been shown to improve attendance.³⁰ There is a need to consider, develop and clinically evaluate behaviour change interventions which target regular dental attendance on an individual patient level, which clinicians can implement in practice and on a population level. The reporting of behaviour interventions has improved with the introduction of evidence-based frameworks and the Template for Intervention Description and Replication (TIDieR) guide checklist³¹ but clinicians looking to employ behaviour change interventions into their practice should understand the theoretical concepts in the design of behaviour interventions, in order to critically appraise which behavioural interventions are effective in different contexts.

Developing behaviour change interventions

The following information is to inform dentists and dental care professionals on the process behind developing behaviour change interventions based on the COM-B model and the BCW.

Understanding the behaviour

When developing a behaviour change intervention, the first aim is to understand the behaviour and identify any barriers to the target behaviour. A clinician encountering an urgent only attender should assess the patient’s capability, opportunity and motivation to become a regular attender.²⁴ Attending for regular dental care is a complex behaviour with many underlying factors, such as not knowing how often to attend (a psychological capability factor), or a reported lack of time (a physical capability factor). Some of the factors behind urgent only dental attendance behaviour, linked to the COM-B model, are listed in Table 2. Not all the factors behind urgent only attendance may be modified or addressed through these processes, so clinicians should aim to address one or two barriers and target the barriers which are most likely to lead to a change in behaviour.²⁴

Table 2

Potential Barriers to Regular Dental Attendance Linked to COM-B Model

CAPABILITY	Physical capability	• Physical ability to get to the dentist (walking distance, public transport) • Physical barriers at the practice, e.g. stairs, no ramp
	Psychological capability	• Not aware of the benefits of regularly attending the dentist• Do not know how regularly they should attend the dentist• Lack of ability to budget for dental care costs• Do not know how to find a practice in the area accepting NHS patients
OPPORTUNITY	Physical opportunity	• Financial limitations• No access to an NHS dentist• Lack of time to attend the dentist• Forgets to book or attend appointments
	Social opportunity	• No positive role models who attend regularly• Social norms among peers/family/colleagues
MOTIVATION	Reflective motivation	• Lack of awareness of implications of not attending for regular dental care• Beliefs that they do not need regular dental care• Beliefs around financial cost of regular dental care
	Automatic motivation	• Anxiety of dental procedures

Identifying appropriate behaviour change techniques

Once there is an understanding of the barriers to the target behaviour, the BCW can be used to identify which intervention function group linked behaviour change techniques are most appropriate to remove the barrier or facilitate the behaviour (see Table 3). Each intervention function is linked to effective evidence-based behaviour change techniques – the “active” component of a behaviour change intervention which aims to modify a process that leads to a certain behaviour.^23,24,32

Table 3

Intervention Junctions Associated with COM-B Factors (Adapted from Michie et al.²⁴)

		COM-B component
		Physical capability	Psychological capability	Physical opportunity	Social opportunity	Reflective motivation	Automatic motivation
Intervention function	Education		✓			✓
	Persuasion					✓	✓
	Incentivisation					✓	✓
	Coercion					✓	✓
	Training	✓	✓	✓			✓
	Restriction			✓	✓		✓
	Environmental restructuring			✓	✓
	Modelling				✓		✓
	Enablement	✓	✓	✓	✓		✓

A behaviour change taxonomy (BCT) app is available (BCT Taxonomy, compatible with iOS/Android) which identifies and groups 93 behaviour change techniques into intervention function categories, and was developed by the BCT Taxonomy Project.³³ Commonly utilised behaviour change techniques by intervention function type are shown in Table 4. Some behaviour change techniques can be considered for more than one intervention function type. Theory-based behaviour change techniques that could be used in a behaviour change intervention to promote regular dental attendance are shown in Table 5.

Table 4

Intervention Functions and Examples of BCT (Adapted from Michie et al.²⁴)

Intervention function	Description	Example BCTs
Education	Increasing knowledge or understanding	Providing information on the benefits of the target behaviourProviding information on the risks of not carrying out the target behaviourGiving feedback on outcomes of the behaviourSelf-monitoring
Persuasion	Using communication to induce positive or negative feelings or stimulate action	Using imageryCiting credible sourcesProviding information on the benefits of the target behaviourProviding information on the risks of not carrying out the target behaviourFeedback on behaviour
Incentivisation	Creating expectation of reward	Using prize drawsFeedback on behaviourMonitoring of behaviour by othersSelf-monitoring
Coercion	Creating expectation of punishment or cost	Financial repercussionsFeedback on behaviourMonitoring of behaviour by othersSelf-monitoring
Training	Imparting skills	Training in new skillsInstruction/demonstration of behaviourFeedback on behaviourSelf-monitoring
Restriction	Using rules to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours)	No BCTs are identified for ‘Restriction’ as most BCTs are focused on the way people feel, think and react rather than the external environment
Environmental restructuring	Changing the physical or social context	Prompts or reminder systemsAdding objects to the environmentRemoving physical barriers to facilitate access, such as providing ramps
Modelling	Providing an example for people to aspire to or imitate	Demonstration of the behaviourUsing family/friends/peers as an example
Enablement	Increasing means/reducing barriers	Behaviour management support, e.g. assistance with a budget, payment plansRemoving physical barriers to facilitate access, such as providing rampsGoal settingAction planningSelf-monitoringSocial support from family/friends/peers

Table 5

COM-B Linked to Intervention Functions and Behaviour Change Techniques to Promote Regular Dental Attendance

COM-B Component		Intervention function(s)	Potential behaviour change technique(s)
Physical capability	• Physical ability to get to the dentist (walking distance, public transport)• Physical barriers at the practice, e.g. stairs, no ramp	Training (T)Enablement (En)	Removing physical barriers to facilitate access, such as providing ramps (En)Social support, e.g. suggest whether friends/family could assist with attendance (En)
Psychological capability	• Not aware of the benefits of regularly attending the dentist• Do not know how regularly they should attend the dentist• Do not know how to find a practice in the area accepting NHS patients• Lack the ability to budget for dental care costs	Education (Ed)Training (T)Enablement (En)	Providing information on benefits of regular attendance and risks of not attending regularly (Ed)Instruction on how often to attend based on risk level (T, Ed)Provide information on how to find out where NHS practices are in the area (Ed, En)Provide information on costs of regular care (Ed)Behaviour management support, e.g. assistance with a budget, giving information on payment plans (T, En)Feedback on oral health needs (Ed)Goal setting (En)Action planning (En)Self-monitoring (En)
Physical opportunity	• Financial limitations• No access to an NHS dentist• Lack of time to attend the dentist• Forgets to book or attend appointments	Training (T)Restriction (R)Environmental restructuring (Env)Enablement (En)	Behaviour management support, e.g. assistance with a budget, payment plans (En)Prompts or reminder systems (Env)Offering to book the patient’s next appointment before they leave (En)
Social opportunity	• No positive role models who attend regularly• Social norms among peers/family/colleagues	Restriction (R)Environmental restructuring (Env)Modelling (M)Enablement (En)	Ask about family/friends who regularly attend the dentist/social comparison (M)Cooperative discussion between dentist–patient on solutions (En)
Reflective motivation	• Lack of awareness of implications of not attending for regular dental care• Beliefs that they do not need regular dental care• Beliefs around financial cost of regular dental care	Education (Ed)Persuasion (P)Incentivisation (I)Coercion (C)	Provide information on benefits of attending regularly and risks of not attending regularly (Ed)Cite evidence-based guidelines (credible sources) (P)Provide information on costs of regular care and information on the cost/benefit analysis of the benefits of regular attendance and risk of higher emergency care costs (Ed)Using imagery such as images of good or poor oral health (P)Feedback on oral health needs (P)Focus on past success (P)
Automatic motivation	• Anxiety of dental procedures	Persuasion (P)Incentivisation (I)Coercion (C)Training (T)Restriction (R)Modelling (M)Enablement (En)	Behaviour management support, e.g. anxiety management support/techniques/CBT (En)Focus on past success (P)Self-monitoring (I, C, T, En)Cognitive reframing (as part of a CBT strategy) (En)

Identify mode of delivery

Once the target barriers and appropriate behaviour change techniques have been identified, the mode of delivery can be determined. The most suitable modes of delivery appropriate to an emergency dental appointment are verbal through face-to-face contact or in written form, such as a leaflet, to reinforce the verbal advice and provide information the patient could take away, as there is often limited time available. Interventions could be developed which utilise social media. To maintain regular dental attendance, interventions which can be implemented over time may need to be developed.

Summary of the behaviour intervention design process

Identify target behaviour: regular dental attendance

Understand the barriers to the behaviour (COM-B) and select the target behaviours most likely to bring about regular dental attendance: what does the intervention have to change in order for the patient to seek regular dental care?

Identify intervention function: education, persuasion, incentivisation, coercion, training, restriction, environmental restructuring, modelling, enablement

Identify appropriate behaviour change techniques: specific behavioural change techniques, e.g. action planning, goal setting, providing information using credible sources

Identify mode of delivery: verbal, e.g. face-to-face, written form, e.g. leaflet, campaign via social media

Conclusion

The COM-B model is used to identify ‘what’ behaviour needs to be altered, and the BCW helps us understand ‘how’ this might be possible. To achieve the aim of having a population with a healthy functioning natural dentition throughout life, dental clinicians involved in providing care to urgent only attenders should look at employing behaviour change interventions grounded in evidence-based theory to promote regular attendance. Behaviour change interventions are more successful when the underpinning theory is understood and applied, therefore it is important that dental clinicians are knowledgeable on the theory behind behaviour change and keep up to date with developments in behaviour change sciences.^17,20,21

Further research is required on the development of behaviour change interventions in oral health promotion and on their clinical effectiveness, at an individual patient level and at population level. Training opportunities and robust research providing an evidence base on the development and implementation of behaviour change interventions in clinical dental practice would allow more uptake of these strategies by dental clinicians.

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Understanding behaviour change to promote regular dental attendance

Abstract

Keywords

Learning Objectives

Introduction

Behaviour change interventions

Behaviour Change Wheel (BCW) and the COM-B model

Behaviour change interventions in dentistry

Developing behaviour change interventions

Understanding the behaviour

Identifying appropriate behaviour change techniques

Identify mode of delivery

Summary of the behaviour intervention design process

Conclusion

References