Guidance

Chapter 3: Behaviour change

Updated 9 November 2021

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement, and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK-wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

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Introduction

Given the right circumstances, most oral diseases can be prevented or managed by ‘healthy behaviours’ such as enjoying a healthy balanced diet and cleaning teeth and gums effectively. Each day, members of the dental team provide guidance to patients of all ages about health-related behaviours as part of contemporary person-centred care^{[footnote 1]}. Helping patients to improve their oral health involves providing tailored advice, teaching new skills, answering questions and regularly reinforcing key messages^{[footnote 2]}, whilst understanding that the ability to change is influenced by a range of individual, environmental and socioeconomic factors as outlined in Chapter 1.

The field of behavioural science has changed significantly in recent years. There have been considerable advances in understanding why individuals behave in certain ways as well as how behaviour change interventions can support, and sustain, change^{[footnote 3][footnote 4][footnote 5]}. It is a journey, rarely an event.

In this chapter, the latest guidance on approaches to supporting individuals to change their health behaviours is summarised^{[footnote 1][footnote 2][footnote 3][footnote 4][footnote 5][footnote 6][footnote 7]} and applied to dental professionals and oral health behaviours. It suggests how recent advances in behavioural science can be used by all dental team members, to enhance existing knowledge and skills. This includes an overview of important considerations when supporting individual patients through the process or cycle of change. Practical case studies are available to illustrate how the guidance may be used in practice.

Behaviours that support oral health

Research highlights the oral health behaviours that dental professionals may need to support their patients to change through brief interventions ^{[footnote 1]}:

• improving oral hygiene (Chapter 8)
• optimising exposure to fluoride (Chapter 9)
• reducing sugar intake and healthier eating (Chapter 10)
• stopping smoking and tobacco use through very brief advice (Chapter 11)
• reducing harmful alcohol consumption through identification and brief advice (Chapter 12)

Many dental professionals will admit to having felt confused or frustrated when patients did not make behaviour changes that were recommended. However, we know that whilst the provision of health information alone may increase knowledge, this will not achieve sustained changes in behaviour for most people.

Even when providing more in-depth support, many health professionals will have experienced how lengthy, and difficult, the process of supporting patients to change their behaviour can be. They will also have seen first-hand how many attempts are required before a new behaviour is maintained, overcoming barriers and resistance.

To understand the complexity of behaviour change, we need to consider the broader influences on patient’s lives. A patient’s ability to change their behaviour is influenced by an array of individual, social and environmental factors, with socio-economic circumstances being a major influence (Chapter 1). This explains why multiple unhealthy behaviours, such as smoking, alcohol misuse, and lack of tooth brushing, may cluster together in particular groups of people.

While some individuals with well-developed social networks and supportive living environments are more likely to succeed, others may find changing a specific behaviour or group of behaviours particularly challenging. We also know that at certain times in people’s lives, they may find changes in behaviour easier (or harder) to sustain. Furthermore, fear and cost are common barriers to dental care and may make it more difficult to support patients in behaviour change. This means that some patients face multiple barriers when attempting to change their behaviours. Indeed, these different barriers to behaviour change may lead to a widening of health inequalities between groups in society.

Bearing in mind the huge potential for oral and general health gain, some of the general principles to best achieve oral health-related behaviour change over time are provided below.

What is important for behaviour change to occur?

Within the field of behavioural science there are many different theories, models and frameworks that can help health professionals support their patients to change their behaviour^{[footnote 1][footnote 2][footnote 3][footnote 4][footnote 5][footnote 6][footnote 7]}. One of the most helpful recent models is COM-B^{[footnote 3][footnote 8]}. This model proposes that for behaviour change to occur, a person must have Capability, Opportunity and Motivation to change Behaviour as outlined below:

Capability

The person must have the physical or psychological ability to change to the desired behaviour. This includes a person’s knowledge of what the desired behaviour is and why it is important, the skills required to make the change and the self-control needed to start and maintain that desired behaviour over the long-term.

Consider, for example, what you could do to help a patient trying to reduce the sugar in their diet. How can you help them to:

• understand why it is important for their health and oral health to reduce their sugar intake?
• choose a healthier alternative they like instead?
• keep on choosing healthier alternatives when their initial enthusiasm wears off?

Opportunity

This refers to the environment in which the person lives, which may include the social environment required to support the behaviour, for example, their income; the physical environment; or the facilities available. In the section above, we have already described how socio-economic circumstances can be a major barrier to behaviour change.

Consider, for example, helping a patient to give up smoking and how you can take account of the following:

• if they are struggling to cope with stressful events in their lives such as unemployment, disability, or homelessness
• if they live or work with others who smoke around them
• how they can access nicotine replacement therapy or local stop smoking support

Motivation

This relates to the person’s motivation to adopt new behaviour, which would require the desire, and intention, to change and to stop or adapt their existing habits.

Consider, for example, what you could do to help a patient routinely brush their teeth with a fluoride toothpaste twice every day. How can you help them to:

• find a time in their daily schedule when tooth brushing would work for them
• think through how to maintain the habit and what to do if they revert to their previous infrequent brushing

Some patients will need support and help across all three areas of the COM-B model, while others might experience specific issues around capability, opportunity and/or motivation. The COM-B model is not a solution to all behaviour change challenges, but it can offer dental professionals a comprehensive framework, when working with patients to better understand what is going on. It is also very helpful in considering when, and how, to facilitate change. This COM-B model has been used to develop a range of techniques that can be employed to change health behaviour. These are described more fully in the next section.

What can dental professionals do?

Dental professionals working with patients can help them to build their motivation to change and support them to act when they are ready. This involves building rapport and empathy, providing support in an appropriate format, and considering the right timing (Figure 3.1).

Changing behaviour should be considered as a cycle. It may start with patients being unaware of the issue, through a time when they are thinking about making a change, to when they are actively preparing to change by planning and setting goals, to when they are ready to act, and then trying to maintain the change avoiding relapse. As the stages of change need not be linear, dental team members should start wherever the patient currently is on the cycle ^{[footnote 9]}. This process should not be considered as having discrete steps and may include the following aspects.

Raising the issue and building motivation

Dental professionals can start conversations with patients by providing information about the specific behaviour which needs to be addressed, and its link to oral and general health (Figure 3.1). They should help their patients understand the short, medium, and longer-term consequences of their oral health-related behaviours. This can also mean discussing what will happen if the person does (or does not) perform the behaviours. To build motivation further, the dental team members can help patients feel positive about the benefits of changing one or more of these behaviours.

Assessing readiness to change

It is important to assess a patient’s readiness to take action to change (Figure 3.1). This can be facilitated by discussing the advantages and disadvantages of making (or not making) a change, and listening for verbal clues about their desire, ability, and reasons for change.

Whilst there may be several oral health behaviours you may wish to tackle with a patient, for general or oral health reasons, it is helpful to recognise that this cannot be achieved all at once. In this situation, it is important to discuss with the patient which behaviour they feel most ready to change, and work with this, even if it is not what you as a health professional would prioritise.

Patients may express resistance to change if they feel the change is too difficult or not right for them at that time. In this case, trying to persuade the patient to change is unlikely to help. Instead, dental professionals should show empathy, discuss the patient’s views, provide support, and keep the opportunity for further discussions open for the future.

Supporting patients to take the next step

If a patient is ready to act, one or more of the behaviour change techniques described below can be used:

• working with the patient to show them how to perform the behaviour and provide tailored instruction
• work out a plan together in terms of simple tasks over time, using SMART goals:
  • Specific – clear and precise goals provide focus and clarity of purpose
  • Measurable – goals that can be easily measured and quantified
  • Achievable – goals that are challenging, but within the patient’s reach – this will increase their self-confidence in making these changes (setting unachievable goals merely demotivates people)
  • Relevant – to the patient’s circumstances, motivations and needs
  • Timely – check that it is the right time to work on the goal. Setting a clear time frame is also important to help maintain motivation and to monitor progress
• help identify barriers to making changes and how they might be overcome
• plan together how they might cope if there is a relapse in their behaviour
• provide encouragement and praise the patient’s efforts at subsequent appointments
• help identify motivating rewards for any progress achieved to help maintain motivation
• signpost or refer patients to other local services or digital resources

Adapted from NICE Behaviour change overview^{[footnote 7]}.

Dental team members already use many of these techniques every day, while some may be less familiar. Examples of these techniques are described in the accompanying patient case studies.

Delivering successful behaviour change

When using behaviour change techniques and delivering behaviour change interventions, consider the source of the intervention (who delivers it), the mode of delivery (how it is delivered) and the schedule (timing – when it is delivered)^{[footnote 5]}.

Source

The source of an intervention is the person who will deliver the intervention with a patient. In dental practices, this may be one dental professional, or several working together and providing a consistent message. To help patients achieve successful behaviour change, dental team members need to build rapport and empathy with their patients to ensure a good relationship^{[footnote 4]}. This rapport is important so that conversations with patients about their oral health behaviours can be supportive and conducive to change.

Effective communication during brief interventions uses a range of skills, which can be remembered using the acronym ‘OARS’^{[footnote 10]}, as shown in Figure 3.1:

• Open questions to explore patients’ feelings and values
• Affirmations that you as the dental professional can see the patient’s point of view, understand the difficulties involved and recognise the patient’s successes
• Reflective listening and clarifications
• Summarising the patient’s thoughts and feelings about making changes to their oral health behaviours

Adapted from NHS Scotland^{[footnote 10]}.

Mode

The mode of delivery, how the behaviour change intervention is to be delivered, should also be considered. Different modes of delivery are appropriate for different patient groups, disease severities and behaviours. Dental team members may need to use more than one mode of delivery or adapt to the needs and preferences of the individual patient.

The most common mode is a face-to-face conversation, but this may be supplemented with printed resources (for example, leaflets, scratch cards or digital resources, such as links to websites, sending of text messages and recommendation of specific apps)^{[footnote 6]}. The NHS app library includes apps which have been assessed to meet a required standard. New forms of delivery are emerging in the digital arena with the use of remote consultations and emails. Patient acceptability of online communication is growing and may also be helpful for oral health.

Schedule

Scheduling behaviour change interventions includes consideration of their frequency, duration, and timing. In terms of frequency, all healthcare providers, including dental team members, have a role in making every contact count to improve the health, (including the oral health) of patients. The ‘Making Every Contact Count’ approach^{[footnote 11]} requires health professionals to make use of every encounter with patients. For dental professionals, recall appointments offer the ideal opportunity to highlight behaviours to change with patients or reinforce earlier interventions. Equally, for patients who do not attend regularly, visits for urgent care can also be utilised as they provide an opportunity to establish a positive relationship^{[footnote 6]} with the option of follow-up care.

The duration of interventions may vary from very brief advice (VBA) or brief advice (BA) through to more in-depth interventions, such as motivational interviewing, which requires additional training.

The timing of behaviour change discussions is important because, as previously mentioned, assessing the patient’s readiness to change will influence the type of support the professional provides. Readiness to change may be more likely at certain key points in the life course, such as pregnancy or new parenthood, leaving school, starting a new relationship, or entering retirement. It is also important to recognise that behaviour change takes time and patients may not complete the whole cycle at their first attempt. There is some evidence to suggest it takes anywhere from 2 to 9 months to develop a new habit depending on the patient and the nature of the habit.

Dental professionals can also provide an environment that is supportive of health behaviour change, for example:

• using the physical space to provide family and breastfeeding-friendly facilities and using displays to support campaigns such as Smile Month, Mouth Cancer Action month, Stoptober and Dry January
• using digital technology, such as the dental practice website, apps, video conferencing, links to self-help websites or social media to provide information, reinforce key messages and provide reminders. Patients can be recommended to use these resources in preparation for or following their appointments. However, it is important to be aware of the need to provide paper resources for patients who are not able or do not want to rely on digital technology

Examples of behaviour change interventions

In addition to the general principles and techniques described above, specific behaviour change interventions have been developed for some oral health-related behaviours:

• oral hygiene for plaque removal (Chapter 8) – OH-TIPPS – a behaviour change strategy for patients to feel more confident in their ability to perform effective plaque removal and help them plan how and when they will look after their teeth and gums
• regular use of fluoride (Chapter 9) – resources to support behaviour change conversations with parents of young children to promote parental supervision of tooth brushing with a fluoride toothpaste as part of oral hygiene (Chapter 8)
• reducing sugar as part of a healthier diet (Chapter 10) – use of diet diaries and other resources, for example Food Scanner App)
• tobacco – Very Brief Advice pathway for smoking (Chapter 11)
• alcohol – Identification and Brief Advice (IBA) (Chapter 12)

These specific techniques and approaches can, and should, be used alongside the wider and more general techniques described above. Patient case studies highlighting common pitfalls and suggested ways to overcome them are provided within the case studies.

Training

While some of the techniques are familiar to dental professionals, additional training may be required to support behaviour change in general or specific oral health behaviour change interventions. A list of helpful publications^{[footnote 1][footnote 2][footnote 3][footnote 4][footnote 5][footnote 6][footnote 7][footnote 8][footnote 9][footnote 10][footnote 11]} and e-learning training programmes has been provided at the end of this chapter and dental team members should be supported to undertake the training for the roles delegated to them and to keep up to date as new programmes become available.

The dental team has an important role in helping to promote healthy behaviours with all patients. Changing behaviour is not an easy task, patient’s desires and circumstances need to be central to the endeavour and different approaches may be needed for different behaviours. It is important that dental team members understand the principles of behaviour change and the various influences on change to enable the provision of the best possible support to patients. The field of behavioural science is rapidly expanding, with many different sources of guidance published. By considering this guidance, and how it can be applied, dental teams can better help patients achieve their oral health goals.

Resources

E-learning for healthcare: behaviour change conversations with parents of young children with accompanying videos.

Leeds School of Dentistry: Rolling with resistance videos including techniques on re-framing and reflection.

OARS: open questions, affirming, reflecting and summarising skills to enable you to build up a partnership with the client and to guide the conversation.

E-learning for healthcare: alcohol identification and brief advice in dental settings.

E-learning for healthcare: alcohol and tobacco brief interventions.

The National Centre for Smoking Cessation and Training (NCSCT) Very Brief Advice on Smoking for Dental Patients.

Oral Hygiene TIPPS video. Oral Hygiene TIPPS is a behaviour change strategy which aims to make patients feel more confident in their ability to perform effective plaque removal and help them plan how and when they will look after their teeth and gums.

Starting conversations with patients and supporting health-related behaviour change.

Behaviour change development framework – Health Education England.

References

1. NICE. Oral health promotion: general dental practice NG30. London: NICE; 15 December 2015. ↩ ↩² ↩³ ↩⁴ ↩⁵

2. NICE. Behaviour change: individual approaches PH49. London: NICE; 2 January 2014. ↩ ↩² ↩³ ↩⁴

3. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 2011;6:42. ↩ ↩² ↩³ ↩⁴ ↩⁵

4. Prochaska JO, DiClemente CC, editors. The transtheoretical approach. 2nd edition. New York: Oxford University Press; 2005. ↩ ↩² ↩³ ↩⁴ ↩⁵

5. Public Health England. Achieving behaviour change. A guide for local government and partners. London: Public Health England; 2019. Report Number: GW-834. ↩ ↩² ↩³ ↩⁴ ↩⁵

6. NICE. Behaviour change: digital and mobile health interventions NG183. London: National Institute for Health and Care Excellence; 2020. ↩ ↩² ↩³ ↩⁴ ↩⁵

7. NICE. Behaviour Change Overview. London: NICE; 2019. ↩ ↩² ↩³ ↩⁴

8. Michie S, van Stralen MM, West R. The behaviour change wheel: a guide to designing interventions. 1st edition. London: Silverback Publishing 2014. ↩ ↩²

9. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390-5. ↩ ↩²

10. NHS Greater Glasgow and Clyde. Skills-OARS Glasgow. NHS Scotland; 27 June 2020. ↩ ↩² ↩³

11. NICE. Making every contact count. London: National Institute for Health and Clinical Excellence; 24 April 2021. ↩ ↩²