Behaviour change medium

Behaviour Change

• Foundation in Clinical Skills and Practice, Year 1 course
• Presented by Jacky Hart and Preena Shah
• Delivered at Eastman Dental Hospital, LSBU Education Centre

GDC Learning Outcomes

• 1.1.1, 1.1.11, 1.7.1, 1.10.1, 1.10.2, 1.10.3, 1.11.1
• 2.3, 3.1, 3.2, 4.1, 6.1, 6.2, 6.3, 11.1

Intended Learning Outcomes

• Describe behaviour change and its relevance to oral and general health
• Familiarise with evidence-based guidelines for oral health behaviours
• Identify factors influencing behaviour using the COM-B model
• Discuss how patient-centred conversations support oral health behaviours in dental hygiene and therapy practice

Assessment

• Formative: Active engagement throughout sessions and peer feedback
• Summative: E-assessment and OSCE
• Future: Effective behaviour change improves patient health outcomes

Links to Prior Learning

• History Taking: Dental, social, and diet
• Delivering Better Oral Health Toolkit: Evidence-based guidance for behaviours
• Communication: Verbal, non-verbal, and clinical conversations

Outline for the Session

• Theory: Definitions, context, evidence for oral health-related behaviours and their evidence; Influences on behaviour (COM-B model); Behaviour change in action, linking to communication
• Practical: Case studies discussions in teams

Definitions

• Behaviour: What we do in response to internal or external factors
• Health Behaviour: What we do that impacts our health, positively or negatively
• Behaviour Change: Doing something that changes the way a person does something

Why is this Important?

• Behaviours impact health and well-being, increasing risk of or protecting from long-term conditions, including oral diseases
• Oral health professionals are crucial in supporting patients to adopt positive behaviours through patient-centred conversations

Evidence-Based Guidance

• NICE Oral Health promotion in general dental practice (NG30) and Behaviour change: Individual approaches (PH49)
• How to adopt a patient-centred approach?
• Interventions for the individual targeting general health
• Scottish Dental Clinical Effectiveness Programme (SDCEP)

Oral health-related behaviours quiz

• Mentimeter recap and test knowledge
• Relating behaviours to oral health and the guidance for them

Oral Health in the UK

• 75% of adults are clean twice a day
• 66% of adults exhibit visible plaque
• 1 in 10 adults have excellent oral health (ADHS 2009)
• Data in the form of a graph showing percentages of excellent oral health by age group (ADHS 2009)

Toothbrushing Advice

• Clean all tooth surfaces and the gumline
• Use powered or manual toothbrushes
• Adapt technique to patient needs
• Benefits: reduces risk of dental caries and periodontal disease

Dietary Guidance

• Reduce frequency and quantity of sugar
• Eat a balanced diet with lots of vegetables and fruit
• Daily free sugar recommendations from the NHS (30g/day for 11+ years, 24g/day for 6-10 years, and 19g/day for 4-6 years) or no more than 5% of total calorie intake

Dietary Intake of Free Sugars

• Graph showing percentages of total calorie intake of free sugars for different age groups and genders (NDNS 2016/17)
• Recommended level of free sugars is 5% or less of total calorie intake

Fluoride Exposure

• Fluoride toothpaste (1450ppm; less for under 6 years old)
• Spit don't rinse
• 76% use fluoride toothpaste

Smoking Advice

• Recommendation is not to smoke
• Encourage smoking cessation
• 14% population smokes in UK (aged 18+ years)
• Additional sessions on Smoking Cessation to come

Alcohol Advice

• Not to exceed 14 units per week

Attendance

• Recommendations based on risk: 3-24 months as per NICE guidance for Dental Checks and intervals between oral health reviews (CG19)
• Figure 6.1.1 showing Dental attendance by age (ADHS 2009)

Building Foundations for Optimal Treatment Outcomes (BSP)

• Treatment plan, explaining disease, risk factors and treatment alternatives, risks and benefits
• Importance of Oral Hygiene improvement; Risk factor reduction
• Individual advice, including interdental cleaning, toothpaste, and mouthwash, +/adjunctive efficacious toothpaste
• Professional Mechanical Plaque Removal (PMPR), including supra and subgingival scaling
• Consider recall periods, smoking cessation, and diabetes control

Impact of Oral Health-Related Behaviours

• Venn diagram with overlapping circles for oral health, systemic health, and behaviours

Motivation

• What motivates individuals to do tasks ?
• Intrinsic and extrinsic motivation

Habits

• Behaviours take 66 days to form into habits

COM-B Model

• For effective behaviour change, interventions should be underpinned by evidence-based theories, relevant to the behaviours to be changed
• The COM-B model is well-recognised in health as key

COM-B Model - Example Application

• Example of eating chocolate illustrating the capability, motivation, and opportunity

COM-B Model applied to Oral Health

• Applying the COM-B model to Oral Health - Capability (Physical skills/dexterity, Psychological capacity to do), Motivation (Habitual, Believes it's beneficial), Opportunity (Social norms/culturally accepted, Able to afford/source tb)

Psychology of Clinical Practice - Case Scenario 1 - Bella

• Case scenario involving a patient (Bella) with a history of dental visits; oral hygiene; bleeding gums; and stopping flossing, and the use of the COM-B model to guide her behaviour modification
• Applying the COM-B model

COM-B Model applied to Case Scenario 1 - Bella

• Applying the COM-B model; Capability (Able to floss but is technique damaging?), Motivation (Emotional reaction to bleeding, Beliefs about consequences), and Opportunity (Not a social norm, Able to afford/source floss)

COM – B + Bella case study

• Exploring Bella's motivation around flossing and the questions you might ask
• Modification and different approaches to address the behaviour

Consider

• The benefits and consequences of behaviour should reflect the values of the patient

Behaviour change in-action

• What can dental professionals do for behaviour change?

Cycle to address behaviour change

• Raise the issue; build motivation; Support patient on next steps; Assess readiness

Raise the issue and build motivation

• Elicit information from patients
• Provide specific information related to patient needs, oral and general health, relating it to patient values

Assess readiness to change

• Discuss the advantages and disadvantages of making changes
• Listen to cues about their desires, ability, and reasons
• If there are multiple behaviours, select one to address
• Address patient resistance
• Review readiness at each visit

Support patients to take the next step

• Demonstrating techniques, Planning, SMART goals, Identifying barriers, Coping mechanisms for relapse, Encouragement, Rewards, and Signposting or referring

Behaviour change techniques (BCTs)

• Numerous BCTs available
• Thinking about how these behaviours are carried out
• Research focusing on communication skills between patient and professional

Essentially

• Patient-professional relationship, Communication skills, Psychology, History taking skills, and Behaviour Management

Communication Skills

• Patient-centered approach, Trust, Respect, Active listening, No judgment, Empathetic, Non-verbal cues, Open questions, Rapport, and Relevant

OARS Framework

• Open questions, Affirmations, Reflections, and Summaries

Question Style

• Open vs Closed questions

Affirmations

• Positive reinforcement for desired behaviour change

Reflective Listening

• Summarising patient's concerns and feelings
• Paraphrasing to show understanding

Summaries

• Summarising patient's information to check if correct
• Identifying anything missed

SCDEP OH TIPPS video

• SCDEP Oral Hygiene TIPPS video

SCDEP OH Video BINGO + examples

• Bingo cards relating to the various techniques in behaviour change

COM-B Model & SCDEP OH video

• Applying the COM-B model to behaviour change techniques and SCDEP OH video concepts

Determining the need and desire for change

• Gathering patient history, oral health education, and continuous review

Summary so far

• Behaviour change and the evidence; Oral health-related behaviours; Positive and negative influences on health; COM-B model; Behaviour change in-action; Raise the issue; Assess patient readiness; Support patients; OARS model; Case scenarios

References

• References included for evidence and different resources used

Learning resources and evidence base

• NICE Guidelines, Oral Health promotion in General Dental Practice(NG30); NICE Guideline: Behaviour change: Individual approaches (PH49); Delivering better oral health: an evidence-based toolkit for prevention; and, Scottish Dental Clinical Effectiveness Programme (SDCEP)
• Relevant web addresses or URLs

Further Learning

• Health Education England e-learning modules on behaviour change
• Article on behaviour change in oral health

Time for application

• Case scenarios

Case scenario 1 - Bella

• Case scenario to demonstrate understanding of the COM-B model for patients, specifically for flossing
• Patient beliefs, clinician advice, relationship description, assumptions, patient behaviour modifications, and suggestions

Case Scenario 2&3: Smoking Cessation Advice

• Case scenarios for addressing smoking cessation with patients

Case Scenario 4: Bob's Story

• Narrative about a patient with advanced stages of oral cancer receiving smoking and alcohol use

Case Scenario 4 - Bob's Story Questions

• Questions about the ethics of treatment and balancing patient wishes with evidence-based treatment

Discussion in groups

• Discussion points in group settings; Information to increase knowledge about interdental brushing; Demonstrations of toothbrushing; Tackling smoking cessation; and, Addressing fluoride use