Sender, Message, and Receiver

Interpersonal communication is the process by which a person sends a message to another person with the intention of evoking a response. Basic communication elements¹ are shown in Figure 4-1. The sender is the person who constructs a message to initiate the interpersonal communication. The message construction process is known as encoding. The message itself contains information the sender wishes to transmit. It must be in a format of symbols that are understandable to the other person. It should be clearly organized and well expressed and may be composed of both verbal and nonverbal content. The message is sent via a channel that involves visual, auditory, and tactile senses. For example, facial expression uses a visual channel, spoken words use an auditory channel, and touch uses a tactile channel. The receiver is the person who accepts the message and deciphers its meaning, a process known as decoding. The receiver must share a common language with the sender to decode the message accurately. Communication is most effective when the receiver and the sender accurately perceive the meaning of each other’s messages.

Figure 4-1 Basic communication model.

Feedback

Communication does not generally stop with one encoded and decoded message. The receiver is prompted to respond and provides a feedback message. The receiver then becomes the sender and the cycle repeats itself. The feedback communication model illustrates how each person has an encoding and a decoding role in the communication process (Figure 4-2). In a social situation, both persons assume equal responsibilities to seek openness and clarification. In the dental hygienist–client relationship, however, the dental hygienist assumes primary responsibility. Dental hygienists need to seek verbal and nonverbal feedback to make sure good communication has occurred. Message transmission is influenced by the sender’s and receiver’s physical and developmental status, perceptions, values, emotions, knowledge, sociocultural background, roles, and environment.

Figure 4-2 Wilbur Schramm feedback model.

(Adapted from Schramm W: How communication works. In Schramm W, ed: The process and effects of mass communication, Urbana, 1955, University of Illinois Press.)

Environmental Factors

The physical surroundings in which communication takes place influence the communication process. For example, people are more likely to communicate effectively in an environment that is comfortable. Factors such as lighting, heating, ventilation, and acoustics may affect the communication process. In the oral healthcare setting, confidentiality may be important if clients are revealing sensitive information about their health. A bustling environment may pose annoying distractions that could block communication.

Internal and Relationship Factors

A person’s perceptions, knowledge, values, emotions, and level of need fulfillment influence the way messages are sent and received.¹

Values

Values are personal beliefs that may have moral and ethical implications. Whatever we consider important in our lives influences the way we communicate our ideas and feelings. Each individual has a unique set of values that has been shaped by personal experiences. The hygienist can influence the communication process by exercising tolerance for and understanding of the wide differences of opinion that exist.

Not all clients value oral health. Individuals have reasons, both known and unknown, for holding their respective values. A person from an impoverished background may have to prioritize values to survive. Oral health and education may not be highly valued when food, shelter, and clothing are not readily available. On high school campuses, a sugar-free diet may not be valued when candy and soft-drink machines beckon. Water fluoridation may not be valued by people who have been deluged with information from antifluoridationists.

Values can be changed, but experts suggest that they are slow to form and to change. For value change to occur in the oral healthcare environment,¹ oral healthcare professionals must do the following:

Be aware of their own values and how they affect the choices they make in planning and implementing oral health behavioral change programs

Understand the client’s values through careful observation and analysis of behavior

Avoid imposing their values on a client who has a different set of values

Sometimes client values related to oral health and disease can be changed by education. The methods used to produce change and the degree of success are dependent on how wide the gap is between the desired value and the client’s current value.

Sociocultural Background

Sociocultural differences are important in social interaction and communication. A dental hygienist who has a broad understanding of cultural diversity is better prepared to communicate with clients from varying backgrounds (see Chapter 5).²

Verbal Communication

Using the spoken word to convey a message is verbal communication. The most important aspects of verbal communication are vocabulary, intonation, clarity, and brevity.¹

Nonverbal Communication

Nonverbal communication is the use of body language rather than words to transmit a message. Effective nonverbal communication complements and strengthens the message conveyed by verbal communication so that the receiver is less likely to misinterpret the message.

Nonverbal communication includes body movement such as facial expression, eye behavior, gestures, posture and gait, and touch. Because body language is hard to control, it often reveals true feelings. It takes practice, concentration, and sensitivity to others for the dental hygienist to become an astute observer of body language. For example, there probably is something wrong with a client who says she is “fine” but is wringing her hands. Dental hygienists also should be aware of their own body language to avoid sending mixed messages to clients. Saying “It’s good to see you” while wearing a frown does not establish trust and may cause anxiety. To facilitate communication, various aspects of body language are discussed in the following sections.

Comfort

Comfort (C in the mnemonic) refers to the hygienist’s ability to deal with embarrassing or emotionally painful topics related to a client’s health; to be aware of the client’s physical and emotional response during dental hygiene care; and to provide verbal support to a client who fears oral healthcare procedures. Aspects of dental hygiene practice related to client comfort and communication include effectively addressing a client’s loss of teeth and need to wear a prosthetic appliance, a client’s inability to seek oral healthcare because of financial difficulties, a client’s fear of injections, and clients’ discomfort from having their personal space “invaded” during care.

Personal space is invisible and travels with a person. Territoriality refers to the need to maintain and defend one’s right to this personal space. During interpersonal communication individuals maintain varying distances between each other depending on their culture, their relationship, and the circumstance. Touching the head and neck area is usually reserved for intimate relationships such as between lovers or a parent and a child. When personal space is violated, people often become defensive and communication becomes ineffective. Because dental hygienists work within the client’s intimate zone of personal space, it is important to convey professional confidence, gentleness, and respect when doing so. Examples of these actions are listed in Box 4-3. To meet the client’s human need for freedom from stress, the hygienist strives to keep the client’s comfort a top priority.

Acceptance

Acceptance refers to the dental hygienist’s ability to accept clients as the people they are without allowing any judgment of the clients’ attitudes or feelings to interfere with communication. For example, a client may appear unwilling to assume responsibility for his or her health and may be critical or untrusting. The client’s poor oral health may seem to be self-imposed and related to an unhealthy lifestyle. But the client’s appearance and attitudes may have deep cultural roots that are unfamiliar to the hygienist. The dental hygienist must develop an attitude of acceptance toward individuals whose values and sociocultural backgrounds seem unusual or foreign.

Responsiveness

Responsiveness in a healthcare provider is the ability to reply to messages at the very moment they are sent. It requires sensitive alertness to cues that something more needs to be said. When a client arrives for a dental hygiene appointment and mentions oral discomfort, the comment should be pursued immediately. Scaling and root planing might have been scheduled, but other problems may be an immediate priority and supersede the planned care.

Empathy

Empathy is said to result when we place ourselves in another’s “shoes.” Empathy means perceiving clients as they see themselves, sensing their hurt or pleasure as they sense it, accepting their feelings, and communicating this understanding of their reality.¹

In expressing empathy the dental hygienist communicates understanding the importance of the feelings behind a client’s statements. Empathy statements are neutral and nonjudgmental. They can be used to establish trust in difficult situations. For example, the dental hygienist might say to an angry client who has lost mobility after a stroke, “It must be very frustrating to know what you want and not be able to do it.” This perception of clients’ viewpoints helps the dental hygienist to better understand them, their reaction to dental hygiene care, and their capabilities for taking responsibility for their own health.

Silence

Silence can be used effectively in communication because it provides an opportunity for the message senders and receivers to gather and reorganize their thoughts and feelings. During silent moments, nonverbal messages such as loss of eye contact or a wrinkled brow can be sent. Remaining silent may be uncomfortable, but adhering patiently to silence demonstrates the hygienist’s willingness to listen and encourages clients to share their thoughts. Skill and timing are required to use silence effectively. The tendency for some is to want to break the silence too soon. Poor timing can prematurely interrupt clients’ efforts in choosing words and frustrate their attempts to communicate.

The nature of dental hygiene care often precludes talking by the client. A common complaint, usually shared good-naturedly among clients, is that their dental hygienist asks them questions when the hygienist’s hands are in their mouths! This typical scenario is unfair to the client. Common courtesy dictates that immediately on asking a question the hygienist removes hands, instruments, and saliva ejectors from the client’s mouth to allow the client an opportunity to respond through speaking, not just grunting.

Listening Attentively

Caring involves an interpersonal interaction that is much more than two persons talking back and forth. In a caring relationship, the dental hygienist establishes trust, opens lines of communication, and listens to what the client has to say. Listening attentively is key because it conveys to clients that they have the hygienist’s full attention and interest. Listening to the meaning of what a client says helps create a mutual relationship.

The dental hygienist indicates interest by appearing natural and relaxed and facing the client with good eye contact (Figure 4-3). Whatever the services being rendered, the client should remain the center of attention, with the hygienist’s ears available to evaluate and respond. Interpersonal attending skills shown in Table 4-1 facilitate active listening and communication.

Figure 4-3 Dental hygienist using eye contact to communicate reassurance.

TABLE 4-1 Checklist of Interpersonal Attending

Adapted from Geboy MJ: Communications and behavior management in dentistry, Baltimore, 1985, Williams and Wilkins.

Conveying Acceptance

Conveying acceptance requires a tolerant, nonjudgmental attitude toward clients. An open, accepting approach is needed to foster a helping relationship between hygienist and client. Care is taken to avoid nonverbal behavior that may be offensive or that may prevent free-flowing communication. Gestures such as frowning, rolling eyes upward, or shaking the head may communicate disagreement or disapproval to the client. The dental hygienist shows willingness to listen to the client’s viewpoint and provide feedback that indicates understanding and acceptance of the person.

Humor

Humor can help decrease client anxiety and embarrassment. Humor is a communication technique that needs to be used comfortably and naturally with clients of all ages and stages of development (Figure 4-4). The therapeutic advantages of humor and laughter have been documented. Laughter decreases serum control levels, increases immune activity, and stimulates endorphin release from the hypothalamus. In so doing, it relieves stress-related tension and pain. Cousins described the role of humor in his recovery from two life-threatening illnesses.³ His experience suggests that laughter and positive emotions are vital to the success of any medical treatment as well as to life in general.

Figure 4-4 Sharing a joke or laughing with clients can assist in reducing stress and support a therapeutic relationship.

Healthcare personnel and facilities can be perceived as frightening by clients of all ages. Humor as a technique of communication can put people at ease. Even a simple smile can help establish a warm social bond. In her book Communication in Health Care, Collins states, “humor has childlike qualities of playfulness. If one can be playful, one still has vestiges of youth and vigor.”⁴ The unexpected, the incongruous, the pun, and the exaggeration or understatement are examples of humor that can be effective with both younger and older clients.

Asking Questions

One of the most critical and valuable tools in the dental hygienists’ arsenal of communication skills is the art of questioning. Although there are many types of questions, there are only two basic forms: closed-ended questions, which are directive, and open-ended questions, which are nondirective.

Open-Ended Questions

Open-ended questions are generally used to elicit a wide range of responses on a broad topic. Open-ended questions usually have the following characteristics:

Cannot be answered with a single word or a simple “yes” or “no”

Begin with what, how, or why

Do not lead the client in a specific direction

Increase dialogue by drawing out the client’s feelings or opinions

Open-ended questions are usually more effective than questions that require a simple “yes” or “no” answer. Open-ended questioning allows clients to elaborate and show their genuine feelings by bringing up whatever they think is important (Box 4-5). Skillful questioning by the dental hygienist promotes communication.

BOX 4-5 Examples of Open-Ended Questions

How do you feel about your oral health?

What are you currently doing each day to care for your mouth?

Why do you feel you will never be able to floss regularly?

Paraphrasing

Paraphrasing means restating or summarizing what the client has just said. Through paraphrasing the client receives a signal that his or her message has been received and understood and is prompted to continue a communication effort by providing further information. The client may say, “I don’t understand how I could have periodontal disease. My teeth and gums feel fine. I have absolutely no pain.” The hygienist could paraphrase the statement by saying, “You’re not convinced that you have periodontal disease or any gum problems because you have no discomfort?” The client may respond, “Right, I just can’t believe anything is wrong with my mouth.” By actively listening and paraphrasing, the dental hygienist’s response allows further analysis of the problem and opens the conversation for communication and problem solving.

The dental hygienist actively listens and analyzes messages received, however, so that the paraphrase is an accurate account not only of what the client actually says, but also of what the client feels. For example, if a client sends verbal or nonverbal messages of anger or frustration about being told to floss more, the dental hygienist could say, “It sounds like this situation has really upset you and that you are frustrated with me for not recognizing your efforts.” This response encourages clients to communicate further about health problems. Passive listening or silence on the part of the dental hygienist, with no attempt to decode the message, could result in an uncomfortable impasse in the communication process.

Clarifying

At times the message sent by the client may be vague. When clarification is needed, the discussion should be temporarily stopped until confusing or conflicting statements have been understood. For example, consider Scenario 4-2, in which a client has come to the oral care environment for oral prophylaxis. In responding this way the hygienist is trying to get clarification. The client’s rush of words seems to be related to her own problems, but the hygienist cannot be sure until the client states it clearly (see the discussion of subcategories of open-ended questions that enhance communication). In addition, the hygienist should be aware that statements made to the client may need clarification. To fulfill their human need for conceptualization and problem solving, clients need to understand why they are asked to comply with a specific home care regimen. In Scenario 4-3, the dental hygienist has completed therapeutic scaling and root planing on the mandibular left quadrant, which has been anesthetized. The more specific the hygienist can be, the clearer the message to the client.

Focusing

Sometimes when clients discuss health-related issues the messages become redundant or rambling. Important information may not surface because the client is off on a tangent. Dental hygienists ask questions to clarify when they are unsure of what the client is talking about. In focusing, however, the hygienist knows what the client is talking about but is having trouble keeping the client on the subject so that data gathering and assessment can be completed. In such cases the dental hygienist encourages verbalization but steers the discussion back on track as a technique to improve communication. Rather than asking a question, a gentle command may be in order, such as “Please point to the tooth that seems to be causing your discomfort,” or “Show me exactly what you do when you floss your back teeth” (Table 4-2).

TABLE 4-2 Subcategories of Open-Ended Questions That Enhance Communication

Stating Observations

Clients may be unaware of the nonverbal messages they are sending. When a client is asked, “How are you, Mrs. Jones?” as a friendly greeting, she may respond, “Oh, just fine.” Her appearance, gait, and mannerisms may indicate something different. She may look slightly unkempt, walk with a slow shuffle, and display generally unenthusiastic gestures and facial expressions. When nonverbal cues conflict with the verbal message, stating a simple straightforward observation may open the lines of communication. The hygienist may say, “You appear very tired, Mrs. Jones.” This is likely to cause the person to volunteer more information about how she feels without need for further questioning, focusing, or clarifying.

To promote positive communication, however, the dental hygienist uses respectful language. The client may feel sensitive about how observations are worded. Saying you look “tired” is different from saying you look “haggard,” which could embarrass or anger a person. Other observations that can soften a client’s response are stating that teeth are “crowded” rather than “crooked,” that a troublesome tongue is “muscular” not “fat,” and that gingiva is “pigmented” not “discolored.”

Offering Information

Providing clients with detailed information facilitates communication. Although providing information may not be enough to motivate people to change health behaviors, clients have a right to receive information based on the hygienist’s expertise so that they can make health-related decisions based on that information. In any setting, a dental hygienist has a professional obligation to provide health information to all clients, not just to individuals who request information.

Summarizing

Summarizing points discussed at a regularly scheduled appointment focuses attention on the major points of the communicative interaction. For example, the dental hygienist may conclude the appointment with, “Today we discussed the purpose of therapeutic scaling and root planing and the periodontal disease process, and we practiced flossing technique. Remember, you decided to floss daily and to try to slip the floss carefully down below the gum line.” If the client is coming in for multiple appointments to receive quadrant or sextant scaling and root planing, the discussion from the previous appointment is summarized before new information is given. Documentation in the client’s chart at each appointment reflects topics discussed at the appointment as related to the client’s goals.

The summary serves as a review of the key aspects of the information presented so that the client can ask for clarification. Adding new information in the summary may confuse the client; however, a comment about what will be discussed at the next appointment is appropriate. Such a statement might be, “At your next appointment, we will talk about use of the Perio-Aid and continue discussion of the periodontal disease process.”

Giving an Opinion

A helping relationship fosters the clients’ ability to make their own decisions about health. A hygienist may be tempted to offer an opinion, which may weaken the clients’ autonomy and jeopardize their need for responsibility for oral health. Clients may volunteer personal information about themselves and may ask for the hygienist’s opinion. It is best in such a situation to acknowledge the individual’s feelings but to avoid the transfer of decision making from client to hygienist. Scenario 4-4 is a hypothetic situation presenting two possible responses by the dental hygienist in an interaction with a client. The latter response by the dental hygienist recognizes feelings without expressing an opinion that could make the client feel worse by confirming a doubt she has about her daughter, as in the first response.

Offering False Reassurance

Hygienists may at times offer reassurance when it is not well grounded. It is natural to want to alleviate the client’s anxiety and fear, but reassurance may promise something that cannot occur. For example, the dental hygienist should not promise clients that they will experience no discomfort during an anticipated dental treatment. Although the dental hygienist may feel confident that the oral surgeon or periodontist is competent and kind, discomfort may be unavoidable. In addition, when clients are distraught about having periodontal disease it is best not to say, “There’s nothing to worry about. You’ll be fine.” Indeed, depending on the amount of bone loss present and the client’s disease susceptibility, the periodontist may not be able to control the disease, even with extensive therapy. Scenario 4-5 illustrates how the dental hygienist can listen to and acknowledge a client’s feelings without offering false assurance that the problem is a simple one.

Being Defensive

When clients criticize services or personnel, it is easy for the hygienist to become defensive. A defensive posture may threaten the relationship between dental hygienist and client by communicating to clients that they do not have a right to express their opinions.

In Scenario 4-6 the dental hygienist’s response ignores the client’s real feelings and hurts future rapport and communication with him. Instead, it would have been better for the hygienist to use the therapeutic communication techniques of active listening to verify what the client has to say and to learn why he is upset or angry. Active listening does not mean that the dental hygienist agrees with what is being said, but rather conveys interest in what the client is saying. This latter approach is illustrated in the Scenario 4-7.

Some care in listening led to discovery of the source of the client’s anger, which was the inconvenience of a particular oral surgeon’s location, parking, and office procedures. By avoiding defensiveness and applying active listening and paraphrasing, the hygienist allowed Mr. Tucker to vent his anger. Therefore communication was facilitated, not blocked.

Showing Approval or Disapproval

Showing either approval or disapproval in certain situations can be detrimental to the communication process. Excessive praise may imply to the client that the hygienist thinks the behavior being praised is the only acceptable one. Often, clients may reveal information about themselves because they are seeking a way to express their feelings; they are not necessarily looking for approval or disapproval from the dental hygienist. In Scenario 4-8 the hygienist’s response cannot be interpreted as neutral.

The discussion in Scenario 4-8 is likely to stop with the dental hygienist’s statements. The client probably sees the hygienist’s viewpoint as supportive of her daughter’s. Perhaps the woman is better off having her daughter drive her. It is also possible that she is capable of walking, likes the exercise, and enjoys the independence of getting to her own appointments. The dental hygienist’s strong statements of approval may inhibit further communication.

In addition, behaviors that communicate disapproval cause clients to feel rejected, and their desire to interact further with the dental hygienist may be weakened. Disapproving statements may be issued by a dental hygienist who is not thinking carefully about how the client may react. Scenario 4-9 exemplifies a dental hygienist’s response that communicates hasty disapproval.

Instead of this response the dental hygienist might have said, “You’re making progress. Tell me more about your activities on those 3 days when you weren’t able to floss. Perhaps together we could find a better way of integrating flossing into your lifestyle.”

Asking Why

When people are puzzled by another’s behavior, the natural reaction is to ask “Why?” When dental hygienists discover that clients have not been following recommendations, they may feel a natural inclination to ask why this has occurred. Clients may interpret such a question as an accusation. They may feel resentment, leading to withdrawal and a lack of motivation to communicate further with the dental hygienist.

Efforts to search for reasons why the client has not practiced the oral healthcare behaviors as recommended can be facilitated by simply rephrasing a probing “why” question. For example, rather than saying, “Why haven’t you used the oral irrigator?” the hygienist might say, “You haven’t used the oral irrigator. Is something wrong?” For anxious clients, rather than asking, “Why are you upset?” the hygienist might say, “You seem upset. Would you like to talk about it?

Changing the Subject Inappropriately

Changing the subject abruptly shows a lack of empathy and could be interpreted as rude. In addition, it prevents the client from discussing an issue that may have important implications for care. Scenario 4-10 is a sample client–dental hygienist interaction.

The dental hygienist’s response shows insensitivity and an unwillingness to discuss Mrs. Johnson’s complaint. It is possible that the client has a periodontal or periapical abscess or some other serious problem. The dental hygienist is remiss in ignoring the client’s attempt to communicate a problem. Communication has been stalled, and the client’s oral health jeopardized. The client should be given an opportunity to elaborate on the message she is trying to send.

Motivational Interviewing⁵

In the communication process a dental hygienist is constantly striving to influence the client’s motivation to perform oral health behaviors. Motivation can be defined as the impulse that leads an individual to action. Many theories of motivation have been formulated and can be appropriately applied to client motivation in the healthcare environment. The motivational interview is a form of patient-centered communication to help clients get “unstuck from the ambivalence that prevents a specific behavioral change” (see Chapter 34).

Preschool and Younger School-Age Children

Communicating with children requires an understanding of the influence of growth and development on language, thought processes, and motor skills. Children begin development with simple, concrete language and thinking and move toward the more complex and abstract. Communication techniques and teaching methods also can increase in complexity as the child grows older.

Nonverbal communication is more important with preschoolers than it is with the school-age child whose communication is better developed. The preschooler learns through play and enjoys a gamelike atmosphere. Hence, dentists often call the dental engine their “whistle” or the “buzzy bee,” and hygienists often refer to their polishing cup as the “whirly bird” and the saliva ejector as “Mr. Thirsty.” Imaginary names help lighten the healthcare experience for small children. Oral health professionals are advised to use simple, short sentences, familiar words, and concrete explanations.

Older School-Age Children and Adolescents

Adolescence is not a single stage of development. The rate at which children progress through adolescence and the psychologic states that accompany the changes can vary considerably from one child to another.⁴ In early adolescence (about 13 to 15 years old), children may rather suddenly demonstrate an ambivalence toward parents and other adults, manifested by questioning of adult values and authority. By late adolescence (18 years and older) much of the ambivalence is gone and values that characterize the adult years have fully emerged. Friendship patterns in early and middle adolescence are usually intense as the child begins to explore companionship outside the family and become established as an independent person (Figure 4-5).

Figure 4-5 Interacting with peers helps to establish independence.

Some common complaints from the adolescent’s point of view can sensitize health professionals for positive interactions with this group of young people. First, a frequently voiced complaint of adolescents is that adults do not listen to them. They seem to feel that adults are in too much of a hurry, appear to be looking for certain answers, or listen only to what they want to hear. A second complaint is that too often a conversation turns into unsolicited advice or a mini-lecture. A young person, asked to describe specific experiences in dentistry, related the following⁸:

Other less-common complaints from adolescents are that they are patronized, that they do not understand questions being asked, and finally that adults lack humor.

Dental hygienists should consider carefully these complaints and practice behaviors that enhance communication with adolescents. Being attentive and allowing the adolescent time to talk enhances rapport and communication. Some rapport-building questions at the beginning of the appointment may relate to family, school, personal interests, or career intentions. It is useful to have some knowledge of the contemporary interests of adolescents, which may include trends in music, sports, and fashion. They want a sense of being understood and do not want to be judged or lectured.

Adolescents have a strong human need for responsibility. An astute dental hygienist can use these unfulfilled needs to motivate the adolescent client to adopt oral self-care behaviors. This educational approach, based on human needs theory, can enhance adolescents’ sense of personal responsibility toward the care of their mouths. In order that adolescents do not feel singled out, a dental hygienist might say, “We encourage all of our adult clients to floss daily. This is because we know it works. We’ve seen the results.” Teenagers do not feel patronized or confused if questions and advice are offered in a sincere, straightforward manner.

Adults

Havinghurst delineated three developmental stages for adults and listed common adult concerns at each stage.⁷ Although communication techniques may not differ greatly for the adult stages, knowledge of general differences in characteristics among age groups can enlighten the hygienist about typical concerns of clients at different periods of adulthood. An awareness of how priorities in life change for adults as they develop can help the hygienist identify learning needs and “teachable moments” for different clients. The Havinghurst adult stages are summarized in Box 4-7 according to early adulthood, middle age, and late maturity. The dental hygienist should be aware, without asking personal questions, that young adults may be trying to institute oral self-care behaviors while adjusting to major life stresses such as bringing up young children, managing a home, or starting a demanding career. Adults in the middle years may be more settled in careers and have less responsibility for child care but may be heavily involved in social responsibilities, adjusting to their personal physical changes, or the demands of caring for aging parents. Older adults may be adjusting to decreasing physical strength, a chronic health problem, retirement, or death of a spouse. The elderly population is a highly diversified group (Figure 4-6). The wide variations in health and psychologic states dictate the necessity of careful assessment of each individual (see Chapter 54).

Figure 4-6 A retired couple enjoying fishing together.

Communication approaches appropriate for adults are the therapeutic communication techniques discussed previously in this chapter. In using the techniques, it is important for the dental hygienist to be familiar with the adult developmental stages and aware of what demands may be preventing adults of the different stages from easily making oral healthcare behavioral changes. Modern adult learning theory has been supported by some basic assumptions (Box 4-8). Keeping these assumptions in mind facilitates communication with adults who become “learners” as dental hygienists become “teachers” in the healthcare setting. These assumptions can enhance communication and the dental hygiene educator’s approach to teaching adults.

Intrapersonal Theories

In addition to exploring behavior, individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind). Intrapersonal factors include knowledge, attitudes, beliefs, motivation, self-concept, developmental history, past experience, and skills. Individual-level theories are as follows.

The Health Belief Model (HBM) addresses the individual’s perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to action, and self-efficacy).

The Stages of Change (Transtheoretical) Model describes individuals’ motivation and readiness to change a behavior.

The Theory of Planned Behavior (TPB) examines the relations between an individual’s beliefs, attitudes, intentions, behavior, and perceived control over that behavior.

Health Belief Model

The HBM was one of the first theories of health behavior and remains one of the most widely recognized in the field. It was developed in the 1950s by a group of U.S. Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease. For example, the Public Health Service was sending mobile x-ray units out to neighborhoods to offer free chest x-ray examinations (screening for tuberculosis). Despite the fact that this service was offered without charge in a variety of convenient locations, the program was of limited success. The question was, “Why?” To find an answer, social psychologists examined what was encouraging or discouraging people from participating in the programs. They theorized that people’s beliefs about whether or not they were susceptible to disease, and their perceptions of the benefits of trying to avoid it, influenced their readiness to act.

In ensuing years, researchers expanded on this theory, eventually concluding that six main constructs influence people’s decisions about whether to take action to engage in preventive behavior. They argued that people are ready to act in the following circumstances:

If they believe they are susceptible to the condition (perceived susceptibility)

If they believe the condition has serious consequences (perceived severity)

If they believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

If they believe costs of taking action (perceived barriers) are outweighed by the benefits

If they are exposed to factors that prompt action (e.g., a reminder from one’s dental hygienist to rinse with 0.05% sodium fluoride twice a day to prevent demineralization of tooth surfaces), called cue(s) to action

If they are confident in their ability to successfully perform an action (self-efficacy)

Together these six components of the HBM provide a useful framework for designing both short-term and long-term behavioral change strategies (Table 4-4). When applying the HBM to planning health programs, practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem, whether these people believe it is serious, and whether they believe action can reduce the threat at an acceptable cost. Attempting to effect changes in these factors is rarely as simple as it may appear.

TABLE 4-4 The Health Belief Model Used in Designing Behavioral Change Strategies

Concept	Definition	Potential Change Strategies
Perceived susceptibility	Beliefs about the chances of getting a condition	Define what populations(s) are at risk and their levels of risk Tailor risk information based on an individual’s characteristics or behaviors Help the individual develop an accurate perception of his or her own risk
Perceived severity	Beliefs about the seriousness of a condition and its consequences	Specify the consequences of a condition and recommended action
Perceived benefits	Beliefs about the effectiveness of taking action to reduce risk or seriousness	Explain how, where, and when to take action and what the potential positive results will be
Perceived barriers	Beliefs about the material and psychologic costs of taking action	Offer reassurance, incentives, and assistance; correct misinformation
Cues to action	Factors that activate readiness to change	Provide “how-to” information, promote awareness, and employ reminder systems
Self-efficacy	Confidence in one’s ability to take action	Provide training and guidance in performing action Use progressive goal setting Give verbal reinforcement Demonstrate desired behaviors

Theory of Planned Behavior

The TPB and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs, attitudes, and intentions. Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior. According to these models, behavioral intention is influenced by a person’s attitude toward performing a behavior and by beliefs about whether individuals who are important to the person approve or disapprove of the behavior (subjective norm). The TPB and TRA assume all other factors (e.g., culture, the environment) operate through the model’s constructs and do not independently explain the likelihood that a person will behave a certain way.

The TPB differs from the TRA in that it includes one additional construct, perceived behavioral control; this construct has to do with people’s beliefs that they can control a particular behavior. This construct accounts for situations in which people’s behavior, or behavioral intention, is influenced by factors beyond their control. It was believed that people might try harder to perform a behavior if they feel they have a high degree of control over it (Figure 4-7). Clients’ perceptions about controllability may have an important influence on behavior.

Figure 4-7 Theory of Reasoned Action and Theory of Planned Behavior.

(From National Cancer Institute: Theory at a glance: a guide for health promotion practice, ed 2, NIH Publication No. 05-3896, Bethesda, Md, 2005, U.S. Department of Health and Human Services, National Institute of Health.)

Figure 4-7 shows the TPB’s explanation for how behavioral intention determines behavior and how attitude toward behavior, subjective norm, and perceived behavioral control influence behavioral intention. According to the model, attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior. Beliefs about social standards and motivation to comply with those norms affect subjective norms. The presence or lack of things that will make it easier or harder to perform the behavior affects perceived behavioral control. Thus a causal chain of beliefs, attitudes, and intentions drives behavior.

Interpersonal Theories

At the interpersonal level, health behavior theories assume individuals exist within, and are influenced by, a social environment. The opinions, thoughts, behavior, advice, and support of the people surrounding an individual influence his or her feelings and behavior, and the individual has a reciprocal effect on those people. The social environment includes family members, co-workers, friends, health professionals, and others. Because it affects behavior, the social environment also affects health. Many theories focus on the interpersonal level, but this chapter highlights Social Cognitive Theory (SCT). SCT is one of the most frequently used and robust health behavior theories. It explores the reciprocal interactions of people and their environments, and the psychosocial determinants of health behavior.

Social Cognitive Theory

SCT describes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence on one another. According to SCT, three main factors affect the likelihood that a person will change a health behavior: self-efficacy, goals, and outcome expectancies. If individuals have a sense of self-efficacy, they can change behaviors even when faced with obstacles. If they do not feel that they can exercise control over their health behavior, they are not motivated to act or to persist through challenges. As a person adopts new behaviors, this causes changes in both the environment and the person. Behavior is not simply a product of the environment and the person, and environment is not simply a product of the person and behavior.

SCT evolved from research on Social Learning Theory (SLT), which asserts that people learn not only from their own experiences, but by observing the actions of others and the benefits of those actions. The updated SLT added the construct of self-efficacy and was renamed SCT. SCT integrates concepts and processes from cognitive, behaviorist, and emotional models of behavioral change, so it includes many constructs (Table 4-6). It has been used successfully as the underlying theory for behavioral change in areas ranging from dietary change to pain control.

TABLE 4-6 Social Cognitive Theory and Potential Change Strategies

Concept	Definition	Potential Change Strategies
Reciprocal determinism	The dynamic interaction of the person, behavior, and the environment in which the behavior is performed	Consider multiple ways to promote behavioral change, including making adjustments to the environment or influencing personal attitudes.
Behavioral capability	Knowledge and skill to perform a given behavior	Promote mastery learning through skills training.
Expectations	Anticipated outcomes of a behavior	Model positive outcomes of healthful behavior.
Self-efficacy	Confidence in one’s ability to take action and overcome barriers	Approach behavioral change in small steps to ensure success; be specific about the desired change.
Observational learning (modeling)	Behavioral acquisition that occurs by watching the actions and outcomes of others’ behavior	Offer credible role models who perform the targeted behavior.
Reinforcements	Responses to a person’s behavior that increase or decrease the likelihood of reoccurrence	Promote self-initiated rewards and incentives.

Reciprocal determinism describes interactions among behavior, personal factors, and environment, where each influences the others. Behavioral capability states that to perform a behavior a person must know what to do and how to do it. Expectations are the results an individual anticipates from taking action. Bandura considers self-efficacy the most important personal factor in behavioral change, and it is a nearly ubiquitous construct in health behavior theories. Strategies for increasing self-efficacy include setting incremental goals (e.g., brushing for 3 minutes twice a day); behavioral contracting (a formal contract, with specified goals and rewards); and monitoring and reinforcement (feedback from self-monitoring or record keeping).

Observational learning, or modeling, is the process whereby people learn through the experiences of credible others rather than through their own experience. Reinforcements are responses to behavior that affect whether or not one will repeat it. Positive reinforcements (rewards) increase a person’s likelihood of repeating the behavior. Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (e.g., when a driver puts the key in the car’s ignition, the beeping alarm reminds him or her to fasten the seatbelt). Reinforcements can be internal or external. Internal rewards are things people do to reward themselves. External rewards (e.g., token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a person’s own desire or commitment to change.

Becoming comfortable with behavioral change theory as a practice instrument may take some work, but the results are well worth it. Behavioral change theory is not simply a tool for academics and researchers; it can be applied to the problems dental hygienists face daily. Theory helps practitioners to understand the dynamics underlying real situations and to think about solutions in a new way.

CLIENT EDUCATION TIPS

Establish a partnership to maintain optimal oral hygiene health for the client.

Provide the most accurate oral health information and feedback on the client’s healthcare options, but respect the client’s wishes regarding healthcare decisions.

Consider cultural and age-appropriate needs of the client in all health education efforts.

Consider theoretic research in all health promotion efforts.

LEGAL, ETHICAL, AND SAFETY ISSUES

Clients have the right to accept or reject the dental hygiene care plan and still retain the respect of the dental hygienist.

It is important to meet the client’s need for conceptualization and understanding of health information to promote health literacy and informed oral healthcare decisions.

The client has the right to personalized, up-to-date, evidence-based recommendations and care from the dental hygienist.

KEY CONCEPTS

Communication during the dental hygiene process of care is a dynamic interaction between the dental hygienist and the client that involves both verbal and nonverbal components.

Factors that may affect the communication process include internal factors of the client and the dental hygienist (e.g., perceptions, values, emotions, and knowledge), the nature of their relationship, the situation prompting communication, and the environment.

Some communication approaches are therapeutic and helpful in assisting clients to make decisions and attain goals related to their comfort and health. Other approaches are nontherapeutic and unsuccessful in helping clients make decisions and attain goals related to their comfort and health.

Communication techniques used by the dental hygiene clinician must be flexible to relate to the full range of client ages through the life span.

Behavioral change theory can be useful in addressing behavioral problems dental hygienists face every day.

Behavioral theory helps practitioners to understand the dynamics underlying real situations and to think about solutions in a new way.

CRITICAL THINKING EXERCISES

1. Identify therapeutic and nontherapeutic communication techniques by name as two people role-play the following client–oral healthcare educator sessions.

In the first session, the “client” should improvise a story of frustration with his or her current oral hygiene regimen by explaining that a heavy workload, family responsibilities, or other interference make it difficult to maintain a good home care regimen. While glancing at a list of the possible responses as a prompt, the “educator” will try to respond with only therapeutic comments. Classroom listeners should try to determine which specific categories of therapeutic communication fit the educator’s comments.

This time as the “educator” glances at the list of possible responses, he or she will try to answer with mostly nontherapeutic responses. Classroom listeners should try to determine which specific categories of nontherapeutic communication fit the educator’s comments.

2. Considering your personality, identify an unhealthy behavioral practice of your own. Identify behavioral theory that may prompt you to change. Now consider why you continue the unhealthy behavior.

3. With each of your next five clients, use the Stages of Change Model to determine their readiness to adopt a new oral self-care behavior. What potential change strategy will you use with each client?