Using the Health Belief Model to Increase Flossing Compliance

Jieun Song, RDH, BA, and Ivianie Exinor, RDH, MPH,  provide a brief overview of the Health Belief Model and explain how they’ve applied the method in their daily practice. 

As dental hygienists, we understand the frustration that comes with trying to convince patients to adhere to a flossing regimen. But with a little creativity and a lot of patience, we can have a huge impact on changing patients’ oral health behavior. 

HEALTH BELIEF MODEL

The Health Belief Model (HBM) emerged through the work of social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal at the United States Public Health Service in the early 1950s.¹ At that time, prophylactic and preemptive screening measures showed low acceptance, making prevention and early detection of diseases such as tuberculosis a paramount concern for the Public Health Service.¹ Noncompliance with oral health regimens was also prevalent during this time and often led to the development of more serious and highly preventable conditions such as gingivitis and periodontitis.

The HBM focuses on understanding patients’ perspectives and accommodating them to modify health-related behaviors. The model can be broken down into perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy.¹

Although the Public Health Service has worked diligently to counter the development of oral health issues, many patients are still averse to practicing regular self-care routines. Flossing, in particular, is one of the most heavily avoided procedures, yet it is perhaps the most crucial aspect of oral care.² Regular flossing has the power to prevent gingivitis, periodontal diseases, and the accumulation of interproximal calculus and dental caries, as well as diminish general oral discomfort caused by lodged food fragments.² Although there is no research to support this theory, it may be that flossing can aid in maintaining dental alignment, considering it removes particles and inhibits growth of calculus, thus preventing shifting pressure in interproximal areas. 

MOTIVATING PATIENTS TO FLOSS

Despite numerous benefits, motivating patients to floss is still a struggle. We all have a general understanding of the HBM, and the theory behind how to put it into practice. However, applying that theory to our day-to-day work is easier said than done, especially when dealing with particularly resistant patients. The most resistant patients tend to be those without chief complaints, as they have no perceived susceptibility, and thereby perceive no severity from lack of flossing and no benefits from beginning flossing. At this point, it is up to us as hygienists to highlight and review any findings with these patients. 

For example, I had a 21-year-old male patient come in with no complaints, but upon examination, I found he had generalized moderate gingivitis. He said he did not floss and was “lazy” about doing so, and also showed little interest in the conversation. In order to draw his attention, I reviewed my findings with him in detail by showing him pictures of healthy gingiva and handing him a mirror to allow for direct comparison. Noticeable inflammation, moderate redness, and bleeding gingiva quickly piqued his interest. I then recommended that he begin flossing at least once a week to begin building a habit and increase over time. He was fairly receptive to the idea and mentioned that he had flossed once or twice at his 3-month follow-up, at which point I commended him for his progress as positive reinforcement.

NEVER GIVE UP

Although this patient reacted well to intervention, not all patients are as easy to reach, and a patient’s regard for oral health can determine what weight your words will carry. Some patients may simply tell you that they do not care to floss and are not concerned about potential negative outcomes. With these patients, it may be best to remain calm and patient and work on building a relationship. It is important to stay positive and persevere and to not take a patient’s lack of interest personally. Over time, even the most difficult people can warm up to you, especially if your workmanship reassures them that you are there to benefit their health and improve their quality of life.

GET CREATIVE

There are many other ways to encourage patients to floss, and the possibilities can multiply with some creativity. One option may be to talk to your office about starting a weekly floss reminder list for patients. You can ask patients if they may be interested in signing up for reminders sent via text message at specified intervals.

The office could also provide small incentives for those who follow through with flossing regimens. The main idea is to encourage patients to create a habit. They may be willing to try different products depending on their perceived barriers. Floss holders would be the most convenient option for most people, as it can be used at any time and is not as involved as traditional floss. Some patients of mine use floss holders while driving during their morning and evening commutes. Other patients with tight interproximal spaces may complain of floss fraying or breaking. For these patients, it is best to recommend PTFE floss. There is currently some controversy over the use of PTFE floss, as it may expose people to unsafe levels of the chemical.³However, PTFE is used in many different applications including cookware, food packaging, water-resistant clothing, and machine parts, all of which have much greater exposure potential.³This being said, it is safe to say that the benefits of flossing greatly outweigh the potential exposure. Still, some patients may be adamant about avoiding such products, at which point floss holders may work just as well. 

Lastly, it is important to mention the barrier that I found most common among children and adolescents, but has also been present in many adult patients: lack of knowledge. It is surprising to find adults who have not been taught to floss properly, especially when they have been receiving dental care their whole lives. Nevertheless, we should always take the opportunity to provide practical training to patients by educating them on the C-shaped flossing technique.

By offering different options to patients that correspond to their complaints, we help eliminate the biggest hurdle of the HBM: “Perceived Barriers.” I have found that focusing heavily on eliminating barriers and providing cues to action to be most effective for initiating intervention. Most patients already have a general knowledge of what can happen when you neglect to floss, so removing barriers and creating cues also brings a patient’s attention directly to the point.

Although the HBM is more than 50 years old, its theories still present a convincing argument that can be applied across all health-related disciplines. The same is true for its application within the field of dentistry, particularly in the case of promoting patient flossing habits. Despite numerous benefits, flossing has typically shown low compliance levels. By using the HBM, we can factor perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy into our patient intervention tactics. Patients with low flossing compliance usually understand potential susceptibility and severity of oral disease and are also usually aware of benefits associated with flossing. Some patients may simply believe they have low risk of developing oral conditions, while others feel more inhibited by specific barriers.

I have found the highest rate of success by focusing on eliminating barriers and providing cues to action to patients, but there is no one right way to apply the HBM. So, whichever way you choose to promote flossing compliance, remember to be creative, remain patient with your patients, and keep trying.

REFERENCES

1. Rosenstock IM. Historical origins of the Health Belief Model. Health Education Monographs. 1974;2:328–335. 
2. Fleming EB, Nguyen D, Afful J, Carroll MD, Woods PD. Prevalence of daily flossing among adults by selected risk factors for periodontal disease–United States, 2011-2014. J Periodontol. 2018;84:933–939. 
3. Boronow KE, Brody JG, Schaider LA, Peaslee GF, Havas L, Cohn BA. Serum concentrations of PFASs and exposure-related behaviors in African American and non-Hispanic white women. J  Expo Sci Environ Epidemiol. 2019;29:206–217.