Application of the health belief model in oral hygiene practice (brushing/flossing): A narrative review

Elwalid F Nasir; Nada M. A. Suliman

doi:10.4103/JIOH.JIOH_204_21

REVIEW ARTICLE

Year : 2022 | Volume : 14 | Issue : 4 | Page : 342-348

Application of the health belief model in oral hygiene practice (brushing/flossing): A narrative review

Elwalid F Nasir, Nada M. A. Suliman
Preventive Department, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia; Faculty of Dentistry, University of Science and Technology, Omdurman, Sudan

Date of Submission	07-Aug-2021
Date of Decision	01-Mar-2022
Date of Acceptance	29-Jun-2022
Date of Web Publication	29-Aug-2022

Correspondence Address:
Dr. Elwalid F Nasir
Preventive Department, College of Dentistry, King Faisal University, Al-Ahsa
Sudan

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/JIOH.JIOH_204_21

Abstract

Aim: Application of the health belief model helps explain when people would/would not engage in preventive health behaviors. Several studies were conducted to explore the model’s applicability in oral health; however, review studies on oral hygiene practice are scarce. The present study aimed to review the application of the model concerning oral hygiene practice and to identify the frequently used constructs of the model. Materials and Methods: This review focussed on the studies published during 2010–2020 using the following databases: PubMed, Web of Science, Research Gate, Cochrane Library, and the keywords used are health belief model, oral hygiene practice, brushing, and flossing. Twenty studies that fulfilled the criteria were included in the present review; among them, 12 were cross-sectional. Cluster sampling was the most frequent used by seven studies. Results: Almost all studies reported verifying the validity/reliability of the instruments used except three, and Cronbach α was the most used. The most used analyses were regression (linear/binomial) by 13 studies, besides χ², t-test, Mann–Whitney, analysis of variance, and Wilcoxon, whereas three studies used statistical models. Nine studies used five constructs, whereas six studies used the extended model with six constructs. Self-efficacy and barriers were the most significant predictors of oral hygiene practice, followed by susceptibility, severity, and benefits. The least significantly related was cues to action, and only one study reported no significant association. Conclusion: This review presented the validity of the psychometric properties of the model in explaining the oral hygiene practice; the review might have a limitation as it is limited by only the last 10 years beside the English language. This review might form a quick reference for the studies during the period of review.

Keywords: Brushing, Flossing, Health Belief Model, Literature Review, Oral Hygiene Practice

How to cite this article:
Nasir EF, Suliman NM. Application of the health belief model in oral hygiene practice (brushing/flossing): A narrative review. J Int Oral Health 2022;14:342-8

How to cite this URL:
Nasir EF, Suliman NM. Application of the health belief model in oral hygiene practice (brushing/flossing): A narrative review. J Int Oral Health [serial online] 2022 [cited 2023 Sep 22];14:342-8. Available from: https://www.jioh.org/text.asp?2022/14/4/342/355014

Introduction

Oral health is affected by individuals’ values and attitudes, besides the changing experiences, perceptions, expectations, and ability to adapt to circumstances.^[1],[2] Health behavior research has explored the effectiveness and applicability of various health models in health behavior modification. Application of psychological theories would provide systematic explanations of the observable behaviors.^[3]

The health belief model (HBM) was developed in the 1950s with the aim of understanding why some people used health services while others did not.^[4] It was initially developed to explain when people would (and would not) engage in preventive health behaviors.^[4] The model’s key variables include perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy. Perceived susceptibility is the subjective belief that one might become ill, get bad health, or enter a harmful state. The feeling of vulnerability to a condition reflects the individual’s subjective perception of the risk of contracting a condition.

In contrast, perceived severity is the belief related to the degree of harm or the seriousness of contracting an illness or bad health. Perceived benefits are the belief in the effectiveness of various actions available hypothesized to be necessary, meaning that individuals should accept recommended actions. Perceived barriers are the belief toward the actual cost/other constraints/difficulties from a possible behavior to reduce the risk of the seriousness of the illness, bad health, or the harmful state; the potential negative aspects of the action could thus act as impediments in the cognitive processes of changing behavior. Cues to action describe the necessary stimulations that facilitate decision-making toward the benefitting behavior.^[4],[5] After 1988, self-efficacy (the belief that one is capable of enacting change) was officially added to the HBM, making a significant contribution to the ability of this model to predict behavioral outcomes.^[6] Self-efficacy has been described as the confidence and the outcome expectation in enhancing health.

The model could be used as a framework for planning oral health interventions.^[7] HBM is a model used to help facilitate individuals to take responsibility for their behavior^[3] and has been described as beneficial for oral health.^[8] However, while many authors have found HBM to be a good model for predicting oral health behaviors,^[8],[9],[10] others have reported that its limitation should be recognized, although the model could be used.^[11],[12]

There has been remarkable success of interventions to change behavior based on behavioral theories. Theory-based designed interventions represent an integrated summary of the hypothesized causal processes involved in behavioral change.^[13]

The rationale for this is that there is no review article which focusses on HBM application in oral hygiene practice (brushing/flossing) based on the literature searched. The problem studied in this review is oral hygiene practice. The intervention is behavioral constructs of the HBM with comparison of different behavioral concepts and status of the study participants. The outcome is the effect of the studies of behavioral aspects on the oral hygiene practice. Therefore, the objectives of the present study were first to review the application of HBM concerning oral hygiene practice and secondly to identify HBM constructs mostly related to oral hygiene practice, including articles published during 2010–2020.

Materials and Methods

The criterion used for inclusion of studies was as follows: studies published in English language during 2010–2020 within the following electronic databases: PubMed, Web of Science, Research Gate, and Cochrane Library. The following keywords were used for electronic searching: Health Belief Model, Oral Hygiene Practice, Brushing, and Flossing. Only accessible full-text studies written in English language were included in this review. We excluded meta-analyses and systematic review articles and publications that used only one construct of the HBM. These studies were reviewed to obtain information on the name of authors, year and country of publication, study design, population and sampling technique, validity/reliability, statistical analyses, HBM constructs used, and HBM constructs associated with the outcomes brushing/flossing [Table 1] and [Table 2].

Table 1: Characteristics of the individual studies that applied HBM concerning oral hygiene practice (brushing/flossing)

Click here to view

Table 2: Sampling, validity/reliability, and statistical analyses of the individual studies

Click here to view

PubMed search showed 76 articles. Research Gate showed 28 articles. Web of Science showed 67 articles. Cochrane Library showed 17 articles. After removing articles before 2010, duplication, articles that used only one construct of HBM, and studies that had other outcomes rather than oral hygiene practice, out of 188, 20 studies met the inclusion criteria and were included in the review [Figure 1].

Figure 1: PRISMA flow chart

Click here to view

Results

We sought and collected the following variables from each study: the characteristics of the study including authors’ names, year of publication, and the county, besides the study design and study population; the dependent variables were the HBM construct used in the study and the main dependent variable was the oral hygiene practice.

Methodological aspects

As shown in [Table 1], 12 studies were conducted in Iran.^{[8],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]} Eight studies were experimental: one quasi-experimental,^[8] one randomized trial,^[14] three interventional studies,^{[19],[25],[26]} one clinical trial,^[18] and three were randomized controlled trials.^{[14],[23],[27]} One was a longitudinal study.^[26] Twelve were cross-sectional studies.^{[11],[12],[15],[16],[17],[20],[21],[22],[24],[28],[29],[30]} Only two studies included dental patients,^[11],[12] two included pregnant women,^[18],[19] and one study included diabetic patients.^[23] Other studies included different general population groups.

Cluster sampling was the most frequently used by seven studies,^{[8],[14],[16],[17],[20],[21],[24]} followed by simple random sampling used by three studies.^{[18],[25],[27]} Two studies used systematic sampling,^[15],[23] and two used stratified random sampling.^[17],[24] Two studies used purposive sampling.^[26],[29] One study used census,^[22] and one used convenient sampling.^[30] Sampling techniques were not explicitly reported in three cross-sectional studies, but the description could be classified as simple random sampling upon invitation of those fulfilling the inclusion criteria.^{[11],[12],[28]} Three studies reported blinding as a measure to reduce information bias.^{[18],[23],[27]}

Seventeen studies reported verification of the validity and reliability of the instrument used, except for three studies. Two studies did not report this issue,^[26],[29] whereas one reported that verification was conducted previously.^[30] Cronbach’s alpha was the most reported procedure used for testing validity/reliability. Four studies reported conducting factor analyses.^{[8],[12],[15],[21]} Different analyses techniques were reported. The most used analysis was a regression (linear/binomial) used by 13 studies.^{[11],[14],[15],[16],[17],[20],[21],[24],[25],[27],[28],[29],[30]} χ² analyses were used by seven studies.^{[8],[18],[20],[21],[23],[27],[30]} The t-test was used by nine studies.^{[8],[16],[18],[19],[20],[23],[25],[27],[28]} Four studies used the Mann–Whitney test,^{[15],[18],[23],[27]} whereas only one study used Wilcoxon.^[23] Three studies used statistical models: structural equation modeling (SEM) was used by Ashoori et al.,^[22] generalized estimating equation (GEE) was used by Schluter et al.,^[26] and a path analysis model (LISREL) was used by Anagnostopoulos et al.^[12] Four studies used the correlation coefficient.^{[8],[16],[20],[24]} Three studies used analysis of variance (ANOVA),^{[16],[19],[20]} and only two studies used Fisher’s exact test^[8],[26] [Table 2].

HBM constructs

Ten studies used the five HBM constructs: susceptibility, severity, benefits, barriers, and self-efficacy,^{[11],[12],[14],[15],[18],[19],[26],[27],[28],[29]} whereas one study used cues to action instead of self-efficacy as the fifth construct.^[8] Six studies used the extended HBM with six constructs: susceptibility, severity, benefits, barriers, self-efficacy, and cues to action.^{[17],[21],[22],[23],[24],[25]} Only two studies used a short version of the HBM, one used barriers, benefits, and self-efficacy,^[20] and the other used only two constructs seriousness and benefit.^[30]Self-efficacy and barriers were the most significantly related to oral hygiene practice reported by 15 studies, followed by susceptibility by nine studies, then severity by eight studies, and benefits by seven studies. The least reported as significantly related to oral hygiene practice was cues to action reported only by three studies,^{[17],[22],[24]} and external locus of control was reported by only one study.^[25] Only one study reported no significant association of the HBM constructs with the oral hygiene practice.^[30]

Nine studies reported correlations between oral hygiene and perceived susceptibility/sensitivity. Of them, five studies were among vulnerable groups: older people,^[27] diabetic patients,^[23] and pregnant women.^[18],[19] Susceptibility was also reported among dental patients^[12] and students.^{[8],[15],[25],[26]} Perceived severity appeared in eight studies as significantly associated with oral hygiene behavior.^{[8],[12],[15],[18],[19],[23],[25],[26]} For example, perceived severity was found to relate to oral health status indirectly through toothbrushing frequency. Anagnostopoulos et al.^[12] reported that perceived severity significantly explained the variance in toothbrushing. The respondents who perceived oral diseases as serious more often perceived greater benefits and fewer barriers in toothbrushing and brushed more frequently. Kasmaei et al.^[15] reported that those who brushed at least twice a day had significantly higher perceived objective severity],[ indicating that a higher level of the perceived threat of consequence from not brushing at least twice a day is considered a preventive factor. Perceived barriers were the second reported predictor by 13 studies. Rahmati-Najarkolaei et al.^[17] found perceived barriers as the significant predictor for oral hygiene behavior. They indicated that having higher perceived psychological barriers, the likelihood of brushing less than a day was approximately two and a half times more than having lower perceived psychological barriers. Another study by the same authors reported that perceived barriers significantly predicted oral hygiene behavior.^[17] Charkazi et al.^[16] showed that perceived barriers were one of the variables significantly explaining the variance of brushing behavior.

Moreover, another study assessing the variance flossing behavior showed that one of the significant predictors was barriers.^[11] School and college students reported barriers as predictors in many studies.^{[8],[15],[22],[25],[28]} Seven studies reported benefits as significant predictors of oral hygiene. Solhi et al.^[8] found a negative correlation between the Oral Hygiene Index scores and perceived benefits. Regarding perceived benefits predictability of the variance in oral hygiene behavior, Charkazi et al.^[16] showed that perceived benefits were one of the variables significantly explaining the variance of oral health behavior. Jeihooni et al.^[18] and Gaffari et al.^[19] reported benefits as significantly associated with oral hygiene among pregnant women. Similarly, benefits are associated significantly with oral hygiene behavior among adults and college students.^[25],[26] Patients also reported benefits as a predictor for their oral hygiene behavior.^[23] Five studies reported cues to action as significant predictors: one study among diabetic patients,^[23] whereas four among students.^{[17],[22],[24],[25]} Regarding cues to action, Charkazi et al. found that 61% of high-school students reported their mother as the most common interpersonal influences, followed by fathers (47%), siblings (31.8%), and teachers (29%). Rahmati-Najarkolaei et al.^[17] showed that the constructs of the HBM and demographic variables explained 18% of the variance in oral health behavior, and cues to action was one of the statistically significant predictors in explaining the variance in oral health behavior. From their hierarchical regression, perceived barriers, knowledge, and cues to action accounted for 17% of the total variance in oral health behavior. The inclusion of the cues to action increased the R² significantly. Moreover, the same authors reported in another study that cues to action significantly predicted oral health behavior.^[20]

In assessing the variance in brushing behavior, it was found that one of the significant predictors was self-efficacy.^[11] As reported by 15 studies, self-efficacy was the most reported predictor for oral hygiene behavior.^{[11],[12],[14],[16],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29]} According to Kasmaei et al.,^[15] those who brushed at least twice a day had significantly higher self-efficacy, indicating better conditions for achieving desirable brushing behavior and could be considered a facilitating factor. Charkazi et al.^[16] showed that self-efficacy was one of the variables significantly explaining the variance of oral hygiene behavior. Rahmati-Najarkolaei et al.^[17] found that self-efficacy significantly predicted oral hygiene behavior.

Similarly, Anagnostopoulos et al.^[12] found that self-efficacy significantly explained the variance in toothbrushing frequency. They also reported that patients with confidence in their ability to brush regularly, and who considered that toothbrushing could be performed successfully, reported more frequently toothbrushing and had higher oral health status. The study found that self-efficacy was related to oral health status indirectly via toothbrushing frequency.

Discussion

Even though this review aimed to explore the application of HBM in oral hygiene practice (brushing/flossing) with the expectation of many articles among dental patients, only two studies included dental patients.^[11],[12] One study reported on vulnerable group elderly,^[27] one included diabetic patients,^[23] and two pregnant women.^[18],[19] Twelve studies were cross-sectional,^{[11],[12],[15],[16],[17],[20],[21],[22],[24],[28],[29],[30]} which are not considered conclusive in confirming causal relationship.^[31] The analytical and interventional studies reported more factors associated with oral hygiene practice than descriptive studies, which might explain the relevance and importance of the study design.^{[8],[19],[23],[25],[26]} The accuracy and consistency of any survey tool (questionnaire) form a significant aspect of research methodology. Most of the reviewed studies conducted explained their methods used to test the validity and reliability of the used questionnaire. The variation in using different methods and aspects of validity was observed. There are different validity tests; some are mandatory to apply and some recommended, depending on the type of the questionnaire used.^[32] There was interchangeable use of terms (severity/seriousness and susceptibility/sensitivity, cues to action/external locus of control) among the studies; this might affect the search for the articles.

The inclusion of all constructs of the HBM was inconsistent, and the number of predicting factors included might have affected the number of associated factors. Only one study did not find an association between HBM constructs and oral hygiene behavior. They reported that the HBM constructs did not reach statistical significance,^[30] which might be because the study used a convenient sample of 100 parents of children and only two constructs (seriousness and benefits) of the HBM.

Self-efficacy was the most reported predictor associated with oral hygiene practice, which proved it as consistent with improvements in oral hygiene.^[2] Perceived barriers were the second reported predictor, which was also valid as one of the most substantial factors.^[33] The authors added some aspects of behavioral outcomes such as the study design and the time interval between measurement of the variables and behavior moderated the association as the objectives of the present literature review.

Limitations

This review might be limited due to the inclusion period of 10 years, as other studies were not included. As a literature review, it might not have presented an in-depth interpretation and explanation of the results as in systematic and meta-analyses reviews. Another limitation to be considered as a risk of bias is the difference in results of the effect size that might be due to the unstandardized use of the number of the HBM constructs by all studies, as well as the different methods of measuring oral hygiene practice.

Conclusion

We could conclude that the HBM is widely used, and the model’s psychometric properties were able to explain the oral hygiene practice among different study populations. This might support the validity of the model in both predicting determinants of oral hygiene behavior, as well as the pattern of oral hygiene behavior change. This literature review might form a quick and simple reference for the studies during the period 2010–2020. Readers might consider the limitations mentioned in the future work regarding the utilization of HBM in oral hygiene practice.

Acknowledgement

We acknowledge the work of previous authors who contributed to the field of application of the HBM.

Financial support and sponsorship

No funding was received for this study.

Conflicts of interest

The authors declare no conflict of interest.

Authors’ contributions

EFN contributed in the literature search, identification and classification of articles, revision and writing of the manuscript. NMAS contributed in the conceptual design of the article, identification and classification of articles, revision and writing of the manuscript.

Ethical policy and Institutional Review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

Not applicable.

References

1.	Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. Am J Orthod Dentofacial Orthop 2017;151:229-31.
2.	Sanaei Nasab H, Yazdanian M, Mokhayeri Y, Latifi M, Niksadat N, Harooni J, et al. The role of psychological theories in oral health interventions: A systematic review and meta-analysis. Int J Dent Hyg 2019;17:142-52.
3.	Hollister MC, Anema MG Health behavior models and oral health: A review. J Dent Hyg 2004;78:6.
4.	Rosenstock IM Historical origins of the health belief model. Health Educ Monogr 1974;2:328-35.
5.	Rosenstock IM, Strecher VJ, Becker MH Social learning theory and the health belief model. Health Educ Q 1988;15:175-83.
6.	Martin LR, Haskard-Zolnierek KB, DiMatteo MR Health Behavior Change and Treatment Adherence: Evidence-Based Guidelines for Improving Healthcare. New York: Oxford University Press; 2010.
7.	Flaer PJ, Younis MZ, Benjamin PL, Al Hajeri M A psychosocial approach to dentistry for the underserved: Incorporating theory into practice. J Health Care Finance 2010;37:101-8.
8.	Solhi M, Zadeh DS, Seraj B, Zadeh SF The application of the health belief model in oral health education. Iran J Public Health 2010;39:114-9.
9.	Kühner MK, Raetzke PB The effect of health beliefs on the compliance of periodontal patients with oral hygiene instructions. J Periodontol 1989;60:51-6.
10.	Saito A, Kikuchi M, Ueshima F, Matsumoto S, Hayakawa H, Masuda H, et al. Assessment of oral self-care in patients with periodontitis: A pilot study in a dental school clinic in Japan. BMC Oral Health 2009;9:27.
11.	Buglar ME, White KM, Robinson NG The role of self-efficacy in dental patients’ brushing and flossing: Testing an extended health belief model. Patient Educ Couns 2010;78:269-72.
12.	Anagnostopoulos F, Buchanan H, Frousiounioti S, Niakas D, Potamianos G Self-efficacy and oral hygiene beliefs about toothbrushing in dental patients: A model-guided study. Behav Med 2011;37:132-9.
13.	Michie S, Johnston M, Francis J, Hardeman W, Eccles M From theory to intervention: Mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol Int Rev-Psychol Appl-Revue Int 2008;57:660-80.
14.	Yekaninejad MS, Eshraghian MR, Nourijelyani K, Mohammad K, Foroushani AR, Zayeri F, et al. Effect of a school-based oral health-education program on Iranian children: Results from a group randomized trial. Eur J Oral Sci 2012;120:429-37.
15.	Kasmaei P, Amin Shokravi F, Hidarnia A, Hajizadeh E, Atrkar-Roushan Z, Karimzadeh Shirazi K, et al. Brushing behavior among young adolescents: Does perceived severity matter. BMC Public Health 2014;14:8.
16.	Charkazi A, Ozouni- Davaji RB, Bagheri D, Mansourian M, Qorbani M, Safari O, et al. Predicting oral health behavior using the health promotion model among school students: A cross-sectional survey. Int J Pediatr 2016;4:2069-77.
17.	Rahmati-Najarkolaei F, Rahnama P, Gholami Fesharaki M, Behnood V Predictors of oral health behaviors in female students: An application of the health belief model. Iran Red Crescent Med J 2016;18:e24747.
18.	Jeihooni AK, Jamshidi H, Kashfi SM, Avand A, Khiyali Z The effect of health education program based on health belief model on oral health behaviors in pregnant women of Fasa City, Fars Province, South of Iran. J Int Soc Prev Community Dent 2017;7:336-43.
19.	Ghaffari M, Rakhshanderou S, Safari-Moradabadi A, Torabi S Oral and dental health care during pregnancy: Evaluating a theory-driven intervention. Oral Dis 2018;24:1606-14.
20.	Rahmani A, Hamanajm SA, Allahqoli L, Fallahi A Factors affecting dental cleaning behaviour among pregnant women with gingivitis. Int J Dent Hyg 2019;17:214-20.
21.	Goodarzi A, Heidarnia A, Tavafian SS, Eslami M Predicting oral health behaviors among Iranian students by using health belief model. J Educ Health Promot 2019;8:10.
22.	Ashoori F, Karimi M, Mokarami H, Seif M Using health belief model to predict oral health behaviors in girl students: A structural equation modeling. Pediatr Dent J 2020;30:24-32.
23.	Malekmahmoodi M, Shamsi M, Roozbahani N, Moradzadeh R A randomized controlled trial of an educational intervention to promote oral and dental health of patients with type 2 diabetes mellitus. BMC Public Health 2020;20:287.
24.	Rahmati-Najarkolaei F, Rahnama P, Fesharaki MG, Yahaghi H, Yaghoubi M Determinants of dental health behaviors of Iranian students based on the health belief model (HBM). Shiraz E Med J 2016;17:e39268.
25.	Asawa K, Chakravarty T, Tak M, Rathod D, Sen N Self-assessment of psychological and mechanical factors affecting oral hygiene among Indian college-going students: A model-guided study. Int Q Community Health Educ 2020;40:307-15.
26.	Schluter P, Lee M, Hamilton G, Coe G, Messer-Perkins H, Smith B Keep on brushing: A longitudinal study of motivational text messaging in young adults aged 18-24 years receiving work and income support. J Public Health Dent 2015;75:118-25.
27.	Keyong E, Thitasomakul S, Tianviwat S Effectiveness of an oral health promotion program for the elderly in Khiri Mat district, Sukhothai province: A randomized control trial. J Int Soc Prev Community Dent 2019;9:225-31.
28.	Zetu L, Zetu I, Dogaru CB, Duta C, Dumitrescu AL Gender variations in the psychological factors as defined by the extended health belief model of oral hygiene behaviors. International Conference Psychology and the Realities of the Contemporary World (PSIWORLD 2013), 4th ed. Vol. 127; 2014. p. 358-62.
29.	Phanthavong S, Nonaka D, Phonaphone T, Kanda K, Sombouaphan P, Wake N, et al. Oral health behavior of children and guardians’ beliefs about children’s dental caries in Vientiane, Lao People’s Democratic Republic (Lao PDR). PLoS One 2019;14:e0211257.
30.	Hiratsuka VY, Robinson JM, Greenlee R, Refaat A Oral health beliefs and oral hygiene behaviours among parents of urban Alaska native children. Int J Circumpolar Health 2019;78: 1586274.
31.	De D, Singh S Basic understanding of study types and formulating research question for a clinical trial. Indian Dermatol Online J 2019;10:351-3.
32.	Taherdoost H Validity and reliability of the research instrument; how to test the validation of a questionnaire/survey in a research. Int J Acad Res Manage 2016;5:28-36.
33.	Sulat JS, Prabandari YS, Sanusi R, Hapsari ED, Santoso B The validity of health belief model variables in predicting behavioral change: A scoping review. Health Educ 2018;118:499-512.