New research developments frequently are neither adopted by providers nor utilized by patients. This dual problem of impacting the behaviors of providers and patients presents a challenge. This paper will present behavioral theories and technologies that can be utilized to impact both provider and patient behaviors

AE Walker

AL Monson

C Benitez

DB Astroth

DC Johnsen

DD Squires

DE Kanouse

E Britt

E Rogers

G Nilsson

GJ Dilley

JL Dolcourt

JM Grimshaw

JM Lockyer

JO Prochaska

K Parker

LL Casbeer

N Stott

N Tinanoff

P Weinstein

PE Mazmanian

Philip Weinstein

PJ Riordan

R Harrison

R Wutoh

TS Tillis

WR Miller

WR Smith

BMC Oral Health

English

PubMed

Crossref

Behavioral Problems In The Utilization Of New Technology To Control Caries: Patients And Provider Readiness And Motivation

New research developments frequently are neither adopted by providers nor utilized by patients. This dual problem of impacting the behaviors of providers and patients presents a challenge. This
paper will present behavioral theories and technologies that can be utilized to impact both provider and patient behaviors

Weinstein, Philip

Name not available

ResearchWorks at the University of Washington

Springer - Publisher Connector

BioMed CentralBMC Oral Health
ssOpen AcceProceedings
Behavioral Problems In The Utilization Of New Technology To 
Control Caries: Patients And Provider Readiness And Motivation
Philip Weinstein*
Address: Department of Dental Public Health Sciences, University of Washington, Seattle, WA 98195, USA
Email: Philip Weinstein* - philw@u.washington.edu
* Corresponding author    
Abstract
New research developments frequently are neither adopted by providers nor utilized by patients.
This dual problem of impacting the behaviors of providers and patients presents a challenge. This
paper will present behavioral theories and technologies that can be utilized to impact both provider
and patient behaviors.
Introduction
Provider Readiness
There is a very small literature on the efficacy of interven-
tions impacting the behaviors of dental providers. The lit-
erature in medicine is larger, but also without much of a
theoretical base [1].
Kanouse and Jacoby [2] suggest that the diffusion model
[3] has led to an overemphasis on the importance of infor-
mation, ignoring other factors such as the practitioners'
motivation to change. Grimshaw and colleagues [4] sug-
gest exploring the application of behavioral theories to
the understanding of professional behavioral change.
Similarly, Walker and colleagues [5] suggest the problem
of understanding why health professionals do or do not
change their practices is similar to finding out why people
do or do not adopt a healthy lifestyle, a research area that
has been extensively investigated. Interestingly, Parker
and Parikh [6] hypothesize that health practitioner behav-
iors may not change as a consequence of continuing edu-
cation because the learner is not "ready to change." These
authors recommend Prochaska and DiClemente's [7]
Transtheoretical Stages of Change Model. This model pos-
tulates that change is a process that proceeds through spe-
cific stages, each of which has key characteristics –
characteristics that are amenable to targeted, stage-specific
or matched interventions. The Transtheoretical Stages of
Change Model may provide a theoretical model to guide
the development and testing of provider interventions.
The Stages of Change Model has enjoyed considerable
success as a means of understanding and promoting
behavior change in people with addictive disorders and
other unhealthful behaviors. This model has recently
been applied to dental disorders [8-10]. The number of
proposed stages and their definitions vary somewhat
depending on the study, but five stages are generally cited
as follows:
Precontemplation (not thinking about or planning to
change within the next 6 months – What problem?)
Contemplation (considering, intending to change with in
the next 6 months – Should I change?)
from Biotechnology and Biomaterials to Reduce the Caries Epidemic
Seattle, USA. 13–15 June 2005
Published: 10 July 2006
BMC Oral Health 2006, 6(Suppl 1):S5 doi:10.1186/1472-6831-6-S1-S5
<supplement> <title> <p>Biotechnology and Biomaterials to Reduce the Caries Epidemic</p> </title> <editor>Rebecca L Slayton, James D Bryers, Peter Milgrom</editor> <note>Proceedings</note> <url>http://www.biomedcentral.com/content/pdf/1472-6831-6-S1-info.pdf</url> </supplement>
© 2006 Weinstein; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
BMC Oral Health 2006, 6:S5Preparation/Action (planning to change in the next
month – Can I change?)
Action (making relevant changes – How do I change?)
Maintenance (sustaining change – Is it worth it?).
There is some evidence that the Stages of Change model is
useful in understanding and influencing practitioner
behaviors. Problem-oriented interventions may be useful.
For example, Nilsson and colleagues [11] found feedback
of individual prescribing rates combined with problem-
oriented outreach visits effective in altering prescribing
rates and patterns for hypertension. Intent to change, the-
oretically at the Preparation Stage, has been found to be
associated with changes in managing cardiovascular dis-
ease [12]. Enhancing commitment to change can be seen
as an intervention in its own right [13,14].
Patient Readiness And Motivation
It is not surprising that information and education have
been insufficient to alter the behaviors of the parents of
children at risk for dental caries. While some parents of
children with ECC are unaware of the etiology of this dis-
ease [15-17], research does not support the efficacy of pro-
viding information to the parents or caretakers [18-20].
Educating patients in dental and medical settings is fre-
quently an exercise in overt persuasion. What appears to
be a convincing line of reasoning to the dental profes-
sional falls on deaf ears or results in reluctance to change.
Patients have reservations about "being told what to do"
[21]. More fundamental is the possibility that direct per-
suasion, whatever the degree of readiness to change,
pushes the patient into a defensive position. There is evi-
dence that the effectiveness of advice giving (information
with persuasion) about lifestyle change is only 5–10%
[22].
While advice giving has not been successful, there have
been promising results using a counseling approach,
which is more patient-centered. For example, in dentistry
a counseling approach has been found to be successful.
Harrison and Wong [23] reported that children whose
mothers had at least two counseling sessions had signifi-
cantly fewer decayed surfaces than children at baseline.
The counseling approach featured one-on-one counseling
by a lay worker, personalization of recommendations,
and telephone follow-up of mothers.
While the Stages of Change theory provides understand-
ing of the process of change, Motivational Interviewing
(MI), a brief counseling approach that focuses on skills
needed to motivate others, provides strategies to move
patients from inaction to action. This brief approach has
been successful in impacting addictive behaviors and has
recently been used to establish positive health-related
behaviors [24]. Recently, Weinstein, Harrison and Benton
[25,26] have reported a study of 240 high-risk infants
aged 6 to 18 months and their parents. They were ran-
domly assigned to MI or traditional health education
groups. After two years there was a 50% reduction in the
incidence of caries in the MI group.
The MI approach allows exploration of a problem in a
supportive environment that expresses acceptance and
provides affirmations of the person's strengths. It involves
asking questions before providing information and
advice. Persons are encouraged to talk, and there is an
attempt to understand the person's frame of reference.
These techniques are borrowed from Rogers' non-direc-
tive patient-centered therapy. However, the approach is
directive; advice is given, with the person's permission,
and is accompanied with encouragement to make choices.
There are two phases to MI. The client or patient is active
in both phases. First there is an attempt to establish rap-
port and trust and to help identify the problem of con-
cern. During this phase the patient or client moves from
the Precontemplative to the Contemplative stage. In psy-
chological field theory terms, the intent is to increase the
gradient of approach. The goals are achieved primarily by
asking open-ended questions and by demonstrating that
the listener has heard the person by paraphrasing or sum-
marizing (active listening). For example, in our protocol
with the parents of 6–18 month old high-risk children, we
asked the parent to answer the question, "What is it like to
be Georgie's mom?" The next question focused on oral
health. "Tell me about your dental health and the health
of your family?" This was following by "What do you want
for your child's dental health?" or "If I (or God) could
grant you one wish for your child's teeth (a dental mira-
cle), what would it be? The last question "sets the hook."
The parent is now telling us what she desires for the oral
health of her child.
The second phase involves moving from the Contempla-
tive to the Preparation/Action stage. Patients at the Con-
templative stage are said to be ambivalent; they have a
need to change, but they perceive obstacles to change. The
person is asked to weigh the pros and cons of changing.
"What are the costs, the benefits of changing? What hap-
pens if you do nothing?" Choice is stressed, and there is
discussion of the potential obstacles to action for each
action option. Working with the person focuses mainly
on identifying a plan to act. Menus of potential changes
are used in even briefer versions of MI.
The attempt in this phase is to lower the gradient of avoid-
ance. Behavior change technology is very useful in helping
the transition between planning and sustained action. ThePage 2 of 4
(page number not for citation purposes)
BMC Oral Health 2006, 6:S5emphasis in this technology is on the establishment and
maintenance of habits. Continuity of care and follow-up
is also part of this approach. A workbook useful in MI
training for dental personnel has been written [27].
MI can be useful in helping establish and then maintain
positive oral health behaviors. However, regimens that
require considerable parental or patient attention will
have higher failure rates. For example, taking a daily fluo-
ride tablet has been found to be a problem for low-
income persons [28]. Compliance with daily parental
tooth cleaning and the chewing or ingestion multiple
times a day of xylitol products may also be problematic.
The more we require, the less the cooperation, even with
an effective behavioral intervention. New dental interven-
tions are needed that require as little as possible of
patients.
While MI has not been used in changing provider behav-
iors, there is some evidence that a provider-centered
approach has been successful. For example, Casebeer and
colleagues [29] found that Web-based instruction for phy-
sicians that used (1) office-practice data to assess needs
and (2) tailored case vignettes with feedback resulted in
changes when compared to a control condition. Assessing
the readiness of a dental provider to change existing prac-
tices and utilize new technology may prove to be a key in
designing MI-driven interventions that may be used on
the internet. Does the provider perceive limitations of the
existing approach? Is he/she aware of the benefits of the
new technology? What are the perceived problems in
adapting the new technology? What happens if nothing is
changed?
Although internet-based continuing education is still in
its infancy, analyses of 16 controlled studies have pro-
vided subjective evidence of short-term changes in pro-
vider behaviors [30]. Moreover, MI software has been
developed that is interactive and has been used on-line to
tailor a counseling approach to identify and then reduce
problem drinking [31]. The application of Stages of
Change Theory and MI-like approaches has significant
promise to impact the behaviors of both patients and pro-
viders.
Competing interests
The author(s) declare that they have no competing inter-
ests.
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Behavioral Problems In The Utilization Of New Technology To Control Caries: Patients And Provider Readiness And Motivation

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