Self-Efficacy Perceptions in Oral Health Behavior
- Dental self-efficacy—a person’s conception about his/her ability to perform oral self-care—is important in changing oral health behavior.
- Sources of dental self-efficacy are the model received from home and school, a dentist’s support, one’s own experience in managing oral self-care, and emotional experiences in dental care.
- In order to improve patients’ dental self-efficacy, the dentist provides information concerning oral health, offers positive feedback to patients, gives support to patients, provides models of oral health behavior, and creates a secure, peaceful atmosphere.
- It is important to improve parents’ dental self-efficacy, which in turn is related to the oral health behavior of their children.
- Motivational interviewing is a useful method for improving self-efficacy and changing health behavior.
Theory of Self-Efficacy
Definition of the Concept
Bandura (1977) has advanced a theory of self-efficacy according to which personal self-efficacy is an important factor in behavior. According to the theory, an efficacy expectation is a conviction that a person can successfully fulfill the behavior which is needed to cause definite outcomes. Expectation of self-efficacy determines the beginning of coping behavior, the amount of effort used, and sustainment of the behavior when obstacles appear. In addition to expectation, component capabilities are also needed in order to produce the desired behavior. These include suitable skills and proper incentives (Bandura, 1977). People are afraid of and avoid situations they feel they cannot manage, whereas they act when they consider themselves able to cope (Bandura, 1977).
Bandura (1977) also defines the term outcome expectancy, which is an individual estimate that a certain action will lead to definite outcomes. Efficacy and outcome expectations are different in relation to their effect on behavior, because one may believe that a certain action will lead to a definite outcome, but if the person does not feel capable of performing the action, outcome expectancy does not have an effect on his/her action (Bandura, 1977).
Dimensions of Self-Efficacy
Efficacy expectations have various dimensions such as magnitude, generality, and strength, which vary. Magnitude includes the idea that the efficacy expectations of some people may be restricted to easy tasks or include very demanding ones. Generality on the other hand means that experiences vary from creating restricted self-efficacy to a more generalized expectation of mastery. Strength varies also, meaning that weak self-efficacy expectations may be canceled by undermining experiences, but people with strong expectations will cope despite such experiences (Bandura, 1977).
Sources of Self-Efficacy
According to Bandura (1977), the sources of self-efficacy are performance attainment, vicarious experience, verbal persuasion, and emotional arousal. Performance attainment is the most powerful source because it can consist of authentic experiences of mastery (Bandura, 1982).
People do not trust in their own experiences as the only source of expectations. Vicarious experiences such as the model of other people also have an effect on self-efficacy expectations (Bandura, 1982). Observing other similar people’s success in performing can increase efficacy expectations among the observers.
In verbal persuasion, people are made to believe that they have capabilities which allow them to attain their objective (Bandura, 1982). Social persuasion may have limited power to induce durable growth in self-efficacy, but it can help in achieving success in performance if the persuasive evaluation is realistic.
People trust partly in their physiological state when they evaluate their capabilities. When tasks demand perseverance and strength, people evaluate their pains, aches, and fatigue as signs of physical inefficacy. Failure is more likely expected when people are viscerally agitated and tense, whereas success comes when they are not hindered by aversive arousal (Bandura, 1982).
Self-Efficacy in Health and Health Behavior
A person’s belief in his/her ability to cope with stressors has an effect on biological systems that mediate disease and health (Bandura, 1992). If a person is exposed to stressors but has not perceived efficacy to manage them, this activates endogenous opiates and autonomic and catecholamine systems (Bandura, 1992). After coping efficacy is enhanced, the person manages these stressors without any distress or activation of stress hormones (Bandura, 2000).
Bandura’s Social Cognitive Theory (SCT) includes self-efficacy as a determinant of health behavior, having an effect on control of health habits and progress of biological aging (Bandura, 2000). A person’s self-efficacy beliefs about his/her own behavior and motivation affect a change in behavior: thinking of changing his/her health habits, enrolling perseverance and motivation, maintaining an achieved habit, and being sensitive to relapse (Bandura, 2000).
Self-efficacy has been found to relate to various health-related practices such as a change in dietary behavior (Cerin, Barnett, & Baranowski, 2009), smoking cessation (Spek et al., 2012), physical activity in diabetes (Qiu et al., 2012), and promoting intake of vegetables and fruits (Thomson & Ravia, 2011). Self-efficacy has also been found to be an important mediator in the relation between exercise and disability among elderly people (Motl & McAuley, 2010), and it is used in educational interventions in heart failure (Yehle & Plake, 2010).
Dental Self-Efficacy in Determining Oral Health Behavior and Oral Health Status
McCaul, Glasgow, and Gustafson (1985) found among 131 college students that self-efficacy and outcome expectations predicted retrospectively reported brushing and flossing and also self-monitoring of these behaviors, whereas Wolfe, Stewart, and Hartz (1991) did not find self-efficacy items among 99 male veterans to relate to plaque index.
Stewart, Strack, and Graves (1997) found among 103 employees that self-efficacy in brushing and flossing scales were significantly correlated with dental knowledge and frequency of brushing, flossing, and dental visits. Outcome expectations of dental disease were significantly correlated with flossing and willingness to spend money in order to save teeth. Outcome expectations of brushing and personal beliefs were correlated with dental visits and willingness to spend to save teeth. The writers interpret their results to suggest that outcome expectations and self-efficacy expectations are a separate domain in oral hygiene beliefs.
Syrjälä, Kneckt, and Knuuttila (1999) found among 149 insulin-dependent diabetes mellitus (IDDM) patients that toothbrushing self-efficacy was related to reported frequency of toothbrushing, approximal cleaning self-efficacy to reported frequency of approximal cleaning, and dental visiting self-efficacy to reported frequency of dental visiting. Dental plaque was inversely correlated with toothbrushing and dental visiting self-efficacy. Women had significantly higher sum scores than men in brushing and dental visiting self-efficacy. Kneckt et al. (1999) reported similarly that a combination of brushing and dental visiting self-efficacy as dental self-efficacy was associated with the sum of decayed surfaces. Dental self-efficacy and diabetes self-efficacy were correlated. Furthermore, Syrjälä et al. (2004) reported on a similar comparative analysis in which psychological characteristics such as self-efficacy, intention, locus of control, or self-esteem most comprehensively explained oral health habits, deepened periodontal pockets, dental caries, diabetes adherence, and HbA1c. Both dental and diabetes self-efficacy were found to be related to diabetes adherence and oral health habits. Only self-efficacy was associated with both oral health habits and diabetes adherence.
Kakudate et al. (2007) and Kakudate, Morita, and Kawanami (2008) have developed self-efficacy scales (SESS) for periodontal patients, including subscales such as SE-DC, self-efficacy in dental consultation; SE-B, self-efficacy in toothbrushing; and SE-DH, self-efficacy in eating habits. In a pilot study, Kakudate et al. (2008) found that patients with successful completion of periodontal therapy had higher SESS and subscale SE-DC scores when compared with patients who failed to follow the periodontal therapy. Later they confirmed these results when they found that those who had middle SESS scores (OR: 1.05, CI: 0.36–3.07) or low SESS scores (OR 4.56, CI: 1. 11–18.74) at the baseline were more likely to lose periodontal maintenance care when compared to those with high scores (Kakudate et al., 2010b).
Self-Efficacy and Other Health Behavior Theories
Tedesco, Keffer, and Fleck-Kandath (1991) found that adding self-efficacy variables into Fisbein and Ajzen’s theory of reasoned action increased the variance of reports of brushing and flossing teeth, and Jönsson et al. (2012) found that when self-efficacy variables were added to the theory of reasoned action, self-efficacy was the way through which normative beliefs had an impact on interproximal cleaning. However, McCaul, O’Neill, and Glasgow (1988) did not find the addition of self-efficacy variables to the theoretical model of reasoned action to enhance prediction of oral health habits.
Buglar, White, and Robinson (2010) found among 92 dental patients that the Health Belief Model’s variable obstacles to brushing and flossing and self-efficacy in brushing and flossing significantly predicted corresponding behavior. The authors concluded that dental professionals ought to urge patients’ self-confidence in brushing and flossing and discuss with patients how they could cope with obstacles to performing oral hygiene. Furthermore, Anagnostopoulos et al. (2011) analyzed Health Belief Model variables and toothbrushing self-efficacy beliefs in dental caries and the frequency of toothbrushing among 125 dental patients. The Health Belief Model variable “severity of oral diseases” as well as higher self-efficacy beliefs were related to a higher frequency of toothbrushing, which was related to better oral status.
Morowatisharifabad et al. (2011) tested the Transtheoretical Model to get an understanding of change in interdental cleaning behavior among 361 12th grade students in Iran. The stages of interdental cleaning and psychological attributes such as self-efficacy and decisional balance were identified. The results showed that about half of the students were in the precontemplation stage and 13% were in the maintenance phase, correspondingly. Decisional balance and self-efficacy differed in terms of behavioral change in interdental cleaning. The authors conclude that the Transtheoretical Model was useful when defining the stages in behavioral change. Empirically supported interventions should be developed in order to enhance interdental cleaning behavior, emphasizing improvement in the self-efficacy of the students in this context.
Lee et al. (2012) analyzed the relation between oral health literacy (OHL) and oral health status and dental neglect, and the role of self-efficacy in mediating or modifying these relations. The study population included 1280 females in the Special Supplemental Nutrition Program for Women, Infants, and Children. A word recognition test was used to measure OHL, and data on oral health status were received with a self-reported item on the National Health and Nutrition Examination Survey (NHANES). It was found that higher OHL was related to better oral status, and self-efficacy was strongly negatively correlated with dental neglect. The authors conclude that increased OHL was related to better oral health status but not to dental neglect. Self-efficacy was strongly correlated with dental neglect and may disseminate the role of literacy in dental status.
Self-efficacy is a determinant of health behavior also in the Theory of Planned Behavior and the Protection Motivation Theory (Bandura, 2000). Furthermore, self-efficacy in health behavior has been found to correlate with locus-of-control beliefs, self-esteem, and intention in health behavior (Syrjälä et al., 2004).
Sources of Dental Self-Efficacy in Oral Health Behavior
According to Bandura (1981), the formation of perceived self-efficacy begins in infancy and grows as a result of interaction with the family and widens in interaction with peers. Self-efficacy is affected by transitional experiences in adolescence, and it is moderated in adulthood by opposing demands and reappraised with advancing age. Thus, formation of self-efficacy continues during the lifetime of a person. Many habits that imperil health are formed in childhood and adolescence (Bandura, 2000).
In order to improve perception of dental self-efficacy in patient-centered interaction, it is important to understand the formation and role of dental self-efficacy. Syrjälä, Knuuttila, and Syrjälä (2001) describe five sources of dental self-efficacy in a qualitative study. They selected five participants for a focused interview on the basis of scores in a quantitative questionnaire about oral health orientation. On the basis of the interview, it was found that one basic source of dental self-efficacy was knowledge about oral health behavior. Two persons with poor dental self-efficacy proposed that a lack of knowledge affected their self-efficacy. The second source of self-efficacy was experience in caring for one’s own oral health. The participants’ own experience of taking care of their teeth either sufficiently or insufficiently, with consequences of good or poor oral health, seemed to be related to better or poorer self-efficacy, respectively. The third dimension was support received from the dentist. People who had gotten support from their dentist had better dental self-efficacy, whereas lacking supportive experience was related to poorer dental self-efficacy. Negative emotional arousal, such as a difficult extraction, was a source of poor dental self-efficacy but, on the other hand, two persons had overcome their previous negative experiences in dental care and now wanted to take care of their teeth, thus resulting in better self-efficacy. The fifth source was the model received in childhood, like from home or school, and the person who had had a model of taking care of teeth regularly in childhood now had better self-efficacy.
The Role of the Family in the Self-Efficacy of Children
Cinar, Tseveenjav, and Murtomaa (2009) have analyzed self-efficacy and toothbrushing among preadolescents and their mothers using the SCT. The study population included Turkish (n = 611) and Finnish (n = 338) preadolescents and their mothers. They found that Turkish preadolescents and mothers had lower toothbrushing frequency and lower self-efficacy when compared with Finnish children and mothers. Finnish children with high self-efficacy more likely also had mothers with high self-efficacy. Maternal self-efficacy accounted for Finnish preadolescents’ toothbrushing behavior (Cinar et al., 2009).
Finlayson et al. (2007a) have analyzed the association between several maternal behavioral, cognitive, and psychosocial factors and brushing habits among preschool children of 1021 African-American families. They used in the analysis previously developed scales for mothers, such as maternal oral-health-related self-efficacy, OHSE; knowledge about appropriate use of bottle, KBU; knowledge of children’s oral hygiene, KCOH; and belief in oral health fatalism, OHF (Finlayson et al., 2005). Maternal oral-health-related self-efficacy, OHSE, was found to predict 1- to 3- and 4- to 5-year-old children’s brushing frequency, and mothers’ better knowledge of children’s oral hygiene, KCOH, was related to 1- to 3- and 4- to 5-year-old children’s brushing frequency (Finlayson et al., 2007a). In another report (Finlayson et al., 2007b), maternal self-efficacy was not, however, associated with early childhood caries among 1- to 5-year-old children.
Kakudate et al. (2010a) have developed “a task-specific self-efficacy scale for maternal oral care” (SESMO), including self-efficacy subscales for brushing (SESMO-B), dietary habits (SESMO-DH), and dentist consultation (SESMO-DC). Negative correlations were found between the number of teeth with decay and SESMO and SESMO-DC scores and positive correlations between frequency of weekly toothbrushing of children’s teeth and SESMO and SESMO-B scores.
Interventions in Self-Efficacy to Improve Oral Health Behavior
Hölund (1990) reports an intervention in which 14-year-old students learned about health matters by teaching younger students. Knowledge about dental caries and sugar, nutrition and sugar, self-efficacy, and beliefs concerning susceptibility were evaluated before and after intervention. Fourteen-year-old students worked first in groups having various topics. In a computer group, dietary habits were analyzed among fourth graders. A culture group analyzed local and national factors affecting dietary habits. A food and fashion group dealt with commercials and body image. A health group compared caries prevalence between fourth and eighth graders. The eighth graders had to present their results on posters to the fourth graders. It was found that the intervention had no effect on posttest self-efficacy, but in a 2-month follow-up, self-efficacy was improved a little.
Stewart et al. (1996) reported an intervention among 123 veterans. Before the intervention, the subjects’ self-efficacy concerning brushing and flossing was evaluated. The participants also completed a Dental Health Knowledge Questionnaire before the study and 5 weeks thereafter. All the participants were given a demonstration of toothbrushing and dental flossing. An educational intervention included four information sessions about periodontal disease and correction of oral hygiene techniques. A psychological intervention included also four sessions based on the model presented by Prochaska and DiClemente (1983)/>