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The adoption of healthy patterns of behaviours conducive to improving and maintaining health are at the centre of health promotion strategies. Health promotion strategies based on changing care policy have been particularly successful.1,2 However, health education programmes which have relied solely on the individual changing their own health actions have had varying levels of success1,2,3.

Criticisms of these latter programmes have been directed to a lack of understanding of psycho-social factors by the health care professionals.4 It has been suggested that providing dental health advice at the expense of understanding how health attitudes and behaviours developed, evolved and were modified with time, were cited as the main reasons for disappointing results.5 It seemed that by ignoring the patients' life histories and experiences it was impossible to understand why patients varied so much in their reactions and responses to one-to-one dental health education.4,5

In an attempt to understand patients' compliance or reluctance to adhere to dental health advice, it was suggested that the development of dental health attitudes, perceptions and behaviours should be central to health education programmes.6 It was essential that dental health professionals were acquainted with their patients' life histories. The factors, which were considered so important in the development of health attitudes and behaviours, became collectively known as the psycho-social determinants of health attitudes and behaviours.

Being aware of the psycho-social determinants of a patient's health behaviours does not give practitioners permission to blame or criticise their patients. It provides a basis for an understanding of the difficulties patients experience when complying with dental health care advice. It must be stressed that the patient does not make a conscious decision either to comply or not comply as their ability to do so is affected by these very psycho-social determinants. Psycho-social factors intervene in the relationship with the health professional making it possible or impossible for the patient to comply. Psycho-social factors influence the treatment alliance (see part 2 of this series) by reducing the means by which patients can use the information given to them for change.4

Dental health professionals are not immune to these psycho-social influences. Their health attitudes and behaviours are equally affected by their life experiences, including personal histories and professional training which should allow the patients' difficulties to be thought of as a dynamic interplay within the dentist-patient interaction. Indeed the dentists' own health beliefs and attitudes may influence the patients' ability to comply with the dental health messages.

This article examines the role of psycho-social factors as determinants of health behaviours. It analyses the development of dental health attitudes and behaviours from the patient, professional and societal perspectives. The aim of this article is to present the practitioner with a structure to understanding the difficulties patients may encounter when trying to comply with dental health care.

The concept of a health career

The development and evolution of health attitudes and behaviours throughout a person's life has been called a health career. A health career provides the health professional with:

...a description of the ways in which an individual's attitudes to a health issue develop over time.7

A person's health career starts at birth and so family attitudes and behaviours are the first influences upon an individual's health perceptions termed primary socialisation.8 During childhood and adolescence health attitudes are affected by friends and peers (secondary socialisation).8 As time passes colleagues (professionalisation)9 and the attitudes of society (social norms) contribute to how a person perceives his/her health. Put simply a health career describes how health perceptions are modified with time and age.7,8,9

The psycho-social determinants of health behaviours contribute to the formation of the health career but also may provide the basis for future problems which may exist when people try to change their health behaviours. When an individual attempts to modify or change their dental health behaviour the path forward is blocked by the factors which were instrumental in the construction of his/her health career in the first place. For instance the individual's socio-economic background, level of education attained, relative wealth/poverty as well as family circumstances are salient in this regard. Previous dental health care experiences, whether good or bad, will also temper the individual's reactions to dental health education. All these psycho-social factors mould an individual's health career, and affect their readiness to modify their health attitudes and change their behaviours.

The concept of a dental health career

Dental health attitudes and behaviours develop and change with age and lifestyle as for any other aspect of health and therefor that a dental health career also exists. In truth a dental health career tracks the development of dental health attitudes from birth through adolescence to adulthood.7

The dental health career: Primary socialisation

In childhood the most important influences upon dental health attitudes and behaviours are those gleaned from parents and family. The small child imitates or identifies with the parents' attitudes and behaviours. During these early years the child mimics the parents' actions. The parent, by caring for the child's bodily and dental health, shows and teaches the young child how to take care of herself.10

It is important to emphasise that small children do not necessarily want their faces washed or teeth cleaned and the parent must do this for them.10 Gradually, as the child's manual dexterity develops, the child will brush her teeth and wash her face as it was done previously by the parent. It is through this process of emotional identification8 with the parent, a process which has been called 'primary socialisation', that children learn to take care of their bodies and teeth.

Case 1 By way of illustration of the process of primary socialisation, a female patient's experiences with her 15-month old daughter are characteristic. The mother had always cleaned her daughter's teeth and this had become quite a game at bed-time until her daughter insisted on 'doing it herself'. She held the brush tight, pushing it into her own mouth, thus imitating her mother's own actions and thus learning how to care for her teeth.

The dental health career: Secondary socialisation

As time progresses the child will start school. At school other influences — teachers and friends and so forth — will shape the child's dental health attitudes and behaviours. As the child makes attachments outside the family — with parental substitutes such as teachers and their peers — another, similar process of emotional identification occurs.8 Through the process known as 'secondary socialisation' the child emulates the attitudes and behaviours of friends and teachers. Occasionally this may lead to difficulties with differences in health attitudes and behaviours between home and school, resulting in what is called 'culture clash'. This so-called culture clash has been reported to occur when dental health professionals' children attend school. Case 2 is typical of such experiences encountered by dental health professionals.

Case 2 Mrs P, a dental health promotion officer, complained about the school her son was attending. The teaching was excellent and she was delighted with the care afforded to her boy but during the last few days at school her son, like the other children, had been given a sweet as a reward for his excellent behaviour. Mrs P, personally, restricted her son's confectionery eating to a Saturday. She felt that he was receiving 'mixed messages' from home and school as a result of the school's reward system.

The importance of school based health education, nevertheless, has been recognised as a means of helping children develop their own health care attitudes and behaviours. The importance placed upon peers as advocates in this regard has been successfully used in child-to-child teaching programmes.11 These programmes recognise the value of peers as a means of providing dental health information to other, usually younger children. In the peer group teaching scenario the older child not only gains a greater understanding of the needs of younger children but also develops his/her own dental health care skills

As time progresses the child enters pre-adolescence and adolescence.13 During pre-adolescence and adolescence more and more friendships are made with people outside the home. The shift from parents and family to friends and peers is mirrored by a change in dental health care attitudes and behaviours. Difficulties arise when the adolescent's wishes are opposed by those of the parent. Recent research examining non-compliance with orthodontic care has clearly shown that it is the conflict between parent and adolescent which influences the success of continuing orthodontic treatment.12

Case 3 illustrates how conflict between a mother and her son affected compliance.What can be learnt from Ms H's experience with Keith? First, Keith had not chosen to return to complete his orthodontic treatment — that had been mother's decision. Secondly, he was dentally anxious and he worried about the prospect of having more teeth extracted. Thirdly, he had made a transference to Ms H, whom he felt was like his mother 'nagging [him]' and finally, in terms of his psychological development was still not interested in his appearance (pre-adolescence). These four psycho-social factors, recognisable by Keith's behaviour and demeanour, contributed to his non-compliance. In later discussion with Ms H, he admitted that he felt that the treatment was being foisted upon him and therefore had decided not to be co-operative. In protest Keith had refused to clean his teeth.

Case 3 The dentist, Ms H, was asked to see Keith, a 14-year old boy, for orthodontic care. Keith already had experience of orthodontic treatment which had failed. Mother was very keen for Keith to have orthodontic treatment and for it to be a success. He had been told by mother that following the initial treatment failure he was now being given a second chance. On examination it was apparent that he had not cleaned his teeth for some days. Ms H referred him to her hygienist and it was decided that before orthodontic treatment would begin Keith would need to improve his oral hygiene. The overall treatment was explained to him, including the need for two further tooth extractions. At this news Keith looked worried and in the ensuing weeks Keith's oral hygiene gradually became worse. Ms H was furious. When Ms H discussed Keith's deteriorating gum health with him, Keith mentioned that his mother nagged him about brushing his teeth. Ms H stated that she felt that Keith was 'a hopeless case'.

The dental health career: Tertiary socialisation7,8,9

In adulthood, psycho-social factors serve to sustain a pressure on individuals which affect their dental health. The process by which this occurs has been termed 'tertiary socialisation'. Tertiary socialisation does not necessarily occur, in the natural order of things, but may be imposed upon the individual by outside agencies. It is proposed that three aspects of tertiary socialisation exist. The first of these is associated with dental health education, the second with the process of professionalisation and the third with the influence of social norms. Tertiary socialisation may (as in professionalisation) or may not (as in dental health education) involve an identification with another person (parent, peer or colleague) or group of people (society) and may or may not be associated with a power differential between people or groups within society. In these respects tertiary socialisation may differ from either primary or secondary socialisation.

Tertiary socialisation and dental health education 7, 8

When the aim of tertiary socialisation in the guise of dental health education claims to modify health attitudes and change behaviours it is doomed to failure. Health education, given in this context, takes little or no account of the psycho-social factors which contributed to inappropriate health actions in the first place. Some people, as in the case of Mr G (see part 3 of this series), may feel there is little point in modifying or changing their dental health behaviours. In such instances there may be a reinstatement of previous behaviours which were detrimental to the patient's dental health. In other circumstances competing lifestyle and health priorities may contribute to the patient's health decisions and actions. The issue of smoking cessation in combination with the prevention of dental caries are examples of how competing health priorities may result in apparent non-compliance.

Case 4 Mr T attended his dentist on a regular basis. His dental health status remained stable and apart from the occasional scale and polish nothing remarkable, in terms of his dental health status, was (noted although he was a smoker). It was with some surprise that, at his next annual examination, a number carious lesions were detected. Mr T was referred to the practice hygienist to discover why he had developed so many carious lesions. He did not describe himself as a heavy smoker but had felt that 'the time had come to give up'. He had been told that 'keeping [his] mouth occupied would help him break the habit'. Every time he craved a cigarette he popped a boiled sweet into his mouth. He reckoned he was eating a lot of sweets.

Mr T could have proved to be a difficult case — his compliance with his doctor's advice competing with that of his dentist's. In order to help Mr T in his conflict — whose advice to take — the hygienist had to acknowledge the need to find yet another substitute for his cigarettes. She suggested the use for sugar free chewing gum or sugar-free sweets. By discovering the reason for Mr T's apparent non-compliance the hygienist was able to find a solution to enable him to maintain his behaviour change. Mr T, however, was exceptional as he was determined to change and he was able to use the advice given to him to modify and maintain his new and healthier pattern of behaviour.

Tertiary socialisation and professionalisation 9

As mentioned previously, professionalisation, (see part 3 of this series), is the process by which an individual becomes a member of a professional body.9 Professionalisation is characterised by a shift from lay to professional health agendas thereby modifying communication styles (this will be covered in part 8 of this series) and changes in health attitudes and behaviour.

With regard to transformation of health care regimes, three processes are important. First, there is the process of identifying with other dental health professionals. As with secondary socialisation, the admired teacher or colleague will be emulated. Teachers' and colleagues' dental health attitudes, clinical and personal actions will be incorporated into the student's patterns of behaviour. These will be observed and incorporated into the acquisition of new skills and knowledge.

The second process in professionalisation is connected with acquiring new health information. Therefore, transformations in health attitudes are also related to an increased awareness of the aetiology of oral diseases. Examples of changing patterns of health care are to be found in the oral hygiene regimes of pre-clinical dental students. When asked how many used dental floss, few replied in the affirmative. The same students, a year later, had changed their behaviours as the majority were now using floss on a daily basis.

These shifts in behaviour were associated with modifications in attitude. For dental students a change in health attitude was associated with a concern for their gingival health. Thinking in this way allows the role of a disease orientated approach to be acknowledged in their preventive health care. This suggests that the changes observed in health actions are, in part, a result of a heightened awareness of the pathological process. As an example (Case 5) concerns about personal gingival health was raised by an hygienist student.

Case 5 During an oral examination, the dentist commented that the student hygienist had a localised area of gingivitis. The young woman became upset and stated, 'This is dreadful! Gingivitis in my mouth, where is it! I must see! It must be attended to immediately,I can't be brushing properly'.

Although acquired early in the practitioner's professional life these shifts in health attitudes and behaviour have a long-term stability. For instance, dentists' children have lower experiences of dental caries compared with equivalent professional groups. These findings suggest that the changes in personal health actions acquired during professionalisation remain fixed with time.14

The third process associated with professionalisation affects society at large. It does this through its power and influence. The power is also connected to the knowledge and training on which the work of the profession is based. Dentistry has gained a monopoly over an area of expertise and the right to self-determination. The recognition of this expertise and knowledge by society affords members of the profession a place within society which influences their dental health attitudes and behaviour.

Tertiary socialisation and social norms

Societal attitudes or social norms affect attitudes towards dental health. At a society level, for instance, public attitudes towards water fluoridation has effectively reduced the availability of fluoride in the public water supplies.

Social norms can be considered as expressions of the beliefs and attitudes of people who belong to a particular social group. In this sense social norms not only afford a cohesiveness to the group but also permit it to have a sense of identity. It is this identity which gives the group its characteristics. Dental health promotion strategies which are targeted at groups of people, in what has been termed the settings approach, acknowledges the importance of social norms as a salient element in behaviour change.

It has been suggested that social norms have a tenacity of their own. Nevertheless, they may be gradually modified with time and between generations or change abruptly with social mobility. For example, social norms can be gradually modified within a three generation family with the attitudes of grandparents being quite different to those of their grandchildren. Social mobility, in terms of movement through socio-economic groups, has been shown to affect dental health attitudes and behaviour in an abrupt way. Social mobility via marriage has been shown to provide the impetus for changes in dental health care actions being associated with changing social norms.15

Conclusions

It has been proposed that people's attitudes and behaviours towards health, in general and dental health in particular, are a culmination of life experiences and events. Influences from childhood, through school and into adulthood have been shown to determine an individual's health perceptions. This has been called a 'health career'. Understanding how health behaviours evolve, develop and are modified with time allows dental health professionals to take a first step in appreciating the complexities involved when people attempt to modify their dental health care attitudes and behaviour.