Authentic Patient Involvement
To encourage individuals to improve their oral health, use andragogy rather than behaviorism
Howard M. Notgarnie, RDH, EdD
A colleague once complained, "That patient doesn't learn. Every time she comes in for her prophy, I show her how to floss, but 6 months later she comes in, and she's still not flossing." This statement implies three dental hygiene diagnoses:
1. Behavioral deficit related to a need for personal responsibility for one's oral health.
2. Healthy oral cavity related to minimal signs of inflammation or demineralization.
3. Deficit in psychomotor skills of flossing related to inadequate interproximal cleansing.
The described patient encounter is characteristic of a behavioral approach to patient education. "Behaviorism" assumes a direct relationship between a precedent and a result. Do what I say, and you'll get what you want. This principle works in laboratory experiments because the environment is controlled for objective measurements. However, a person's health status is affected by non-behavioral factors.1
Historically, behaviorism's objectivity gave a sense of scientific credibility to psychology that had not long earlier elevated biology and the physical sciences. It was an important step, particularly in measuring the psychological aspects of non-human animals, and defined learning as a change in behavior, with little attention given to communication. However, learning is not merely about a change in behavior; it is also about knowing and valuing something. Behaviorism with respect to human learning is therefore manipulative. It violates the ethical principle of autonomy. Moreover, a systematic review of oral health instruction showed that instruction aimed at behavioral change had little effect on behavior and no effect on the signs of health associated with caries risk and periodontal diseases.2
This tradition of behavioral approach arose from health professionals defining patients' health status, prescribing actions to address that health status, and expecting patients to follow through on that prescription because they value their health the same way we do. However, as healthcare professionals, we often bias goals toward our own values, and the communication of our knowledge is not always correct or complete. In addition, the patients also learn from a variety of sources, which can be even more misleading. As a result, with a behavioral approach alone, patients do not always truly understand why they are being prescribed certain actions or products and may not yet value the intended result.
In contrast, when patients actually learn the theory behind a health deficit and can, with guidance, choose their own behavior changes and interventions, they will choose an individualized plan with a clear, attainable goal.1
This contrasting approach is termed "andragogy." Andragogy recognizes that patients will learn when they are ready and internally motivated to learn something that is meaningful to them. They already have some knowledge, and when they learn something new, they incorporate the new knowledge into their pre-existing paradigm, if they can fit that knowledge into their needs and have control over what they learn. Patients educated with this andragogical approach become involved, active learners who seek services and self-care tools to solve health deficits.3
Applying andragogy begins with assessment. If our colleague completed a periodontal evaluation, she could have plenty of data indicating demineralized spots and inflammation. Patients can see these signs and easily incorporate this knowledge into their paradigm; it is uncomfortable to have a lesion, so this becomes a motivator. If the periodontal evaluation reveals a healthy mouth, great! Instead of lecturing the patient to take up a habit she currently doesn't need, casually talk about a health issue the patient may find interesting. I explained to patients that the calculus I remove doesn't cause periodontal disease, but because it harbors biofilm, we remove it to make a more cleansable surface. I explained how a large amalgam can fracture a tooth over time. Conversations like these come to the forefront when the periodontal evaluation or other diagnostic services don't show great results.
The diagnosis could also be improved with andragogy. Prophylaxis, by definition, implies a healthy mouth. From the patient's point of view, the dental hygienist is doing the same thing she always does. If she saw something going wrong, she would do something different. Since there is nothing wrong, the self-care regimen needs no change. The patient doesn't need this lecture. But was "healthy" the correct diagnosis? Or prophy the correct treatment? Stating the diagnosis and showing its signs elicit patients' search for solutions.
Andragogy could improve intervention. The dental hygienist was approaching the need for flossing as a psychomotor deficit, a deficit that had not been established. Maybe this person is already good at flossing but does not care to do it. Maybe this person is using other interdental cleaners or would use them if a dental hygienist introduced them. If there is gingivitis or periodontitis, the dental hygienist should treat it with the appropriate scaling procedure and more frequent care. If there is an elevated risk of caries, fluoride treatment and use of prescription strength fluoride at home could be recommended. Not only is this the standard of care, but it demonstrates to the patient that something is wrong and needs attention.
Dental hygienists encourage healthy behavior, but behaviorism violates autonomy, does not address the patient's values, and does not actually improve health. Andragogy, on the other hand, fosters patients taking personal responsibility for their health and treatment. They accept standard of care, commit to appointments, and receive cost-effective care that promotes a healthy life.
About the Author
Howard M. Notgarnie, RDH, EdD, is a retired clinical dental hygienist and owns the continuing education service Advanced Professional Education in Toms River, New Jersey.
References
1. Clark JE, Sirois E. Coercion versus self-selection when treating issues of overfatness: a narrative review. Health Educ J. 2023;82(5),475-486.
2. Soldani FA, Lamont T, Jones K, et al. One-to-one oral hygiene advice provided in a dental setting for oral health. Cochrane Database Syst Rev. 2018;10:CD007447.
3. Niksadat N, Rakhshanderou S, Negarandeh R, et al. Concordance of the cardiovascular patient education with the principles of andragogy model. Arch Public Health. 2022;80:4.
