Journal of American College Health

ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: https://www.tandfonline.com/loi/vach20

Effectiveness of a theory of planned behavior-

based intervention for promoting periodontal
preventive behaviors among medical students in
Taiwan

Huei-Lan Lee, Ying-Chun Lin, Wu-Der Peng, Chih-Yang Hu, Chien-Hung Lee,
Yuan-Jung Hsu, Yea-Yin Yen & Hsiao-Ling Huang

To cite this article: Huei-Lan Lee, Ying-Chun Lin, Wu-Der Peng, Chih-Yang Hu, Chien-Hung Lee,
Yuan-Jung Hsu, Yea-Yin Yen & Hsiao-Ling Huang (2019): Effectiveness of a theory of planned
behavior-based intervention for promoting periodontal preventive behaviors among medical
students in Taiwan, Journal of American College Health, DOI: 10.1080/07448481.2019.1628029

To link to this article: https://doi.org/10.1080/07448481.2019.1628029

Published online: 09 Jul 2019.

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JOURNAL OF AMERICAN COLLEGE HEALTH
https://doi.org/10.1080/07448481.2019.1628029

MAJOR ARTICLE

Effectiveness of a theory of planned behavior-based intervention for promoting

periodontal preventive behaviors among medical students in Taiwan
Huei-Lan Lee, MSa,b
, Ying-Chun Lin, PhDa
, Wu-Der Peng, PhDc, Chih-Yang Hu, PhDd, Chien-Hung Lee, PhDb,e,
Yuan-Jung Hsu, MSa,f, Yea-Yin Yen, PhDa, and Hsiao-Ling Huang, DrPHa,e
a
Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; bDepartment of Public Health,
College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan; cDepartment of Medical Sociology and Social Work, College of
Humanities and Social Science, Kaohsiung Medical University, Kaohsiung, Taiwan; dDepartment of Environmental & Occupational Health
Sciences, School of Public Health, Health Science Center, Louisiana State University, New Orleans, LA, USA; eDepartment of Medical
Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; fSchool of Dentistry, College of Dental Medicine, Kaohsiung Medical
University, Kaohsiung, Taiwan

ABSTRACT ARTICLE HISTORY

Objective: To evaluate the effectiveness of an oral self-care education intervention based on the Received 22 June 2018
Theory of Planned Behavior in Taiwanese undergraduates. Revised 17 February 2019
Participants: We recruited 63 and 90 students in the experimental group (EG) and comparison Accepted 3 June 2019
group (CG), respectively, from a medical university.
KEYWORDS
Methods: A quasi-experimental design was employed. The EG received health education and a Health education;
brief action and coping planning intervention. periodontal; health
Results: The EG was significantly more likely to brush for more than 3 minutes (adjusted odds behavior; theory of
ratio [aOR] ¼ 2.52), use the modified Bass brushing technique (aOR ¼ 7.81), and floss (aOR ¼ planned behavior
21.21) at the 2-week follow-up than was the CG. At the 6-week follow-up, the combined effect of
high action and coping planning with high perceived power for predicting floss use was observed
in the EG (p < 0.05).
Conclusions: Intervention may promote periodontal-disease-preventing behaviors in undergradu-
ates, particularly for achieving adherence to daily flossing.

Introduction degrees; although 60% of the surveyed adults were aware of

how to use dental floss to clean interdental spaces, only 16%
Periodontal disease, the most common chronic oral disease,
actually flossed.8
mainly results from infection and inflammation of the gums
The World Health Organization defines the social
and bones surrounding and supporting the teeth.1 Severe
accountability of medical schools as the obligation to direct
periodontal disease can lead to loss of alveolar bone, increas-
education, research, and service activities toward addressing
ing tooth mobility and eventually leading to tooth loss and
the priority health concerns of the country, region, and
subsequent loss of oral function, reducing quality of life. In
a US study,2 46% of adults aged 30 years or older (corre- nation that they have a mandate to serve.9 Indeed, if a phys-
sponding to 64.7 million people) had periodontitis; of them, ician or medical student leads a healthy lifestyle, this may
8.9% had severe periodontitis, and the incidence of peri- have a positive influence on patients, helping them make
odontal disease increased with age, with 70.1% of adults favorable choices and lead healthy lives.10,11 The students
aged 65 years or older having periodontal disease. attending a medical school that encourages healthy personal
Gingivitis can be controlled and treated through good practices were discovered to have a significant influence on
oral hygiene and regular professional cleaning. Regular their counseling of patients about preventive interventions.12
interproximal or interdental cleaning is associated with less Oral health and self-care behavior performance is typically
bacterial plaque, dental calculus, and gingivitis.3 Regular more optimal among people with higher education levels,
flossing removes plaque from interproximal areas effect- such as university students.13,14 However, a survey compar-
ively.4–6 In Taiwan, permanent tooth extraction due to den- ing the periodontal health status and oral health behaviors
tal caries is common in all age groups, but that due to of Japanese and Chinese dental students reported less use of
periodontal disease is becoming more prevalent in patients interdental devices and a higher gingival bleeding rate in the
aged older than 35 years.7 A Taiwanese survey reported that Chinese students than in the Japanese students (7.6% vs.
more than 90% of adults had periodontal disease to varying 33.1% and 37.0% vs. 7.6%, respectively).15

CONTACT Hsiao-Ling Huang [email protected] Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, 100 Shih-
Chuan 1st Road, Kaohsiung City 80708, Taiwan.

Equality contribution
ß 2019 Taylor & Francis Group, LLC
2 H.-L. LEE ET AL.

Psychosocial variables and intention to engage in healthy predictors of flossing behavior at the 4-week follow-up,
behaviors can predict health behavior changes.16–18 The accounting for 2.3% of the variance in this variable.27
Theory of Reasoned Action (TRA), introduced by Fishbein Action plans have become crucial tools in patient self-man-
in 1967,19 predicts the intention to perform a behavior, agement programs, and in one study, successful completion
rather than the behavior itself. The TRA determines behav- was associated with improved health and self-efficacy out-
ioral intention by measuring attitude and social normative comes at 6 months.28 A longitudinal study examined action
perceptions. Attitude is determined by people’s beliefs about and coping planning of physical exercise in 352 cardiac
the outcomes or attributes of a behavior (i.e., behavioral patients23 during rehabilitation treatment and followed up at
beliefs) weighted by their evaluations of those outcomes or 2 and 4 months after discharge. The study reported that
attributes. Similarly, people’s subjective norms are deter- action planning was more important at the earlier stage of
mined by their normative beliefs—whether their relevant behavior change; however, participants with higher coping
others would approve or disapprove of them performing the planning level after discharge were more likely to report
behavior—weighted by their motivation to comply with the doing more exercise 4 months after discharge. Thus, both
expectations of these relevant others. The success of the action and coping planning interventions may be included
TRA in explaining a behavior depends upon the degree to at different stages for promoting long-term lifestyle changes.
which the behavior is under volitional control. However, Health care students are future health care providers. In
whether TRA components sufficiently predict behaviors general, health care providers have an entire career of deliv-
without volitional control remains unclear. ering care and serve as role models and coaches, encourag-
The Theory of Planned Behavior (TPB), proposed by
ing others to adopt healthy lifestyle behaviors; accordingly,
Ajzen,18 is an extension of the TRA that includes an add-
they must provide dental-related preventive counseling and
itional construct regarding the Perceived Behavioral Control
be knowledgeable on dental issues. Therefore, the present
(PBC). According to the TPB, PBC is determined by control
study conducted oral health education, with action and cop-
beliefs concerning the presence or absence of facilitators and
ing planning strategies, intervention for promoting peri-
barriers to behavior performance, weighted by the perceived
odontal-related preventive self-care behaviors in
power or effect of each factor in facilitating or inhibiting the
behavior. Thus, a person with strong control beliefs about undergraduates studying health science. We evaluated the
the presence of factors facilitating a behavior has high PBC. potential effects of action and coping planning strategies
One study examined the value of the TPB model of together with PBC on postintervention adherence to
behavioral intention and self-efficacy expectation regarding daily flossing.
the dental hygiene behaviors of 131 students recruited from
introductory psychology classes (mean age, 24 [range,
18–45] years).20 The findings revealed that the TPB model
accounted for 32% and 30% of the variance in intention to Materials and methods
brush and to floss teeth, respectively. Moreover, a study Design
with 487 participants reported that PBC was the most accur-
ate predictor of oral hygiene behavior.21 This quasi-experimental study was approved by the
The intention–behavior gap refers to when an individual Institutional Review Board of Kaohsiung Medical University
forms an intention but fails to act on it.22 Intentional behav- Hospital (KMUH-IRB-20110161).
ior requires self-regulation. Planning, a prospective and self-
regulatory strategy, involves mental simulation linking con-
crete responses to future situations. Planning can be divided
into two subconstructs: action planning, wherein partici- Participants
pants complete a planning form stating when, where, and
how they will achieve a behavioral goal during the next The study participants were college students at a medical
week, and coping planning, wherein they determine how to university in Southern Taiwan. In a priori sample size esti-
address the barriers to achieving their goal.23,24 Behavioral mation, 51 participants per group was calculated as provid-
change needs to address issues of action implementation ing 80% power (two-sided type 1 error of 5%) for detecting
rather than motivational factors alone.25 People are more a 0.5 effect size. In total, we recruited 63 students from the
likely to perform a regular behavior if where and when they Department of Public Health and 90 students from the
will perform the behavior are planned, facilitating the trans- Department of Medical Social Work to form the experimen-
formation of a behavioral intention into an actual behavior. tal group (EG) and comparison group (CG), respectively.
In a prospective study conducted over 6 weeks and with 258 The EG received short-term oral health educational instruc-
undergraduate psychology and educational science students tion and a handbook on oral self-care and floss use; this
in Berlin, Germany, planning appeared to be a significant group also completed an if–then action planning form. By
predictor of adherence to a daily flossing regimen.26 contrast, the CG received only a leaflet on floss use. In total,
Another study, which had a prospective design and used 61 (96.8%) and 78 (86.7%) participants in the EG and CG,
1,509 25-year-old Norwegians as a sample, demonstrated respectively, completed the study at all time points. Figure 1
that intention and action planning were independent presents a flowchart of the research design.
 JOURNAL OF AMERICAN COLLEGE HEALTH 3

Figure 1. Flowchart of research design.

Measures prevent tooth decay.” Each item was rated on a 5-point

Likert scale ranging from 1 (completely disagree) to 5 (com-
A structured questionnaire was developed to collect baseline
pletely agree). Evaluation (Cronbach’s a ¼ 0.86) was meas-
and follow-up data. All instruments were adapted from
ured using 10 items, such as “Brushing my teeth every day
those in the literature. The questionnaire obtained demo-
to prevent decay is important,” each of which was rated on
graphic information and data regarding oral self-care behav-
iors, TPB components, and action and coping planning. a 5-point Likert scale ranging from 1 (unimportant) to
Each measure was checked for scale reliability and internal 5 (important).
consistency. An expert panel reviewed the questionnaire to
assess its content validity. To ensure adequate comprehen-
sion of the scales, the questionnaire was pilot tested among Subjective norm
30 college students. The TPB variables were measured using To assess subjective norm, normative beliefs (Cronbach’s
three scales, namely attitude, subjective norms, and PBC;
a ¼ 0.88) were measured using 15 items, such as “My family
each scale was divided into two dimensions. Furthermore,
thinks I should use dental floss every day.” Moreover,
the action and coping planning variables were measured
motivation to comply (Cronbach’s a ¼ 0.88) was measured
using planning scales.
using 15 items, such as “I want to floss every day if my fam-
ily thinks I should.” Responses to the normative beliefs and
Attitude toward oral hygiene behaviors motivation to comply items were rated using 5-point Likert
To assess attitude toward oral hygiene behaviors, behavioral scales ranging from 1 (completely agree) to 5 (completely dis-
beliefs (Cronbach’s a ¼ 0.87) were measured using 9 items, agree) and from 1 (very likely) to 5 (very unlikely),
such as “I think that by brushing my teeth every day, I can respectively.
4 H.-L. LEE ET AL.

Perceived Behavioral Control (PBC) instruction and a handbook on oral self-care and floss use;
To assess PBC, control beliefs (Cronbach’s a ¼ 0.79) were this group also completed an if–then action planning form.
measured using 10 items, such as “The extent to which By contrast, the CG received only a leaflet on floss use. The
flossing habits were influenced by the provision of free oral-health-related handbook contained information on
floss,” and perceived power (Cronbach’s a ¼ 0.69) was meas- tooth and periodontal structures, descriptions of caries and
ured using four items, such as “Learning how to use floss is periodontal disease, and instructions on periodontal disease
easy for me.” Items concerning control beliefs and perceived prevention. In addition, the EG received a self-care kit with
power were evaluated using 5-point Likert scales ranging detailed information on why and how to perform oral self-
from 1 (very easy) to 5 (very difficult) and from 1 (very care (i.e., the modified Bass brushing and flossing techni-
unlikely) to 5 (very likely), respectively. ques). A one-time group instruction session covering a
health education course was arranged for the entire EG.
This 2-hour course was delivered by a dental hygienist in a
Action and coping planning classroom during the students’ lunch break.
The EG received an additional part of the questionnaire, The action and coping planning strategies taught in the
which contained scales regarding planning for flossing and intervention were adapted from the literature.26 The EG was
measured action and coping planning variables from Times required to complete an if–then action planning form, which
1 to 3.27,29 Five items were employed to measure action was divided into two sections. In the first section, the partic-
planning: the stem “I have made a detailed plan ipants were required to plan where, when, and how to use
regarding … ” followed by (a) “ … when to floss my teeth,” floss and to record their floss use at home. In the second
(b) “ … where to floss my teeth,” (c) “ … how to floss my part, the participants were required to formulate plans to
teeth,” (d) “ … how often to floss my teeth,” and (e) “ … how overcome the barriers they might encounter during the pro-
much time to spend flossing.” Coping planning was meas- cess. The entire if–then planning process lasted 15 minutes.
ured using seven items: the stem “I have made a detailed The free floss boxes provided to the EG contained 5 m of
plan regarding … ” followed by (a) “ … what to do if some- floss. Five boxes were provided to each participant (two and
thing interferes with my plan,” (b) “ … how to cope with three boxes at Times 1 and 2, respectively). All boxes were
possible setbacks,” (c) “ … what to do if I forget to floss,” returned, and the length of unused floss was measured. All
(d) “ … what to do in difficult situations to act according to boxes were encoded with participant identification numbers.
my intentions,” (e) “ … how to motivate myself,” (f) “ … how
to cope with bleeding gums,” and (g) “ … how to cope with
pain.” The internal consistency and reliability of the action Data collection
and coping planning scale were 0.95 and 0.92, respectively.
Data were collected at three assessment time points: pretest
(Time 1), 2-week follow-up (Time 2), and 6-week follow-up
Oral self-care behaviors (Time 3). At Time 1, the participants completed a self-
Flossing (past behavior) at Time 1 was assessed using the administered structured questionnaire comprising items con-
item “Have you ever used floss in the past?” At Time 2, cerning demographic information (e.g., age and sex), TPB
flossing behavior was assessed using the item “How often variables, and oral self-care behaviors. The EG was also
did you floss during the last 2 weeks?” The response to this required to complete the action and coping planning scales.
item was coded as 0 (never) or 1 (at least once daily). Floss At Time 2, the participants completed an identical posttest
packets were distributed at Times 1 and 2 and collected at questionnaire. The EG returned the planning forms and two
Times 2 and 3, respectively; the leftover floss was measured. floss boxes, the length of floss remaining was recorded, and
Frequency of brushing was assessed using the item “How the EG was provided with three more boxes of floss and sec-
often did you brush your teeth?” The response to this item ondary planning forms. At Time 3, the participants com-
was coded as 1 (once daily), 2 (twice daily), or 3 (three or pleted a second posttest questionnaire. The EG completed
more times daily). Brushing method was coded as 0 (other) planning scales and returned the floss boxes.
or 1 (modified Bass brushing technique). Brushing duration
was coded as 0 (3 minutes or less) or 1 (more than
Data analysis
3 minutes). Toothbrush choice was coded as 0 (non-ultra-
compact head and hard bristles) or 1 (ultracompact head and All analyses were performed using STATA (version 10.0).
soft bristles). Toothbrush replacement time was coded as 0 Descriptive statistics were calculated for each variable. The
(more than 3 months or when broken) or 1 chi-square test was used to compare the demographics of
(within 3 months). the EG and CG. A p value of < 0.05 indicated a statistically
significant difference between the two groups. The paired t
test was used to compare mean within-group differences in
Intervention
TPB measures and planning variables from the baseline to
The peer group educational intervention was conducted posttest. The two-sample t test was employed to compare
from May to December 2012. A well-trained researcher mean between-group differences in TPB measures from the
approached participants and recruited them in their class- baseline to posttest. The effect size (Cohen’s d) of the con-
rooms. The EG received short-term oral health educational tinuous variables was calculated as the mean difference
 JOURNAL OF AMERICAN COLLEGE HEALTH 5

between the baseline and follow-up, and between the EG measurement divided by the standard deviation of the sam-
and CG baseline and follow-up mean difference ple. An effect size of 0.20 is small, 0.50 is moderate, and
0.80 is large.30 Logistic regression analysis was employed to
Table 1. Descriptive information arranged by two group. determine the influence of the intervention on oral self-care
EG CG behaviors between Times 1 and 2 in the two groups. The
Factor/category n (%) n (%) P-value adjusted odds ratio (aOR) and 95% confidence intervals
Gender (CIs) were calculated in the multivariate analysis. To test the
Male 25 (39.7) 17 (18.9) 0.005 combined effects of perceived power, along with action and
Female 38 (60.3) 73 (81.1)
Socioeconomic status coping planning, on floss usage prediction in the EG at
High 16 (25.4) 17 (18.9) 0.388 Time 3, action and coping planning and perceived power
Moderate 39 (61.9) 55 (61.1)
Low 8 (12.7) 18 (20.0)
were classified as “high” or “low” using the median scores.
Living conditions
Live in own house 18 (28.6) 21 (23.3) 0.279
Live in dormitory 24 (38.1) 46 (51.1) Results
Live in rent 21 (33.3) 23 (25.6)
Parents’ Marital status Table 1 presents the demographic information of the EG
Married 59 (93.7) 82 (91.1) 0.241
Divorce 3 (4.8) 2 (2.2)
and CG. The proportion of male participants was signifi-
Widowed 1 (1.6) 6 (6.7) cantly higher in the EG than in the CG (39.7% vs. 18.9%).
Have a boy (girl) friend Sociodemographic variables did not significantly differ
Yes 15 (23.8) 16 (17.8) 0.648
Ex-boy(girl) friend 17 (27.0) 25 (27.8) between the groups.
Never 31 (49.2) 49 (54.4) Table 2 details the effect sizes and mean differences in TPB
Chi-square test. EG: Experimental group. CG: Comparison group. measures and planning variables at all time points among

Table 2. Values at baseline and at 2- and 6-week follow-up, effect sizes and mean differences of theory of planned behavior (TPB) measures and planning varia-
bles among undergraduates.
EG CG Mean difference
between EG and CG
Mean (SD) Effect sizea Mean (SD) Effect sizea (95% CI) p-value
Effect sizeb (95% CI)
TPB variables
Attitude toward behavior
Behavioral beliefs
Baseline 38.3 (3.7) 38.1 (3.4)
Two-week 39.7 (3.6)‡ 0.56 38.1 (3.7) 0.00 1.33 (0.33,2.31) 0.009 0.46 (0.11,0.80)
Evaluation
Baseline 38.9 (3.9) 39.5 (5.0)
Two-week 40.3 (3.7)† 0.43 39.0 (5.0) 0.08 1.83 (0.34,3.31) 0.016 0.42 (0.08,0.76)
Subjective norm
Normative beliefs
Baseline 53.3 (5.8) 53.7 (8.0)
Two-week 56.9 (6.3)‡ 0.73 54.5 (7.5) 0.09 2.74 (0.21,5.28) 0.034 0.37 (0.03,0.71)
Motivation to comply
Baseline 59.4 (8.0) 58.0 (8.0)
Two-week 60.0 (6.1) 0.08 57.2 (8.1) 0.10 1.34 (1.28,3.97) 0.312 0.17 (0.16,0.51)
Perceived behavioral control
Control beliefs
Baseline 34.1 (4.2) 34.5 (5.0)
Two-week 35.5 (4.1)† 0.34 34.0 (4.4) 0.10 1.84 (0.36,3.32) 0.015 0.42 (0.08,0.77)
Perceived power
Baseline 14.3 (2.7) 13.3 (3.4)
Two-week 15.1 (2.3)‡ 0.37 13.6 (2.7) 0.08 0.53 (0.34,1.40) 0.228 0.21 (0.13,0.55)
Planning
Baseline 35.1 (6.6)
Two-week 43.8 (6.3)‡ 1.66
Six-week 45.3 (6.5)‡ 1.71
Action planning
Baseline 15.2 (3.3)
Two-week 18.2 (3.1)‡ 1.07
Six-week 19.2 (2.9)‡ 1.38
Coping planning
Baseline 19.8 (3.8)
Two-week 25.6 (3.8)‡ 1.58
Six-week 26.2 (4.1)‡ 1.56
SD: standard deviation; CI: confidence interval.
†Paired-t test, p < 0.05 for the comparison from the baseline to 2-week follow-up and 6-week follow-up at the same group.
‡Paired-t test, p < 0.01 for the comparison from the baseline to 2-week follow-up and 6-week follow-up at the same group.

p-value were calculated for the difference in means by two independent samples t-test between the EG and CG at 2-week follow-up.
a
Effect size calculated and as the mean difference between baseline and follow-up measurement.
b
Effect size calculated and as the mean difference of change between baseline and 2-week follow-up measurement between the EG and CG. Effect size are
Cohen d; an effect size of 0.20 is small, 0.50 is moderate, and 0.80 is large.
6 H.-L. LEE ET AL.

Table 3. Logistic regression analysis of oral self-care behaviors from the baseline to 2-week’s follow-up in the two groups.
EG CG
a
Variables n (%) n (%) OR (95%CI) p-value
Change in frequency of tooth brushing
3þ times of brushing (per day) 5 (8.2) 3 (3.9) 1.59 (0.34–7.41) 0.550
Brushing teeth 3þ min 15 (24.6) 7 (9.0) 2.52 (1.33–9.84) 0.012
Modified bass method use 18 (29.5) 4 (5.1) 7.81 (2.42–25.14) <0.001
Ultra-compact head and soft 15 (24.6) 9 (11.5) 2.24 (0.88–5.69) 0.090
bristles toothbrush
Toothbrush replacement 11 (18.0) 6 (7.7) 2.25 (0.75–6.69) 0.145
Change in use of dental flossing 28 (45.9) 3 (3.9) 21.21 (5.93–76.26) <0.001
a
OR was adjusted for gender.

Figure 2. The combined effects of perceived power along with action planning (A) and coping planning (B) on predicting floss usage in the experimental group at
6-week’s follow-up.
Note:
denotes p < 0.05, compared with low perceived power and low action planning in (A) and low perceived power and low coping planning in (B).

undergraduates. The behavioral beliefs (38.3 ± 3.7 vs. (aOR: 21.21; 95% CI: 5.93–76.26). However, tooth brushing
39.7 ± 3.6), evaluation (38.9 ± 3.9 vs. 40.3 ± 3.7), normative frequency, toothbrush choice, and toothbrush replacement
beliefs (53.3 ± 5.8 vs. 56.9 ± 6.3), control beliefs (34.1 ± 4.2 vs. time did not significantly differ between the two groups.
35.5 ± 4.1), and perceived power (14.3 ± 2.7 vs. 15.1 ± 2.3) scores Figure 2 illustrates the combined effects of perceived
of the EG were significantly higher at Time 1 than at Time 2. power in addition to action planning (Figure 2-A) and cop-
The significant mean differences in behavioral beliefs (mean ing planning (Figure 2-B) at Time 2 on predicting floss use
difference: 1.33; 95% CI: 0.33–2.31; effect size: 0.46), evaluation in the EG at Time 3. Compared with the participants with
(mean difference: 1.83; 95% CI: 0.34–3.31; effect size: 0.42), high perceived power and high action planning, those with
normative beliefs (mean difference: 2.74; 95% CI: 0.21–5.28; low perceived power and low action planning had an
effect size: 0.37), and control beliefs (mean difference: 1.84; 95% increased floss use (877.1 vs. 569.7 cm, p ¼ 0.030). Similarly,
CI: 0.36–3.32; effect size: 0.42) scores were observed in the EG floss use was higher in the participants with high perceived
than in the CG. The mean planning scores increased from power and high coping planning than in those with low per-
Time 1 (35.1 ± 6.6) to Time 2 (43.8 ± 6.3, p < 0.01) and Time 3 ceived power and low coping planning (988.9 vs. 604.7 cm,
(45.3 ± 6.5, p < 0.01). Compared with that at Time 1, the mean p ¼ 0.010). No significant interaction was identified between
action and coping planning scores at Times 2 and 3 were sig- perceived power and action and coping planning.
nificantly different in the EG.
Table 3 shows the effects of the health education inter-
Discussion
vention on oral self-care behaviors from Time 1 to Time 2
in the two groups. Compared with the CG, the EG was Our study demonstrates that a short-term theory-based
more likely to brush for more than 3 minutes (aOR: 2.52; intervention that employed a planning form has the poten-
95% CI: 1.33–9.84), use the modified Bass brushing tech- tial to promote self-care behaviors that can prevent peri-
nique (aOR: 7.81; 95% CI: 2.42–25.14), and use dental floss odontal disease in undergraduates. This simple and brief
 JOURNAL OF AMERICAN COLLEGE HEALTH 7

planning intervention may have affected the students’ floss- power. The finding that PBC, action planning, and coping
ing behavior over 6 weeks. The finding indicates an increase planning are predictive of oral self-care behavior is in agree-
in floss use when college students plan when, where, and ment with previous studies.26,27,29 Our intervention aimed
how to use floss. Studies involving a similar sample have to build the self-confidence of the participants by increasing
suggested that the flossing behavior of university students is their perceived power to overcome obstacles to performing
improved when they make such plans.26,31 However, barriers oral self-care behaviors. One study reported PBC as the
including the inability to resist temptation or cope with most critical factor predicting oral hygiene behavior; simul-
external obstacles are common during plan implementation. taneous control over obstacles to performing the target
Therefore, forming a coping plan can facilitate the perform- behavior markedly influences decisions regarding behavior
ance of an activity and suppress potential interference effects execution.21 Moreover, when people perceive that behavior-
on behaviors.32 contributing factors (e.g., benefits and anticipated positive
In our results, the EG had significantly higher levels of outcomes) more strongly influence their decisions regarding
behavioral beliefs, evaluation, normative beliefs, and control behavior execution than do behavior-hindering factors (e.g.,
beliefs at Time 2 than the CG. Thus, the health educational costs and anticipated negative outcomes), they are more
intervention may have improved the level of TPB variables. likely to perform relevant health behaviors.18
All effect sizes between Time 1 and Time 2 were higher in the
EG than the CG. Medium effect sizes were detected for behav-
ioral beliefs and normative beliefs and small effect sizes were Limitations
detected for evaluation, control beliefs, and perceived power This study had several limitations. First, the gender difference at
in the EG. The effect sizes of the TPB variables were found to baseline between the two groups may threaten the internal valid-
be small in the CG. However, small-to-medium effect sizes for
ity of the findings. However, the gender variable was accounted
behavioral beliefs, evaluation, normative beliefs, and control
for in our multiple regression models. Second, we used a self-
beliefs were observed in the present study. Regarding belief-
report questionnaire for data collection. Because of social desir-
based measures, the most significant mean difference between
ability concerns, the participants may have provided answers
the EG and CG and the highest effect size were obtained for
that they perceived to be preferable rather than providing
behavioral beliefs, followed by control beliefs and normative
answers that reflected their actual habits and plans, particularly
beliefs. In agreement with some TPB-based intervention stud-
regarding floss use. We verified floss use frequency by measuring
ies,33,34 teaching using a leaflet resulted in significantly higher
the length of floss in the returned floss boxes, potentially reduc-
TPB measure scores than reading a leaflet only.
ing concerns regarding validity. Third, large CIs were obtained
Our study demonstrated that the group education approach
for brushing time, use of the modified Bass brushing technique,
incorporating planning intervention may effectively enhance
oral self-care behaviors including brushing time, brushing tech- and flossing behavior performance. The precision of the point
nique, and floss use. Young adults are a focal group for inter- estimate for the study results may have been limited because of
ventions, because it is at this stage of life that self-regulated self- these large CIs. A larger sample is suggested in future studies.
care behaviors are developed. The health education activities Fourth, the current recommendations for periodontal health
implemented in this study contributed by instructing the stu- maintenance emphasize teeth brushing, daily flossing, and peri-
dents in correct concepts, showing that teaching college stu- odic dental checkups. However, in the present study with a
dents appropriate brushing and flossing techniques can short-term intervention period, we could not monitor the regu-
increase their self-efficacy for floss use and ensure more appro- larity of the participants’ dental visits; this variable must be
priate brushing, subsequently leading to a reduction in plaque addressed in future studies. Finally, the participants were health
formation and preventing periodontal disease. This finding is science students at a medical school. The findings thus cannot be
consistent with previous results, indicating that action and cop- generalized to other settings and populations.
ing planning can prompt oral hygiene behavior when people Nevertheless, this study may have several implications
have high conscious control over their behavior.29,32 because it indicates the potential effects of theory-based oral
This study determined the effects of action and coping health education interventions on oral self-care behaviors in
planning with perceived power of PBC for predicting long- undergraduates. Our study showed higher flossing frequency
term floss use in the EG. The participants who showed (45.9%) among the public health students in a medical univer-
more progress in their coping planning at Time 2 were sity at the 2-week follow-up after the intervention compared
found to floss more frequently at Time 3 than those who with the baseline. Therefore, it is safe to make practical recom-
did not plan to floss. Despite having a low progressive mendations for health care professionals on the basis of our
action plan, the participants in this study were observed to research. Moreover, the findings indicate that perceived power
have more frequent floss use at Time 3 (6-week follow-up) is a significant factor affecting adherence to daily flossing.
when their perceived power was high. In addition, strong Thus, to promote self-care behaviors, interventions should tar-
planning and high perceived power at Time 2 predicted an get participants’ perceived power over these factors to increase
increase in floss use at Time 3. This indicates that coping or long-term behavioral performance.
action planning alone cannot affect flossing behavior over In conclusion, high perceived power of behavior control,
6 weeks; long-term behavioral change requires an interven- along with action and coping planning strategies may be par-
tion based on action or coping planning with high perceived ticularly promising for ensuring people adhere to daily flossing
8 H.-L. LEE ET AL.

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Conflict of interest disclosure
5978(91)90020-T.
The authors have no conflicts of interest to report. The authors con- 19. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health
firm that the research presented in this article met the ethical guide- Education: theory, Research, and Practice. 4 ed. San Francisco,
lines, including adherence to the legal requirements, of Taiwan and CA: Jossey-Bass; 2008.
received approval from the Institutional Review Board of Kaohsiung 20. Mccaul KD, O’Neill HK, Glasgow RE. Predicting the perform-
Medical University Hospital. ance of dental hygiene behaviors: An examination of the
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