Self-efficacy, planning and action control in an oral self-care intervention

Article (PDF Available)inHealth Education Research 30(4):671-81 · August 2015with 161 Reads
DOI: 10.1093/her/cyv032 · Source: PubMed
Abstract
To evaluate a theory-guided intervention on oral self-care and examine the possible mechanisms among self-regulatory factors, two brief intervention arms were compared, an information-based education treatment and a self-regulation treatment focusing on planning and action control. Young adults (N = 284; aged 18-29 years) were assessed at baseline and 1 month later. The self-regulation intervention improved levels of oral self-care, dental planning and action control. Moreover, a moderated mediation model with planning as the mediator between experimental conditions and dental outcome, and self-efficacy as well as action control as moderators elucidated the mechanism of change. More self-efficacious participants in the self-regulation condition benefitted in terms of more planning, and those who monitored their actions yielded higher levels of oral hygiene. Dental self-efficacy, dental planning and action control are involved in the improvement of oral self-care. Their joint consideration may contribute to a better understanding of health behavior change. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.
Self-efficacy, planning and action control in an oral
self-care intervention
Guangyu Zhou
1
*, Caiyun Sun
2
, Nina Knoll
1
, Kyra Hamilton
3,4
and
Ralf Schwarzer
5,6
1
Department of Educational Science and Psychology, Freie Universita
¨t Berlin, Habelschwerdter Allee 45, 14195 Berlin,
Germany,
2
Henan Vocational College of Chemical Technology, Zhengshanglu 548, 450042 Zhengzhou, Henan Province,
China,
3
School of Applied Psychology, Griffith University, 176 Messines Ridge Rd, Mt Gravatt 4122, Australia,
4
School of
Psychology and Speech Pathology, Curtin University, Kent Street, Bentley, Perth 6102, Australia,
5
Institute for Positive
Psychology and Education, Australian Catholic University, Barker Road 25A, 2135 Strathfield, Australia and
6
University of
Social Sciences and Humanities, Warsaw, Poland
*Correspondence to: G. Zhou. E-mail: guangyu@zedat.fu-berlin.de
Received on November 7, 2014; accepted on June 18, 2015
Abstract
To evaluate a theory-guided intervention on oral
self-care and examine the possible mechanisms
among self-regulatory factors, two brief inter-
vention arms were compared, an information-
based education treatment and a self-regulation
treatment focusing on planning and action con-
trol. Young adults (N¼284; aged 18–29 years)
were assessed at baseline and 1 month later.
The self-regulation intervention improved levels
of oral self-care, dental planning and action con-
trol. Moreover, a moderated mediation model
with planning as the mediator between experi-
mental conditions and dental outcome, and self-
efficacy as well as action control as moderators
elucidated the mechanism of change. More self-
efficacious participants in the self-regulation con-
dition benefitted in terms of more planning, and
those who monitored their actions yielded higher
levels of oral hygiene. Dental self-efficacy, dental
planning and action control are involved in the
improvement of oral self-care. Their joint consid-
eration may contribute to a better understanding
of health behavior change.
Introduction
Interdental cleaning, including the practice of
regular use of dental floss or interdental brushes,
is an effective preventive measure which impacts
on both dental caries and periodontal disease [1].
Although the benefits of adherence to good oral
hygiene behaviors are well known, a large
number of young adults brush or floss their teeth
less than the recommended time or not at all [2].
Lack of self-regulatory skills are associated with a
disinclination to change health behaviors, includ-
ing deficits in self-efficacy, planning and action
control [3–6]. In this study, the health action pro-
cess approach (HAPA) [7–9] was adopted to guide
the study and provides a theoretical framework for
the influence of motivational and self-regulatory
factors in health behavior change. The HAPA as-
sumes that self-efficacy, planning and action con-
trol operate in concert (mediator and moderator)
when it comes to translate a behavioral intention
into action [8, 9]. These processes involved in be-
havior change apply to the adoption as well as to
the maintenance of health-enhancing behaviors.
Beneficial effects of self-regulatory skills on
dental flossing have been reported [4, 10, 11].
For young adults, using dental floss or interdental
brushes is widely unfamiliar in major parts of the
world [12]; thus, there is a need to develop effect-
ive, parsimonious interventions that are based on
sound health behavior theory. Given the import-
ance of self-regulatory factors such as self-
efficacy, planning and action control on interdental
cleaning behaviors, the interplay between these
HEALTH EDUCATION RESEARCH Vol.30 no.4 2015
Pages 671–681
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factors are examined in the context of such a brief,
theory-based oral self-care intervention.
Perceived self-efficacy: confidence in being
able to act
Perceived self-efficacy is the confidence in one’s
ability to execute a difficult or resource-demanding
behavior [13]. The barrier in this context is not the
technical difficulty of oral self-care behavior, but
rather the regular performance as an integral part
of daily life which is not easy for some people.
Self-efficacy predicts a range of health behaviors
including oral self-care [14–18]. One study, for ex-
ample, investigated the combined roles of oral self-
care self-efficacy and self-monitoring in predicting
the frequency of dental flossing as part of one’s
dental routine, and whether a self-regulation inter-
vention would make a difference to flossing behav-
iors by comparing an intervention group with
controls [5]. The treatment improved dental self-ef-
ficacy levels. Completing self-regulatory tasks had
strengthened individuals’ self-beliefs of being cap-
able to adhere to regular oral self-care. Furthermore,
a sequential mediator model showed that the in-
crease in self-efficacy also improved self-monitor-
ing. Participants who optimistically believed that
they could adhere to oral self-care were also more
compliant with using their flossing calendar. As a
result, their level of daily flossing was further im-
proved. This finding showed that the health behavior
process can be specified as a chain of constructs,
with self-beliefs not only as an immediate outcome
of interventions but also as a predictor of subsequent
behaviors. Thus, those who had become more self-
efficacious and who had self-monitored their behav-
ior yielded higher frequencies of dental flossing [5].
A sequential mediation chain is just one possible
mechanism that could link interventions with behav-
ioral outcomes. Other mechanisms, such as moder-
ation effects, may also yield meaningful results.
Planning: a prospective self-regulatory
skill
Behavioral intentions are more likely to be trans-
lated into action when people develop preparatory
strategies, such as making action plans of approach-
ing a difficult task. Mental simulation helps to iden-
tify cues to action. Action plans may follow the
SMART principles which means that they should
be specific (a narrow behavior), measurable, assign-
able (who will perform), realistic and time-related
(when to perform the action). These are well-known
principles that stem from the field of business man-
agement and help to guide individuals in writing
goals and objectives [19]. Meta-analyses support the
effects of planning on health behaviors [20–23].
Planning may also include the anticipation of bar-
riers and the generation of alternative behaviors to
overcome them [24]. People imagine scenarios that
hinder them in performing their intended behavior
and develop one or more plans to cope with such a
challenging situation. Planning can be altered and,
furthermore, can be easily communicated to individ-
uals with self-regulatory deficits. Randomized-con-
trolled trials have documented evidence in support
of such planning interventions [25]. In the context of
oral self-care, action planning and coping planning
have been found instrumental to improving people’s
oral hygiene practices [26, 27].
Action control: a retrospective and
concurrent self-regulatory skill
While planning is a prospective strategy, i.e. behav-
ioral plans are made before the situation is encoun-
tered, action control is a concurrent self-regulatory
strategy, where the on-going behavior is continu-
ously evaluated with regard to a behavioral standard.
Action control comprises monitoring one’s pro-
gress, comparing performance with goals and in-
vesting more effort if needed [4, 6]. Action
control, in particular self-monitoring, is an essential
behavior change technique (BCT) that can be
applied to a variety of health behaviors [28]. When
people keep records of their behavior, such as in the
form of a diary or checkmarks on their calendar,
they become aware of gains and deficits which
lead them to take further action. In a study by
Schu
¨zet al. [4], in which an intervention to adopt
dental flossing was conducted, action control had a
beneficial effect only for those participants who
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were already somewhat motivated to increase their
oral self-care. In other words, action control worked
in the volition (post-intentional) stage but not in the
earlier motivation (pre-intentional) stage. In a study
by Suresh et al. [6], however, the action control
intervention enhanced adherence to dental flossing
regardless of participants’ stage of change. Patients
with periodontal disease received a brief interven-
tion consisting of a self-monitoring tool for dental
flossing in the form of a diary. Flossing frequency,
dental plaque and bleeding scores improved in both
stage-matched and stage-mismatched patients. In
another study by Schwarzer et al. [5], the self-moni-
toring component of action control operated as a
mediator between dental self-efficacy and dental
flossing. In this latter study, it was the component
of making daily recordings in the dental calendar
that was revealed as the most proximal predictor
of improved oral self-care.
The proposed self-regulatory mechanisms
When it comes to translating intentions into action,
the most likely and well-established mechanism is to
specify planning as a mediator between independent
and dependent variables [25]. One study, for ex-
ample, explored the effects of a brief behavioral
intervention for dental flossing, and whether a plan-
ning intervention would yield greater effects than an
education group [2]. A randomized-controlled trial
was used to assign 194 participants into two groups.
The results showed that individuals receiving the
planning intervention significantly outperformed
those in the education control condition at 2 and 8
weeks post-intervention. However, the functional
role of self-efficacy was less obvious. Most research
on self-efficacy has pointed to its value as a pre-
dictor, mediator or outcome, depending on the re-
search context [5]. Self-efficacy can be a facilitator
of behavior as well as a consequence of behavior
[13]. Recent work on other health behaviors, how-
ever, has found self-efficacy to operate as a moder-
ator, either with motivation on planning or with
planning on behavior [29–31]. This interactive
effect means that the relationship between two
variables depends on levels of self-efficacy.
For example, in highly self-efficacious individuals
the slope between an independent and a dependent
variable can be much steeper than for less self-
efficacious individuals. People who harbor self-
doubts may not see a point in planning their actions.
Thus, they would not benefit from a self-regulation
treatment compared with those with optimistic self-
beliefs who would be expected to experience more
gain.
Even when people make good plans, this does not
guarantee that they will perform and maintain the
planned action. They may try to floss a few times,
but eventually discontinue their actions. Thus,
action control needs to come into play. Suresh
et al. [6], for example, evaluated the effects of
action control on dental flossing with a prospective
trial among 73 dental patients and found that keep-
ing a flossing diary can increase flossing and reduce
plaque and bleeding scores at a 4-week follow-up.
Motivated individuals who monitor their behaviors
carefully, by recording them in their calendar for
example, become aware of discrepancies between
their intentions and their actual performance
which, in turn, lets them recover from lapses and
trigger maintenance. The relationship between plan-
ning and behavior may, therefore, depend on levels
of action control. The latter then operates as a mod-
erator. Self-efficacious individuals feel encouraged
to monitor their progress and gain more confidence
from their mastery experience. Accordingly, the
proposed mechanism is a moderated mediation
model with planning as the mediator and self-
efficacy and action control as moderators.
Aims and hypotheses
To our knowledge, this is the first study to examine
the moderator roles of self-efficacy and action con-
trol in a self-regulation intervention to improve oral
health behaviors. In this study, the self-regulation
intervention included two targeted constructs:
planning and action control. A theory-based self-
regulation oral health intervention focused on
planning and action control was compared with an
information-based education intervention. An ex-
perimental 2 (conditions: self-regulation group
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versus education group) 2 (times: Time 1 versus
Time 2) design was conducted among young adults.
Oral health behavior, indicated by dental flossing
frequency, served as the primary outcome whereas
planning and action control served as secondary out-
comes. The aim of this study was to evaluate the
effectiveness of the two brief intervention arms on
oral hygiene behavior and to elucidate the possible
mechanisms among self-regulatory factors for this
important health behavior.
It is assumed that the self-regulation intervention
will improve levels of oral self-care, planning and
action control. Moreover, dental self-efficacy,
dental planning and action control will be involved
in the behavior change process in terms of a moder-
ated mediation model.
Hypothesis 1: The self-regulation group will
perform dental self-care at a higher level than
the education group.
Hypothesis 2: The self-regulation group will
achieve a higher level of dental planning than
the education group.
Hypothesis 3: The self-regulation group will
achieve a higher level of action control than
the education group.
Hypothesis 4: Planning will mediate between
intervention and dental hygiene behavior.
Hypothesis 5: Dental self-efficacy will mod-
erate the intervention-planning relationship.
Hypothesis 6: Action control will moderate
the planning-behavior relationship.
Method
Participants and procedure
Participants comprised a convenience sample drawn
from optional and compulsory courses in a major
university in China who had indicated interest to par-
ticipate in the study on oral health. To detect medium-
size effects (Cohen’s d¼0.5) with a power of 0.80
(¼0.05) [22], a sample size of at least 51 partici-
pants per condition was determined using the
software G*Power 3. A 3:2 oversampling of the
self-regulation intervention group compared with
theeducationgroupwaschosentoobtainalarger
sample of individuals participating in the novel inter-
vention condition. Trained graduate psychology re-
search assistants approached 294 potential study
participants of whom N¼284 (ages 18–29 years;
83% male) gave their informed consent to participate.
Participants were assigned to the two conditions (166
participants in the self-regulation group and 118 par-
ticipants in the education group) according to the
specified 3:2 ratio. Of these 284 college students,
69 dropped out at follow-up, reporting a lack of
time to attend the second measurement occasion.
For the final data analyses, 88 participants were allo-
cated to the education intervention arm and 127 to the
self-regulation intervention arm.
The research assistants allocated participants,
who were blinded to the study conditions, to one
of the two intervention arms. In their respective
classes, participants were instructed by the research
assistants to complete the pre-test materials. The
pre-test questionnaires (Time 1) asked for demo-
graphic information as well as social-cognitive vari-
ables and dental care frequency. Participants then
received the interventional materials and completed
the corresponding tasks based on their group assign-
ment. One month later (Time 2), during their same
class time, participants were invited to fill in an iden-
tical post-test questionnaire. See Fig. 1 for the flow
of participants throughout the study. All participants
were offered three interdental brushes and those
who completed the questionnaires at the two assess-
ment points had a chance to enter into a prize drawto
win 100 yuan (US$16 dollars).
Measures
All measures in this study were adopted from
Schwarzer [7], except the assessment of dental floss-
ing which was taken from Sniehotta et al. [11]. The
questionnaires were translated from English to
Chinese by two bilingual psychology researchers
and approved by two clinical psychologists, and
tested in a pilot study to assure all scales could be
well understood.
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Dental flossing was assessed with an open-format
item: ‘During the last week, I have flossed my
teeth... times per day’. Daily flossing frequency
was multiplied by seven to yield the weekly fre-
quency. The assessment has been validated against
a measure of residual dental floss [11, 32].
Self-efficacy was assessed with three items for task
self-efficacy. A sample item is ‘I am confident that I
can start flossing immediately on a regular basis even
if it is time consuming’. Responses were rated from 1
(not at all true)to4(exactly true). Cronbach’s was
0.79 at Time 1 and 0.62 at Time 2.
Planning was assessed with six items, three items
measuring action planning and three items measur-
ing coping planning. A sample item of action plan-
ning is ‘I have made a concrete and detailed plan
regarding when and where to floss my teeth’. One
sample item of coping planning is ‘To keep my
flossing habit in difficult situations, I have made a
concrete plan regarding what to do if something
interferes with my flossing goal’. Responses were
rated from 1 (not at all true)to4(exactly true).
Cronbach’s was 0.87 at Time1 and 0.83 at Time 2.
Action control was assessed with three items. A
sample item is ‘I have consistently monitored when,
how often and how to floss my teeth’. Responses
were rated from 1 (not at all true)to4(exactly
true). Cronbach’s was 0.80 at Time 1 and 0.73
at Time 2.
Interventions
The interventions were delivered by the same
trained research assistants in participant classrooms
after class. Participants in both groups received
Fig. 1. CONSORT flow diagram.
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educational materials related to oral health, which
were adopted from the American Dental
Association [33] by two clinical psychologists.
They were instructed to read the materials and
then completed corresponding tasks depending on
their group assignment. The planning intervention
was adapted from Schu
¨zet al. [2]. The whole pro-
cess lasted 15 min.
The education intervention provided information
about oral hygiene. In terms of BCTs, the leading
components were goal setting (BCT 1.1), instruction
on how to practice oral self-care (BCT 4.1) and in-
formation about health consequences (BCT 5.1)
[28]. Participants received a package with detailed
information on why and how to perform oral self-
care. This was followed by asking participants to
anticipate at least three benefits of performing oral
self-care twice a day, and three risks of not doing so.
After that, participants were asked to set a goal to
achieve oral health by using dental flossing at least
two times per day. To balance the time length with
the self-regulation group, they also received a quiz
on fruit and vegetable consumption.
In the self-regulation intervention,inadditionto
receiving the education materials, individuals were
instructed to generate three action plans and three
coping plans on dental flossing, and also required to
fill in a calendar with their daily flossing records. In
terms of BCTs, the main components were planning
(BCT 1.2 and BCT 1.4) and self-monitoring of be-
havior (BCT 2.3) [28]. First, participants read the
materials and completed the same tasks about oral
health as the education group. Second, they were
required to fill in two table boxes to generate their
own plans for dental flossing. One table pertained to
action plans, in which participants were instructed to
fill in when, where and how often they planned
to practice dental flossing. The other table was de-
signed to let them generate their own coping plans.
For this task, participants were required to fill in
three obstacles that may prevent them from perform-
ing oral self-care and then identify corresponding
methods to overcome these obstacles. Finally, par-
ticipants in the self-regulation group were given a
dental flossing calendar with the suggestion to
record their daily flossing over 1 month.
Ethical considerations
The study was approved by the local participating
college Institutional Review Board.
Analytic procedure
First, using SPSS 22, independent-sample t-tests,
2
test and MANOVA were used for attrition ana-
lysis and to investigate potential differences at
Time 1. Second, repeated-measures ANOVA
were conducted with experimental conditions
(education intervention ¼0, self-regulation inter-
vention ¼1) as a between-subjects factor using
dental flossing per week, dental planning and
action control of dental flossing as dependent vari-
ables, measured at two points in time. Third, a me-
diation analysis was performed using the
PROCESS macro [34]. Planning to floss was spe-
cified as a mediator between experimental condi-
tions and dental flossing at Time 2, controlling for
baseline behavior (Time 1 dental flossing as a cov-
ariate). Bias-corrected bootstrapping with 5000
resamples was chosen to establish 95% confidence
intervals for direct, indirect and total effects. A
confidence interval not including zero as well as
aPvalue <0.05 for the indirect path indicated sig-
nificant mediation. Fourth, a conditional process
analysis was performed [34] to examine the pos-
sible moderation of mediation. Moderated medi-
ation was tested with planning at Time 2 as a
mediator between experimental groups and dental
flossing at Time 2 while self-efficacy at Time 1
served as a first-stage moderator (between condi-
tions and planning), and action control at Time 2
served as a second-stage moderator (between plan-
ning and dental flossing). All analyses were based
on the longitudinal sample with 215 participants.
(In addition, we have generated 10 imputed SPSS
data sets with the full sample of 284 participants.
Based on multiple imputation, ranges of effects
from 10 repeated measures ANOVAs are presented
in the following [from worst to best]. For dental
flossing, the main effects of time F(1282), values
ranged from 30.47 to 57.73,
2
ranged from 0.10 to
0.15 and all Pvalues were <0.05. For the inter-
action effects F(1282), values ranged from 2.45 to
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8.33,
2
ranged from 0.01 to 0.03 and 9 of 10 P
values were <0.05. For planning, the main effects
of time, F(1282), values ranged from 31.50 to
42.55,
2
ranged from 0.10 to 0.13 and all P
values were <0.05. For the interaction effects
F(1282), values ranged from 68.94 to 99.73,
2
ranged from 0.20 to 0.26 and all Pvalues
were <0.05. For action control, the main effects
of time F(1282), values ranged from 29.70 to
41.28,
2
ranged from 0.10 to 0.13 and all P
values were <0.05. For the interaction effects,
F(1282), values ranged from 39.46 to 63.45,
2
ranged from 0.12 to 0.18 and all Pvalues
are <0.05.) The expectation maximization
method was used to impute missing data for self-
efficacy Time 1 (0.5%), dental flossing Time 1
(3%), planning Time 2 (0.2%) and dental flossing
Time 2 (2%).
Results
Attrition analyses
Results indicated that individuals who remained in
the study (n¼215; 75.7%) reported slightly higher
self-efficacy (M¼2.21, SD ¼0.81 versus M¼2.07,
SD ¼1.00; t(282) ¼1.80, P<0.05), action control
(M¼2.13, SD ¼0.74 versus M¼1.95, SD ¼1.04;
t(282) ¼3.18, P<0.05), planning (M¼2.13,
SD ¼0.74 versus M¼1.95, SD ¼1.03,
t(282) ¼1.69, P<0.05) and dental flossing
(M¼0.97, SD ¼3.31 versus M¼0.57, SD ¼2.37,
t(282) ¼1.11, P<0.05) compared with those who
dropped out. No differences emerged with regard to
sex (
2
¼1.09) and age (M¼21.35, SD ¼1.39 ver-
sus M¼21.11, SD ¼1.25), both P>0.05.
Randomization check
A
2
test and MANOVA revealed no baseline dif-
ferences across experimental conditions (self-regu-
lation group versus education group) regarding age
and sex as well as dental flossing (M¼0.59,
SD ¼2.49 versus M¼0.83, SD ¼2.97), self-
efficacy (M¼2.12, SD ¼0.82 versus M¼2.25,
SD ¼0.91), planning (M¼2.02, SD ¼0.78 versus
M¼2.19, SD ¼0.87) and action control (M¼1.96,
SD ¼0.87 versus M¼2.03, SD ¼0.89) (all
P>0.05, see Table I).
Intervention effects
To examine the intervention effects at Time 2, re-
peated-measures ANOVAs were computed. For
dental flossing, there was a main effect for time,
F(1213) ¼40.44, P<0.01,
2
¼0.16, indicating
that behavior had increased overall. Moreover, a
Table I. Means and standard deviations for dental flossing, planning, self-efficacy and action control for both groups at two points
in time
Variable/Group
Time 1 Time 2
MSD F(1282) P
2
MSD F(1213) P
2
Dental flossing
a
Self-regulation 0.59 2.49 0.56 0.46 0.002 2.70 4.41 3.42 0.06 0.02
Education 0.83 2.92 1.67 3.36
Planning
Self-regulation 2.02 0.78 2.97 0.09 0.01 2.53 0.69 17.57 0.00 0.08
Education 2.19 0.87 2.14 0.63
Self-efficacy
Self-regulation 2.12 0.82 1.70 0.19 0.01 2.25 0.65 0.79 0.38 0.01
Education 2.25 0.91 2.17 0.73
Action control
Self-regulation 1.96 0.87 0.46 0.50 0.002 2.58 0.71 26.47 0.00 0.11
Education 2.03 0.89 2.08 0.72
Note.
a
Flossing during the past week.
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significant time condition interaction, F(1213) ¼
6.33, P<0.05,
2
¼0.03 emerged, indicating that
participants of the self-regulation intervention had
benefitted more than those from the education inter-
vention (see Fig. 2). Hypothesis 1 was confirmed.
For planning, there was a main effect for time,
F(1213) ¼30.62, P<0.01,
2
¼0.13, indicating
that planning had increased. Moreover, a significant
time condition interaction, F(1213) ¼59.11,
P<0.05,
2
¼0.22 emerged, indicating that partici-
pants of the self-regulation intervention had bene-
fitted more than those from the education
intervention. Hypothesis 2 was confirmed.
For action control, there was a main effect for
time, F(1213) ¼24.24, P<0.01,
2
¼0.10, indicat-
ing that action control had increased. Moreover, a
significant time condition interaction, F(1213) ¼
41.61, P<0.01,
2
¼0.16 emerged, indicating that
participants of the self-regulation intervention had
benefitted more than those from the education inter-
vention. Hypothesis 3 was confirmed.
Mediation analysis
Planning at Time 2 was considered to serve as a
mediator between experimental condition and
dental flossing at Time 2. A path model, controlling
for baseline behavior, yielded the expected results.
The indirect effect of treatment on dental flossing
via planning at Time 2 was 0.93 (95% CI [0.46,
1.58]). Hypothesis 4 was confirmed.
Moderated mediation analysis
Moreover, it was examined whether the former
simple mediation effect was different for individuals
with different levels of self-regulatory skills.
Participants who had higher or lower self-efficacy
and action control may benefit differently from the
treatment. Based on the procedures by Hayes [34] to
test moderation, Time 1 self-efficacy was specified
as a moderator between the experimental condition
and planning, whereas Time 2 action control was
specified as a moderator between planning and
dental flossing at Time 2. A path model, controlling
for Time 1 dental flossing, yielded the expected re-
sults (see Fig. 3). Planning Time 1 was predicted by
condition (¼0.32, 95% CI [0.81, 0.15],
SE ¼0.24, P>0.05), self-efficacy (¼0.11, 95%
CI [0.04, 0.26], SE ¼0.08, P>0.05) and the con-
dition self-efficacy interaction (¼0.35, 95% CI
[0.14, 0.55], SE ¼0.10, P<0.05) at Time 2, with
24% of planning variance being accounted for.
Dental flossing Time 2 was predicted by baseline
behavior (¼0.75, 95% CI [0.44, 1.05],
SE ¼0.10, P<0.05), condition (¼0.09, 95% CI
[0.85, 1.02], SE ¼0.07, P>0.05), planning
(¼0.44, 95% CI [2.65, 1.78], SE ¼0.14,
P>0.05), action control (¼2.08, 95% CI
[4.24, 0.08], SE ¼0.15, P>0.05) and the
planning action control interaction at Time 2
(¼1.09, 95% CI [0.21, 1.96], SE ¼0.06,
P<0.05), with 39% of behavior variance being ex-
plained. Given the overall significant interaction
terms, significance tests were conducted on the hy-
pothesis that the conditional indirect effect equals
zero at specific values (M,±1 SD) of the moderators.
Planning mediated the effect of the condition on
dental flossing at the mean (M) and high levels (±1
SD) of action control and at the high levels (±1 SD)
of self-efficacy. In particular, the strength of the con-
ditional indirect effect increased along with levels of
self-efficacy (¼0.42 at ±1 SD, P<0.05) and
action control (¼1.54 at M,P<0.05). At the
high levels of both moderators, the conditional in-
direct effect from experimental groups to dental
flossing outcome was 0.29 (95% CI [0.15, 0.48],
whereas at the low levels of both moderators, the
Fig. 2. Dental flossing times per week in the experimental con-
ditions (self-regulation and education) at two points in time.
G. Zhou et al.
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at Freie Universitaet Berlin on September 25, 2015http://her.oxfordjournals.org/Downloaded from
conditional indirect effect from experimental groups
to dental flossing outcome was 0.02 (95% CI
[0.03, 0.10].
Probing the moderated effects of self-efficacy and
action control yielded two simple slope diagrams (see
Figs. 4 and 5) showing that participants with higher
self-efficacy at Time 1 and with higher action control
at Time 2 benefitted most from the self-regulation
intervention. Hypotheses 5 and 6 were confirmed.
Discussion
This study evaluated a theory-based oral health
intervention in young adults with the aim to identify
social–cognitive mechanisms of behavior change.
The active control group consisted of the usual in-
formation approach to educate participants about the
Fig. 3. Effects of experimental conditions (1 ¼self-regulation intervention, 0 ¼education intervention) via planning to floss on dental
flossing, moderated by action self-efficacy in the first stage and by action control at the second stage, controlling for baseline dental
flossing. Unstandardized solution; bootstrapped with 5000 resamples (n¼215). Note: *P <0.05; **P <0.01.
Fig. 4. Interaction of self-efficacy (Time 1) with experimental
conditions on planning to floss (Time 2).
Fig. 5. Interaction of planning to floss (Time 2) with action con-
trol (Time 2) on weekly dental flossing (Time 2).
Dental self-efficacy, planning and action control
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benefits of oral hygiene and how to use dental floss.
The self-regulation intervention had a particular
focus on planning and action control in addition to
the educational materials. Findings revealed that this
latter group achieved a higher level of dental floss-
ing frequency at 1-month follow-up in line with
higher levels of planning and action control. This
finding highlights the role of these two key self-
regulatory skills as active ingredients of the treat-
ment. Moreover, planning mediated between
experimental conditions and the dental flossing out-
come, underscoring its operative function in the
change process. Such findings are emerging as com-
monplace for a range of health behaviors [25].
A significant contribution of this study was the
identification of the moderator roles of self-efficacy
and action control. In the conditional process ana-
lysis [34], the simple mediation model was enriched
by these two moderators, with dental self-efficacy
operating on the left side of the model as a first-stage
moderator, whereas action control operated on the
right side as a second-stage moderator. Participants
with higher levels of self-efficacy evidenced more
positive effects from the intervention and reported
higher levels of planning at follow-up. It is likely,
but not examined in this study, that these partici-
pants may have also generated more plans during
the intervention session itself. Furthermore, partici-
pants with higher levels of action control at Time 2
were more likely to translate their plans into dental
flossing compared with those who did not monitor
their behavior and, as such, were not as successful in
adopting or maintaining this type of oral self-care.
It is the main characteristic of conditional process
models that the mediation does not work for every-
one. As moderators come into play, the mediation
effects are valid only for subgroups of participants,
in the case of this study for those with higher levels
of self-efficacy and action control. This discovery
provides an important insight into mechanisms of
behavior change. Previous studies that did not suc-
ceed in changing behaviors may have ignored the
possibility that certain subgroups actually have been
successful. Not applying conditional process ana-
lyses prevents researchers from discovering such
hidden effects. To identify such subgroups, one
needs relevant constructs that operate in concert.
In this study, the joint functioning of self-efficacy,
planning and action control was examined, which
are key constructs in the HAPA [7, 8].
The findings of this study need to be interpreted in
light of its limitations. Assessments were self-
reported and dental flossing was measured retro-
spectively for the past week. As an alternative to
self-report, one could use on-going behavioral as-
sessments such as dental calendars that allow for
constant record keeping [4]. In this study, however,
the dental calendars were used as a treatment and not
as a daily assessment tool. Dental floss was provided
but its use was not objectively measured. In the
study by Schu
¨zet al. [4], participants returned
their leftover floss and residual floss was measured,
yielding a correlation of r¼0.65 with self-reports.
Another limitation lies in the lack of discriminant
validity between action planning and coping plan-
ning. Due to their high intercorrelation, the two
measures needed to be collapsed into a single plan-
ning variable. Future research should collect more
process data on the intervention itself, assessing the
number and quality of plans that participants gener-
ate during the session. The same applies to all BCTs
[28] that are more or less active ingredients of the
treatment. Moreover, a longer period of time for
follow-up assessments is suggested to investigate
long-term effects of the intervention and behavioral
maintenance. Nevertheless, this study which
adopted a theory-guided intervention has attempted
to further elucidate the mechanisms of changing oral
hygiene behaviors. The findings make a contribution
to the cumulative knowledge about self-regulatory
and social-cognitive components in health behavior
change.
Conflict of interest statement
None declared.
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