There is strong evidence to support the use of TPB for smoking cessation programs; a meta-analysis study of 35 data sets from primary studies, and found that the construct ‘perceived behavior control’ is the most predictive of smoking cessation because it influences both intentions and behavior.61 The authors suggest that the culture of the country is also important as a mediating factor, with some cultures enhancing the effects of smoking cessation programs, mirroring findings from a separate study.62 This suggests that particularly ‘perceived behavior control’ may be relevant for understanding the effects of TPB for smoking cessation programs, and perhaps culture should be considered as an additional important factor.

In contrast, another systematic review found no strong evidence to support the effectiveness of interventions based on TPB for dietary behavior change in adolescents and young adults; this means that TPB might not be effective in bringing the desired change.63 A systematic review assessing the efficiency of questionnaires based on TPB for behavioral change found that there were errors in the estimation of sample size, namely, demographic data, measures, and the process of development of the questionnaires.64 This means that there were methodological issues in the evaluation of many TPB interventions.

For oral health, TPB has been widely applied to predict behavior related to oral health including toothbrushing, dental flossing, and dental attendance.65–70 When broadly used, the theory could successfully predict a significant portion of the variance in oral health-related behaviors.67,68,70 For example, one study found that they could successfully predict 57% of the variation in oral hygiene habits and 66% of the variance in dental attendance.67 Another study provided more cautious support of TPB, suggesting that cultural differences may exist regarding the most appropriate application of the theory.62 The authors conducted a study to identify predictors of oral hygiene and found that in the Caribbean, the best predictors were attitude and social norms, while in Nepal, perceived behavioral control and expected social outcomes were most predictive.62 The majority of these studies have adopted cross-sectional designs to assess the predictive power of TPB variables on oral health-related behaviors.65–70 These studies support the ability of TPB variables to predict intentions and behavior of oral health, saying that these studies do not assess the effectiveness of an intervention based on TPB in changing behavior.

Only one RCT had incorporated TPB constructs in intervention to improve the periodontal condition of adults.39 However, based on the review, the constructs were used as a basis for predicting behavior change rather than the basis of the intervention. Their findings supported those of a clinical RCT assessing the effectiveness of TPB in changing behavior.71 The authors applied a full-factorial experimental design to determine the effects of three interventions based on the three main TPB constructs to improve physical activity. The choice of physical activity was based on the strong correlation of TPB to predict the behavior. They found that the interventions changed the intention related to the behavior.71 However, the interventions failed to achieve behavior change. This study suggests that TPB has a limited influence on behavior.

For free sugars intake, no studies were found that assessed the effectiveness of applying the TPB to reducing free sugars intake related to dental caries among adults.22

There is some support for the use of TPB for changing some health-related behaviors. But, there is a need for more RCTs to assess the effectiveness of interventions based on TPB that aim to improve oral health-related behaviors.22 It appears that self-efficacy/perceived control is the most important component of the TPB for predicting behavior.39 A major limitation of the theory is that it considers individuals as rational decision-makers;45 however, this is not always the case. For example, patients with dental anxiety may not attend dental clinics on a regular basis.72 In this case, the behavior of not attending regularly is based on emotion (fear) rather than rational decision-making. Finally, the findings of this review need to be considered against recent work in the field suggesting that TPB is not a helpful model in the design of behavior change interventions.71 It has been argued that the TPB is insufficient as a tool for behavior change, but can predict behavior only, which does not serve the purpose of behavioral change science.73 For free sugars intake, the TPB could be useful in predicting free sugars intake, in particular, perceived behavior control seems likely to be a strong predictor.

Information-Motivation-Behavioral Skills Model (IMB)

The IMB model suggests that individuals perform a behavior only if they expect a net benefit from it.74 According to the model, three constructs contribute to behavior change, which are information, motivation, and behavioral skills. Figure 4 illustrates the relationship between the constructs.75

The IMB model has been applied to a wide variety of health-related behaviors. The IMB model was initially applied to minimize HIV risk behaviors.76–78 For instance, interventions based on the IMB model were used to promote women to use female condoms during intercourse with their partners,78 and the model has shown to be effective in reducing the HIV risk behavior between individuals.76

Within the last five years, three studies from different health domains have tested the effectiveness of the IMB model for changing behavior.79–81 The shared findings indicate that there is no strong evidence to support or reject the effectiveness of interventions based on the IMB model for sustaining new short-term health behavior change. However, their findings are further called into question after a systematic review found that the IMB model achieved healthy behavior change that was sustained for 12 months.82 Because of this, it seems there is some evidence to support the use of the model for health-related behavior change for up to one year, but there is a need for more high-quality studies to assess its effectiveness beyond a one-year follow-up.

The IMB model has been applied in two studies related to oral health; to gather information and change the behavior of oral healthcare providers83 and to examine the practicality of oral health education.84 Despite the promising findings from the studies,83,84 caution should be expressed for several reasons. First, the studies were both based on specific populations – prenatal care providers and HIV patients – and both were non-experimental studies, which means there was no causal assessment of the intervention in improving oral health behavior.73,74 Additionally, in one study, the model constructs were not directly assessed.84 There has been no effective research on the potential usefulness of the model for toothbrushing, interdental cleaning, oral health adherence, and diet control including free sugars intake related to dental caries in adults.22

There are some promising applications of the IMB model to changing general health behavior for up to one year if researchers follow the three phases of the model application when designing interventions. Because of this, there is some possibility that this model could also be useful for oral health-related behavior change in the short term. However, due to a lack of research related to oral health applications, this application remains uncertain. Further, there are some significant limitations to the model. First, the model assumes that individuals are rational decision-makers,85 but this is not always the case as individuals can engage in actions based on emotions.58 A criticism of the IMB model is its lack of specificity regarding the components of the three core constructs. Whereas other models specify the nature of the information and motivation elements, the IMB model is not as specific. Thus, any effects maybe because the constructs identified in the IMB process are similar to those in other models, which means that the change was from the intervention instead of the model. Finally, the model does not take into account the context of behavior change, such as environmental and social factors. Therefore, the usefulness of this model in reducing free sugars intakes among adults may be limited.

PRIME Theory of Motivation

The PRIME Theory of motivation is a very complex framework, which considers the brain as the energizer and director of an individual’s behavior.75 It is based on the principle, “At every moment we act in pursuit of what we most desire (want or need) at that moment”.75 The theory was developed as a patchwork of elements from previous theories, focusing on elements that help explain and predict behavior.86,87 Although not a behavior change theory in itself, given the central role that motivation plays in undertaking behavior change, the PRIME Theory of motivation is reviewed here.86,87 As shown in Figure 5, there are five subsystems within PRIME, including plans, responses, impulses and inhibitors, motives, and evaluations.75

PRIME Theory has been mainly applied to one behavior, namely, tobacco use. It was been applied initially to smoking cessation interventions in conjunction with behavioral change techniques.89,90
A RCT examining the effectiveness of a PRIME-based smoking cessation interactive webpage compared to a passive information providing webpage found that 10% quit smoking for six months in both groups, which is similar to the success rate of one-to-one counseling.91

An observational cohort study investigated the usefulness of a smartphone app based on PRIME Theory and behavior change techniques (BCT) to quit smoking (even though it was not clear exactly how this app was created).92 Approximately 19% of the participants quit smoking for 28 days, so the authors concluded that the app could help certain smokers to stop. Both studies show that PRIME may be effective, but they only have short-term follow-ups and were applied to online or via apps settings, which can miss populations who are not using apps or online smoking cessation programs.

PRIME Theory has not been applied to specific oral health behaviors including reducing free sugars intake related to dental caries among adults,22 although some have suggested that it may be appropriate to apply to do so.73

In summary, the PRIME Theory of motivation has not been applied to specific oral health behaviors and has not been applied to most other health-related behaviors. Because of this lack of evidence-base, more studies are needed before recommendations regarding its application to adult oral health behaviors can be made. Additionally, the theory can be used in conjunction with the capability, opportunity, motivation, and behavior (COM-B) model.75

Behavior Change Wheel (BCW) framework

The BCW framework considers the importance of the contexts in which actions or behaviors take place.75 Also, the framework draws a systematic and coherence plan on how to achieve behavior change, from understanding the context of the behavior to offering many function interventions and categories and techniques to achieve the behavior change.75,93

The BCW comprises three layers, as demonstrated in Figure 6 and explained below:93

• It starts with the inner layer, which is the hub of the wheel, and it is used to identify the most proximal determinants of behavior at the individual or population levels. The COM-B model is used for this purpose, and the theoretical domain framework (TDF) can be used for further analysis along with the COM-B to model the behavior.
• The second layer is the intervention functions, which contains a range of functions, which are effective in achieving behavior change. The application of these functions depends on COM-B model analysis of the behavior.
• The outer layer (the rim of the wheel) contains policy categories, which support the delivery of the intervention functions and modify the context in which individual behavior occurs.

Four initial tools are applied within the BCW framework when designing effective interventions: COM-B model, TDF, BCT, and mode of delivery ontology (MoDO).89,94 These tools all work together, under the BCW framework, where COM-B model is for understanding behavior, TDF is further analysis of behaviors, BCTs are used to change behaviors, and MoDO is used to deliver the BCT. The relationship between the four tools with BCW is shown in Figure 7. The BCW framework suggests eight steps (grouped into three stages) for designing effective interventions for behavior change.95

The BCW has been used for different purposes. For example, it provides a system for coding behavioral interventions and has been utilized within systematic reviews to categorize interventions used to change behavior and as a system for designing interventions. To date, the BCW has been used as part of systematic reviews in the following fields: head and neck cancer,96 research design,97 and adherence to medicine related to cardiovascular disease.98 The BCW framework was also used to develop behavior change interventions for weight management-healthy,99,100 rehabilitation,101 capacity building,102 smoking cessation,103 and men’s sexual health.104 In general, most authors found that the BCW was a useful theory for designing interventions.100,102,103

However, one of the challenges in using the BCW framework was difficulty in achieving a consensus among scientists about the importance of a dimension in behavior change after data gathering.104 Also, it has been suggested that the BCW framework is not designed for transforming behavior change plans into software application features, so in one study, the authors had to rely on other sources for selecting appropriate interventions.105 The BCW framework has been described as “less directive and helpful” because the authors believe that and policy categories of the BCW framework are not as well defined as their names suggested in the framework irrespective of the behavior analysis stage.101 For example, the outer layer of the system (policy categories) is not well defined and fit more under the policy level. This led them to fit all of their intervention components under one-category: service provision. However, they felt that the BCT Taxonomy (v1) was useful in the development of behavior change interventions because it provided them with common terminology, which helped in describing the aim of each component of the interventions. Unfortunately, none of these studies was a RCT. Currently, few clinical trial protocols have been published that aim to test the effectiveness of interventions based on the BCW framework in different health-related behaviors, these include physical activity106,107 and men’s sexual health.108

The BCW framework, with its tools and stages, has not been tested in specific oral health behaviors among the adult population, including reducing free sugars intake.22 For example, TDF was used to understand factors that influence the application of fluoride varnish on Scottish children’s teeth.105 Another example is the use of TDF in understanding the factors that influence the management of patient’s with bacterial infections in dental settings.109 The BCW framework and its tools may provide a useful theory for the design of interventions to enhance oral health.73

In summary, the BCW system, along with its associated tools, appears to be the most suitable for capturing the complexity of adult oral health-related behaviors, in particular reducing free sugars intake among adults. The previous applications to general settings have demonstrated that it can be successfully applied to design interventions and to analyze and understand behaviors. Furthermore, it explicitly links behavior analysis with behavior interventions.110 Its usefulness with regard to oral health remains to be explored. The BCW would be a very useful framework for free sugars intake because it offers the opportunity to systematically analyze the context in which the consumption of free sugars takes place.

Conclusion

There is good evidence to suggest that interventions based on theory are more effective than interventions developed without a theory-based approach. Oral health education does not influence diet control behavior in the long term; it mainly increases knowledge with possible behavior change in the short-term. Of the six theories of behavior change and a framework reviewed here, there is limited evidence from intervention studies based on social cognition models, including TTM and TPB. However, these models can predict free sugars intake, in particular individual constructs, including self-efficacy, goal setting, and action planning. The BCW and its tools offer hope for the development of effective behavior change interventions to reduce free sugars intake among adults because of the comprehensiveness they provide. However, their use in oral health is limited at the moment. More studies, including trials, are suggested to apply BCW and its tools when developing interventions for reducing free sugars intake.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

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