Download Factors associated with orthodontic patient compliance with intraoral

Factors associated with orthodontic patient
compliance with intraoral elastic and headgear wear
Rebecca d. Egolf, DMD, MS,* Ellen A. BeGole, PhD,** Harry S. Upshaw, PhD***
Chicago, IlL
Factors related to compliance with the wearing of headgear and intraoral elastics were explored in a
sample of 100 university clinic orthodontic patients. Data were gathered by means of a questionnaire
that comprised items presumed to be associated with orthodontic compliance. These items were not
patient characteristics, but variables of beliefs, attitudes, perceptions, and reasons thought to be
associated with compliance. The 58 questions were reduced through alpha factor analysis and the
imposition of a coefficient alpha restriction to 12 factors. These 12 factors were named according to
the questions they comprised. To assess whether these factors were indeed related to compliance,
correlation coefficients were calculated between the factor scores (independent variables) and the
criterion of compliance with headgear and elastics (dependent variable). Compliance was rated on a
three-point scale. Four factors were found to be weakly, though significantly, correlated with
compliance. These factors were combinations of personality type, negative motives (pain,
inconvenience, and dysfunction), and positive motives (general health awareness, specific dental
knowledge, and personal oral embarrassment). The findings were compared with existing theories of
patient behavior. (AM J ORTHOODENTOFACORTHOP1990;97:336-48.)
A
compliant or cooperative orthodontic patient may be described as one who practices good oral
hygiene, wears appliances as instructed without abusing
them, follows the appropriate diet, and keeps appointments so that the goal of a stable, functioning, esthetic
dentition can be achieved expeditiously. The cooperative orthodontic patient has been described in many
studies that identified the patient by demographic and
personal characteristics, such as age, sex, social class,
personality type, and severity of malocclusion.
Since the sex of the patient is one of the easiest
attribute variables to assess, it is frequently reported
although it may not be the central question of the study.
Of eight studies relating gender to various aspects of
orthodontic cooperation, three t3 reported girls to be
more cooperative than boys, and five4-8 found no difference between the sexes.
Age, on the other hand, is consistently and significantly associated with patient cooperation in the studies
Based on research submitted by Dr. Egolf in partial fulfillment of the requirements for the Master of Science degree, Department of Orthodontics, University
of Illinois at Chicago.
*Orthodontic private practice; attending staff member, Michael Reese ilospital
and Medical Center.
**Professor of Biostatistics, Department of Orthodontics, University of Illinois
at Chicago.
***Professor of Psychology, University of Illinois at Chicago.
811113886
336
reviewed. 4"7"9Patients 12 years of age or slightly younger are more compliant than older children.
Personality tests have been used by a number of
investigators, generally with the goal of being able to
predict patient cooperation by identifying particular personality types. Both GabrieP ° andMcDonald 8 used the
California Test of Personality. This test purports to measure a number of psychosocial domains, such as selfreliance, sense of personal worth, or social skills."
GabrieP ° found a low correlation between the scores
from items of the California Test of Personality and a
posttreatment, subjective assessment of motivation. He
believed this correlation was too low to be predictive.
McDonald, 8 however, reported a significant correlation
between scores on the California Test of Personality
and patient cooperation.
Using the Adjective Check List of 300 adjectives
and 15 needs, Allen and Hodgson4 described the
cooperative patient as 14 years of age or younger,
enthusiastic, outgoing, energetic, wholesome, selfcontrolled, responsible, trusting, determined to do well,
hardworking, forthright, and obliging. The uncooperative patients were pictured as more than 14 years old,
of superior intelligence, hardheaded, independent,
aloof, often nervous, temperamental, impatient, individualistic, easygoing, self-sufficient, intolerant of prolonged effort or attention, and disregarding the wishes
Voh~me97
Number 4
of others. However, when these traits plus age and sex
were correlated with cooperation, only age was found
to be a significant predictor.
Kreit et al.I constructed a personality inventory and
administered it to 1386 patients. The correlation of
questions with a rating of cooperation produced a description of the uncooperative patient. These patients
were characterized as being concemed with appearance,
having conflict with their parents, and requiring the
presence of authority to enforce ethical behavior.
EI-Mangoury, ~2 in a study of orthodontic patient
cooperation, also constructed tests to assess patient personality. High-need achievers, high-need affiliators,
and internally motivated patients were shown to be better cooperators. However, Albino et al) 3 reported patient cooperation was related to an external locus of
control.
Socioeconomic status was found to be related to
cooperation. Two studies 2.7 reported that patients in the
lower middle or lower classes are more cooperative.
Some would expect a relationship between the
severity of the malocclusion and the amount of patient cooperation. Both Grew and Hermanson ~4 and
McDonald 8 found no correlation. With respect to the
decision to seek orthodontic treatment, studies differ
regarding the severity of the malocclusion and its relation to the child's desire for treatment, x5.~6Bell et al. 25
observed that, among orthognathic surgery patients, the
patients' self-perception of their profiles is more important than the diagnostic criteria in their decision to
undergo orthognathic surgery.
The foregoing studies sought to identify the cooperative orthodontic patient on the basis of immutable
chracteristics or attribute variables. The child is described as younger and in the lower middle socioeconomic class. They may have a variety of personality
characteristics not adequately described by one personality theory and a wide range in severity of malocclusion.
Purpose/hypothesis
The purpose of this research was to explore reasons
orthodontic patients comply with the wearing of headgear and elastics. This was done by examining the variables of beliefs, attitudes, reasons, and perceptions
thought to be associated with cooperative behavior. It
was a nonexperimental, retrospective, exploratory field
study, which therefore, had no hypothesis) 7
To discover meaning in such a multitude of variables, the statistical technique of alpha factor analysis
was used. This procedure mathematically reduces a
Factors associated with patient compliance
337
large number of variables to a smaller number of hypothetical variables or factors.Z~ The question remained
whether the factors, which were thought to reflect reasons patients comply, were indeed associated with cooperative behavior. To verify this mathematically, the
cooperation of the patient was rated and this criterion
of cooperation was correlated with the factors.
MATERIALS AND METHODS
Independent variables
A questionnaire was constructed for data collection.
The questionnaire items (independent variables) were
taken from the literature and from existing tests 3""'~9'2°
and were reformulated when necessary. Additional
questions were suggested by patients and by experts in
the field. A pilot questionnaire was administered to five
subjects to determine the appropriateness of the reading
level, to identify ambiguous questions and overly technical language, and to measure completion time. The
instrument was refined by deletion or rephrasing of
questions and was subsequently readministered to another five subjects with the same objectives.
The first portion of the questionnaire consisted of
36 questions regarding general beliefs, attitudes, and
concepts related to health. The response scale was of
the Likert type as shown in Table I. The second portion
of the questionnaire was a combination of items concerning specific reasons for the patient's compliance or
noncompliance with four or five statement choices presented. The remaining questions assessed demographics, patient characteristics, or patient history.
Dependent variable (criterion of cooperation)
The criterion chosen was subjective assessment by
the clinician of the patient's cooperation in wearing
headgear or intraoral elastics. These two treatment aids
were selected because they are under the patient's direct
control. Some dimensions of compliance, such as keeping of appointments and payment, are more under parental control. The dimension of oral hygiene was notincluded since it was not shown by Crawford 7 or EIMangoury u to be correlated with appliance wear. Nor
was appliance breakage chosen because, in the present
setting (a university teaching clinic), it may be more a
reflection of the skill of the student orthodontist than
the uncooperative behavior of the patient. Furthermore,
a broken appliance might be the result of material failure
and, in fact, be due to excellent wear) °
The criterion was rated on a three-point scale: excellent, average, and poor. The orthodontist assigned
the patient to one of these categories, depending on the
338
Egolf, BeGole, attd Upshaw
Am. J. Orthod.Dentofac. Orthop.
April 1990
T a b l e I, R e s u l t s o f the q u e s t i o n n a i r e ( P e r c e n t a g e o f p a t i e n t r e s p o n s e is r e p o r t e d . Q u e s t i o n s c o m p r i s i n g
factors w h i c h c o r r e l a t e w i t h c o o p e r a t i o n are n o t e d . )
I. Straight front teeth are very important.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
3%
5%
50%
42%
2. Having braces can help you have fewer problems with your mouth later on. (Factor 1I, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
I%
8%
64%
27%
3. People with nice smiles have more friends.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
12%
47%
27%
11%
3%
4. Some patients cooperate better if their parents or the orthodontist gives them a reward. (Factor I, Pain/Dysfunction, Internal/External)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
16%
36%
26%
19%
3%
5. Some people have braces to help their bite. (Factor I1, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
2%
10%
8%
54%
26%
6. Parents and the orthodontist become more upset with broken braces than they should.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
13%
35%
36%
11%
5%
7. It's easier to wear braces if your friends are wearing them too.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
11%
39%
12%
32%
6%
8. Some people want braces because their friends have them. (Factor IX, Self-confidence)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
18%
44%
14%
23%
1%
9. Straight teeth can help prevent gum problems.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
4%
12%
31%
41%
12%
10. People with pleasing smiles get ahead in life.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
14%
37%
26%
22%
1%
11. Having a healthy body is very important. (Factor II, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
1%
0%
2%
52%
45%
12. Straight teeth are easier to clean. (Factor 11, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
3%
5%
20%
57%
15%
13. Some day most people probably will have false teeth.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
8%
30%
21%
39%
2%
14. Patients who understand their treatment are more cooperative. (Factor II, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
1%
3%
8%
56%
32%
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Factors associated with patient compliance
Table I. C o n t ' d
15. If a patient notices something wrong with the braces, he/she should wait until the next appointment to mention it.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
28%
49%
8%
i 2%
3%
16. Parents should reward a child for properly wearing headgear and rubber bands. (Factor I, Pain/Dysfunction,
Internal/External)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
7%
34%
29%
25%
5%
17. Parents should not make their children wear braces if they don't want to do so.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
20%
54%
13%
11%
2%
18. Most people don't understand how uncomfortable and annoying braces can be. (Factor I, Pain/Dysfunction,
lnterual/External)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
2%
10%
1 I%
50%
27%
19. Having regular medical and dental check-ups is very important. (Factor II, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
0%
2%
38%
60%
20. Some patients lose or break their headgear or appliances to annoy their parents or the orthdontist. (Factor III,
Stoic/Sensitive)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
15%
46%
27%
10%
2%
21. Wearing headgear or rubber bands definitely helps straighten teeth.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
1%
5%
10%
50%
34%
22. A person can decide how much and when to wear headgear, rubber bands, or a retainer better than the orthodontist.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
37%
48%
7%
5%
3%
23. A family should help the patient to remember to wear headgear, retainer or rubber bands.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
1%
10%
56%
33%
24. A person is more willing to cooperate and follow directions when the orthodontist explains what's being done
and why. (Factor II, Health Awareness)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
1%
5%
47%
47%
25. Some families argue more when a child wears braces. (Factor I, Pain/Dysfunction, Internal/External, and
Factor III, Stoic/Sensitive)
Strongly
Strongly
agree
disagree
Disagree
Neither
Agree
2%
33%
34%
30%
1%
26. Wearing braces can be worse than having crooked teeth.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
34%
43%
11%
8%
4%
27. Speaking clearly with braces can be a problem. (Factors I, Pain/Dysfunction, Internal/External, and Factor IX,
Self-confidence)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
1i %
i 8%
i 9%
40%
12%
339
340
Egolf, BeGole, and Upshaw
Am. J. Orthod. Dentofac. Orthop.
April 1990
Table I. C o n t ' d
28. Straight teeth will help a person avoid gum disease and cavities.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
4%
17%
35%
37%
7%
29. Some kids who don't cooperate with the orthodontist are also problem children at home. (Factor III, Stoic/
Sensitive)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
6%
27%
34%
30%
3%
30. If a patient has a problem with his/her braces, he/she should call the orthodontist immediately. (Factor I,
Pain/Dysfunction, Internal/External)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
4%
7%
57%
32%
31. Some kids can get along well at home and still be bad orthodontic patients.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
0%
7%
23%
65%
5%
32. Braces can be used to treat jaw joint problems.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
1%
3%
41%
42%
13%
33. If parents want their children to wear braces, the children should do it.
Strongly
.
Strongly
disagree
Disagree
Neither
Agree
agree
4%
16%
27%
45%
8%
34. Straightening back teeth for a better bite is very important.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
2%
2%
12%
59%
25%
35. Wearing braces can cause serious eating problems. (Factor I, Pain/Dysfunction, Internal/External)
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
9%
38%
27%
21%
5%
36. Kids cooperate better with an orthodontist who is stem.
Strongly
Strongly
disagree
Disagree
Neither
Agree
agree
16%
32%
32%
19%
1%
37. Is wearing braces ever painful for you? (Factor I, Pain/Dysfunction, Internal/External)
No. (16%)
Yes, only once in a while. (24%)
Yes, sometimes. (56%)
Yes, most of the time. (4%)
38. If braces are painful does the pain keep you from wearing headgear or rubber bands.? (Factor I, Pain-Dysfunction,
Internal/External, and Factor Ill, Stoic/Sensitive)
No, braces aren't painful. (15%)
The pain doesn't keep me from wearing headgear or rubber bands. (32%)
Yes, pain occasionally keeps me from wearing headgear and rubber bands. (37%)
Yes, pain often keeps me from wearing headgear and rubber bands. (13%)
Yes, I couldn't wear headgear or rubber bands because of the pain. (3%)
39. Does wearing braces affect your speech? (Factor I, Pain/Dysfunction, Internal External)
No. (46%)
Yes, but only several times. (31%)
Yes, part of the time. (22%)
Yes, all of the time. (1%)
40. If your speech is affected, does that keep you from wearing headgear or rubber bands? (Factor I, Pain/Dysfunction,
Interual/Extemal)
No, my speech isn't affected. (45%)
Volume 97
Number 4
Factors associated with patient compliance
Table I. C o n t ' d
My
My
My
My
speech is
speech is
speech is
speech is
affected
affected
affected
affected
but that doesn't keep me from wearing headgear or rubber bands. (45%)
and that sometimes keeps me from wearing headgear or rubber bands. (6%)
and that frequently keeps me from wearing headgear and rubber bands. (2%)
and that always keeps me from wearing headgear and rubber bands. (2%)
41. Do you ever not wear your headgear or rubber bands because you are too lazy?
No, being lazy isn't a reason. (56%)
Yes, being lazy is a reason once in a while. (34%)
Yes, I'm always too lazy to wear my headgear or rubber bands. (10%)
42. Has wearing braces ever caused problems at home for you? (Factor I, Pain/Dysfunction, Internal/External)
No. (79%)
Yes, but not much of a problem. (19%)
Yes, it has been a problem. (2%)
Yes, braces have caused big problems. (0%)
43. Has wearing headgear ever been an embarrassment to you? (Factor III, Stoic/Sensitive)
No, because I didn't wear headgear. (31%)
I have worn headgear but was never embarrassed. (25%)
Yes, I have worn headgear and ~vas embarrassed sometimes. (33%)
Yes, I have worn headgear and was embarrassed a lot. (5%)
Yes, I have worn headgear and was embarrassed most of the time. (6%)
44. Does wearing braces make chewing difficult? (Factor I, Pain/Dysfunction, Internal/External)
No, I can chew OK. (50%)
Yes, chewing is sometimes difficult. (41%)
Yes, chewing is often difficult. (9%)
Yes, chewing is always a problem. (0%)
45. Has difficulty chewing kept you from wearing headgear or rubber bands? (Factor I, Pain/Dysfunction,
Internal/External)
Chewing was not a problem. (48%)
Chewing was a problem but it didn't keep me from wearing headgear or rubber bands. (27%)
Difficulty chewing occasionally kept me from wearing headgear or rubber bands. (21%)
Difficulty chewing often kept me from wearing headgear or rubber bands. (1%)
Difficulty chewing always kept me from wearing headgear or rubber bands. (3%)
46. Did being sick ever keep you from wearing headgear or rubber bands? (Factor I, Pain/Dysfunction, Internal/External)
No, I was never sick. (20%)
I was sick but it didn't keep me from wearing headgear or rubber bands. (44%)
Yes, but it hasn't happened often. (28%)
Yes, it has happened occasionally. (5%)
Yes, it has been a big problem. (3%)
47. Did family problem such as your parents getting separated or divorced ever keep you from coming to the orthodontist
or wearing your headgear or rubber bands?
No, I didn't have such family problems. (83%)
I had family problems but it didn't interfere with wearing headgear or rubber bands. (15%)
Yes, but it was a minor problem. (2%)
Yes, it was a problem (0%).
Yes, it was a big problem. (0%)
48. Did moving keep you from visiting the orthodontist or wearing headgear or rubber bands?
No, I didn't move. (87%)
I moved but it didn't interfere with my orthodontic treatment. (10%)
Yes, it was a little problem. (3%)
Yes, it was a big problem. (0%)
49. Did you need to convince your parents you needed braces?
No. (87%)
Yes, I had to talk a little to convince them. (10%)
Yes, I had to talk a lot to convince them. (2%)
Yes, I had a great deal of trouble convincing them. (1%)
50. Did a death in your family ever keep you from coming to your appointment or wearing your rubber bands or headgear?
No, there were no deaths in my family. (79%)
341
342
Egolf, BeGole, and Upshaw
Am. J. Orthod. Dentofac. Orthop.
April 1990
Table I. C o n t ' d
There was a death in my family but it didn't interfere with orthodontic treatment. (17%)
Yes, but it was not a big problem. (1%)
Yes, it was a problem. (2%)
Yes, it was a major problem. (1%)
51. How self-conscious were you about your teeth before you had braces? (Factor I11, Stoic/Sensitive)
Not at all self-conscious. (19%)
A little self-conscious. (41%)
Somewhat self-conscious. (19%)
Very self-conscious. (20%)
52. Were braces a money problem for your family?
No. (47%)
Yes, but not very much of a problem. (36%)
Yes, the cost of braces was a problem. (14%)
Yes, the cost of braces was a big problem. (2%)
53. Before you had braces did you have a problem chewing?
No. (81%)
Yes, but there were only a few foods that gave me problems. (12%)
Yes, chewing was a problem. (6%)
Yes, chewing was a big problem for me. (1%)
54. Did you have a problem with your jaw joint (TMJ) before you had braces? (Factor III, Stoic/Sensitive)
No. (79%)
Yes, but it was a little problem. (13%)
Yes, it was sometimes a problem. (4%)
Yes, it was a big problem. (4%)
55. Has wearing braces ever kept you from participating in sports or playing a musical instrument?
No, I don't play sports or a musical instrument. (15%)
No, braces didn't keep me from playing sports or a musical instrument. (63%)
Yes, but it was a little problem. (14%)
Yes, it was a problem. (5%)
Yes, it was a big problem. (3%)
56. Do you always wear your headgear, rubber bands or other appliances the amount of time recommended by the orthodontist? (Factor I, Pain/Dysfunction, Internal/External, and Factor IX, Self-Confidence)
No, I rarely wear it. (29%)
No, I wear it about half the time. (45%)
No, I miss once in a while. (22%)
Yes. (4%)
57. Who should decide how much to wear headgear, rubber bands or other appliances?
The orthodontist. (93%)
Me. (7%)
My parents. (0%)
58. How crooked were your teeth before braces?
Not at all crooked. (45%)
Not very crooked. (35%)
Somewhat crooked. (17%)
Very crooked. (3%)
59. Is missing school or work because of orthodontic appointments a problem for you or your parents?
No. (43%)
Yes, but it's a little problem. (32%)
Yes, it's sometimes a problem. (20%)
Yes, its a big problem. (5%)
60. Did anyone else encourage you to get braces?
No, it was my decision alone. (40%)
Yes, others encouraged me. (60%)
Please check those persons who encouraged you.
Mother (64%)
Father (44%)
Volume 97
Number 4
Factors associated with patient compliance 343
Table I. Cont'd
My dentist (37%)
My guardian (1%)
Friends (22%)
Husband or wife (0%)
My family (brother, sister, uncles, aunts or grandparents) (29%)
61. When was your last check-up at your family dentist?
Less than 6 months ago. (46%)
Between 6 months and a year ago. (24%)
Over l year ago. (27%)
62. Do either of your parents wear false teeth? Yes (45%) No (55%)
63. How many times a day do you brush your teeth?
Twice a day or more. (73%)
Once a day. (25%)
Less than once a day. (2%)
64. How would you rate your cooperation in wearing braces?
Poor (8%)
Average (51%)
Excellent (41%)
65. Do you or anyone in your family use dental floss? Yes (77%) No (23%)
66. What is your father's occupation?
66. What is your mother's occupation9
67. What is you religion?
Protestant (9%)
Catholic (71%)
Jewish (2%)
Other (18%)
69. What would you say the biggest reason is for not wearing headgear or rubber bands.
Pain (28%)
Eating (4%)
Other (14%)
Speech (3%)
Laziness (10%)
Sports (2%)
Forgetfulness (9%)
Lost (2%)
Embarrassment (6%)
Sleep (2%)
Nuisance (6%)
Irresponsible (1%)
No excuse (6%)
Doesn't help (1%)
No response (5%)
Illness (1%)
70. Your name
(mean = 15.3 yrs.)
71. Your age.
previous rate o f tooth movement, the changes in tooth
relationships, the tooth mobility, and the radiographic
changes. These changes are the observable results o f
wearing headgear and intraoral elastics. A subjective
assessment from patient examination, chart notations,
and memory was thought to be sufficiently accurate
since the patient/practitioner relationship was longterm and well established. Furthermore, since the study
was ex post facto, headgear devices with timing mechanisms, rubber band counts, patient reports, or quantified treatment results were not feasible.
Dentistry. The subjects were at least 10 years old, exhibited no reading difficulties, and had been in treatment a minimum o f 3 months. They were wearing or
had worn intraoral elastics or a headgear. All patients
who were scheduled for adjustments and who met these
criteria were asked to participate. The purpose o f the
study was briefly explained by the student orthodontist
and further clarified on the face sheet o f the questionnaire. Only a few patients declined to participate and
only one questionnaire was unusable. Data collection
took approximately 1 month.
Sample selection and questionnaire administration
Reliability and validity of the instrument
The sample consisted o f 100 orthodontic patients in
active treatment at the University o f Illinois College o f
For a test to be useful and have meaning, it must
be both reliable and valid. Reliability is the consistency
Am. J. Orthod.Dentofac. Orthop.
April 1990
344 Egolf, BeGole, and Upshaw
Table II. Correlation between alpha factors and levels of compliance; alpha values for each factor
Factor
1
2
3
4
5
6
7
8
9
10
11
12
[
Description
Pain/dysfunction, internal/external
Health awareness
Stoic/sensitive
Social importance of beauty
Acquiescence
Well adjusted/insecure
Fatalism/determinism
Authority
Self-confidence
Importance of straight teeth for
oral health
Oral beauty and success
Orthodontics/family relations
[
Alpha
I
r
0.91 !
0.853
0.762
0.735
0.715
0.701
0.672
0.648
0.621
0.594
0,241
-0.289
-0,374
0.126
0.025
- 0.033
- 0.076
- 0.070
0.252
0.061
0.560
0.523
0,011
0.129
I
0,017"
0.004*
0.0002*
0.218
0.810
0.748
0,460
0.492
0.012"
0.550
0.912
0.206
*Factors significantly correlated with the criterion of compliance.
with which an instrument repeatedly measures an entity. 17,21,22TO maximize reliability, alpha factoring was
used. Intercorrelations of the item scores yielded a measure of reliability known as Cronbach's alpha. 22 The
larger the value of alpha, the more internally consistent
are the items in the factor.
Validity is the extent to which an instrument measures what it purports to measure. 17.21.22Content validity
was established by the formulation of questions deemed
relevant to the situation and subjects being examined
and a critical review of these questions. As stated, questionnaire items were taken from the literature and were
also suggested by experts and patients. The instrument
was then examined by orthodontists and a psychologist.
RESULTS
Factors extracted from the independent variables
Alpha factor analysis was used to reduce the 58
questions to more basic, underlying factors. For an item
in the questionnaire to be included for consideration
under a factor, the absolute factor loading value was
required to be greater than 0.32. Positive and negative
values were considered since the factors were bipolar,
i.e., included questions that were both positive and
negative.
The chosen cutoff point for factors was a coefficient
alpha of 0.5. This retained 12 of 21 factors, accounting
for 77.4% of the variance. The names for the factors
were developed through examination of the retained
questions that constituted the factor. As an example,
the following are the statements to which the patients
were asked to respond that made up factor II (health
awareness): (2) Having braces can help you have fewer
problems with your mouth later on. (5) Some people
have braces to help their bite. (11) Having a healthy
body is very important. (12) Straight teeth are easier
to clean. (14) Patients who understand their treatment
are more cooperative. (19) Having regular medical and
dental checkups is very important. (24) A person is
more willing to cooperate and follow directions when
the orthodontist explains what is being done and why.
(34) Straightening back teeth for a better bite is very
important.
The association between the factors extracted from
the questionnaire and the ratings of patient cooperation
was assessed with the use of Pearson's product-moment correlation coefficients, as seen in Table II.
Four factors were found to correlate weakly, but significantly, with compliance: Factor I (pain/dysfunction,
internal/external), factor II (health awareness), factor
III (stoic/sensitive), and factor IX (self-confidence).
Reliability and validity of the instrument
Not only was alpha factor analysis used for data
reduction; it was also used as a measure of reliability
or internal consistency of the factors derived from the
questionnaire. Factors were retained with alpha values
greater than 0.5, although most factors had higher alpha
values indicating a greater degree of reliability.
DISCUSSION
Four factors were found to be associated with cooperation in the wearing of headgear and elastics and
accounted for 38% of the variance. Factor I was an
amalgamation of pain/dysfunction in speaking and
chewing and internal/external personality questions.
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Number 4
Factor II contained health questions. Factor III was labeled stoic/sensitive and also contained questions regarding pain. Factor IX was best termed self-confidence
or self-assurance.
PRIMARY OBSERVATIONS
Personality/pain-dysfunction
The seemingly unrelated variables of personality
type and pain/dysfunction formed two nebulous factors, factors I and III. This is in agreement with Burns, 23
who observed that the way one copes with the pain and
oral dysfunction associated with braces is probably a
reflection of that patient's personality orientation.
Factor I confirmed the findings of EI-Mangoury 12
and Albino et al. 13 that personality as described by the
Rotter internal/external paradigm is related to particular
aspects of orthodontic patient compliance. As defined
by Rotter 19and EI-Mangoury,~z internally motivated patients will act to better their environment and are in
control; an internally motivated patient perceives a
causal relationship between results and his or her own
behavior. Externally motivated patients feel powerless
and believe they have little control over events, ascribing results to luck, chance, fate, or powerful others
(parents and orthodontists). This internal/external or
locus-of-control concept evolved from social learning
theory and has been the focus of many studies, many
of them concerning patient compliance. It is perhaps
an oversimplification of the theory to describe an orthodontic patient's personality as simply internal or external. Furthermore, this limited description does not include the personality characteristics contained in factors
III and IX, namely, self-assurance and stoicism, or the
characteristics of achievement and affiliation theory.
Observations concerning pain and psychological
variables were also made by Jones and Richmond, 24
who found no correlation between pain and orthodontic
force applied as reflected in the degree of crowding.
They suggested that the pain threshold was related to
the variables of emotion, attitude, and motivation.
The importance of pain to the patient is frequently
underestimated in the clinical setting. Its importance
should not be summarily dismissed, since pain was
cited in the open-ended question as the most frequent
reason for not wearing headgear or rubber bands. Furthermore, question 38 ("If braces are painful, does the
pain keep you from wearing headgear or rubber
bands?") was significantly correlated with compliance
(r = 0.292, p < 0.003).
As a clinically useful principle, patients who are
stoic or internally motivated will comply with the wear-
Factors associated with patient compliance
345
ing of headgear and elastics despite pain and problems
in speaking and chewing. Other patients will require
more preparation regarding the amount of discomfort
they may expect and methods to reduce it.
SECONDARY OBSERVATIONS
Self-perception
Another clinically applicable finding deals with patients' self-consciousness regarding their perceived
dental disfigurement. Factor III included question 51
("How self-conscious were you about your teeth before
you had braces?"). This question, when considered
alone, was correlated negatively with cooperation
(r = - 0 . 3 3 2 , p < 0.0008). This means the degree to
which the patient is embarrassed or self-conscious regarding tooth malalignment, no matter how minor, appears to be related to cooperation with treatment.
Both the patients and the orthodontists agreed on
which malocclusions were severe (r = 0.25, p <
0.05), supporting the findings of Lewit and VirolainenY + However, cooperation was not correlated with
severity. Therefore, in screening for potential cooperation, a meaningful question would be "How selfconscious or embarrassed are you by your teeth?" rather
than a rating of the severity of the malocclusion.
Embarrassment and apathy
Embarrassment about wearing a headgear was not
a major reason cited for noncompliance. In the openended questions, 6% of the patients gave embarrassment as the reason for not wearing headgear. This was
consistent with the 6% in question 43 who reported
they were embarrassed most of the time while wearing
headgear. The headgear embarrassment question did not
correlate with compliance. This differs from the observation by GabrieF 6 that embarrassment is important
in headgear noncompliance.
In the open-ended questions, 16% of the patients
reported laziness, forgetfulness, nuisance, or no excuse
as the primary reason for not wearing headgear. These
reasons could be described as apathy. In addition, the
single question of laziness (question 41) was significantly correlated with compliance (r = 0.364, p <
0.0002). As this relates to personality theory, the externally motivated patient may be apathetic regarding
elastic and headgear wear. At this point, the challange
becomes one of motivating the patient with this personality orientation.
Health awareness
Factor II, health awareness, contained questions
about general health attitudes, specific dental infor-
346
Am. J. Orthod. Dentofac. Orthop.
April 1990
Egolf, BeGole, and Upshaw
mation, and a question related to the need to acquire
information about treatment. Other studies have shown
that acquisition of knowledge concerning a disease does
not increase compliance. ~7 However, factor II would
tend to indicate that a high initial baseline of health
knowledge and awareness may be related to increased
compliance with the wearing of headgear and elastics.
CURRENT THEORIES OF PATIENT BEHAVIOR
Does the information collected from this exploratory study support existing theories of patient behavior?
The Health Belief Model
The first theory of patient behavior to be considered
is the Health Belief Model. It grew out of an effort by
social psychologists in the early 1950s to formulate a
theory and make recommendations for increasing compliance with screening tests, such as tests for tuberculosis. Today the basic beliefs or variables of the
Health Belief Model, as perceived by the patient, are
susceptibility, severity, beneficial actions, and barriers
to action, plus demographic and sociopsychological
variables and cues to action or stimuli. 28
Kegles,:9'3° in studying the Health Belief Model and
its applicability to dentistry, found the belief of susceptibility to he weakly related to preventive dental
visits of factory workers. A better predictor of the likelihood of making preventive visits was the history of
previous visits.
The present study did not find a significant relation
between compliance with the use of headgear and elastics and history of checkups (r = 0.025, p < 0.812).
It is surmised that the differences in findings may be
ascribed to the child's dependency on the parent in
providing transportation and making appointments.
The belief of severity may be construed to be selfconsciousness about the dental deformity. As applied
to orthodontics, it may be difficult or unnecessary to
separate the beliefs of susceptibility and severity. The
variable of beneficial action was supported by the positive correlations between cooperation and factor II
(health awareness).
Other elements of the Health Belief Model are bartiers, cues to action, and modifying factors. Specific
barriers to action, such as economics and family disruption, generally can be managed by the small number
of patients affected by these concerns. These reasons
for noncompliance did not form a single factor on the
analysis. They are not reasons for noncompliance with
headgear and elastic wear but may affect other aspects
of compliance, such as the keeping of appointments.
The aspect of the Health Belief Model termed
modifying factors is seen here to include personality
type as evidenced by factors I (internal/external), III
(stoic/sensitive), and IX (self-confidence). Cues to
action may include a general positive health orientation
and specific dental knowledge.
It may be concluded from the significant factors
found that many components of the Health Belief Model
are applicable to the orthodontic situation. Personality
variables and barriers to action deserve equal ranking
with the beliefs of general health awareness and susceptibility.
This is consistent with the observation of Tulloch
et al.3~ concerning another orthodontic patient behavior.
"The health belief model, formulated to express the
various interactions involved in treatment-seeking behavior, can with some modification and extension provide a reasonable framework for considering the utilization of orthodontic treatment."
Health Locus of Control
Wallston and Wallston 2° developed the Multidimensional Health Locus of Control from Rotter's Internal/External Scale. Originally it was validated by the
study of attitudes concerning hypertension and obesity.
It was further expanded and refined to include internal,
powerful others, and chance health loci of control and
renamed Multidimensional Health Locus of Control
Scales.
From the significant factors found in this research
and the findings of Allan and Hodgson, 4 EI-Mangoury, t2
and Albino et al., ~3 it can be stated that the Multidimensional Health Locus of Control Scale does not recognize all the personality traits necessary for a construct
of orthodontic patient personality. Furthermore, variables other than personality type (e.g., the factors of
pain/dysfunction and health awareness) must be included.
Good patient/bad patient behavior
Taylor3z theorized that hospital patients, whether
healthy or acutely or chronically ill, faced with loss of
control and depersonalization, behave as either good or
bad patients. Good patients are compliant, follow instructions, and exhibit undemanding, respectful, considerate behavior. They may be type B individuals who
have a high need for approval or a high sensitivity to
social desirability. Bad patients complain, demand attention, insist on information, and are suspicious of
treatment. They may be type A individuals who need
to be in control.
The loss of control in becoming an orthodontic patient is certainly not as extensive as it is when one
becomes a hospital patient. The description of the good
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Number 4
hospital patient appears applicable to the orthodontic
patient. However, the characterization of the bad hospital patient as one who reacts because his or her need
to be in control has been thwarted may not apply to the
orthodontic patient. Examination of the questions in
factor II, which is concerned With attribute motivation,
supports the contention that internally motivated patients cooperate better with the orthodontic therapy involving headgear and elastics and is consistent with the
research of EI-Mangoury. t2 This probably is because
the orthodontic patient is given the opportunity to participate in therapy and to be in control. This agrees with
the recommendation by Taylor 32 that self-care is important for both good and bad patients. The need-forinformation question contained in factor II supports her
contention that patient education is important. The selfhelp/education combination was also identified by
Powers and Wooldridge. 33
Social learning theory
The Social Leaming Theory formulated by Bandura ~
claims that social behavior develops as the result o f
observing others and of reinforcement. 35 The value of
this theory to account for oral hygiene behavior was
examined by McCaul et al.36 They essentially correlated
brushing and flossing frequencies of 131 adults with
variables thought to be appropriate to the social learning
theory, namely, specific knowledge o f dental disease,
actual skill in brushing and flossing, self-assessment of
brushing and flossing proficiency (self-efficacy expectations), belief in effectiveness of brushing and flossing
(outcome expectations), barriers, and dental behavior
of significant others. The variables of self-efficacy and
outcome expectations, behavior of significant others,
and barriers (forgetting and inconvenience) were found
to be correlated (r ranging from - 0.42 to + 0.48) with
oral hygiene frequency. The Social Learning Theory,
as presented by Bandura 34 a n d a d a p t e d for the dental
patient by McCaul et a1.,36 appears to contain components accounted for in the Health Belief Model and
omits personality variables, which in the present study,
were found to be important. Its value in developing a
construct of orthodontic cooperation is limited. It may
be approprate, however, for developing methods to address noncompliant behavior.
CONCLUSIONS
Major factors related to patient compliance with
headgear and elastic wear are personality type, pain,
interference with oral activities, health awareness, and
self-consciousness about the oral condition. There are
other factors and variables, such as finances, disrupting
personal events, and social pressures, that may be rel-
Factors associated with patient compliance
347
evant on an individual basis and for short periods of
time. They also may play a very important role in accounting for other aspects of patient cooperation, such
as appointment keeping or oral hygiene, which were
not explored in this study.
The question o f why orthodontic patients comply
requires more than a single answer or variable. Orthodontic cooperation with wearing of headgear and intraoraI elastics appears to involve a combination of the
nature of a person's personality; negative motives (pain,
inconvenience, and dysfunction); and positive motives
(general health awareness, specific dental knowledge,
and personal oral embarrassment).
The theory of patient behavior, which is best supported by these findings, is the Health Belief Model.
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Reprint requests to:
Dr. Ellen A. BeGole
Department of Orthodontics
University of Illinois at Chicago
PO Box 6998
Chicago, IL 60680
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