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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 ORTHOO DENTOFAC ORTHOP 1990;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 five 4-8 found no dif- ference 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 require- ments 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

reviewed. 4"7"9 Patients 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 self- reliance, 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 Hodgson 4 described the cooperative patient as 14 years of age or younger, enthusiastic, outgoing, energetic, wholesome, self- controlled, 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, indi- vidualistic, easygoing, self-sufficient, intolerant of pro- longed effort or attention, and disregarding the wishes

336

Voh~me 97 Number 4 Factors associated with patient compliance 337

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.~6 Bell 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

large number of variables to a smaller number of hy- pothetical 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 tech- nical 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 demograph- ics, 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 pa- rental control. The dimension of oral hygiene was not- included since it was not shown by Crawford 7 or EI- Mangoury 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, Resul t s o f the ques t i onna i r e (Pe rcen t age o f pa t i en t r e sponse is r epor ted . Ques t i ons c o m p r i s i n g

fac tors w h i c h cor re la te wi th coope r a t i on are no ted . )

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 disagree Disagree Neither Agree

0% I% 8% 64% 3. People with nice smiles have more friends.

Strongly disagree Disagree Neither

12% 47% 27%

4. Some patients cooperate better if their parents or the orthodontist gives them a reward.

Strongly agree 27%

tion, Internal/External) Strongly disagree Disagree Neither Agree

16% 36% 26% 19% 5. Some people have braces to help their bite. (Factor I1, Health Awareness)


2% 10% 8% 54% 6. Parents and the orthodontist become more upset with broken braces than they should.


13% 35% 36% 11% 7. It's easier to wear braces if your friends are wearing them too.


11% 39% 12% 32% 8. Some people want braces because their friends have them. (Factor IX, Self-confidence)


18% 44% 14% 23% 9. Straight teeth can help prevent gum problems.


4% 12% 31% 41% 10. People with pleasing smiles get ahead in life.


14% 37% 26% 22% 11. Having a healthy body is very important. (Factor II, Health Awareness)


1% 0% 2% 52% 12. Straight teeth are easier to clean. (Factor 11, Health Awareness)


3% 5% 20% 57% 13. Some day most people probably will have false teeth.


8% 30% 21% 39% 14. Patients who understand their treatment are more cooperative. (Factor II, Health Awareness)


1% 3% 8% 56%

Strongly agree

3%

Strongly agree 26%

Strongly agree

5%

Strongly agree

6%

Strongly agree

1%

Strongly agree 12%

Strongly agree

1%

Strongly agree 45%

Strongly agree 15%

Strongly agree

2%

Strongly agree 32%

Strongly Agree agree 11% 3%

(Factor I, Pain/Dysfunc-

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Table I . C o n t ' d

Factors associated with patient compliance 3 3 9

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)


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 disagree Disagree Neither Agree

15% 46% 27% 10% 21. Wearing headgear or rubber bands definitely helps straighten teeth.


1% 5% 10% 50%

Strongly agree

2%

Strongly agree 34%

22. A person can decide how much and when to wear headgear, rubber bands, or a retainer better than the orthodontist.


37% 48% 7% 5% 3% 23. A family should help the patient to remember to wear headgear, retainer or rubber bands.


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 disagree Disagree Neither Agree

33% 34% 30% 1% 26. Wearing braces can be worse than having crooked teeth.


34% 43% 11% 8%

Strongly agree

2%

Strongly agree

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

1 i % i 8% i 9% 40% 12%

340 Egolf, BeGole, and Upshaw

Table I . C o n t ' d

Am. J. Orthod. Dentofac. Orthop. April 1990

28. Straight teeth will help a person avoid gum disease and cavities. Strongly disagree Disagree Neither

4% 17% 35% 29. Some kids who don't cooperate with the orthodontist are also problem children at

Sensitive) Strongly disagree Disagree Neither

6% 27% 34%


home. (Factor III, Stoic/


30. If a patient has a problem with his/her braces, he/she should call Pain/Dysfunction, Internal/External)


0% 4% 7% 57% 32% 31. Some kids can get along well at home and still be bad orthodontic patients.


0% 7% 23% 65% 5% 32. Braces can be used to treat jaw joint problems.


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.


2% 2% 12% 59% 25% 35. Wearing braces can cause serious eating problems. (Factor I, Pain/Dysfunction, Internal/External)


9% 38% 27% 21% 5% 36. Kids cooperate better with an orthodontist who is stem.


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%)

the orthodontist immediately. (Factor I,

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%)

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Table I. C o n t ' d

Factors associated with patient compliance 341

My speech is affected but that doesn't keep me from wearing headgear or rubber bands. (45%) My speech is affected and that sometimes keeps me from wearing headgear or rubber bands. (6%) My speech is affected and that frequently keeps me from wearing headgear and rubber bands. (2%) My speech is affected 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%)


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%)

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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 occupation 9

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.

70.

71.

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%)

Your name

Your age. (mean = 15.3 yrs.)

previous rate of tooth movement, the changes in tooth relationships, the tooth mobility, and the radiographic changes. These changes are the observable results of wearing headgear and intraoral elastics. A subjective assessment from patient examination, chart notations, and memory was thought to be sufficiently accurate since the pat ient /pract i t ioner relationship was long- term and well established. Furthermore, since the study was ex post facto, headgear devices with t iming mech- anisms, rubber band counts, patient reports, or quan- tified treatment results were not feasible.

Sample selection and questionnaire administration

The sample consisted o f 100 orthodontic patients in active treatment at the University of Illinois College of

Dentistry. The subjects were at least 10 years old, ex- hibited no reading difficulties, and had been in treatment a minimum of 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 of the study was briefly explained by the student orthodontist and further clarified on the face sheet of the questionnaire. Only a few patients declined to participate and only one questionnaire was unusable. Data collection took approximately 1 month.

Reliability and validity of the instrument

For a test to be useful and have meaning, it must be both reliable and valid. Reliabil i ty is the consistency

344 Egolf, BeGole, and Upshaw Am. J. Orthod. Dentofac. Orthop. April 1990

Table II. Correlation between alpha factors and levels of compliance;

Factor [ Description [ Alpha

1 Pain/dysfunction, internal/external 0.91 ! 2 Health awareness 0.853 3 Stoic/sensitive 0.762 4 Social importance of beauty 0.735 5 Acquiescence 0.715 6 Well adjusted/insecure 0.701 7 Fatalism/determinism 0.672 8 Authority 0.648 9 Self-confidence 0.621

10 Importance of straight teeth for 0.594 oral health

11 Oral beauty and success 0.560 12 Orthodontics/family relations 0.523

alpha values for each factor

I r I 0,241 0,017"

- 0 . 2 8 9 0.004* - 0 , 3 7 4 0.0002*

0.126 0.218 0.025 0.810

- 0.033 0.748 - 0.076 0,460 - 0.070 0.492

0.252 0.012" 0.061 0.550

0,011 0.912 0.129 0.206

*Factors significantly correlated with the criterion of compliance.

with which an instrument repeatedly measures an en- tity. 17,21,22 TO 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. 17.21.22 Content 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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Factor II contained health questions. Factor III was la- beled 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 19 and 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, ascrib- ing 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. Fur- thermore, 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-

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 .332 , 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 Virolai- nenY + However, cooperation was not correlated with severity. Therefore, in screening for potential cooperation, a meaningful question would be "How self- conscious 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 open- ended 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-


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 tuber- culosis. 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 like- lihood 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 self- consciousness 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 bar- tiers, cues to action, and modifying factors. Specific barriers to action, such as economics and family dis- ruption, 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 pro- vide a reasonable framework for considering the utili- zation of orthodontic treatment."

Health Locus of Control

Wallston and Wallston 2° developed the Multidimen- sional Health Locus of Control from Rotter's Inter- nal/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 Multidi- mensional Health Locus of Control Scale does not rec- ognize 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

Taylor 3z 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 in- structions, and exhibit undemanding, respectful, con- siderate 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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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 in- volving 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-for- information question contained in factor II supports her contention that patient education is important. The self- help/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 of 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 andadapted 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 ad- dress 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-

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. Ortho- dontic cooperation with wearing of headgear and in- traoraI 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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