1

British Journal of Health Psychology (2014)

© 2014 The British Psychological Society
www.wileyonlinelibrary.com

A brief intervention changing oral self-care,

self-efficacy, and self-monitoring
Ralf Schwarzer1,2*, Agata Antoniuk2 and Maryam Gholami1,3
1
Department of Psychology, Freie Universit€at Berlin, Germany
2
University of Social Sciences and Humanities, Wroclaw, Poland
3
International Max Planck Research School on the Life Course (LIFE), Berlin, Germany

Background and aim. The roles of self-efficacy and self-monitoring as proximal

predictors of dental flossing frequency are studied in the context of an oral health
intervention.
Materials and methods. A study among 287 university students, aged 19 to 26 years,
compared an intervention group that received a brief self-regulatory treatment, with a
passive and an active control group. Dental flossing, self-efficacy, and self-monitoring
were assessed at baseline and 3 weeks later.
Results. The intervention led to an increase in dental flossing regardless of experimental
condition. However, treatment-specific gains were documented for self-efficacy and
self-monitoring. Moreover, changes in the latter two served as mediators in a path model,
linking the intervention with subsequent dental flossing and yielding significant indirect
effects.
Conclusions. Self-efficacy and self-monitoring play a mediating role in facilitating dental
flossing. Interventions that aim at an improvement in oral self-care should consider using
these constructs.

Statement of contribution
What is already known on this subject?
 The adoption and maintenance of oral self-care can be facilitated by a number of social-cognitive
variables.
 Interventions that include planning, action control, or self-efficacy components have been shown to
improve dental flossing.
 In one recent study on flossing in adolescent girls, planning intervention effects were mediated by
self-efficacy.

What does this study add?

 Self-monitoring is associated with better oral self-care.
 A 10-min intervention improves self-efficacy and self-monitoring.
 Self-efficacy and self-monitoring operate as mediators between treatment and flossing.

*Correspondence should be addressed to Ralf Schwarzer, Health Psychology (10), Freie Universit€at Berlin, Habelschwerdter Allee
45, 14195 Berlin, Germany (email: ralf.schwarzer@fu-berlin.de).

DOI:10.1111/bjhp.12091
2 Ralf Schwarzer et al.

There is a global increase in caries and other oral conditions that require better dental
health care (Bagramian, Garcia-Godoy, & Volpe, 2009; Petersen, 2008). Daily flossing can
help to prevent periodontal disease and tooth decay. Although adherence to oral hygiene
behaviours is essential, and their benefits are well known, a large number of persons
brush or floss their teeth much less frequently than recommended (Sch€ uz, Sniehotta,
Wiedemann, & Seemann, 2006). Psychosocial factors are associated with a disinclination
to change health behaviours, including lack of self-efficacy and lack of self-regulatory
skills (Sch€
uz, Sniehotta, & Schwarzer, 2007; Suresh, Jones, Newton, & Asimakopoulou,
2012).

Perceived self-efficacy
Perceived self-efficacy is the confidence in one’s ability to execute a difficult or
resource-demanding behaviour. The barrier here is not the technical difficulty of oral
self-care but rather the regular performance as an integrated part of daily life which is not
easy for some people. Self-efficacy predicts a range of health behaviours including oral
self-care (Anagnostopoulos, Buchanan, Frousiounioti, Niakas, & Potamianos, 2011;
Buglar, White, & Robinson, 2010; J€ €
onsson, Baker, Lindberg, Oscarson, & Ohrn, 2012;
Mizutani et al., 2012; Stewart, Wolfe, Maeder, & Hartz, 1996).
According to the health action process approach (HAPA; Schwarzer, 2008), to adopt or
maintain health behaviours, one can be motivated by psychological constructs such as
outcome expectancies and self-efficacy. Furthermore, after forming a behavioural
intention, one needs self-regulatory skills such as planning and action control to translate
the intention into actual health-enhancing behaviours (Gholami, Knoll, & Schwarzer,
under review; Sch€ uz et al., 2007; Schwarzer, 2008). Studies have reported beneficial
effects of self-regulatory skills on dental flossing (Munster Halvari, Halvari, Bjornebekk, &
Deci, 2012; Sch€ uz et al., 2006; Sch€
uz, Wiedemann, Mallach, & Scholz, 2009; Sniehotta,
Araujo Soares, & Dombrowski, 2007). A combination of self-efficacy and planning are
associated with higher frequency in dental self-care (Pakpour, Hidarnia, Hajizadeh, &
Plotnikoff, 2012; Pakpour & Sniehotta, 2012). In a randomized controlled trial with
Iranian adolescent girls, Gholami et al. (under review) identified effects of a brief
self-regulatory intervention on dental flossing. Changes in self-efficacy mediated between
treatment conditions and outcomes.

Self-monitoring
Also, self-regulatory skills such as action control facilitate adherence to dental flossing
with self-monitoring being the most studied component of action control (Sch€ uz et al.,
2007; Suresh et al., 2012). Action control comprises monitoring one’s progress,
comparing performance with goals, and investing more effort if needed. Monitoring is
an essential behaviour change technique (BCT) that can be applied to a variety of health
behaviours (Michie et al., 2013). When people keep records of their behaviours in form of
a diary or checkmarks on their calendar, they become aware of gains and deficits, which
leads them to take further action. In the study by Sch€uz et al. (2007), in which an action
control intervention (self-monitoring tool for dental flossing) was conducted, self-mon-
itoring had a beneficial effect only for those students who were already somewhat
motivated to increase their oral self-care. In other words, self-monitoring worked in the
volition (post-intentional) stage of the participants, but not in the earlier motivation
(pre-intentional) stage.
 Self-regulatory intervention changing oral self-care 3

However, in the study by Suresh et al. (2012), the action control intervention
enhanced adherence to dental flossing regardless of participants’ stage of change. Patients
with periodontal disease received a brief intervention consisting of a self-monitoring tool
for dental flossing in the form of a diary. Flossing frequency, dental plaque, and bleeding
scores improved in both stage-matched and stage-mismatched patients.

Planning
According to the HAPA, the volitional process is not only characterized by self-efficacy and
self-monitoring, but also by planning. A distinction has been made between action
planning and coping planning (Schwarzer, 2008). Action planning refers to the when,
where, and how of an intended behaviour, whereas coping planning pertains to the
anticipation of barriers and ways to overcome them. A great deal of research has
documented the pivotal role of planning interventions for a variety of health behaviours
(Hagger & Luszczynska, 2014; Kwasnicka, Presseau, White, & Sniehotta, 2013). The
present study includes planning as one necessary intervention component, but the focus
of the analyses lies on self-efficacy and self-monitoring.

The proposed mechanism

Self-efficacy is a facilitator of behaviour as well as a consequence of behaviour (Bandura,
1997). People who harbour self-doubts do not see a point in planning their actions.
However, planning can help them gain a clearer picture of the nature of the task. The
challenging task is segmented into steps that can be mastered in a sequence. Thus, an
intervention with self-regulatory components should facilitate a sense of being capable to
manage the challenge. As people begin to change, for example, by adopting a new
behaviour such as flossing, they are more likely to continue and maintain this behaviour
when constantly monitoring how well they do. Self-efficacious individuals feel encour-
aged to monitor their progress and gain more confidence from their mastery experience.
Therefore, it seems plausible that a volitional intervention improves self-efficacy and
self-monitoring, leading eventually to the maintenance of daily flossing.

Aims of the study

This study investigates an oral health intervention focusing on dental flossing among
Polish university students. The research question addresses the effectiveness of a 10-min
self-regulatory treatment as compared to control conditions. The experimental group
receives tasks that are supposed to increase self-regulatory skills and improve the
confidence in being capable to change behaviours. Outcome variables are dental flossing,
self-efficacy, and self-monitoring. Another research question concerns the putative
mechanisms of changes in social-cognitive variables and behaviours. A path model is
hypothesized in which the intervention serves as a distal predictor of the behavioural
outcome, whereas the social-cognitive variables are more proximal. Whether and how
these proximal factors operate as mediators between treatment and subsequent dental
flossing will be explored. Hypotheses are as follows: (1) the brief self-regulatory
intervention will lead to higher levels of dental flossing as compared to the control group,
(2) the brief self-regulatory intervention will lead to higher levels of dental self-efficacy as
compared to the control group, (3) the brief self-regulatory intervention will lead to higher
4 Ralf Schwarzer et al.

levels of self-monitoring of flossing as compared to the control group, and (4) self-efficacy
and self-monitoring mediate between intervention and behaviour.

Method
Participants and procedure
A brief self-regulation intervention to improve oral hygiene was conducted among Polish
university students in March and April 2013 with two assessment points in time, three
weeks apart. Participants were invited to the study through adverts in university housing
settings. They provided informed consent and were treated in line with APA ethical
guidelines. Attending the programme was voluntary. A total of 287 students (183 women,
104 men) from various fields of study were recruited and assigned to an intervention group
(n = 106), an active control group (n = 114), and a passive control group (n = 67). An
attempt was made to completely randomize groups in a 1:1:0.5 ratio, but could not be fully
achieved due to constraints at local settings. Individuals, couples, as well as groups of
students were approached for the study. Students were contacted face-to-face in alternating
sequence. They worked on the materials on the spot, while the investigator waited to
collect the completed forms, which took about 10 min in most cases. Participants were
blinded about the allocation throughout the study. The pre-test (Time 1; T1) questionnaires
included demographic information (e.g., age, sex, date, place) and social-cognitive
variables as well as dental flossing frequency. The identical post-test (Time 2; T2)
questionnaires were filled out by participants after 3 weeks in the same setting. Mean age of
the longitudinal sample was 21.36 years with SD = 1.55 and a range from 19 to 26 years.

Measures
Assessments were made in a parsimonious manner using a minimum set of items validated
in previous studies (Sch€uz et al., 2006; Schwarzer et al., 2007).
Dental flossing (past behaviour) was assessed with the open-format item ‘During the
last week, I have flossed my teeth…..times per day’.
Self-efficacy was measured with the item: ‘I am confident that I can frequently floss my
teeth regularly on a long-term basis even when I am in a hurry’. Responses were rated on a
scale ranging from 1 = not at all true, 2 = rather not true, 3 = likely true to 4 = exactly
true.
Self-monitoring was measured with the item: ‘During the last week, I have consistently
monitored when, how often, and how to floss my teeth’. Responses were rated on a scale
ranging from 1 = not at all true, 2 = rather not true, 3 = likely true to 4 = exactly true.

Intervention and control conditions

In the intervention condition (n = 106), participants received with their pre-test
questionnaire a brochure that had a volitional focus. In terms of BCTs, the leading
components were self-efficacy (BCT 15), planning (BCT 1.4), and self-monitoring (BCT
2.3; Michie et al., 2013). First, participants received information about dental flossing:
what it is, why it is done, and how it is done. Second, they were encouraged to generate
action plans for three occasions. These were subdivided into frequency, timing, and
technique, yielding a total of nine cells to fill out (‘Have you made a plan on flossing your
teeth in addition to brushing them? If so, please write here your most important plans
 Self-regulatory intervention changing oral self-care 5

regarding…how often to floss your teeth, …when to floss and how much time to spend
for flossing, …how to use dental floss’). After each of the three situations, a question
pertaining to self-efficacy was posed on a 4-point scale (‘How certain are you that you
can follow these plans?’). After completing these action plans, participants were
instructed to generate three coping plans, which included both barrier identification and
problem-solving (‘If I face difficult situations that might prevent me from flossing…, then
I plan to overcome them by…’). This was a six-cell design (three situations with critical
events and coping strategies), each followed by a statement pertaining to self-efficacy (‘I
am certain that I can follow these plans’). At the end, all participants in the intervention
group received a self-monitoring task (‘We provide a dental flossing calendar to help you
stick to your plans for the next weeks. Please find your calendar attached, and fill it in
regularly’).
Participants in the active control group (n = 114) received an educational pamphlet.
First, they received the same information about dental flossing: what it is, why it is done,
and how it is done. Second, they were encouraged to write down benefits of flossing
(positive outcome expectancies) and risks of not caring for one’s oral health.
In the passive control condition (n = 67), participants only received the question-
naires at two assessment points without any intervention.

Analytical procedure
Analyses were performed with SPSS 20. To examine intervention effects, repeated-mea-
sures analyses of variance were computed with dental flossing, self-efficacy, and
self-monitoring as dependent variables at two points in time, and experimental conditions
as the between-subjects factor.
A mediation model to predict post-test dental flossing was specified with baseline
flossing as a covariate, using the procedures by Hayes (2012, 2013). Sequential mediation
was specified by an effect of treatment on self-efficacy change, self-efficacy change on
self-monitoring change, and self-monitoring change on dental flossing behaviours.
Confidence intervals were determined by bootstrapping using 5,000 resamples. A
replication of the model was computed, using full information maximum likelihood
(FIML) with MPLUS, to yield standardized coefficients for the imputed total sample.

Results
Attrition analyses
Results indicated that individuals who continued study participation (n = 144; 50%) were
slightly younger (21.19 [SD = 1.57] compared with 21.83 [SD = 1.84] years), t(1,
265) = 3.04, d = .48, p = .003. More women than men had returned at T2, v2(1) = 6.88,
p = .01. Besides that, no other differences emerged with regard to treatment condition,
dental flossing, self-efficacy, and self-monitoring (all p > .05). Of those 144 students
returning at T2, n = 48 were in the self-regulatory intervention group, whereas n = 96
were in the control groups.

Randomization check
A MANOVA was computed to check for possible bias in the assignment to treatment
groups. Results revealed no baseline differences across the study conditions regarding age
6 Ralf Schwarzer et al.

and sex as well as the dependent variables dental flossing, self-efficacy, and self-moni-
toring (all p > .05).

Intervention effects
Preliminary analyses determined that the active and passive control groups did not differ
substantially in terms of dependent variables at T2. Therefore, they were collapsed into
one single control group (n = 96) which was then compared to the self-regulatory
intervention group (n = 48). Means, standard deviations, and group comparison statistics
for all variables are summarized in Table 1. Correlations are in Table 2.
To examine the intervention effects at post-test (T2), repeated-measures ANOVAs were
computed. For dental flossing, there was a substantial effect for time, F(1, 135) = 15.52,
p < .001, g2 = .10, meaning that all groups improved. However, there was no specific
treatment effect, F(1, 135) = 0.03, p = .86, and no interaction between treatment and
time, F(1, 135) = 1.84, p = .18 which may also be attributed to lack of power (0.27).
Dental flossing frequency became higher for the entire sample, and, thus, the first

Table 1. Means and standard deviations (SD) of dental flossing, self-efficacy, and self-monitoring as well
as change scores in both groups

Change
Time 1 Time 2 scores

Variable/Group M SD F(1, 284) p g2 M SD F(1, 141) p g2 M SD

Flossing
Intervention 0.45 0.7 0.36 .55 .00 1.04 1.2 0.48 .49 .00 0.61 1.22
Control Group 0.52 0.97 0.89 1.24 0.3 1.3
Self-efficacy
Intervention 2.35 0.86 3.7 .05 .01 2.54 0.85 3.72 .05 .03 0.19 1.08
Control Group 2.4 0.74 2.27 0.75 0.13 0.78
Self-monitoring
Intervention 1.91 0.79 0.11 .74 .00 2.29 0.99 7.07 .01 .05 0.38 0.96
Control Group 1.94 0.84 1.88 0.8 0.12 0.77

Note. Dental flossing was answered in an open-format; self-efficacy and self-monitoring responses were
rated on a scale ranging from 1 = not at all true, 2 = rather not true, 3 = likely true, to 4 = exactly true.

Table 2. Correlation matrix for age, sex, self-efficacy, self-monitoring, and flossing

Age Sex S-efficacy T1 S-efficacy T2 S-monitor T1 S-monitor T2 Flossing T1

Age 1.00
Sex$ .06 1.00
S-efficacy T1 .04 .07 1.00
S-efficacy T2 .17 .11 .31* 1.00
S-monitor T1 .02 .20* .26* .24* 1.00
S-monitor T2 .05 .06 .10 .53* .47* 1.00
Flossing T1 .09 .22* .26* .18 .32* .20* 1.00
Flossing T2 .12 .19* .20* .36* .29* .47* .42*

Note. Sex (0 = women, 1 = men).

*p < .05.
 Self-regulatory intervention changing oral self-care 7

hypothesis could not be confirmed. There was only a weak trend in favour of the
self-regulation group (see Figure 1).
For self-efficacy, there was no effect for time, F(1, 141) = 0.15, p = .70, and no
treatment effect, F(1, 141) = 0.95, p = .33. Nevertheless, an interaction between
treatment and time, F(1, 141) = 3.96, p = .049, g2 = .03 (see Figure 2) was found such
that students from the intervention group had increased levels of self-efficacy, whereas
students from the control groups had decreased levels at post-test, confirming the second
hypothesis.
For self-monitoring, there was a trend for time, F(1, 141) = 3.05, p = .08, g2 = .02,
and no main effect for experimental condition, F(1, 141) = 1.64, p = .20. However, there

Figure 1. Dental flossing frequency per day in the experimental conditions at two points in time (range
0–10 per day within last week).

Figure 2. Levels of self-efficacy in the experimental conditions at two points in time (range 1–4).
8 Ralf Schwarzer et al.

Figure 3. Levels of self-monitoring in the experimental conditions at two points in time (range 1–4).

was an interaction between groups and time, F(1, 141) = 10.94, p = .001, g2 = .07 (see
Figure 3). Whereas self-monitoring levels remained unchanged in the control condition,
they substantially increased in the self-regulatory intervention group, confirming the third
hypothesis.

Mediation analysis
Although the experiment did not yield a direct effect of the experimental condition on
later oral self-care, there is the possibility that the treatment may have an indirect effect
through the psychological constructs that had been responsive to the intervention. The
following analysis addresses the question of whether the observed changes in self-efficacy
and self-monitoring were instrumental in the change of dental flossing frequency. To test
mediation, self-efficacy as well as self-monitoring change scores were considered to serve
as sequential mediators between the intervention and dental flossing. A path model,
controlling for baseline behaviour, yielded the expected results. There was an effect of
self-efficacy change on self-monitoring change, and also an effect of self-monitoring
change on dental flossing at post-test. The total indirect effect was 0.11 (95% CI 0.03,
0.27), the indirect effect of treatment on dental flossing via self-monitoring was 0.07 (95%
CI 0.01, 0.20), and the indirect effect of treatment on dental flossing via changes in
self-efficacy and self-monitoring was 0.02 (95% CI 0.002, 0.08), confirming the fourth
hypothesis.
As these regression analyses, based upon the procedures by Hayes (2012, 2013),
yielded unstandardized parameters for the longitudinal sample (n = 136), a replication
was performed with MPLUS based on the total sample (n = 287), imputed with FIML, that
yielded standardized parameters, v2(2) = 2.09, p = .35; TLI = .99; RMSEA = .01, p = .57.
Including auxiliary variables in the missing mechanism of FIML did not change results.
Figure 4 displays the sequential mediation model with parameter estimates based on the
two solutions.
 Self-regulatory intervention changing oral self-care 9

Figure 4. Mediation model with effects of experimental conditions (1 = treatment, 0 = controls) via
changes in self-efficacy and changes in self-monitoring on dental flossing at T2, controlling for baseline
dental flossing. Unstandardized solution; bootstrapped with 5,000 resamples (n = 136). Standardized
solution (in italics) after imputation (n = 287). *p < .05; **p < .01.

Discussion
This study examined whether a self-regulatory intervention would make a difference in
flossing-related cognitions and behaviours in university students. The intervention was
theory-guided, inspired by the HAPA (Schwarzer, 2008) that includes self-regulatory
constructs such as perceived self-efficacy and action control skills (e.g., self-monitoring).
The intervention took only a few minutes, and outcomes were assessed 3 weeks after
baseline. Therefore, it is not surprising that there was no differential effect on actual
flossing frequency, although a time effect was documented. This means that on average,
all students, regardless of experimental conditions, benefitted from the study. The
purpose was to explore the feasibility of a very brief intervention following an idea by
Sniehotta et al. (2007) who had conducted a 1-min intervention, changing oral self-care
behaviour.
Although there was no time x group interaction effect for behaviour, such differential
effects were visible for self-efficacy and self-monitoring, confirming that the mindset of
students had changed as a consequence of the self-regulatory treatment condition. All
effects were small, which can possibly be attributed to the very parsimonious nature of the
intervention in terms of intensity and duration. Moreover, given the fact that only 20% of
the dental flossing variance was accounted for, it is likely that other psychological factors
are responsible, which could be included in future studies. Flossing on a regular basis
should become a habit, and habit strength is developed by behavioural repetition, which
hardly materialized within this brief 3-week time interval (Wiedemann, Gardner, Knoll, &
Burkert, 2014).
The self-regulatory constructs are regarded as proximal antecedents of behaviour. This
way, they were specified in a path model as mediators between experimental conditions
and subsequent dental flossing behaviours. Two pathways emerged. First, the shorter
path from conditions via change in self-monitoring was significant. Second, the longer
path from conditions via self-efficacy change via self-monitoring change also yielded an
indirect effect on dental flossing at T2. Uncovering such a mechanism lends optimism to
health promotion efforts, as the non-existence of a direct effect does not exclude the
existence of an indirect pathway to behaviour change.
10 Ralf Schwarzer et al.

Most previous research has identified a single factor or mediator (such as self-efficacy)
that facilitates changes in oral self-care. Some have examined the joint effects of
self-efficacy and planning (Pakpour & Sniehotta, 2012; Pakpour et al., 2012). In contrast,
sequentially operating mediators are rarely investigated. Gholami et al. (under review)
have identified a sequential mediation via intention and self-efficacy on dental flossing.
The present research is in line with their findings, using self-monitoring as the most
proximal antecedent of oral self-care. Self-monitoring should be most supportive for
flossing maintenance in persons who have already a strong intention to improve or
maintain oral health (Sch€ uz et al., 2007) although the research on such stage-specific
effects is still controversial (Suresh et al., 2012).
The present findings suggest to conduct future HAPA studies with more time points to
allow for a fine-grained sequential analysis. Instead of using T2 T1 change scores, one
could specify separate measurement points in time for each element in the hypothesized
sequence. An alternative research design would put a stronger focus on the role of
intentions by dividing participants into pre-intenders and post-intenders. In such a design,
the present key variables might emerge as more predictive in the volitional subgroup and
less so in those who need to be motivated for flossing. Planning interventions have been
found to be most effective within samples of already motivated individuals (Hagger &
Luszczynska, 2014; Kwasnicka et al., 2013). Thus, stages of change should be considered
in future research designs.
There are some limitations. Assessments were self-reported and dental flossing was
measured retrospectively. One could use on-going behavioural assessments such as a
dental calendar that allows for constant record keeping (Sch€ uz et al., 2007). In the present
study, the dental calendars were used as a treatment, but not as a daily assessment tool. To
examine the assumed mechanisms of the intervention, effects of its components (such as
action control, action planning, and coping planning) should be tested, because
otherwise the active ingredients of complex interventions cannot be identified.
Moreover, a follow-up assessment after a few months is suggested to investigate
longer-term effects of the intervention. All variables were assessed most parsimoniously
by single items only. Although parsimony is important in field studies, future research
should consider employing the use of more refined psychometric tools and compare
single-item with multiple-item scales because the question whether one is more valid than
the other is an on-going debate (Bergkvist & Rossiter, 2007).
Nevertheless, the theory-guided intervention design may have further elucidated the
mechanisms of changing oral hygiene behaviours, in this case dental flossing. The findings
partly replicate similar studies with different health behaviours and, thus, make a
contribution to the cumulative knowledge about self-regulatory and social-cognitive
components in health behaviour change.

References
Anagnostopoulos, F., Buchanan, H., Frousiounioti, S., Niakas, D., & Potamianos, G. (2011).
Self-efficacy and oral hygiene beliefs about toothbrushing in dental patients: A model-guided
study. Behavioral Medicine, 37, 132–139. doi:10.1080/08964289.2011.636770
Bagramian, R. A., Garcia-Godoy, F., & Volpe, A. R. (2009). The global increase in dental caries. A
pending public health crisis. American Journal of Dentistry, 22, 3–8.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.
 Self-regulatory intervention changing oral self-care 11

Bergkvist, L., & Rossiter, J. R. (2007). The predictive validity of multiple-item versus single-item
measures of the same constructs. Journal of Marketing Research, 44, 175–184. doi:10.1509/
jmkr.44.2.175
Buglar, M. E., White, K. M., & Robinson, N. G. (2010). The role of self-efficacy in dental patients’
brushing and flossing: Testing an extended health belief model. Patient Education and
Counseling, 78, 269–272. doi:10.1016/j.pec.2009.06.014
Gholami, M., Knoll, N., & Schwarzer, R. (under review). A brief self-regulatory intervention increases
dental flossing in adolescent girls in Iran.
Hagger, M. S., & Luszczynska, A. (2014). Implementation intention and action planning
interventions in health contexts: State of the research and proposals for the way forward.
Applied Psychology: Health and Well-Being, 6. doi:10.1111/aphw.12017
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation,
moderation, and conditional process modeling. Retrieved from: http://www.afhayes.com/
public/process2012.pdf
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A
regression-based approach. New York: The Guilford Press.
J€
onsson, B., Baker, S. R., Lindberg, P., Oscarson, N., & Ohrn,€ K. (2012). Factors influencing oral
hygiene behaviour and gingival outcomes 3 and 12 months after initial periodontal treatment:
An exploratory test of an extended Theory of Reasoned Action. Journal of Clinical
Periodontology, 39, 138–144. doi:10.1111/j.1600-051X.2011.01822.x
Kwasnicka, D., Presseau, J., White, M., & Sniehotta, F. (2013). Does planning how to cope with
anticipated barriers facilitate health-related behavior change? A systematic review. Health
Psychology Review. Advance online publication. doi:10.1080/17437199.2013.766832
Michie, S., Richardson, M., Johnston, M., Abraham, Ch, Francis, J., Hardeman, W., . . . Wood, C. E.
(2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered
techniques: Building an international consensus for the reporting of behavior change
interventions. Annals of Behavioral Medicine, 46, 81–95. doi:10.1007/s12160-013-9486-6
Mizutani, S., Ekuni, D., Furuta, M., Tomofuji, T., Irie, K., Azuma, T., . . . Morita, M. (2012). Effects of
self-efficacy on oral health behaviours and gingival health in university students aged 18 or
19 years old. Journal of Clinical Periodontology, 39, 844–849. doi:10.1111/j.1600-051X.2012.
01919.x
Munster Halvari, A. E., Halvari, H., Bjornebekk, G., & Deci, E. L. (2012). Self-determined motivational
predictors of increases in dental behaviors, decreases in dental plaque, and improvement in oral
health: A randomized clinical trial. Health Psychology, 31, 777–788. doi:10.1037/a0027062
Pakpour, A. H., Hidarnia, A., Hajizadeh, E., & Plotnikoff, R. C. (2012). Action and coping planning
with regard to dental brushing among Iranian adolescents. Psychology, Health & Medicine, 17,
176–187. doi:10.1080/13548506.2011.596551
Pakpour, A. H., & Sniehotta, F. F. (2012). Perceived behavioral control and coping planning predict
dental brushing behavior among Iranian adolescents. Journal of Clinical Periodontology, 39,
132–137. doi:10.1111/j.1600-051X.2011.01826.x
Petersen, P. E. (2008). World Health Organization global policy for improvement of oral
health-World Health Assembly 2007. International Dental Journal, 58, 115–121.
Sch€
uz, B., Sniehotta, F. F., & Schwarzer, R. (2007). Stage-specific effects of an self-monitoring
intervention on dental flossing. Health Education Research, 22, 332–341. doi:10.1093/her/
cyl084
Sch€
uz, B., Sniehotta, F. F., Wiedemann, A., & Seemann, R. (2006). Adherence to a daily flossing
regimen in university students: Effects of planning when, where, how and what to do in the face
of barriers. Journal of Clinical Periodontology, 33, 612–619. doi:10.1111/j.1600-051X.2006.
00967.x
Sch€
uz, B., Wiedemann, A. U., Mallach, N., & Scholz, U. (2009). Effects of a short behavioral
intervention for dental flossing: Randomized-controlled trial on planning when, where and how.
Journal of Clinical Periodontology, 36, 498–505. doi:10.1111/j.1600-051X.2009.01406.x
12 Ralf Schwarzer et al.

Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption
and maintenance of health behaviors. Applied Psychology: An International Review, 57, 1–29.
doi:10.1111/j.1464-0597.2007.00325.x
Schwarzer, R., Schüz, B., Ziegelmann, J. P., Lippke, S., Luszczynska, A., & Scholz, U. (2007). Adoption
and maintenance of four health behaviors: Theory-guided longitudinal studies on dental flossing,
seat belt use, dietary behavior, and physical activity. Annals of Behavioral Medicine, 33,
156–166. doi:10.1007/BF02879897
Sniehotta, F. F., Araujo Soares, S. U., & Dombrowski, V. (2007). Randomized controlled trial of a
one-minute intervention changing oral self-care behavior. Journal of Dental Research, 86, 641–
645. doi:10.1177/154405910708600711
Stewart, J. E., Wolfe, G. R., Maeder, L., & Hartz, G. W. (1996). Changes in dental knowledge and
self-efficacy scores following interventions to change oral hygiene behavior. Patient Education
and Counseling, 27, 269–277. doi:10.1016/0738-3991(95)00843-8
Suresh, R., Jones, K., Newton, J. T., & Asimakopoulou, K. (2012). An exploratory study into whether
self-monitoring improves adherence to daily flossing among dental patients. Journal of Public
Health Dentistry, 72, 1–7. doi:10.1111/j.1752-7325.2011.00274.x
Wiedemann, A., Gardner, B., Knoll, N., & Burkert, S. (2014). Intrinsic rewards, fruit and vegetable
consumption, and habit strength: A three-wave study testing the Associative Cybernetic Model.
Applied Psychology: Health and Well-Being, 6. doi:10.1111/aphw.12020

Received 7 August 2013; revised version received 7 January 2014