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The Premack principle, self-monitoring, and the maintenance of preventive dental health behaviour Ramer, Donald Gordon 1979

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THE PRSMACK PRINCIPLE, SELF-MONITORING, AND THE MAINTENANCE OF PREVENTIVE DENTAL HEALTH BEHAVIOUR by DONALD GORDON RAMER B.A., University of British Columbia, 1972 M.A., University of British Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF PSYCHOLOGY We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1979 © Donald Gordon Ramer, 1979 In present ing t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree tha t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r re ference and s tudy. I f u r t h e r agree that permiss ion f o r ex tens ive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s en t a t i v e s . I t i s understood tha t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed wi thout my w r i t t e n pe rm i s s i on . Psychology Department of , The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook P lace Vancouver, Canada V6T 1W5 October 19, 1979 Date ! i . ABSTRACT Preventive dental programs designed to reduce the incidence of g ing iv i t is and periodontal disease have met with only l imited success. The advent of behavioural technology offered a possible application to this problem. The present study examined the effects of two behavioural techniques, the Premack Principle and self-monitoring, on the maintenance of preventive dental health behaviour. Experiment 1 attempted to determine the va l id i ty of the Premack Principle using both toothbrushing and f lossing as instrumental and contingent responses. Twelve female students of a dental assist ing instructional program were exposed to various baseline and contingency conditions of brushing and f loss ing , dai ly for 11 weeks, according to a single-subject reversal design. When access to the contingent response was prevented, six of the twelve subjects showed a re l iable increase in instrumental responding. Compared to baseline performance, six of seven subjects and four of twelve subjects evidenced reinforcement effects due to a contingency which allowed unlimited and. l imited access, respectively, to the contingent response. However, increases in instru-mental responding observed during these conditions fa i led to surpass those observed when access to contingent responding was prevented, in a l l but three subjects. These results would suggest that many observed increases in instrumental responding which are often cited as evidence supporting the Premack Principle may be due in fact simply to the unavai labi l i ty of the contingent response. Additional theoretical implications of these findings were discussed. Experiment 2 fac tor ia l ly compared two levels of the Premack Principle (contingency vs. no contingency between f lossing and brushing) i i . with three levels of self-monitoring (no SM, SM-frequency, and SM-frequency plus evaluation). Ninety f i r s t and second year university student volunteers were assigned to one of six treatment groups. Instruction in brushing and f lossing technique as well as application of the appropriate experimental manipulation was provided i n two instruc-t ional sessions. Subjects' oral hygiene was assessed according to a gingival index and a plaque index before, one month following, and seven months following instruction.. Repeated measures analysis of variance revealed only a signif icant Assessment effect . A l l treatment groups showed an equivalent large degree of improvement in oral hygiene from pre- to one month postinstruction. Improved plaque scores were maintained over the six-month follow-up period; gingival scores, however, were not. A no-treatment control group differed from the six treatment groups only at the one-month postinstructional assessment. These results show.that instructions to implement a contingency between f lossing and brushing, and different levels of self-monitoring, fa i led to augment the short-term gains in oral hygiene produced by instruction in brushing and f lossing technique per se. None of the experimental components d i f ferent ia l ly contributed to maintenance. A third and f ina l experiment examined the effect of the Premack Principle on the maintenance of .ef fect ive brushing and f lossing within a private dental c l i n i c . Thirty dental patients were alternately assigned to an experimental Premack Principle group or a control group. Subjects of both groups received two sessions of individualized instruc-t ion in oral hygiene techniques. Repeated measures analysis of variance showed only a signif icant Assessment effect , from pre-to three months postinstruction, only for plaque, but not g ingival , scores. Instructions i i i . t o impose a contingency between f l o s s i n g and brushing f a i l e d to produce an e f f e c t . The r e s u l t s of t h i s study demonstrated that n e i t h e r s e l f - m o n i t o r i n g nor i n s t r u c t i o n s t o impose a contingency between f l o s s i n g and brushing c o n t r i b u t e d t o the maintenance of e f f e c t i v e o r a l hygiene behaviour. Self-management programs must become more concerned w i t h the i s s u e of maintenance, p a r t i c u l a r l y f o l l o w i n g c e s s a t i o n of experimental or t h e r a -p e u t i c contact. I m p l i c a t i o n s f o r maintenance s t r a t e g i e s were discussed. i v . TABLE OF CONTENTS Page ABSTRACT I LIST OF TABLES v i LIST OF FIGURES v i i LIST OF APPENDICES v i i i GLOSSARY ix ACKNOWLEDGEMENT x i INTRODUCTION • 1 REVIEW OF THE DENTAL LITERATURE 2 Effects of Bacterial Plaque 2 . Plaque Control Agents 5 Plaque Control Programs: Mass Media 10 Plaque Control Programs: School Settings 12 Plaque Control Programs: C l in ica l Settings 18 REVIEW OF THE BEHAVIOURAL LITERATURE 28 Premack Principle . . . 28 Self-monitoring 36 EXPERIMENT 1 53 Method 54 Results and Discussion 63 EXPERIMENT 2 67 Method 68 Results 74 Discussion 83 V . Page EXPERIMENT 3 . . 85 Method 86 Results and Discussion 88 GENERAL DISCUSSION 9 3 REFERENCE NOTES 104 REFERENCES 105 APPENDICES 122 v i . LIST OF TABLES Page Table 1. Summary of experimental procedure and resul ts , Experiment 1 57 Table 2. Response contingency parameters, Experiment 1 58 Table 3. Mean gingival and plaque index scores, Experiment 2 . 76 Table 4 - . Repeated measures Analysis of Variance summary table, Experiment 2 . 78 Table 5. Mean gingival and simplif ied plaque .index scores, Experiment 3 89 Table 6. Repeated measures Analysis of Variance summary table, Experiment 3 91 v i i . LIST OF FIGURES Page Figure 1. Daily duration of brushing and f lossing across experimental conditions, Experiment 1 . . . 59 Figure 2. Mean gingival and plaque index scores, Experiment 2 77 Figure 3- Mean gingival and plaque index scores, Experiment 3 90 v i i i . LIST OF APPENDICES Page Appendix I Subject consent form .122 Appendix II Faculty of Dentistry disclaimer 123 Appendix III Medical history form 124 Appendix IV Postexperimental questionnaire, Experiment 1 125 Appendix V Self-monitoring chart: No-contingency, SM-frequency 127 Appendix VI Self-monitoring chart: No-contingency, SM-frequency + evaluation 128 Appendix VII Self-monitoring chart: Contingency, SM-frequency 129 Appendix VIII Self-monitoring chart: Contingency, SM-frequency + evaluation 130 Appendix IX Scoring c r i t e r i a for the gingival index (Gl) and plaque index (P l l ) 131 Appendix X Subject data form 132 Appendix.XI Preinstructional questionnaire, Experiment 2 . . 133 Appendix XII One-month postinstructional questionnaire, Experiment 2 137 Appendix XIII Seven-month postinstructional questionnaire, Experiment 2 139 Appendix XIV No-treatment control subjects' questionnaire, Experiment 2 143 Appendix XV Postexperimental study description . . . 144 GLOSSARY1' Some of the dental terminology which may he urifamiliar to the reader are defined here. buccal. Adjacent to the cheek. calculus. Tartar, the hard mineral deposit on teeth, formed from calcium phosphate and carbonate, and organic matter. dental caries. Tooth decay, a disease of the ca lc i f ied structures of the teeth, characterized by decalci f icat ion of the mineral components and dissolution of the organic matrix. desquamation. Peeling off of the epi thel ia l layer. erythrosine dye. A red dye, used to stain bacterial plaque. f luoride. A compound of fluorine with another element, which binds with tooth enamel to increase i t s resistance to the deleterious effects of dental caries. gingiva(e). The fibrous tissue covered by mucous membrane that immediately surrounds a tooth. gingival exudate. The outpouring of exudate from gingival t issues, part icular ly during gingival inflammation. g ing iv i t i s . Any inflammation of the gingival t issue. interproximal. Between the proximal surfaces of adjoining teeth. intrasulcular. Within the shallow grove between the gingiva and the surface of the tooth, and extending around i t s circumference. Intrasulcular brushing pertains to plaque removal from this area. l ingual . Next to , or toward, the tongue. mandible. Lower jawbone. material alba. A soft white deposit which forms around the necks of the teeth; composed of food debris, dead tissue elements, and purulent matter; serves as a medium for bacterial growth in the the development of plaque. maxilla. Uppper jawbone. 1. from Boucher (1974-). X . neutrophil. A mature.white blood c e l l . Perio-aid. Instrument used in the present study. to measure gingival integri ty. periodontal disease (periodontit is) . Inflammation of the periodontal tissues result ing in destruction of the periodontal membrane and supporting alveolar bone; a chronic, progressive disease of the periodontium. plaque. A sticky transparent substance that accumulates on the teeth; composed of mucin derived from sal iva and of bacteria and their products. x i . ACMOWLEDGEMENT The completion of t h i s p r o j e c t would not have been p o s s i b l e without the a s s i s t a n c e provided by many people. I would l i k e t o express my g r a t i t u d e t o the f o l l o w i n g : A l l a n Best, f o r h i s i n i t i a l encouragement; Terry Saunders and Richard Tees-, f o r t h e i r h e l p f u l c r i t i c i s m s of the proposal of the study; David Lawson and Don W i l k i e , f o r t h e i r h e l p f u l comments and support during the l a t t e r stage of the study; John S i l v e r , f o r h i s encouragement and expert advice and ass i s t a n c e i n d e n t a l procedures; Park Davidson, who provided sage advice and unfla g g i n g support throughout a l l stages of the study; the s t a f f and students of the Vancouver V o c a t i o n a l I n s t i t u t e Dental A s s i s t i n g Program, and i n p a r t i c u l a r , Faye Condon, who was in s t r u m e n t a l i n the execution of the f i r s t experiment; Ed Fukushima and h i s s t a f f , f o r t h e i r generous time and a s s i s t a n c e ; "~ Penny Anderson, f o r her expert coaching i n o r a l hygiene i n s t r u c t i o n ; the U.B.C. F a c u l t y of D e n t i s t r y , f o r p r o v i d i n g c l i n i c space; V i r g i n i a Green and Ralph Hakstian, f o r t h e i r advice and ass i s t a n c e i n data a n a l y s i s ; John Kozak and John L i n d , who convinced me that data a n a l y s i s could be fun; K e i t h Humphrey, Margaret Kendrick, and Sandy M i l s , f o r t h e i r buoyant support and encouragement; and, Ruth A l l a n , who e x p e r t l y and p a t i e n t l y typed the manuscript. x i i . I am most of a l l indebted to Janet, not only for providing expert dental assessment of a l l subjects i n the second experiment, but for her continual support and patience. Her contribution to this project was immeasurable. 1. INTRODUCTION Behavioural technology or ig inal ly found application in the educational and mental health f i e lds . Appropriate and inappropriate classroom behaviours, for example, could be increased and decreased via reinforcement and punishment, or extinction, procedures, respectively. Similarly behavioural intervention has been used to increase socia l ly appropriate behaviours in mental health settings. More recently behavioural technology has found application in the treatment and prevention of physical disorders. The term "behavioural medicine" has been coined to describe this new approach (Schwartz and Weiss, 1977). Health professionals are becoming increasingly aware of the importance of appropriate l i f e s t y l e behaviours to the attainment of optimal physical (and mental) health. Excesses and deficiencies are apparent in l i f es ty le behaviours which detract from optimal physical health. Overeating and lack of exercise are obvious examples. Equally obvious i s the need for the development and validation of new behavioural techniques for application to both accelerative and decelerative l i f es ty le behaviours. The f i e l d of preventive dentistry presents an interesting avenue for the development and application of behavioural technology. Improvement in oral hygiene can be achieved by increasing requisite behaviours such as tooth brushing and f loss ing. The present study investigated the effects of two behavioural techniques, the Premack Principle and self-monitoring, within the context of a preventive dental program. The following chapters w i l l review the relevant dental l i terature and the Premack Principle and self-monitoring l i teratures. 2. REVIEW OF THE DENTAL LITERATURE Effects of Bacterial Plaque Inadequate dental health care has been, and continues to he, a major socia l problem. The results of epidemiological studies i l lus t ra te the widespread prevalence of dental caries and periodontal disease. These are age-related diseases. Typical ly, dental caries exerts i t s most deleterious effects on children and adolescents; g ingiv i t is and subsequent periodontal disease become increasingly prevalent i n young adults. A recent, large-, American survey found that the average number of decayed, missing, and f i l l e d teeth more than doubled from 4-0 to 8.7 in children from the age of 12 to 17 years. The most abrupt increase in the incidence of caries occurs between age 18 and 21 (Kelly and Harvey, 1974-)• A previous U.S. Public Health Service survey found that half of 32,000 six tol7-year-old students sampled had g ingiv i t is (Kelly and Van Kirk, 1965). In Vancouver, 15 to 35 percent of children aged 5 to 19 years have been estimated to suffer periodontal disease requiring treatment (Br i t ish Columbia Dental Health Survey, 1968). Estimates of periodontal disease are much higher for adults, as prevalence increases with age. Periodontal disease i s the major cause of tooth loss past the age of 35 (American Dental Association, 1953). U.S. Public Health Service surveys have estimated that 75 percent of dentulous,adults are affected by g ingiv i t is or periodontal disease. This figure continues to r ise with increasing age (Kelly and Van Kirk, 1965). The high prevalence of periodontal disease in adult populations has been well established throughout the entire world "(.Grant, Stern, and Everett, 1968; Greene, 1973). 3. Periodontal disease, i f le f t untreated, w i l l eventually result in destruction of the periodontium, and subsequent tooth loss . This condition i s preceded by g ing iv i t i s , or inflammation of the gingiva, which results from i r r i t a t i o n by the accumulation of bacterial plaque. The course of periodontal disease has been best observed experimentally in animals. Lindhe., Hamp, and Loe (1973) observed the long-term effects of plaque accumulation in beagles maintained on a diet of soft food. Over the f i r s t few days, plaque formed along the gingival margin of each tooth. There shortly followed a rapid increase in gingival exudate and the migration of neutrophils. After four to f ive weeks of plaque accumulation, c l i n i c a l signs of g ing iv i t is were observed, including alterations of gingival texture and colour,, and an increased tendency to bleed. F ina l ly , loss of connective tissue attachment, or periodontal destruction, became apparent after six to eight months. Periodontal destruction continued over the four-year period of a follow-up study (Lindhe, Hamp, and Loe,. 1975). Control' animals had plaque removed from their teeth dai ly , and maintained noninflammatory gingiva and a healthy periodontium over the same time period. Interestingly, the course of periodontal disease was not completely predictable: two of the experimental animals fa i led to show sub-gingival deposits, and did not evidence periodontal disease. The course of g ingiv i t is was f i r s t experimentally produced in humans by Loe, Theilade, and Jensen (1965). Twelve subjects with i n i t i a l l y healthy gingiva ceased a l l oral hygiene for varying lengths of time. Three subjects developed g ingiv i t is within 10 days. Gingivi t is occurred in the other subjects between 15 and 21 days. On resumption of effective oral hygiene procedures,, gingival inflammation was resolved in about one week. Addit ional ly, plaque bacteriology went through three dist inct stages, each associated with a corresponding stage of 4. gingivit is. . . Further bacteriology.was associated with age, not thickness, of plaque. Theilade, Wright, Jensen, and Loe (1966) observed a reduction in gingival inflammation as.early as one day following resumption of effective oral hygiene, following 21-day plaque accumulation. Gingival inflammation was closely related to plaque accumulation during this period. There i s l i t t l e doubt that plaque accumulation w i l l produce g ing iv i t i s , and that prevention of plaque accumulation w i l l prevent g ing iv i t i s ' (Loe, 1970). While plaque i s the primary et io logical factor in g ing iv i t i s , and subsequently periodontal disease, i t s role in. caries, i s less certain. It has been suggested that separate mechanisms, both associated with plaque metabolism, are responsible for g ingiv i t is and caries (Lavelle, 1975). Chemical prevention of plaque formation in young adults resulted in a re lat ive ly lower Caries Index, even with frequent rinses of sucrose, compared to subjects who allowed plaque to accumulate (Loe, Fehr, and Schiott, 1972). Daily professional f lossing of selected teeth in f i r s t grade children produced at least a 50 percent reduction in caries incidence, compared to contralateral unflossed teeth, over an eight-month, and a 20-month period (Wright, Banting, and Feasby, 1976, 1977). 5. Plaque/Control Agents It i s apparent from, these studies that control of plaque formation can prevent g ing iv i t is and s igni f icant ly reduce caries incidence. As plaque production i s an ongoing process, optimal plaque control would involve disrupting i t s metabolism before accumulation can occur. Various chemotherapeutic agents, most notably chlorhexidine, have been tested. Twice daily r insing with a chlorhexidine solution, for example, was found to prevent new plaque formation for 22 days (Loe et a l . , 1972). While this is a re lat ive ly new topic of investigation, recent work is encouraging. Chlorhexidine has been found to be effective in;::preventing the formation of new plaque, but not effective against existing subgingival plaque, for research periods up to two years (Axelsson, Lindhe, and Waseby, 1976; Nagle and Turnbull, 1978). Ear l ie r reviews, while supporting the effectiveness of chlorhexidine, have also reported a variety of systemic side ef fects , including gingival soreness and desquamation, and staining of tooth surfaces. Also, chemotherapeutic plaque control agents have a l i m i t e d spectrum.-of antibacteri-a l act iv i ty . F ina l ly , their long-term eff icacy has not been evaluated (Mandel, 1972; Parsons, 197-4). Thus chemical plaque control remains a future, but not present, poss ib i l i t y as a viable public dental health measure. Additional measures have included retarding the growth and accumulation of plaque, and increasing tissue resistance to i t s deleterious effects. Plaque feeds on sucrose; restr ic t ing sucrose intake should therefore retard i t s accumulation. This i n fact does occur, accompanied by a slower rate of caries act iv i ty (Loe et a l . , 1972). However, periodontal disease i s rampant in many areas where sucrose intake i s 6. low (Greene, 1973; Mandel, 1972). Plaque has even been observed to accumulate in animals which were tube-fed (Egelberg, 1965). Assuming that plaque accumulation is inevitable, some attempts have been made to increase tooth and periodontal tissue resistance. Most success has been achieved with a reduction in caries produced by topical or systemic application of f luoride solutions. For example, semiannual topical application of f luoride paste resulted in a signif icant decrease in caries act iv i ty in children over a three-year period (Gish, Mercer, Stookey, and Dahl, 1975). A voluminous l i terature supports the contention that f luoridating the public water supply w i l l produce about a 50 percent decrease in caries incidence (Davies, 1974-). Unfortunately, f luoride has no similar prophylactic effect on g ing iv i t is (Birkeland, Jorkjend, and Fehr, 1973; Frandsen, McClendon, Chang, and Creighton, 1972). It i s also .doubtful"''whether :.tlie.-toxicity.of • plaque can be'reduced nutr i t ional ly (Morhart and Fitzgerald, 1976), or whether periodontal tissue immunity to plaque can be increased, nutr i t ional ly (Alfano, 1976). The only rel iable method of preventing g ingiv i t is and periodontal disease is the regular mechanical removal of plaque from tooth surfaces. Contrary to popular be l ie f , chewing coarsely textured food, such as apples, may produce a decrease in some oral debris, but w i l l not remove accumulated plaque (Birkeland and Jorkjend, 1974; Wade, 1971). Some controversy exists as to the optimal frequency of plaque removal, both for the prevention of g ingiv i t is and the prevention of caries. The evolution of bacterial toxic i ty through dist inct stages associated with age would suggest optimal plaque removal just before tox ic i ty exceeds tissue resistance, or every three to ten days (Arnim, 1971). Preventive programs which recommend plaque removal several times each 7. day for the prevention of g ingiv i t is are empirically unfounded (Loe, 1971). Alexander (1970, cited i n Kelner, Wohl, Deasy, and Formicola, 1974) found that brushing more frequently than once daily had no effect on gingival inflammation. Lang, Cumming, and Loe (1973) found that complete plaque removal every 4-8 hours maintained healthy gingiva as effect ively as plaque removal every 12 hours, over a six-week period ( in young adults with previously clean teeth and healthy gingiva). Increasing the interval to three days, however, resulted i n a gradual increase in gingival inflammation (Kelner et a l . , 1974). Thus b i -da i ly plaque removal appears suff icient to prevent 'gingivi t is , at least in healthy young adults over a short period of observation. Data from a long-term animal study corroborate this conclusion (Saxe, Greene, Bohannan, and Vermil l ion, 1967). Regarding caries prevention, the data are less clear. For example, many studies have attempted to relate frequency of brushing to a decrease in caries incidence, reporting small.but usually insignif icant resul ts . Typical ly , children with good oral hygiene have a lower caries incidence, but the difference i s small compared to children with poor oral hygiene (Andlaw, 1978). The lack of clear agreement .in studies reviewed by Andlaw and ear l ier by Heifetz, Bagramian, Suomi, and Segreto (1973) i s most l i ke ly due to the ineffective method of brushing employed by most .subjects studied. Most frequency data are derived, from sel f - report . There is usually no indication of eff icacy of plaque removal. When plaque i s removed dai ly , either professionally or under supervision., caries incidence i s reduced (Wright et a l . , 1976, 1977), but this reduction may not be s t a t i s t i c a l l y (or c l i n i c a l l y ) signif icant (Horowitz, Suomi, Peterson, and Lyman, 1977; Horowitz, Suomi, Peterson, Voglesong, and Mathews, 1976). 8. At present, b i -da i l y plaque removal would appear to be suff icient for the prevention of g ing iv i t i s . The ontogenesis of plaque into a c l i n i c a l l y recognizable substance over 2-4 hours would suggest the eff icacy of i t s dai ly removal. The optimal frequency of plaque removal for caries prevention i s not known (Heloe and Konig, 1978). There i s also a paucity of information on the most effective technique for plaque removal (Suomi, 1971; Heifetz : et a l . , 1973). Preventive programs have typica l ly espoused brushing as the most effective technique for plaque removal, usually without empirical val idation. Brushing has been found effective in removing plaque, and hence reducing g i n g i v i t i s , buccally and l ingual ly , but not as effective i n removing plaque from interproximal tooth surfaces (Frandsen, Barbano, Suomi, Chang, and Houston, 1972; Lindhe and Koch, 1967). This is c r i t i c a l because plaque i n i t i a l l y accumulates interproximally (McHugh, 1970). A high correlation has been observed between interproximal plaque accumualtion and severity of g ing iv i t is (Lang, Ostergaard, and Loe, 1972). As dental f loss w i l l ef fect ively clean interproximal surfaces (Richardson, 1975), i t s use as an adjunct to brushing would seem appropriate. A recent study compared brushing and f lossing with brushing alone, in subjects with an i n i t i a l l y high incidence of. sulcular bleeding. The addition of f lossing s igni f icant ly reduced the number of gingival bleeding sites after eight days (Carter, Barnes, Radentz, Levin, and Bhaskar, 1975). It has been stated repeatedly that there i s no current alternative to the control of g ing iv i t is and periodontal disease by the regular removal of hard and soft deposits from the tooth surfaces (Greene, 1973). Hard deposits must be removed professionally. Soft deposits can best be removed by the appropriate personal use of a toothbrush and dental f loss (McHugh, 1970). Gingivi t is can be prevented by a thorough d a i l y removal of a l l s o f t deposits from a l l t o o t h surfac (Lang et a l . , 1973). 10. Plaque Control Programs: Mass Media Preventive programs designed to reduce the prevalence of dental disease have t radi t ional ly approached the problem by introducing the concept of preventive dental health to the community through several avenues, including mass media compaigns, educational campaigns in the school system, and instructional programs in dental c l i n i c s . Mass media campaigns have attempted.to disseminate dental knowledge to both community and national populations. An example at the community level is the "Dr. Dial" program, a highly-touted program which used a combina-t ion of mass media and recorded messages in an attempt to increase public awareness of dental health (De Car l i s , 1973; Weiss, Lee, and Williams, 1972). The campaign apparently succeeded with this goal, as a high level of community interest, was demonstrated. In the or iginal study, 1-4 percent of a l l dental v i s i t s were prompted by the program (Weiss et a l . , 1972). At the national level., the American Dental Association has sponsored te levis ion spot announcement campaigns designed for adult and chi ld audiences. Unfortunately there has been no systematic evaluation of these campaigns (Thornton, 1974-). The media have also been employed at the national level by commercial interests, to s e l l products purported to contribute to dental health. While some benefits of such advertising have been observed, such as the increased use of fluoridated dentifr ice and the inferred increase In per capita frequency of brushing (Thornton, 1974), the public remains largely misinformed on matters of dental health. Recent surveys, for example, have estimated that 75 percent of adults and.even a larger percentage of children, do not real ize that plaque i s implicated in dental disease (Epstein, Moore, and McPhail, 1974; Linn, 1976). Despite the exceedingly 11. high prevalence of periodontal disease, National Opinion Surveys conducted in the United States in 1959 and 1965 found that unlike caries, periodontal disease i s not considered a personal threat by most people. Also, i t i s generally believed that satisfactory prevention can occur through regular brushing, in the absence of additional hygiene aids (Putnam, O'Shea, and Cohen, 1967). Such.misconceptions are doubtlessly reinforced by the preponderance of advertising for breath sweeteners and toothpaste, which are of dubious value in the prevention of g ingiv i t is and periodontal disease. 12. Plaque Control Programs: School Settings Preventive dental programs have existed in one form or another in school curricula for many years (Dollar and Sandell, 1961). Unt i l recently, however, such programs have been supported more by intui t ion than by empirical data (Rayner and Cohen., 1971; Young, 1970). One program which has been advertised to be advantageous due to low cost and high effectiveness has been the "Toothkeeper" program. Dentists instruct teachers to instruct their students in a l l aspects of preventive dental health. Recent evaluations of this program have unfortunately fa i led to demonstrate i t s ef f icacy. Smith, Evans, Suomi, and Friedman (1975) and Stamm, Kuo, and Nei l (1975) fa i led to observe signif icant dental improvement over no-treatment control subjects, at the end of the 16-week program. Graves, McNeal, Haefner, and Ware (1975) observed Toothkeeper subjects to improve s l ight ly on gingival and plaque measures compared to subjects exposed to a t radi t ional dental program. The plaque score, however:, showed a less than 10 percent improvement throughout the program. Further, improvement for Toothkeeper subjects was not maintained over a 16-week follow-up. Possible reasons for the poor relat ive performance of the Toothkeeper program include lack of teacher preparation and lack of provision to transfer oral hygiene s k i l l s from school to home (Smith et a l . , 1975). One of the earl iest studies to validate empirically the effect of dental instruction was performed by Wi l l i fo rd , Muhler, and Stookey (1967). High school students were given six lectures on dental health over a three-month period by a dentist. By the end of this period, their performance on the Simplif ied Oral Hygiene Index (OHI-S) (Greene and Vermil l ion, 1964-), the Periodontal Index (Russell , 1956), the 13. Dental Health Test (Dental IQ), and self-reported frequency of brushing was s igni f icant ly better than that of control subjects of a different school. Interestingly, experimental subjects continued to improve over the next three months.in the absence of continued dental instruction. Podshadley and Schweikle (1970) found that a one-session lecture/ demonstration in brushing given to grade three and four children resulted in sl ight improvement on the Patient Hygiene Performance (PHP) (Podshadley and Haley, 1968) index, over two-week, and four-month, follow-up periods. However, these scores did. not d i f fer s igni f icant ly from those of a no-treatment control group.. The authors concluded that measurement per se contributed to most of the change. Stolpe, Mecklenburg, and Lathrop (1971) presented an intensive 12-week brushing and f lossing program to children in grades four, f i ve , and s ix . The signif icant improvement in OHI-S scores achieved over the school year regressed during summer vacation to levels below the or ig inal scores. The net result over the follow-up.period was an increase in dental knowledge, but no or negative changes in dental attitudes and behaviour. Anaise and Zilkah (1976) found that semimonthly booster instructional sessions maintained PHP scores in schoolchildren over a one year period, regardless of i n i t i a l instructional format. Control subjects improved over the f i r s t month, then regressed. It would be interesting to see whether treatment gains would have regressed following termination of the booster sessions. Some success has been realized with regular supervision of oral hygiene, part icular ly when accompanied with reinforcement. Stacey, Abbott, and Jordan (1972) improved oral hygiene in children.at a summer camp by means of demonstration, instruct ion, supervision, feedback, and reinforcement of improved brushing and f lossing effectiveness. Privi leges served as reinforcers. Unfortunately there was no control group. Lattal (1969) successfully reinforced,toothbrushing in children at a summer camp. Brushing was brought under contingent control of swimming in a reversal design employing eight subjects. In a long term study, children whose brushing was supervised at school for three years showed improvement on the Gingival Index (Gl) (Loe and Si lness, 1963) and Plaque Index (P l l ) (Silness and Loe, 1964) at each year end, compared to controls. However, these treatment gains regressed to levels of nonsignificance one year following cessation of supervision (Lindhe and Koch, 1967). It is possible that the supervised brushing of this study fa i led to provide for transfer from school to home. Horowitz et a l . (1977) also fa i led to observe maintenance of improved plaque and gingival scores over summer vacation, following supervised brushing and f lossing over two school years. Supervision of children's oral hygiene behaviour appears to be effective so long as the supervision is in effect. It i s disappointing that maintenance i s not realized even following three years of supervision. Other programs have sought to fac i l i t a te maintenance with the inclusion of additional treatment, components. A lber t in i , Boffa, and Kaplis (1973) provided what they considered an optimal environment for children to adopt preventive health behaviours. An extensive program which involved children at several conceptual levels of dental health focused on.changing dental health behaviours of brushing and f loss ing , and not attitudes. While the program appeared successful at the end of i t s 12 week duration, no follow-up data were reported. Martens, Frazier, H i r t , Meskin, and Proshek (1973) d i f ferent ia l ly reinforced second grade subjects with tokens exchangeable for toys according to the degree of improvement in oral hygiene. Experimental subjects also 15. participated in dental learning-projects. F ina l ly , there was intensive individualized interaction with a dental hygienist. Compared to students exposed to the standard dental curriculum, this highly involving program produced signi f icant ly better modified PHP scores., both at project termination and at six month follow-up. Experimental subjects also evidenced a more effective brushing technique. Albino, Juliano, and Slakter (1977) developed an extensive dental program, which included a variety of instructional and motivational techniques. Experimental subjects received annual dental prophylaxes and additional dental procedures, supplemented with instruction in brushing in the f i r s t year. A parent-monitored behaviour modification program in which both brushing and f lossing frequency, and effectiveness were reinforced was added to a modified instructional program. In the third year, peer group leaders were assigned to small: groups, which participated in a "belief consistency" program (Rokeach, 1971) designed to reduce inconsistencies between personal values and reported dental health behaviour. The groups also competed with each other for a prize given for the greatest col lect ive ly reduced plaque score. F ina l ly , the parent-monitored behaviour modification program was continued through the third year. The experimental group was compared with two control groups, each of.which received an annual prophylaxis and dental health lecture. One control group additionally received annual topical f luoride and sealant application. The experimental subjects evidenced s l ight ly but s igni f icant ly better plaque scores, but not gingival scores, only at the 30-month assessment, period, at the end of the third school year. None' of the gingival or plaque scores of the other semiannual assessments was s igni f icant , compared to control subjects. It i s somewhat surprising that such an extensive program would f a i l to show differences of greater magnitude. Additional analyses were performed on manipulations made i n the third.year of the program (Albino, Tedesco-Stratton and Greenberg, Note l ) . Students who were c lass i f ied as leaders according to sociometric measures participated in the home-based behaviour modification program. Postexperimental assessment revealed more oral hygiene improvement in these students, relat ive to non-leaders who did not participate in the behaviour modification program. It is not clear whether this program, or leadership status assigned to these students, contributed to these resul ts . A more recent study (Albino, in press) compared two behaviour change techniques with tradi t ional instruction and a no-treatment control. Seventh grade students served as subjects. Both an approach designed to reduce inconsistencies between expressed attitudes and actual oral hygiene behaviours and a cognitive behaviour rehearsal technique produced signif icant reductions i n plaque, but not g ingival , scores one week following treatment. Only subjects exposed to the be l ie f consistency treatment continued, to show improvement at six and twelve weeks following treatment, relat ive to control subjects. This approach does appear promising. However, as in many such studies, s t a t i s t i c a l l y signif icant group differences often represent differences of negligible c l i n i c a l import. The previous studies focused on changing children's behaviour to improve their oral health. V/hen this i s combined with frequent professional prophylaxis, excellent results have been reported (Axelsson et a l . , 1976). Schoolchildren exposed to this regimen showed a s ign i -f icant ly reduced incidence of g ingiv i t is and caries over a two-year period. Lindhe, Axelsson, and Tollskog (1975) instructed children and their parents i n oral hygiene procedures. During the f i r s t two years of this program, children's teeth were professionally cleaned 17. every two weeks. The frequency of prophylaxis was decreased to every four or every eight weeks during the third year. Both experimental and control subjects brushed under supervision with 0.2 percent sodium fluoride once per month. The experimental program, combining instruction with regular prophylaxis with fluoride application resulted in v i r tual total elimination of g ingiv i t is and carious lesions. Moreover, excellent oral hygiene standards were established and maintained. Similar results have been reported by Hamp, Lindhe, Fornel l , Johansson and Karlsson (1978), who in addition found that regular r insing with a f luoride solution w i l l contribute to the prevention of car ies, but this effect can be greatly enhanced by improved ora l hygiene habits. Most programs which have been designed to optimally prevent g ing iv i t is and caries in children cannot be considered entirely successful. Regular, supervision of effective oral hygiene behaviour i s effective only so long as supervision i s i n effect . Oral hygiene s k i l l s developed in such programs typica l ly f a i l to transfer from the school to the home environment (Haefner, 1972). Some attempts have been made to fac i l i t a te home transfer by the inclusion of parent part ic ipat ion. These programs have met with some success. Generally, programs which employ a diversity of intervention strategies seem most effect ive. The Karlstad program of oral hygiene instruction combined with frequent prophylaxis presents encouraging resul ts , part icular ly when compared with typical remedial treatment, in terms of a cost-benefit perspective (Birkeland and Axelsson, 1976). 18. Plaque Control Programs: C l in ica l Settings In addition to mass media campaigns and school programs, preventive dentistry has sought to exert an influence in the dental c l i n i c . Preventive dentistry became a popular edi tor ia l topic in the early 1970's, accompanied bya.plethora of "how-to" publications. Character-i s t i c a l l y , such writing has not included supportive data. In response to the question: "Which efforts of the dentist have been shown to be effective in inducing preventive behaviours in. the patient?", Corah recently repl ied: "I know.of no evidence which demonstrates that dentists have any effect whatsoever." (1974, p.. 227). Indeed, the dental l i terature had been characterized by an absence of evaluation of dental health programs (Burt, 1974). Fortunately this statement i s less applicable today than i t was several years ago. One of the earl iest preventive dental programs for adults was described by Lovdal, Arno, Schei, and Waerhaug ( l96l ) . Fourteen hundred Oslo factory workers were instructed In oral hygiene techniques. Every six months, or three months for those i n greater need, subjects received additional instruction as well as professional supra- and subgingival prophylaxis. The 800 subjects who completed the five-year program showed a considerable reduction in g ing iv i t is and tooth loss , compared with expected untreated outcomes. There was no control group. Improvement was posit ively related to subjects' eff iciency of oral hygiene and compliance with instructions. More recently the effectiveness of a similar combined program of regular prophylaxis and instruction has been evaluated (Suomi, Greene, Vermil l ion, Doyle, Chang, and Leatherwood, 1971). Adult experimental subjects received complete prophylaxis and intensive instruction at two- to four-month intervals over three years. Control subjects received only an annual examination. At the end of three years, experimental subjects had cleaner teeth, less gingival inflammation, and a slower rate of apical migration of gingival attachment, compared to controls. A subsequent follow-up examination 32 months later revealed that the or iginal treatment gains were to some extent maintained, although differences between the two groups on some of the indices were now smaller (Suomi, Leatherwood, and Chang, 1973). Such a program appears promising as a public health measure, provided that resources are available. The eff icacy of a program combining regular prophylaxis with instruction receives further support from.similar programs evaluated in school settings (Axelsson et a l . , 1976; Hamp et a l . , 1 9 7 8 ; Lindhe et a l . , 1975). It i s d i f f i c u l t to determine the relat ive contribution of prophylaxis and instruction to the re lat ively successful maintenance which has been reported in these studies. Possibly i t is the interaction between the two factors which i s most ef fect ive, but this has not been determined. Much attention has recently been focused on the effect of various modes of instruction on changing oral hygiene behaviour. Durlak and Levine (1975) combined group instruction with Individual feedback and evaluation i n a program in which oral health improved over a f ive month follow-up. One important aspect of this program was the emphasis on self-diagnosis in the army outpatient subjects. No control group was employed. When the effects of individual versus group instructional formats were compared in a chi ld dental program, no differences i n oral hygiene measures were found. However, Individual instruction led to more s k i l l improvement in brushing technique (Anaise and Zi lkah, 1976). Radentz, Barnes, Carter, A i l o r , and Johnson (1973) found that one showing of video-taped f lossing instruction to groups of army 20. dental patients improved f lossing performance. Proficiency was further improved by the addition of one subsequent session of individual instruction (Radentz, Barnes, Kenigsberg, and Carter, 1975). In these two studies f lossing proficiency was rated, not determined by i t s effectiveness in plaque removal. Kois, Kotch, Cormier, and Laster (1978) found that both l ive and video-taped Instruction resulted in equal improvement in PHP scores over a five-week follow-up. Addit ional ly, while subjects' i n i t i a l dental I.Q., or dental knowledge evidenced by questionnaire data, had some predictive value for the f ina l PHP scores, their i n i t i a l plaque scores fa i led to predict f ina l PHP scores. Probably even simpler than video-taped instruction i s the use of a self-teaching manual. Zaki and Bandt (1974) reported two experiments which investigated the use of a manual developed at the University of.Minnesota. In the f i r s t of these experiments, periodontal patients (following a professional prophylaxis) were given a tooth brush and dental f loss and allowed to study the manual and practice plaque control s k i l l s . They showed signif icant improvement in PHP scores and a s k i l l performance test score over a two-week period, relat ive to control subjects given the dental materials only. In the second study, a single session of individual instruction and feedback added s l igh t ly , but not s t a t i s t i c a l l y s igni f icant ly , to the treatment gains produced by two sessions of exposure to the se l f - instruct ional manual. Improvement was measured i n dental hygiene students one week following the last treatment session. These studies have shown that dental hygiene performance can be improved with re lat ive ly minor intervention. Unfortunately most have only employed extremely short follow-up periods. Experience with school dental programs has shown that long-term maintenance i s the exception rather than the ru le , even after intensive intervention. 21. A br ief program of plaque control instruction i s not l i ke ly to prove effective over an extended period of time. For example, Legler, Gilmore, and Stuart (1971) reported a signif icant improvement in plaque, gingival and calculus measures 30 days following a program of chairside dental health instruct ion. Six months la ter , i n i t i a l treatment gains had regressed to near pretreatment leve ls . The use of fear appeals, evaluated i n studies of attitude change, has also been investigated in the dental area. Janis and Feshback (1953.) and Leventhal, Singer, and Jones (1965) found that fear appeals, when coupled with information providing instruction in avoiding.feared consequences, leads to an expression of greater, intent or attitude, to carry out the desired behaviour. In agreement with Janis and Fe.shback, Ramirez, Lasater, Anderson., Cameron, Connor, Davis, and Meon (1971) found that low fear messages produced the greatest change in intention to brush and self-reported frequency of brushing. Providing recommendations also increased intention to brush. The high fear message resulted in the greatest information retention. However, a l l groups improved equally on the behavioural measure of brushing effect ive-ness. Evans, Rozelle, Lasater, Dembroski, and Allen (1970) included a message which emphasized positive consequences of brushing, with other messages of fear appeals and recommendations. They found, that positive communication, and not high fear appeal (Ramirez et a l . , 1971) produced greatest information retention. Both high fear and low fear messages resulted in greatest intention to brush. While a l l groups increased their reported frequency of brushing, positive •communication'and .in-elaborate instruction produced the most oral hygiene improvement. Treatment gains in a l l groups regressed over the six-week post-communication period. The Evans et a l . and Ramirez, et a l . studies show a discrepancy 22. between Intention to behave,, self-reported behaviour, and actual behaviour. It i s apparent that the f i r s t two measures must be validated by the th i rd , when the focus, i s on behaviour change. It i s possible, however, that the reported discrepancy between reported and actual behaviour i s exaggerated, as discrepant measures were used ( i . e . frequency vs. effectiveness of brushing). More recently Evans, Rozelle, Nobl i t t , and Williams (1975) found that none.of their manipulations, including fear messages, instruct ions, and feedback, was any more effective than repeated measurement per se in maintaining plaque scores over 10 weeks. These reports have typ ica l ly used didactic instruction as a vehicle for behaviour change. Recently addit ional techniques have been evaluated. Newcomb (197-4) for example, found that dental students who had been instructed in effective oral hygiene procedures successfully served as models to improve oral hygiene scores of their peers, over six weeks. Several studies have evaluated the effects of disclosing for the presence of plaque. This, procedure requires the application of a solution which renders v is ib le any plaque remaining on the teeth following cleaning. It thus provides immediate feedback of the effect ive-ness of oral hygiene procedures. Cohen, Stol ler , .Chace, and Laster (1972) provided the f i r s t evidence that dai ly disclosing of plaque could s igni f icant ly reduce plaque scores, even when subjects were not instructed in effective brushing techniques. In this study perio-dontal patients instructed to disclose for plaque and then brush showed re lat ive ly improved P1I scores compared to control subjects instructed to brush only, over the six-week experimental period. Both groups equally improved their Gl scores. Friedman, Evans, Paver, Bridges, and Burdine (1974) found that plaque disclosure was as effective as, 23. but no more so than other forms of instruction and feedback in improving PHP scores over an eight-week period . Barrickman and Penhall (1973) found that daily, disclosing for plaque s igni f icant ly added to the effect of instruction alone regarding P1I scores. Subjects additionally-allowed .to graph their GI and P1I scores at each of six weekly assessments showed the largest reduction in P1I scores, over the six-week period. However, the study employed a very small number of college student volunteer subjects (ns of f ive and s ix ) . A l l groups showed similar reduction in their GI scores. Too few subjects were available for the 10-week follow-up, but i t appears that gingival and plaque scores were regressing toward preassessment leve ls . F ina l ly , a recent study has reported some promising results of greater patient involvement in their oral hygiene (Godin, 1976). Six periodontal patients taught. plaque control procedures, including scaling their own teeth, and given optical devices for plaque disclosure were compared with six subjects who were taught plaque control procedures and who had their teeth professionally cleaned. No differences in gingival scores were observed at any assessment, nor in PHP scores after two-weeks of treatment, but the se l f -sca l ing group showed s igni f icant ly better PHP scores at f ive months following treatment. The effects of disclosing for plaque.are equivocal. Regular disclosure for presence of plaque appears to be as effective as various instructional procedures on a number of indices of oral health. Monitoring the results of plaque disclosure may increase effectiveness. Adequate maintenance of these procedures has not been clearly demonstrated. Studies which show relat ive improvement in plaque indices but not gingival indices can not be said to have demonstrated clear ly eff icacious techniques. Oral hygiene program goals are typica l ly expressed in terms of improving gingival health, thus preventing periodontal disease, 24. and not i n terms of short-term episodic plaque removal. As is apparent from this review, preventive dental programs have not enjoyed a large degree of success. Inappropriate measures of effectiveness have often been employed. Ear l ier studies, for example, focused on information retention, attitude change, and self-reported behaviour as dependent measures of program effectiveness. There is l i t t l e evidence which clearly relates any of these factors to actual preventive dental health behaviour. For example, Evans et a l . (1970) and Ramirez, Wershow, and Pelton (1969) found discrepancies between information retention, reported oral hygiene behaviour, and actual oral hygiene scores. There,has been l i t t l e or no relat ion reported between bel ie f of caries suscept ib i l i ty , or other dental attitudes, and frequency of v is i t ing the dentist, or self-reported frequency of brushing (Bene, Novasky, and Geldart, 1974; Keleges, 1961, 1974). The patient typica l ly f a i l s to maintain appropriate dental behaviour even when convinced that such behaviour w i l l eventually pay off (Van Zoost, 1975). However, Weigel and Amsterdam (1976) have recently observed an increased correlation between PHP scores and dental attitudes following oral hygiene instruct ion. There was an i n i t i a l poor correlat ion, suggesting that subjects must have a knowledge of appropriate techniques to reduce the often reported discrepancy between attitudes and behaviour. Studies investigating patient personality characteristics have reported that patients who demonstrate an internal locus of control of reinforcement (Rotter, 1966) tend to show a greater orientation toward prevention (Ramirez et a l . , 1969), and to obtain regular checkups, but do not brush or f loss more frequently (Williams, 1972) or show reduced plaque scores (Ayer, Barnes, and Macy, 1973) compared with externals. Measures of sel f -report . have typ ica l ly not been validated. In the medical l i terature , estimates of compliance based on chi ld patients or their mothers' reports of taking essential medication have been shown to be grossly inaccurate, when validated with urine tests (Gordis, Markowitz, and L i l ienfe ld , . 1969). Also, the discrepancy between attitudes and behaviour has been documented in numerous studies in the medical l i terature, part icular ly in the area of cancer prevention programs (Green, 1970). Many preventive dental programs have assumed that immediate change in oral hygiene attitudes, or behaviour, w i l l be maintained. Many dentists have focused on the issue of.maintenance by emphasizing the negative long-term consequences of incurring unnecessary pain and extensive dental treatment, or f i n a l l y losing.one's teeth, due to inadequate care. This may produce attitude change, but typica l ly w i l l not produce maintained, behaviour change (Corah, 1974). Often aversive control i s employed for immediate attitude or behaviour change, but this tends to promote avoidance of the dental practi t ioner. Gale (1972) reported that fear of the dentist 's disapproval ranked third in a l i s t of 25 fears which people have about the dental si tuation. Also, messages which emphasize the negative consequences of f a i l i n g to improve oral hygiene habits have not been demonstrated to be any more effective than merely providing information on how. to keep one's teeth clean (Evans et a l . , 1970; Ramirez et a l . , 1971). Unfortunately, whether emphasizing positive consequences of improved dental habits w i l l maintain behaviour change, i s questionable. Of the few long-term studies, which have been done, most produce improved oral cleanliness and gingival health which tend to be short - l ived. Eventual regression to , and often beyond, pretreatment status is typical (See Shulman, 1974, and Suomi, 1971 for additional reviews). 26. Focusing on delayed consequences, whether positive or negative, i s unlikely to contribute s igni f icant ly to behaviour change. Immediate consequences are much more salient to the control of behaviour (Mahoney and Thoresen, 1974; Thoresen and Mahoney, 1974-). Putnam et a l . (1967) have suggested that preventive dental behaviour i s d i f f i c u l t to promote because i t f a i l s to meet any immediate need. National Opinion Surveys of 1959 and 1965, for example, showed that, unlike caries, periodontal disease i s not viewed as a personal threat by most people. If any preventive dental procedure i s l i ke ly to be ef fect ive, i t must reinforce behaviour which i s requisite to the maintenance of dental health, i . e . , brushing and f lossing. The use of naturally occurring reinforcers would seem best suited for the promotion of maintenance. For example, i t is possible that one.dental behaviour could serve to reinforce another, so that both would be maintained. Brushing is typica l ly performed much more regularly than f lossing (Linn, 1976; Young, 1970). As both act iv i t ies are complementary for optimal oral health, maintenance of f lossing may be established by using brushing as a reinforcer. A contingent arrangement between f lossing and brushing is scarcely different from a normal contiguousarrangement, which would be expected to f ac i l i t a te i t s implementation. This type of contingency, in which one - behaviour reinforces another, has been researched in the behavioural l i terature as the Premack Pr inciple . An effective preventive dental procedure should also produce good general izabi l i ty from the training environment to the home environment. Oral hygiene performance i s usually evaluated in the training environment. The dental patient could be trained to evaluate his own performance regularly at home, with subsequent intermittent professional evaluation... This could be accomplished by self-monitoring, which requires the 27. monitor to systematically observe and record his own behaviour. Sel f -monitoring provides an opportunity for the evaluation of a part icular target behaviour, and seems appropriate for application to brushing and f lossing. In addition to providing the monitor with performance feedback, self-monitoring records can also be evaluated by dental health professionals. The use of self-monitoring as a behaviour change technique has been the topic of much recent research, which w i l l be described following a discussion of the Premack Pr inciple. 28. REVIEW OF THE BEHAVIOURAL LITERATURE Premack Principle It has been reported re l iab ly in the experimental operant l i terature that a contingent relationship between responses of di f fer ing probabil ity of occurrence i s analogous to a response-reinforcement relationship. According to Premack, "For any pair of responses,. the more probable one (contingent response) w i l l reinforce the less probable one (instrumental res -ponse)" (1965, p. 132). This pr inciple of behaviour has been called the di f ferent ia l -probabi l i ty hypothesis, and i s more commonly known as the Premack Pr inciple . Premack1s. early work led him.to questiom-seriously the t radi t ional assumption of trans-si tuat ional i ty of reinforcement, and la ter , punish-ment. For example, by experimentally manipulating the relat ive probabil i ty of running and drinking in ra ts , Premack (1971) showed that running could both reinforce and.punish drinking. Premack suggested that reinforcement value may be predicted by assessing d i f ferent ia l momentary response  probabil i ty. This concept i s c r i t i c a l to the Premack Pr inciple . Momentary response probabil i ty may be assessed by calculating the rat io of the actual duration of responding to the possible duration of responding in a free-operant environment (Premack, 1971). In the case of running reinforcing drinking, for example, running occurred for a longer duration than drinking in a situation where both responses were equally possible. Reinforcement effects were obtained by arranging a contingency between drinking, the instrumental event, and running, the contingent event. Punishment occurred simply by reversing the probabil i ty rat io between these two responses, by means of imposing water deprivation. 29. The Premack Principle would appear to lend i t s e l f admirably to c l i n i c a l application. Reinforcers derived from the cl ient 's.behavioural repertoire could be contingently arranged to increase desired instrumental behaviour. Indeed, the classroom management and self-management l i teratures are replete with supposed application of the Premack Pr inciple. For example, Homme, De Baca, Devine, Steinhorst, and Rickert (1963) have unsystematically observed that high probabil i ty behaviours such as running and screaming, which are t radi t ional ly punished, can successfully reinforce s i t t ing and attending to the blackboard, in nursery school children. Hosie, Gentile, and Carrol l (1974) successfully reinforced school children's report writing by contingent arrangement of a preferred act iv i ty , painting or clay modeling. Relative preference was determined by time spent in each act iv i ty during a free-time period. Contingent preferred act iv i ty produced both an increase in speed of report writing and a larger number of students completing the report, compared with the less preferred contingent act iv i ty . With inst i tut ional ized patients, a variety of behaviours has served as reinforcers, often through the medium of tokens (Ayllon and Azin, 1968). Mitchel l and Stoffelmayr (1973) observed that low-frequency work behaviour., of two chronic schizo-phrenics resistant to t radi t ional reinforcers, increased following the application of contingent s i t t i ng , which normally occurred at very high frequency. Within self-management programs, frequently occurring behaviours such as smoking, drinking, eating, washing, thinking, and urination have been employed as contingent events to reinforce increases or decreases in various behaviours congruent with subjects' goals. These studies are reviewed extensively by Danaher (1974), Johnson and Elson (Rote 2), and Knapp (1976). 30. Despite extensive experimental val idation of the pr inciple in ex-perimental animal studies ( e . g . , Premack, 1965, 1971), similar validation has not been observed- conclusively in human application (Danaher, 1974-; Knapp, 1976). This conclusion i s based on methodological deficiencies inherent in attempts of human application. Premack (1965) specified several methodological constraints. The responses under consideration must be in t r ins ica l l y maintained, that i s , performed for their own sake and not for the subsequent presentation of another stimulus. Their relat ive momentary probabil i ty must be assessed within a free-operant environment. Their reinforcing value must be.shown to be reversible, i . e . , each of the paired responses must be shown to be capable of reinforcing the-other, depending upon .their relat ive momentary response probabil i ty. F ina l ly , and perhaps most importantly, an increase i n performance of the instrumental event -must . be accompanied by a decrease in performance of the contingent event, relat ive to baseline rates. A survey of the applied l i terature invoking the Premack Principle shows that a l l of these.contraints have been violated. For example, most application studies in the coverant (covert operant) control l i terature (e .g . , Homme, 1965) reviewed by Danaher (197-4) and Johnson and Elson (Note 2) have employed contingent responses that are extr ins ica l ly maintained. Also, response frequency and subjective preference have often been interchanged, with momentary response probabi l i ty . . When attempts have been made to assess momentary response probabi l i ty , they have often done so inappropriately, by obtaining average response probabil i ty data. In application studies reviewed by Knapp (1976), no demonstration of reinforcer revers ib i l i ty was made. Most important, according to Knapp, i s the neglect to control for the increase in the instrumental event due simply to the removal of the opportunity to perform the contingent event. 31. The importance of including this control procedure Is evident by the results of an experiment reported by Premack and Premack (1963), in which rats increased their normal daily food intake when deprived of the opportunity to run in an act iv i ty wheel. Only two studies have included this c r i t i c a l control , and their results were contradictory to each other. In the f i r s t of these studies, Eisenberger, Karpman, and Trattner (1967) instructed college student subjects not to perform the more probable response (turning, a wheel, for most subjects), during free opportunity to perform the less probable response (bar pressing). Compared to baseline rates, duration of low probabil i ty responding decreased. When wheel turning was made contingent on bar pressing, reinforcement effects were observed only with subjects whose baseline instrumental response rate was low, and whose contingent response rate was suppressed by the contingency. More recently, Robinson and Lewinsohn (1973) re in-forced depressed subjects' low frequency verbal behaviour with the oppor-tunity to emit high frequency depressive talk. While this contingency appeared to produce an increase in low frequency talk over baseline and control group rates, the difference was s t a t i s t i c a l l y similar to that observed in the deprivation control group, in which high.frequency de-pressive talk was prevented. It i s not. entirely certain-, 'therefore, .that" positive :Premack 'Principle •results are actually -due "to the contingency in effect i n applied studies. Simply depriving subjects of the opportunity to perform high probabil i ty behaviour resulted in a decrease in low probabil i ty behaviour in the Eisenberger et a l . study and an increase in similar behaviour In the Robinson and Lewinsohn study.. Clearly these discrepant findings warrant further investigation. 32. The large number of methodological shortcomings -inherent in attempts of application of the Premack Principle exemplify the d i f f i c u l t y of s t r ic t adherence to Premack's or iginal constraints. Perhaps most d i f f i c u l t to real ize in pract ica l application i s the accurate assessment.of momentary response probabi l i ty. Premack (1971) has outlined three procedural problems l ike ly to invalidate response duration as a measure of momentary probabil i ty. Responses may have a different rate of decay within a session. For example, fatigue may d i f ferent ia l ly affect two responses of di f fer ing physical require-ment: Second, parameter values used during contingency sessions should equal those observed during baseline. F ina l ly , response duration may distort the probabil i ty of those responses'whose frequency i s small but preference i s large. Copulation may serve as an appropriate example of this situation. Considering the d i f f i c u l t i e s involved, i t i s doubtful whether the or iginal formulation of the Premack Principle could ever real ize general appl icabi l i ty in c l i n i c a l situations. A recent reformulation of the. Premack Principle has suggested that the concept of momentary response probabi l i ty, as well as being d i f f i c u l t to assess, is also unnecessary. A l l i son and Timberlake (1974) successfully reinforced rats ' 0.4$ saccharin l ick ing with access to 0.3% saccharin. While 0.4% saccharin l ick ing increased during the contingency, i t was not.clear whether this was t ru ly a reinforcement effect since not a l l the available 0.3% solution was consumed. This issue was resolved and the results extended in a subsequent experiment when rats were required to l i c k 0.1% saccharin contingent on 0.4% saccharin l i ck ing . The weaker solution again served as the contingent response. In both experiments, rats preferred the 0.4% solution. Thus a contingent low probabil i ty response successfully reinforced an instrumental high probabil i ty response. Further, i t was shown that reinforcement was not due simply to a rest r ic t ion of the 0.1% solution. 33-There i s additional evidence to question the va l id i ty of Premack*s d i f ferent ia l probabil i ty hypothesis. In the previously described study of Eisenberger, Karpman, and Trattner (1967), college student subjects increased their high probabil i ty wheel turning when contingent low probabil i ty bar pressed was reduced below operant rate. Marmaroff (1968, cited in Dunham, 1977) found that reinforcement occurred with rats ' running and drinking, one reinforcing the other, only when the contingency imposed a reduction in the rate of contingent responding. This was the case when either response was made contingent on the other, regardless of relat ive probabil i ty. Also, A l l i son and Timberlake's (197-4) results obtained with time held constant.have been extended to a situation in which the' amount of responding was held constant (Al l ison and Timberlake, 1975). In th is study, rats ' latency to respond instrumentally decreased when the contingency imposed an increased latency to respond contingently. F ina l ly , Bauermeister and Schaeffer (1974) obtained a reversal of reinforce-ment relat ion within a single session. Three rats which were 23-hour water deprived i n i t i a l l y preferred l i ck ing , then subsequently preferred running. In the f i r s t subsession, a run to l i ck contingency produced an increase in.running with a concomitant decrease in l i ck ing . A similar reversal of results occurred in the second subsession, when running was contingent on l i ck ing . While these data were used to support the importance of accurate assessment of relat ive momentary response probabi l i ty, they also present an additional example of reinforcement accompanied by a reduction in contingent response rate. Premack (1965) recognized that an increment i n instrumental responding is typ ica l ly accompanied by a decrement in contingent responding. He further posited that contingent response reduction i s necessary for reinforcement to.occur. It now appears that contingent response reduction 34. may also be suff icient for the occurrence of reinforcement. This conclusion has given r ise to the response deprivation hypothesis of reinforcement. Response deprivation occurs " i f the animal, by performing i t s baseline amount of the instrumental response, i s unable to obtain access to i t s baseline amount of the contingent response" (Timberlake and A l l i s o n , 1974, p. 152). Dunham (1977) has outlined a similar, posi t ion, cal l ing i t the optimal duration hypothesis. This hypothesis involves two important properties.of responding: burst duration, the amount of time spent responding once the subject enters that state, and interburst in terva l , , the amount of time observed between successive bursts of responding. According to Dunham's optimal.duration model, reinforcment w i l l occur when the contingency imposes either a decrease in burst duration or an increase in interburst interval , of the contingent response. Simi lar ly , punishment w i l l result from an increase in burst duration or a decrease in interburst in terval , of the contingent response. Although, according to Dunham (1977), supportive data are not yet available, the optimal duration model nevertheless offers an attempt to operationalize Premack's notion of "momentary probabil i ty", and thus more accurately specify conditions which w i l l produce an increase, a decrease, and no change in instrumental behaviour. Both the response deprivation hypothesis and the optimal duration hypothesis obviate the need to invoke the concept of d i f ferent ia l momentary response probabil i ty as an explanation for reinforcement. Response deprivation or optimal duration would appear to be better suited to c l i n i c a l application due to their relat ive ease of assessment, as well as their empirical u t i l i t y . . However, the optimal duration hypothesis is as yet lacking experimental ver i f ica t ion . Also, the effects of simply rest r ic t ing access to the contingent stimulus have not been adequately controlled i n 35. studies purporting to support the response deprivation hypothesis. This c r i t i c a l control , discussed ear l ier , has been shown to produce increases, decreases, and no change in instrumental behaviour. Clearly this issue should be resolved. 36. Self-monitoring .. ; Self-monitoring (SM) .was i n i t i a l l y usedrin''.tih,e. behavioural self-management l i terature as a convenient data col lect ion device. It was part icular ly appropriate when the target behaviour occurred at very.low frequency, or when the target behaviour was inaccessible to an external observer, such as with thoughts. However SM was occasionally observed to al ter the frequency of the target behaviour, usually in a c l i n i c a l l y favourable direct ion. For. example, SM has been observed to produce increases in studying (Broden, Ha l l , and Mit ts , 1971; Johnson and White, 1971), college students 1 performance i n a programmed learning task (Mahoney, Moore, Wade, and Moura, 1973), oral class part icipat ion (Gottman and McFall , 1972), maternal attention to appropriate chi ld behaviour (Herbert and Baer, 1972), number of study questions attempted by college students (Kazlo, 1976), and compliance with drug taking (Epstein and Masek, 1978). Similar ly , SM has been shown to produce decreases i n a variety of decelerative behaviours, including disruptive classroom behaviour (Broden, et a l . , 1971), face-touching (L ip inski , Black, Nelson, and Ciminero, 1975), and eating (Romanczyk, Tracey, Wilson, and Thorpe, 1973; Stuart, 1971). Addit ional ly, the l i terature abounds with case studies demonstrating reactive effects of SM (see Nelson, 1977, for a recent review). These observations of the react iv i ty of SM suggest that SM may prove more useful as a behavioural self-management technique than as a re l iable measuring device. However, the l i terature also contains numerous examples of non-reactivity of SM. Ballard and Glynn (1975), for example, found that self-reinforcment' (SR) increased chi ldren's writing behaviour, where SM did not. Greiner and Karoly (1976) found that neither SM nor SM combined with SR improved college students' study 1 37. behaviour more than training in a standard study method. When compared to additional self-management - procedures, including relaxation training and environmental planning, SM fa i led to decrease frequency or severity of migraine headaches over a 60-week study (Mitchell and White, 1977). Sutherland, Amit, Golden, and Roseberger (1975) reported that SM had no effect on rate of smoking, independent of subjects' motivation to quit. F ina l ly , weight control programs have reported discrepant results of SM. Stollak (1967) found that SM eating habits over eight weeks in the absence of experimenter contact fa i led to produce weight loss . Stollak.... obtained within- and between-group' replications of this f inding. When female subjects who had been members of TOPS (Take Off Pounds Sensibly) for the previous three months were instructed to self-monitor their dai ly weight, a sl ight group weight gain was obtained. Subsequent self-monitoring of both food and dai ly weight continued to produce weight gain (Hal l , 1972). Mahoney, Moura, and Wade (1973) found that self-monitoring daily weight, and adaptive and nonadaptive eating habits and thoughts was ineffective in producing weight l o s s , compared to self-consequation. However, Mahoney (1974) found that self-monitoring daily weight and eating habits during a two-week baseline was reactive. Subsequent SM plus the addition of performance goals maintained this i n i t i a l weight loss . There i s additional evidence that SM w i l l contribute to weight loss only when appropriate target behaviours are monitored. This issue w i l l be discussed later . Fa l l ing between the extremes of observations of react iv i ty and non-react iv i ty of SM is the observation that the effects of SM can attenuate following an i n i t i a l period of react iv i ty . Stuart (1971) reported one of the earl iest posit ive instances of react iv i ty of SM with weight loss , but this effect attenuated over time. Subjects self-monitored 38. their eating habits over a five-week baseline period, with an associated mean weight loss of 4.5 l b . Most weight was lost during the f i r s t week. Fixsen, P h i l l i p s , and Wolf (1972) found that both peer monitoring and SM produced i n i t i a l l y reactive but transitory increases in delinquent boys' room cleaning behaviour. Self-rreports of great improvement were obtained, but actual improvement was extremely short - l ived. Simi lar ly , Layne, Rickard, Jones and Lyman (1976) reported i n i t i a l but short- l ived improvement i n "cleanup" in behaviour disturbed children. At this point, i t . seems inappropriate to question-whether oSMJ is--a reactive process..-. .-. L i t t l e understanding of. the variables underlying the react iv i ty of SM can be gained simply by enumerating positive and negative instances of react iv i ty (McFall, Note ;3; Nelson,'1977). The var iab i l i ty of results of studies employing "SM is perhaps best typi f ied by a study performed by Zimmerman and Levitt (1975). They asked 14 therapists to instruct cl ients to self-monitor, v ia wrist counters, a variety of speci f ic target behaviours for two weeks. Sixteen of 22 cl ients reported to have benefitted from SM, expressing either increased awareness, knowledge, or understanding about the target behaviour. Behaviour change occurred with eight of the 22 c l ients . Recent research has actively sought to delineate speci f ic variables which may contribute to the react iv i ty of SM. Variables Contributing to the Reactivity of SM Nature of the monitored.behaviour. Some studies have demonstrated different degrees and directions of. react iv i ty due to SM, depending on the target behaviour being monitored. Gottman and McFall (1972) instructed high school students to monitor either their instances of oral class part icipat ion or their instances of unfu l f i l l ed urges to 39. part icipate. Monitoring part icipation resulted i n an increase in that behaviour; monitoring urges produced decreased part ic ipat ion. Simi lar ly , Herbert and Baer (1972) found that maternal attention to appropriate chi ld behaviour increased due to SM and instructions. When the target was inappropriate chi ld behaviour, instructions and SM fa i led to produce a decrease in attention. Also, Nelson, Hay, Hay, and Carstens (1977) reported small increases in posit ive statements, and negligible decreases in negative statements, when teachers self-monitored positive or negative statements i n c lass , in the absence of: instructions to change. The importance of spec i f ic i ty of the monitored response was demonstrated by Johnson and White (1971), who observed college students' academic grades to improve•significantly only when study behaviour was monitored. Self-monitoring of dating behaviour and no SM fa i led to produce a similar increase in grades. Peacock, Lyman, and Rickard (1978) found that SM was reactive only with easy room-cleaning tasks, and not more d i f f i c u l t tasks, performed by boys at a summer camp. Differing degrees of react iv i ty depending on the target behaviour were reported by Hayes and Cavior (1977), i n what was reportedly the f i r s t study to demonstrate the effects of multiple response monitoring. Self-monitoring was increasingly reactive with verbalizations containing value judgments, verbal nonfluencies ("urn", "ah", e t c . ) , and most reactive with face touching. This would suggest the existence of a continuum of react iv i ty , possibly along the dimension of response spec i f ic i ty . Face touching may be more obviously discrete than verbalizations containing value judgments. Addit ional ly, Hayes and Cavior found that monitoring one behaviour was more reactive than concurrently monitoring two or three. Two studies compared the effects of self-monitoring cigarettes smoked with self-monitoring urges to smoke. McFall (1970) modeled smoking 40. at the beginning of each class during which students self-monitored. According to unobtrusive records kept by non-smoking class members, SM resulted in an increase in smoking.in the SM-smoking group, and an insignif icant decrease i n smoking ih ' the SM-urges group. None of the subjects had expressed a desire to reduce their smoking. Self-monitoring may have contributed to an increase In both monitored behaviours, i f one assumes that the sl ight decrease in smoking evidenced by the SM-urges group was accompanied by an increase in the frequency of successfully resisted urges. These results have been c r i t i c i z e d , however, as due to possible demand characteristics of the d i f ferent ia l instructions (Orne, 1970). More recently Karoly and Doyle (1975) reported that SM-smoking and SM-urges were equally reactive in decreasing smoking in subjects who had expressed no.desire to quit smoking. However, the se l f -monitored data of this study may have been inaccurate, as no r e l i a b i l i t y checks were performed. Di f ferent ia l react iv i ty of target behaviours i s perhaps, most apparent in studies of weight control . . Mahoney, Moura, and Wade (1973) asked overweight subjects to self-monitor dai ly weight and adaptive and mal-adaptive eating habits and thoughts. At the end of four weeks, these subjects lost s l ight ly , though not s igni f icant ly , more weight than control subjects. In a subsequent study, Mahoney (1974) found that self-monitoring of dai ly weight and eating habits (food quantity and quali ty, and situational determinants) during a two-week baseline phase produced equally signif icant weight loss in the three experimental groups performing this task. Similar results have been reported by Stuart (1971). When subjects self-monitored number of b i tes , with instructions to decrease this frequency, weight loss equalled that of subjects exposed to an 41. intensive self-management program (Hal l , Ha l l , Hanson, and Borden, 1974). Joachim (1977) found that self-monitoring of daily, food and drink intake was associated with weight loss in ' a mildly retarded female, whereas self-monitoring dai ly weight was ineffect ive. This case study has received empirical corroboration in studies which demonstrated the superiority of self-monitoring calor ic intake over self-monitoring daily weight (Romanczyk, 1974), and. over self-monitoring discriminative stimuli associated with eating (Green, 1978). Self-monitoring caloric intake was as effective as additional self-management procedures over a four-week training period. While a complete self-management program was most effective over a 12-week follow-up, SM continued to produce substantial weight loss (Romanczyk et a l . , 1973). These data suggest that SM is most reactive when the target behaviour is easi ly discriminable and relevant to the subject. Timing and schedule of self-monitoring. Several studies have attempted to determine whether SM is d i f ferent ia l ly reactive when i t i s performed either before or after the target behaviour. Kanfer (1970a) has predicted that premonitoring a c l i n i c a l l y relevant target behaviour would produce more change than postmonitoring, as the chain of events associated with that behaviour would be interrupted early, allowing for the emission of a more appropriate alternative. Cavior and Marabotto (1976) obtained par t ia l support for this prediction. Self-monitoring videotaped verbal interaction before a test interaction was more reactive than monitoring during the test interaction, but only for verbal behaviour designated by the subjects as negative. Opposite results were obtained for posit ive verbal behaviour. Bellack, Rozensky, and Schwartz (1974) found that premonitoring food intake (description of food, stimuli 42. associated with eating) produced marginally more weight loss than post-monitoring, at six-week outcome and three-month follow-up. Rozensky (1974-) reported similar results in a case of smoking cessation, based on self-report data, although the treatment sequence was confounded. Two studies, however, stand i n disagreement with Kanfer's prediction. Green (1978) reported that pre- and postmonitoring produced no d i f ferent ia l effect with eit;her calor ic intake or discriminative eating st imul i . Also, Nelson, Hay, and Koslow-Green (1977, cited in Nelson, 1977) found no d i f ferent ia l effect of pre- or postmonitoring appropriate or inappropriate classroom verbalizations in young children. If the schedule of SM affects behaviour in a manner similar to schedules of reinforcement ( e . g . , Ferster and Skinner, 1957), one would predict that continuous SM would produce greatest i n i t i a l react iv i ty , while intermittent SM would produce greatest resistance to extinction. Only two studies have compared the ef fect .of schedules of SM. Mahoney, Moore, Wade, and Moura (1973) reported longer time spent in a learning task due to continuous monitoring, compared with „recording every third correct response. However, no differences occurred in the other dependent measures of number of problems completed or accuracy of performance. Frederiksen, Epstein, and Kosevsky (1975) found that continuous SM produced greater smoking reduction than dai ly or weekly monitoring. Unfortunately continuous monitoring was also associated with the greatest degree of subject a t t r i t ion , possibly due to the aversive nature of the task requirement. Further, i n i t i a l differences were reduced to nonsignificance at six months follow-up. Accuracy of self-monitoring. As SM was i n i t i a l l y used as an assessment technique, accuracy was of major concern. As a therapeutic 43. device, accuracy of SM may be unimportant, or even irrelevant. Studies attempting to corroborate the accuracy of self-monitored data have reported varying discrepancies of r e l i a b i l i t y . Fortunately for c l i n i c a l u t i l i za t ion of SM as a behaviour change technique, there has been unanimous observation that react iv i ty occurs independently of accuracy, or r e l i a b i l i t y . Reactivity of SM has been found to be unrelated to accuracy with face-touching (Lipinski and Nelson, 1974; Nelson, Lipinsky, and Black, 1975), verbal behaviour (Hayes and Cavior, 1977), maternal attention to chi ld behaviour (Herbert and Baer, 1972), and children's classroom behaviour (Broden et a l . , 1971; Kaufman and O'Leary, 1972). In these studies self-monitored data were compared with external observations. The Hayes and Cavior study reported a considerably reduced frequency of nonfluencies due to SM despite a r e l i a b i l i t y estimate between self-recorders and observers of .00. Intensive training in SM and. contingencies favouring increases in agreement between self-recorders and observers have produced increases in the accuracy of SM, but no concomitant change in react iv i ty (Bornstein, Mungas, Quevillon, K n i i v i l a , M i l le r , and Holombo, 1978; Fixsen et a l . , 1972; Lipinski et a l . , 1975; Nelson, Lipinsky, and Boykin, 1978). Epstein, M i l l e r , and Webster (1976) observed subjects' respiration rates to decrease quite dramatically during SM. When required to perform a concurrent reinforced task, percentage of SM errors more than doubled. Repiration, however, remained at the same low rate as during the SM-only condition, despite the increase in SM errors. It i s apparent, then, that react iv i ty of SM is v i r tua l ly unrelated to the accuracy of the self-recorded data. Instructions. Early studies ( e . g . , McFall , 1970) have been c r i t i c i zed for possibly.confounding the effects of SM by creating demand character-i s t i c s due to d i f ferent ia l instructions (Orne, 1970). Even when experimental 44. instructions are held constant, subjects may create their-own impl ic i t expectations for behaviour change due to the experimental situation (Kazdin, 1974b). Herbert and Baer (1972), for example, confounded SM with.instructions to change the frequency of the target behaviour in a part icular direct ion. Nelson et a l . (1977) found that instructions augmented the marginal changes in teachers' use of positive and negative classroom statements. Karoly and Doyle (1975) fac tor ia l ly compared self-monitoring urges to smoke versus self-monitoring completed cigarettes with high versus low expectancy that SM would produce a decrease in cigarette- consumption:. Subjects were college students who expressed no desire to quit smoking. Only the expectancy manipulation was s igni f icant . While these studies suggest that SM may be reactive due to instructions, additional data would dispute this contention. Self-monitoring has been observed to produce consistent decreases in face-touching (a negatively valued behaviour) by college students, despite varying conditions of expectancy imparted to the subjects before monitoring (Nelson et a l . , 1975). These results have been extended to the target responses of eyeblinking (Hutzel l , 1977) and use of f i r s t person pronouns (Nelson, Kapust, Dorsey, and Hayes, 1977, cited in Nelson, 1977). In this la t ter study, instructions to alter the rate of f i r s t person pronouns were effective only in the absence of SM. When subjects self-monitored, instructions had no effect. It appears, then, that instructions, expectations, or experimental demand may augment the react iv i ty of SM. However i t i s doubtful, whether the react iv i ty of SM can be explained by these effects alone. Valence of the monitored behaviour. The general observation of changes in self-monitored behaviours in a c l i n i c a l l y desirable direction suggests that the valence of the monitored behaviour may contribute to 45. react iv i ty . Broden et a l . (1971) reported an increase in appropriate study behaviour in one student and a decrease i n inappropriate talking out in another. Single subject reversal (ABA) designs attributed behaviour change to SM. When two teachers were asked to monitor their frequency of positive and negative statements in c lass , a small increase and negligible decrease in these behaviours occurred,-respectively, compared to baseline frequency (Nelson, Hay, Hay, and Carstens, 1977). Several studies have found that SM is only i n i t i a l l y reactive with boys' room-cleaning (Fixseh et a l . , 1972; Layne et a l . , 1976; Peacock et a l . , 1978). If behaviour must be posit ively or negatively valued for change to occur, these results are consistent, as peer reports have determined that room-cleaning i s neutrally valued (Peacock et a l . , 1978). When the valence of room-cleaning i s increased by the imposition of a contingency, a predictable increase i n this behaviour occurs (Layne et a l . , 1976). Experimental manipulations extend the observations that the valence of SM contributes to react iv i ty . Cavior and Marabotto (.1976) observed self-monitored verbal behaviours to change according to the valence attributed to them by the subjects themselves. A weak relationship between valence and react iv i ty was reported by Hayes and Cavior (1977), whose subjects self-monitored, in different combinations, face-touching, verbal nonfluencies, and value judgments. Relative valence was determined by subjects. Self-monitoring has also been observed to change behaviour in the predicted direction when different valences were assigned ident ical target behaviours, namely the use of f i r s t person pronouns (Kazdin, 1974a), and eyeblinking (Sieck and McFall , 1976). F ina l ly , Nelson, Lipinsky, and Black (1976a) asked adult retarded subjects to self-monitor their rates of face-touching, object-touching, and talking. These 46. behaviours were depicted as undesirable, neutral , and desirable, respectively. Relative to base rates, these behaviours changed in the predicted direct ion, i . e . , face-touching decreased, talking increased, and object-touching did not change. Subject motivation. Related to the issue of valence i s motivation for behaviour change. Early reports of react iv i ty due to SM were derived primarily.from the c l i n i c a l l i terature . Self-monitoring, or any c l i n i c a l procedure for that matter, would be expected to contribute to behaviour change congruent to the c l ien t 's goals. Indeed, there i s no evidence that SM has contributed to behaviour change i n a direction contrary to a c l i e n t ' s , or subject 's, motivation. McFall found that subjects of one study who were motivated to quit smoking decreased their smoking rate regardless of the SM procedure employed (McFall and Hammen, 1971), while in another study, self-monitoring number of cigarettes smoked actually increased frequency of smoking in unmotivated subjects (McFall, 1970). A more appropriate comparison was made by Lipinski et a l . (1975), who induced an expectancy that SM would produce smoking reduction i n subjects motivated and unmotivated to quit smoking. Only the motivated subjects reduced cigarette consumption. Unfortunately, i n this study there was no corroboration of the self-report data upon which the conclu-sions were based. Such corroboration was provided, however, by Komaki and Dore-Boyce (1978), who observed that SM produced an increase in classroom part ic ipat ion only in those subjects highly desirous of such change. Further ver i f icat ion of the necessity of motivation for the react iv i ty of SM would be provided by experimenter manipulation, of subject motivation. Consequences of SM: Performance Goals, Feedback, and Reinforcement. Self-monitoring may be reactive due to i t s function of providing expl ic i t 47. feedback regarding performance to. the monitor. On the basis of knowledge derived from such feedback, the monitor can compare current performance with a performance goal , and then make necessary adjustments to reduce the discrepancy. Performance which i s consistent with the performance goal may be reinforcing to the monitor (Kanfer, 1970, 1975). For example, Richards (1975) found that self-monitoring, the number of hours studied and pages read on a cumulative.graph produced a larger increase in studying than other self-management procedures. Contrary to the results of other weight control studies, Fisher, Green, Fr iedl ing, Levenkron, and Porter (1976) reported that self-monitoring daily weight produced a mean weight loss of 9.6 lb . (range 0-26 lb . ) over an average 39 days in 11 subjects. This weight l o s s , comparable to that achieved by more extensive programs, occurred when subjects monitored their daily weight on a graph on which was drawn a diagonal representing goal performance, allowing for dai ly comparison. Some studies have attempted to isolate the relat ive contributions of performance goals, feedback, and reinforcement to the react iv i ty of SM. Mahoney, Moore, Wade, and Moura (1973) found that SM plus feedback of correct responses in a programmed learning task resulted in longer time spent at the task, and more correct math.,, but not verbal, responses. Similarly Fink and Carnine (1975) found that feedback combined with self-monitoring the number of arithmetic errors on a graph reduced errors; feedback alone had no effect. When feedback combined with SM was compared to SM alone, an incremental effect was observed in subjects'; use of f i r s t person pronouns i n a sentence completion task (Kazdin, 1974a). The addition of performance goals produced a similar increment. Richards, McReynolds, Holt, and Sexton (1976) fac tor ia l ly compared two levels of 48. information feedback with.three levels of self-administered consequences i n an experimental study s k i l l s program. Neither condition enhanced the effectiveness of SM. However, subjects who were i n i t i a l l y uninformed regarding time spent studying showed greater improvement than informed subjects. The authors suggested that the.feedback conditions fa i led to add to react iv i ty of self-monitoring due to subjects' uncontrolled increasing attendance to feedback. Recently Richards, Anderson, and Baker (1978) reported that SM and external-monitoring produced a change in the use of f i rst -person pronouns only when they provided information feedback. Feedback, then, appears to be an important function of SM, part icular ly when i t provides information allowing for comparison of current performance with performance goals. Reinforcement contingent on behaviour change has been shown to augment the react iv i ty of SM. Turkewitz, O'Leary, and Ironsmith (1975) demonstrated that tokens exchangeable for privi leges could successfully shape and maintain children's evaluation and rating of both accelerative academic and decelerative disruptive behaviour. Lipinski. et a l . (1975) found reinforcement.contingent on decreases i n face-touching to produce decrements beyond those observed during SM. Similar ly , when Nelson et a l . (1976a) reinforced increases in adult retardates' accuracy of self-monitoring, the react iv i ty of two of three monitored behaviours increased. Postexperimental questioning revealed that subjects believed reinforcement to be contingent on changes in the target behaviours. A second experiment reported by these investigators demonstrated reinforced SM to produce more consistent behaviour change than a token economy program. It i s not clear whether these subjects also believed that reinforcement was contingent on target behaviour change, and not on completion of self-monitoring records. Seymour and Stokes (1976) have suggested that 49. SM is ineffective when,back-up reinforcers are not used. For example, Fixsen et a l . (1972) found that SM,. when not supported by reinforcement, fa i led to increase room-cleaning In pre-delinquent boys. Also, Santagrossi, O'Leary, Romanczyk,.and Kaufman (1973) fa i led to observe a decrease in disruptive behaviour when contingent back-up reinforcers. were not employed. Back-up reinforcement, contingent on behaviour change has been shown to improve upon the react iv i ty .of SM with disruptive behaviour, (Kaufman and O'Leary, 1972), classroom behaviour (Glynn and Thomas, 1974-), work and verbal behaviour (Seymour and Stokes, 1976; Sanson-FIsher, Seymour, Montgomery, and Stokes, 1978), and cleanup behaviour (Layne. et a l . , 1976). F ina l ly , public posting of self-monitoring records and praise have each been shown to contribute to increases in self-monitored compositional response rates in school children (Van Houten, H i l l , and Parsons, 1975; Van Houten, Morrison, Jarv is , and McDonald, 1974). Maintenance of SM Effects To date, many studies have demonstrated the react iv i ty of SM. Unfortunately, as with the demonstration of many.behavioural phenomena, follow-up studies are sorely lacking. The few that have been done--, have provided equivocal data. Rozensky (1974) described a successful case where self-monitoring antecedent to smoking produced and maintained abstinence over six months. Romanczyk et a l . (1973) reported that se l f -monitoring caloric intake produced substantial weight loss over a 12-week follow-up period. However, Joachim (1977) has reported a case where weight loss due to self-monitoring daily weight plus food and drink intake was not maintained when SM was discontinued. Self-monitoring number of b i tes , plus instructions to decrease this number, produced weight loss persisting through three but not six months (Hall et a l . , 1974). 50. Frederiksen et a l . (.1975) found the i n i t i a l react iv i ty of SM with smoking to attenuate'over six months.. Studies employing a single-subject reversal (ABA) design ( e . g . , Broden et a l . , 1971; Hutzel l , 1977; Lipinski and Nelson, 197-4) to demonstrate react iv i ty of SM have, found behaviour change to persist only during the self-monitoring phase. However, Herbert and Baer (1972) used a reversal.design to demonstrate increased maternal attention to appropriate chi ld behaviour. Maternal attention fa i led to return to baseline following cessation of SM. While no additional follow-up data were provided, this behaviour may have come under control of increased appropriate chi ld behaviour. Some studies have produced generalization and maintenance of behaviour change by the creative combination of SM and various reinforcement procedures. Kaufman and O'Leary (1972).successfully taught children.to self-evaluate appropriate behaviour as a means of maintaining a low rate of disruptive behaviour which was i n i t i a l l y brought under the control of a token economy. Several studies have successfully faded tokens or ig inal ly contingent on accurate and reactive SM (Sanson-Fisher et a l . , 1978; Seymour and Stokes, 1976; Turkewitz et a l . 1 9 7 5 ) . Maletzky (1974) produced maintenance by fading the self-monitoring procedure. Broden et a l . (1971) found that teacher praise maintained study behaviour which was i n i t i a l l y increased by SM. F ina l ly , H a l l , Ha l l , Borden, and Hanson (1975) compared various follow-up procedures with subjects who had undergone a three-month weight control program.. Subjects who mailed in self-monitoring records of daily.weight and food intake at two-week intervals continued to lose at least, as much weight as subjects exposed to biweekly therapy booster sessions, over a three-month follow-up. Both these groups compared favourably with subjects of a no-contact group, who gained weight since part icipating i n the i n i t i a l program. 51. Summary Recent investigations of SM have moved beyond simple demonstrations of react iv i ty and are attending to the question: What are the conditions which contribute to the react iv i ty of SM? While the recent l i terature cannot yet provide unequivocal answers to this question, some contributing factors are becoming apparent. The nature of the target behaviour may d i f fe rent ia l ly contribute to the reactive effects of SM. Accuracy of SM appears to be unrelated to react iv i ty . It i s not known i f absolute frequency of the target behaviour is related to react iv i ty . Data relevant to the timing of SM are inconclusive. Self-monitoring every response may be more reactive than intermittent monitoring, but again, the data are inconclusive. It i s also unknown whether intermittent self-monitoring contributes to maintenance of behaviour change. The question of maintenance has been largely ignored. Although early studies have been c r i t i c i zed for possibly confounding the effects of SM with instructions or demand for behaviour change, more recent studies have demonstrated react iv i ty due to SM even following instructions designed to produce counterdemand. Expectancy i s a doubtful contributor to the react iv i ty of SM. The only instruction which has re l iably contributed to react iv i ty of SM is valence induction. Self-monitoring has most consistently produced behaviour change in highly motivated individuals who record the occurrence of a target behaviour which i s relevant to a performance goal. Reinforcement contingent on behaviour change can further enhance react ivi ty of SM. The current theoretical explanations of SM stress the importance of i t s consequences. Rachlin (19V4-) has suggested that SM provides the monitor with cues which help bridge the gap between immediate and delayed consequences. Monitoring 52. food, intake, for example, may serve to cue the monitor to the negative long-range consequence of obesity. If this cue serves to supercede the immediate positive consequences which the monitor typica l ly derives from eating, - - SM should in this case produce a decrease in food consump-t ion. A similar but more mediational explanation has been proposed by Kanfer (1970, 1975), who has suggested that SM allows the monitor the opportunity to compare his own performance with a consensually-or self-defined performance goal. When a- discrepancy exists, self-manage-ment begins a feedback loop whichinitiates adjustive behaviour to reduce the discrepancy. Kanfer'js model of self-regulation includes three main components: self-monitoring, self-evaluation according to a c r i te r ion , and self-reinforcement for meeting that cr i ter ion . While i t i s d i f f i c u l t to separate-these components experimentally, recent attempts to do so suggest that they may d i f ferent ia l ly contribute to successful behavioural se l f -management. Spates and Kanfer (1977) compared the relative contributions of self-monitoring, cr i ter ion-set t ing, and self-evaluation plus se l f -reinforcement to young children's performance on a simple learning task. The results of training in various combinations of these techniques suggest that cr i ter ion-sett ing i s most effective. Training in the other techniques resulted i n insignif icant increments in performance over that produced by cr i ter ion-set t ing, suggesting their additive effect in the self-regulat ion of behaviour. However, self-monitoring in this situation consisted only of observing that a response had been made without regard for i ts appropriateness. Also, the study focused on differences result ing from prior training in techniques of sel f -regulat ion. No attempt was made to ensure that subjects actually employed these procedures. 53. EXPERIMENT 1 This experiment was performed within a laboratory setting to determine whether the Premack Principle (response deprivation hypothesis) could be experimentally validated with tooth brushing and f loss ing. Following baseline recording, access to one response was manipulated contingently with the performance of the other. Effects due simply,to preventing the occurrence of the contingent response were controlled. In order to establish the va l id i ty of the Premack Pr incip le , the instru-mental event would have to increase in duration more during the contingency than during prevention of occurrence of the contingent event. It was expected that reinforcement would be accompanied by a decrease in duration of the contingent response. Should the response deprivation hypothesis prove to be va l id , both brushing and f lossing should be amenable to reinforcement ef fects, regardless of relat ive momentary response probabil i ty. 54. Method Subjects Twelve students of the Dental Assisting Program at Vancouver Voca-t ional Institute volunteered to serve as subjects. The female students ranging in age from 17 to 40 years comprised the .entire afternoon-evening class. Subjects had recently received instruction in brushing and f lossing techniques. The experimental regimen occurred daily on weekdays during the period normally reserved for oral hygiene, immediately following dinner. Subjects were instructed not to practise oral hygiene at any other time during classroom hours. They were told before volunteering that the study was designed to determine normal time spent brushing and f lossing under different conditions. Subjects were requested to brush and f loss as normally as possible, under obvious experimental constraints. Subject consent forms (Appendix I ) were signed prior to the f i r s t experimental session. Procedure A single-subject reversal design (Sidman, I960) exposed subjects to various orders of the following conditions: A: Baseline, free access to brushing and f lossing. A toothbrush, toothpaste, and dental f loss were available for subjects' use. Subjects were told that they were free to brush, f l o s s , or do nothing, during the experimental session. B: Contingent response deprivation control . Subjects were instructed not to engage in the response normally performed second, which was to later serve as the contingent event. Subjects were also free to do nothing i f they wished. This condition allowed for comparison 55. with the contingency conditions, thus controll ing for possible effects of response deprivation per se ( e . g . , Knapp, 1976). C. Response contingency, unlimited access to contingent event. Subjects were permitted access to the contingent event only when they had performed the instrumental event for the duration specif ied by the contingency. Instrumental and contingent events were those responses assigned subjects in B. Once the contingency was sa t is f ied , subjects were free to perform the contingent event as long as they wished. D. Response contingency, l imited access to contingent event. Following requisite instrumental performance, subjects were allowed limited access to the contingent event. Subjects were permitted to return to the instrumental event in order to earn more opportunity to perform the contingent event. The contingency arrangement required an increase in instrumental responding i f baseline contin-gent responding was to be maintained. Comparison of C and D was expected to provide information on the importance of reduced contingent responding in reinforcement processes. Subjects were exposed to experimental conditions in the order indicated in Table. 1. Numerical subscripts of Conditions C and D indicate different contingency values (reinforcement c r i t e r i a ) , which are more fu l l y described in Table 2. With two exceptions, each condition was of two weeks (maximum 10 days) duration. The f i n a l return to baseline (Condition A) and Conditions C^ and C^ each lasted one week. In order to minimize disruption of subjects' normal order of brushing and f loss ing , the target, or instrumental event was that response normally performed f i r s t . For example, subject SI normally flossed before brushing. In this case 56. f lossing became the target response for the duration of the experiment. With one exception (S9), a l l subjects indicated a preference for brushing over f lossing. If preference can be equated with relative momentary response probabil i ty, ' the present experiment provided a further test of reinforcer revers ib i l i t y , as both brushing and f lossing served as contingent events. Dependent Measures As this experiment was primarily interested in changes i n duration of brushing and f loss ing, duration data comprised the main dependent measure. Subjects were arranged in pairs to consecutively record their partners' duration of brushing and f lossing with a stopwatch. Each subject was responsible for her partner's adherence to the current experimental condition. Experimental constraints were accurately described to each subject at the beginning of each experimental condition. A l l sessions were conducted in the same room, with the same subject pairs recording each other's data. Observers were substituted during occasional absences. Stopwatches were checked.for accuracy at various stages throughout the experiment. Each observer was unobtrusively checked for accuracy of recording on several occasions. Subjects were questioned before and after the experiment to deter-mine their usual frequency of and relat ive preference for brushing and f lossing. Subjects were also asked to describe their hypotheses concerning the experiment, and perceived reactions to each experimental condition (Appendix IV). At the conclusion of the study, subjects were provided with f u l l information regarding experimental hypotheses. 57. Table 1 Summary of Experimental Procedure-.and Results, Experiment 1 Order Sequence of_ Increase in Increase in Increase in ibject (RI - R2) Conditions RI During B RI During C RI During SI F - B ABDADA N 3 - Y S2 F - B ABD1AD2A N N S3 B - F ABDiAD2A N Y S4 B - F ABD1AD2A N N S5 B - F ABAADA Y N S6 F - B ACBADA Y Y Y S7 F - B ACBADA Y Y N S8 F - B ACBADA Y Y N S9 B - F AC1C2BADA N N N S10 B - F ACjC2BADA Y Y Y S l l B - F ACiC2BADA Y Y N S12 B - F ACxC2BADA N Y N 1. Usual order of brushing (B) and f lossing (F) . 2. A: baseline. B: contingent response deprivation control. C: response contingency; unlimited access to contingent event. D: response contingency; l imited access to contingent event. 3. Y: yes N: no 58. Table 2 Response Contingency Parameters, Experiment 1 Subject Condition (instrumental: Contingent Response Contingency Criterion) 51 D(1 'F:20 M B) 1 , 52 Di(l 'F:15"B) D 2 ( l 'F:10"B) S3, S4 DX(1'B:30"F) D 2 ( l 'B:20"F) 55 D(1'B:15"F) 56 C (9 'F :B ) 2 , D(l'F:15"B) 57 C(7'F:B) D(l'F:10"B) 58 C(5'F:B) D(l*F:20"B) S9, S l l , S12 Ci(3'B:F) C 2 (4 'B:F) D(l 'B:20'»F) S10 Ci(4'B:F) C 2 (5 'B:F) D(l'B:20"F) lv E . g . , subject SI was allowed 20 seconds of brushing following each minute of f loss ing , during Condition D. 2. E . g . , subject S6 was allowed unlimited access to brushing contingent on nine minutes of f loss ing. • F loss ing I I I I I I — A B D A D A c E A B A A D A Cond i t ions Figure 1. Daily duration of brushing and f lossing across experimental conditions. 60. • F loss ing oBrushing crO-o-o -^o-o-o YIO 8r-S 4 p-o-o-o-o-o-o-o o-o-o-o-o-o-o-o cr° H 6 -i2 B U « | A Cond i t i ons D 2 Figure 1 (continued). ) 6 1 . Figure 1 (continued). S 9 i i e- S10 c E o S11 (0 3 Q 6 4 0 L - | | J L 62. • F loss ing oBrushing 8|- - i a H4 i -|6 S12 6 r - i 6 A C i C2 B A Cond i t i ons Figure 1 (continued). 63. Results and Discussion Accuracy of observation was within f ive seconds on a l l occasions in which r e l i a b i l i t y checks were made. Data collected on two occasions when the stopwatch stopped prematurely were discarded. In a l l other cases, missing observations were due to absence from class, or class cancellation. Individual records of subjects' duration data are presented in Figure 1. Changes, in duration of the target, or instrumental, event (Rl) during contingency and response deprivation control conditions are summarized in Table 1. An increase in Rl was only considered re l iable i f average response duration increased by at least 10 percent above the largest average baseline value. During the response depriv-ation control condition (B), six of the twelve subjects demonstrated a re l iable increase in the target response. Increases were observed with both brushing and f loss ing , regardless of the order of experimental conditions. Of the seven subjects exposed to the response contingency condition with unlimited access to the contingent event (Condition C), six subjects increased their instrumental responding of both brushing and f lossing relat ive to baseline rates. Subject S9 increased her duration of brushing to the value specif ied by the contingency, but also increased her baseline duration of brushing to approximately the same extent. Only four subjects re l iab ly demonstrated increased instrumental responding during Condition D, when access to the contingent event was l imited. The i n i t i a l large increase in instrumental responding demonstrated by subject S3 was reduced during a more stringent contingency. Compared with baseline performance, reinforcement effects were demonstrated by six of seven subjects in Condition C, and by four of twelve subjects in Condition D. However, reinforcement was only apparent 64. with subjects SI, S3, and S12, when target response increases due to contingent response deprivation were accounted for . Knapp (1976) has c r i t i c i zed many attempted applications, of the Premack Principle for their neglect to control for the observed increase in instrumental responding due simply to the removal of the opportunity to perform the contingent response. Data from the present study f a i l to resolve this issue sat is factor i ly . Previous studies (Eisenberger, Karpman, and Trattner, 1967; Robinson and Lewinsohn, 1973) have reported discrepant results due to contingent response deprivation. In the present study, half the subjects increased their instrumental responding when the opportunity to perform the contingent response was withheld. Three of these subjects (S5, S7, and S8) increased instrumental responding during the contingent response deprivation control condition in excess of their instrumental responding during either contingency condition. The present experiment employed two different response contingency conditions: l imited (Condition D) and unlimited (Condition C) access to the contingent event following requisite instrumental performance. A l l seven subjects exposed to Condition C increased their duration of instrumental responding to satisfy the contingency. During this contingency condition, unlimited contingent responding did not decrease below baseline, and i n some cases even increased. Contingencies are more typ ica l ly arranged as in Condition D, allowing only l imited access to the contingent event. In each of the four cases of increased instrumental responding during this condition, contingent responding declined. This is consistent with previous observations of decreases in contingent responding during reinforcement. As the contingencies in Condition D required an increase over baseline in instrumental responding i f baseline contingent responding was to be maintained, most subjects simply reduced their duration of contingent responding. These subjects indicated following termination of the experiment that they responded to the increasingly stringent contingency by trying to increase their eff iciency of contingent responding, rather than increasing their duration of instrumental responding. Subject S3, for example, evidenced a reinforcement effect during Condition Dj . A subsequent and..more : - stringent.contingency, imposed during Condition D 2 produced decreases in both instrumental and contingent, responding, reducing the previously observed reinforcement effect . In Condition C, however, subjects increased their duration of instrumental responding to meet the contingency requirement. These data suggest that reinforcement processes attributed to the Premack Principle may in fact be due to the unavai labi l i ty of the contingent response, Increases in instrumental responding evidenced by four subjects during Condition D were at least equalled by similar increases during Condition B by subjects S6 and S10. The contingency arrangement employed in Condition C, however, offers possible promise for applied u t i l i t y . A l l subjects exposed to Condition C increased instrumental responding, both brushing and f loss ing , according to the contingency requirement. Condition C allowed unlimited access to the contingent event, once the contingency requirement had been met. This arrangement i s more easi ly applicable to an applied situation than that of Condition D. For example, subjects could be asked to perform an instrumental response ( e . g . , f lossing) before gaining unlimited access to a contingent response ( e . g . , brushing). Results of the present experiment suggest that such a contingency should produce increases in instrumental responding whether i t i s brushing or f lossing. Experiments 2 and 3 attempted to determine whether the opportunity to brush could serve as a contingent reinforcer of f loss ing, within experimental and c l i n i c a l preventive dental programs. 67. EXPERIMENT 2 Many c l i n i c a l and school dental programs have produced only short-l ived changes in oral hygiene. The present experiment factor ia l ly compared the effects of different levels of SM with the Premack Principle on the maintenance of toothbrushing and f loss ing, over a one-month experimental period and a six-month follow-up period. Instruction per se was expected to he effective i n the i n i t i a t i o n , but not mainte-nance, of brushing and f lossing. This has been found consistently in the dental l i terature . Simi lar ly , the i n i t i a l l y reactive effects of SM have often been found to attenuate following an i n i t i a l period of react iv i ty . Self-monitoring which provides feedback relevant to perfor-mance goals has been shown to augment the reactive effects of SM alone. In the present experiment, evaluative SM, which provided performance feedback, was expected to maintain effective brushing and f loss ing. F ina l ly , a contingency between f lossing and brushing was expected to contribute to maintenance so long as subjects maintained the contingency. The factor ia l design of the experiment allowed for the evaluation of any interaction between application of the Premack Principle and SM. 68. Method- Sub j ects One hundred and f ive volunteer subjects were so l ic i ted from f i r s t and second year psychology and nursing classrooms at the University of Br i t ish Columbia. The experimenter explained that he was interested in assessing the effects of instructions on toothbrushing and f loss ing. Volunteers were accepted as subjects i f . they fe l t that their oral hygiene was in need of improvement, and i f they agreed to attend two instructional sessions and three assessment sessions, the third occuring at the end of summer vacation. Addit ional ly, subjects were telephoned for confirma-tion of their agreement to these c r i t e r ia . A l l subjects signed subject consent and medical history forms (Appendices I, II, and III) pr ior to the f i r s t assessment session. Instructional Sessions During the. week following the f i r s t assessment 90 subjects attended the f i r s t instructional session i n groups of four to 12. Subjects were presented with a br ief description of the effects of bacter ial plaque and the benefits of effective dai ly plaque removal from a l l tooth surfaces. Stat is t ics relevant to the prevalence of periodontal disease were provided. Subjects were then instructed in intrasulcular brushing (Bass, 1954, described in Wilkins, 1971) and f lossing techniques. As well as didactic instruction and chalkboard i l l u s t r a t i o n , instruction was also provided via modeling and feedback. Each subject was provided with an Odonto adult toothbrush, a 50-yard spool of Odonto unwaxed dental f l o s s , a small Butler disposable mouth mirror, and 10 Butler "Red-cote" erythrosine dye tablets, with instructions for their use. Subjects practised intrasulcular brushing and f loss ing , and received individual guidance 69. and feedback, for the remainder of the 45-minute session. Throughout this session, emphasis was placed on the positive nature of effective brushing and f lossing. Subjects were encouraged to spend 15 minutes each day to thoroughly remove a l l plaque. As there i s no evidence to suggest that toothpaste contributes to plaque removal, subjects were told that they could effect ively remove plaque without using toothpaste. This would allow them to brush while performing some other passive task, such as watching te lev is ion, in a location other than the bathroom. However, i f subjects fe l t the need to continue using toothpaste, they were encouraged to do so. For the second instructional session one week following the f i r s t , experimental subjects were assigned to one of six treatment conditions. Generally, subjects remained with their or ig inal group from the f i r s t instructional session. These groups were assigned to experimental condi-tions so that each experimental group contained 15 subjects. Two levels of the Premack Pr inciple , presence and absence of a contingent relationship between f lossing and brushing were fac tor ia l ly compared with 3 levels of SM: no self-monitoring, self-monitoring of frequency of brushing and f loss ing , and self-monitoring of frequency plus evaluation of brushing and f lossing. Charts (Appendices V through VIII) were provided to subjects of the four self-monitoring groups. During the second 45-minute instructional session oral hygiene procedures discussed in the f i r s t session were reviewed. Subjects then received instruction in employing the Premack Pr incip le , or SM, where appropriate. Premack subjects (contingency) were instructed to perform the preferred response ( e . g . , brushing) only after performing the less preferred response ( e . g . , f lossing) once per day. This method of response assignment seemed most appropriate for the present study, as previous 70. work has shown that the assessment of relat ive momentary response probabil i ty i s unnecessary. Self-monitoring subjects were instructed to indicate the time of each occasion of brushing and f lossing (SM-frequency). Subjects In the SM-frequency and evaluation condition were instructed additionally to evaluate the effectiveness of their oral hygiene, and to record these data, according to the semiweekly schedule indicated by the chart. At these times subjects were required to count and indicate the number of teeth on which plaque remained after cleaning, using erythrosine dye tablets as disclosing agents. They were then instructed to remove any remaining plaque from a l l teeth. In addition to the six fac tor ia l ly compared groups, a seventh group (n = 15) was assigned as a wait ing- l ist control . These subjects did not attend either instructional session. They were told at the f i r s t assessment that the instructional groups were f u l l , but that instruction would be available in the near future. Dependent Measures As this study was primarily interested in evaluating the outcome of changes i n oral hygiene behaviour, the Gingival Index (Gl) (Loe and Si lness, 1963) and Plaque Index (P l l ) (Silness and Loe, 1964-) comprised the main dependent measures. According to these indices, a score of 0, 1, 2, or 3 was assigned to the buccal, l ingual , and both interproximal surfaces of each of six representative teeth: maxillary right f i r s t molar, maxillary right central inc isor , maxillary le f t f i r s t premolar, mandibular l e f t f i r s t molar, mandibular l e f t central inc isor , and mandibular right f i r s t premolar. If a designated tooth was missing, the f i r s t d is ta l tooth was selected. A description of scoring c r i t e r i a for the GI and P l l and the subject data form, are appended 71. (Appendices IX and X). Thus a composite score was derived for each subject by adding the scores assigned each of four surfaces of each of six teeth, then dividing by 24, for both the Gl and the P1I. Composite scores for these indices could f a l l between 0 and 3, increasing with increasing amounts of gingival inflammation and bacterial plaque. The Gl and the P1I have been widely used and are reported to be both val id and re l iab le . Ol iver, Holm-Pedersen, and Loe (1969) have shown that Gl scores correlate highly with the amount of gingival exudation and histological measures of g ing iv i t i s . Gingival Index scores have also been shown to correlate highly with Russel l 's (1956) Periodontal Index scores (Loe and Si lness, 1963). The P1I, which considers differences in plaque thickness at the gingival margin, has been shown to correlate highly (r_ up to .995) with Gl scores (Silness and Loe, 1964). Differences in plaque thickness at the gingival margin are strongly related to tota l area of plaque on the tooth surface (Lang, Ostergaard, and Loe, 1972).. Also, unstained P1I scores correlate highly with plaque weight (Loesche and Green, 1972). The six teeth typ ica l ly measured, and used in the present study, have been found to be representative of the entire dentition (Ramfjord, 1974). When int ra-and inter-rater r e l i a b i l i t y rates are reported, they tend to be in the range of 0.8. Intra-rater r e l i a b i l i t y tends to be higher than inter-rater r e l i a b i l i t y ; both can be increased with training (Hazen, 1974; Mandel, 1974). Birkeland and Jorkjend (1975), for example, found no signif icant differences in Gl or P1I scores assigned subjects on consecutive days by the same trained examiner. In the present study, a registered dental hygienist with six years' experience, bl ind to experimental conditions, evaluated subjects according 72. to the Gl and the P1I at the three assessment sessions. Subjects were examined indiv idual ly , in a standard dental unit under quartz halogen i l lumination. Individual teeth were dried with compressed a i r , and the adjacent gingiva were probed with a "Perio-aid". The examiner was trained to a high degree of r e l i a b i l i t y before the study, and tested for r e l i a b i l i t y antecedent to and during the f i r s t assessment session. In addition to Gl and P1I data, subjects were requested to answer questionnaires at the three assessment sessions (Appendices XI to XIII). The questions were designed to provide additional information about subjects' oral hygiene habits, knowledge, and attitudes. There were three assessment sessions, occurring one week before the f i r s t instructional session, one month following the second instructional session, and six to seven months following the second assessment. Only four of the or iginal wai t ing- l ist control group subjects returned for the second assessment. Many of the others who refused to return for th is assessment expressed dissat isfact ion at not having received instruction by this time. An additional 12 subjects were so l ic i ted from the same student population, for assignment to a no-treatment control group. These subjects were told that volunteers were needed for the assessment of normal oral hygiene i n young adults. The request for volunteers did not imply that any treatment or instruction would be given. Due to temporal constraints, this new group of no-treatment control subjects was assessed six weeks and f ina l l y 14 weeks following the f i r s t assessment. These subjects responded.to an abbreviated questionnaire, at the last two assessments (Appendix XIV). 73. Summary of Experimental Procedure (for the six experimental groups)  Assessment 1 - subject consent forms and medical history. - GI-1, P1I-1, and Questionnaire 1. ( l week) Instruction 1 - instruction in rationale and techniques for effective brushing and f lossing. ( l week) Instruction 2 - assignment to experimental condition. - review of brushing and f lossing techniques. - instruction in experimental techniques (Premack Principle and SM). (4- weeks) Assessment 2 - GI-2, P1I-2, and Questionnaire 2. (6 months) Assessment 3 - GI-3, P1I-3, and Questionnaire 3-Following the f ina l assessment, subjects were given a br ief written description of the study (Appendix XV), and an opportunity to obtain f ina l results. 74. Results Examiner Re l iab i l i ty Both inter- and intra-examiner r e l i a b i l i t y coefficients were calculated by dividing the number of agreements by the tota l number of observations. Following one session of training to score colour slides of anterior teeth, the hygienist who performed a l l assessments was tested for agreement with her previous scoring of colour s l ides , and with the scoring of a periodontist who participated in the training session. Re l iab i l i ty coefficients varied from .79 to .89. These are consistent with those reported in the l i terature. Inter-rater r e l i a b i l i t y rates improved (.90 to .95) when subjects were assessed during the f i r s t assessment session. Preinstructional Measures A one-way analysis of variance (ANOVA) performed on the plaque and gingival index scores of the seven experimental groups was nonsignificant. With one exception, one-way ANOVA and "^analyses of a l l subject character-i s t i c s indicated no signif icant group differences before the f i r s t instructional session. Experimental groups did d i f fer on size of instruct ional group (F (5,76) = 7.28, p < .001), but instructional group size was not related to change in either dental index, at the two post-instructional assessments. Postinstructional Measures Subject Compliance. At one month postinstruction, 95 percent of Premack Principle subjects reported f lossing before brushing, according 75. to the experimental requirement. Ninety-two percent of self-monitoring subjects returned charts at this time, of which 86 percent had been completed at least six days per week. Chi-square analysis revealed no signif icant differences in proportions of subject compliance. Subjects additionally reported equal instructional emphasis on the impor-tance of dai ly brushing and f lossing. Expectations for improvement were equivalent across experimental groups. Subject a t t r i t ion at both postinstructional assessments was not s igni f icant ly different across the six experimental groups. At the follow-up assessment, group size varied from 10 to 12 subjects. A l l 12 subjects of the no-treatment control group returned for each assessment. Dental Indices. The experimental design included a factor ia l comparison of the Premack Principle with self-monitoring, as well as a comparison with a no-treatment control condition, across three assessments. To fac i l i ta te factor ia l analysis, a minimum number of cases was randomly discarded so that experimental group size was proportional across c e l l s . Mean gingival and plaque index scores included in the s t a t i s t i c a l analysis are shown in Table 3 and Figure 2. Two separate repeated measures analyses of variance were performed on gingival and plaque index scores (see Table 4). The f i r s t analysis fac tor ia l ly compared two levels of the Premack Principle (PP) with three levels of SM across three assessments. Only the Assessment factor was signif icant (p < .01), for both dental indices. Neither between-group factor, nor any of their interactions was signi f icant . Tukey post-hoc comparisons revealed that the largest difference occurred between the f i r s t two assessments, before and one month following instruction (p < .01). Gingival scores were also s igni f icant ly different between one month and seven months postinstruction (p < .01), but not between pre- and seven months 76. Table 3 Mean Gingival and Plaque Index Scores, Experiment 2 Condition Gingival Index No Contingency SM-none SM-frequency SM-frequency + evaluation Contingency SM-none SM-frequency SM-frequency + evaluation No-treatment Control 1. n 10 10 10 11 11 11 12 Assessment, Months Following Instruction 0 M 7 •SD M SD M 1.146 .346 .704 .277 1.017 SD 1.183 .283 .596 .267 .946 .079 1.046 .357 .658 .251 .992 .043 .101 1.189 .171 .625 .211 .943 .135 1.201 .257 .712 .338 .970 .122 1.148 .319 .625 .260 .909 .123 1.167 .199 1.069 .132 .972 .176 Plaque Index No Contingency SM-none 10 SM-frequency 10 SM-frequency + evaluation 10 Contingency SM-none. . 11 SM-frequency 11 SM-frequency + evaluation 11 No-treatment Control 1 " 12 1.258 .294 .254 .223 .592 .367 1.154 .411 .379 .247 .537 .228 1.167 .344 .300 .183 .437 .262 1.352 .310 .235 .205 .511 .449 1.352 .222 .436 .336 .557 .398 1.208 .342 .170 .182 .500 .421 1.031 .258 .847 .338 .660 .381 1. No-treatment control subjects were assessed six and 14 weeks following the f i r s t assessment. 78. Table 4 Repeated Measures Analysis of Variance Summary Table, Experiment 2 Source DF SS MS F PP By SM By Assessment Gingival Index PP 1 0.001 0.001 0.007 SM 2 0.008 0.004 0.044 PP*SM 2 0.122 0.061 0.633 Error 57 5.480 0.096 Assessment 2 7.968 3.984 106.938** PP*Assessment 2 0.076 0.038 1.021 SM*Assessment 4 0.110 0.028 0.741 PP*SM*Assessment 4 0.043 0.011 0.289 Error 114 4.247 0.037 Plaque Index PP 1 0.034 0.034 0.209 SM 2 0.362 0.181 1.102 PP*SM 2 0.098 0.049 0.298 Error 57 9.360 0.164 Assessment 2 31.155 15.577 237.380** PP*Assessment 2 0.175 0.088 1.334 SM*Assessment 4 0.268 0.067 1.021 PP*SM*Assessment 4 0.116 0.029 0.444 Error 114 7.481 0.066 Group by Assessment Gingival Index Group 6 0.724 0.121 1.319 Error 68 6.218 0.091 Assessment 2 7.321 3.661 111.136** Group *As s e ssment 12 1.229 0.102 3.110** Error 136 4.480 0.033 79. Source DF SS MS F Plaque Index Group 6 1. .180 0. 197 1. .115 Error 68 11. .992 0. 176 Assessment 2 29. .758 14. 879 240. .057** Group *Ass e s sment 12 3. .279 0. 273 4. .409** Error 136 8, .429 0. 062 * * p < .01 pbstinstruction. Plaque scores, however, did not d i f fer s igni f icant ly between the two postinstructional assessments. It appears, then, that improved P l l scores were maintained over the follow-up interval , while s imi lar ly improved GI scores were not. The second analysis compared the six treatment groups and the no-treatment control group, across assessments. Both the Assessment main effect and the Group by Assessment interaction were highly signif icant (]3 < .01), for both dental indices. Lack of treatment group differences in the factor ia l analysis would suggest that the inclusion of the no-treatment control group in the present analysis was responsible for the signif icant interaction. Scheffe comparisons between the experimental groups combined and the no-treatment control group were, signif icant only at the one-month postinstructional assessment (GI: F(6,57) = 33.256, p < .01; P l l : F(6,57) = 30.613, p < .01). Similar comparisons were not signif icant at the follow-up assessment. Tukey comparisons of no-treatment control group means also revealed s igni f icant ly different P l l scores between the f irst and last assessments; gingival scores, however, were not s igni f icant ly different. Correlational Analyses. The administration of questionnaires at each assessment allowed for correlational analysis of self-report data with dental outcome data of a l l experimental subjects. At the i n i t i a l preinstructional assessment, self-reported frequency of f lossing during the past 24 hours was inversely related to plaque index scores (r (98) = - .24, p < .01). However, frequency of f lossing during the past week was not s igni f icant ly related to plaque or gingival index scores. Self-reports of brushing frequency were not related to either dental index. At one month postinstruction, however, self-reported frequency of the past weekly and dai ly f lossing was signi f icant ly inversely 81. related to both dental indices, when dental preinstructional scores were held constant (-.4-1 ^ r (89) ^ - .49, p < .01). Addit ional ly, subjects who reported an increase in frequency of f lossing and an increased daily duration of both f lossing and brushing since instruction tended to have lower (better) plaque and gingival scores (-.35 < r (89) < —-S - .45, p < .01). At.the follow-up assessment, seven months postinstruction, frequency of f lossing was s t i l l inversely related to dental scores, controll ing for the effects of preinstructional dental scores, although not as strongly (-.22 ^ r (72) < -.31, P < .05). When the one-month postinstructional dental scores were held constant, the follow-up scores were no longer related to self-reported frequency of f loss ing. At no assessment was frequency of brushing related to either dental index. At the f i r s t assessment, only two questionnaire items related to preinstructional dental indices. There was a signif icant relationship between subjects' estimate of their dental health on a seven-point scale and their actual dental health as determined by the gingival (r (83) = .25, p < .05) and plaque (r (84) = .37, p < .01) indices. Also, subjects' estimate of the importance of toothbrushing i n the maintenance of dental health was related to their i n i t i a l gingival (r_ (84) = .25, p < .05) and plaque (r (84) = .27, p < .01) scores. Part ia l correlational analysis, holding the appropriate preinstructional dental scores constant, revealed only a signif icant relationship between preinstructional perceived importance of toothbrushing and gingival scores at the one month post-instructional assessment (r (83) = .27, p < .01). No other correlation between self-report measures and postinstructional dental indices was s igni f icant . It i s not surprising that frequency of brushing was unrelated to 82. either dental index at any assessment. Subjects were i n i t i a l l y brushing at least twice per day, and maintained this frequency throughout the study. The postinstructional improvement in dental indices was accompanied by an increase in frequency of f lossing (from two to about six times per week), but not brushing. Both brushing and f loss ing , however, apparently increased in duration. At the f i n a l assessment, experimental subjects reported f lossing an average of four times during the previous week. Prior to receiving oral hygiene instruction in the present study, subjects showed some ab i l i t y in estimating the state of their dental health. Those who recognized the importance of brushing tended to evidence better--dental health. This relationship was maintained through one month postinstruction, but only with gingival index scores. No other indicator of subject knowledge, motivation, or health value, estimate, or locus of control was related to changes in dental indices following instruction. 83. Discussion A l l treatment groups demonstrated str ik ing improvement in oral hygiene, part icular ly on the plaque index, over the one-month post-instructional period. Only improved plaque scores were maintained over the follow-up period; gingival scores regressed toward preinstructional levels . In considering the question of maintenance, more weight must be given the gingival scores, as plaque accumulation can be eliminated i n one concerted instance of brushing and f loss ing. Signif icant d i f fe r -ences in gingival scores, however, are only observed following regular plaque removal, typica l ly over at least one week (Loe, Theilade, and Jensen, 1965). In the present study, maintained improvement in plaque scores over the follow-up period indicate maintenance of only the know-ledge of brushing and f lossing techniques. A concomitant maintenance of gingival scores, which in fact did not occur, would provide stronger evidence for the maintenance of oral hygiene performance. Only one of the original expectations was validated by the present resul ts . Instruction in effective oral hygiene performance per se did indeed.produce short-term behavioural change. Such change was equivalent to that produced by additional treatment components. The present data fa i led to shed any l ight on a putative effective compo-nent of self-monitoring. Previous research has suggested that se l f -monitoring must contain an evaluative component to produce behaviour change. Such an effect may have been masked in the present study by a possible cei l ing effect created by the effectiveness of oral hygiene instruct ion. A self-imposed contingency between f lossing and brushing also fa i led to augment other treatment effects. At no assessment was there a signif icant interaction between self-monitoring and the Premack Pr inciple . 8 4 . Comparison of the treatment conditions with the no-treatment control provided the most interesting outcome of this experiment. This group was included in the design to control for the effect of repeated assessment. Due to temporal constraints, these subjects were assessed two months following the second assessment, and.therefore were not s t r i c t l y compar-able to the experimental subjects. Also, expectations for improvement due to oral hygiene instruction were not imparted to no-treatment control subjects, as they were to experimental treatment subjects. Nevertheless, no-treatment control subjects showed signi f icant ly improved plaque scores, but not gingival scores, between the f i r s t and third assessments. Evans, Roselle, Nobl i t t , and Williams (1975) reported that repeated measurement per se produced a decrease in plaque scores s t a t i s t i c a l l y equivalent to that produced by various persuasive.communications up to 10 weeks following treatment. In the present experiment, group instruction in oral hygiene rationale and procedures produced clear improvement in gingival and plaque scores, relat ive to measurement per se, one month following instruct ion. At follow-up, however, which occurred for the no-treatment and treatment conditions at two and six months respectively following the second assessment, these differences were reduced to nonsignificance. 85. EXPERIMENT 3 Experiment 2 obtained data from subjects so l ic i ted from a university student population spec i f ica l ly for experimental purposes. Most people seek treatment, and hence receive preventive dental instruct ion, from private dental c l i n i c s . It i s possible that private dental patients would respond d i f ferent ia l ly to an experimental manipulation such as the Premack Pr inciple . The present experiment sought to determine th is . 86. Method Subjects Thirty subjects selected from the new patient population of a private dental c l i n i c were asked to participate in an experimental evaluation of oral hygiene instruct ion. Patients who evidenced prolonged periodontal disease were excluded from the study. A l l subjects were treated as typical dental patients. Prior to experimental part ic ipa-t ion , subjects verbally agreed to the request that their assessment data could be used for experimental purposes. Procedure Following an i n i t i a l dental assessment, subjects were alternately assigned to the experimental Premack Principle group or the control group. Two instructional sessions, separated by up to one week, followed. During these sessions, the f i r s t of approximately 45 minutes, the second of 30 minutes duration, subjects were individually provided with a rationale and techniques for effective oral hygiene. Brushing and f lossing techniques were ident ical to those taught in Experiment 2. In the present study, however, individual instruction by a cer t i f ied dental assistant required each subject to show mastery of brushing and f lossing technique, before dental treatment was provided. During the two instructional sessions, subjects in the Premack group were instructed and subsequently agreed to brush, at least once per day, only following f lossing. Subjects in both groups were told that f lossing was equally important as brushing. The contingent order of these two behaviours was stressed only to Premack subjects. Control subjects did not receive instructions to brush and f loss in a specif ic order. 87. Dependent Measures Subjects were assessed immediately before instruct ion, and three months following instruction. During the interim period any necessary dental work was in i t i a ted , and in most cases, completed. Instruction and assessment was administered by one of three.cert i f ied dental assistants. Gingival inflammation was evaluated according to the GI, administered as in Experiment 2. The P l l was simplif ied so as to differentiate between simple presence and absence of plaque. A score of 0, indicating absence, or 1, indicating presence, of plaque was assigned to the same tooth surfaces as in Experiment 2. Addit ional ly, subjects reported their frequency of brushing and f lossing during the previous seven days and 24 hours, at the f i n a l assessment session. Assessment forms were- similar to those used in Experiment 2. Each dental assistant instructed and assessed approximately one-third of the subjects of each group. One of the dental assistants terminated employment and was replaced half way through the study. Each assistant was requested to assess each subject only once, to ensure blindness to group membership. Unfortunately, due to pract ical constraints, some subjects were assessed by the same assistant at both assessment periods. Most, however, were not. Each assistant was br ie f ly trained and tested for re l iable administration of the dental indices before performing any assessment. 88. Results and Discussion Re l iab i l i ty Estimates of interobserver r e l i a b i l i t y were determined by dividing the number of agreements by the total number of observations, for each pair of observers. Re l iab i l i ty varied between .58 and .79, considerably lower than in Experiment 2. This may have been due in part to inadequate r e l i a b i l i t y t ra ining, or more l i ke ly to the lack of experience of dental assistants i n the administration of oral hygiene indices. Dental Indices Mean Gl and simplif ied P1I scores of the 12 control subjects and 10 Premack Principle subjects who returned for the three-month post-instructional assessment are shown in Figure 3 and Table 5. These data were analyzed according to repeated measures analysis of variance (see Table 6). The gingival scores of both groups showed a negligible nonsignificant decrease. Plaque scores, however, showed a much larger, signif icant decrease from pre- to three months postinstruction. Group differences, however, were nonsignificant, both for the Group factor and for the Group by Tr ia ls interaction. Only the main Tr ia ls effect for simplif ied P1I scores was signi f icant . These data would suggest that two sessions of individual oral hygiene instruction were effective in reducing simplif ied P1I but not Gl scores in private dental c l i n i c patients over a three-month period. The additional instruction to impose a contingency between f lossing and brushing appeared to have l i t t l e effect. Although the Group by Tr ia ls interaction of plaque scores approached significance (p = .073), the gingival data fa i led to corroborate this trend. A similar relat ive improvement in Table 5 Mean Gingival and Simplified Plaque Index Scores, Experiment 3 Condition n Preinstruction Mean SD Postinstruction Mean SD Gingival Index Premack Principle Control 10 12 1.158 1.278 .338 .392 1.104 1.24-0 .238 .293 Simplified Plaque Index Premack Principle Control 10 12 .892 .878 .141 .156 .233 .448 .237 .297 1.4 1.0 x HI Q Z < .6 o z o • 2 k Control Premack Principle J L -.1.0 .6 3 0 A S S E S S M E N T , MONTHS FOLLOWING INSTRUCTION c/> •D m o > O c m z o m x Figure 3. Mean gingival and plaque index scores, Experiment 3. o Table 6 Repeated Measures Analysis of Variance Summary Table, Experiment 3 Gingival Index Source Group Error Tr ia ls Group*Trials Error SS .177 2.850 .023 .001 1.319 DF 1 20 ::.i l 20 MS ,177 ,142 ,023 ,001 ,066 F 1.243 0.353 0.011 Simplif ied Plaque Index Group Error Tr ia ls Group*Trials Error .111 1.133 3.234 .142 .790 1 20 ' 1 1 20 .111 .057 3.234 .142 .040 1.952 81.852** 3.582 * * p < .01 92. plaque over gingival scores was observed in Experiment 2, suggesting maintained knowledge but not practice of oral hygiene techniques. Subjects exposed to oral hygiene instruction i n both studies reported f lossing approximately four times during the week pr ior to the f ina l assessment, just over half the recommended frequency. As in Experiment 2, subjects reported brushing about twice per day. In the present experiment, seven of the 10 Premack subjects reported that they routinely flossed before brushing, as predicted by the contingency requirement. Only four control subjects regularly flossed before brushing. This difference, however, was not signif icant (Fisher's exact test (one-tailed) = 0.115). The re la t ive ly high ratio of brushing to f lossing evidenced by Premack subjects suggests that the contingency was v i r tua l ly ignored, three months following instruction. 93. GENERAL DISCUSSION The Premack Principle essential ly posits that reinforcement occurs when a more probable response follows a less probable response, in a contingent arrangement. The results of Experiment 1 in the present study would suggest that the observed change in response duration may often, but not always, be due to contingent response deprivation. That i s , simply preventing the occurrence of the contingent response, as i s the case when a contingency i s in effect , may account for the observed increase in the duration of the instrumental response.. This notion, or ig inal ly alluded to in.an experiment by Premack and Premack (1963), and later elaborated by Knapp (1976), i s also supported by data reported by Robinson and Lewinsohn (1973). Ear l i e r , prevention of the contingent response was found not to be associated with an instrumental response increase (Eisenberger et a l . , 1967). Indeed, i n the present study, prevention of the occurrence of the contingent response produced an increase in instru-mental response duration in some subjects, and no change in others. This, then, i s apparently not a universal phenomenon. Researchers planning to employ the Premack Principle as a behavioural technique should nevertheless.be.aware that any observed increase in instrumental responding may in fact be due to contingent response deprivation. Experiment 1 also addressed the issue of the necessity of contingent response reduction for the occurrence of reinforcement. There has been unanimous agreement that reinforcement i s typica l ly accompanied by a reduction in contingent responding, compared to baseline performance. Some workers in this area ( e . g . , Dunham, 1977; Timberlake and A l l i s o n , 1974) would further argue that contingent response reduction i s necessary 94. (and even suff ic ient) for the occurrence of reinforcement. However, reinforcement schedules employed in studies upon which these conclusions are based typical ly arrange for the alternation of instrumental and contin-gent responding. Such an arrangement corresponds with Condition D of Experiment 1. When the contingency allowed unlimited access to contingent responding following increased instrumental responding, relat ive to baseline, instrumental responding increased to meet the contingency requirement. This type of contingency arrangement would seem better suited to applica-t ion to a self-management program, such as with the maintenance of toothbrushing and f loss ing , than the arrangement exemplified by Condition D. However, i n the present experiment, the potential influence of exper-imenter demand ( e . g . , Orne, 1970) cannot be dismissed. Subjects were told that they were free not to perform the instrumental response according to the contingency requirement, and thus not be allowed access to the contingent response. Considering their (br ief) history of brushing and f lossing during the experimental time period, and the concurrent behaviour of their peers, i t i s not surprising that no subject availed herself of this alternative. It seems doubtful that such rigorous perfor-mance would be maintained without these supports, such as in the home environment. One f i n a l point raised by the results of Experiment 1 concerns Premack's or iginal notion of relative momentary response probabil i ty. A contingent increase in instrumental responding occurred with both brushing and f lossing. A l l but one subject ident i f ied brushing as the preferred act iv i ty . If response duration is equated with probabi l i ty , then this trend becomes reversed, with f lossing the preferred act iv i ty . A l l but one subject engaged i n f lossing for a longer duration during 95. the i n i t i a l baseline. As reinforcement occurred with either behaviour serving as the instrumental and contingent event, relat ive momentary response probabil i ty as a predictive or explanatory concept becomes redundant. Considering the results of Experiment 1 and those of recent studies reviewed by Dunham (1977) and Timberlake and Al l ison (1974), reinforcement would appear to be more accurately described by the response deprivation hypothesis. Dunham's (1977) optimal duration hypothesis, which adds the property of interburst interval to that of burst duration, needs to be more f u l l y explored. In Experiments 2 and 3, an attempt was made to promote maintenance of effective toothbrushing and f lossing by the application, of a contingency between these two behaviours. Experiment 2 also employed different levels of self-monitoring. Subjects in Experiment 2 were young university students; Experiment 3 u t i l i zed private dental patients as subjects. Instruction In the Premack Principle fa i led to contribute to mainte-nance i n either experiment, beyond the effect of instruction in oral hygiene procedures per se. In Experiment 3, a Premack Principle by Tr ia ls interaction approached, but did not obtain, s t a t i s t i c a l s i g n i f i -cance, when the plaque scores were analyzed. Unfortunately the gingival scores did not show a similar trend. As has been previously discussed, gingival scores more accurately than plaque scores ref lect a person's usual oral hygiene performance. Despite the apparent u t i l i t y of the Premack Principle in experimental situations, adaptability to. a self-management program remains questionable. As Mahoney (1972) has pointed out, an application of the Premack Principle requires self-imposed deprivation of the contingent event, i f reinforcement 96. is to occur. Skinner (1953) has made a dist inct ion between "controlled" (instrumental) and "controll ing" (contingent) responses. While the instru-mental response may be controlled by the contingent response, the maintenance of the contingency must ultimately be controlled. To use toothbrushing and f lossing in this example, contingent brushing may control f lossing so long as the contingency is in effect . Once this control i s weakened, reinforcement can no longer be expected to'occur. Many self-management programs are sabotaged when the cl ient increasingly engages in unearned contingent responding (Goldiamond, 1976). It 'seems, plausible that the Premack Principle fa i led to show any clear maintenance effect in the present study due to subjects' fa i lure to maintain the contingency between f lossing and brushing. Thus while the technique may be effect ive, i t s successful implementation as a self-management strategy needs further examination. In addition to the Premack Pr inciple , Experiment 2 also examined self-monitoring as a possible self-management technique for preventive dental programs. Self-mora toring^also fa i led to augment the-effects of. oral hygiene instruction alone. The results of previous studies in the self-monitoring l i terature would suggest that toothbrushing and f lossing would be ideal reactive target responses. Both responses are highly spec i f ic , discrete, and easi ly measurable. As they relate to gingival health, both responses have a positive valence. Dental instruction was designed to produce strong expectations of positive outcome, and subjects indicated that this in fact occurred. Subjects also indicated a willingness to spend the necessary daily time to improve their oral health. Subjects who per iodical ly evaluated and monitored their oral hygiene technique by means of plaque disclosing tablets were expected to demonstrate oral hygiene improvement at least equivalent to the other self-monitoring conditions. The scale used for evaluation, counting 97,-the number of teeth on which plaque remained, was simple and allowed for observation of improvement. Other studies have shown that regular plaque disclosure i s at least as effective as instruction and other forms of feedback, in reducing plaque scores over six to eight weeks (Barrickman and Penhall, 1973; Cohen et a l . , 1972; Friedman et a l . , 1974). The Friedman et a l . study found plaque disclosure, equally effective as instruct ion; the other two studies found that plaque disclosure improved on instruct ion, as determined by changes in plaque, but not gingival , scores. Barrickman and Penhall (1973) additionally reported that most improvement on plaque scores occurred when subjects graphed their weekly P l l and GI data. This f inding, however, was based on extremely small group sizes. Studies in the self-monitoring l i terature in which feedback contributes to react iv i ty have already been described (Fink and Carnine, 1975; Kazdin, 1974a; Mahoney, Moore, Wade, and Moura, 1973). When SM provides information which allows for comparison of current performance with performance goals, react iv i ty is.enhanced (Fisher et a l . , 1976; Richards, 1975; Richards et a l . , 1976, 1978). The Fisher et a l . study provides the only example of weight loss due to self-monitoring daily weight. Subjects were able to compare their daily weight with goal weight which was indicated by a diagonal on their self-monitoring graph. In the present study, subjects in the self-monitoring frequency plus evaluation condition of Experiment 2 were not provided with expl ic i t performance goals. A l l subjects who self-monitored frequency of brushing and f lossing were asked to perform these act iv i t ies once per day. It is possible that subjects who additionally evaluated their oral hygiene effectiveness would have shown greater improvement i f a performance goal cr i ter ion had been arranged. Monitoring dai ly performance on a graph also presents an interesting poss ib i l i t y . This might better i l lus t ra te the cumulative 9 8 . effect of cr i ter ion performance to the monitor. The lack of clear treatment group differences at one month post-instruction may also be due to the powerful contribution of oral hygiene instruct ion. The treatment control group which received one group instruc-t ional session followed by one review session showed substantial improvement on both dental indices one month la ter . Experiment 2 employed university students who spend much of their .time in didactic instruct ion, and thus might be expected to benefit most from this type of instructional format. Other subject samples, however, have shown short-term benefit from didactic instruct ion. Radentz et a l . (1973) found that videotaped instruction produced equivalent improvement in f lossing technique as individualized instruct ion, in army recruit subjects. A combination of these two modes of instruct ion, however, produced greatest improvement in f lossing (Radentz et a l . , 1975). Wi l l i ford et a l . (1967) found that six lectures given by a dentist to high school students resulted i n improved dental scores over the three-month experimental per iod. . Treatment gains not only persisted but increased over a three-month follow-up period. Zaki and Bandt (1974) have even demonstrated improved plaque scores and oral hygiene performance in periodontal patients provided with an opportunity to study a self-teaching manual. It i s apparent, part icular ly after examination of the. one-month postinstructional results of Experiment 2 of.the present study, that minimal intervention may be suff ic ient to in i t ia te effective oral hygiene performance. It also seems l ike ly that the evaluation of additional instructional techniques becomes exceedingly d i f f i c u l t against such greatly improved performance. While instruction was expected to produce short-term gains, the additional treatment components of Experiment 2 were expected to produce s igni f icant ly greater maintenance. Six months following the postinstructional 99, assessment, however, no.clearly signif icant group differences were apparent. Even the no treatment control group was s t a t i s t i c a l l y equivalent to the treatment groups, although these subjects were assessed only two, and not s ix , months following the second assessment. This finding corroborates some previous research, regarding the effects of measurement per se. Podshadley and Schweikle (1970) found that repeated assessment produced as much improvement in plaque scores over a four-month interval as one session of instruct ion, in young public school children. Evans et a l . (1975) reported similar results with junior high, school students. These findings underline the importance of ..employing appropriate control groups, when evaluating any behaviour change technique. The continued improvement.in no-treatment control subjects in Experiment 2 also i l lustrates the desi rabi l i ty of performing multiple assessments, i n order for appro-priate experimental comparison. Unt i l recently the question of durabil i ty of behavioural intervention has not been seriously entertained. Keeley, Schemberg, and Carbonell (1976) , for example, found that most operant studies published during 1972 and 1973 contained insuff ic ient follow-up data to evaluate maintenance. This trend has unfortunately persisted in the recent self-monitoring l i terature . There are, however, a number of studies which have examined this issue. Those described ear l ier have provided equivocal data. Some studies have demonstrated behaviour change to persist only during self-monitoring, while others have shown that behaviour change i n i t i a l l y produced by self-monitoring i s maintained for varying lengths of time. Hal l et a l . (1974) have discussed the importance of selecting an appro-priate follow-up period. They found that weight loss due to self-monitoring was maintained over three, but not s ix , months. The majority of experimental evidence.supports the contention that the effects of self-monitoring are ephemeral. 100. When self-monitored behaviour change has persisted, i t has usually occurred due to the imposition of additional techniques. Fading of SM (Maletzky, 1974), or of tokens which were contingent on reactive SM (Sanson-Fisher et. a l . , 1978; Seymour and Stokes, 1976; Turkewitz et a l . , 1975) has successfully produced maintenance. Teacher praise has been found to maintain students' study behaviour which was i n i t i a l l y increased during SM (Broden et a l . , 1971). F ina l ly , Hal l and her colleagues have evaluated an interesting self-monitoring maintenance procedure. In the f i r s t study, subjects who had participated in a weight reduction program mailed in self-monitoring records at bimonthly intervals. These subjects improved on treatment gains at least as much as subjects who attended bimonthly booster sessions, over a three-month follow-up period. A no-contact group gained weight over this period (Hall et a l . , 1975). More recently, Ha l l , Bass, and Munroe (1978) found that subjects who mailed their self-monitoring records to the therapist every two weeks, and subjects who attended bimonthly booster Sessions both maintained weight loss better than minimal-contact subjects over six months. However, at one-year follow-up, six months following the cessation of maintenance procedures, there were no signif icant differences between the three groups. Kingsley and Wilson (1977) also found weight gain to ensue following termination of successful booster sessions. There i s l imited evidence, then, that SM w i l l produce maintained behaviour change. There is even less evidence that behaviour change can be maintained by the Premack Pr inciple . Additional procedures must be implemented to promote maintenance, following behaviour change or ig inal ly produced by these techniques. Results of the dental studies reviewed ear l ier are consistent with this f inding. One of the most successful treatment regimens has included oral hygiene instruction 101. and supervision combined with frequent professional prophylaxis and fluoride application. This type of program typica l ly results in improved plaque and gingival scores and reduced caries incidence (Axelsson,et a l . , 1976; Hamp et a l . , 1978; Lindhe et a l . , 1975). Unfortunately, consistent with many behavioural follow-up studies, improved oral health typica l ly regresses to, and often beyond, pretreatment leve ls , once supervision is discontinued (Lindhe and Koch, 1967; Horowitz et a l . , 1977). Suomi et a l . (1971), however, provided adult subjects with prophylaxis and instruction at two- to four-month intervals over three years. At a 32-month follow-up, experimental subjects evidenced better oral health than controls, although differences were less than at the end of the three-year treatment period (Suomi et a l . , 1973). Several other studies in the dental l i terature have reported promising follow-up data. Durlak and Levine (1975) reported that army outpatients' oral hygiene improved over a five-month follow-up .interval following group instruction in oral hygiene and evaluation techniques, and individualized feedback. Subjects learned to evaluate their own performance, gains. Unfortunately there was no control group. Martens et a l . (1973) found that instruct ion, part icipat ion in.dental learning projects, indvidualized interaction with a dental hygienist, and token reinforcement for improved oral hygiene resulted in better plaque scores, over a six-month follow-up, in second grade subjects. Control subjects were exposed to a standard dental curriculum. F ina l ly , Godin (1976) found that six periodontal patients who were taught plaque control procedures, including scaling the hard deposits from their own teeth, and provided with opt ical devices for plaque disclosure, evidenced plaque and gingival scores equal to those of six control subjects who were taught plaque control procedures and had their teeth professionally cleaned. Experimental subjects continued to 102. improve their plaque scores, relat ive to control subjects, over the f ive -month follow-up interval . This finding has part icular ly interesting implications for maintenance, as removal of hard deposits from the teeth has t radi t ional ly fa l len within the professional domain. These results suggest, the importance of patient part icipation in treatment. Also, Weisenberg (1974-) has suggested that dental practit ioners might benefit from contract management to increase patient part ic ipat ion. Reduced fees, for example, may contingently increase patient adherence to a home-based plaque-control program. On the basis of sparse follow-up data, there would appear to be at least two approaches to the maintenance of oral hygiene procedures. F i r s t , professional treatment can be supplemented with periodic "booster" sessions, providing the subject with regular contact with the treatment environment. I n i t i a l treatment gains appear to be maintained for the duration of this regimen. Compared to remedial treatment, this type of program which focuses on prevention of g ingiv i t is and periodontal disease compares favourably from a cost-benefit perspective (Birkeland and Axelsson, 1976). Failure to maintain this kind of regimen, however, can result i n the gradual deterioration of oral health. A second approach to maintenance of behaviour change involves generalization of treatment effects to the natural environment. The present study attempted to accomplish this by presenting the Premack Principle and self-monitoring as s k i l l s which subjects could employ on their own, long after i n i t i a l instruct ion. Neither technique can be considered successful in the present study. There are, however, some studies which present provocative examples of successful generalization to the natural environment. Hunt and Azrin (1973) found that controlled social drinking as a treatment goal for alcoholics was more successful when family members were supportive, 103. and served to reinforce adherence to the treatment program. Stuart and Davis (1972) have suggested that family members might successfully reinforce appropriate eating behaviour in obese subjects. Their hypothesis has recently received empirical support. Brownell, Heckerman, Westlake, Hayes, and,'Monti (1978) found that obese subjects lost most weight at three and six month assessment sessions when their spouses agreed to participate in treatment and were trained in behavioural weight control techniques. The substantial weight losses achieved by these subjects were not real ized by subjects whose spouses were uncooperative, or who were cooperative but not trained in the behavioural techniques.. The importance of:"family involvement in medical treatment programs has also been discussed by Becker and Green (1975). Behaviour change programs, then, might produce more durable results by reorienting their focus from the transient treatment environment to the stable natural environment. 104. REFERENCE NOTES 1. Albino, J . E . , Tedesco-Stratton, L . , and Greenberg, J . S . Leadership,  sat isfact ion, and health status: Effecting changes in dental behavior. 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APPENDIX I ' Subject Consent Form Basic Rights and Privileges of Volunteer Subjects Any person who volunteers to participate in experiments conducted hy f u l l or part-time members of the faculty of the Department of Psychology at the University of British Columbia, by their employees, or by the graduate and undergraduate students working under the direction of faculty members of the above named Department, is entitled to the following rights and privileges. 1 . The subject may terminate and withdraw from the experiment at any time without being accountable for the reasons for such an action. 2. The subject shall be informed, prior to the beginning of an experiment, of the maximum length of time the experiment might take and of the general nature of the experiment. 3. The subject shall be informed, prior to the beginning of an experiment, of the nature and function of any mechanical and electric equipment which is to be used in the experiment. In cases where the subject is in direct contact with such equipment, he shall be informed of the safety measures designed to protect him from physical injury, regardless of how slight the possibility of such injury i s . 4. The subject shall be informed prior to the beginning of an experiment, of the aspects of his behavior that are to be observed and recorded and how this is to be done. 5. Any behavioral record that is obtained during the course of the experiment is confidential. Any behavioral records that are made public through either journal papers or books, public addresses, research colloquia, or classroom presentations for teaching purposes, shall be anonymous. 6. The subject shall be offered, at the end of an experiment, a complete explanation of the purpose of the experiment, either orally by the experimenter or, at the option of the experimenter, in writing. The subject shall also have the opportunity to ask questions pertaining to the experiment and shall be entitled to have these questions answered. 7. The subject has the right to inform the Chairman of the Departmental Committee on Research with Human Subjects of any perceived violations of, or questions about, the afore-mentioned rights and privileges. TITLE OF STUDY: DATE: I have read the above statement of my rights as a volunteer subject, understand the conditions of this experiment and am participating voluntarily. SIGNED: 123. APPENDIX II Faculty of Dentistry Disclaimer I understand that this study is being sponsored by the Department of Psychology as part of a PhD dissertation. Further, the Faculty of Dentistry assumes no responsibi l i ty for this study, other than providing f a c i l i t i e s for the study's execution. My part icipation in this study does not ent i t le me to subsequent treatment or other services supplied by the Faculty of Dentistry. Signed: Date: 124. APPENDIX III Medical History Form Name: Yes No 1. Do you see a doctor regularly? Why? (Answer at foot of page). 2. Are you presently under treatment for any i l lness? 3. Are you taking medicines of any kind or have you taken medicines during the past six months (e.g. heart p i l l s , insu l in , cortisone)? What are they? 4. Do you take b i r th control p i l l s ? 5. Have you in the past had any major i l lness or operation? 6. Do you have heart disease (e.g. Rheumatic fever, congenital defect)? 7. Are you a diabetic? 8. Have you ever bled heavily or had any other d i f f i cu l ty after dental treatment? 9. Do you currently suffer any dental pain or discomfort? Please elaborate on the above questions, where necessary: 125. APPENDIX IV Postexperimental Questionnaire, Experiment 1 Name 1. What do you think was the purpose of this study? Row did this assumption affect your brushing and flossing? 2. When you were not allowed to brush, or f l o s s , did you compensate for this by brushing or f lossing longer, or by brushing or f lossing longer or more often at home? 3. When you had to do one (e.g. brush) for a certain amount of time to be allowed to do the other (e.g. f l oss ) , did you tend to spend longer with the f i r s t , (e .g. brush) or try to do the second (e.g. f loss) more ef f ic ient ly? 126. 4. Do you think that your brushing and f lossing takes a longer or shorter time when someone i s recording? 5. Do you think that there i s any change in the amount of time you spend brushing and f loss ing , after part icipating i n this study? 6. Additional comments? APPENDIX V Self-monitoring Chart: No-Contingency, SM- Frequency Please indicate, each day, the times when you brushed and flossed your teeth. Name Also, please bring this chart with you to the next assessment session in March. S u n Man Tues Wed Thur Fri Sat 6 7 8 9 10 11 1 2 1 3 14 15 16 17 18 19 20 21 22 2 3 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10 11 12 1 3 14 15 16 17 18 APPENDIX VI Self-monitoring Chart: No-Contingency, SM-Frequency + Evaluation Please indicate, each day, the time when you brushed and flossed your teeth. Name On the days specified (D), disclose for plaque after brushing and flossing, and indicate the number of teeth on which plaque remains. Then remove this plaque. Please bring this chart to the next dental assessment in Jferch. Sun Mon Tues Wed Thur F r i Sat 6 7(D: ) 8 9(D: ) 10 11 12 13(D: ) 14 15(D: ) 16 17 18 19 20 21(D: ) 22 23(D: ) 24 25 26 27(D: ) 28 1(D: ) 2 3 4 5 6 7(D: ) 8 9(D: ) 10 11 12 13(D: ) 14 15(D: ) 16 17 18 APPENDIX VII Self-monitoring Chart: Contingency, SM-Frequency Please indicate, each day, the time and order of brushing and flossing. Remember that flossing must occur before brushing. Please bring this chart to the next dental assessment in March. Tues Wed Thur F r i Sat 6 7 8 9 10 11 12 13 K 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10 11 12 1 3 14 15 16 17 18 APPENDIX VIII Self-monitoring Chart: Contingency, SM-Frequency + Evaluation Please indicate, each day, the time when you brushed and flossed your teeth. Name Remember, you can only brush after you have flossed. On the days specified (D), disclose for plaque after flossing and brushing, and indicate the number of teeth on which plaque remains. Then remove this plaque. Please bring this chart to the next dental assessment in March. 6 7 8 9 10 11 12 13(D: ) 14 15(D: ) 16 17 18 19 20 21(D: ) 22 23(D: ) 24 25 26 27(D: ) 28 1(D: ) 2 3 4 5 6 7(D: ) 8 9(D: ) 10 11 12 13(D: ) 14 15(D: ) 16 17 18 131. APPENDIX IX Cr i ter ia for the Gingival Index (Gl) ' * 6: Normal gingiva. 1: Mild inflammation - sl ight change in colour, sl ight oedema. No bleeding on probing. 2: Moderate inflammation - redness, oedema and glazing. Bleeding on probing. 3: Severe inflammation - marked redness and oedema. Ulceration. Tendency to spontaneous bleeding. 2 Cr i ter ia for the Plaque Index (P1I) ' 0: No plaque in the gingival area. 1: A f i lm of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may only be recognized by running a probe across the tooth surface. 2: Moderate accumulation of soft deposits within the gingival pocket, on the gingival margin and/or adjacent tooth surface, which can be seen by the naked eye. 3: Abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface. 1. from Loe•and-Silness, 1963. 2. from Silness and Loe, 1964. 132. APPENDIX X Subject Data Form Subject: Inflammation M F D L 16 Plaque M F D L 11 24 36 31 44 133. APPENDIX XI Preinstructional Questionnaire, Experiment 2 UBC Dental Study Name Age Address Sex Phone # Please answer a l l the following questions. Confidentiality i s guaranteed. 134. 1. Have you ever received formal oral hygiene instruction? yes no 2. When was the last time you v is i ted a dental office? 3. What was the reason for that v is i t? (a) toothache, or other pain (b) routine check-up (c) routine hygiene treatment (d) routine dental repair (e) specialized treatment (e.g. orthodontic, endodontic) ( f ) other (specify) 4. Assuming that you had to do one or the other, would you rather brush or f loss your teeth? 5. How many times in the last 7 days did you brush? floss? 6. How many times in the last 24 hours did you brush? floss? 7. When Where In what order do you normally brush and floss? 8. How long do you think i t normally takes you to brush? floss? 135. 9. How many others l ive in your household? 10. How many of these people regularly (at least once per day) brush? floss? 11. How important i s i t for you to have good health? (please c i rc le one number) extremely not at a l l 1 2 3 4 5 6 7 12. How important i s i t for you to have healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 13. How important i s i t for you to keep your teeth for the rest of your l i f e ? extremely not at a l l 1 2 3 4 5 6 7 14. Doyouthink i t i s possible to keep your own teeth for the rest of your l i f e ? yes, def ini tely def ini te ly not 1 2 3 4 5 6 7 15. How important do you think regular brushing is for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 16. How important do you think regular f lossing i s for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 136. 17. How important do you think your diet i s to your dental health? extremely not at a l l 1 2 3 - 4 5 6 7 18. To what extent i s your dental health dependent on your own actions? to ta l ly not at a l l 1 2 3 4 5 6 7 19. To what extent is your physical health dependent on your own actions? tota l ly not at a l l 1 2 3 4 5 6 7 20. How would you describe the present state of your physical health? extremely good extremely poor 1 2 3 4 5 6 7 21. How would you describe the present state of your dental health? extremely good extremely poor 1 2 3 4 5 6 7 22. Would you be wi l l ing to spend 15 minutes each day brushing and f lossing your teeth, i f i t would improve your dental health? yes, def ini te ly def ini te ly not 1 2 3 4 5 6 7 23. Do you smoke? yes no If yes, how much? 24. Do you regularly use a mouthwash, or breath sweetener? yes no 137. APPENDIX XII One-month Postinstructional Questionnaire, Experiment 2 UBC Dental Study Name 1. Since the f i r s t dental assessment in Jan. /Feb. , have you received professional oral hygiene treatment, either from a dentist or a hygienist? yes no 2. How many times in the last 7 days did you brush? floss? 3. How many times in the last 24- hours did you brush? floss? 4. Since part icipating in this study, do you brush more often, less often, or the same number of times each day, as before? (Please c i rc le one) 5. Do you f loss more often, less often, or the same number of times each day? 6. Since part icipating in this study, do you brush for a longer, shorter, or the same period of time, each time you brush, as before? 7. Do you f loss for a longer, shorter, or the same.period of time, each time you floss? 8. Do you think i t is possible to deep your own teeth for the rest of your l i f e? (please c i rc le one number) yes, def in i te ly def ini te ly not 1 2 3 4 5 6 7 9. How important do you think regular brushing is for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 138. 10. How important do you think regular f lossing is for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 11. To what extent i s your dental health dependent on your own actions? to ta l ly not at a l l 1 2 3 4 5 6 7 12. During the instructional sessions, how much emphasis do you fee l was placed on the importance of dai ly brushing and flossing? a great deal none 1 2 3 4 5 6 7 13. Do you think that your instructional group is expected to improve on the dental indices, more, l ess , or the same as the other groups? 14. If more, or l ess , why do you feel this way? 15. What, in your opinion, would be the best way to motivate effective brushing and flossing? Thank you ENORMOUSLY for your part ic ipat ion, and hope to see you in September. Good luck in your exams, 139. APPENDIX XIII Seven-month Postinstructional Questionnaire, Experiment 2 UBC Dental Study: Follow-up Name 1. Have you received oral hygiene treatment since the last assessment? yes no If yes, when? 2. Since part icipating in this study, have your oral hygiene habits changed from before?, yes no If yes, how? In your opinion, what was responsible for this change? 3. How many times in the last 7 days did you brush? floss? 4. How many times in the last 24 hours did you brush? floss? 5. How many times in a typical week during the summer did you brush? floss? 6. In what order do you normally brush and floss? 7. How important i s i t for you to have good health? (please c i rc le one number) extremely not at a l l 1 2 3 4 5 6 7 140. 8. How Important i s i t for you. to have healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 9. How important i s i t for you to keep your teeth for the rest of your l i f e ? extremely not at a l l 1 2 3 4 5 6 7 10. Do you think i t i s possible to keep your own teeth for the rest of your l i f e ? yes, def in i te ly def ini te ly not 1 2 3 4 5 6 7 11. How important do you think regular brushing is for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 12. How important do you.think regular f lossing is for maintaining healthy teeth and gums? extremely not at a l l 1 2 3 4 5 6 7 13. How important do you think your diet i s to your dental health? extremely not at a l l 1 2 3 4 5 6 7 14. To what extent i s your dental health dependent on your own actions? to ta l ly not at a l l 1 2 3 4 5 6 7 141. 15. To what extent i s your physical health dependent on your own actions? to ta l ly not at a l l 1 2 3 4 5 6 7 16. How would you describe the present state of your dental health? extremely good extremely poor 1 2 3 4 5 6 7 17. How would you describe the present state of your physical health? extremely good extremely poor 1 2 3 4 5 6 7 18. Do you smoke? yes no If yes, how much? 19. Do you regularly use a mouthwash, or breath sweetener? yes no 20. Which brand of the following do you now use? toothbrush toothpaste dental f loss 142. 21. Approximately how long after the instructional sessions last spring did you maintain effective regular brushing and flossing? never brushed and flossed regularly 1 month 2 months 3 months 4 months 5 months s t i l l brushing and f lossing regularly 22. What do you think was most effective in motivating effect ive oral hygiene habits? 23. What do you think should have been done, in addition to this program? 143. APPENDIX XIV No-treatment Control Subjects' Questionnaire, Experiment 2 UBC Dental Study Name 1. Have you received oral hygiene treatment since the f i r s t assessment in August? yes no If yes, when? Were you also provided with brushing and f lossing instruction at this time? yes no 2. Since the August assessment, have your oral hygiene habits changed from before? yes no If yes, how? 3. 4. How many times in the last 7 days did you brush? How many times in the last 24 hours did.you brush? floss? floss? 144. APPENDIX XV • Postexperimental Study Description UBC Dental Study Q: What was this study a l l about, anyhow? A: I'm glad you asked that question. Let me start at the beginning. Within the. context of a dissertat ion, my interests were twofold: to contribute to the knowledge of mechanisms of behaviour change, and to develop a viable preventative dental health program. The present study sought therefore to compare the effects of two behavioural manipu-lations on the maintenance of brushing and f lossing. (I real ly did the study because i t was a requirement for the degree I ) The two behavioural manipulations were self-monitoring, and the arrangement of a contingency between f lossing and brushing. Self-monitoring simply refers to the systematic observation of one's own behaviour. In this study, some subjects were asked to monitor the frequency of f lossing and brushing, on a daily basis , for one month. Others were additionally asked, following f lossing and brushing, to disclose for plaque twice weekly, according to a schedule, and then count and record the number of teeth on which plaque remained. They would subsequently remove this plaque. These subjects would be monitoring not only their frequency of f lossing and brushing, but their eff iciency of plaque removal as well . Presumably they would be evaluating the effectiveness of dai ly f lossing and brushing. The second manipulation required some subjects to impose a contingency between f lossing and brushing, such that, once a day, they could only 145. brush after they had f lossed. There are behavioural data which suggest that a preferred act iv i ty can reinforce a less preferred ac t iv i ty , i f the two are arranged contingently. According to previous relat ive frequency and self-reported preference, brushing i s preferred to f lossing. Thus brushing should, according to the theory, reinforce, or increase the probabil i ty of, f lossing. In addition to 6 treatment groups, there was a no-treatment control , to observe the effects of repeated measurement alone. A l l other subjects received instruction i n brushing and f lossing i n the f i r s t session, and instruction according to treatment group in the second. Some subjects were exposed to only one manipulation; others to various combinations, according to this schematic: Self-monitoring frequency and none frequency evaluation contingency no contingency n = 15 no treatment control Self-monitoring, and contingent arrangement between brushing and f lossing comprised the independent variables. The main dependent variables consisted of a gingival index and a plaque index. Four surfaces of each of six teeth were scored according to a 0-3 scale, 0 representing healthy gums, and no plaque, and 3 representing inflamed gums, and plaque extending well past the gingiva on the tooth surface. Scores on these indices were compared pre- and post- instruction, and at a 6 month follow-up interval . 

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