Abstract
Effective flossing is essential for preventing periodontal disease. However, in a rural Appalachian community, adherence to flossing routines remains low, contributing to significant oral health disparities. The purpose of this study was to conceptualize intention of initiation and sustenance of flossing behaviors using the multi-theory model (MTM) of health behavior change. A cross-sectional survey was administered to individuals recruited from a shopping mall in rural Appalachia. The MTM constructs were measured and data were analyzed using multiple linear regression models. Of the 228 participants, 55% did not floss daily. Behavioral confidence (β = 0.571, p < 0.001) was a significant predictor for the intention of initiation of flossing among non-daily flossers, while emotional transformation (β = 0.377, p = 0.836) significantly explained sustenance among non-daily flossers. For daily flossers, changes in the physical environment (β = 0.432, p = 0.003) significantly predicted the intention of initiation of flossing, whereas emotional transformation (β = 0.344, p = 0.008) and practice for change (β = 0.594, p < 0.001) significantly predicted sustenance of flossing behavior. The MTM appears to be a robust framework for understanding and predicting flossing behaviors in rural Appalachian populations. Interventions designed to enhance behavioral confidence, physical environment changes, emotional transformation, and practice for change could improve flossing adherence. Further research should explore these constructs to develop targeted public health strategies.
Keywords: Appalachia, Flossing, Health behavior, Periodontal disease, Public health
Subject terms: Dental diseases, Dental public health
Introduction
The importance of oral hygiene in maintaining healthy teeth and periodontal tissues is well known. An important aspect of this hygiene is flossing. Bacteria in the mouth are often the cause of periodontal disease and unhealthy tissues1. Toothbrushing with flossing has been found to promote oral health and significantly decrease gingival bleeding after only 2 weeks2. Controlling plaque build-up may assist in preventing inflammatory problems of the gums and dental caries3. Flossing is a method that attempts to decrease the amount of bacterial plaque buildup between teeth to prevent oral health complications such as dental caries and gingivitis. It is especially important to use in combination with toothbrushing to remove plaque from areas that are unreachable by the toothbrush. Studies have shown that there is an increased benefit in preventing gingivitis when added to toothbrushing routines4.
Proper oral health is not just a problem found in adults, but it also greatly affects children. Dental caries have been reported to affect two-thirds of children between the ages of 5–175. Maintaining a healthy oral environment is not only important for tissues found within the mouth but also for the overall health of an individual. Proper oral hygiene not only protects teeth and periodontal tissues against disease but may also promote health in other systems of the body such as the cardiovascular system. It has been found that oral bacteria such as A. actinomycetemcomitans and S. mutans may be etiologic factors for the development of cardiovascular disease6.
There has also been found to be a socioeconomic and geographical component to oral health. A behavioral risk survey from the CDC reports that the Appalachian region of the Eastern United States experiences an increase in oral health disparities compared to other regions7. The Appalachian region consists of approximately 25 million people8 and is comprised of many rural communities that comprise 42% of the population9. The region has been known to have higher rates of gingivitis, dental caries, periodontitis, and chronic oral health issues compared to other regions in the U.S.10. According to the CDC, West Virginia, a state located within the Appalachian region, sees a much higher rate of dental caries and tooth loss than the rest of the country11. Approximately two-thirds of adults over the age of 65 have lost six or more teeth and one-third have lost all their teeth11. The rest of the United States sees a much lower rate of tooth loss, 40% and 17%, respectively11. Another study in West Virginia, found that 40% of respondents did not brush their teeth daily, and 70% did not floss at all12.
Flossing of teeth to promote oral health is a significant public health issue that needs to be addressed in rural Appalachian communities. There are many reasons like overall poverty, disparity, lack of health literacy, and lack of oral health literacy, responsible for the lack of adherence to flossing routines found in rural Appalachia13, and further research is needed to determine why these public health behaviors exist. Furthermore, actions need to be taken to promote flossing.
One way to promote a change in public behavior is to use the fourth-generation multi-theory model (MTM) of health behavior change14. This model can be broken down into two components: intention of initiation and continuation14. Intention of initiation refers to the likelihood of initiation of a change in behavior or the adoption of a new behavior14. This initiation is influenced by three main constructs: participatory dialogue, behavioral confidence, and changes in the physical environment14. “Participatory dialogue” is initiated by an educator and consists of the advantages outweighing the disadvantages of the behavior change14. “Behavioral confidence” may come from several sources such as health educators, influential people, religious or spiritual beliefs, or oneself14. Lastly, “changes in the physical environment” is confined to strictly the physical environment and is related to the availability and accessibility of physical resources14.
Continuation refers to the continuing of a health behavior change14. The continuation of a health behavior is also influenced by three main constructs: emotional transformation, practice for change, and changes in the social environment. “Emotional transformation” involves taking one’s emotions and directing them towards the change in health behavior. “Practice for change” entails constantly thinking about the health behavior change to remain focused and mindful14. The “changes in the social environment” may be natural or artificial and are derived from social support and helping relationships14. The MTM has been applied previously to explain flossing intention and continuation in a sample of African American and Latinx adolescents in the United States15. However, there is a need to further explore factors associated with flossing among adults in Appalachia. Thus, the present study assessed how well the MTM constructs predicted the intention of initiation and continuation of flossing in a rural Appalachian community, expanding on previous research in this area1.
Methods
Study design and participants
This cross-sectional study was conducted from July 2019 to January 2020 in a rural Appalachian community in Kentucky. Participants were recruited from a local shopping mall using a convenience sampling method. The inclusion criteria required participants to be adults residing in the Appalachian region and willing to participate in a survey regarding their flossing habits. Consenting adults completed the demographic section and the MTM battery.
Survey instrument
The survey was designed to assess the constructs of the multi-theory model (MTM) for health behavior change, focusing on both the intention of initiation and sustenance of flossing behaviors using MTM scales developed in a previous study15. All MTM scales were assessed for content validity by a panel of experts, have demonstrated sufficient internal consistency reliability, and have shown acceptable construct validity through structural equation modeling in previous research15; in the present study we again evaluated internal consistency for each multi-item scale (see Data Analysis).
Initiation constructs
Initiation of flossing behavior change was assessed using one item: “How likely is it that you will initiate flossing your teeth in the near future?” This item was rated on a Likert scale ranging from 0 = not at all likely to 4 = completely likely.
Participatory dialogue
This construct measured the perceived advantages and disadvantages of flossing, aiming to understand the participants’ dialogue with themselves and others about the benefits and barriers of adopting the behavior, and was assessed using 10 items (5 perceived advantages items, 5 perceived disadvantages items). Items included statements such as “If you thoroughly floss your teeth every day, you might be healthy” and “If you thoroughly floss your teeth every day, it might be inconvenient.” Items were rated on a Likert scale ranging from 0 = never to 4 = very often. The five perceived advantages items and five perceived disadvantages items were summated to create composite variable scores for both perceived advantages and disadvantages with a possible range from 0 to 20 for each variable.
Behavioral confidence
Five items were used to assess participants’ confidence in their ability to initiate and maintain flossing as a regular habit. Items included statements such as “How sure are you that you can thoroughly floss your teeth every day in the next week?” and “How sure are you that you can thoroughly floss your teeth every day without getting inconvenienced?” Items were rated on a Likert scale ranging from 0 = not at all sure to 4 = completely sure. A composite variable was created by summating scores from all five items, resulting in a final variable with a range from 0 to 20.
Changes in the physical environment
Three items were used to determine the participants’ access to flossing tools and resources that facilitate the behavior. Items included statements such as “How sure are you that you will find a suitable floss for flossing your teeth every day?” Items were rated on a Likert scale ranging from 0 = not at all sure to 4 = completely sure. A composite variable was created by summating scores from the items, resulting in a final variable with a range from 0 to 12.
Sustenance constructs
Sustenance of flossing behavior change was assessed using one item: “How likely is it that you will floss your teeth every day from now on?” This item was rated on a Likert scale ranging from 0 = not at all likely to 4 = completely likely.
Emotional transformation
Three items were used to evaluate the extent to which participants could channel their emotions positively toward maintaining a flossing routine. Items included statements such as “How sure are you that you can direct your emotions/feelings toward the goal of thoroughly flossing your teeth every day?” Items were rated on a Likert scale ranging from 0 = not at all sure to 4 = completely sure. A composite variable was created by summating scores from all items, resulting in a final variable with a range from 0 to 12.
Practice for change
Three items assessed the participants’ ability to continuously practice and integrate flossing into their daily routines. Items included statements such as “How sure are you that you can keep a diary/record to monitor the goal of flossing your teeth every day?” Items were rated on a Likert scale ranging from 0 = not at all sure to 4 = completely sure. A composite variable was created by summating scores from all three items, resulting in a final variable with a range from 0 to 12.
Changes in the social environment
Three items were used to assess support from family, friends, and the broader community that could help sustain flossing behavior. Items included statements such as “How sure are you that you can get the help of a family member to support you with thoroughly flossing your teeth every day?” Items were rated on a Likert scale ranging from 0 = not at all sure to 4 = completely sure. A composite variable was created by summating scores from all three items, resulting in a final variable with a range from 0 to 12.
Data collection
Data were collected using a structured, self-administered questionnaire, which included demographic questions and items related to the MTM constructs. To encourage participation, respondents were offered a choice of a toothbrush or toothpaste upon completing the survey.
Ethical considerations
The study received ethical approval from the Institutional Review Board (IRB) of the parent university. All procedures were performed in accordance with relevant guidelines and regulations required for research conducted among human participants. All participants provided informed consent before participation, ensuring their understanding of the study’s purpose and their rights as participants.
Data analysis
Descriptive statistics were used to summarize the demographic characteristics of the participants and the scores for each MTM construct. Analyses were conducted separately for daily (n = 102) and non-daily (n = 126) allowing direct comparison of constructs between groups. Before hypothesis testing, we examined the internal-consistency reliability of every multi-item MTM scale by calculating Cronbach’s α coefficients. Values ≥ 0.70 were considered acceptable. Multiple linear regression models were employed to identify the predictors of intention to sustain flossing. The initiation model included participatory dialogue, behavioral confidence, and changes in the physical environment as independent variables (Table 4). The sustenance model included emotional transformation, practice for change, and changes in the social environment as predictors. For both models, the significance of each predictor was assessed, and the adjusted R-squared values were reported to indicate the proportion of variance explained by the model. Additionally, one-way ANOVA was conducted to explore the relationship between income categories and intent to initiate flossing, and age and flossing sustenance. Due to the small sample size for some income categories, specific groups were combined or excluded as necessary to ensure robust analysis.
Table 4.
Multiple regression models for Initiation and Sustenance of flossing.
| Not flossing daily | ||||||
|---|---|---|---|---|---|---|
| Initiation model | b | S.E | B | p | LBCI | UBCI |
| Participatory dialogue: advantages–disadvantages | − 0.001 | 0.013 | − 0.008 | 0.922 | − 0.028 | 0.025 |
| Behavioral confidence | 0.123 | 0.021 | 0.571 | < 0.001 | 0.081 | 0.165 |
| Changes in the physical environment | 0.006 | 0.031 | 0.020 | 0.836 | − 0.055 | 0.068 |
| Model statistics: Adjusted R2 = 0.322, F(3, 120) = 20.496, p < 0.001 | ||||||
| Sustenance model | b | S.E | B | p | LBCI | UBCI |
| Gender | 0595 | 0.177 | 0.243 | 0.001 | 0.244 | 0.946 |
| Emotional transformation | 0.139 | 0.036 | 0.377 | < 0.001 | 0.067 | 0.211 |
| Practice for change | 0.045 | 0.037 | 0.114 | 0.225 | − 0.028 | 0.117 |
| Changes in the social environment | 0.053 | 0.031 | 0.148 | 0.091 | − 0.009 | 0.114 |
| Model Statistics: Adjusted R2 = 0.354, F(4, 120) = 17.956, p < 0.001 | ||||||
| Daily flossers | ||||||
|---|---|---|---|---|---|---|
| Initiation model | b | S.E | B | p | LBCI | UBCI |
| Participatory dialogue: advantages–disadvantages | − 0.004 | 0.012 | − 0.044 | 0.731 | − 0.028 | 0.020 |
| Behavioral confidence | 0.036 | 0.023 | 0.213 | 0.126 | − 0.010 | 0.082 |
| Changes in the physical environment | 0.127 | 0.041 | 0.432 | 0.003 | 0.045 | 0.210 |
| Model statistics: Adjusted R2 = 0.254, F(3,45) = 6.456, p = 0.001 | ||||||
| Sustenance model | b | S.E | B | p | LBCI | UBCI |
| Emotional transformation | 0.127 | 0.045 | 0.344 | 0.008 | 0.035 | 0.218 |
| Practice for change | 0.168 | 0.032 | 0.594 | < 0.001 | 0.104 | 0.232 |
| Changes in the social environment | − 0.040 | 0.034 | − 0.130 | 0.246 | − 0.109 | 0.029 |
| Model Statistics: Adjusted R2 = 0.578, F(3, 46) = 23.383, p < 0.001 | ||||||
S.E. = standard error of the estimate; LBCI = lower bound of the 95% confidence interval; UBCI = upper bound of the 95% confidence interval.
Results
A total of 228 participants from rural Appalachian Kentucky were included in the study, with 126 (55.0%) reporting that they did not floss daily. The demographic characteristics of the sample are detailed in Table 1. The sample was predominantly women (52%), White (77.3%), married (38.4%), and earned less than $50,000 annually (34.1%). All scales used in the study demonstrated acceptable evidence of internal consistency reliability (α = 0.82–0.95).
Table 1.
Demographic characteristics of study sample (n = 228).
| Mean (SD) | n (%) | |
|---|---|---|
| Age | 38.11 (17.93) | |
| Gender | ||
| Female | 119 (52.0) | |
| Male | 71 (31.0) | |
| Race/ethnicity | ||
| White | 177 (77.3) | |
| Racial minority | 9 (3.9) | |
| Marriage status | ||
| Married | 88 (38.4) | |
| Single | 78 (34.1) | |
| Other | 17 (7.4) | |
| Education level | ||
| Less than high school | 7 (3.1) | |
| High school or GED | 58 (25.3) | |
| Some college | 69 (30.1) | |
| Bachelor’s degree | 28 (12.2) | |
| Graduate degree | 18 (7.9) | |
| Professional degree | 3 (1.3) | |
| Income | ||
| Less than $50,000 | 78 (34.1) | |
| $50,000–$99,999 | 50 (21.8) | |
| $100,000–$150,000 | 13 (5.7) | |
| More than $150,000 | 1 (0.4) | |
| Prefer not to answer | 32 (14.0) | |
| Employment | ||
| Employed | 104 (45.4) | |
| Non-employed | 78 (34.1) | |
| Hours worked | 38.11 (12.94) | |
| Daily flossing | ||
| Yes | 102 (44.5) | |
| No | 126 (55.0) |
Percentage totals may not equal 100 due to missing data in the form of participant omission.
The descriptive statistics and group means for the initiation constructs of the Multi-Theory Model (MTM) between daily flossers and non-daily flossers are presented in Table 2. Non-daily flossers had significantly lower scores in behavioral confidence (M = 11.75, SD = 5.26) compared to daily flossers (M = 16.76, SD = 4.05), p < 0.001. Changes in the physical environment scores were also lower for non-daily flossers (M = 8.12, SD = 3.52) compared to daily flossers (M = 9.92, SD = 2.29), p < 0.001. For the sustenance constructs, non-daily flossers had lower scores in emotional transformation (M = 6.72, SD = 3.29) compared to daily flossers (M = 9.90, SD = 2.50), p < 0.001. Practice for change scores were lower for non-daily flossers (M = 4.86, SD = 3.10) compared to daily flossers (M = 7.56, SD = 3.26), p < 0.001. Changes in the social environment scores were also lower for non-daily flossers (M = 6.63, SD = 3.41) compared to daily flossers (M = 8.58, SD = 3.00), p = 0.001.
Table 2.
Descriptive statistics for study variables with test of group means between face covering compliant and non-compliant individuals.
| Not flossing daily (n = 126) | Daily flossers (n = 102) | p value | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Possible range | Observed range | Mean (SD) | Cronbach’s alpha | Possible range | Observed range | Mean (SD) | Cronbach’s alpha | ||
| Initiation Intention | 0–4 | 0–4 | 2.11 (1.12) | – | 0–4 | 2–4 | 3.47 (0.73) | – | < 0.001 |
| Participatory dialogue: advantages | 0–20 | 0–20 | 14.71 (4.64) | 0.91 | 0–20 | 0–20 | 15.41 (5.04) | 0.87 | 0.337 |
| Participatory dialogue: disadvantages | 0–20 | 0–20 | 8.72 (4.70) | 0.85 | 0–20 | 2–20 | 8.81 (5.32) | 0.83 | 0.916 |
| Participatory dialogue: advantages–disadvantages | − 20–+ 20 | − 20– + 20 | 6.03 (6.63) | – | − 20– + 20 | − 15–+ 20 | 6.69 (7.60) | – | 0.570 |
| Behavioral Confidence | 0–20 | 0–20 | 11.75 (5.26) | 0.93 | 0–20 | 4–20 | 16.76 (4.05) | 0.91 | < 0.001 |
| Changes in the physical environment | 0–12 | 3–12 | 8.12 (3.52) | 0.95 | 0–12 | 4–12 | 9.92 (2.29) | 0.89 | < 0.001* |
| Sustenance | 0–4 | 0–4 | 1.74 (1.21) | – | 0–4 | 0–4 | 3.41 (0.92) | – | < 0.001* |
| Emotional transformation | 0–12 | 0–12 | 6.72 (3.29) | 0.92 | 0–12 | 4–12 | 9.90 (2.50) | 0.88 | < 0.001 |
| Practice for change | 0–12 | 0–12 | 4.86 (3.10) | 0.82 | 0–12 | 0–12 | 7.56 (3.26) | 0.80 | < 0.001 |
| Changes in the social environment | 0–12 | 0–12 | 6.63 (3.41) | 0.84 | 0–12 | 0–12 | 8.58 (3.00) | 0.83 | 0.001 |
*Estimates attained for significance testing are based on Welch’s t-test.
The zero-order correlation matrix in Table 3 shows the relationships among the MTM constructs for both daily and non-daily flossers. Significant correlations were found among the constructs, indicating their interconnectedness. For daily flossers, intent of initiation was significantly correlated with behavioral confidence (r = 0.387, p < 0.01) and changes in the physical environment (r = 0.503, p < 0.001). For non-daily flossers, intent of initiation was significantly correlated with behavioral confidence (r = 0.582, p < 0.001) and changes in the physical environment (r = 0.388, p < 0.001). Sustenance was significantly correlated with emotional transformation (r = 0.706, p < 0.001) and practice for change (r = 0.601, p < 0.001) for daily flossers, with similar correlations observed for non-daily flossers.
Table 3.
Zero-order correlation matrix of study variables.
| Construct | 1 | 2 | 3 | 4 | |
|---|---|---|---|---|---|
| Daily flossers (n = 102) | |||||
| 1 | Initiation Intention | – | 0.129 | 0.387** | 0.503*** |
| 2 | Participatory dialogue advantages– disadvantages | – | 0.048 | 0.212 | |
| 3 | Behavioral confidence | – | 0.416** | ||
| 4 | Changes in the physical environment | – | |||
| 1 | Sustenance | – | 0.601*** | 0.706*** | 0.282* |
| 2 | Emotional transformation | – | 0.534*** | 0.541*** | |
| 3 | Practice for change | – | 0.382** | ||
| 4 | Changes in the social environment | – | |||
| Not flossing daily (n = 126) | |||||
| 1 | Initiation Intention | – | 0.157 | 0.582*** | 0.388*** |
| 2 | Participatory dialogue advantages–disadvantages | – | 0.297** | 0.221* | |
| 3 | Behavioral confidence | – | 0.651*** | ||
| 4 | Changes in the physical environment | – | |||
| 1 | Sustenance | – | 0.533*** | 0.432*** | 0.405*** |
| 2 | Emotional transformation | – | 0.615*** | 0.533*** | |
| 3 | Practice for change | – | 0.451*** | ||
| 4 | Changes in the social environment | – | |||
The results of the multiple regression models for the intention to initiate and sustain flossing are detailed in Table 4. Among non-daily flossers, the initiation model showed that Behavioral Confidence was a significant predictor (β = 0.571, p < 0.001), explaining 32.2% of the variance, Adjusted R2 = 0.322, F(3, 120) = 20.496, p < 0.001. In the sustenance model for non-daily flossers Adjusted R2 = 0.354, F(4, 120) = 17.956, p < 0.001, Emotional Transformation was a significant predictor (β = 0.377, p < 0.001) as well as gender identity (β = 0.243, p = 0.001). Among daily flossers, the initiation model showed that Changes in the Physical Environment was a significant predictor (β = 0.432, p = 0.003), explaining 25.4% of the variance, Adjusted R2 = 0.254, F(3, 45) = 6.456, p = 0.001. In the sustenance model for daily flossers, Emotional Transformation was a significant predictor (β = 0.344, p = 0.008), Adjusted R2 = 0.578, F(3, 46) = 23.383, p < 0.001. Practice for Change was significant (β = 0.594, p < 0.001).
Discussion
This study aimed to understand and predict flossing behaviors among the rural Appalachian population using the Multi-Theory Model (MTM). The results revealed significant insights into the factors influencing the intention to initiate and sustain flossing habits in this community among both non-daily and daily flossers. Behavioral confidence and changes in the physical environment emerged as significant predictors for the intention of initiation of flossing behaviors. Findings from this study showed that enhancing behavioral confidence and modifying the physical environment may significantly impact the intention of initiation of flossing behaviors in rural Appalachian populations, while emotional transformation and practice for change are also crucial for sustaining flossing behaviors. This highlights the importance of targeted interventions addressing both psychological and environmental factors influencing oral hygiene practices. Additionally, the results of this study underscore the importance of an individual’s perception of their confidence to initiate engagement in dental hygiene behaviors and the need for accessible dental hygiene resources in promoting the adoption of flossing habits.
For the sustenance of flossing, emotional transformation was a crucial factor for both non-daily and daily flossers, whereas practice for change was important for daily flossers. This highlights the role of emotional engagement and cognitive reinforcement in maintaining healthy behaviors over time16. Programs designed to sustain flossing behaviors should focus on helping individuals transform their emotional attitudes toward oral hygiene and incorporate regular reminders or cues to reinforce the behavior17. Emotional transformation may be facilitated through motivational interviewing, where individuals are encouraged to connect their oral health habits to their personal values and goals18. Practice for change may be supported by creating habit-forming routines and using technology, such as apps and reminders, to reinforce the behavior19.
One notable finding was that income was significantly related to the intention of flossing initiation among the daily flossing group20. However, this variable was not included in the regression analysis due to the small number of individuals with complete data, as indicated by the degrees of freedom. The results of the one-way ANOVA suggest that the significant differences were primarily between the group that preferred not to disclose their income and all other income groups. This finding warrants further exploration.
It is possible that individuals who prefer not to disclose their income may have unique characteristics or face particular barriers to adopting flossing behaviors21. These barriers could include financial constraints, lack of access to dental care resources, or differing health priorities22. Individuals in lower income brackets might experience greater stress and limited time, which could detract from their ability to maintain regular flossing habits23. Conversely, higher-income individuals may have better access to dental hygiene products and professional advice, making it easier to adopt and sustain flossing behaviors23. Further research is needed to understand the specific barriers and motivators within this subgroup to design effective interventions.
The study also found that age was significantly associated with the sustenance of flossing behaviors. Older participants were more likely to sustain flossing compared to younger individuals24. This may be attributed to increased health awareness and the higher likelihood of experiencing dental issues that come with aging, which could motivate consistent flossing24. Additionally, older adults might have more established routines and a greater appreciation for preventive health measures24. Younger individuals, on the other hand, may prioritize other aspects of their busy lives over oral hygiene25. Educational campaigns tailored to younger populations that emphasize the long-term benefits of flossing and integrate flossing into their daily routines may help improve their oral health behaviors.
Public health interventions
The findings of this study have several implications for public health interventions targeting a rural Appalachian community. Interventions aimed at boosting individuals’ confidence in their ability to floss effectively and modifying their physical environment to make flossing more convenient could be beneficial26. For example, providing flossing demonstrations, distributing free flossing tools, and creating supportive environments in schools and workplaces could help increase the initiation of flossing27. Strategies to promote flossing should consider the socioeconomic and demographic factors influencing behavior21. Tailored interventions that address financial barriers enhance behavioral confidence and leverage emotional and cognitive reinforcement are likely to be more effective28.
Additionally, public health campaigns could benefit from focusing on the unique challenges faced by specific subgroups, such as those who prefer not to disclose their income29. Understanding and addressing the underlying reasons for this group’s reluctance to adopt flossing behaviors could lead to more inclusive and effective health promotion strategies30. Campaigns could also incorporate community-based approaches involving local leaders and healthcare providers to build trust and relevance among the target population.
Recommendations for research
Future research should aim to include a larger and more diverse sample to validate these findings and explore the nuanced barriers and facilitators of flossing behavior in greater detail. Longitudinal studies could provide deeper insights into the long-term effectiveness of interventions designed based on the MTM constructs. Research could also explore the impact of integrating flossing interventions with other health-promoting behaviors, such as diet and exercise, to create a holistic approach to improving overall health. Investigating the role of cultural factors and social norms in shaping flossing behaviors in a rural Appalachian community could further enhance the design of tailored interventions.
Limitations
The findings reported for this study should be considered in the context of the following limitations. The study relied on the use of self-report data, which has the potential for bias due to the social desirability of responses. The study also used a cross-sectional research design, which prevents any determination of causation or directionality between the variables in the study. Further, the sampling strategy used an intercept sampling process of mall patrons, which may limit the generalizability of the study findings. Participants in the present study may not be representative of the larger population in the Appalachian region. Some psychological variables exhibited moderate to strong correlations. It is expected that psychological predictors of behavior exhibit an interrelatedness. To ensure the integrity of regression models tolerance and variance inflation factor (VIF) were used to ensure the absence of multicollinearity. Where data allows, future studies may incorporate a path-model analytic design to examine relations among predictor variables. Future studies should use longitudinal study designs or implement interventions to overcome the limitations in the present study.
Conclusions
In conclusion, this study highlights the multifaceted nature of flossing behaviors and the importance of considering a wide range of factors in promoting oral hygiene. By addressing both psychological and environmental influences using the MTM, public health initiatives may better support the adoption and maintenance of healthy behaviors in underserved communities. Tailored, culturally sensitive interventions that consider the unique socioeconomic and demographic characteristics of rural Appalachian populations are crucial for improving oral health outcomes and being considered culturally robust. Through continued research and targeted public health efforts, it is possible to reduce oral health disparities and enhance the overall well-being of this community.
Acknowledgements
We would like to thank the Center for Animal and Human Health in Appalachia at the College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, USA for funding this study.
Author contributions
AHW, MS, VKN, and RED were responsible for conceptualization, study design, and instrumentation. BL and CD collected the data. RED and VKN analyzed data. All named authors contributed to the interpretation of results and drafting of the manuscript. RED is the guarantor and accepts full responsibility for the finished work and/or the conduct of the study, had access to data, and controlled the decision to publish.
Funding
This study was funded by the Center for Animal and Human Health in Appalachia at the College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, USA.
Data availability
Data is available at a reasonable request submitted to Robert E. Davis, the corresponding author.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is available at a reasonable request submitted to Robert E. Davis, the corresponding author.