A Qualitative Examination of Flossing As a Habit and Non-Habit

Theoretical Background and research questions/hypothesis: Good oral health is essential to overall well-being and quality of life, yet largely preventable oral diseases are causing Americans pain and disability — resulting in unnecessary healthcare spending. Since 2014, Washington Dental Service Foundation (WDSF) began work on a social marketing campaign, The Mighty Mouth, to influence how oral health is perceived and motivate people to change their behaviors to prevent oral disease. Campaign evaluation showed attitudinal measures and daily brushing behavior in Washington have topped out, however just over half (65%) of people report flossing their teeth “yesterday,” which is critical to oral health. Furthermore, national data from NHANES indicate people who floss do so infrequently (32%: 6-7 times in the last week; 29%: 1-5 times; 39% 0 times). WDSF worked with Marketing for Change to explore what establishes habitual flossing, using a habit theoretical framework, metaphor elicitation, message testing and doer-non-doer comparisons following subjects over time.   

Methods: Adults aged 45 to 70 living in Washington volunteered to participate in a moderated online discussion board. Participants engaged in discussion on three separate occasions over a two week period. They were segmented by flossing frequency data into: “Regular flossers” (6-7 times per week), “Occasional flossers” (3-5 times per week), “Seldom flossers” (1-2 times per week) and “Never flossers” (0 times per week). Regular and occasional flossers were sorted into a “Doer” board, and seldom and never flossers into a “Non-Doer” board. Flossing homework assignments were completed by participants between discussion days. Forty-six participants were recruited and 38 participated throughout the entire discussion.  

Results: People who floss at least occasionally report positive rewards after flossing such as feelings of cleanliness and satisfaction. Non-Doers find flossing torturous. They know the health benefits, but have gone years without obvious negative impact. During the two-week period, Non-Doers experienced the immediate cleanliness of flossing after the initial discomfort was overcome. Flossing frequency improved during the study for every audience segment, other than for regular flossers who were maxed out.

Conclusions: A two-step pathway may be necessary to convert Non-Doers into Doers. First, a motivational prompt is needed to spur behavioral sampling. Then, as flossing frequency increases, habit support is needed to maintain the behavior. Flossing is not a new message for most people so creative treatments that paint the behavior in a new light should be considered to spur sampling. Committing to a flossing plan and increasing behavioral triggers may support habit formation.

Implications for research and/or practice: Nearly everyone says oral health is important to overall health, but there is inconsistency between that belief and self-reported behavior. Public health practitioners have the opportunity to use social marketing to influence oral health behaviors in a way health education alone cannot. Developing successful strategies starts with exploring differences between people who practice the desired health behavior and those who do not. This research is the first of its kind, that we know of, to analyze Doer vs. Non-Doer flossing behavior outside of a dental clinic setting.