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Structural Equation Modelling of a Theory of Planned Behaviour based health coaching intervention to improve nurses’ oral hygiene care for stroke patients: A Randomized Controlled Trial

This randomized controlled trial demonstrates that a Theory of Planned Behavior-based health coaching intervention significantly improved ICU nurses' oral hygiene care for stroke patients by enhancing their attitudes and perceived behavioral control, which were identified as key predictors of intention and behavior through Structural Equation Modelling.

Original authors: Diplina Barman, Ipseeta Menon, Melissa Glenda Lewis, Kunal Jha, Avinash Jnaneswar, Suman Kanungo

Published 2026-08-06

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Diplina Barman, Ipseeta Menon, Melissa Glenda Lewis, Kunal Jha, Avinash Jnaneswar, Suman Kanungo

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the human body as a bustling, high-tech city. In this city, the mouth is the grand front gate. Usually, this gate is guarded by a diligent security team (your teeth and gums) that keeps the bad guys (bacteria) from sneaking in and causing chaos in the rest of the city. But sometimes, the gate gets damaged or the guards get tired, and the bad guys slip through, leading to fires and disasters in other parts of the city, like the lungs. This is especially true for people who have had a "stroke," which is like a major traffic jam in the brain's control center. When the brain's control center is jammed, the body's ability to clean its own gate often shuts down, leaving the front door wide open for trouble.

To fix this, we need the city's maintenance crew—the nurses—to step in and clean the gate. But here's the tricky part: even if the nurses know they should clean the gate, they don't always do it. Why? Science has a theory called the "Theory of Planned Behavior" (TPB) to explain this. Think of TPB as a three-legged stool that supports a person's decision to act. The first leg is Attitude (Do I think cleaning the gate is a good idea?). The second leg is Subjective Norms (Do my friends and bosses think I should do it?). The third leg is Perceived Behavioral Control (Do I feel like I have the time, tools, and ability to actually do it?). If any leg is wobbly, the stool falls, and the action doesn't happen. This study asks: Can we use a special "coaching" session to fix the wobbly legs of the nurses' decision-making stool so they actually clean the mouths of stroke patients?

The Experiment: Coaching the Caregivers

In this story, researchers in Bhubaneswar, India, decided to test if they could boost the maintenance crew's performance using a "health coaching" program. They gathered 389 nurses working in Intensive Care Units (ICUs) where stroke patients are treated. They split these nurses into two teams: a "Training Team" (the intervention group) and a "Standard Team" (the control group).

The Standard Team watched a regular 15-minute video about brushing teeth. The Training Team, however, got a special 15-minute "health coaching" session based on the Theory of Planned Behavior. This wasn't just a lecture; it was an interactive workshop using 3D models to show exactly how to care for a stroke patient's mouth, followed by a six-month "remind-and-reinforce" campaign. Every two weeks, the Training Team got short videos, digital posters, and text messages to keep the lesson fresh in their minds. The researchers checked in with everyone at the start, and then again at one, three, and six months to see how their attitudes and actions changed.

What They Found: The Power of Attitude and Confidence

After six months, the results were clear. The Training Team showed a massive improvement in their willingness to clean mouths and their actual cleaning habits. The Standard Team, on the other hand, didn't see much change.

The researchers used a fancy statistical tool called Structural Equation Modelling (SEM) to look under the hood of the nurses' minds. They discovered something fascinating about the "three-legged stool" of the Theory of Planned Behavior.

In the group that didn't get the special coaching, there was a weird glitch. The nurses often intended to clean the mouths, but they didn't actually do it. It was like having a car with a full tank of gas and a map, but the engine wouldn't start. The study found that for these nurses, just having a good attitude or feeling social pressure wasn't enough to get the job done.

However, in the Training Team, the special coaching fixed the engine. The study found that Attitude was a major driver. This is the "Is this a good idea?" leg of the stool. The nurses who held strong positive beliefs about the task were the ones who formed the intention to do it. But there was another key player: Perceived Behavioral Control. While the coaching didn't make "Can I do it?" the sole predictor of intention in the statistical model, it was crucial in the broader picture. The data showed that in the trained group, both a strong "This is a good idea" belief and a strong "I have the ability" feeling worked together to turn intention into real action. The coaching made them feel capable and convinced them of the value of the work, creating a dual pathway where positive beliefs and confidence combined to drive behavior.

Interestingly, the study found that one common idea didn't seem to drive the change in this specific setting: that peer pressure or "what others think" (Subjective Norms) was the main engine. The data showed that even if nurses felt everyone expected them to clean mouths, it didn't significantly predict their actions unless they also felt they could do it. In this context, the social pressure leg of the stool didn't seem to help the chair stand up on its own.

The Bottom Line

This study suggests that to get nurses to provide better oral care for stroke patients, you can't just tell them "it's important" or "everyone expects you to do it." You have to give them the tools and the confidence to believe they can actually do it, while also reinforcing that it is the right thing to do. The "health coaching" worked because it strengthened the nurses' positive attitude toward the task and their belief in their own abilities. When the nurses felt in control and valued the work, their good intentions finally turned into good actions, keeping the "front gate" of the body safe and secure. The researchers found that this approach effectively bridged the gap between knowing what to do and actually doing it, offering a promising path to better care for stroke survivors.

Technical Summary: Structural Equation Modelling of a Theory of Planned Behaviour based health coaching intervention to improve nurses' oral hygiene care for stroke patients

Problem Statement
Stroke is a leading cause of mortality and disability globally, with a particularly high burden in Low-and-Middle-Income Countries (LMICs) like India. Stroke survivors often suffer from neurological impairments (e.g., dysphagia, motor deficits) that compromise their ability to maintain oral hygiene, placing them at high risk for oral infections, aspiration pneumonia, and prolonged hospitalization. Despite the established link between oral care and systemic health outcomes, oral hygiene remains a low-priority nursing activity in Intensive Care Units (ICUs), often overshadowed by acute clinical tasks. In the Indian context, barriers include inadequate training, staffing shortages, and a lack of stroke-specific oral health content in nursing curricula. While behavioral frameworks like the Theory of Planned Behavior (TPB) have shown promise in other health domains, their application to ICU nurses' oral hygiene practices for stroke patients in India remains largely unexplored. There is a critical need for evidence-based, theoretically grounded interventions that address not only knowledge deficits but also the behavioral variables underpinning daily practice.

Methodology
The study employed a randomized, non-blinded, parallel-arm, pre-post interventional design conducted over six months (March–October 2023) in three randomly selected hospitals in Bhubaneswar, India.

Participants: 402 registered nurses working in ICUs caring for stroke patients were recruited. After randomization, 202 were assigned to the intervention group and 200 to the control group. The final analysis included 389 participants (200 intervention, 189 control) with a 92.26% follow-up rate at six months.
Intervention: The intervention group received a 15-minute health coaching session based on the TPB, addressing specific barriers identified in preliminary interviews. This session utilized 3D customized props and was followed by periodic reinforcement (every 15 days) via 5-minute videos, digital posters, enacted clips, and text messages for six months.
Control: The control group received standard 15-minute educational videos on general oral hygiene maintenance.
Data Collection: A validated, self-structured questionnaire based on the TPB (9 domains, 28 items) was administered at baseline, and at one, three, and six months post-intervention. The instrument assessed behavioral beliefs, attitudes, subjective norms, perceived behavioral control (PBC), intention, and behavior. The tool demonstrated excellent internal consistency (Cronbach's alpha = 0.95).
Analysis: Descriptive statistics and repeated measures ANOVA were used to compare mean domain scores over time. Structural Equation Modelling (SEM) was performed using maximum likelihood estimation to test the hypothesized relationships among TPB constructs (Attitude, Subjective Norms, PBC, Intention, Behavior) and to evaluate the model fit using indices such as RMSEA, SRMR, CFI, and TLI.

Key Results

Quantitative Improvements: Repeated measures ANOVA indicated that the intervention group showed statistically significant improvements ( $p < 0.001$ ) in behavioral beliefs, attitudes, subjective norms, and intention to perform behavior over the six-month period compared to the control group. The control group showed no significant improvement in behavioral beliefs or generalized intention.
SEM Findings (Control Group): In the control group, the TPB structure was disrupted. While Perceived Behavioral Control (PBC) predicted Intention, Attitude and Subjective Norms did not significantly influence Intention. Crucially, a significant "intention-action gap" was observed: Intention was negatively associated with Behavior ( $\beta = -0.24, p = 0.001$ ), suggesting that motivation alone did not translate into practice, likely due to structural or organizational barriers.
SEM Findings (Intervention Group): The intervention group exhibited a well-functioning TPB structure. Both Attitude ( $\beta = 0.35, p < 0.001$ ) and PBC ( $\beta = 0.35, p < 0.001$ ) were strong, significant predictors of Intention. Furthermore, Intention significantly predicted Behavior ( $\beta = 0.19, p = 0.004$ ), and Attitude had a direct, strong influence on Behavior ( $\beta = 0.43, p < 0.001$ ). This indicates the intervention successfully enabled nurses to convert intentions into concrete actions.
Model Fit: The SEM model demonstrated acceptable fit (SRMR = 0.052; CFI = 0.899), with a significant improvement over the null model.

Key Contributions and Claims of Significance
The paper claims that a TPB-based health coaching intervention, reinforced by digital materials, effectively strengthens the motivational and intention-to-action pathways for oral hygiene care among ICU nurses.

Mechanism of Change: The study demonstrates that while knowledge is necessary, it is insufficient without addressing attitudinal and control factors. The intervention successfully shifted the behavioral pathway, allowing nurses to translate positive attitudes and perceived control into actual clinical practice.
Contextual Relevance: The findings highlight that in the Indian ICU context, subjective norms (social pressure) play a limited role in driving intention compared to individual attitudes and perceived control.
Clinical Impact: The authors assert that integrating regular oral hygiene maintenance into routine ICU care, supported by behavioral theory, can reduce the risk of nosocomial infections (such as ventilator-associated pneumonia) and lower mortality rates for stroke patients.
Policy Implications: The study suggests that incorporating oral hygiene care practices into national health policies and nursing curricula is essential for improving the systemic health of geriatric and stroke patients with limited dexterity.

Limitations and Modesty
The authors acknowledge that the study is modest in its scope, noting that the control group's attrition and reliance on self-reported data may introduce bias. They emphasize that while the intervention improved behavioral outcomes, the partial predictive potential of TPB components suggests that external factors (e.g., organizational workload, resource availability) also moderate the intention-behavior relationship. The paper concludes that future research should utilize more complex SEM path modeling with latent variables to further disentangle these relationships, and that behavioral change requires regular reinforcement rather than one-off training.

Technical Summary: Structural Equation Modelling of a Theory of Planned Behaviour based health coaching intervention to improve nurses' oral hygiene care for stroke patients

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