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Critical Issues in Dental Education |
Ms. Heaton is a Graduate Student in Clinical Psychology, Departments of Psychology and Behavioral Science, University of Kentucky; Dr. Smith is a Professor, Department of Behavioral Science, University of Kentucky College of Medicine; and Dr. Raybould is a Professor, General Dentistry and Preventive Medicine, and Director, General Practice Residency and Adult Special Patient Care, University of Kentucky College of Dentistry. Direct correspondence and requests for reprints to Dr. Ted Raybould, A-219 Kentucky Clinic, College of Dentistry, University of Kentucky, Lexington, KY 40536-0284; 859-323-6513 phone; 859-323-2036 fax; tprayb1{at}email.uky.edu.
Key words: dental health surveys, dental health services, anxiety, health services accessibility
Submitted for publication 05/17/04; accepted 07/19/04
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Abstract |
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To date, no studies have investigated differences between rural and urban areas with regards to use of dental services. Mueller et al.6 examined the prevalence of unmet dental needs in both metropolitan (urban) and nonmetropolitan (rural) areas. Their results suggested that while participants in metropolitan areas were more likely to have dental insurance than those in nonmetropolitan areas, and lack of insurance was named as the greatest barrier to receiving dental care, there were no significant differences in unmet dental needs between rural and urban areas. Questions still remain, however, as to differences between these two geographic regions in terms of overall use of dental services and attitudes toward dental care. Kentucky contains urban areas as well as significantly less populated rural areas and therefore provides opportunities to assess differences in dental services and attitudes between metropolitan and rural areas.
The goals of the study reported here were to investigate patterns of dental treatment in one urban and two rural Kentucky areas and to identify the challenges facing practitioners in these areas. To fully assess the effectiveness of clinics in rural areas, information must be gathered regarding reasons for and barriers to seeking dental care among this population and in a comparable urban population. It is also essential to assess the scope of clinical care needed to sustain clinics in these areas, particularly patient care services provided by postdoctoral residents. In this study, dental patients and other individuals in two rural Kentucky counties and one urban county were asked to identify their reasons for seeking and avoiding dental care and were asked to share their perceptions of their overall level of dental health.
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Methods |
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Menifee County (rural general population sample).
Menifee County, an area of 204 square miles located in Eastern Kentucky, has approximately 6,700 residents, nearly 98 percent of which are Caucasian. The county seat is Frenchburg, whose population in 1990 was 625. Fifty-eight percent of adults over the age of twenty-five were high school graduates as of 2002, and the median household annual income in 1999 was $22,000.7 At the time of this study, individuals in Menifee County had access to regular medical services through the Community Health Center (which contains a dental clinic) and emergency services through a medical center in an adjoining county. There are no hospitals located in Menifee County.
Data in this county were collected over a three-month period in 1999. Participants were 100 adults in the general population (71 percent female) ranging from eighteen to seventy-five years of age (Mage=42.8, s.d.=15.1) who were recruited for participation by members of the Menifee County Health Council. Members of this health council reviewed the data collection questionnaire, described below, prior to its completion by participants. As the council members requested that the questionnaire not contain items related to income or education levels, 1999–2001 census data were used when comparing demographic information among the three counties. Furthermore, because approximately 98 percent of residents in Menifee and Jackson counties are Caucasian and the majority of patients at university clinics (including the Kentucky Clinic at the University of Kentucky) are Caucasian, items regarding ethnicity were not included in any of the questionnaire administrations.
As individuals from the general population tend to report more irregular dental attendance and more dental fear than patients surveyed in dental clinics,8 participants from the general population of Menifee County (a county demographically similar to Jackson County) were surveyed to provide a contrast to dental patients surveyed in Jackson and Fayette counties. Ten health council members recruited participants directly and administered the questionnaires in person. Upon completion, council members returned the questionnaires by mail to the principal investigator. Responses were kept confidential by asking participants to not include any identifying information on the questionnaire. Participants did not receive any incentives for completion of the questionnaires.
Jackson County (rural dental patient sample).
Jackson County, an area of 346 square miles located in Eastern Kentucky, has approximately 14,000 residents, nearly 99 percent of which are Caucasian. The county seat is McKee, whose population in 1990 was 870. Fifty-three percent of adults over the age of twenty-five had received a high school diploma as of 2002, and the median household annual income in 1999 was $20,000.9 Data in this county were collected from patients seeking dental treatment in the White House Clinic in McKee, Kentucky. This clinic is staffed by one full-time and one part-time University of Kentucky (UK) faculty member, one HRSA-supported resident,10–11 one hygienist, three assistants, one receptionist, one secretary, and one clinic coordinator. Separate medical facilities are also housed in this clinic for individuals seeking medical care during working hours. Individuals living in Jackson County receive emergency medical services through a hospital-based emergency room in an adjoining county. Aside from the dentists at the White House Clinic, there is one additional dentist in private practice in Jackson County.
Data in this county were collected during the summer of 2001. Participants were seventy-one adult dental patients (73 percent female) ranging in age from eighteen to seventy-two years (Mage=34.9, s.d.=12.4). Upon arriving at the clinic for a previously scheduled appointment, participants were offered the opportunity to participate in research when they registered for their appointments. Upon agreeing to participate, each participant was given a questionnaire packet with instructions to not include any identifying information on the forms. The questionnaires were then collected and returned to the principle investigator by mail. Participants did not receive any incentives for completion of the questionnaires.
Fayette County (urban dental patient sample).
Fayette County, an area of 285 square miles located in Central Kentucky, has approximately 264,000 residents, 81 percent of which are Caucasian. The boundaries of Fayette County and the city of Lexington are shared, such that residents of Fayette County also reside in Lexington. In 2002, 86 percent of adults over the age of twenty-five were high school graduates, and the median household annual income in 1999 was $40,000.12 Fayette County contains over 100 dentists in private practice and is served by over a dozen hospitals.
Patients seeking dental treatment at the Kentucky Clinic at the University of Kentucky in Lexington (Fayette County) were recruited for this study in a similar manner to those in Jackson County. Data were collected during the spring and summer of 2003. This clinic is part of the University of Kentucky (UK) campus and is staffed by three faculty members (two full-time and one part-time), three HRSA-supported residents,10–11 four hygienists, seven assistants, one sterilization technician, two receptionists, one clinic coordinator, and one secretary.
Participants were 104 adult dental patients (67 percent female) ranging in age from twenty to eighty-two years (Mage=42.2, s.d.=13.6). Patients completed the questionnaires in the waiting area prior to receiving dental treatment, sealed the questionnaire packets in envelopes, and placed them in a labeled box in the waiting area. The questionnaires were then collected and returned to the principle investigator. Participants did not receive any incentives for completion of the questionnaires.
Questionnaires
Because the three sites completed the study at different times, various items were added and/or omitted to the questionnaire completed at each site. As the scope of the study expanded, additional sites were added over time. Through item analysis of each site’s data, items were retained and omitted in attempts to obtain comprehensive data. The data presented in this article were obtained through a set of nine common items administered to participants at all three sites. These items consisted of demographic questions (age, gender), as well as items related to self-rated dental health, dental attendance patterns, and dental fear. To assess perceived barriers to receiving regular dental care, participants were also asked about their perceptions of the importance of dental care as well as the effects of cost, fear, location, and time on dental attendance. (See Table 1
for specific items.) These items were developed by the principal investigator, in part through items from previous surveys, and pilot tested on a small group of graduate students and administrative staff to ensure item clarity.
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The questionnaire data from all three counties were analyzed separately and then together using SPSS Version 11.0. Data from the combined analyses are presented below. Statistical analyses included both descriptive (frequency distributions, percentages) and analytic (independent-samples t tests, regression analyses) tests.
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Results |
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. Participants in Jackson County were significantly younger than their Menifee (t=3.7, p<.001) or Fayette counties (t=3.5, p<.001) counterparts. There were no age differences between the Menifee County patients and Fayette County participants. Menifee County participants rated their dental health significantly higher than did the Jackson (t=3.08, p<.01) or Fayette County (t=2.01, p<.05) dental patients. Patients in Fayette County reported seeking dental treatment more often than did respondents in Menifee County (t=2.3, p<.05) or patients in Jackson County (t=2.7, p<.01), and also reported dental care as being more important than did those in Menifee (t=3.39, p<.01) or Jackson (t=4.37, p<.001) counties. There were no differences in dental attendance or perceived importance of dental care between Menifee and Jackson counties.
No differences (p’s<.05) were found among the three locations on the general dental fear item ("How do you rate your overall feelings about visiting a dentist for treatment?"). Between-group differences for the three locations, however, were found on a number of other items, such as reasons for the previous visit, having dental insurance, fear of specific aspects of dentistry, and previous barriers to dental care, as shown in Table 1.
Correlations
Partial correlations, controlling for location, were computed for each of the primary variables of interest and are shown in Table 2. All correlations were calculated using 275 participants from all three locations. Age was positively correlated with the purpose of the previous visit (r=.15, p<.05). Older participants were more likely to have most recently seen a dentist for emergency reasons, for the fitting or checking of dentures (r=.23, p<.001), or for a restoration (r=.14, p<.05). Age was also positively correlated with not previously perceiving a need for dental care (r=.14, p<.05). Age was negatively correlated with having avoided dental care due to cost (r=–.15, p<.05).
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Self-rated dental health was positively correlated with dental attendance (r=.46, p<.001), importance of dental care (r=.36, p<.001), and the previous dental visit being for a cleaning or checkup (r=.25, p<.001). Additional negative correlations with self-rated dental health included dental fear (r=–.18, p<.01), having avoided dental care due to cost (r= –.23, p<.001), feeling nervous or scared in the dental environment (r=–.18, p<.01), and having a negative prior dental experience (r=–.18, p<.01).
Perceived importance of dental care was positively correlated with self-rated dental health (r=.36, p<.000), dental attendance (r=.42, p<.001), and the previous dental visit being for a cleaning or checkup (r=.16, p<.01). Importance of dental care was negatively correlated with dental fear (r=–.15, p<.05), having a negative prior dental experience (r=–.22, p<.001), and the previous dental visit being for the treatment of pain (r=–.13, p<.05).
Dental fear was positively correlated with specific fears of pain (r=.48, p<.001), injections (r=.32, p<.001), and drilling (r=.24, p<.001), feeling nervous or scared in the dental environment (r=.57, p<.001), and having had a negative prior dental experience (r=.36, p<.001), in addition to the variables mentioned above. Dental fear was negatively correlated with the previous dental visit being for a cleaning or checkup (r=–.12, p<.05), having dental insurance (r= –.17, p<.01), and having avoided dental care due to cost (r=–.13, p<.05).
In addition to the variables mentioned above, dental attendance was positively correlated with the previous dental visit being for a cleaning or checkup (r=.17, p<.01). Attendance was negatively correlated with dental fear (r=–.26, p<.001), feeling nervous or scared in the dental environment (r=–.14, p<.05), and the previous dental visit being for the treatment of pain (r=–.23, p<.000), injury (r=–.17, p<.01), or for the fitting or checking of dentures (r=–.22, p<.001).
Regression Analyses
To predict three of the primary variables of interest (self-rated dental health, dental attendance, and dental fear), stepwise regression analyses were performed involving the previously established correlates of each variable. In predicting self-rated dental health, county/location was entered in the first step to account for variance contributed by between-group differences, as previously described. In the second step, all previously identified correlates of self-rated dental health (see Table 2) were entered into a stepwise regression model to establish the model of best fit. Finally, all remaining variables were entered to account for any remaining variance. After accounting for differences among the locations, the resulting model (Table 3) included dental attendance, having avoided dental care due to cost, importance of dental care, the previous dental visit being for a cleaning or checkup, and feeling nervous or scared in the dental environment. This model accounted for 32 percent of the variance in self-reported dental health.
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) were entered into a stepwise regression model to establish the model of best fit. Finally, all remaining variables were entered to account for any remaining variance. After accounting for differences among the locations, the resulting model (Table 3) included self-rated dental health, importance of dental care, the previous dental visit being for the fitting or checking of dentures, the previous dental visit being for a cleaning or checkup, dental fear, and having a negative prior dental experience. This model accounted for 42 percent of the variance in dental attendance.
In predicting dental fear, county/location was not entered into the model, as there were no previously identified group differences in dental fear. The first step, therefore, involved entering all previously identified correlates of dental fear (see Table 2) into a stepwise regression model to establish the model of best fit. All remaining variables were then entered in a stepwise manner in a second step of account for any remaining variance. The resulting model (Table 3) included feeling nervous or scared in the dental environment, a specific fear of pain, a specific fear of injections, dental attendance, a specific fear of drilling, having had a negative prior dental experience, and having avoided dental care due to cost. This model accounted for 52 percent of the variance in dental fear.
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Discussion |
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Results from the present study suggest also strong relationships among the three primary variables of interest. Even when controlling for the type of location (rural vs. urban), these relationships remain consistent. While dental attendance, dental fear, and oral health are not well studied in Appalachian populations, the current findings are consistent with those found elsewhere in behavioral dentistry literature. For example, prior research has examined dental fear across rural and urban locations and found no consistent differences by location.8 A study of adult dental patients in the United Kingdom found "casual attenders" had poorer oral health and were more fearful of receiving dental care than were "regular attenders."16 In a similar Norwegian study of military recruits, the authors identified patients characterized by "general negative oral health/preventive oral health related behaviour," including irregular attendance, high dental fear, and poorer oral health.17 In Sweden, highly phobic patients who sought regular dental care despite their fears had fewer missing teeth and less negative impact of their dental conditions on daily functioning than did phobic patients who sought treatment only when necessary.18
In our study, some important differences among patients in the three study sites did emerge with regard to the three primary variables of interest, although these variables were strongly interrelated. Participants in urban Fayette County reported more frequent attendance, thought receiving dental care was more important, and were more likely to have sought treatment most recently for scheduled restorative treatment than either of the rural counties. In addition, they were less likely to have seen a dentist most recently for emergency treatment and to have avoided dental care previously due to cost than their rural counterparts. Finally, while the Fayette County participants were more afraid of pain during dental treatment than those in Menifee County, this fear was not as great as that reported in Jackson County. In general, those participants receiving dental care in a university-based residency practice appeared to be more proactive about their dental care and have a more positive opinion of dentistry than did those in more rural areas.
Participants in Fayette County, which is among the top 15 percent of Kentucky counties in median household incomes,12 were more likely to have dental insurance than other respondents. In an area where dental insurance is much more common, more frequent dental attendance is not surprising. In an analysis of national 1994 data by Mueller et al.6 relating to unmet dental needs, those without insurance had significantly more unmet dental needs than insured participants. The primary obstacles in receiving dental care named in that study included cost, difficulty scheduling appointments, and lack of insurance. Interestingly, there were no significant differences in that study between metropolitan (urban) and non-metropolitan (rural) areas in unmet dental needs, despite those in urban areas having insurance more often than those in rural areas.6
While respondents sampled from the general population in rural Menifee County reported avoiding dental treatment due to cost more often than those in Fayette County, they were not as concerned about the cost of dental care as subjects in rural Jackson County. The Menifee participants reported better dental health and had avoided treatment less often due to being "scared" or having a negative prior experience as compared with dental patients in Fayette or Jackson counties. Interestingly, while the Menifee participants reported better dental health than the other participants and had avoided dental care more often due to a perception of "no need" for dental treatment, they also reported that their most recent dental treatment involved the receipt or adjustment of dentures than did other respondents. Overall, the attitudes about dental care expressed by subjects recruited from the general population in Menifee County may be defined as "benign neglect," in that dentistry is perceived to be a useful service when necessary but is not a crucial part of overall health.
Although Menifee and Jackson counties are comparable in terms of ethnic diversity, educational levels, income, and access to medical services, differences emerged on variables between these two locations and between Jackson and Fayette counties. Patients surveyed in Jackson County were younger, received more emergency care, sought less preventative care, were more afraid of intraoral injections, and had avoided dental care in the past more often due to cost than respondents in either Fayette County or Menifee County. These participants also had lower self-rated dental health, thought dental care was the least important, sought dental treatment less often, and were more likely to have sought treatment for pain most recently than other participants, although not at a statistically significant level. In general, these participants seemed to seek treatment only when necessary and had a more negative view of dental care than other respondents. The role of dental clinics in rural areas such as Jackson County may be both treatment- and education-oriented, as practitioners attempt to both maintain their patients’ oral health as well as educate them regarding the importance of good oral health.
Individuals in these three counties were surveyed between 1999 and 2003, and thus it may be argued that differences found among these locations may be attributed to factors related to time, rather than geography. Factors such as dental fear, however, have been found to be very consistent over both location and time. A literature review of self-reported dental fear spanning more than thirty years found very little change in dental fear in both college student and general population samples across time and location.8 The results from the current data show consistency from site to site across such variables as dental fear, dental attendance, and perceived importance of dental care, particularly between the two rural locations. It is believed that while differences between sites may be attributed in part to time factors, variations across locations were produced primarily by geographic location and the demographic factors associated with these locations.
One similarity between the rural (Jackson) and urban (Fayette) dental clinics was the presence of a General Practice Residency (GPR) program, with each clinic employing at least one postdoctoral GP resident. As one primary goal of a GPR program is to provide postdoctoral training opportunities, clinics served by GP residents are often able to provide dental care to those individuals with fewer economical resources. According to 2000 census data, Jackson County fell in the bottom 10th percentile for estimated median incomes in Kentucky, accentuating disparities in terms of access to health care.9 Possibly the most important of these resources is education about the importance of regular dental care. According to a 1999 survey done by the Centers for Disease Control and Prevention, Kentucky had the highest overall level of edentulism in the United States,3 and this complete tooth loss is often compounded by a lack of dental insurance and lower education levels. Dental residents at these sites are able to provide their patients with education on the importance of dental care and the role of oral hygiene in overall health in preventing systemic diseases.19–20
Dental practitioners across locations must be willing to not only provide dental care to patients, but also educate their patients regarding the importance of regular dental care and good oral hygiene. This is particularly important in more rural areas, where emphasis may not regularly be placed on maintaining good oral health. As part of a postdoctoral GPR training curriculum in rural areas, for example, residents may be encouraged to spend additional time with patients, discussing factors such as perceived barriers to care, dental fear, and attitudes toward dental care. While discussion of these factors is important within any dental practice, the results of the current study suggest that it is crucial that these factors are addressed with patients in rural areas.
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Footnotes |
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REFERENCES |
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This article has been cited by other articles:
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  C. A. Martin, D. W. McNeil, R. J. Crout, P. W. Ngan, R. J. Weyant, H. R. Heady, and M. L. Marazita Oral Health Disparities in Appalachia: Orthodontic Treatment Need and Demand J Am Dent Assoc, May 1, 2008; 139(5): 598 - 604. [Abstract] [Full Text] [PDF]
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