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Abstract
The purpose of this study was to evaluate the knowledge, comfort, practice behaviors, and perceived barriers of dental hygienists in North Carolina regarding their delivery of oral health preventive services to infants and toddlers. A questionnaire was mailed to 2,000 dental hygienists randomly selected from the North Carolina Board of Dental Examiners database. The response rate was 43 percent. The majority of the respondents were female and worked in private practice. Forty-two percent reported that they delivered preventive care to infants/toddlers (action stage of readiness). Of the 58 percent who reported not delivering care, two-thirds were contemplating caring for this population (contemplation stage), but only 10 percent of these were very likely to make changes in the next six months. Those with higher comfort levels and fewer perceived practice constraints were more likely to be in the action stage. Although these dental hygienists may be willing to consider providing care, they perceived a lack of continuing education opportunities, unfamiliarity with pediatric guidelines, and their current practice situation as significant barriers. Strategies to increase comfort and diminish practice constraints for North Carolina dental hygienists should be considered to improve access to oral health care for infants and toddlers. Teaching strategies in dental hygiene education that include both didactic and clinical experiences in treating infants and toddlers could be beneficial.
- infants and toddlers
- dental hygienists
- dental hygiene education
- preventive care
- stage of readiness
- access to care
- barriers to care
The Commission on Dental Accreditation (CODA) standards for the accreditation of dental hygiene education programs require that students be competent in providing care through the entire life span, including the child, adolescent, adult, and geriatric patient.1 There exist, however, significant gaps in our current oral health care system regarding the care of those at highest risk, including young children. Despite early childhood caries (ECC) being the most common chronic disease in children, a limited dental workforce exists to care for this cohort of the population.2,3 Workforce inadequacies are likely to worsen with the Affordable Care Act mandating delivery of preventive oral health services to all children.4 Since general dentists and the entire dental team provide the greatest safety net for young children, dental educators must ask themselves what role they should play in creating a dental workforce that is comfortable and competent in following the guideline that each child should have established a dental home by the age of one year.
The role of dental hygienists in general dental practices presents an opportunity to assist in the delivery of preventive oral health services in early childhood. The profession of dental hygiene is one of the fastest growing occupations in the United States, so these oral health professionals’ potential role should not be overlooked.5–7 In a study of dental hygienists in Maryland, however, a substantial proportion of respondents reported lacking knowledge about ECC as an infectious and transmissible disease and having a very low concern about the importance of nutritional counseling.8
Since changing knowledge alone is insufficient to obtain desired behaviors, attention should be paid to behavior change as gradual and transitioning through stages of readiness.9 The transtheoretical model of change focuses on the individual’s decision making in the context of social, cognitive, educational, cultural, and peer-related influences on behavior. This model thus provides a framework for exploring dental hygienists’ stage of readiness and factors that may influence each stage. While most work using this model has focused on patient behavior changes,10,11 using these stages can help shape educational, motivational, and behavior-changing interventions to encourage dental hygiene students and dental hygienists already in the workforce to engage in the care of young children. For the latter, evidence suggests that professional training is a time when students cement their clinical skill set and, subsequently, are more likely to perform the skills after graduating and entering clinical practice.12
Thus, the aim of this study was to evaluate the effects that knowledge, comfort, and practice behaviors have on the stage of readiness of dental hygienists in North Carolina with respect to providing oral health care for infants and toddlers. We also sought to define these dental hygienists’ perceived barriers to providing such care. Stage of readiness was examined as a way to inform the educational process and determine how best to prepare the current practice workforce and the next generation of dental hygienists to provide oral health care for young children.
Methods
Using a cross-sectional survey design, we designed the study to assess oral health practices, knowledge, comfort, stage of readiness, and barriers of dental hygienists in North Carolina to provide preventive care to infants and toddlers. We obtained a list of licensed registered dental hygienists from the North Carolina Board of Dental Examiners; this sampling frame had 3,468 potentially eligible participants. A simple random sample of 2,000 dental hygienists was selected. Even assuming a very low response rate of 20 percent, 400 returned surveys would provide an adequate sample size to detect a medium effect with 80 percent power and alpha at 0.05.13
The survey items, developed originally for a survey of North Carolina general dentists,14 were modified to appropriately address dental hygiene practice, and a section was added to address barriers that would hinder these practitioners’ willingness to provide care. The survey had a total of sixty-one questions in eleven sections corresponding to the following primary domains: behaviors, value of infant oral health, comfort/confidence, knowledge, barriers, infant oral health guideline15 awareness, continuing education (CE), educational background, practice setting, demographics, and stage of readiness. The survey took approximately ten minutes to complete.
For stage of readiness, we simplified the five-stage model of pre-contemplation, contemplation, preparation, action, and maintenance9 to three stages: action/maintenance, contemplation/preparation, and pre-contemplation.16–18 Stage of readiness was measured with responses to two questions. The first was “Do you care for infants and toddlers in your practice?” A positive response indicated active stage of readiness. If the respondent answered no, a second question was asked to further distinguish stage of readiness. The second question asked: “How ready are you to implement a preventive infants and toddlers oral health program in your practice?” Possible responses ranged from one to ten, with 1 indicating “very ready” and 10 “not ready” to change. Responses from 7 to 10 on the scale were considered to be in pre-contemplation and 1 to 6 in the contemplation/ preparation stage. This categorization was based on the median (rounded up) of the scale, not from the distribution of responses. The survey was pilot tested by five dental hygienists and was reviewed by the research committee members to ensure feasibility and content validity.
Following approval by the Biomedical Institutional Review Board of the University of North Carolina at Chapel Hill, we mailed the survey in spring 2011. The survey was created using Teleform, allowing direct scanning with verification of returned surveys and entry of responses into an ACCESS database. Participants were asked to complete the survey and return it in a provided stamped envelope. Using the Salant and Dillman method,19 we sent a postcard reminder to all participants one week after the initial mailing. Three weeks later, we sent a letter and replacement questionnaire to nonrespondents; and seven weeks after the first mailing, a final letter and questionnaire were sent to the remaining non-respondents. A unique identification number was assigned to each survey. Only the research assistant had access to the linkage file connecting the survey identification number with the personal identifiers used to contact potential respondents. All data were stored in a password-protected database that was accessible only to the research team.
Dental hygienists who graduated between 1998 and 2010 and practiced at least part-time (>20 hours per week) in a private or public practice in North Carolina were included in the analyzed sample. Retired dental hygienists, those practicing outside the state or abroad, and those in specialty practices were excluded.
The outcome variable was dental hygienists’ stage of readiness (pre-contemplation, contemplation/preparation, action/maintenance) for delivering preventive services to infants and toddlers in their practices. Explanatory variables were classified as primary or secondary. The primary explanatory variables were comfort, knowledge, educational barrier, and practice constraint barrier. Comfort and knowledge were assessed using a five-point rating scale of eight and six items, respectively. The original responses to the comfort items (1=very comfortable) were reverse keyed so that a 1 represented “very uncomfortable” and 5 represented “very comfortable.” For knowledge, 1 represented “strongly disagree,” and 5 represented “strongly agree.” Four of the original knowledge items were negatively worded. The responses to these items were reverse keyed. Reverse keying was performed before computing the respondents’ total scores and before conducting the statistical analyses. The purpose of the reverse keying was so that high scores for comfort and knowledge reflected relatively high levels of the attribute being measured. Average scores were calculated for each respondent for the eight comfort items and the six knowledge items assuming an underlying continuity of the averaged responses. Higher scores indicated greater comfort and greater knowledge.
Cabana et al.’s framework to evaluate physicians’ adherence to practice guidelines was used to develop the barrier items.20 Based on factor analysis, barrier items were grouped into two categories: education and practice behaviors. Items were assessed using a five-point Likert scale of four and three items, respectively. For each item, 1 represented “strongly disagree (item is a barrier)” and 5 represented “strongly agree (item is a barrier).” Average scores for each barrier category were calculated for each respondent. Higher scores indicated that the category was perceived as a strong barrier.
The secondary explanatory variables were categorized age (<30, 30 to 40, >40) and hours in practice per week (<21, 21–29, >29), years since graduation, percentage of patients insured by Medicaid, utilization of continuing education, familiarity with American Academy of Pediatric Dentistry (AAPD) guidelines, and categorized metropolitan area. All geographic data were linked based on zip code information to determine metropolitan versus non-metropolitan practice location (Table 1). Value of providing care is reported as a descriptive statistic only because of the correlation with stage of readiness.
Bivariate analysis of dental hygienists’ responses with stage of readiness, by number and percentage of respondents in each category and total respondents
Univariate, bivariate, and generalized logits models were performed using SAS 9.1 (SAS Institute, Inc., Cary, NC, USA) with level of significance set at p<0.05. For the bivariate analysis, the chi-square test was used for nominal variables and one-way ANOVA for continuous variables. To assess the effect of demographic, practice, and provider characteristics on stage of readiness (pre-contemplation, contemplation, action), a generalized logits approach using a generalized logits model with main effects was used. In the first model, the primary explanatory variables were forced to be included in the model, and a forward selection process was used to test whether any of the secondary explanatory variables added significantly to the explanation of the outcome. None of the secondary explanatory variables were statistically significant and were removed from the model. A backward selection was then used on the primary explanatory variables in the reduced model to produce a final model.
Results
The survey response rate was 43 percent (n=859). One hundred and one respondents did not meet the eligibility criteria and were excluded from the analysis, leaving a sample of 38 percent (n=758). The majority of the respondents were female (99 percent) and working in private practice (94 percent). Seventy-four percent held a certificate or associate dental hygiene degree, and 63 percent reported providing patient care more than thirty hours per week.
Delivery of Care
Forty-two percent (n=316) of the respondents reported providing preventive care to infants and toddlers (active stage). Thirty-nine percent (n=297) did not currently deliver these services but were willing to do so (contemplation/preparation), and 19 percent (n=145) were neither delivering these services nor considering doing so at this time (pre-contemplation) (Figure 1). Of the contemplation/preparation group, 10 percent (n=31) reported being very likely to begin providing care to children less than three years old in the next six months.
Survey response and dental hygienist stage of readiness
The average number of years since graduation and the average percentage of patients in the practice covered by Medicaid were significantly different among the three stages of readiness groups (Table 1, p=0.01) as was the distribution of age categories, particularly the proportion of younger respondents. Younger dental hygienists were more likely to be in the active stage when compared with the older dental hygienists (p≤0.01). This was also reflected in the average number of years since graduation, with more recent graduates (median eight years) more likely to be in the active stage. Dental hygienists in practices that had the lowest average percentage of Medicaid patients were more likely to be in the pre-contemplation stage (Table 1).
While only 4 percent of the respondents reported caring for children up to two years of age “often,” 44 percent and 80 percent chose “often” when asked about providing care to three to six year-olds and six to twelve year-olds, respectively (Figure 2). Only 13 percent reported that their practice accepted children six to eighteen months of age for the first dental visit, 19 percent reported accepting children for the first dental visit beginning at twenty-four months and 68 percent at three years (Figure 3). When asked how often preventive oral health guidelines in general were discussed with caregivers related to caries prevention or caregivers were counseled about a child’s oral development, 83 percent and 66 percent reported “often,” respectively.
Practice behaviors reported by North Caroline dental hygienists in relation to infants and toddlers
Age that North Carolina dental practices accept children for first dental visit, as reported by dental hygienists in study
Value, Knowledge, and Barriers
Three-fourths of the respondents rated the value of preventive care of infants and toddlers as high (>7 on a ten-point scale), and the vast majority were confident in their ability to discuss proper feeding practices for infants/toddlers (82 percent) and provide proper preventive care (62 percent). However, only 41 percent felt comfortable dealing with a crying infant. The proportion of respondents in the active stage who rated the value of preventive care as high was considerably higher than those in the contemplation and pre-contemplation stages. Similarly, the distribution of comfort and confidence scores was shifted toward the “more comfortable” and “more confident” in the active stage respondents.
The overall sum score for knowledge about infant and toddler preventive care was shifted toward the higher range in the active group, indicating generally greater knowledge about preventive care in that group. A higher proportion of active stage dental hygienists reported having taken CE courses related to oral health care for infants and toddlers. While 76 percent of the respondents answered the nutritional questions correctly and 63 percent correctly answered questions about the infectious nature of ECC and fluoride protocols, only 14 percent answered the items about preventive care guidelines correctly (Figure 4). The proportion of respondents who were aware of the AAPD infant oral health guidelines was significantly higher in the active stages, but 38 percent of those in the active stage were not familiar with the guidelines and 29 percent were “unsure.”
Level of agreement (knowledge) of North Carolina dental hygienists regarding infants’ and toddlers’ oral health (T=true, F=false)
One-half of the respondents (50 percent) agreed that practice constraints were a barrier. Fewer agreed that lack of awareness about guidelines (37 percent), lack of education on infants and toddlers care (26 percent), and lack of CE opportunities (20 percent) were barriers for their provision of preventive oral health care to infants and toddlers. Significantly fewer dental hygienists in the active stage agreed that either lack of education or practice constraints were barriers to providing care as indicated by the lower overall sum barrier scores for these categories.
Regression Analysis
The results from the adjusted forward and backward selection models and the unadjusted proportional odds model are shown in Tables 2 and 3. In the multivariable model, none of the provider characteristics (age, years since graduation, hours per week in practice, utilization of CE, familiarity with AAPD guidelines) nor the practice characteristics (percent of patients with Medicaid, metropolitan area) added significantly to explanation of the stage of readiness beyond the variables (comfort, knowledge, educational barrier, and practice constraint barrier) that were theoretically related to the stage of readiness (Figure 5). In the final model, only comfort level and practice constraint barriers were statistically significant after the backward selection process. For every unit increase in comfort (i.e., as individuals became more comfortable treating infants/toddlers), the respondents were 2.70 times more likely to be in the action stage than in the pre-contemplation stage (p<0.0001) and 2.99 times more likely to be in the contemplation/preparation stage than in the pre-contemplation stage (p<0.0001). Respondents who perceived practice constraints to be less of a barrier to the provision of care to infants/toddlers were more likely to be in the action stage or in the contemplation stage than in the pre-contemplation stage.
Effects of primary and secondary variables in the outcome stage of readiness to provide preventive care to infants and toddlers
Note: Study found that comfort and practice barriers had significant effects on dental hygienists’ stage of readiness.
Generalized logits model results by forward and backward selections
Odds ratios for stage of readiness
Discussion
This study aimed to examine the role dental hygienists can have in the care of young children’s oral health by assessing their knowledge, comfort, values, practice behaviors, stage of readiness, and barriers encountered in delivering preventive oral care to this cohort of the population. Our findings indicated that while the dental hygienists valued infant and toddler oral health, they lacked knowledge in this area. Furthermore, these dental hygienists’ readiness to care for infants and toddlers was related to their comfort in providing care and inversely related to practice constraints, suggesting that they have significant barriers to overcome to successfully embrace their involvement in the care of young children’s oral health.
Manski and Parker’s findings in a study of dental hygienists in Maryland indicated a lack of knowledge of infants’ and toddlers’ oral health that is consistent with our study.8 Both the Maryland study and ours were framed to assess the knowledge about preventive care for this cohort, including awareness about pediatric dental practice guidelines. The North Carolina dental hygienists reported being comfortable in providing preventive oral care; however, their responses suggested that the majority lacked familiarity and awareness of pediatric dental practice guidelines for infants and toddlers. Manski and Parker’s study reported underutilization of fluoride varnish for children; similarly, we found that knowledge about fluoride protocols for infants was surprisingly low.
Our study also provides important information about the readiness of dental hygienists to provide preventive care in early childhood and the factors influencing their willingness. MacFarland et al. found that, for every unit increase in comfort, general dentists were 3.12 times more likely to be in the active/maintenance stage of readiness than in the contemplation/preparation stage and 5.55 times more likely to be in the action/maintenance stage than in the pre-contemplation stage.14 Our findings similarly indicated that higher levels of comfort were reported by individuals in the action/maintenance stage rather than in the pre-contemplation stage. At an educational and practice level, the question remains about how best to promote comfort and self-efficacy in the knowledge and skill set necessary to perform infant oral health education, examination, and fluoride varnish application for the entire dental team.
In the educational arena, Fein et al.21 found an increase in comfort and confidence among senior dental students when exposed to a clinical rotation and an infant and toddler oral health tool kit (Baby Oral Health Program Kit). When asked whether these students would engage in the provision of preventive oral health services in early childhood, 80 percent responded positively to future motivation to care for this cohort of the population. It is important to mention that cultural proficiency also played a significant role in the comfort of those students who spoke their patient’s first language. A similar study assessed the impact of a different infant oral health program affiliated with a local community health center.22 Those authors found that graduates of the program who had this experience were more likely to recommend care of children before their second birthday and reported greater willingness to care for young children in their practices. To date, no studies exist that include dental hygiene students and assess the impact of this training as part of these early childhood oral health programs.
At a practice level, some work exists to help improve adoption of new skills in clinical practice. Weinstein23 in his work on challenges in utilizing new technology for caries control discusses patients and provider stage of readiness and motivation as key to promoting behavior change. Casebeer et al.24 reported that tailored Internet education based on data collected from physicians’ own offices and the assessment of their individual needs were related to changes in practice behaviors; this is a strategy to consider in the context of stage of readiness to promote provider change to care for children’s oral health. Having a better understanding of factors that affect providers’ comfort and the barriers that hinder their confidence may further assist in strategy development to move providers along the stages of readiness for change.
Similarly, in our study, the dental hygienists’ perception of current practice constraints was significantly associated with their stage of readiness. Therefore, motivating general dentists to embrace infant and toddler oral health in their practice will be critical to promoting the involvement of allied dental professionals to improve access. Since motivating providers in the care of young children can be complex, strategies need to be broad and system-based. Simpson suggested the importance of sustainable initiatives by using a comprehensive approach.25 While focused and individualized strategies that target office-practice behaviors and providers’ motivation to offer care as a way to benefit their practice and the community are key, systems that help support these initiatives merit further attention. Among them are broader policy agendas, particularly improvement in reimbursement, to ensure adequate care for all children at risk.
To further emphasize this broader approach, collaboration across and within disciplines should be encouraged, particularly during dental education. Wilder et al., among others, have argued for greater incorporation of inter- and intraprofessional education into dental curricula.26 One way of expanding intraprofessional education would be for dental schools to increase dental hygiene and dental student interaction in training for delivering preventive oral health care for infants and toddlers. Such joint education would help both types of oral health professionals raise their comfort level in working together to improve the oral health of these young patients.
Accreditation standards for dental and dental hygiene education do not specifically address care for infants and toddlers. We see this as a missed opportunity in dental education to promote oral health messages that can influence behaviors across one’s professional life.27 The predoctoral dental accreditation standards28 require graduates to be competent in delivering oral health care for the child, adolescent, adult, and geriatric patient as established by the school within the confines of general dentistry. Although they require graduates to be proficient in patient assessment and diagnosis, comprehensive treatment planning, health promotion, and disease prevention, the standards are not sufficiently specific in relation to infants and toddlers. While dental hygiene accreditation standards1 are more specific with respect to competence in the comprehensive collection of patient data and proficiency in delivery of patient-centered treatment, these standards also lack focus on the child as a patient and do not define the specific competencies a graduate must have to care for this cohort.
Among the goals of dental and dental hygiene curricula should be efforts and strategies to increase the comfort of all dental providers in providing care to the early childhood age group. This could be accomplished by exposing students to more hands-on experiences with infants and toddlers as a vehicle to help change the stage of readiness to provide care for this group of patients. Consideration should be given to evidence indicating that distributed practice (multiple experiences) over massed practice (one-time skill experience) has greater effectiveness in skill acquisition.29 The North Carolina and Iowa infant oral health programs are examples of educational models that provide multiple dental student experiences and could be expanded to include dental hygienists as a comprehensive part of the dental team. Implementing these models would require adjustments to the curricular hours spent in this area, which are currently lacking in dental programs, with an average of two hours and twenty minutes reported for early childhood oral health in U.S. dental schools.30
The strengths of this study are the large sample size and the use of a unique framework as the foundation to assess barriers to provide care. However, our findings should be considered in the context of the study’s limitations. First are the possible response bias, poor memory, and/or content misunderstanding inherent in any survey study design. Second, the sample is restricted to dental hygienists in one state, thus limiting the generalizability of these findings.
This study does highlight important factors that directly affect the process of change in behaviors of providers to care for populations in need. It is of high importance to create curricula that engage and promote the delivery of preventive oral health services to all children, but particularly those at highest risk. General dentists and dental hygienists will continue to be important adjuncts to pediatric dentists in providing primary and secondary prevention to infants and toddlers in clinical practice; therefore, optimizing their involvement is critical to accomplishing the oral health goals for children.
Conclusion
This study found that the dental hygienists surveyed highly value preventive care for infants and toddlers. However, strategies to increase comfort and diminish practice constraints should be considered to improve dental hygienists’ stage of readiness to care for this population. Such strategies should begin in education with clinical training for the entire dental team. Both didactic and clinical experiences in academic programs will be key to helping oral health care providers feel comfortable in providing these services to infants and toddlers.
Acknowledgments
This study was supported by an unrestricted grant from the Colgate-Palmolive Company.
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