A D D R E S S I N G T H E O R A L H E A LT H C A R E O F S P E C I A L N E E D S C H I L D R E N
ARTICLE ABSTRACT Objectives: To examine the oral health knowledge and practices of pediatric nurses who coordinate healthcare services for special needs children and to identify those factors that influenced their perceived effectiveness in managing their patients’ oral health needs. Methods: Self-reported data were collected from 376 nurses employed at Children’s Medical Services who responded to an online survey. Likert scale scores were used to specifically assess the nurses’ perceived effectiveness in addressing the oral health needs of special needs children. Results: Characteristics significantly associated with special needs pediatric nurses who described themselves as “effective or very effective” included: the self-perception of being very knowledgeable about basic oral health, receiving four or more hours of continuing education training, and securing dental appointments for the majority of their pediatric special needs patients with minimal waiting times. Conclusion: Findings reveal that oral health knowledge significantly influenced nurses’ perceived effectiveness in addressing the oral health needs of special needs children, as well as their ability to secure timely dental appointments. These results support the need to incorporate oral health education into nursing curricula and expand upon the dental workforce available and willing to treat disabled patients.
KEY WORDS: oral health, children, special needs, medical staff
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Addressing the oral healthcare needs of special needs children: pediatric nurses’ self-perceived effectiveness Carrigan L. Parish, DMD;1* Richard Singer, DMD, MS;2 Stephen Abel, DMD;3 Lisa R. Metsch, PhD4 1
Senior Project Director, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY; 2Doctoral Graduate Student, University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, Miami, FL; Assistant Professor, Nova Southeastern College of Dental Medicine, Department of Orthodontics, Fort Lauderdale, FL; 3 Associate Dean for Community and Professional Initiatives, University at Buffalo School of Dental Medicine, Buffalo, NY; 4Chair Sociomedical Sciences, Stephen Smith Professor of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, Volunteer Faculty, University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, Miami, FL. *Corresponding author e-mail: [email protected], [email protected] Spec Care Dentist 34(2): 88-95, 2014
Int r od uct ion
Dental disease in America has been called the “silent epidemic” by the Surgeon General’s Report-2000.1 In 2008, the Centers for Medicaid and Medicare conducted dental reviews of 16 states having low dental utilization rates and found that the primary barriers to dental care contributing to this “epidemic” were: limited dental provider availability, low reimbursement rates, administrative obstacles for dental providers, lack of understanding about dental benefits for beneficiaries, missed dental appointments, transportation, cultural competency, and need for education about the importance of dental health.2 Not surprisingly, the most vulnerable and underserved populations continue to encounter significant oral health problems despite numerous federal strategies that have been implemented to address various aspects of oral health care delivery.2 Persons with disabilities represent a particularly disadvantaged group with regard to the receipt of dental care. A qualitative study conducted in Massachusetts with disabled individuals and their healthcare proxies reported that individuals with disabilities experienced wait times for dental appointments ranging between 3 months to over 1 year.3 In comparison, a nationwide survey of all pediatric dental program directors in the U.S. reported that the average waiting time to secure a dental appointment ranged from 28 to 71 days.4 The cost of care as a barrier to dental treatment was
the focus of a recent study that found that individuals with disabilities in Florida were almost twice as likely to report a lack of dental care due to cost considerations, compared to their nondisabled counterparts (p < .001).5 More over, one survey of 37 residential facilities housing special needs individuals throughout Florida found that less than one-third of their residents had received comprehensive dental services, and the remainder received very limited services or emergency treatment only. This study further highlighted that 40% of the caregivers surveyed on behalf of their 362 residents
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12035
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could not identify dentists willing to treat their special needs residents, including the 75% of residents deemed “cooperative.”6 According to the US Department of Health and Human Services in 2005– 2006,7 approximately 14% of U.S. children under 18 years old had existing special health care needs, while 21.8% of US households occupied by children had at least one child with special needs.7 Among all children with special health care needs, preventive dental health care ranked highest as the service that was most needed but not received.7 “Access to care” disparities also exist between insured versus uninsured children. One study by Newacheck et al.8 found that uninsured children were almost five times more likely to be unsuccessful at securing needed dental treatment compared to insured children. It has been suggested that one of the key components to a successful community-based health program lies in the ability of general health practitioners, who serve as medical gatekeepers for disabled individuals, to recognize and identify needed dental care services.9 Children with special healthcare needs are frequently seen by physicians and nurses, but not generally by dentists.9,10 The available literature shows that nurses have limited knowledge of oral health problems due to limited or nonexistent training in oral health assessments and dental care protocols.11-19 This problem extends beyond the United States; deficiencies in oral health knowledge, protocols, assessments, and formal trainings within the nursing community have been reported in studies conducted in Hong Kong, Sweden, and South Africa.20-22 An Israeli study of nurses treating pediatric patients with cerebral palsy found a lack of knowledge about basic dental principles, including the prevention of dental caries and the prevalence of periodontal disease in this patient population.23 Similarly, one local study assessing nurses’ dental knowledge based on a questionnaire distributed to hospital nurses demonstrated a lack of knowledge regarding dental caries, gingivitis, and the dental complications i Survey
associated with systemic disease and medications.24 This author emphasized the importance of educating nurses about the rationale behind certain oral health practices and procedures, reasoning “it is unrealistic to expect nurses to undertake oral care mechanistically without understanding its importance.”24 However, little is known about the oral health knowledge, attitudes, and practices of nurses working with families of children with special health care needs. For oral health education to be effective, it should in theory be designed with an understanding of nurses’ characteristics, beliefs, attitudes, values, skills, and past behaviors.25 Within this context, this study reports findings from a statewide survey that examined the involvement of nurses in addressing the oral health care of special needs children and their families. The nurses surveyed have direct contact with special needs children and are responsible for managing their overall health care; therefore, they have the potential to greatly help promote oral health and disease prevention and prioritize referrals to those children with greatest need. Thus, the purpose of this study was to identify the oral health knowledge, attitudes, and practices of nurses and identify the barriers that limit their effectiveness in managing special needs children’s oral health issues.
satellite clinics.26 The agency functions through 22 area offices statewide and employs more than 500 nurses in the capacity of either care coordinators or nursing supervisors. CMS care coordinators arrange health care services for special needs children and assist families in accessing multidisciplinary primary care services in “medical home” settings, while CMS nursing supervisors oversee groups of care coordinators and assist them with their client case loads. Individuals were eligible for this study if they were employed as either a care coordinator or a nursing supervisor at CMS during the study period, were at least 18 years old, and understood written English. The survey was conducted from December, 2010 to February, 2011. CMS provided the e-mail addresses for all 516 CMS care coordinators and nursing supervisors with authorization from the CMS Deputy Secretary. The CMS Social Services Consultant contacted all of the potential participants prior to the release of the e-mail to inform them of the upcoming survey. Using a modified version of Dillman’s total design method27 for survey distribution, reminder e-mails were sent biweekly to nonresponders. E-mail addresses were recorded for distribution, tracking and reminder purposes and were not linked to the corresponding survey responses. Participants were not compensated for their participation.
M e th od s
Measures
Participants The current study utilized self-reported data collected in an online survey of pediatric care coordinators and nursing supervisors employed by Children’s Medical Services (CMS) throughout the state of Florida, USA. CMS is the primary Florida state agency responsible for the case management and coordination of primary, specialized, and ancillary healthcare services for children with special health care needs at facilities including CMS clinics, designated hospitals, convalescent facilities, private healthcare offices, specialized treatment centers, and regional and
The 46-item survey was developed and distributed electronically using the webbased program Survey Monkey.i The survey assessed CMS nurses’ demographic, educational, and practice characteristics, including the following: prior attendance at formal training sessions about oral health, sources of oral health information, perceived oral health knowledge, perceptions of barriers to optimal dental care, perceptions of the general priority placed on oral health, involvement with oral health, and availability of dental care to CMS children. The survey instrument was developed around a conceptual framework to model
Monkey is a software program with guided tools for creating, administering, and analyzing web-based surveys through a secure, encrypted Internet connection.
Parish et al.
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the outcome of interest, namely, barriers to nurses’ perceived effectiveness in addressing their CMS clients’ oral health. A barrier was defined as any factor that limits or restricts nurses’ perceived effectiveness, including knowledge, attitudes, and external factors that may preclude access to care.28 Self-efficacy was defined as the confidence and conviction that nurses feel in managing CMS children’s oral health needs.29 Self-efficacy has been proposed as the most important prerequisite for behavior change through its influence on the amount of effort invested in a given task and the level of performance attained.30-32 In this conceptual framework, knowledge and beliefs impact behavior-specific self-efficacy; enhanced knowledge and beliefs then result in increased understanding of a specific condition (in this case, oral health). Additional understanding leads to increased behavior-specific self-efficacy and outcome expectancy, i.e., improvements in oral health-involved nursing practices and improved access to oral healthcare for special needs children.30,31,33 Therefore, knowledge and attitudes were postulated as contributors to perceived effectiveness and included in the model. External barriers, such as lack of resources, were also included because the ability of nurses to manage their CMS children’s oral health care effectively may reasonably be influenced by such external “environmental” factors.28 To specifically assess the dependent variable, perceived effectiveness, respondents were asked: “Please rate how effective you feel you are in addressing your CMS children’s dental care.” The responses were scored on a Likert34 scale that ranged from 1 (not effective) to 5 (very effective). The responses were further dichotomized to “effective or very effective” (ratings of 4 or 5, respectively) and “less than effective” (ratings of 1–3) for the purpose of analysis.
Statistical analysis SPSS Statistics version 20 (IBM) was used to conduct the data analysis. The outcome of interest was nurses’ self-perceived effectiveness in addressing their CMS children’s oral health needs. Each
90 S p e c C a r e D e n t i s t 3 4 ( 2 ) 2 0 1 4
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demographic characteristic of the CMS care coordinators and nursing supervisors was summarized using univariate analysis (Table 1). Bivariate analysis was then performed using Pearson’s chisquared tests to assess the association between each independent variable and the dependent variable, self-reported effectiveness in addressing CMS children’s oral health needs. Independent variables with a bivariate p-value ≤ .20 were then included in the multiple regression analysis of the dependent variable following the method of Homer and Lemeshow35 (Table 2).
R es ul t s
The current analysis is based upon 376 survey respondents, corresponding to a 73% participation rate. A total of 22 subjects (4%) elected not to participate after reading the cover letter, and an additional 118 subjects (23%) did not provide any response to the survey invitation for reasons unknown. Table 1 describes the univariate individual demographic characteristics of respondents and bivariate associations with self-reported effectiveness in addressing their CMS children’s oral health. Females made up the vast majority of respondents (94.1%), and the median age of respondents was 51 years. When asked to evaluate their perceived knowledge of oral health, just over one-fourth of respondents (27.7%) described themselves as “very knowledgeable.” Over half reported getting information regarding oral health from journals and print media (58.2%) and oral health trainings (50.3%), while only 15% gained information through self-directed learning (e.g., online research, etc.). Over one-fifth of study participants (22.3%) reported having no sources of oral health information. More than half (55.1%) had never attended an oral health continuing education course or training. When asked how often primary care physicians provided feedback on their patients’ oral health status, almost 70% of respondents said “rarely” or “never.” Oral health was also not found to be of utmost importance to the children’s families; 41% of CMS nurses stated
that their CMS families gave “low” or “no” priority towards their children’s oral health. When asked about the frequency of CMS children’s dental visits, 56.2% of the respondents reported that less than 60% of their CMS children had seen a dentist within the past 12 months. Furthermore, 60% of the respondents stated that the average waiting time for a CMS child to see a dentist was “more than 1 month,” and almost 80% of CMS nurses had a child under their care be denied treatment by a d entist. Analysis of the dependent variable showed that, when nurses were asked about their self-perceived effectiveness in addressing their CMS children’s oral health, less than half of nurses (42.9%) perceived themselves as “effective” or “very effective” (ratings of 4 and 5, respectively). After controlling for age, gender, and the other covariates in the logistic regression model, several characteristics were found to be significantly associated with those CMS nurses who labeled themselves as “effective or very effective.” CMS nurses who described themselves as very knowledgeable about basic oral health information were almost three times more likely to describe themselves as effective or very effective in addressing the dental care needs of their CMS children as opposed to those who felt less than effective (AOR = 2.99, 95% CI: 1.69, 5.29). Similarly, the model showed that those participants who received continuing education training in oral health (defined as four or more hours) were more than twice as likely to describe themselves as effective or very effective (AOR = 2.34, 95% CI: 1.04, 5.27). Ease of obtaining care was also a statistically significant variable. CMS nurses were about 2.5 times more likely to feel effective or very effective if their CMS children waited, on average, less than one month for dental appointments (AOR = 2.62, 95% CI: 1.51, 4.55). Finally, those who reported that the majority (greater than 60%) of their clients had a dental appointment within the past twelve months were almost three times more likely to describe themselves as effective or very effective (AOR = 2.86, 95% CI: 1.67, 4.92).
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Table 1. Description of individual characteristics and associations with self-reported effectiveness in addressing their CMS children’s oral health. Characteristic
Overall (n = 376) N
%
Effective or very effective N (%)
a
Age (in years)
.038 24–35
41
11.7
14 (41.2)
36–45
52
14.9
17 (37.8)
46–55
113
32.4
46 (46.5)
56–65
125
35.8
41 (38.0)
66–74
18
5.1
8 (61.5)
Genderb
0.551 Male
Amount of time
9
2.5
3 (33.3)
Female
354
97.5
130 (43.3)
10 years
113
30.8
39 (41.1)
employedc
.703
CMS Districtd
Job
p-value
.003 Northwest
32
9.1
4 (15.4)
North Central
45
12.7
13 (33.3)
Northeast
26
7.4
8 (33.3)
Central
34
9.6
10 (38.5)
East Central
49
13.9
16 (38.1)
West Central
80
22.7
37 (54.4)
Southeast
69
19.5
36 (59.0)
Southwest
18
5.1
5 (33.3)
titlee
.774 Care Coordinator
293
82.3
111 (43.4)
Nursing Supervisor
63
17.7
21 (41.2)
Self-reported knowledgef
Source of oral health
.000 Less than very knowledgeable
220
67.9
65 (32.0)
Very knowledgeable
104
32.1
65 (63.7)
No information
84
25.0
41 (51.3)
.093
Self-directed learning
56
16.7
17 (34.7)
.189
Journals and print media
219
65.2
99 (48.1)
.016
Training and continuing education
189
56.3
84 (46.9)
.124
informationg
Total time in oral health CE courseh
.041 No training
207
60.7
76 (39.6)
ARTICLE ABSTRACT Objectives: To examine the oral health knowledge and practices of pediatric nurses who coordinate healthcare services for special needs children and to identify those factors that influenced their perceived effectiveness in managing their patients’ oral health needs. Methods: Self-reported data were collected from 376 nurses employed at Children’s Medical Services who responded to an online survey. Likert scale scores were used to specifically assess the nurses’ perceived effectiveness in addressing the oral health needs of special needs children. Results: Characteristics significantly associated with special needs pediatric nurses who described themselves as “effective or very effective” included: the self-perception of being very knowledgeable about basic oral health, receiving four or more hours of continuing education training, and securing dental appointments for the majority of their pediatric special needs patients with minimal waiting times. Conclusion: Findings reveal that oral health knowledge significantly influenced nurses’ perceived effectiveness in addressing the oral health needs of special needs children, as well as their ability to secure timely dental appointments. These results support the need to incorporate oral health education into nursing curricula and expand upon the dental workforce available and willing to treat disabled patients.
KEY WORDS: oral health, children, special needs, medical staff
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Addressing the oral healthcare needs of special needs children: pediatric nurses’ self-perceived effectiveness Carrigan L. Parish, DMD;1* Richard Singer, DMD, MS;2 Stephen Abel, DMD;3 Lisa R. Metsch, PhD4 1
Senior Project Director, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY; 2Doctoral Graduate Student, University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, Miami, FL; Assistant Professor, Nova Southeastern College of Dental Medicine, Department of Orthodontics, Fort Lauderdale, FL; 3 Associate Dean for Community and Professional Initiatives, University at Buffalo School of Dental Medicine, Buffalo, NY; 4Chair Sociomedical Sciences, Stephen Smith Professor of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, Volunteer Faculty, University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, Miami, FL. *Corresponding author e-mail: [email protected], [email protected] Spec Care Dentist 34(2): 88-95, 2014
Int r od uct ion
Dental disease in America has been called the “silent epidemic” by the Surgeon General’s Report-2000.1 In 2008, the Centers for Medicaid and Medicare conducted dental reviews of 16 states having low dental utilization rates and found that the primary barriers to dental care contributing to this “epidemic” were: limited dental provider availability, low reimbursement rates, administrative obstacles for dental providers, lack of understanding about dental benefits for beneficiaries, missed dental appointments, transportation, cultural competency, and need for education about the importance of dental health.2 Not surprisingly, the most vulnerable and underserved populations continue to encounter significant oral health problems despite numerous federal strategies that have been implemented to address various aspects of oral health care delivery.2 Persons with disabilities represent a particularly disadvantaged group with regard to the receipt of dental care. A qualitative study conducted in Massachusetts with disabled individuals and their healthcare proxies reported that individuals with disabilities experienced wait times for dental appointments ranging between 3 months to over 1 year.3 In comparison, a nationwide survey of all pediatric dental program directors in the U.S. reported that the average waiting time to secure a dental appointment ranged from 28 to 71 days.4 The cost of care as a barrier to dental treatment was
the focus of a recent study that found that individuals with disabilities in Florida were almost twice as likely to report a lack of dental care due to cost considerations, compared to their nondisabled counterparts (p < .001).5 More over, one survey of 37 residential facilities housing special needs individuals throughout Florida found that less than one-third of their residents had received comprehensive dental services, and the remainder received very limited services or emergency treatment only. This study further highlighted that 40% of the caregivers surveyed on behalf of their 362 residents
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12035
19/02/14 12:40 PM
A D D R E S S I N G T H E O R A L H E A LT H C A R E O F S P E C I A L N E E D S C H I L D R E N
could not identify dentists willing to treat their special needs residents, including the 75% of residents deemed “cooperative.”6 According to the US Department of Health and Human Services in 2005– 2006,7 approximately 14% of U.S. children under 18 years old had existing special health care needs, while 21.8% of US households occupied by children had at least one child with special needs.7 Among all children with special health care needs, preventive dental health care ranked highest as the service that was most needed but not received.7 “Access to care” disparities also exist between insured versus uninsured children. One study by Newacheck et al.8 found that uninsured children were almost five times more likely to be unsuccessful at securing needed dental treatment compared to insured children. It has been suggested that one of the key components to a successful community-based health program lies in the ability of general health practitioners, who serve as medical gatekeepers for disabled individuals, to recognize and identify needed dental care services.9 Children with special healthcare needs are frequently seen by physicians and nurses, but not generally by dentists.9,10 The available literature shows that nurses have limited knowledge of oral health problems due to limited or nonexistent training in oral health assessments and dental care protocols.11-19 This problem extends beyond the United States; deficiencies in oral health knowledge, protocols, assessments, and formal trainings within the nursing community have been reported in studies conducted in Hong Kong, Sweden, and South Africa.20-22 An Israeli study of nurses treating pediatric patients with cerebral palsy found a lack of knowledge about basic dental principles, including the prevention of dental caries and the prevalence of periodontal disease in this patient population.23 Similarly, one local study assessing nurses’ dental knowledge based on a questionnaire distributed to hospital nurses demonstrated a lack of knowledge regarding dental caries, gingivitis, and the dental complications i Survey
associated with systemic disease and medications.24 This author emphasized the importance of educating nurses about the rationale behind certain oral health practices and procedures, reasoning “it is unrealistic to expect nurses to undertake oral care mechanistically without understanding its importance.”24 However, little is known about the oral health knowledge, attitudes, and practices of nurses working with families of children with special health care needs. For oral health education to be effective, it should in theory be designed with an understanding of nurses’ characteristics, beliefs, attitudes, values, skills, and past behaviors.25 Within this context, this study reports findings from a statewide survey that examined the involvement of nurses in addressing the oral health care of special needs children and their families. The nurses surveyed have direct contact with special needs children and are responsible for managing their overall health care; therefore, they have the potential to greatly help promote oral health and disease prevention and prioritize referrals to those children with greatest need. Thus, the purpose of this study was to identify the oral health knowledge, attitudes, and practices of nurses and identify the barriers that limit their effectiveness in managing special needs children’s oral health issues.
satellite clinics.26 The agency functions through 22 area offices statewide and employs more than 500 nurses in the capacity of either care coordinators or nursing supervisors. CMS care coordinators arrange health care services for special needs children and assist families in accessing multidisciplinary primary care services in “medical home” settings, while CMS nursing supervisors oversee groups of care coordinators and assist them with their client case loads. Individuals were eligible for this study if they were employed as either a care coordinator or a nursing supervisor at CMS during the study period, were at least 18 years old, and understood written English. The survey was conducted from December, 2010 to February, 2011. CMS provided the e-mail addresses for all 516 CMS care coordinators and nursing supervisors with authorization from the CMS Deputy Secretary. The CMS Social Services Consultant contacted all of the potential participants prior to the release of the e-mail to inform them of the upcoming survey. Using a modified version of Dillman’s total design method27 for survey distribution, reminder e-mails were sent biweekly to nonresponders. E-mail addresses were recorded for distribution, tracking and reminder purposes and were not linked to the corresponding survey responses. Participants were not compensated for their participation.
M e th od s
Measures
Participants The current study utilized self-reported data collected in an online survey of pediatric care coordinators and nursing supervisors employed by Children’s Medical Services (CMS) throughout the state of Florida, USA. CMS is the primary Florida state agency responsible for the case management and coordination of primary, specialized, and ancillary healthcare services for children with special health care needs at facilities including CMS clinics, designated hospitals, convalescent facilities, private healthcare offices, specialized treatment centers, and regional and
The 46-item survey was developed and distributed electronically using the webbased program Survey Monkey.i The survey assessed CMS nurses’ demographic, educational, and practice characteristics, including the following: prior attendance at formal training sessions about oral health, sources of oral health information, perceived oral health knowledge, perceptions of barriers to optimal dental care, perceptions of the general priority placed on oral health, involvement with oral health, and availability of dental care to CMS children. The survey instrument was developed around a conceptual framework to model
Monkey is a software program with guided tools for creating, administering, and analyzing web-based surveys through a secure, encrypted Internet connection.
Parish et al.
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the outcome of interest, namely, barriers to nurses’ perceived effectiveness in addressing their CMS clients’ oral health. A barrier was defined as any factor that limits or restricts nurses’ perceived effectiveness, including knowledge, attitudes, and external factors that may preclude access to care.28 Self-efficacy was defined as the confidence and conviction that nurses feel in managing CMS children’s oral health needs.29 Self-efficacy has been proposed as the most important prerequisite for behavior change through its influence on the amount of effort invested in a given task and the level of performance attained.30-32 In this conceptual framework, knowledge and beliefs impact behavior-specific self-efficacy; enhanced knowledge and beliefs then result in increased understanding of a specific condition (in this case, oral health). Additional understanding leads to increased behavior-specific self-efficacy and outcome expectancy, i.e., improvements in oral health-involved nursing practices and improved access to oral healthcare for special needs children.30,31,33 Therefore, knowledge and attitudes were postulated as contributors to perceived effectiveness and included in the model. External barriers, such as lack of resources, were also included because the ability of nurses to manage their CMS children’s oral health care effectively may reasonably be influenced by such external “environmental” factors.28 To specifically assess the dependent variable, perceived effectiveness, respondents were asked: “Please rate how effective you feel you are in addressing your CMS children’s dental care.” The responses were scored on a Likert34 scale that ranged from 1 (not effective) to 5 (very effective). The responses were further dichotomized to “effective or very effective” (ratings of 4 or 5, respectively) and “less than effective” (ratings of 1–3) for the purpose of analysis.
Statistical analysis SPSS Statistics version 20 (IBM) was used to conduct the data analysis. The outcome of interest was nurses’ self-perceived effectiveness in addressing their CMS children’s oral health needs. Each
90 S p e c C a r e D e n t i s t 3 4 ( 2 ) 2 0 1 4
scd12035.indd 90
demographic characteristic of the CMS care coordinators and nursing supervisors was summarized using univariate analysis (Table 1). Bivariate analysis was then performed using Pearson’s chisquared tests to assess the association between each independent variable and the dependent variable, self-reported effectiveness in addressing CMS children’s oral health needs. Independent variables with a bivariate p-value ≤ .20 were then included in the multiple regression analysis of the dependent variable following the method of Homer and Lemeshow35 (Table 2).
R es ul t s
The current analysis is based upon 376 survey respondents, corresponding to a 73% participation rate. A total of 22 subjects (4%) elected not to participate after reading the cover letter, and an additional 118 subjects (23%) did not provide any response to the survey invitation for reasons unknown. Table 1 describes the univariate individual demographic characteristics of respondents and bivariate associations with self-reported effectiveness in addressing their CMS children’s oral health. Females made up the vast majority of respondents (94.1%), and the median age of respondents was 51 years. When asked to evaluate their perceived knowledge of oral health, just over one-fourth of respondents (27.7%) described themselves as “very knowledgeable.” Over half reported getting information regarding oral health from journals and print media (58.2%) and oral health trainings (50.3%), while only 15% gained information through self-directed learning (e.g., online research, etc.). Over one-fifth of study participants (22.3%) reported having no sources of oral health information. More than half (55.1%) had never attended an oral health continuing education course or training. When asked how often primary care physicians provided feedback on their patients’ oral health status, almost 70% of respondents said “rarely” or “never.” Oral health was also not found to be of utmost importance to the children’s families; 41% of CMS nurses stated
that their CMS families gave “low” or “no” priority towards their children’s oral health. When asked about the frequency of CMS children’s dental visits, 56.2% of the respondents reported that less than 60% of their CMS children had seen a dentist within the past 12 months. Furthermore, 60% of the respondents stated that the average waiting time for a CMS child to see a dentist was “more than 1 month,” and almost 80% of CMS nurses had a child under their care be denied treatment by a d entist. Analysis of the dependent variable showed that, when nurses were asked about their self-perceived effectiveness in addressing their CMS children’s oral health, less than half of nurses (42.9%) perceived themselves as “effective” or “very effective” (ratings of 4 and 5, respectively). After controlling for age, gender, and the other covariates in the logistic regression model, several characteristics were found to be significantly associated with those CMS nurses who labeled themselves as “effective or very effective.” CMS nurses who described themselves as very knowledgeable about basic oral health information were almost three times more likely to describe themselves as effective or very effective in addressing the dental care needs of their CMS children as opposed to those who felt less than effective (AOR = 2.99, 95% CI: 1.69, 5.29). Similarly, the model showed that those participants who received continuing education training in oral health (defined as four or more hours) were more than twice as likely to describe themselves as effective or very effective (AOR = 2.34, 95% CI: 1.04, 5.27). Ease of obtaining care was also a statistically significant variable. CMS nurses were about 2.5 times more likely to feel effective or very effective if their CMS children waited, on average, less than one month for dental appointments (AOR = 2.62, 95% CI: 1.51, 4.55). Finally, those who reported that the majority (greater than 60%) of their clients had a dental appointment within the past twelve months were almost three times more likely to describe themselves as effective or very effective (AOR = 2.86, 95% CI: 1.67, 4.92).
Addressing the oral healthcare of special needs children
19/02/14 12:40 PM
A D D R E S S I N G T H E O R A L H E A LT H C A R E O F S P E C I A L N E E D S C H I L D R E N
Table 1. Description of individual characteristics and associations with self-reported effectiveness in addressing their CMS children’s oral health. Characteristic
Overall (n = 376) N
%
Effective or very effective N (%)
a
Age (in years)
.038 24–35
41
11.7
14 (41.2)
36–45
52
14.9
17 (37.8)
46–55
113
32.4
46 (46.5)
56–65
125
35.8
41 (38.0)
66–74
18
5.1
8 (61.5)
Genderb
0.551 Male
Amount of time
9
2.5
3 (33.3)
Female
354
97.5
130 (43.3)
10 years
113
30.8
39 (41.1)
employedc
.703
CMS Districtd
Job
p-value
.003 Northwest
32
9.1
4 (15.4)
North Central
45
12.7
13 (33.3)
Northeast
26
7.4
8 (33.3)
Central
34
9.6
10 (38.5)
East Central
49
13.9
16 (38.1)
West Central
80
22.7
37 (54.4)
Southeast
69
19.5
36 (59.0)
Southwest
18
5.1
5 (33.3)
titlee
.774 Care Coordinator
293
82.3
111 (43.4)
Nursing Supervisor
63
17.7
21 (41.2)
Self-reported knowledgef
Source of oral health
.000 Less than very knowledgeable
220
67.9
65 (32.0)
Very knowledgeable
104
32.1
65 (63.7)
No information
84
25.0
41 (51.3)
.093
Self-directed learning
56
16.7
17 (34.7)
.189
Journals and print media
219
65.2
99 (48.1)
.016
Training and continuing education
189
56.3
84 (46.9)
.124
informationg
Total time in oral health CE courseh
.041 No training
207
60.7
76 (39.6)
