Sakalauskiene ORIGINAL ARTICLE et al
Satisfaction with Dental Care and Its Role in Dental Health-related Behaviour Among Lithuanian University Employees Zana Sakalauskienėa/Vita Machiulskieneb/Heikki Murtomaac/Miira M. Vehkalahtid Purpose: To assess factors related to satisfaction with dental care and its role in dental health-related behaviour among Lithuanian university employees. Materials and Methods: Our cross-sectional survey collected data on respondents’ satisfaction with dental care using 24 statements. The self-administered questionnaire also inquired about dental attendance, dental health-related behaviour and attitudes, self-assessed dental status and background details. All 35- to 44-year-old employees (n = 862) of four universities in Lithuania were invited to participate; 64% (n = 553) responded, 78% of them were women. Statements on satisfaction with technical, personal and organisational dimensions of the dental surgery were assessed using a five-point scale, ranging from entirely agree to entirely disagree, with higher scores indicating stronger agreement. Overall satisfaction scores were summed and subjects divided into tertiles to evaluate dental health-related behaviour. For the logistic regression model, subjects were divided into two groups of satisfaction level (below and above the mean of the sum score). Results: Subjects were highly satisfied with dental care, with the mean sum score being 99.5 (SD = 12.62, range 59–120). Stronger satisfaction was reported by those visiting private practices (p < 0.001) and the same dentist longer (p = 0.006) and by those who entirely agreed with the statements on dental health-related attitudes (p ≤ 0.001). The logistic regression model showed that higher satisfaction with dental care level was more likely for those who indicated check-up-based regular dental attendance (OR = 1.7) and brushing their teeth at least twice daily (OR = 1.6). Conclusions: Satisfaction with dental care is positively related to individuals’ dental health-related attitudes and behaviour among highly-educated subjects in particular. Key words: dental health attitudes, dental healthcare evaluation, dental health practices, dental patient preference Oral Health Prev Dent 2015;13:113-121 doi: 10.3290/j.ohpd.a33925
a
Assistant Teacher, Clinical Department of Dental and Maxillary Orthopaedics, Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Idea, performed survey and statistical evaluation, wrote the manuscript.
b
Professor, Clinic of Dental and Oral Pathology, Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Participated in planning the study, contributed substantially to discussion, proofread the manuscript.
c
Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland. Contributed substantially to discussion, proofread the manuscript.
d
Adjunct Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland; Adjunct Professor, Department of Community Dentistry, Institute of Dentistry, University of Oulu, Oulu, Finland. Idea, planned the analyses, consulted on statistical evaluation, co-wrote and proofread the manuscript.
Correspondence: Zana Sakalauskienė, Clinical Department of Dental and Maxillary Orthopaedics, Faculty of Odontology, Lithuanian University of Health Sciences, Sukileliu pr. 51, Kaunas LT-50106, Lithuania. Tel: +370-698-48641. Email: [email protected]
Vol 13, No 2, 2015
Submitted for publication: 27.02.13; accepted for publication: 26.05.13
D
ental care satisfaction can be evaluated with regard to technical, interpersonal, and financial dimensions as well as accessibility and convenience of dental care (Davies and Ware, 1982). Satisfaction depends on various factors, such as background characteristics of the patient (Skaret et al, 2005; Kikwilu et al, 2009), dentists’ practice type (Skaret et al, 2005; Milgrom et al, 2008) as well as dentists’ gender (Sondell et al, 2002) and communication skills (Butters and Willis, 2000; Sondell et al, 2002; Schouten et al, 2003; Kikwilu et al, 2009; Bayat et al, 2010), the latter being one of the most important factors. Research on satisfaction with dental care has most commonly evaluated attitudes toward dental care and use of dental services, including careseeking behaviour (Milgrom et al, 2008; Grytten et
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al, 2009). To measure patient satisfaction, some studies have developed their own questionnaires (Butters and Willis, 2000; Sgan-Cohen et al, 2004; Bedi et al, 2005) and others have adapted or modified existing instruments such as the Dental Satisfaction Questionnaire (Skaret et al, 2004) or the Dental Visit Satisfaction Scale (Sondell et al, 2002; Schouten et al, 2003; Mussard et al, 2007). Questionnaires enable assessment of patients’ opinion, not only about the skill of the clinician, but also about other aspects of dental care. However, these instruments have been criticised as being insensitive and lacking discriminatory power (Skaret et al, 2005). Satisfied patients seem to be more cooperative, with regular attendance and compliance with prescribed treatment regimens (Butters and Willis, 2000; Sgan-Cohen et al, 2004). Greater satisfaction may therefore be helpful in improving dental health-related behaviour, which is relevant in controlling dental caries and periodontal diseases (Sanders et al, 2006). Dental care satisfaction has not been assessed in Lithuania. Since the last decade of the 20th century, Lithuanian dental health care has been undergoing the transition from a government-based, strictly controlled and heavily subsidised system to one based on private ownership. These changes are likely to affect the utilisation of dental services, and may increase dental health inequalities in the future. We assessed factors related to satisfaction with dental care based on subjects’ most recent dental visit among 35- to 44-year-old university employees. Since satisfied patients may also be more willing to follow recommendations regarding preventive dental health-related behaviour, such as regular toothbrushing and check-ups, we evaluated the role of satisfaction with dental care in dental health-related behaviour.
MATERIALS AND METHODS The Kaunas Regional Ethics Committee for Biomedical Research (Lithuania) approved the study protocol. This cross-sectional questionnaire survey was conducted anonymously among employees of four selected universities in Lithuania in 2005 (Sakalauskienė et al, 2009). Of the total number of 10 universities in the country, one university from each of four university cities (Vilnius, Kaunas, Klaipėda and Šiauliai) was invited to participate on
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the basis of having no medical teaching profile. University employees aged 35–44 years were considered an educated group representing the highest level of dental health-related behaviour as well as the most financially stable part of the country’s population. Based on the lists of the human resources department, all present employees of the four universities in the age range defined above (n = 862; 629 females) received a personally addressed envelope with a four-page questionnaire and an invitation letter signed by the authors, explaining the study and requesting response. Satisfaction with dental care was assessed using statements covering three dimensions: technical competence and personality of the dentist, and organisation of the dental surgery. A total of 39 statements were selected from previously used instruments for similar studies in other countries (Davies and Ware, 1982; Murtomaa and Masalin, 1982). All statements were translated from English into Lithuanian and back for the final version of the questionnaire. The statements were tested in a pilot study on a sample of adult patients visiting dental clinics at Kaunas University of Medicine in 2004. The reliability of instruments scale was measured by the reliability coefficient, Cronbach’s α = 0.7. Factor analysis with a rotated component matrix was applied to each dimension of dental care satisfaction. After evaluation of principal component analysis in a rotated matrix and distribution of the mean scores of dental care satisfaction, 24 statements were selected (Table 1). Each statement was assessed using a five-point Likert scale (1–5), where higher scores indicated stronger satisfaction. For the analyses, the scores were summed for each dimension. For evaluation of overall satisfaction, scores of all dimensions were summed and subjects equally divided into tertiles according to the distribution of sum scores: 35% fell into the highest tertile, 33% the middle tertile and 32% into the lowest tertile. For the logistic regression model, the subjects were dichotomised according to the overall satisfaction score sum into a lower level (score sums below the mean; n = 265, 49% of all respondents) and a higher level (score sums above mean; n = 271, 51% of all respondents). Questions about the dentist included dentists’ gender and age and aspects related to visiting this dentist. Dentists’ age was assessed by five options that were later dichotomised into ≤ 40 years and older than 40 years. The question ‘How long have you been visiting the same dentist?’ offered five response alter-
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natives which were later pooled into three: two years and more, less than two years, and this was my first visit. The type of practice was recorded as private or public. Fear experience during the most recent dental visit was measured by the statement ‘I did not feel any fear during the visit’ with five response alternatives, later dichotomised as feeling fear or not. Dental status was evaluated by self-reported number of lost teeth and dental health and appearance. The number of lost teeth was inquired about with six alternatives, later categorised into three: none, 1-2, and ≥ 3 teeth, with the request not to count wisdom teeth. The questions ‘How would you assess your dental health?’ and ‘How would you assess your dental appearance?’ offered five response alternatives from ‘very good’ to ‘very poor’, later grouped in two. The answer ‘no opinion’, given by 1% of the subjects for both questions, was excluded from the analyses. Dental health-related attitudes were assessed by the following statements: ‘Good dental health is important to me’ and ‘Good dental appearance is
Table 1 Statements related to satisfaction with dental care according to the dimensions Technical competence of the dentist (9 statements) This dentist worked gently. This dentist was careful with instruments. This dentist checked and recorded everything precisely. This dentist minimised pain. This dentist was wearing a mask. This dentist was wearing gloves. This dentist knew what he/she was doing. This dentist’s work was of high quality. This dentist was thorough. Personality of the dentist (9 statements) This dentist answered my questions comprehensively. This dentist was self-confident. This dentist respected me. This dentist understood my dental problems. This dentist was calm. This dentist was friendly. This dentist expressed sympathy. This dentist clearly explained what he/she was doing. This dentist clearly explained the costs of my treatment. Organisation of the dental surgery (6 statements) This dentist’s surgery was in a convenient location. This dentist’s equipment seemed to be modern. This dentist’s working hours were flexible. This dentist stayed on schedule. In this dentist’s office there was a pleasant atmosphere. This dentist’s fees were not too high.
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important to me’, both offering five response options from ‘entirely agree’ to ‘entirely disagree’. To assess dental health-related behaviour, we inquired about respondents’ toothbrushing, interdental cleaning and regular dental attendance. The question ‘How often do you normally brush your teeth?’ offered five response options, later dichotomised as: ‘at least twice daily’ and ‘less than twice daily’. The question ‘How often do you use the following tools for interdental cleaning?’ listed three tools: a toothpick, dental floss and an interdental brush with the same response options as for toothbrushing and were later dichotomised into using any interdental tool on a daily basis or not. Missing answers were taken as never using the tool in question. Regular dental attendance was inquired about with three alternatives, later categorised as preventive check-up and trouble-based visit. Respondents’ age, gender, education and income served as background information. Level of education was reported in four categories, later dichotomised into ‘less than university’ and ‘university degree’. Four answer alternatives were provided for the question ‘What was your household income per person during the past six months?’ Responses were categorised as below average (less than 500 litas), average (500–1000 litas) and above average (more than 1000 litas), where 500 litas corresponded to €145. A total of 553 subjects (64%) chose to respond. Those not reporting a dental visit within the past five years (n = 17) were excluded, leaving 536 subjects. Of these subjects, 80% were women, 82% had a university degree and 39% reported household income as average, 38% as below average, and 23% as above average. Subjects’ mean age was 40.1 years (SD = 3.19). Statistical significance of differences between the groups was assessed by ANOVA for mean values and by chi-square tests for frequencies. Logistic regression modelling was applied to analyse relationships between above-average satisfaction and dental health-related behaviour, simultaneously controlling for the background factors. The corresponding odds ratios (OR) and their 95% confi dence intervals (95% CI) were estimated. The fit of the model was assessed using the Hosmer and Lemeshow test. The study power was measured by the two proportions Z-test, comparing data on satisfaction with dental care between two studies: the present one and one previously performed (Bedi et al,
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Table 2 Satisfaction with dental care according to background characteristics of 35- to 44-year-old university employees in Lithuania reporting a dental visit within the past five years (n = 536) Gender
Education
Income (5 answers mising)
Dimensions of satisfaction
Women n = 427
Men n = 109
University n = 443
Less than university n = 93
Above average n = 120
Average n = 211
Below average n = 200
Technical competence of dentist (9 statements)
38.2 (0.26)
37.3 (0.53)
38.2 (0.26)
37.3 (0.58)
39.1 (0.47)
38.2 (0.37)
37.3 (0.40)
Personality of dentist (9 statements)
38.0 (0.26)
Organisation of dental surgery (6 statements)
23.7 (1.18)
Overall satisfaction (24 statements)
99.9 (0.61)
p = 0.115 37.4 (0.50)
p = 0.158 38.0 (0.25)
p = 0.261 23.2 (0.33)
37.2 (0.53)
38.7 (0.47)
p = 0.157 23.6 (0.17)
p = 0.190 97.9 (1.19)
p = 0.014
24.0 (0.33)
23.6 (3.24)
p = 0.677
p = 0.128
36.9 (0.40)
p = 0.003
23.8 (0.35)
99.8 (0.60)
38.4 (0.32)
23.5 (0.26)
p = 0.365
98.2 (1.35)
101.9 (1.15)
p = 0.278
100.2 (0.81)
97.7 (0.94)
p = 0.011
Satisfaction assessed by 24 statements using a 5-point Likert scale (values from 1 to 5), with higher scores indicating stronger satisfaction. The scores were summed into three dimensions and shown as means (standard error) of the sums. Statistical analysis by ANOVA.
Table 3 Distribution (%) of subjects into levels of overall satisfaction with dental care according to dentist and practice-related factors among 35- to 44-year-old university employees in Lithuania reporting a dental visit within the past five years (n = 536) Subjects (%) in each satisfaction category Dentist and practice-related factors Dentists’ gender Women Men 1 answer missing
n
Highest tertile (35%)
Middle tertile (33%)
Lowest tertile (32%)
431 104
36 29
33 33
31 38
p = 0.242 Dentists’ age (years) ≤40 >40 3 answers missing
225 308
34 36
38 29
28 35
p = 0.090 Practice type Private Public 3 answers missing
415 118
38 25
35 27
27 48
p < 0.001 Visiting the same dentist 2 ≥ years < 2 years This was first visit to this dentist 2 answers missing
321 104 109
40 26 28
33 35 31
27 39 41
p = 0.006 Feeling fear No Yes 2 answers missing
412 122
40 18
36 30
24 52
p < 0.001 Assessment of satisfaction statements – see Table 2. Statistical analysis by chi-square test.
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2005). For this test, overall satisfaction with the last dental visit in the present study was measured by a separate question ‘How satisfied are you with this last dentist?’, offering five answer alternatives from ‘entirely satisfied’ to ‘entirely dissatisfied’; 88% indicated being satisfied or entirely satisfied. The comparison of the two studies using the two proportions Z-test showed the present study power value to be 0.8 (p = 0.05), which was thus considered sufficient to interpret the obtained results for the selected study population.
RESULTS Subjects were quite satisfied with their dental care; the sum score of overall satisfaction was 99.5 (SD = 12.62, median = 100, range 59–120) and in terms of dimension, 38.0 (SD = 5.47, median = 38, range 20–45) for technical competence of the dentist, 37.9 (SD = 5.26, median = 37, range 12–45) for dentists’ personality and 23.6 (SD = 3.58, median = 24, range 8–30) for organisation of the dental surgery. The sum scores of the three dimensions correlated strongly (r = 0.6–0.7). Table 2 presents satisfaction with dental care in the three dimensions and overall as mean sum scores according to subjects’ background characteristics. The only differences found were between the income groups, where the greatest satisfaction scores were among those with an above average income. At least one ‘entirely agree’ answer was given in each of the three dimensions by 58%, in one to two dimensions by 26% and in none of the dimensions by 16% of subjects. Such an answer in three dimensions was most frequent among those with a higher education (59%) or income (65%) but in none of the dimensions among those with a lower education (29%) or income (23%). The differences according to education and income with regard to ‘entirely agree’ answers in three dimensions were statistically significant (p < 0.001 and p = 0.006, respectively). Table 3 presents percentages of subjects falling into each tertile of overall satisfaction according to dentist and practice-related aspects. Those having visited a private dentist or the same dentist for longer than two years or feeling no fear were overrepresented in the highest tertile, while those having visited a public dentist or the same dentist for less than two years or feeling dental fear were overrepresented in the lowest tertile. All of these differ-
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ences were significant, while dentist gender and age had no impact on tertile allocation. A similar comparison according to self-assessed dental health and appearance and to statements related to dental health-related attitudes appears in Table 4. Overrepresentation was found both in the highest tertile for those assessing their dental health and appearance as good or very good and in the lowest tertile for those assessing these as poor or very poor (p ≤ 0.002). Those who reported entirely agreeing with the statements about importance of dental health and appearance were overrepresented in the highest tertile and underrepresented in the lowest tertile of satisfaction level (p ≤ 0.001). Table 5 presents subjects’ dental health-related behaviour and its variation within each satisfaction category. The vast majority of those in the highest and middle tertiles reported brushing their teeth at least twice daily, whereas almost half of those in the lowest tertile reported less frequent brushing (p = 0.001). Regarding regular dental attendance, 65% of those in the highest tertile reported going to check-ups, while 62% of those in the lowest tertile reported only a trouble-based attendance (p < 0.001). The logistic regression model (Table 6) showed that higher satisfaction with dental care was more likely for those who indicated check-up-based regular dental attendance (OR = 1.7) or reported brushing their teeth at least twice daily (OR = 1.6) or had a higher income (OR = 1.3). The logistic regression model fitted the data well (p = 0.547). The p-value tells how well the fitted model describes the situation in the data. Therefore, the fact that all values were non-significant shows that the model fitted the data well. Models yielding significant goodnessof-fit p-values (e.g.
Satisfaction with Dental Care and Its Role in Dental Health-related Behaviour Among Lithuanian University Employees Zana Sakalauskienėa/Vita Machiulskieneb/Heikki Murtomaac/Miira M. Vehkalahtid Purpose: To assess factors related to satisfaction with dental care and its role in dental health-related behaviour among Lithuanian university employees. Materials and Methods: Our cross-sectional survey collected data on respondents’ satisfaction with dental care using 24 statements. The self-administered questionnaire also inquired about dental attendance, dental health-related behaviour and attitudes, self-assessed dental status and background details. All 35- to 44-year-old employees (n = 862) of four universities in Lithuania were invited to participate; 64% (n = 553) responded, 78% of them were women. Statements on satisfaction with technical, personal and organisational dimensions of the dental surgery were assessed using a five-point scale, ranging from entirely agree to entirely disagree, with higher scores indicating stronger agreement. Overall satisfaction scores were summed and subjects divided into tertiles to evaluate dental health-related behaviour. For the logistic regression model, subjects were divided into two groups of satisfaction level (below and above the mean of the sum score). Results: Subjects were highly satisfied with dental care, with the mean sum score being 99.5 (SD = 12.62, range 59–120). Stronger satisfaction was reported by those visiting private practices (p < 0.001) and the same dentist longer (p = 0.006) and by those who entirely agreed with the statements on dental health-related attitudes (p ≤ 0.001). The logistic regression model showed that higher satisfaction with dental care level was more likely for those who indicated check-up-based regular dental attendance (OR = 1.7) and brushing their teeth at least twice daily (OR = 1.6). Conclusions: Satisfaction with dental care is positively related to individuals’ dental health-related attitudes and behaviour among highly-educated subjects in particular. Key words: dental health attitudes, dental healthcare evaluation, dental health practices, dental patient preference Oral Health Prev Dent 2015;13:113-121 doi: 10.3290/j.ohpd.a33925
a
Assistant Teacher, Clinical Department of Dental and Maxillary Orthopaedics, Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Idea, performed survey and statistical evaluation, wrote the manuscript.
b
Professor, Clinic of Dental and Oral Pathology, Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Participated in planning the study, contributed substantially to discussion, proofread the manuscript.
c
Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland. Contributed substantially to discussion, proofread the manuscript.
d
Adjunct Professor, Department of Oral Public Health, Institute of Dentistry, University of Helsinki, Helsinki, Finland; Adjunct Professor, Department of Community Dentistry, Institute of Dentistry, University of Oulu, Oulu, Finland. Idea, planned the analyses, consulted on statistical evaluation, co-wrote and proofread the manuscript.
Correspondence: Zana Sakalauskienė, Clinical Department of Dental and Maxillary Orthopaedics, Faculty of Odontology, Lithuanian University of Health Sciences, Sukileliu pr. 51, Kaunas LT-50106, Lithuania. Tel: +370-698-48641. Email: [email protected]
Vol 13, No 2, 2015
Submitted for publication: 27.02.13; accepted for publication: 26.05.13
D
ental care satisfaction can be evaluated with regard to technical, interpersonal, and financial dimensions as well as accessibility and convenience of dental care (Davies and Ware, 1982). Satisfaction depends on various factors, such as background characteristics of the patient (Skaret et al, 2005; Kikwilu et al, 2009), dentists’ practice type (Skaret et al, 2005; Milgrom et al, 2008) as well as dentists’ gender (Sondell et al, 2002) and communication skills (Butters and Willis, 2000; Sondell et al, 2002; Schouten et al, 2003; Kikwilu et al, 2009; Bayat et al, 2010), the latter being one of the most important factors. Research on satisfaction with dental care has most commonly evaluated attitudes toward dental care and use of dental services, including careseeking behaviour (Milgrom et al, 2008; Grytten et
113
Sakalauskiene et al
al, 2009). To measure patient satisfaction, some studies have developed their own questionnaires (Butters and Willis, 2000; Sgan-Cohen et al, 2004; Bedi et al, 2005) and others have adapted or modified existing instruments such as the Dental Satisfaction Questionnaire (Skaret et al, 2004) or the Dental Visit Satisfaction Scale (Sondell et al, 2002; Schouten et al, 2003; Mussard et al, 2007). Questionnaires enable assessment of patients’ opinion, not only about the skill of the clinician, but also about other aspects of dental care. However, these instruments have been criticised as being insensitive and lacking discriminatory power (Skaret et al, 2005). Satisfied patients seem to be more cooperative, with regular attendance and compliance with prescribed treatment regimens (Butters and Willis, 2000; Sgan-Cohen et al, 2004). Greater satisfaction may therefore be helpful in improving dental health-related behaviour, which is relevant in controlling dental caries and periodontal diseases (Sanders et al, 2006). Dental care satisfaction has not been assessed in Lithuania. Since the last decade of the 20th century, Lithuanian dental health care has been undergoing the transition from a government-based, strictly controlled and heavily subsidised system to one based on private ownership. These changes are likely to affect the utilisation of dental services, and may increase dental health inequalities in the future. We assessed factors related to satisfaction with dental care based on subjects’ most recent dental visit among 35- to 44-year-old university employees. Since satisfied patients may also be more willing to follow recommendations regarding preventive dental health-related behaviour, such as regular toothbrushing and check-ups, we evaluated the role of satisfaction with dental care in dental health-related behaviour.
MATERIALS AND METHODS The Kaunas Regional Ethics Committee for Biomedical Research (Lithuania) approved the study protocol. This cross-sectional questionnaire survey was conducted anonymously among employees of four selected universities in Lithuania in 2005 (Sakalauskienė et al, 2009). Of the total number of 10 universities in the country, one university from each of four university cities (Vilnius, Kaunas, Klaipėda and Šiauliai) was invited to participate on
114
the basis of having no medical teaching profile. University employees aged 35–44 years were considered an educated group representing the highest level of dental health-related behaviour as well as the most financially stable part of the country’s population. Based on the lists of the human resources department, all present employees of the four universities in the age range defined above (n = 862; 629 females) received a personally addressed envelope with a four-page questionnaire and an invitation letter signed by the authors, explaining the study and requesting response. Satisfaction with dental care was assessed using statements covering three dimensions: technical competence and personality of the dentist, and organisation of the dental surgery. A total of 39 statements were selected from previously used instruments for similar studies in other countries (Davies and Ware, 1982; Murtomaa and Masalin, 1982). All statements were translated from English into Lithuanian and back for the final version of the questionnaire. The statements were tested in a pilot study on a sample of adult patients visiting dental clinics at Kaunas University of Medicine in 2004. The reliability of instruments scale was measured by the reliability coefficient, Cronbach’s α = 0.7. Factor analysis with a rotated component matrix was applied to each dimension of dental care satisfaction. After evaluation of principal component analysis in a rotated matrix and distribution of the mean scores of dental care satisfaction, 24 statements were selected (Table 1). Each statement was assessed using a five-point Likert scale (1–5), where higher scores indicated stronger satisfaction. For the analyses, the scores were summed for each dimension. For evaluation of overall satisfaction, scores of all dimensions were summed and subjects equally divided into tertiles according to the distribution of sum scores: 35% fell into the highest tertile, 33% the middle tertile and 32% into the lowest tertile. For the logistic regression model, the subjects were dichotomised according to the overall satisfaction score sum into a lower level (score sums below the mean; n = 265, 49% of all respondents) and a higher level (score sums above mean; n = 271, 51% of all respondents). Questions about the dentist included dentists’ gender and age and aspects related to visiting this dentist. Dentists’ age was assessed by five options that were later dichotomised into ≤ 40 years and older than 40 years. The question ‘How long have you been visiting the same dentist?’ offered five response alter-
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natives which were later pooled into three: two years and more, less than two years, and this was my first visit. The type of practice was recorded as private or public. Fear experience during the most recent dental visit was measured by the statement ‘I did not feel any fear during the visit’ with five response alternatives, later dichotomised as feeling fear or not. Dental status was evaluated by self-reported number of lost teeth and dental health and appearance. The number of lost teeth was inquired about with six alternatives, later categorised into three: none, 1-2, and ≥ 3 teeth, with the request not to count wisdom teeth. The questions ‘How would you assess your dental health?’ and ‘How would you assess your dental appearance?’ offered five response alternatives from ‘very good’ to ‘very poor’, later grouped in two. The answer ‘no opinion’, given by 1% of the subjects for both questions, was excluded from the analyses. Dental health-related attitudes were assessed by the following statements: ‘Good dental health is important to me’ and ‘Good dental appearance is
Table 1 Statements related to satisfaction with dental care according to the dimensions Technical competence of the dentist (9 statements) This dentist worked gently. This dentist was careful with instruments. This dentist checked and recorded everything precisely. This dentist minimised pain. This dentist was wearing a mask. This dentist was wearing gloves. This dentist knew what he/she was doing. This dentist’s work was of high quality. This dentist was thorough. Personality of the dentist (9 statements) This dentist answered my questions comprehensively. This dentist was self-confident. This dentist respected me. This dentist understood my dental problems. This dentist was calm. This dentist was friendly. This dentist expressed sympathy. This dentist clearly explained what he/she was doing. This dentist clearly explained the costs of my treatment. Organisation of the dental surgery (6 statements) This dentist’s surgery was in a convenient location. This dentist’s equipment seemed to be modern. This dentist’s working hours were flexible. This dentist stayed on schedule. In this dentist’s office there was a pleasant atmosphere. This dentist’s fees were not too high.
Vol 13, No 2, 2015
important to me’, both offering five response options from ‘entirely agree’ to ‘entirely disagree’. To assess dental health-related behaviour, we inquired about respondents’ toothbrushing, interdental cleaning and regular dental attendance. The question ‘How often do you normally brush your teeth?’ offered five response options, later dichotomised as: ‘at least twice daily’ and ‘less than twice daily’. The question ‘How often do you use the following tools for interdental cleaning?’ listed three tools: a toothpick, dental floss and an interdental brush with the same response options as for toothbrushing and were later dichotomised into using any interdental tool on a daily basis or not. Missing answers were taken as never using the tool in question. Regular dental attendance was inquired about with three alternatives, later categorised as preventive check-up and trouble-based visit. Respondents’ age, gender, education and income served as background information. Level of education was reported in four categories, later dichotomised into ‘less than university’ and ‘university degree’. Four answer alternatives were provided for the question ‘What was your household income per person during the past six months?’ Responses were categorised as below average (less than 500 litas), average (500–1000 litas) and above average (more than 1000 litas), where 500 litas corresponded to €145. A total of 553 subjects (64%) chose to respond. Those not reporting a dental visit within the past five years (n = 17) were excluded, leaving 536 subjects. Of these subjects, 80% were women, 82% had a university degree and 39% reported household income as average, 38% as below average, and 23% as above average. Subjects’ mean age was 40.1 years (SD = 3.19). Statistical significance of differences between the groups was assessed by ANOVA for mean values and by chi-square tests for frequencies. Logistic regression modelling was applied to analyse relationships between above-average satisfaction and dental health-related behaviour, simultaneously controlling for the background factors. The corresponding odds ratios (OR) and their 95% confi dence intervals (95% CI) were estimated. The fit of the model was assessed using the Hosmer and Lemeshow test. The study power was measured by the two proportions Z-test, comparing data on satisfaction with dental care between two studies: the present one and one previously performed (Bedi et al,
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Table 2 Satisfaction with dental care according to background characteristics of 35- to 44-year-old university employees in Lithuania reporting a dental visit within the past five years (n = 536) Gender
Education
Income (5 answers mising)
Dimensions of satisfaction
Women n = 427
Men n = 109
University n = 443
Less than university n = 93
Above average n = 120
Average n = 211
Below average n = 200
Technical competence of dentist (9 statements)
38.2 (0.26)
37.3 (0.53)
38.2 (0.26)
37.3 (0.58)
39.1 (0.47)
38.2 (0.37)
37.3 (0.40)
Personality of dentist (9 statements)
38.0 (0.26)
Organisation of dental surgery (6 statements)
23.7 (1.18)
Overall satisfaction (24 statements)
99.9 (0.61)
p = 0.115 37.4 (0.50)
p = 0.158 38.0 (0.25)
p = 0.261 23.2 (0.33)
37.2 (0.53)
38.7 (0.47)
p = 0.157 23.6 (0.17)
p = 0.190 97.9 (1.19)
p = 0.014
24.0 (0.33)
23.6 (3.24)
p = 0.677
p = 0.128
36.9 (0.40)
p = 0.003
23.8 (0.35)
99.8 (0.60)
38.4 (0.32)
23.5 (0.26)
p = 0.365
98.2 (1.35)
101.9 (1.15)
p = 0.278
100.2 (0.81)
97.7 (0.94)
p = 0.011
Satisfaction assessed by 24 statements using a 5-point Likert scale (values from 1 to 5), with higher scores indicating stronger satisfaction. The scores were summed into three dimensions and shown as means (standard error) of the sums. Statistical analysis by ANOVA.
Table 3 Distribution (%) of subjects into levels of overall satisfaction with dental care according to dentist and practice-related factors among 35- to 44-year-old university employees in Lithuania reporting a dental visit within the past five years (n = 536) Subjects (%) in each satisfaction category Dentist and practice-related factors Dentists’ gender Women Men 1 answer missing
n
Highest tertile (35%)
Middle tertile (33%)
Lowest tertile (32%)
431 104
36 29
33 33
31 38
p = 0.242 Dentists’ age (years) ≤40 >40 3 answers missing
225 308
34 36
38 29
28 35
p = 0.090 Practice type Private Public 3 answers missing
415 118
38 25
35 27
27 48
p < 0.001 Visiting the same dentist 2 ≥ years < 2 years This was first visit to this dentist 2 answers missing
321 104 109
40 26 28
33 35 31
27 39 41
p = 0.006 Feeling fear No Yes 2 answers missing
412 122
40 18
36 30
24 52
p < 0.001 Assessment of satisfaction statements – see Table 2. Statistical analysis by chi-square test.
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Oral Health & Preventive Dentistry
Sakalauskiene et al
2005). For this test, overall satisfaction with the last dental visit in the present study was measured by a separate question ‘How satisfied are you with this last dentist?’, offering five answer alternatives from ‘entirely satisfied’ to ‘entirely dissatisfied’; 88% indicated being satisfied or entirely satisfied. The comparison of the two studies using the two proportions Z-test showed the present study power value to be 0.8 (p = 0.05), which was thus considered sufficient to interpret the obtained results for the selected study population.
RESULTS Subjects were quite satisfied with their dental care; the sum score of overall satisfaction was 99.5 (SD = 12.62, median = 100, range 59–120) and in terms of dimension, 38.0 (SD = 5.47, median = 38, range 20–45) for technical competence of the dentist, 37.9 (SD = 5.26, median = 37, range 12–45) for dentists’ personality and 23.6 (SD = 3.58, median = 24, range 8–30) for organisation of the dental surgery. The sum scores of the three dimensions correlated strongly (r = 0.6–0.7). Table 2 presents satisfaction with dental care in the three dimensions and overall as mean sum scores according to subjects’ background characteristics. The only differences found were between the income groups, where the greatest satisfaction scores were among those with an above average income. At least one ‘entirely agree’ answer was given in each of the three dimensions by 58%, in one to two dimensions by 26% and in none of the dimensions by 16% of subjects. Such an answer in three dimensions was most frequent among those with a higher education (59%) or income (65%) but in none of the dimensions among those with a lower education (29%) or income (23%). The differences according to education and income with regard to ‘entirely agree’ answers in three dimensions were statistically significant (p < 0.001 and p = 0.006, respectively). Table 3 presents percentages of subjects falling into each tertile of overall satisfaction according to dentist and practice-related aspects. Those having visited a private dentist or the same dentist for longer than two years or feeling no fear were overrepresented in the highest tertile, while those having visited a public dentist or the same dentist for less than two years or feeling dental fear were overrepresented in the lowest tertile. All of these differ-
Vol 13, No 2, 2015
ences were significant, while dentist gender and age had no impact on tertile allocation. A similar comparison according to self-assessed dental health and appearance and to statements related to dental health-related attitudes appears in Table 4. Overrepresentation was found both in the highest tertile for those assessing their dental health and appearance as good or very good and in the lowest tertile for those assessing these as poor or very poor (p ≤ 0.002). Those who reported entirely agreeing with the statements about importance of dental health and appearance were overrepresented in the highest tertile and underrepresented in the lowest tertile of satisfaction level (p ≤ 0.001). Table 5 presents subjects’ dental health-related behaviour and its variation within each satisfaction category. The vast majority of those in the highest and middle tertiles reported brushing their teeth at least twice daily, whereas almost half of those in the lowest tertile reported less frequent brushing (p = 0.001). Regarding regular dental attendance, 65% of those in the highest tertile reported going to check-ups, while 62% of those in the lowest tertile reported only a trouble-based attendance (p < 0.001). The logistic regression model (Table 6) showed that higher satisfaction with dental care was more likely for those who indicated check-up-based regular dental attendance (OR = 1.7) or reported brushing their teeth at least twice daily (OR = 1.6) or had a higher income (OR = 1.3). The logistic regression model fitted the data well (p = 0.547). The p-value tells how well the fitted model describes the situation in the data. Therefore, the fact that all values were non-significant shows that the model fitted the data well. Models yielding significant goodnessof-fit p-values (e.g.
