In recent years, the study of satisfaction in Spain and other developed countries in ... Primary Dental Care, Department 9, Valencia Health Service. Associate ...
Satisfaction Evaluation in Primary Dental Care
Parental Satisfaction with Children’s Primary Dental Care in Valencia, Spain Carmen Llena, Gonzalo Clemente and Leopoldo Forner
Key Words: Parental Satisfaction, Dental Care Delivery, Primary Dental Care, Spain
Aim: To evaluate parents’ satisfaction with the dental care that their children received in a primary dental care unit in Valencia, Spain. Methods: A cross-sectional study was designed. Parents were given a self-administered questionnaire with questions on accessibility, information received from the dentist and hygienist, staff interest in their child, dentist’s and hygienist’s apparent professional com petence, handling of the child’s behaviour, cleanliness of the office (surgery), overall parent satisfaction, parent’s and child’s age, and parental educational level. The chi-square test was used to assess overall parental satisfaction and the other study variables. For the multivariant study, CHAID (CHi-square Automatic Interaction Detection) analysis was used. Results: Out of a possible 400 respondents, 389 completed the
INTRODUCTION Health service use is conditioned by factors related to its organisation, the healthcare professionals who work within it, and the needs and demands of the population. For health centres to function properly, the management of patient demands and available time are crucial.1 All these factors are strongly related to patients’ ultimate satisfaction with the care that they receive within the health service. User satisfaction is one of the most important components for measuring health service quality. As Donabedian (1996) states, it is impossible to describe quality correctly without the clients’ point of view, because their opinions provide information on the success or failure of the health system in meeting patients’ expectations.2 Generally, it has been assumed that user satisfaction more or less directly indicates that the service fulfils clients’ expectations.3,4 It is therefore essential to determine users’ satisfaction in their assessment of the quality of health service provision.5
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questionnaire, of whom 384 completed it in full. The variables significantly associated with overall parental satisfaction were waiting time before the consultation, cleanliness of the surgery, the manner in which appointments were made, staff attitude with regard to helping, listening and understanding, the dentist’s and hygienist’s professionalism, handling of the child’s behaviour, and information given by the dentist and hygienist. In logistic regression, the aspects that significantly explained parental satisfaction were the professionals’ apparent competence, the information given by the dentist, staff interest in their child, and the handling of the child’s behaviour. Conclusion: The parents who took part in this study were satisfied with the care that their children received, mainly with aspects related to professional competence and information provided.
In recent years, the study of satisfaction in Spain and other developed countries in relation to health services has become an increasingly valuable instrument for health service marketing and research.6 It is accepted by health service providers and some researchers that patient satisfaction is an important outcome of the work performed by health professionals and that this factor is associated with patients’ use of services and their behaviour. This justifies the use of patient satisfaction to measure improvements in quality.7,8 Analysis of satisfaction is also being used as an instrument for justifying various healthcare reforms.9 There are three reasons why satisfaction should be considered a significant measure of the outcomes of care. First, studies show that satisfaction is a good predictor of patient compliance with treatment and continuing to visit a clinic and service provider. Secondly, patient satisfaction is a useful instrument for evaluating clinical and communication models, such as success in informing or involving patients in taking decisions on the type of care that they receive. Thirdly, patients’ opinions
C Llena PhD, MD, DDS. Primary Dental Care, Department 9, Valencia Health Service. Associate Professor, Department of Stomatology, University of Valencia, Spain. G Clemente DI, PhD. Professor, Department of Statistics, Statistics and Operations Research, University of Valencia, Spain. L Forner PhD, MD, DDS. Professor, Department of Stomatology, University of Valencia, Spain.
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can be used systematically to improve organisation of service provision.10 Satisfaction is based on the interaction between patient expectations and patient perception of the services that they receive. Thus, subjective perceptions accompanied by prior expectations shape the expression of service quality.11 There is a consensus that public opinion, expressed through different channels, either through patient satisfaction questionnaires alone or in combination with other quantitative methods, offers essential information on how members of the public see the operation of the health services. As such, it is a public participation instrument for improving healthcare quality.12 Increasing importance is being attached to one of the quality indicators that measures results, namely patient satisfaction with higher quality care.13 Consumer satisfaction can be regarded by the staff involved as an indicator or predictor of the effectiveness of their management of the patient concerned during the care process. It has been shown that dissatisfied patients do not keep their appointments and do not comply with their treatment or medication. Also, they are more inclined to leave their practitioner and to change their health plan.14 A larger number of patient questionnaires have become available for assessing the outcome or quality of healthcare in different conditions and settings. All these measures were recently grouped within the term ‘patient-reported outcomes’, which refers to all concepts and measures concerning health and healthcare as perceived and reported by patients. Patientreported outcomes represent the effects of treatment provided for them, assessed entirely from their perspective. Different questionnaires have been developed and used to measure different concepts, such as quality of life, health-related quality of life, health perceptions, symptoms, and satisfaction with treatment/care.15 In dentistry, two frequently used assessment tools for studying dental clinic users’ satisfaction are the Dental Visit Satisfaction Scale (DVSS)16 and the Dental Satisfaction Questionnaire (DSQ);17 the latter assesses views on dentistry in general, rather than specific dental visits. The DVSS comprises three elements: information-communication, understandingacceptance, and technical competence. Both of the scales have limitations and have been revised and adapted for use in different populations.18-21 In Spain, most of the autonomous regions/cities have developed public health dental programmes with preventive activities (mainly fluoride mouthrinsing, oral health education, and the application of fissure sealants). Some have also established a basic coverage for the care and treatment of the permanent dentition of children (aged 6-15 years) with public finance and the public or private provision of services. In the autonomous region of Valencia, where this study was conducted, the provision of child healthcare has been funded and developed as a public model. To date, there has been no assessment of parental
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satisfaction with the oral healthcare within this model. However, such a study has taken place in Andalusia where oral healthcare programmes for children aged 6-15 years benefit from public financing and public and private provision.22 Many of the questions in the DVSS and the DSQ were not relevant to the oral health model in the Valencia region. For this reason, an assessment tool was developed in order to evaluate parents’ satisfaction with the care that their children received in primary care dental units in the Valencia region. It was based on criteria such as professional competence, staff interest in caring for and understanding children and their parents, handling of the children’s behaviour, and dental services organisation (accessibility, facilities and cleanliness of the surgery).
AIM The aim of this study was to evaluate parents’ satisfaction with the oral healthcare that their children received in a primary dental care unit in a Spanish region through a self-administered questionnaire.
METHODS A cross-sectional study was carried out at the Department 9 Primary Dental Care Unit in the Valencian autonomous region during the first half of 2009. The population of 0 to 15-yearold potential users of the service in this department was 60,370 children and in the previous year, the total number of children who visited the unit was approximately 7000. The study was independently reviewed and approved by the Ethical Board of the University General Hospital of Valencia. The Valencia Health Agency Primary Dental Care Unit’s mission is to promote oral health and prevent disease in children under the age of 15 years with preventive activities (mainly fluoride mouthrinsing, dental education, and the application of sealants) and to provide care for the permanent dentition of children (6-15-year-olds). Children attend the Unit either as a result of paediatrician referrals or at the request of their parent(s). All local children therefore have the same opportunity to attend this Unit, which covers the population from the Health Department 9 and has three primary care health centres. Each of the three health centres has a dental surgery, which is attended by the same dentist and dental hygienist. The study population consisted of parents who brought their children to any of the three Primary Dental Care Unit surgeries between January and June 2009 and whose children had attended with a parent at least once before the study. This previous visit was required because it ensured that when they were asked to complete the questionnaire, all parents who took part had experienced at least two visits to a unit and, consequently, were in a better position to judge their satisfaction than those making a first visit. Sample size was calculated for a 95% confidence interval, estimating a final sample size of 384 individuals. To ensure a
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balanced representation from the three health centres in the sample, it was calculated that the proportion of individuals in the sample for each centre would correspond to the proportion of the local population it served (40%, 33%, and 27%, respectively). The sample was randomly selected in each health centre, using a table of random numbers that were assigned daily to each patient from the list of those with review appointments. The questionnaire that was used was based on others previously published16-22 and included some questions that had not previously been asked. These were handling of the children’s behaviour, waiting room adaptation for children, and age and educational level of parents. The questionnaire comprised 15 questions and was reviewed by three dentists from the Valencian Health Agency working in primary care. These dentists gave their opinions on the pertinence, relevance and ease of understanding of the questions and suggested modifications. The revised questionnaire was then piloted by 43 parents attending the dental unit during one week. The patients were asked to comment about difficulties, doubts or
‘overall satisfaction’, and the other study variables was analysed with the chi-square test. The CHAID (CHi-square Automatic Interaction Detection) was used for multivariate analysis. This method allowed the relationship between a dependent variable and multiple independent or explanatory variables to be assessed.
RESULTS Cronbach’s alpha was 0.834, an indication of high reliability of the results. Only 11 (3%) parents refused to take part in the study. A total of 389 questionnaires were received, of which five were excluded because fewer than 60% of the questions were answered. Thus 384 questionnaires were analysed.
Information about children and parents (Table 1) Eighty-three children (21.5%) were under the age of 7 years, 176 (45.8%) were between 7 and 10 years, and 125 (32.7%) were between 11 and 15 years. With regard to parental age,197 (51.3 %) of the sample were between the ages of 31 and 40, 156 (40.6%) were between 41 and 50, and only 31 (8.1%) were between Table 1: Information about children and parents 20 and 30 years old. Q1. Child’s age (years) 12 NR Total The majority of the 384 parents— Number of responses 83 17 159 125 384 301 (78.38%)—were female. Fortyfive (11.7%) parents said they were university educated, 168 (43.8%) said Q2. Parent’s age (years) 16-20 21-30 31-40 41-50 51-60 >60 NR Total they had secondary education, and Number of responses 31 197 156 384 169 (44%) that they had only primary education; two respondents did not Q3. Parent’s level of education < Primary Primary Secondary University NR Total answer this question. Parental age Number of responses 169 168 45 2 384 and education level showed signifiNR = no response cant association with overall parental satisfaction. Younger parents (aged suggestions to improve the questionnaire. A second revision from 20 to 30 years) and those with a university education was then made to the questionnaire and the resulting version were the least satisfied. was used in this study. Apart from questions on parental satisfaction, parents were also asked to state their age, their Parents’ comments about administration of dental care unit child’s age, their (the parent’s) level of education, waiting time (Table 2) for the appointment, time in the waiting room, appropriateness One hundred and seventy-nine parents (53.6%) had requested of the facilities, and difficulty or otherwise of contacting the an appointment between three and six months earlier, 104 dental unit. Responses were measured on a five-point Likert (31.1%) more than six months before, and 51 (15.3%) less than scale (very satisfied, satisfied, neither satisfied nor dissatisfied, three months before (percentages obtained from the answered not very satisfied, not satisfied at all). items—334). One hundred and seventy-five (55.7% of the The questionnaire was self-administered and was given to the answered items) parents had experienced difficulties in contactparents following the dental visit by staff other than those from ing the dental unit before the date scheduled for their child’s the dental surgery. Parents were given an explanation. They visit. Of these, 128 were due to the difficulty in arranging the answered the questions in a part of the health centre away from appointment by telephone and 47 due to the lack of appropriate the dental unit in order to facilitate anonymous answers. information on the appointment card. However, these variables The resulting data were analysed with statistical software did not significantly influence overall parent satisfaction. (SPSS version 15.0; SPSS Inc, Chicago, USA). Reliability was The median time waiting in the clinic before seeing the calculated using Cronbach’s alpha. Descriptive analysis of the dentist was between 15 and 30 minutes, with 245 (63.8%) data was performed. The independence between the item children waiting 30 minutes or less. This variable was found
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are shown in Table 3. All the variables were graded as at least acceptable (‘neither satisfied nor dissatisfied’). The mean of all the variables significantly associated with overall parent Parental satisfaction with professional dental treatment (Table 3) satisfaction, except for the variable ‘treatment received when The variables relating to the information and care received making the appointment’, was in all cases satisfactory. Eightyfrom the dentists associated with overall parental satisfaction six (22.4%) parents considered that their overall satisfaction was acceptable. The remaining 298 (77.6%) considered that they were Table 2: Parents’ comments about administration of the dental care unit satisfied or very satisfied. Q4. Time (months) waiting for consultation 6 NR Total The organisational aspects found to be significantly associated with Number of responses 51 179 104 50 384 overall parental satisfaction were the waiting time before seeing the denQ5. Time (minutes) waiting to go in 45 NR Total tist/hygienist and the cleanliness of Number of responses 62 183 101 38 384 the surgery. The aspects related to the care received which significantly Q6. Was the waiting room adequate for a child? Yes No NR Total influenced overall satisfaction were Number of responses 188 194 2 384 the treatment received when making the appointment, staff interest in serving, listening and attending, the Q7. Cleanliness of surgery (see Table 4) 1 2 3 4 5 NR Total dentist and hygienist’s perceived Number of responses 120 198 66 384 professionalism and handling of the child’s behaviour. Finally, the inforQ8. If you needed to contact the dental unit Yes No NR Total mation-related aspect with a signifibefore the appointment, was it simple? cant influence on user satisfaction Number of responses 139 175 70 384 was found to be information given by the dentist and hygienist.
to be significantly associated with overall parental satisfaction (P
