Community Consultation of Families with Young Children about a New dental Service Centre in Southeast London- Juniper Publishers
Juniper
Publishers-Open Access Journal of Dentistry & Oral Health
Abstract
Objectives: To engage families with
young children and empower them to inform service provision; explore the
views and expectations of families with young children in West Norwood
area of how dental services may be best provided at the West Norwood
Health and Leisure Centre (WNHLC); explore barriers to dental care,
uptake and use of dental services.
Research design: Cross-sectional questionnaire survey
Participants: 1,016 parents/guardians with children aged seven and under.
Main outcome measure: Willingness to access the dental service.
Results:An overall response rate of
24% (246/1016) was achieved. The majority (72%, n=178) were unaware of
the dental services at the Centre. Lack of convenient appointment times
(43%, n=106) was the most common barrier to accessing dental care
reported by families. Approximately 48% of parents indicated their
willingness to bring their children to the WNHLC, the majority of them
were NHS users (75%, n=89, OR=1) who attended the dentist occasionally
(65%, n=77, OR=4.8, p<0.01). Essential facilitating factors were
friendly dental care providers (81%, n=203), ease of getting
appointments (76%, n=186) and suitable opening hours (74%, n=183).
Conclusion: The results of this
study signified the need of collaboration with local settings to
increase awareness about its dental services. The uptake of service
would depend upon factors such as its opening hours, ease of getting
appointments, having a patient-friendly dental team. The results of the
study will inform future dental service provision at the Centre in the
light of NICE guidelines (NICE, 2008).
Keywords: Outreach; Skill-Mix; Access; Barriers; Communication; Dental services; NHSIntroduction
Access to dental services is a major policy and
public concern in the UK, which is considered as “one of the
contributing factors for improvement of oral health”[1,2]. Differences
in oral health and oral health service utilization exist at all levels
for various reasons ranging from psychosocial characteristic of
individuals to regional deprivation [3,4] (Nuttall, Freeman,
Beavan-Seymour, Hill). It is evident from local studies in England that
there is inequity in access in deprived areas of London [5,6,7].
The borough of Lambeth is the fifth most socially and
economically deprived borough in London and distinctive in terms of its
young and dynamic population, ethnic diversity and a highly mobile
population (Census Information Scheme, 2012
&Trust for London and New Policy Institute, 2010-2014). The oral
health needs among pre-school children in local children’s centers are
high [8]. Despite availability of free dental services to children and
more equitable dental services for adults through the National Health
Service in the UK, health service data reveals lower access rates in
Lambeth than London and England [9,10].
Numerous attempts to address inequity in access to
dental services by reorienting dental services to ameliorate oral health
inequalities [11]. The WNHLC is one of the initiatives of the local
authorities in partnership with the NHS to improve health and wellbeing
of the residents in the West Norwood area of south Lambeth (West Norwood
News, 2009). The dental service at the WNHLC provided as a part of
King’s outreach programme, is perceived as an opportunity that will
serve the local community by providing primary dental care in holistic
way
The high need for dental service and low level of service
uptake, as in the West Norwood area, reflects a poor ‘fit’ between
the patient and health care system [12]. Community engagement
in planning, development and management of health related
activities that affect them have been a strategic recommendation.
There is evidence that engaging communities in service design
and delivery empowers them and strengthens community
cohesion making health policy initiatives more sustainable (NICE,
2008). Therefore we set out to assess the families’ perceptions of
barriers in accessing dental services and the factors that would
motivate them to bring their children more often, thus enabling
prevention as well as treatment services [10].
The aim of the project was to explore the views of families
with young children in order to ascertain their expectations of
how dental services may be best provided at the WNHLC, with
a view to informing the structure and delivery of dental services
at this site.
Methods
Chemicals
Ethical approval was granted by King’s College London
Research and Ethics Committee (Ref number BDM/12/13-
77).Based on the local data, children below seven years were
included in the sample [8]. Initially, seven primary schools and
four children’s centres in the West Norwood area from Lambeth’s
Local Authority website [10] within a radius of one mile from the
WNHLC were approached and invited to participate in the study.
Five primary schools and one children’s centre participated and
distributed questionnaires to 1,016 parents and guardians of
children aged five to seven years.
An initial approach with the gatekeepers was made through
a written invitation and promotion was undertaken through
posters and newsletters. The parents/guardians were given the
questionnaire with an information sheet by the class teachers
in an anonymous envelope. The information sheet contained
detailed information about the study and emphasized voluntary
and anonymous participation. Attempts were made to enhance
the response rate by approaching the schools via reminder
letters, emails and phone calls and pens were given as an
incentive and extra questionnaires were kept in each school
(Dillman, Smyth, Christian, 2008).
A two-page questionnaire was derived from validated
questions from the Child’s Dental Health Survey 2003 [3].
Questions on quality of dental care and barriers were derived
from the local surveys [8,13]. The questionnaire consisted of
mainly close-ended questions that derived information about the
awareness of the Centre and its dental service, socio-demographic
features, dental service usage, barriers, preferences, etc. The final
open-ended question requested any suggestions for the dental
service at the Centre. Only 246 parents/guardians returned
completed surveys to their respective class teachers. However,
this number was considered adequate since a calculated sample
size with 80% power at 5% level of significance was 84 to test
the proportion of parents/guardians willing to bring their children, using the chi square test. A multivariate regression
analysis was used to assess factors independently associated
with willingness to bring children to the centre. The regression
model was adjusted for variables such as the awareness of
the WNHLC and its dental service, child’s and respondents’
attendance pattern, child’s and respondents’ type of dental care,
influence of dental students on the respondents’ decision to avail
the service. Quantitative data was analysed using SPSS software
whilst responses to open question were analysed using simple
thematic framework methodology.
Results
Response
Out of the eleven institutions targeted, five primary schools
and one children’s centre agreed to participate in our survey. A
response rate of 24% (range 17% to 80% at school level) was
achieved.
Socio-demographic characteristics as reported by the respondents
The majority of parents (92%, n=225) and children (54%,
n=133) were female. The average age of child was six years
ranging from one to nine years? The presence of siblings was
identified by 32 respondents (12%). In terms of ethnicity, a
majority of the parents identified their children as White (53%,
n=131) followed by Black (21%, n=52) and multiple/mixed
(20%, n=49), Asian (5%, n=11) and other (1%, n=3) ethnic
groups. Here in after, respondents will be referred to as parents.
Reported dental attendance patterns and type of dental care received
In response to questions about dental attendance patterns,
it was reported that 47% parents (n=116) and 64% of their
children (n=158) attended a dentist regularly. A further 31%
parents (n=76) and 25% children (n=61) reported occasionally,
while 20% parents (n=50) and 11% children (n=27) were
reported as attending only when in trouble. There was a
significant association between child and parental attendance
patterns (p<0.001).
When asked about the type of dental service used, out of
246 parents, 71% parents indicated that they received NHS
care (n=174) that was either paid for (40%, n=99) or free (31%,
n=75). On the other hand, a slightly higher proportion of 79%
children (n=193) were reported as being provided NHS dental
care. Furthermore, 17% parents (n=41) utilized private dental
care out of them 40% (n=16) reported utilizing NHS dental care
for their children. A notable proportion of 13% children (n=32)
were reported as utilizing private dental care
Reported awareness about west norwood centre and its dental service
With regards to the awareness of WNHLC, 51% parents
(n=125) were aware about the Centre while the majority (73%,
n=178) had no perception about its dental service as reported.
Of the 125 parents who were aware of the centre, 52% (n=65)
had no knowledge of its dental wing.
Willingness to bring child to the west norwood centre’s dental service and influence of supervised dental students on decision to bring their child
Overall, 48% (n=119) of parents indicated a willingness to
bring their child to the centre whilst 36% (n=89) were unsure
about the Centre or required more information. Of the 119
parents who reported that they would bring their child, the
dominant ethnic groups were White (46%, n=55), Black (27%,
n=32) and of mixed ethnicity (19%, n=23). The results suggested that among those who showed willingness to bring their child,
75% (n=89) of parents and a higher proportion of 82% children
(n=97) were NHS users. There was significant association
between the child’s ethnicity (p<0.01), child’s dental attendance
(p<0.05) and parental dental attendance (p<0.001) and their
willingness to visit the Centre with Whites, parents and children
attending occasionally or only in trouble identifying that they
were more likely to use the service. Less than half of the parents
(44%, n=107) indicated that the provision of dental treatment by
dental students at the centre would not influence their decision
to visit the Centre as shown in Table 1.
Reported reasons for delay to access dental care for children
The lack of convenient appointment time was the most
important barrier to take their children to the dentist reported
by the parents (43%, n=106). A significant association was found
between lack of convenient appointment time and willingness
of parents to bring their child to the Centre (p<0.01) with the
parents most willing to bring their child to the centre reporting
the lack of convenient appointment time as a barrier to care.
Figure 1 displays responses to what are the important
features of a quality dental service for children. The six key
features showed agreement, having a friendly dental care
provider being the most important issue. Parents were asked
about their preferred time to visit a dentist. The majority of the
parents indicated that after school followed by weekends and
school holidays are the most appropriate times for their children
to visit a dentist. The parents were asked to choose from a range
of options on how, and where, the Centre’s dental service could
best promoted the two families in the area who do not have a
dentist. The vast majority of the parents endorsed advertisement
at the schools (87%, n=214) followed by GPs (74%, n=183) and
children’s centres (63%, n=154) as shown in Figure 2.
Parental suggestions
A final question was an open question regarding anything
else the respondents would like to suggest as to how the dental
service at the West Norwood Health and Leisure Centre could
best serve the local families. This accounted to 25% (n=61) of
the total responses.
Maxwell’s dimensions of quality, has been widely used
to evaluate and assess the quality of health services [14]. The
comments and suggestions of parents were in line with Maxwell’s
dimensions. Of all the dimensions of quality, ‘accessibility’ was
predominately evident in the responses. The most repeated
theme that emerged in accessibility were opening hours, ease of
getting appointments, online registration, and special provision
for children with learning disability, advertisement to increase
awareness about the availability of the service in Norwood. In
relation to ‘relevance’ of the dental service, there was a standard
suggestion for the centre to emphasize on preventative services
and oral health awareness through schools and children’s centres
via seminars, workshops, lectures, etc. ‘Acceptability’ mainly was
apparent in terms of accepting supervised dental students as
the primary dental care provider. Areas of concerns regarding
supervised dental students emerged as duration of treatment,
experience in handling children, and change of provider in
every visit, maturity level and confidence linked to anxiety
of respondents. There was a clear demand for transparency
of personnel including need of trained and experienced
supervisors along with a sufficient workforce through means of
dental auxiliaries. Comments in relation to ‘equity’ were raised in relation to acceptance of adults at an affordable rate. The
parents recommended use of patient-friendly aids such as online
booking system, text reminders to increase the ‘effectiveness’
of the dental service. Adequacy of staff was highlighted as an
important criterion to increase the ‘efficiency’ of services.
Discussion
The latest report on Children and Young People’s Health
(2014) recommends improvement in oral health outcomes and reduction in oral health inequalities by putting families with
young children at the heart of commissioning [10]. This study
gave an opportunity to understand the nature of the service
users in terms of socio-demographic characteristics, their
barriers in accessing dental care and the potential areas that
need to be considered in service design and capacity building at
the new centre.
In this study, the majority of the respondents were females.
The gender profile of the children in the study sample was
identical to Lambeth’s general children population with 51%
female and 48% male (Lambeth First 2011). In terms of ethnicity,
the sample showed similar characteristics to the Lambeth
population with the maximum number of respondents classifying
themselves as ‘white’ followed by ‘black’ and ‘multiple’ ethnic
groups. The willingness to use the new centre showed variations
with respect to ethnicity, respondents classifying themselves as
‘white’ being more willing to use the dental service at the new
centre.
The majority of the parents and their children were users of
the NHS dental care, which were similar to the results from the
national survey. Additionally, similarity in results to the national
surveys was evident in terms of dental attendance patterns;
the majority of the parents and their children reported visiting
their dentists for regular check-ups (Morris et al. 2006; Office
for National Statistics 2011). This finding may be a result of
response bias as a questionnaire approach may have filtered
out the ones who are less likely to visit a dentist or respond
to a survey because evidence suggests that Lambeth has low
uptake of dental care [6, 8-10]. There could also be two other
possibilities in that the questionnaire attracted pro-active
parents or the parents genuinely attend the dentist regularly as
reported (Benett 2013).
Parental and child’s attendance patterns were seen to be
strongly associated with each other which is similar to findings
from the national survey (Morris et al. 2006). As reported by
other studies, in this population the parental perception of dental need predicted their dental attendance [15,16]. This
study also showed that there was an association between
parents’ attendance pattern and their willingness to bring
their child to the new centre’s dental service. Those being nonregular
attenders reported they were more likely to use the
dental service at the centre. This may have an positive impact
on reducing oral health inequalities as evidence shows that oral
health and associated problems are associated with attendance
pattern [17] (Richards & Ameen 2002).
This study showed that, according to their parents, the
majority of children were reported to have had no recent dental
problem. These findings do not necessarily suggest absence of
dental problems but may be a result of ‘social desirability’ or lack
of awareness of the child’s oral health as highlighted in previous
studies [13] (Sjöström & Holst 2002).
A significant relation between the age of the child and
the time since the last dental visit was observed, which was
more pronounced in the 5-7 age groups. Various reasons may
contribute to this finding. One may be that decay in deciduous
molars is more common in this age group as highlighted in other
studies (Levine, Pitts, Nugent 2002; Milsom, Blinkhorn, Tickle
2008).
In terms of barriers to access to dental care for their children,
the study highlighted that lack of convenient appointment
times was the most common difficulty faced by the parents. In
addition, parents being busy, failure to find a dentist followed by
fear of cost were also found to hinder the use of dental service.
These findings confirm results from previous researches done in
the area [5,8,13,18]. In response to the most convenient time to
bring their children, there was a definite preference of having
appointments after school, at weekends and during school
holidays. Finally, in terms of defining a quality dental practice for
children, it was found that a child-friendly dental care provider
with ease of getting appointments and suitable opening hours
are important factors that need to be considered, which are in
parallel to previous research evidence [19,20].
With regards to dental care being provided by dental
students, there was a mixed response with less than half of the
parents approving the concept, which was similar to the findings
of another recent local study [19]. Suggestions in terms of
necessity of mandatory supervision of the students along with
issues linked to the experience and level of expertise were made.
The barriers as well as preferences suggested by the
parents
are key features that need to be considered while planning
the service delivery at the new centre. An area that will need
to be clarified is the discrepancy between preferred time for
appointments and the working hours of the dental students.
Traditionally dental students have provided care during normal
9-5 office hours, Monday to Friday. It should also be born in mind
that after school is not always the best time to treat children
as they may be tired after a day at school. However, Saturday
opening may also be a consideration as the health and wellbeing centre
will be open seven days a week (Swider & Valukas 2004).
Furthermore, awareness of the centre and its dental services
was relatively low. However, it may be suggested that this study
might have had the positive effect of raising awareness of the
dental service at the centre amongst the parents who had no
previous knowledge of it. There is a need to initiate collaboration
between the Centre and the local settings such as schools, general
practitioners (GPs) and children’s centres in order to promote
the centre.
There were a number of limitations encountered during the
study. Feedback from the ethics committee suggested that ‘any
identifiable information (e.g. post code) should not be considered
in the survey to protect anonymity’. Indeed the previous study in
West Norwood found that taking the post code information from
participants did not benefit the overall study [19]. It should be
born in mind however that it is recognised that socio-economic
disparities are evident in oral health and related issues and any
bias in this area would not be detectable. The study design initially
included a qualitative approach using interviews/focus groups
that would have been ideal to explore the views and expectations
of families with young children but the schools found it difficult
to implement them (Ritchie, Lewis, Nicholls, Ormston, 2013).
The cross sectional self-administered questionnaire approach
featured a response rate of 24%, which varied between schools.
The fairly low response rate may introduce ‘non-responder’ bias
and could be a result of the lack of knowledge of the proposed
service (Berg 2005). Despite attempts to engage with the schools
and children’s centres and increase response rates by displaying
posters and putting up a note in the school newsletter as well as
a pen as incentive (Dillman et al. 2008; Edwards, et al. 2002), the
engagement of parents and guardians through the schools was
questionable.
Response bias was minimised by formatting the
questionnaires as suggested by William (2003) that included
non-leading, non-ambiguous simple and short questions,
the page-layout and clarity of the questionnaire. It has been
suggested that respondents often answer according to the social
norms prevailing rather than the factual situation and hence
social desirability might be a factor that may bias the results of
questionnaire surveys (Sjöström & Holst 2002). Also, the study
had a majority of females and it has been observed in national
data that women are more likely to report accessing dental care
than men (Office for National Statistics 2011). However, the
semi-structured questionnaire design had many advantages and
produced 246 responses that gave an opportunity to explore
various areas. It also provided the parents, an opportunity to
provide anonymously suggestions for future dental service
provision.
This research was one of its kind in informing future
actions
to ensure that West Norwood Health and Leisure Centre’s
Dental Service, serves the local population and maximises the
acceptability and utilisation of the service by catering services with
service user involvement. The ‘White Paper (2010)’ in their
slogan (No decision about me, without me) mentions that the
consumers of services should be the heart of everything and
in charge of decision-making about their care. Perhaps, if the
suggestions were implemented, measuring the outcomes could
add to the predictability of such a contemporary approach.
Conclusion
The study suggests that the awareness of parents/guardians
using the West Norwood Dental Services would increase if
the Centre promotes itself and collaborates with schools and
children’s centres and GPs. The results of the study show that
uptake of dental service would depend upon factors such as
opening hours, ease of getting appointments especially after
school and weekends, having a friendly dental team in a child
friendly dental setting. This study provided evidence that parents
of young children whose patterns of dental attendance are
less than ideal may be more interested in attending the centre.
The results of the study will inform dental service provision
at the West Norwood Health and Leisure Centre, although
implementing the findings may be challenging and will require
inter-sectorial co-operation.
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