| What explains obtaining dental care? |
| To recognize some of the limitations of current explanations of dental utilization | |
| To become familiar with premises to guide the development of a model of the dental care process | |
| To understand the components of a model of the dental care process | |
| To recognize the four blocks that influence the probability of beginning an episode of care | |
| To be familiar with the contents (variables) within each of the four blocks | |
| To understand the assigned reading and how its findings relate to the model of the dental care process | |
What explains obtaining dental care?
| Recent review of the literature – | ||
| (Journal of Dental Research, April 2002) | ||
| Dutch government (1995) reformed the public health insurance system | ||
| Evaluation study was planned to study the effects of insurance reform | ||
What explains obtaining dental care?
| Evaluation study - the role of dental insurance in dental utilization | ||
| required a variable list comprised of independent explanatory variables | ||
| No forceful theoretical argument | ||
| for restricting the potential explanatory variables | ||
What explains obtaining dental care?
| 144 articles met the study criteria | ||
| 143 were surveys | ||
| 1 controlled trial | ||
| Resulted in a list of 538 explanatory variables | ||
| Grouped into patient, dentist, and system variables | ||
What explains obtaining dental care?
| Comprehensive behavioral model | ||
| explaining dental utilization | ||
| has not emerged | ||
| Knowledge of dental use is fragmented | ||
| across variety of health behavior models | ||
| many empirical investigations of dental use | ||
Limitations to existing studies of dental use
| Few studies have used a multidisciplinary approach | ||
| Narrow focus of previous studies fragments understanding of dental care process | ||
| Economic studies have rarely considered measures of values | ||
| Psychologists often have failed to measure social status and have ignored economic variables | ||
Limitations to existing studies of dental use
| Another limitation is the descriptive nature of many past studies | ||
| Have repeatedly shown that use of dental services highly correlated with income, education, age, sex, perceived need, and other personal characteristics | ||
| Have also often reported inconsistent results | ||
Limitations to existing studies of dental use
| Factors important to explaining use of dental services receive minor attention or ignored altogether | ||
| Perhaps most prominent neglected factor is the provider | ||
| Patients generally ignorant of their clinical oral health status | ||
| Providers and characteristics of their practice may have substantial influence on dental use | ||
Limitations to existing studies of dental use
| Another lacking element is consumer search | |||
| Unclear: | |||
| whether individuals search for lower fees | |||
| or for providers with certain characteristics | |||
| e.g., reputation for quality, or painless dentistry, a comfortable office, or other considerations | |||
Limitations to existing studies of dental use
| Consumer search (cont.) | ||
| Some evidence that influenced by individual’s social network | ||
| The notion of “shopping” (the seeking of care from different providers) among group-approved providers | ||
| Others have described the role of the “lay referral system” in locating a usual source of care | ||
Premises to guide development of model of dental care process
| Empirically supported causal models of obtaining dental care are rare | |||
| 1) Must reflect fundamental choices regarding use of professional dental care | |||
| asymptomatic individuals | |||
| symptomatic individuals | |||
| 2) For those who visit the DDS | |||
| episode of care becomes the basic unit of analysis | |||
| (a sequence of dental services in a period for health maintenance) | |||
Premises to guide development of model of dental care process (cont.)
| 3) Use of dental services regarded not just as outcome | ||
| rather as a decision-making process | ||
| 4) Provider can influence individual’s use of dental services | ||
| throughout the decision-making process | ||
Premises to guide development of model of dental care process (cont.)
| 5) Dental care processes take place within a larger social structure | ||
| Can place constraints on that process | ||
| 6) Main reason for dental visits | ||
| Maintain or improve oral health and quality of life | ||
| Not to purchase dental services | ||
| A social process | ||
| Includes | ||
| the dentist | ||
| the patient | ||
| sometimes other family members | ||
| insurers as well | ||
| Initiated by some form of stimulus | ||
| Asymptomatic cues | ||
| Symptomatic – e.g., toothache | ||
| Patients influence future treatment | ||
| Self-diagnosis | ||
| Search for DDS capable of providing services that patient desires | ||
Probability of beginning episode of care
| Organized into 4 interrelated blocks: | ||
| Structure | ||
| History | ||
| Cognition | ||
| Expectation | ||
Probability of beginning an episode of dental care
Probability of beginning
episode of care
Block 1 - Structure
Probability of beginning
episode of care –
Structural - sociodemographic variables
| Age | |||
| Used as an explanatory variable in a large number of studies | |||
| Studies typically report utilization patterns falling in an inverted U-shaped curve | |||
| With the very young and the very old seldom using dental services | |||
| Adolescents and young adults having the highest use of services | |||
| Moderate decline in use observed in middle age | |||
Probability of beginning
episode of care –
Structural - sociodemographic variables
| Gender | ||
| Used as an explanatory variable in a large number of studies | ||
| Studies typically report a larger portion of females than males saw a dentist during past year | ||
| These findings have not been considered in a theoretical perspective | ||
Probability of beginning
episode of care –
Structural - sociodemographic variables
| Race and ethnicity | ||
| Used as an explanatory variable in a large number of studies | ||
| The most consistent finding is that a larger proportion of whites than non-whites use dental services | ||
| Studies have found differences according to ethnicity as well | ||
Probability of beginning
episode of care
Block 1 - Structure
Probability of beginning
episode of care –
Structural – social class variables
| Income | |||
| Perhaps the most frequently reported explanatory variable | |||
| Considered a primary barrier to seeking care | |||
| Initially thought to be the key variable associated with utilization | |||
| on assumption that if income equalized by providing financial assistance, barriers to utilization diminished | |||
| This finding not confirmed | |||
| has led to considerably more investigation of other social/demographic/ psychological factors affecting utilization | |||
Probability of beginning
episode of care –
Structural – social class variables
| Occupation | |
| One of the most measurable dimensions of SES – has received considerable study in utilization research | |
| Available findings indicate: | |
| lower use among the unskilled and semi-skilled population than among those in higher level populations.. | |
| with highest utilization rate found among professional/ exec level occupations |
Probability of beginning
episode of care –
Structural – social class variables
| Education | ||
| Another SES variable frequently used in studies of dental utilization | ||
| Generally utilization increases as the level of education increases | ||
| Gaps in utilization between the very poorly educated and those with moderate education larger.. | ||
| than differences in utilization among other educational groups such as hs and college graduates | ||
Probability of beginning
episode of care –
Structural – social class variables
| SES (socioeconomic status) | |
| SES as composite measure of income, occupation, and education hypothesized to be related to use | |
| Not frequently used in research because is difficult to measure | |
| Numerous studies have found that utilization of dental services increases as social status increases |
Probability of beginning
episode of care
Block 1 - Structure
Probability of beginning
episode of care –
Structural - insurance variable(s)
| Insurance | ||
| Private dental insurance | ||
| By reducing the cost of care, increases the probability of visiting the dentist | ||
| Medicaid dental insurance has not reduced disparities in dental care use | ||
Probability of beginning
episode of care
Block 1 - Structure
Probability of beginning
episode of care –
Structural - environment variables
| Geographic location | |
| Frequently studied variable in utilization research | |
| Proportion of persons visiting the dentist varies in different regions | |
| Other factors: urban vs. rural, inner city vs. other urban, large vs. small towns, density of population influence patient utilization | |
Probability of beginning
episode of care –
Structural – environment variables
| Community variables | |||
| Several variables, other than size, influence dental service utilization: | |||
| among the most significant of these is community water fluoridation | |||
| Utilization found to be lower in those areas where water is fluoridated | |||
| Healthier teeth? | |||
| Indicator of the preventive orientation of the comty? | |||
Probability of Beginning an Episode of Dental Care
History block
Usual
source of care
| Having a usual source of care eliminates the cost of search | ||
| Thereby increasing the probability of entering an episode of care | ||
| Having a regular provider also has direct effects on the cognition block | ||
| by increasing the salience of dental care | ||
History block
Past
preventive behavior
| 1) Continuity of care | ||
| Places past experience on a continuum ranging from regular preventive visits to avoidance of dental care over an extended period | ||
| There is evidence that dental behavior determines dental attitudes and not vice versa | ||
| 2) Oral self-care | ||
| Similarly dental values are formed by experience with health behaviors, such as brushing and flossing | ||
History block
Quality
of care/oral health stock
| Quality of care | ||
| Assessment of past outcomes –physiological, functional, quality of life, economic, durability | ||
| Can influence cognition and expectation blocks | ||
| Oral health stock | ||
| Individuals inherit an initial “stock” of oral health that depreciates over a lifetime | ||
| Person’s oral health shapes perceptions about the salience of dental care and expected rewards and costs (e.g., in terms of pain necessary to restore oral health) | ||
Probability of beginning an episode of dental care
| Dental knowledge | |||
| Dental satisfaction with past episodes of dental care | |||
| Perceived salience of dental care | |||
| Perceived symptoms | |||
| Valuation of oral health | |||
| Perceived norms | ||||
| Expectations about health behavior - such as the frequency considered acceptable for seeing a health provider | ||||
| Perceived norms may be influenced by the social environment – the family can be important | ||||
| Perceived norms may be influenced by the dentist | ||||
| – use of recall systems | ||||
| – ways DDS signal expectations to patients regarding appropriate preventive behavior | ||||
Probability of beginning an episode of dental care
| Expected rewards | |||
| For the symptomatic individual | |||
| associated with belief or faith that services will result in eliminating or reducing the symptom | |||
| Also the reward of “having done the right thing” and social approval of family and friends | |||
| For the asymptomatic individual making a preventive visit | |||
| Expected rewards defined mainly by the individual’s belief that regular checkups will prevent future problems from occurring | |||
| If motivated by esthetics, belief that services will improve appearance | |||
| Expected costs | |||
| Time, money | |||
| Perceived ability to afford an episode of care in terms of fees and time | |||
| Social costs | |||
| Anxiety about the dental episode – expected pain, fear, anxiety | |||
| Self-esteem – the perceived “social distance” between provider and patient | |||
| Cost of search – especially for individuals without a usual source of care | |||
| Level of uncertainty associated with any of the above: | |||
| greater uncertainty about the costs/more confidence in the rewards… | |||
| could lead to increased probability of beginning an episode | |||
| Based on the close association of income and patterns of utilization | |||
| might predict that cost is the leading barrier in not seeking care | |||
| Has seldom, if ever, been the predominant self-reported reasons given | |||
| When cost barriers removed in low income groups | |||
| the utilization rate does not necessarily rise unless some other form of motivation, such as dental health ed given | |||
| There is a clear need for more research to determine | |||
| how actual dental need influences perceived need | |||
| and how both of these affect action | |||
| In order to increase utilization of dental services results of research suggest need to direct attention at both beliefs and actions | |||
| The belief system needs to be one that incorporates concept that oral disease has consequences and that taking action alters these consequences | |||
| Interventions need to be based on an UNDERSTANDING OF THE MULTIPLE FACTORS influencing utilization | |||
Model for dental utilization for any reason - Block 1– Structure– (In reading)
Model for dental utilization for any reason - Block 2 – History– (In reading)
Model for dental utilization for any reason-Block 3-Cognition– (In reading)
Model for dental utilization-Block4-Expectations– (In reading)