Lecture 7 – September
3, 2003
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What explains obtaining dental care? |
Objectives
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To recognize some of the limitations of
current explanations of dental utilization |
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To become familiar with premises to
guide the development of a model of the dental care process |
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To understand the components of a model
of the dental care process |
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To recognize the four blocks that
influence the probability of beginning an episode of care |
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To be familiar with the contents
(variables) within each of the four
blocks |
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To understand the assigned reading and
how its findings relate to the model of the dental care process |
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What explains obtaining
dental care?
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Recent review of the literature – |
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(Journal of Dental Research, April
2002) |
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Dutch government (1995) reformed the
public health insurance system |
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Evaluation study was planned to study
the effects of insurance reform |
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What explains obtaining
dental care?
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Evaluation study - the role of dental
insurance in dental utilization |
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required a variable list comprised of
independent explanatory variables |
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No forceful theoretical argument |
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for restricting the potential
explanatory variables |
What explains obtaining
dental care?
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144 articles met the study criteria |
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143 were surveys |
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1 controlled trial |
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Resulted in a list of 538 explanatory
variables |
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Grouped into patient, dentist, and
system variables |
What explains obtaining
dental care?
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Comprehensive behavioral model |
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explaining dental utilization |
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has not emerged |
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Knowledge of dental use is fragmented |
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across variety of health behavior
models |
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many empirical investigations of dental
use |
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Limitations to existing
studies of dental use
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Few studies have used a
multidisciplinary approach |
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Narrow focus of previous studies
fragments understanding of dental
care process |
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Economic studies have rarely considered
measures of values |
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Psychologists often have failed to
measure social status and have ignored economic variables |
Limitations to existing
studies of dental use
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Another limitation is the descriptive
nature of many past studies |
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Have repeatedly shown that use of
dental services highly correlated with income, education, age, sex, perceived
need, and other personal characteristics |
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Have also often reported inconsistent
results |
Limitations to existing
studies of dental use
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Factors important to explaining use of
dental services receive minor attention or ignored altogether |
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Perhaps most prominent neglected factor
is the provider |
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Patients generally ignorant of their
clinical oral health status |
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Providers and characteristics of their
practice may have substantial influence on dental use |
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Limitations to existing
studies of dental use
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Another lacking element is consumer
search |
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Unclear: |
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whether individuals search for lower
fees |
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or for providers with certain characteristics |
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e.g., reputation for quality, or painless dentistry, a comfortable
office, or other considerations |
Limitations to existing
studies of dental use
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Consumer search (cont.) |
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Some evidence that influenced by
individual’s social network |
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The notion of “shopping” (the seeking of care from different providers) among
group-approved providers |
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Others have described the role of the
“lay referral system” in locating a usual source of care |
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Premises to guide
development of model of dental care process
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Empirically supported causal models of obtaining
dental care are rare |
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1) Must reflect fundamental choices
regarding use of professional dental care |
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asymptomatic individuals |
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symptomatic individuals |
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2) Use of dental services regarded not
just as outcome |
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rather as a decision-making process |
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Premises to guide
development of model of dental care process (cont.)
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3) For those who visit the DDS |
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episode of care becomes the basic unit
of analysis |
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(a sequence of dental services in a period for health
maintenance) |
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4) Provider can influence individual’s
use of dental services |
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throughout the decision-making process |
Premises to guide
development of model of dental care process (cont.)
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5) Dental care processes take place
within a larger social structure |
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Can place constraints on that process |
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6) Main reason for dental visits |
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Maintain or improve oral health and
quality of life |
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Not to purchase dental services |
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Slide 15
Model of dental care process
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Key to developing a comprehensive
model -View use/nonuse of
professional dental services as a decision-making process |
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With distinct, identifiable beginning
& end points |
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Composed of multiple stages |
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Episode of dental care is just one part
of the process |
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Path one takes is determined largely by
the interdependent decisions of the individual (parent/guardian) and the
provider |
Model of dental care process
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For any member of any population
process initiated by some form of stimulus (or cue) |
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Varies for symptomatic and asymptomatic
individuals |
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For asymptomatic |
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Cue might be recall reminder from DDS |
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Toothpaste commercial reminding to
brush regularly |
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Habit |
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For symptomatic |
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Cue is primarily the detection of a
dental symptom & its evaluation |
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Establishes the meaning &
significance of the illness |
Model of dental care process
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Assessment of symptoms – decision to go
to DDS |
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A social process |
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Small % of symptoms actually reach the
DDS |
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Two levels of measurement in the
presence of dental symptoms: |
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1) Those that are clinically observed
& measured |
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2) Those which are perceived and
self-reported |
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Perceived symptoms are a key variable |
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constitute a major determinant of
self-care |
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or provider-based care |
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20% of urban males sample in Norway did
not go to DDS because thought symptoms would go away spontaneously |
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Model of dental care process
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Eventually both symptomatic &
asymptomatic individuals decide whether
or not to visit the dentist |
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For asymptomatic - decision to visit
DDS |
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weigh potential benefits against
potential costs |
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in terms of time, money, pain, other factors |
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if perceived benefits outweigh
perceived costs, probably make appt for oral exam |
Model of dental care process
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Symptomatic individual –decision to
visit DDS |
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If individual can cope with the symptom |
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Or if nonprofessional treatments are
available |
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(modified diet, aspirin) |
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Influenced by social/ethnic group
beliefs |
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May decide not to go the dentist |
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Process of seeking professional dental
care ends |
Model of dental care process
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If either asymp or symp indiv lacks
usual provider of care – or if new provider is desired |
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Must search for a source of care |
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Individuals can influence future
treatments: |
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thru self-diagnosis |
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thru search for DDS capable of
providing services the individual wants |
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Success of search may be determined
partially by the provider |
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such as DDS’ rejection of low-income
Medicaid children |
Model of dental care process
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Although search occupies only one cell
in Figure 1, can occur virtually at any point in the process: |
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Person without a usual source of care
searches for a dentist |
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Patient dissatisfied with a treatment
plan may search for another dentist |
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Episode of care formally begins when
the “patient” presents for an oral exam |
Probability of beginning
episode of care
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Organized into 4 interrelated blocks: |
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Structure |
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History |
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Cognition |
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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
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Age |
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Used as an explanatory variable in a
large number of studies |
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Studies typically report utilization
patterns falling in an inverted U-shaped curve |
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With the very young and the very old
seldom using dental services |
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Adolescents and young adults having the
highest use of services |
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Moderate decline in use observed in
middle age |
Probability of beginning
episode of care –
Structural - sociodemographic variables
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Gender |
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Used as an explanatory variable in a
large number of studies |
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Studies typically report a larger
portion of females than males saw a dentist during past year |
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These findings have not been considered
in a theoretical perspective |
Probability of beginning
episode of care –
Structural - sociodemographic variables
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Race and ethnicity |
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Used as an explanatory variable in a
large number of studies |
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The most consistent finding is that a
larger proportion of whites than non-whites use dental services |
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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
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Income |
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Perhaps the most frequently reported
explanatory variable |
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Considered a primary barrier to seeking
care |
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Initially thought to be the key
variable associated with utilization |
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on assumption that if income equalized
by providing financial assistance, barriers to utilization diminished |
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This finding not confirmed |
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has led to considerably more investigation of other
social/demographic/ psychological factors affecting utilization |
Probability of beginning
episode of care –
Structural – social class variables
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Occupation |
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One of the most measurable dimensions
of SES – has received considerable study in utilization research |
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Available findings indicate: |
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lower use among the unskilled and
semi-skilled population than among those in higher level populations.. |
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with highest utilization rate found
among professional/ exec level occupations |
Probability of beginning
episode of care –
Structural – social class variables
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Education |
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Another SES variable frequently used in
studies of dental utilization |
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Generally utilization increases as the
level of education increases |
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Gaps in utilization between the very
poorly educated and those with moderate education larger.. |
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than differences in utilization among other educational groups
such as high school and college graduates |
Probability of beginning
episode of care –
Structural – social class variables
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SES (socioeconomic status) |
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SES as composite measure of income,
occupation, and education hypothesized to be related to use |
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Not frequently used in research because
is difficult to measure |
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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)
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Insurance |
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Private dental insurance |
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By reducing the cost of care, increases
the probability of visiting the dentist |
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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
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Geographic location |
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Frequently studied variable in
utilization research |
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Proportion of persons visiting the
dentist varies in different regions |
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Other factors: urban vs. rural, inner
city vs. other urban, large vs. small towns, density of population influence
patient utilization |
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Probability of beginning
episode of care –
Structural – environment variables
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Community variables |
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Several variables, other than size,
influence dental service utilization: |
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among the most significant of these is community water
fluoridation |
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Utilization found to be lower in those
areas where water is fluoridated |
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Healthier teeth? |
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Indicator of the preventive orientation
of the community? |
Probability of beginning
episode of care
Block 1 – Structure – (In reading)
(Noting signif vars. in bivariate analyses)
Probability of Beginning an
Episode of Dental Care
History block
Usual
source of care
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Having a usual source of care
eliminates the cost of search |
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Thereby increasing the probability of
entering an episode of care |
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Having a regular provider also has
direct effects on the cognition block |
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by increasing the salience of dental care |
History block
Past
preventive behavior
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1)
Continuity of care |
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Places past experience on a continuum
ranging from regular preventive visits to avoidance of dental care over an
extended period |
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There is evidence that dental behavior
determines dental attitudes and not vice versa |
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2)
Oral self-care |
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Similarly dental values are formed by
experience with health behaviors, such as brushing and flossing |
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History block
Quality
of care/oral health stock
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Quality of care |
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Assessment of past outcomes
–physiological, functional, quality of life, economic, durability |
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Can influence cognition and expectation
blocks |
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Oral health stock |
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Individuals inherit an initial “stock”
of oral health that depreciates over a lifetime |
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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) |
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Probability of beginning
episode of care
Block 2 – History – (In reading)
(Noting signif vars. in bivariate analyses)
Probability of beginning an
episode of dental care
Cognition block
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Dental knowledge |
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Dental satisfaction with past episodes
of dental care |
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Perceived salience of dental care |
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Perceived symptoms |
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Valuation of oral health |
Cognition block (cont.)
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Perceived norms |
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Expectations about health behavior -
such as the frequency considered acceptable for seeing a health provider |
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Perceived norms may be influenced by
the social environment – the family can be important |
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Perceived norms may be influenced by
the dentist |
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– use
of recall systems |
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– ways DDS signal expectations to
patients regarding appropriate preventive behavior |
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Probability of beginning
episode of care
Block 3 – Cognition – (In reading)
(Noting signif vars. in bivariate analyses)
Probability of beginning an
episode of dental care
Expected rewards and costs
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Expected rewards |
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For the symptomatic individual |
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belief or faith that services will
result in eliminating or reducing the symptom |
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also the reward of “having done the
right thing” and social approval of family and friends |
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For the asymptomatic individual making
a preventive visit |
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belief that regular checkups will
prevent future problems from occurring |
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if motivated by esthetics, belief that
services will improve appearance |
Expected rewards and costs
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Expected costs |
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Time, money |
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Perceived ability to afford an episode
of care in terms of fees and time |
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Social costs |
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Anxiety about the dental episode –
expected pain, fear, anxiety |
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Self-esteem – the perceived “social
distance” between provider and patient |
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Cost of search – especially for
individuals without a usual source of care |
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Level of uncertainty associated with
any of the above: |
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greater uncertainty about the costs/more confidence in the
rewards… |
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could lead to increased probability of
beginning an episode |
Probability of beginning
episode of care
Block 4 – Expectations – (In reading)
(Noting signif vars. in bivariate analyses)
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)
Summary
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Based on the close association of
income and patterns of utilization |
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might predict that cost is the leading
barrier in not seeking care |
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Has seldom, if ever, been the
predominant self-reported reasons given |
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When cost barriers removed in low
income groups |
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the utilization rate does not
necessarily rise unless some other form of motivation, such as dental health
ed given |
Summary (cont.)
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There is a clear need for more research
to determine |
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how actual dental need influences
perceived need |
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and how both of these affect action |
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In order to increase utilization of
dental services results of research
suggest need to direct attention at both beliefs and actions |
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The belief system needs to be one that
incorporates concept that oral disease has consequences and that taking
action alters these consequences |
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Interventions need to be based on an
UNDERSTANDING OF THE MULTIPLE FACTORS influencing utilization |