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INTRODUCTION
Much has been written regarding
access to care of the growing elderly population and
their needs1,2. There appears to be an imbalance
between the need for care1 and access to
care. The elderly population are less likely reported
to utilize dental services than any other population
group in the United States3. Similarly, the
1978-79 Canadian Health Survey showed that 67% of the
elderly had not visited a dentist within the previous
5 years4. A comparison of the attendance
of elderly Canadians with their U.S. and U.K. counterparts
over a one year period indicates the level of attendance
in Canada (23%) is half that of the other countries5.
Some studies indicate that attitudes towards dentistry
and oral health may be changing. Several authors have
stated6,7,8,9, that in the future the elderly
will be better educated than previous generations of
older adults, and have higher expectations about maintaining
and preserving their natural dentition.
The
institutionalized or medically or physically compromised
elderly, however, is a special type of population, which
is subject to the approvals of gatekeepers to care before
care can be accessed. When the client is cognitively
impaired, a new set of variables are introduced in the
form of designated family members, caregivers or administrators,
who are responsible for the oral health care of the
client and the treatment the client will receive. The
problems are interdependent and inextricably related,
but for the purposes of academic consideration can be
grouped as follows:
·
Access to care
· Perceptions of the importance and need for
oral health care services
· The delivery of dental services
· The benefit of providing dental services
Kiyak
suggests that the reasons for low utilization patterns
in the elderly are related to perceived need for care
and perceived importance of oral health, as well as
the number of natural remaining teeth and knowledge
of the available dental resources in the community.
The more traditionally cited barriers of - cost, fear
and physical access are thought to be less important.
Although this may be the case for the well elderly,
surrogate decision-makers govern access to healthcare
services for those who are medically or physically compromised.
Differences in attitudes and perceptions, with respect
to oral health, may lead to better or worse access for
these clients. The key stakeholders for consideration
in the control of access to care would include the following
groups:
·
Clients or residents of homes
· Caregivers
· Family members
· Nursing staff
· Physicians
· Administrative staff
· Dental professionals
· Faculties of dentistry
· District Health Units
· Local government-health advisers
· Federal government-health advisers
· Professional dental organizations
· Professional dental licensing authorities
The
stakeholders may affect the delivery of dental services
to elderly populations because of the positive or negative
effects on the provision of services for the populations,
for which they are responsible. Negative influences
may be governed by the perceptions held by stakeholder
groups. These perceptions should be explored and defined,
in terms of their cause, which may vary from lack of
education in the importance of oral health care, to
perceived lack of benefit from oral health services
for the elderly population.
The
goals associated with this investigation, which can
be related to the provision of oral health care:
· Better understanding the demands of the elderly
population.
· Better understanding of the barriers to care
faced by the various population types and their location.
· Improved information on where and how to target
educational and service resources, in order to reduce
barriers.
This
report describes the perceptions of stakeholders on
the importance of and need for oral health care services.
The specific objective is to:
· Investigate the perceptions of the clients
and family members in the provision of oral health care
to elderly populations.
METHODS
The population studied was institutionalized
elderly people, i.e. those over the age of 65 years,
resident in nursing homes. The populations investigated
were from chronic care facilities without a dental program.
A sample size of 100 was taken from nursing homes willing
to be included in the study.
The method included a structured
interview with clients/residents and family members
regarding the importance and priorities of dental services
for elderly people in institutions.
Consent was obtained from all
participants.
Exclusion criteria were:
· Cognitive impairment
· Unidentified or inaccessible caregiver or designated
family member
· More than one main caregiver
· Client in extremely poor health, with a poor
prognosis, i.e. less than 2 years
· Those unwilling to participate in the study
Inclusion criteria were:
· Clients resident in institutions willing to
participate in the study
· Cognitively competent clients
Interviews were performed by the same person throughout
the study. All information was collected by a dental
health care professional.
Data was obtained via a variety
of methods according to category:
· Client characteristics via interview and medical
charts
· General health information via interview and
medical chart
· Perceptions of oral health via interview
Procedure
Health perceptions and opinions
were collected on questionnaires used in an interview
with either the client or stakeholder. The nursing homes
in Simcoe County were identified and those homes were
contacted to ascertain whether or not the home had access
to on-site dental services. The administrator of the
homes without dental services were contacted by letter
to ask whether they would participate in a survey of
perceptions of dental care for the residents of institutions
for the elderly.
The homes were followed-up by
telephone within a week of sending out the letter and
the administrator of the home was asked whether or not
he or she would be willing to participate in the study.
Once a commitment was made by the home, to participate,
the administrator was asked to provide a list of cognitively
intact residents who may be asked to participate directly
in the study. The residents were then contacted in person
to gain consent for participation.
Appointments were made with
each of the residents to answer questionnaires regarding
perceptions of importance and priorities of dental services.
Data were collected in hard copy and then subsequently
entered into Excel for descriptive analysis of the importance
of the dental services questionnaire data.
RESULTS
Importance and priorities of
dental services
Residents
Results from each home were
tabulated separately and also a cumulative report was
produced. The residents of the nursing homes participating
in the study categorized 16 types of dental services
as essential, important, of value, of little value or
unimportant.
The responses showed a general
trend that the residents felt that dental services were
of value, with 893 responses representing 72% of all
valid responses (not including missing values) being
placed in the essential or important categories. In
total 170 responses (12%) were missing values, the majority
of these (140 or 82% of the missing values) were for
three services: root canals, implants into the bone
to replace missing teeth and implants into the bone
to stabilize dentures. Figures 1-3 separate the perceived
importance of services into high, medium and low, respectively.
Dentures to replace teeth, denture
relines and adjustment, fillings, cleanings, pain relief
treatment, tooth removal, and check-ups were all highly
important for the nursing home residents (80% or above
scored these services as essential/important). Advanced
treatment of gum disease, emergency treatment, instructions
to caregivers and seniors, and complex treatment to
restore teeth were of moderate importance (between 50-80%
scored these services as essential/important). Dental
services provided by a specialist, root canal treatment,
implants into bone to replace teeth or stabilize dentures
were deemed low in importance to the residents. Lack
of knowledge of the potential benefits of dental implants
could possibly account for the high number of non-responses
to these two questions (60% non-response for these two
questions combined).
More specific information can
be seen from responses to the question regarding the
priorities of dental services. In providing the top
3 service priorities the residents were able to identify
the most important dental services for the nursing home
environment, in their opinion. On amalgamating the responses
of the 3 categories those services, which have been
determined as most important can be readily identified
(Figure 4).
Figure 4. Priorities of Services
(Non-Scalar)
The
residents reported the following services more frequently
as being in the top 3-priority list (reported in order
of most frequency): Cleanings to prevent mouth disease,
check-ups including X-rays, fillings, dentures to replace
teeth, and denture relines and adjustments. Figure 4
further illustrates the priority breakdown within each
service category (1st, 2nd, or 3rd).
When asked about the necessary frequency of the provision
of dental services in the nursing home environment,
the majority (79%) of the residents thought that either
6 months or 1 year would be desirable. The majority
(17% of the total and 85% of the remainder) of the other
respondents felt that a more frequent service should
be maintained (Figure 5).
Figure 5. Desired Availability
of the Services
There
was a general consensus that the Government or state
should provide nursing home dentistry and that it should
be free (Figure 6). However, most of the residents felt
that Nursing home dentistry, where it is provided, was
value for money. Though 7% felt that the Government
should not provide dental services in nursing homes
and 5% thought it was currently not value for money.
Thirteen percent even thought that nursing home dentistry
should not be provided free of charge.
Figure 6. Percentage that
agree with the following statements
The age range of the residents
giving these opinions was between 69 and 99 years of
age (Figure 7). The majority of these residents classified
themselves as irregular attendees (23%), or those who
only attended the dental professional when in pain (64%).
Figure 7 age of the residents
Not surprisingly most of the
residents (70%) were females. This reflects the demographic
trends related to life expectancy of those over the
age of 65 years1.
Family members
A similar pattern of responses
was found when family members of nursing home residents
were asked the same questions.
Again the vast majority (70%)
of responses relating to the importance of the various
dental services listed were deemed to be essential or
important. This indicates the general value attached
to dental services in the nursing home environment.
Figures 8-10 show the breakdown
of the 16 services into high, medium and low importance
groupings. The groupings are very similar to those identified
by residents. However, caregivers rated a few services
higher in importance - emergency dental services, treatment
of advanced gum disease, and services by a specialist.
While caregivers and residents rated similar services
high in importance, caregivers rated these services
as essential more frequently than did residents (44%
vs. 11%). When examining responses to the 16 services
individually, categories were collapsed into two groupings,
positive responses (essential/important/of value) and
negative responses (of little value/unimportant). Chi-square
testing revealed that residents and caregivers were
significantly different in their responses to only three
services (see Table 1).
The
priorities identified by the sample of family members
also gives an indication of those services deemed most
important. Again the most frequently cited dental services
in the "top 3 services" provide a summary
of the most prioritized services (Figure 11). Caregiver
priorities were more diffusely spread across service
areas than residents' priorities. However, in common
with residents, caregivers rated cleanings, check-ups,
and fillings the highest in priority. Dentures to replace
teeth and denture adjustments were also high in priority
for caregivers, but to a lesser degree than for residents.
Figure 11 Priority of service
(non-scalar)
A clear majority of family members
(70%) thought that dental services should be available
on a biannual basis, with the majority of others stating
that yearly would be adequate (23%). Caregivers also
had a stronger preference for 6-monthly availability
of services than did residents (70% vs. 44%). Both groups
preferred either 6-monthly, or annual availability of
services.
Figure 13 Desired availability
of services
Almost all of the family members
(39 out of 40) felt that the Government or State should
provide dental services for nursing homes, the services
should be free, and that nursing home dentistry is value
for money (Figure 14).
Figure 14 Do you agree with
the following statement
Percentage that agreed with
the statement N = 40
The majority of the family members
who participated (78%) classified themselves as regular
dental attendees (have attended annually and in the
last year). Only 2 people admitted to attending only
when in pain (5%). Although the majority of participating
family members were female (55%), 45% were males, which
suggests a representative view is provided.
DISCUSSION
Perceptions of the importance
and priorities of dental services have not been reported
in the literature. The importance of these perceptions
lies in the exploration of the concept of access11. Part
of the concept includes the notion of acceptability
of the services to the potential patient. This can only
be determined through interviewing prospective users
of the services to determine what is important and acceptable
to them. The views of residents and other major stakeholders,
including family members, are extremely important to
access to care. As would be expected, the results indicate
that where services are not made available to the institutionalized
population, attendance falls and a pattern of interventive
care when in pain replaces preventive dental behaviors.
The availability of dental services, however, in institutions
is something that is desired by most residents, who
also suggested that the service should be funded by
the government (>70%), it should be free of charge
(>70%) and that services should be available either
once or twice every year (>80%). Even though the
pattern of attendance is markedly different in the family
members interviewed (>80% are regular attenders),
their perceptions are in very close agreement with the
residents group, perhaps suggesting that if services
were available the residents would utilize them, as
both groups desire the same type and pattern of services.
The value of dental services appears to be recognized
in the same way.
In order to improve access and
utilization an additional aspect should be investigated
to establish what type of services are desired, and
would be utilized. Residents and family members graded
the importance of a list of dental services and prioritized
them, to identify the most important services in this
setting. Over 70% of responses from all participants
in both groups placed the dental services listed in
either the essential or important categories, indicating
the general appreciation of dental services in the institutionalized
setting.
Those services, which were identified
as essential most often, were very similar in both groups,
with the top 3 being identical - Cleanings, Check-ups
and Fillings. The first 2 relate to prevention, which
is contrary to the oral health behavior in institutions
within the study, possibly as a result of lack of availability
of services. The remaining 2 positions in the top 5
important services were the provision of dentures and
relines and adjustments of dentures, for residents,
and the relief of dental pain and the provision of dentures
for family members. A combined list of most important
dental services for both groups would therefore include
cleanings, check-ups, fillings and the provision of
dentures.
The reliability of this assumption
is undermined by the categorization of the services
into categories of essential or important. The services
with the most responses in these categories for the
residents are (in order of most responses first) provision
of dentures, denture relines or adjustments, fillings,
cleanings, relief of pain, tooth removal and check-ups.
This is similar to the priority list above.
The family members identified
the following services as being classified as having
the most responses in the essential or important categories
- provision of dentures, denture relines or adjustments,
relief of pain, emergency dental services, check-ups,
fillings and cleanings at the same level. This follows
a similar pattern to residents' responses, with denture
care being a top priority, but the treatment of pain
and emergency dental care is considered more important
to family members. Other than this the list is almost
identical with that of the residents.
A profile of the desired services
in nursing homes from this study would probably be one
which provided emergency and regular preventive care
- with the capability of providing simple restorative
and denture care as necessary. Complex care was not
seen as a priority in either group.
Those services, which appear
in the categories of little value or unimportant can
also provide information on the types of services, which,
perhaps, would not be utilized. Residents identified
the following services in these categories most often
- tooth implants, specialist services, root canal therapy,
oral hygiene education and implant stabilized dentures.
This is comparable with those identified by family members
- tooth implants, implant stabilized dentures and root
canal treatments. There is an agreement between the
groups around the lack of importance of implants and
root canal therapies. Specialist services were not thought
to be important by the residents and generally both
groups did not regard complex treatments as important
as basic treatments.
The inference of these responses
is that a basic program is desired, not one providing
a comprehensive list of services. If this truly reflects
the desires and needs of this population then a modest
range of services could be provided at minimal cost
with utilization by the whole dental team as follows:
Diagnosis/restorative care/extractions
- Dentist and Dental Nurse
Prevention - Dental Hygienist
Dentures - Dentist/Denturist and Dental Technician dependent
on cost of services
CONCLUSION
The residents in the nursing
homes studied and their family members share similar
views in the types and frequency of dental services
that should be provided in the nursing home setting.
They describe a basic dental service of check-ups and
preventive care, with restorative, denture and surgical
intervention where necessary. Complex care is not a
priority. Services should be available once or twice
a year.
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