Barriers to the treatment of childhood caries perceived by dentists working in different countries

Transcription

1 Community Dental Health (2004) 21 (Supplement), BASCD 2004 Barriers to the treatment of childhood caries perceived by dentists working in different countries Cynthia M Pine 1, Pauline M Adair 2, Girvan Burnside 1, Alison D Nicoll 1, Angela Gillett 1, S Aida Borges-Yáñez 3, Zdenek Broukal 4, John Brown 5, Dominique Declerck 6, Feng Xi Ping 7, Tshepo Gugushe 8, Jaranya Hunsrisakhun 9, Edward C M Lo 10, Sudeshni Naidoo 11, Ursuline Nyandindi 12, Vibeke Juul Poulsen 13, Noëline Razanamihaja 14, Christian Splieth 15, Betty King Sutton 16, Teo Choo Soo 17 and Helen Whelton 18 1 WHO Collaborating Centre on Oral Health in Deprived Communities, University of Liverpool Dental School, England; 2 Department of Clinical Psychology, The Royal Hospitals, Belfast, Northern Ireland; 3 Universidad Nacional Autonoma de Mexico, Mexico; 4 Institute of Dental Research, Prague, Czech Republic; 5 University of Texas Health Science Center, San Antonio, USA; 6 School of Dentistry, Oral Pathology and Maxillofacial Surgery, Catholic University Leuven, Belgium; 7 School of Stomatology, Shanghai Second Medical University, China; 8 Faculty of Dentistry, Medical University of Southern Africa, South Africa; 9 Faculty of Dentistry, Prince of Songkla University, Thailand; 10 Faculty of Dentistry, University of Hong Kong; 11 Department of Community Dentistry, University of Stellenbosch, Tygerberg, South Africa; 12 Ministry of Health National School Health Programme, Dar-es-Salaam, Tanzania; 13 Faculty of Health Sciences, University of Copenhagen, Denmark; 14 Faculty of Odonto-Stomatology, University of Majunga, Madagascar; 15 University of Greifswald, Germany; 16 Department of Health and Human Services, Raleigh, North Carolina, USA; 17 Faculty of Dentistry, National University of Singapore 18 Oral Health Services Research Centre, University Dental School Cork, Ireland Objective To explore whether dentists beliefs and attitudes to providing preventive and restorative dental care for young children can form a barrier to the provision of care. Basic research design the Barriers to Childhood Caries Treatment (BaCCT) Questionnaire, a standardised international measure was developed and applied. Participants Through a research consortium, each site was asked to recruit 100 dentists. The sample participating was not intended to be nationally representative. Dentists were mainly randomly selected and contacted by mail with one or more mailings depending on site. Results: 2,333 dentists in 14 countries and 17 sites participated. Factor analysis identified four factors as potential barriers. Two factors were found to be barriers in many sites. First, in most countries, dentists agreed that young children s coping skills limit their ability to accept dental care. Secondly, dentists with negative personal feelings, for example, that providing care can be stressful and troublesome and that they feel time constrained. Differences in dentists beliefs can be partly explained by their work profile, with those treating children often, and those working under systems where they feel they can provide quality care being least likely to identify barriers to providing care for children. Conclusions: The BaCCT Questionnaire was determined to be a valid psychometric measure. Separately, it was found that health systems do impact on dentists ability to deliver preventive and restorative care for children but that these effects vary across countries and further work is needed to determine how best these should be examined. Key words: behavioural science, health services research, treatment of caries, children Introduction In many countries, child dental health improved after the introduction of fluoridated toothpastes but there has been little or no improvement amongst young children during the 1990s (Marthaler et al., 1996). Further, for many of those children with caries, the proportion of the disease that has been treated restoratively has reduced (Nugent and Pitts, 1997) without any accompanying evidence that preventive care has increased. In some countries the value of general dental practitioners restoring deciduous teeth has been questioned (Tickle et al., 2002), whilst in others clear guidance exists that restorations should be provided although variations in provision have been found (Robison et al., 1998). The overall aim of this part of this international project was to investigate which types of dental care systems (and dental personnel) are most likely to result in minimum exclusion and more favourable health outcomes for young children with dental caries. This paper examines an aspect of this research question by presenting the results of applying a standardised measure developed by a consortium of paediatric and public health dentists and psychologists working in a number of countries, under different health care systems and cultural norms, exploring whether dentists beliefs and attitudes to providing dental care for young children can form a barrier to the provision of care. The following research questions were addressed. Do Correspondence to: Cynthia Pine, Clinical Dental Sciences, University of Liverpool Dental Hospital, Pembroke Place, Liverpool, L3 5PS, United Kingdom

2 dentists believe that young children themselves, their parents, the health care system or dentists beliefs in their own ability to deliver care to be barriers to the provision of dental care for children? Do dentists believe that it is worthwhile to restore children s teeth? Are any differences between dentists beliefs about providing preventive or restorative dental care for children explained by differences in time qualified, type of employment or their gender? Method Barriers to Childhood Caries Treatment (BaCCT) Questionnaire, a standardised measure This standardised measure was developed within the international consortium of dental scientists drawn together under a planning grant funded by the National Institute of Dental and Cranio-facial Research (NIDCR) of the National Institutes of Health (NIH), U.S.A. The development and initial validation of the measure has been described in detail in Pine et al. (2004). There are no available standardised measures assessing dentists beliefs and attitudes that could act as barriers to the management of dental caries in young children. However, there are a number of published studies in medicine describing the assessment of barriers in pain management (Pargeon and Hailey, 1999). A Barriers Questionnaire has been developed (Ward et al., 1993) and the consortium used this approach as a model to developing the dentists barriers questionnaire. Studies have described potential barriers to the receipt of preventive or restorative dental care for children (Edelstein, 2002; McGrath and Frager, 1996), and four domains have been defined. These domains and example statements within each are given below. Dentists were advised that the questionnaire related to providing care for young children, defined as 3 to 6 years. Examples of statements (items) included in the measure, Barriers to Childhood Caries Treatment (BaCCT) Questionnaire, under each domain. Child domain: Children (aged 3-6 years) get upset easily. Children don t like sitting in the dental chair. Children can t cope very well with dental treatment. Parent/family domain: Parents expect dentists to do preventive dental procedures. Parents prefer their child s treatment to be done in one visit. If a child has toothache, parents are more likely to ask for extractions, rather than fillings. Dentists treatment perceptions domain: Dentists feel there is little point in filling deciduous teeth. Children can only be treated well by dentists with further training in paediatric dentistry. Dentists find filling children s teeth stressful. Health care system domain: The payment dentists would receive for putting a filling in a deciduous tooth is inadequate. Dentists rarely have enough time to spend with child patients. The payment dentists receive for providing preventive care to children is inadequate. A total of 53 statements (items) were included in the questionnaire. Dentists were asked to rate their level of agreement with each statement on a 5 point Likert scale 1= Strongly disagree; 2= disagree; 3=neither agree nor disagree; 4=agree; 5=strongly agree. The 53 statements were preceded by 14 general questions about the dentists themselves and their current work. The statements from each of the domains were put in a mixed order in the final questionnaire. Some items were deliberately constructed so that disagreement would represent a barrier, rather than agreement, and the results were re-coded appropriately. Where needed according to site, the questionnaire was translated from English and back translated by a native speaker. Dentists participating Each site was asked to recruit 100 dentists. The sample of dentists participating in the survey was not intended to be nationally representative at any one site. However, questions within the questionnaire enabled the sample of dentists to be described by their patterns of practice, e.g. work in the public dental service, their years of qualification and gender, % working part-time (<4 days per week). Actual numbers recruited varied between sites, and the data were weighted so that each site contributed equally to the analysis. A description of geographical area of practice, employment type, sample selection and contact method for dentists included in the study for each site is given in Table 1. Almost all sites targeted dentists in general dental practice, where most children are treated, except in Denmark where the majority of children are still seen in the public dental service. However, in several sites a wide range of employment settings was included and these data were available for supplementary analysis. Dentists were mostly randomly selected and contacted by mail with one or more mailings depending on site. At the 2 sites using postgraduate meetings as the contact method, these were general meetings rather than specialist paediatric dentistry meetings. Statistical Analysis The responses to the completed questionnaires were entered into SPSS for analysis. Items have been re-coded to ensure that the direction of all items was the same. This was necessary as for some items disagreeing would be a barrier to providing care and for others, agreeing with the item would constitute a barrier. For example the following 2 items: Parents don t want dentists to fill their children s decayed teeth Parents expect dentists to fill their children s decayed teeth Factor Analysis Items on the questionnaire were derived from four constructs describing possible barriers to the dental care of children, particularly those with caries in deciduous teeth. In order to complete the development of this dental measure, factor analysis was applied. Factor analysis is used to generate a small number of factors from a large number of variables that allows the variation in the large 113

3 Table 1. Description of geographical area of practice, employment type, sample selection and contact method for dentists included in the study. (GDPs: General Dental Practitioners). Country/Site Geographical area Employment type Sample selection and contact method Belgium Leuven and surrounding areas GDPs who have attended Random by mail postgraduate course (70% of dentists) China Hong Kong Hong Kong GDPs Random by mail China Shanghai Shanghai and surrounding areas Dentists in hospitals, Random by mail paediatric dentists Czech Republic Whole country GDPs Accessed at compulsory postgraduate education meetings Denmark Copenhagen county Public dental service Random by mail Germany Whole country GDPs Random by mail Ireland Whole country GDPs, public dentists, Random by mail paediatric dentists, dentists in hospitals Madagascar Majunga province GDPs, public dentists, All dentists by mail hospital dentists Mexico Mexico City GDPs, public dentists, Random by mail paediatric dentists Singapore Whole country GDPs, public dentists, Random by mail hospital dentists South Africa Cape Eastern and Western Cape, GDPs, public dentists, Accessed at postgraduate meetings and Kwa-Zulu Natal Kwa-Zulu Natal hospital dentists (60 70% of dentists attend) South Africa Gauteng Gauteng province GDPs, public dentists, All dentists in area by mail hospital dentists Tanzania Whole country GDPs, hospital dentists, All dentists by mail Thailand Songkhla province GDPs, public dentists, Random by mail hospital dentists UK Selected health authorities GDPs Random by mail in all 4 countries of the UK US North Carolina Whole state GDPs, public dentists, Random by mail, supplemented by paediatric dentists, dentists attendees at a local dental society in hospitals meeting. US Texas City of San Antonio All types, paediatric Random by mail specifically targeted number of variables to be explained. This allows refinement of the measure and improves reliability to yield a psychometrically valid measure. Qualitative and iterative methods led to the selection of the optimum items in each factor. Items were discarded if they loaded only onto factors with less than 3 items, or if they loaded weakly onto multiple factors. An item was considered to load onto a factor if it had a loading of greater than 0.3. Internal consistency of the measure, Cronbach s alpha In order to examine the reliability of the overall measure and of dentists responses to items within the factors, Cronbach s alphas were calculated. This statistic is a coefficient of reliability or consistency and is a function of the inter-item correlation. Chi-Squared Automatic Interaction Detection (CHAID) The exhaustive CHAID algorithm within SPSS Answer Tree version 3 was used to model the data. This method fully partitions the data into groups using a set of possible predictor variables, to give the best prediction of a target variable. Starting with the whole data set, the data is partitioned automatically using the predictor that shows the most significant relationship with the target variable. The significance of the relationships between predictors and target variables is assessed using the F- statistic. The categories of the predictor variables are merged automatically to give the best split for each variable. This process is then repeated within each of the subgroups, until there are no more significant results, or the groups become too small to split further. The groups that cannot be split further, are called terminal nodes, and each case is included in one and only one of these nodes. Results Profiles of dentists participating at each site are given in Table 2. In total, 2,333 dentists in 14 countries and 17 sites have contributed to this international study. Overall 72% of the dentists had been qualified for at least 10 years, 43% were female and 20% were in a public dental service. Dentists in public dental services were targeted more in some countries, e.g. Denmark, Madagascar and Thailand as they are more involved in the delivery of dental care for children. In order to ensure that the contributions from each site could contribute to the factor analysis equally, the results were weighted in 114

4 Table 2. Description of dentists who completed the questionnaire by country, years of qualification, percentage (%) working part time, % in public dental service Country/Site Dentists profile Number of dentists % qualified % female % part-time % in public n > 10 years dental service Belgium China Hong Kong China Shanghai Czech Republic Denmark Germany Ireland Madagascar Mexico Singapore South Africa Cape and Kwa-Zulu Natal South Africa Gauteng Tanzania Thailand UK US North Carolina US Texas All sites (weighted) Countries, n= 14 Sites, n=17 Total respondents, n = 2,333 Table 3a. Factor analysis of Barriers to Childhood Caries Treatment (BaCCT) Questionnaire (from all sites: Factors 1 & 2) Name of Factor Items within the Factor Item loadings Factor 1 (Child factor ability of Children don t like sitting in the dental chair 0.76 young children to accept dental care) Most children are fearful of dental treatment 0.73 Children don t like the sound of the dental drill 0.64 Children can t cope very well with dental treatment 0.62 Children can t accept dental treatment 0.57 Children (aged 3-6 years) get upset easily 0.55 Factor 2 (Dentists personal factor Dentists feel apprehensive if they have to do a filling for a child 0.69 how providing care for children Dentists find filling children s teeth stressful 0.69 affects dentists) Dentists enjoy filling children s teeth 0.63 Dentists don t like giving local anaesthetic to children 0.55 Providing dental treatment for children is troublesome 0.51 Dentists rarely have enough time to spend with child patients 0.51 Dentists prefer to refer children to be treated by other colleagues 0.50 Table 3b. Factor analysis of Barriers to Childhood Caries Treatment (BaCCT) Questionnaire (data from all sites: Factors 3 & 4) Name of Factor Items within the Factor Item loadings Factor 3 (Value dentists On the whole, decayed deciduous teeth are best left untreated, rather than filled 0.76 place on restorative care If decayed deciduous molar teeth are not causing any symptoms they are best left untreated 0.71 factor) Dentists feel there is little point in filling deciduous teeth 0.60 Dentists feel there is no reason to fill deciduous teeth 0.60 The time it would take to fill deciduous teeth would be better spent with other patients 0.52 Dentists would not fill cavities in children who are not good attenders 0.50 Dentists would not fill cavities in children who attend regularly 0.50 Factor 4 (Family factor If a child has toothache, parents are more likely to ask for extractions 0.72 effect of parents Parents expect dentists to fill their children s decayed teeth 0.69 expectations) Parents don t see the need for filling deciduous teeth 0.68 Parents don t want dentists to fill their children s decayed teeth 0.68 If their child had a decayed molar their parents would expect it to be extracted

5 Table 4. Reliability of final overall measure, and 4 factors within each site, and for all sites, measured by Cronbach s alpha Countries and sites Overall Factor 1 Factor 2 Factor 3 Factor 4 measure Child factor Dentists personal Value dentists Family factor ability of factor how place on effect of parents young children providing care restorative expectations to accept for children care factor dental care affects dentists All sites Belgium China Hong Kong China Shanghai Czech Republic Denmark Germany Ireland Madagascar Mexico Singapore South Africa Cape and Kwa-Zulu Natal South Africa Gauteng Tanzania Thailand UK US North Carolina US Texas subsequent analyses, so that in effect, each site contributed 100 responses. Factor analysis The factor analysis results including the data from all sites, weighted as described above, resulted in 4 factors of 27 items and these are given in Table 3a and 3b. The loading for each item is also given. This is the correlation between the item and the factor to which it belongs, and can be interpreted as the proportion of item variance explained by the factor. The descriptive term given to the factor is intended to convey the principal theme of the items within the factor. The first factor identified related to dentists beliefs about young children s ability to accept dental care and included 6 items relating to children s emotional responses including fear, coping skills and general response to the dental environment and procedures (Table 3a). The second factor included 7 items and was the first of two factors linked to dentists beliefs and attitudes about themselves as providers of dental care to children. The items included those relating to dentists confidence in filling children s teeth and whether dentists find treating children stressful. The third factor depicted in Table 3b comprised 7 items expressing the value dentists place on restoring the deciduous dentition, essentially whether there is any benefit to providing this type of care. The fourth factor of 5 items is described here as a family factor. The items comprise dentists beliefs about what parents expect or ask for in relation to their children s dental care. Whether these factors generated by the analysis constitute barriers to the receipt of care depends on the strength of agreement that dentists place on the items. Internal consistency of the measure The overall measure generated good levels of consistency (Table 4), as for each factor, all values of Cronbach s alpha were above acceptable levels of consistency, i.e and above (Nunnally, 1978). The relative rating of each factor as a barrier to the provision of preventive and restorative dental care for young children Table 5 tabulates the mean scores for all factors by site. The means are those from the response categories of 1= strongly disagree, 2= disagree, 3=neither agree nor disagree, 4= agree, 5= strongly agree. As described above, the order of response has been reversed in the analysis where needed, so that the directions are the same. By convention, any average value above 3 is deemed a potential barrier and these values have been highlighted in bold within the table. Two factors consistently have resulted in mean values over 3. The highest values related to factor 1, the child factor. In most countries, dentists agree that young children s coping skills limit their ability to accept dental care, in effect the age of the child constitutes a barrier. The second factor generating scores over 3 in around two thirds of sites was factor 2, related to dentists personal feelings about providing care for young children. Many dentists agree with the statements comprising factor 2, e.g. that providing care for children can be stressful and troublesome for the dentist and that they feel time constrained. In contrast, the majority of dentists disagree with statements that suggest that there is little value in restoring decayed deciduous teeth (factor 3). Furthermore, parents expectations about the care that they wish their child to receive (factor 4) were only seen as a barrier at 3 of the 17 sites. In order to explore which types of dentists are most likely to perceive children s coping skills as barriers to the provision of dental care, a multivariate analysis was undertaken using CHAID. The variables included as 116

6 Table 5. Mean factor scores (standard deviation) for each site Sites Factor 1 Factor 2 Factor 3 Factor 4 Child factor Dentists personal Value dentists Family factor ability of factor how place on effect of parents young children providing care restorative expectations to accept for children care factor dental care affects dentists All sites 3.2 (0.7) 3.1 (0.7) 2.0 (0.6) 2.6 (0.7) Belgium 2.9 (0.8) 2.9 (0.5) 1.6 (0.4) 2.2 (0.6) China Hong Kong 3.5 (0.7) 3.3 (0.5) 2.3 (0.6) 2.8 (0.6) China Shanghai 3.6 (0.4) 3.0 (0.5) 2.0 (0.4) 2.3 (0.5) Czech Republic 3.5 (0.5) 3.2 (0.4) 2.3 (0.4) 2.7 (0.5) Denmark 2.4 (0.6) 2.3 (0.5) 1.6 (0.4) 1.9 (0.5) Germany 3.1 (0.6) 2.7 (0.6) 1.6 (0.5) 2.0 (0.4) Ireland 2.7 (0.6) 3.1 (0.7) 2.1 (0.6) 2.6 (0.6) Madagascar 3.5 (0.7) 3.2 (0.8) 2.3 (0.7) 3.1 (0.5) Mexico 3.3 (0.7) 2.7 (0.7) 2.1 (0.6) 2.9 (0.8) Singapore 3.4 (0.7) 3.4 (0.6) 2.0 (0.5) 2.8 (0.6) South Africa Cape and Kwa-Zulu Natal 3.2 (0.6) 3.1 (0.6) 2.1 (0.6) 3.0 (0.8) South Africa Gauteng 3.2 (0.7) 3.1 (0.6) 1.9 (0.5) 2.8 (0.7) Tanzania 3.6 (0.5) 3.1 (0.6) 2.3 (0.7) 3.5 (0.6) Thailand 3.6 (0.5) 3.2 (0.5) 1.9 (0.4) 3.1 (0.5) UK 3.0 (0.6) 3.4 (0.6) 2.1 (0.5) 2.5 (0.5) US North Carolina 2.9 (0.6) 3.0 (0.6) 1.6 (0.4) 2.3 (0.5) US Texas 3.0 (0.6) 3.1 (0.6) 1.8 (0.4) 2.4 (0.6) Figures in bold are for mean factor scores >3.00 and indicate that factor as a barrier to the provision of dental care. Figure 1. Results of the CHAID analysis to identify which groups of dentists are more likely to believe that the ability of children aged 3 to 6 to accept dental care (Factor 1) acts as a barrier to providing care. 117

7 possible predictors were sex of the dentist, number of years working as a dentist, whether the dentist was in the public dental service, and whether the dentist was part time. In addition variables on the dentist s level of satisfaction with their dental care system with respect to preventive services, restorative services, and overall quality of care were entered, along with whether they feel there was enough emphasis on preventive and/or restorative services in their country s health care system. The results of the analysis are depicted diagrammatically in Figure 1. This figure should be read from left to right. The column on the far left, gives the overall mean child factor score from all sites (n=2333) of The column on the far right is labelled terminal nodes and provides the endpoint of this multivariate analysis. Dentists have been grouped (automatically by the programme) such that they form groups with similar responses with no individual belonging to more than one group. The terminal nodes are the most efficient grouping of the data. Two groups of dentists, in Groups F and H, have average scores below 3, i.e. do not agree that young children cannot cope with dental care. The first of these dentists groups, Group F, with a score of 2.86 treat mostly children in their day-to-day practice, have been qualified for between 6 and 21 years and are satisfied with the quality of care they can provide under their health system. The country of practice of each of these dentists was examined. Dentists in Group H came from 14 sites, however, one country predominated, as 25% of dentists in this terminal node were working in Denmark. Dentists forming Group H had the lowest mean score of 2.62, i.e. least likely to consider children themselves as a barrier to the receipt of care. These dentists treat mostly children in their day-to-day practice and have been qualified for more than 21 years. These dentists came from 13 sites, but 2 sites predominated with 50% working in Denmark and 20% working in the United States. Significant characteristics that explain the variation in the mean scores obtained for the other groups relate to dentists level of satisfaction with the dental care system when providing preventive care, restorative services, and the quality of care the dentists feel they can provide under their system. Dentists from almost all sites comprised Groups A to D. However, some sites predominated. For example, 79% of the dentists from the U.S. sites were in Groups A to C, i.e. were very satisfied or satisfied with the dental care system when providing preventive services. In contrast, 67% of dentists working in the UK and 78% of those surveyed working in Figure 2. Results of CHAID analysis to identify which groups of dentists are more likely to identify dentists personal feelings about providing treatment for children (Factor 2) act as a barrier to care. 118

8 Germany were dissatisfied or very dissatisfied in relation to the provision of preventive dental services. Dentists in Group C had the highest mean factor score of 3.41 and comprised dentists who were satisfied with the provision of preventive care but felt their system did not place enough emphasis on restorative services. Although dentists in this group were working in 15 of the 17 sites, no dentists were working in Denmark and the biggest group, 43% were working in African countries or Thailand. The second multivariate analysis undertaken examined which types of dentists are most likely to regard their own responses to treating children as a barrier to providing care (see items in factor 2). The same variables were entered into the model as potential explanatory variables and the results of this analysis are presented in Figure 2. Again, the most significant variable entering the model first, was whether the dentists treat mostly adults or children. Those with the lowest mean factor score of 2.33 treated mostly children and were very satisfied with the quality of care they can provide under their dental care system. One site predominated, dentists working in Denmark who comprised 46% of this group. The highest mean factor score of 3.54, i.e. those most likely to have negative responses to treating children, treated mostly adults in their day-to-day practice and were very dissatisfied with the quality of care they could provide under their system. 49% of dentists in this group worked in the UK with the second largest group of 18% working in South Africa. Differences between the factor analysis and the underlying model on which the measure was based The original model identified 4 domains that could act as barriers to the provision of preventive and restorative care for children. These domains were children themselves; their parents and families; the dentist as care provider; the health service system under which the dentists operated. As can be seen from the factor analysis, the items structured to assess the first 3 of these domains were confirmed to form coherent factors. In addition, the factor analysis divided the dentists domain into two distinct factors, Factor 2 and Factor 3. Factor 2 were more general dentists beliefs and attitudes about providing care for children, e.g. that dentists lack confidence in filling children s teeth; that dentists find treating children stressful. Factor 3 relates to dentists beliefs about the value of restoring deciduous teeth. Therefore, the first 3 domains of child, dentist, family, were held in common internationally and generated the four factors described above (Tables 3a and 3b). That is, dentists working as far apart, for example, as Ireland and China responded in a similar way to statements about children, parents and themselves as care providers, only varying in their strength of agreement or disagreement. However, the 4 th domain in the original model that related to dentists opinions about whether the health care system posed barriers to the care of children did not produce a coherent factor in the analysis that used data from all the sites that participated. The fact that dentists operated under many different health care systems meant that there was no common group of items that constituted a factor. Nevertheless, in several countries individual item analyses, identified aspects of the health care system dentists felt were important barriers to the provision of child dental care. Mean scores for selected items relating to the impact of health services on the provision of child dental care are shown in Table 6. A notable finding was that Denmark was the only country in which dentists did not Table 6. Mean item scores (standard deviation) for some of the dental health service items (statements) by site. The payment The payment Parents don t Dentists rarely The dental care dentists would dentists receive want to pay have enough system puts receive for for providing for filling time to spend more emphasis putting a filling preventive care deciduous teeth with child on fillings in a deciduous to children patients rather than tooth is is inadequate prevention inadequate All sites 3.5 (1.2) 3.8 (1.0) 3.0 (1.1) 3.0 (1.1) 3.4 (1.1) Belgium 2.6 (1.1) 3.6 (1.1) 2.0 (0.8) 2.3 (0.9) 3.7 (0.9) China Hong Kong 3.5 (1.1) 3.5 (1.0) 3.2 (1.0) 3.2 (1.0) 3.3 (0.9) China Shanghai 3.6 (1.0) 3.8 (0.8) 2.9 (0.9) 2.8 (1.0) 2.9 (1.1) Czech Republic 4.1 (0.8) 3.9 (0.9) 3.6 (0.8) 3.2 (1.1) 3.8 (0.8) Denmark 2.7 (1.1) 2.9 (0.8) 2.5 (0.9) 2.3 (1.0) 2.6 (1.1) Germany 3.9 (1.1) 3.9 (1.0) 3.0 (0.0) 2.7 (1.1) 3.7 (0.9) Ireland 3.1 (1.0) 3.8 (0.9) 2.9 (1.0) 2.9 (1.0) 3.5 (1.0) Madagascar 3.1 (1.4) 3.6 (1.4) 2.5 (1.4) 3.4 (1.1) 3.6 (1.5) Mexico 2.6 (1.2) 3.0 (1.3) 3.0 (1.1) 2.8 (1.1) 3.6 (1.2) Singapore 4.1 (0.9) 4.1 (0.9) 2.8 (1.0) 3.4 (0.9) 3.6 (0.9) South Africa Cape and Kwa-Zulu Natal 3.5 (1.1) 3.8 (1.0) 2.7 (1.0) 3.1 (1.1) 3.3 (1.0) South Africa Gauteng 3.7 (1.1) 3.9 (0.9) 2.7 (1.0) 3.0 (1.0) 3.5 (0.9) Tanzania 3.0 (1.1) 3.3 (1.2) 2.7 (1.1) 3.1 (1.2) 2.2 (1.1) Thailand 3.2 (1.0) 3.5 (0.9) 3.4 (1.0) 2.7 (1.0) 3.3 (1.1) UK 4.2 (0.9) 4.4 (0.8) 4.1 (0.8) 3.7 (0.9) 4.1 (0.8) US North Carolina 4.1 (1.1) 4.1 (1.1) 2.7 (0.9) 2.5 (0.9) 3.0 (1.0) US Texas 3.2 (1.1) 3.6 (1.0) 2.7 (1.0) 2.7 (0.9) 3.2 (0.9) Figures in bold are for mean factor scores >3.00 and indicate that factor as a barrier to the provision of dental care. 119

9 identify any of these health service characteristics as barriers to delivering restorative or preventive dental care for young children. In contrast, dentists in the UK and the Czech Republic identified all the statements listed as barriers. They found barriers to care both from the payment side, their own time, their perceptions of what parents want, and the emphasis of the dental care system. Concerns about the adequacy of payment to dentists both for restorative and preventive care were a common finding in many sites. However, it is clear from the factor analysis that payment is by no means the only barrier dentists perceive to the provision of children s dental care. Discussion This is formative research and the results are not meant to be nationally representative but initial evaluations that can be used to identify potential areas of further investigation. Some tentative conclusions can be drawn to the research questions posed. In most sites, dentists believe that the ability of children aged 3 to 6 years to accept dental care forms a barrier to the provision of that care. Further, in many sites how dentists respond to the need for providing care for children can be a barrier for providing that care, for example dentists who see treating children as stressful or troublesome. However, dentists do see value in restoring deciduous teeth and in general, parental expectations do not constitute a barrier. Differences in dentists beliefs can be partly explained by their work profile, with those treating children often, and those working under systems where they feel they can provide quality care being least likely to identify barriers to providing care for children. This initial study has identified significant barriers to providing care for children under the UK health care system. This is reinforced by the Department of Health in England that is seeking to evaluate new methods of care delivery in general (Department of Health, 2002). Similar problems were identified in Germany and the Czech Republic. In contrast, the Danish system was favourable to child dental care as dentists working under this system generated the lowest mean scores and no factors were seen as constituting a barrier. In conclusion, the robustness of the measure of dentists attitudes to providing preventive and restorative care for young children has been demonstrated, as has the need to examine barriers within health care systems in more detail. The factors identified as barriers were relatively consistent across a wide range of settings. The 27 items resulting from the factor analysis comprise an international measure in relation to dentists attitudes of themselves as caregivers, child patients and their parents and can be used to identify which groups of dentists are least likely to identify barriers to providing child dental care. Health systems do impact on dentists ability to deliver preventive and restorative care for children but that these effects vary across countries and further work is needed to determine how best these should be examined. Acknowledgements With thanks to those dentists and supporting members of the research consortium who were involved in the development of the measure and in data collection across the international sites.stephen Adair, B Bünger, David Butcher, Usuf Chikte, Eu Oy Chu, Morag Curnow, Chris Deery, Mark Edwards, Gillian Elliott, David Ferrier, Andrew Forgie, Jill Fortuin, Justin Franks, June Fraser, Wendy George, Caroline Glinka, C Hölzel, Stephen Hsu, Maria Irigoyen-Camacho, Erika Lencova, Maggie Leggate, R Liston, Teresa Loh-Lee, Jane Lothian, Anna MacDonald, Carol MacIntyre, Patricia Manson, Gerardo Maupomé, Wendy McCombes, Donald McIntosh, Betty Mok, Poul Erik Petersen, Kenneth Provan, David Purdell-Lewis, Magne Raadal, Rashmi Shah, Chris Southwick, Gordon Thompson, David Torgersen, Adeline Wong, and He Yan This study was funded by the National Institutes of Health, USA, NIH grant number DE Additional funding was obtained from the Ministry of Health, Czech Republic, Grant No References Department of Health (2002): NHS Dentistry: Options for Change. 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