Was I still on the waiting list? A study about people waiting for public dental care

Transcription

1 A study abut peple waiting fr public dental care September 2009

2 Health Issues Centre Inc. Level 5, Health Sciences 2 LA TROBE UNIVERSITY VIC 3086 (03) Fax: (03) Website: inf@healthissuescentre.rg.au A study abut peple waiting fr public dental care 2

3 TABLE OF CONTENTS PAGE NO: ACKNOWLEDGEMENTS 5 EXECUTIVE SUMMARY 6 STUDY DESIGN... 6 DATA COLLECTION AND ANALYSIS... 6 RECOMMENDATIONS BACKGROUND RATIONALE FOR THE STUDY BROADER CONTEXT SOCIAL PERSPECTIVE OF DENTAL CARE MEDICARE FUNDING OF DENTAL CARE VICTORIA S PUBLIC DENTAL SERVICE DIANELLA COMMUNITY HEALTH DENTAL SERVICES AT DIANELLA IMPACTS OF ORAL HEALTH STATUS RESEARCH METHODS DENTAL WAITING STUDY STUDY PARTICIPANTS PROJECT STEPS RECRUITMENT PRE-INTERVIEW TELEPHONE CALLS CRITERIA USED RESPONSES TO RECRUITMENT IN-DEPTH INTERVIEWS RESPONSES TO OFFER OF APPOINTMENT AND APPOINTMENT ATTENDANCE FOLLOW-UP TELEPHONE CALLS DATA ITEMS A study abut peple waiting fr public dental care 3

4 3. RESULTS LIMITATIONS OF THE STUDY DEMOGRAPHY OF STUDY PARTICIPANTS PRE-INTERVIEW TELEPHONE CALLS IN-DEPTH INTERVIEWS PRE-INTERVIEW TELEPHONE CALLS PROBLEMS ACCESSING CONSUMERS WHY THEY DID NOT WANT TO PARTICIPATE FACE-TO-FACE INTERVIEWS ORAL HEALTH IMPACT PROFILE (OHIP) QUALITATIVE ANALYSIS OF IN-DEPTH INTERVIEWS THEMES FROM IN-DEPTH INTERVIEWS POST-INTERVIEW TELEPHONE CALLS SUMMARY OF FINDINGS 50 KEY FINDINGS DISCUSSION 52 THE DEBATE RETHINKING EMERGENCY CARE REDUCING THE WAIT MAXIMISING RESPONSES TO APPOINTMENTS DELIVERY OF INFORMATION IMPROVING HEALTH LITERACY CONSUMER FEEDBACK DATABASE MANAGEMENT ORGANISATIONAL BARRIERS RECOMMENDATIONS 56 REFERENCES 58 APPENDIX 1: MANAGEMENT OF WAITING LISTS 60 APPENDIX 2: FURTHER DATA 63 A study abut peple waiting fr public dental care 4

5 ACKNOWLEDGEMENTS Health Issues Centre, in cllabratin with Dental Health Services Victria and Dianella Cmmunity Health, cnducted the study with funding frm the Department f Human Services Victria, the Victrian Health Prmtin Fundatin, and Dental Health Services Victria. The Prject Reference Grup prvided advice and supprt. It cmprised: Mark Sullivan Dr Sachidanand Raju Dr Hanny Calache Dr Elisha Riggs Frank McNeil Val Jhnstne Tny McBride Dell Hrey Charin Naksk Nicla Bruce Dianella Cmmunity Health Dianella Cmmunity Health Dental Health Services Victria University f Melburne Cnsumer representative Cnsumer representative Health Issues Centre Research Divisin, Faculty f Health Sciences, La Trbe University Health Issues Centre Health Issues Centre Additinal input was sught frm: Neela Knara Mueen Albreihi Dianella Cmmunity Health Dianella Cmmunity Health Nicla Bruce and Charin Naksk cnducted the interviews. Martin Whelan f Dental Health Services Victria prvided technical assistance with data cllectin. We wuld like t acknwledge the invaluable cntributins f all staff members at Dental Practice, Dianella Cmmunity Health, especially Maria and the receptin staff wh assisted with recruitment f study participants. We are especially grateful t the public dental patients at Dianella Cmmunity Health wh kindly tk part in the study. Nicla Bruce, Charin Naksk, and Tny McBride wrte the reprt with valuable input frm the Reference Grup. A study abut peple waiting fr public dental care 5

6 EXECUTIVE SUMMARY This study explred the experiences and perceptins f public dental patients wh had been n the waiting list fr public dental care at Dianella Cmmunity Health, including thse wh did nt end up using the service. The aim f the study was t: Investigate factrs (including health literacy) that influence decisins t keep r nt keep appintments made by peple n public dental waiting lists t attend dental clinics. Explre peple s perceptins f their ral health status and general health status, and assciated behaviurs, while waiting fr public dental care. Study design The study invlved peple wh have been n the waiting list fr public dental treatment at Dianella Cmmunity Health, Bradmeadws, fr tw years r mre. Peple were recruited t take part in the study befre they were sent a letter ffering them dental appintments at Dianella. As it was anticipated that the interviews might affect behaviur in regard t making and keeping dental appintments, the behaviur f a cntrl grup ffered appintments at the same time at Dianella were recrded and mnitred as a cmparisn. A Reference Grup was set up t prvide in-depth feedback at different pints f the research, particularly fllwing cmpletin f the majr part f the study. Data cllectin and analysis Data cllectin tk place when: 150 cnsumers received letters f invitatin t take part in the study 107 cnsumers tk part in the pre-interview telephne calls 47 cnsumers including 11 frm Arabic backgrunds tk part in-depth interviews 60 cnsumer recrds were mnitred withut interventin as a cntrl grup. The analysis incrprated quantitative and qualitative strategies, including simple statistics, cntent analysis and grunded thery strategies. The quantitative and qualitative analyses were then scrutinised tgether fr further meaning, allwing a greater level f interpretatin. A study abut peple waiting fr public dental care 6

7 Key Findings In answer t the questin as t why peple wh are registered n the waiting list at Dianella decide t keep r nt keep their appintment was fund t be a cmbinatin f factrs. These included changes that had ccurred during lng waiting perids, lw English literacy and health literacy, family cmmitments and thers assciated with lw sciecnmic and cultural backgrunds. These factrs were cnsidered t be cmplex and t include an interrelatin f all the key findings belw. The fllwing pints cver key findings frm this study: The numbers f cnsumers attending their dental appintment increased dramatically fllwing participatin in this study. Peple wh spend lng perids f time n the waiting list can face deteriratin in their general and scial health. Access t emergency dental care is acknwledged t be imprtant t thse waiting fr public dental care, yet it is nt readily available. The current database system at Dianella des nt supprt nging engagement with peple n the waiting list. The ppulatin n the public dental waiting list at Dianella are culturally and linguistically diverse with lw levels f English literacy. There is a lack f knwledge and cnsequently a high level f misunderstanding abut public dental care amng thse n the waiting list. Infrmatin abut public dental care is nt readily available t members f the Dianella cmmunity. There was a level f anger, frustratin and unhappiness amng participants; this impacted n their attitudes twards dental care and thse prviding that care. Preliminary telephne interviews prvided an avenue fr expressin fr thse wh did nt wish r culd nt be interviewed. Study participants prvided sme excellent suggestins and alternative ways t manage sme f the abve. A study abut peple waiting fr public dental care 7

8 Recmmendatins 1. When peple are registered and put n the waiting list Recrd additinal cntact details including next f kin, mbile phne numbers and if any. Cnsider a needs assessment (a mre sphisticated triage) that indicates hw lng peple can wait befre their cnditin deterirates. Give written as well as verbal infrmatin in the frm f a brchure (as described belw). 2. Develp a strategy fr engagement Develp a brchure and make it available Design a pster that wuld be placed at the waiting area f the dental clinic, which culd be read by thse waiting fr service at the dental desk Using Dianella health prmtin services as a guide, develp peer cnnectins with Dianella grups, external grups and cmmunity rganisatins. Using these links then develp a health literacy campaign t infrm cnsumers abut the health service system, public dental services and hw t navigate thrugh the system Wrk n a cllabrative apprach with lcal cmmunity rganisatins, ethnic media and small cmmunity grups prmting services at Dianella and encuraging peer educatin Develp culturally sensitive services with input frm the abve internal and external cultural services Cnsider engaging family members thrugh the schls prgram. 3. While peple are n the waiting list Make regular cntact by phne and/r letters t prvide infrmatin abut the prgressin f the waiting list Enable tw-way cmmunicatin with cnsumers t facilitate telephne cntact. Perhaps ffer regular fcus grup discussins and/r randm cntact by telephne with cnsumers wh are n the waiting list t ensure innvatins are being targeted crrectly, t learn abut ways t imprve public dental services at Dianella, including the develpment f preventin strategies. 4. When peple have reached the tp f the waiting list Letter f ffer is t be made t appear mre friendly with perhaps a clurful envelpe Letter f ffer is t be made simple, in plain English with a summary in key CALD languages Give a reminder by telephne r message nce the appintment is made Ask fr simple feedback at appintment and ask fr suggestins fr service imprvements. 5. Institute service delivery changes Liaise and cllabrate with primary care prviders such as GPs abut prviding peple with chrnic cnditins a care plan t enable them t receive dental treatment under the Medicare dental scheme Develp a set f prtcls with dental receptin staff fr handling cmplex r prblematic situatins; that is, fr staff t deal with the waiting list data and fr dealing with anxius patients. 6. Explre the feasibility f a centralised emergency referral In cllabratin with ther lcal dental prviders, cnsider the feasibility and develpment f a centralised emergency service that culd direct peple in need t a cnvenient and accessible emergency service. This shuld be cnsidered in assciatin with the delivery f infrmatin abut lcal cmmunity and public transprt availability. A study abut peple waiting fr public dental care 8

9 1. BACKGROUND This study built n findings f the Dental Csts Study cnducted by the Health Issues Centre in cllabratin with Dental Health Services Victria and Dianella Cmmunity Health (Hrey, Naksk, McBride, & Calache, 2008, p. 1). Several questins were raised by this study abut the use (r nt) f dental services, and attitudes f thse n the waiting list twards dental care. In particular we were interested in the fllwing: Did they becme ineligible fr public dental care while waiting; fr example, having fund jbs? Had they sught dental care elsewhere, either thrugh emergency care r frm private dentists? Had peple mved away frm the catchment area? Did ther issues, such as ill-health r family cmmitments, affect their ability t attend? Were they s frustrated by the anticipated r actual waiting time that they ignred fllw-up cmmunicatin frm the service? Was pr literacy a barrier t understanding the ffers made by the service? Was lw level f health literacy a barrier t service use? The Victrian Gvernment is currently wrking n imprving waiting time management in public dental services by cnsulting service prviders and examining lcal and internatinal appraches (DHS, 2007a). The intentin f this study was t cmplement the fcus n the service by lking at issues affecting cnsumers, the key stakehlders in the system. It explred the experiences f peple n a dental waiting list t understand their circumstances and their reasns fr using r nt using the services, despite their needs. 1.1 Ratinale fr the Study As nted abve, Health Issues Centre, in cllabratin with Dental Health Services Victria and Dianella Cmmunity Health, cnducted an earlier study at Dianella Cmmunity Health, Bradmeadws (Hrey et al. 2008). The Dental Csts Study (DCS) was the first cmprehensive study f cmparative csts f public dental care in Victria. It investigated csts t the system and t cnsumers f delayed dental treatment fr users f public dental health clinics amng tw grups f dental patients. One grup was n the waiting list fr mre than tw years; anther grup was n the waiting list fr tw t fur mnths. The study als explred the impact f delayed dental treatment n health and scial behaviurs. Key findings frm Hrey et al included: A higher average cst t the system fr prpsed treatment amng the lnger-waiting grup fr diagnstic services and peridntal, enddntic and restrative treatments, and fr dentures. A majrity f study participants reprted scial csts assciated with their quality f life frm issues related t ral health. Fr example: In the previus mnth, ver half reprted aviding cld fds (56%) cmpared with 17% f Australian adults in the Natinal Oral Health Survey (NOHS [Slade, Spencer, & Rberts-Thmsn, 2007]). Over half reprted experiencing pain because f prblems with muth r teeth (56% cmpared with 15% in the NOHS). Mre than a quarter reprted feeling self-cnscius because f their ral health. Mre than 20% reprted experiencing interrupted r unsatisfactry meals ften r very ften in the previus fur weeks. One in fur peple said they felt embarrassed r tense fairly ften r mre frequently because f prblems with their muth r teeth, and ne in six peple in the study reprted using ver-the-cunter medicatin t manage dental pain fairly. A study abut peple waiting fr public dental care 9

10 One in 10 peple reprted that prblems with their ral health affected intimacy with thers and with sleeping. Imprtantly, the Health Issues Centre reprt suggested that the receipt f timely dental care is significant t verall dental health, and that it results in significantly less interventin and slightly lwer cst t the dental service. At Dianella, hwever, the waiting list fr nn-emergency public dental care remains between tw t three years. The intentin f this study is, therefre, t investigate the significance f such waiting frm the perspective f thse wh have arrived at the tp f the waiting list. 1.2 Brader Cntext The Wrld Health Organizatin (1964) defines health as a state f cmplete physical, scial and mental well being and nt merely the absence f disease r infirmity. Cnsistent with this definitin, it fllws that being rally healthy means that peple can eat, speak and scialize withut discmfrt r embarrassment, and withut active disease in their muth which affects their verall well being (Oral Health Strategy Grup, 1994). Gd ral health is mre than just having gd teeth and healthy gums. Accrding t the Australian Health Ministers Advisry Cuncil (AHMAC) Steering Cmmittee fr Natinal Planning fr Oral Health, dental prfessinals aim t achieve ral health by ensuring that peple s lives are nt affected by ral mucsal disease, ral cancer, jaw jint prblems, malcclusin, malfrmatin r trauma t the jaw and middle f the face (2001). Timely treatment f dental prblems helps prevent ral disease and tth lss with the number f natural teeth present impacting n a persn s capacity t chew and eat a balanced and nutritius diet. A key study f public dental health by the Australian Institute f Health and Welfare (AIHW [Brennan, 2008]) shwed that public dental patients have significantly wrse ral health than the general Australian ppulatin. The higher prevalence f inadequate dentitin with the increased presence f decayed teeth and peridntal pckets suggest that disadvantage in ral health status is related t lwer sciecnmic status and inability t access timely dental services. Recently a significant interim reprt fr Australia by the Natinal Health and Hspitals Refrm Cmmissin (2009) entitled A Healthier Future fr All Australians: Interim Reprt prpsed that public dental shuld underg significant refrm. Of particular cncern are the findings that prpse: Als that Als that Many Australians suffer frm pr ral health, smetimes waiting years t receive basic dental care thrugh the public dental system as they cannt affrd, r d nt have access t, private dentists. Arund 650,000 adults are n public dental waiting lists; the average waiting time is just ver tw years (27 mnths). Public dental services are under-resurced. Services prvided thugh public dental services are predminantly fr emergency care such as extractins. There is limited fcus n preventin and restrative wrk. Gd access t preventive and restrative dental care and, fr thse wh need them, prperly fitted dentures, is essential t gd ral health, and is als imprtant t maintaining gd general health. Anther recent reprt by the Australian Institute f Health and Welfare (AIHW), 2009 emphasised that: The cumulative effects f past dental disease and treatment are reflected in tth lss and the wearing f dentures Peple with n natural teeth have limited ral functin and, althugh they wear dentures, they reprt mre ral health prblems n average than peple with natural teeth. (2009) A study abut peple waiting fr public dental care 10

11 AIHW fund that public dental care patients wh attended emergency care typically attended fr relief f pain. They als fund that: public dental patients were much mre likely t have fewer teeth cmpared with the general Australian ppulatin; their dental decay was higher; and they were mre likely t have larger peridntal pckets. Added t the cmplicatins resulting frm lng waiting lists was the issue discussed by Teusner, Chrispuls, and Spencer (2008) in their AIHW reprt int the supply and demand f dental practitiners. They cncluded that there was a chrnic undersupply f dental practitiners, which, they estimated, wuld increase int the future. Hwever, in respnse t this, there has been a significant increase in the number f ral health students being trained, funded by the federal gvernment, in the last tw years. Despite ppulatin trends shwing a general imprvement in ral health, Australian adults eligible fr public dental care have cnsistently shwn lwer levels f ral health cmpared t ther Australian adults in studies based n self-reprt (AIHW., 2001, 2005, 2006). They are als mre likely t rate their ral health as pr and t be dissatisfied with life (Sanders & Spencer, 2005). These self-perceptins f pr ral health are cnfirmed by clinical assessments f public dental patients, which reveal a higher rate f extractins and emergency dental treatment cmpared t the Australian ppulatin (AIHW, 1999, 2002(a), 2002(b); Brennan, Spencer, & Slade, 1997, 2001). One f the main reasns attributed t pr ral health amng lw incme Australians is their pattern f dental attendance. They are less likely t attend dentists regularly than peple frm higher incme grups and this is the nly knwn dental self-care behaviur that differs between peple f different sciecnmic status (Chen & Hunter, 1996; Harfrd, Ellershaw, & Stewart, 2004; Sanders, Sanders, Carter, & Stewart, 2004). Access t timely clinical examinatin is likely t be beneficial because it enables early detectin and diagnsis with the use f preventive interventins (Wright & Satur, 2000). Organisatinal barriers, such as extended waiting times, may limit the effectiveness f dental health services t prvide timely care. Limited resurces in the public sectr have led t waiting times exceeding five years in sme parts f Victria (Scpelians, 2006). In 2006, the average waiting time fr all public patients in Victria was 26 mnths, althugh patients at the Ryal Dental Hspital in Melburne waited less than a mnth fr dental care (Department f Human Services [DHS], 2007a, 2007b). Cultural diversity is a key characteristic f the Dianella catchment. A reprt n racial difference in dental health care use, cnducted in Flrida (Gilbert et al., 1997) cncluded there were racial differences in respnsiveness t new dental symptms, and there were differences in ther predictrs f dental care utilisatin. These differences may cntribute t racial disparities in ral health in areas such as Dianella, where there is significant racial diversity. Extended waiting times fr dental visits therefre culd have a number f imprtant cnsequences fr bth the dental service and thse receiving care. First, ral health is likely t deterirate, leading t a need fr mre extensive restrative treatment r increased risk f tth lss. Secnd, delayed treatment is likely t increase demand fr emergency dental services, which generally results in tth extractin rather than tth preservatin. This pattern f care shifts csts frm preventive t emergency treatments Scial perspective f dental care The Australian Cuncil f Scial Services (2006) undertk a reprt entitled Fair dental care fr lw incme earners: Natinal reprt n the state f dental care. In this reprt sme key statements were made that are pertinent t the situatin f peple n waiting lists fr public dental care: The scial impacts f pr adult ral health are immense. Over a quarter f Australian adults experienced painful aching because f prblems with their teeth, muth r dentures in A quarter reprted aviding fds and nearly a third reprted that they fund it uncmfrtable t eat. Just under a quarter f Australian adults reprted that they felt self-cnscius r A study abut peple waiting fr public dental care 11

12 embarrassed because f ral health prblems. (Australian Cuncil f Scial Service, 2006 p.1) Cnsequently, sme recmmendatins stated that: All eligible adults shuld receive at least ne curse f general ral health care every tw years n average. Adults with greater dental needs shuld be recalled mre frequently N ne shuld have t wait lnger than 24 hurs t receive emergency dental care fr swelling, infectin and bleeding, r serius and persistent pain. The abve recmmendatins serve as a cmparisn by which t appraise cnsumer experiences f waiting fr dental care Medicare funding f dental care Since 2007 there has been a limited prvisin f Medicare funding fr dental care. This has been ffered t peple with a chrnic disease under the Medicare chrnic disease dental scheme (Australian Gvernment, 2007). T be eligible under this scheme a persn must be deemed by their GP t have a chrnic medical cnditin with cmplex care needs and in which their ral health must be impacting n, r likely t impact n, their general health. The Australian Gvernment website defines a chrnic medical cnditin as: ne that has been r is likely t be present fr at least six mnths. It may include, but is nt limited t, cnditins such as asthma, cancer, cardivascular illness, diabetes mellitus, arthritis, mental illness, musculskeletal cnditins and strke. (Australian Gvernment, 2007) < The limited nature f this scheme means that thse wh think they may qualify must attend their lcal GP fr assessment and referral t a dentist. 1.3 Victria s Public Dental Service Dental Health Services Victria (DHSV) is respnsible fr the delivery and purchase f public dental care fr children and disadvantaged adults in Victria. The majr service is lcated at the Ryal Dental Hspital in Melburne. DHSV subcntracts cmmunity health services t prvide cmmunity-based dental care under cnditins set by the Victrian Department f Human Services (DHS), which funds the system. While the average waiting time fr general dental care acrss the state in 2006 was 26 mnths (DHS, 2007a) waiting times varied at different public clinics, frm less than ne mnth t 68 mnths. In ne-third f the clinics, waiting times were 10 mnths r mre abve the state average (DHS, 2007a). Anther reprt (DHS, 2007b) cncentrated n waiting times in the public dental system and the drivers f waiting times in the public dental system. It identified pssible slutins t reduce waiting times at a lcal and state-wide level but did nt address t a great degree the need fr increased funding. While the prject lked specifically at waiting times, they suggested there were brader demand management issues within the public dental system. Peple wh are seen frm waiting lists accunt fr arund half the peple receiving care. Children, yuth, special needs, emergency and pririty care clients are amng the clients seen utside the waiting lists. The reprt recmmended that, lcally, agencies with access t DHS-funded private sectr vuchers culd help reduce waiting times thrugh the prvisin f such vuchers. In the lnger term, it was cnsidered that additinal infrastructure wuld reduce waiting times. Other suggestins included: Better use f and strnger relatinships with private sectr. A study abut peple waiting fr public dental care 12

13 Systems t ensure clients are nly n ne waiting list and nt being seen at ne r mre clinics; fr example, central waiting lists, catchment areas. Sterilisatin nurse fr all medium t large clinics t increase prductivity. Central recruitment and emplyment f clinicians, perhaps thrugh large hub-andspke type partnerships. Better infrmatin prvided t clients abut managing their wn ral health when they jin the waiting list, and/r health prmtin initiatives t supprt thse already n waiting lists. Extensin f fluridatin. Fcusing n preventin thrugh integrated health prmtin and targeting effrt t children. Lng-term slutins t prgress bth plicy and funding supprt were prpsed. 1.4 Dianella Cmmunity Health Dianella Cmmunity Health (DCH) has a large catchment area, cvering mst f the City f Hume n Melburne s nrthern urban-rural fringe. It prvides primary and cmmunity health services t ne f the prest and mst diverse cmmunities in the state. Bradmeadws is ranked as the third mst disadvantaged suburb in Melburne (Hume City Cuncil, Dianella Cmmunity Health, & Sunbury Cmmunity Health Centre, 2007). Mre than 130,000 peple live in the area. The average age is 32.5 years, making it ne f the yungest municipalities in Victria. The ppulatin is expected t grw by abut 40% ver the next 10 years, especially amng thse aged 65 years and mre. It is a culturally diverse cmmunity, with ver ne-third f the ppulatin brn utside Australia. In the last seven years, peple frm Iraq, Turkey and Lebann have mved t the area. Other than English, the majr languages fr residents include Turkish, Italian and Arabic. Hume has the highest prprtin f Cathlic and Muslim residents cmpared t ther lcal gvernment areas in Melburne. The unemplyment rate in Hume is abve the Victrian average and individual and husehld incmes are belw average (Hume City Cuncil et al., 2007). In 2006, less than tw-thirds f the ppulatin were in the paid wrkfrce and nearly ne in 10 was unemplyed. It is imprtant t nte that the ppulatin as depicted can be described as lw sci-ecnmic and in a hard t reach categry as cnsidered in recent research by Swinburne Institute f Scial Research entitled Cmmunity Cnsultatin and the 'Hard t Reach' (Brackertz, 2007). This grup was identified as requiring special cmmunicatin strategies t engage them Dental Services at Dianella The cmmunity dental prgram is ffered t eligible clients by Dianella Cmmunity Health s Bradmeadws clinic. T participate, clients must qualify fr a cncessins card that is either a Pensin r a Health Care Card, and be abve 18 years f age. A c-payment applies. In the financial year , the dental team treated 4,829 clients and prvided 42,188 treatments (Hrey et al. 2008) These included services fr 2,532 patients wh received emergency dental care (Dianella Cmmunity Health, 2007). In 2006 and 2007, Dianella had 4.06 effective full-time (EFT) dentists and 4.32 EFT dental nurses fr the adult dental prgrams. It has six dental chairs, tw f which are fr schl dental services. On mst days dentists receive 13 t 14 dental visits each (Raju, 2006). Dianella dental service perates at capacity fr bth adult and schl dental services. It has a stable dental wrkfrce, which allws it t maximise its resurces (Dianella Cmmunity Health, 2007a). Hrey et al. (2008) als described hw the dental service at DCH received between 30 and 40 telephne calls every wrking day abut half f these fr emergency care. Calls are assessed ver the phne by the dental receptinist and allcated t either the general waiting list r the denture waiting list. On average, 170 patients were added t the waiting lists each mnth 137 fr general dental services and 33 fr prsthetic services (Raju, 2006). A study abut peple waiting fr public dental care 13

14 Peple wh reprted pain were transferred t a cmputerised triage system that assesses the urgency f their treatment needs. Sme emergency patients wuld be given an appintment n the same day while thers might wait up t five weeks (Raju, 2006), depending n the urgency categry level that is assigned t them. Dianella Dental Services has a limited capacity t prvide emergency care t its patients. Fr example, during Nvember 2008 t January 2009, just ver 50% f the peple wh called fr urgent attentin were given the appintments (Rgnrust, 2009). See Figure 1 belw and Table 2 in Appendix 1. Figure 1: Demand and Supply f Emergency Services Demand and Supply f Emergency Services Ttal requests fr emergency service Appintments given Nn-eligible clients re-directed t ther services Unable t prvide appintments Nv-08 Dec-08 Jan-09 In February 2006, there were 5,116 patients waiting fr dental treatment n the electrnic dental database at Dianella. These cmprised 4,381 peple waiting fr general services and 735 peple waiting fr prsthetic r denture services. The estimated waiting time was 30.9 mnths fr general patients (Victrian Minister fr Health, 2006). This was higher than the state-wide average waiting time fr general care in March 2006 f 26 mnths (DHS, 2007a). It is usual practice at Dianella t mail ut ffers f dental appintments in batches. Letters are sent t the 150 t 200 peple at the tp f the waiting list every few weeks. They are given abut fur weeks t make an appintment. Only abut 30% f thse ffered appintments fr general services, and 60 70% f thse ffered appintments fr denture services make appintments. The waiting time fr appintments is abut three t fur weeks (Raju, 2006). Dianella is estimated t require an additinal 10 dental chairs. These chairs are planned t be lcated in Craigieburn, but nt until 2011 (Dianella Cmmunity Health, 2007a, 2007b). Als dcumented (Dianella, 2008) was the high level f mrale amng dental staff Management f waiting lists at Dianella Fr a detailed accunt f the management f waiting lists at Dianella please see Appendix 1. A study abut peple waiting fr public dental care 14

15 1.5 Impacts f Oral Health Status Accrding t Hrey et al. (2008) ral health is clsely linked t general health, t the selectin and preparatin f fd which in turn influences whether there is an adequate diet, nutritinal status and general health status. They argue that adults with reduced chewing capacity that leads t diets lw in fibre and Vitamin C are at increased risk f cardivascular disease. Reduced dietary fibre and Vitamin C intake has als been assciated with an increased risk f diabetes, strke and cataract frmatin. Hrey et al. (2008) included evidence in their study n hw a reduced intake f fruit, vegetables and dietary fibre is assciated with an increased risk f cancers in the digestive system such as clrectal cancer. Pr ral health is als seen t reduce peple s quality f life in many ways and it is estimated that the quality f life f ne in six Australian adults is adversely affected by ral health prblems (AIHW, 2006). Abut ne in 10 respndents in a natinal health survey reprted frequently experiencing painful aching, uncmfrtable eating, pr sense f taste and truble prnuncing wrds; and ne in 12 reprted frequently feeling tense, embarrassed r self-cnscius because f prblems with their muth r teeth (AIHW, 2006). Peple wh suffered dental prblems have als been fund t lack the scial cnfidence fr successful jb interviews. A study abut peple waiting fr public dental care 15

16 2. RESEARCH METHODS 2.1 Dental Waiting Study In this study we wanted t explre the experiences and perceptins f public dental patients wh had been waiting fr public dental care, including thse wh did nt end up using the service. Aims The study aimed t: Investigate factrs (including health literacy) influencing decisins f peple n public dental waiting lists t attend dental clinics. Explre peple s perceptins f their ral health status and general health status, and assciated behaviurs, while waiting fr public dental care. The study therefre investigated the participants : Perceptins f ral health care needs Knwledge f ral health services Previus experience f service use Intentins t make appintment with public dental health services Reasns underlying their appintment intentins Experiences f waiting fr a public dental appintment Reasns fr behaviurs that differ frm their stated intentins. We hped this wuld give us increased understanding f the factrs mtivating cnsumer behaviur, especially: Barriers and mtivatrs t the use f public dental services by eligible cnsumers Life stries arund the knwledge and perceptins f ral health needs and ral health services amng peple in a hard-t-reach grup. Cmbined quantitative and qualitative research methds were emplyed fr this study. A pre-interview telephne call was utilised fr recruitment and cllectin f initial data. This was fllwed by structured face-t-face interviews with a sample f peple wh have been waiting fr public dental care at Dianella Cmmunity Health, Bradmeadws. Qualitative data cllectin was supprted by a quantitative assessment f the Oral Health Impact Prfile (OHIP). The appintment behaviur f interviewees was subsequently tracked, and a brief telephne interview undertaken with thse participants wh changed their mind abut taking up, r nt, their appintment fr care. As the interviews were judged t ptentially affect behaviur in regard t making and keeping dental appintments, the behaviur f a cntrl grup being ffered dental appintments at the same time was als mnitred. 2.2 Study participants The study invlved peple wh had been n a waiting list fr public dental treatment at Dianella Cmmunity Health, Bradmeadws, fr tw years r mre. Sixty peple were t be recruited t take part in the study s in-depth structured interviews shrtly befre they were sent a letter ffering dental appintments at Dianella. Further feedback was received frm a number f cnsumers via telephne calls after the interviews. A study abut peple waiting fr public dental care 16

17 Bradmeadws is a culturally diverse cmmunity with a high number f new immigrants arriving frm Iraq, Turkey and Lebann (Hume City Cuncil, Dianella Cmmunity Health et al., 2007). Arund 17% f participants in the Dental Csts Study were brn in the Middle East and Arabic is the secnd mst cmmn language spken at hme (after English [Hrey, Naksk, McBride, & Calache, 2008]). Fr these reasns, the study aimed t recruit up t 20% f the participants frm Arabic-speaking backgrunds. Participants in the study included adults aged 18 and ver wh wuld be receiving a letter ffering a dental appintment frm Dianella within tw mnths. Peple wh were unable t cnsent r with n capacity t cnsent, such as thse with mental disability, were nt recruited. 2.3 Prject Steps The study was undertaken in the fllwing steps: 1. Obtained apprval frm Dental Health Services Victria Human Research Ethics Cmmittee. 2. Established a Prject Reference Grup cmprising prject partners, ther public dental researchers and cnsumer representatives. The grup was regularly infrmed f prject prgress and any issues. Members were invited t give feedback via . The grup met nce t prvide input t the analysis and draft final reprt. 3. Accessed the dental waiting list at Dianella Cmmunity Health and identified peple n the list wh wuld be sent an ffer f a dental appintment within eight weeks. One hundred and fifty cnsumers were cntacted by letter, which explained the study and hw t participate in it. A shrt descriptin f the study in the Arabic language was included. Attached t the letter was prject infrmatin and cnsent frm in plain English. 4. One week after sending the letter, Health Issues Centre researchers made telephne cntact with all ptential participants (150), prviding further infrmatin abut the study and answering questins. If they wanted t participate in the study, a schedule fr an interview at Dianella was made. 5. Face-t-face interviews were cnducted with 47 participants at Dianella Cmmunity Health. It had been planned t interview 60 peple, but fr several reasns, including data saturatin discussed later, 47 were eventually interviewed (see sectin 2.3.3). The interviews included a mix f structured questins, such as the Oral Health Impact Prfile (OHIP), plus pen-ended qualitative questins. With the participant s cnsent, the interview was digitally recrded. Interviews lasted apprximately 30 minutes. Interpreters were used if necessary. The participant was paid $30 fr their time and transprtatin t the interview. 6. When the cnsumers recruited fr the study reached the tp f the dental waiting list, letters ffering dental appintments frm Dianella Cmmunity Health were sent t them. Cnsumers were given fur t six weeks t make an appintment. Health Issues Centre researchers recrded respnses f all ptential participants and thse in the cntrl grup. 7. Rates f respnse t letters ffering dental appintments and attendance at appintments were cmpared between grups. 8. Fllw-up interviews by telephne were cnducted with interviewed participants wh had seemed t behave differently t their stated intentin at interview; that is, with thse wh said that they intended t make an appintment but failed t d s, and vice versa. The prject steps are presented in Diagram One displayed n the fllwing page. A study abut peple waiting fr public dental care 17

18 Figure 2: Prject Steps Letter f ffer sent by Dianella Deadline fr appintments Cntrl grup cnsumers N=60 Data recrded: Public dental waiting list Ptential cnsumers fr interview grup N=150 (max) Decisin t make appintment Appt. (Y/N) Attend (Y/N) Change (Y/N) N change in decisin First telephne call (Recruitment) Recruitment letter sent by HIC n behalf f Dianella ~47* facet-face interviews (Intentin t attend) Data recrded: As abve Change in decisin Telephne interview Data recrded: Reasn fr decisin change * Fr explanatin see page 20 A study abut peple waiting fr public dental care 18 Health Issues Centre,September 2009

19 2.4 Recruitment The Health Issues Centre btained a list f the 210 cnsumers at the tp f the dental waiting list frm Dianella Cmmunity Health in Nvember Of these, 65 (31%) were brn in Australia and 141 (67%) were brn verseas, in 27 cuntries. The largest grups f cnsumers were brn in Turkey (29), Italy (23), Iraq (21) and Lebann (19). The 210 cnsumers were arbitrarily divided int 150 ptential participants fr telephne calls and face-t-face interviews (interventin grup) and 60 cnsumers t be mnitred fr recrds f respnses t dental appintment ffers (cntrl grup). They were recruited in three cnsecutive stages f at a time. Fr example, when a letter f invitatin t take part in the study, cntaining prject infrmatin and cnsent frm, was sent t the first 50 cnsumers n the waiting list, anther 20 cnsecutive cnsumers n the list were marked as members f the cntrl grup. There were sme irregularities n the Dianella database; fr example, 11 cnsumers were part f the preceding prject, the Dental Csts Study. These cnsumers had jined the waiting list shrtly befre being recruited fr the first study (i.e., were at beginning f list, nt end) and they had cmpleted their curse f care as part f the Dental Csts Study in Accrding t Dianella Dental Services, peple wh have cmpleted their curse f care need t wait fr 12 mnths befre they can jin the waiting list again. Cnsequently, their recrds shuld have been remved frm the current database. Nevertheless, as they wuld receive a letter ffering a dental appintment frm Dianella, Health Issues Centre cnsidered them eligible fr recruitment in this study. An Arabic sub-sample was assured frm the large number f peple n the waiting list wh identified themselves as Arabic Pre-interview Telephne Calls Health Issues Centre researchers made telephne calls t the first 50 cnsumers in the first week f December The next rund f telephne calls t anther 50 cnsumers was made in mid-january 2009, and the third rund t the last 50 cnsumers in the beginning f February Between each batch f recruitment, 20 cnsecutive cnsumers after the first 50 n the list were allcated t the cntrl grup. Their recrds f respnses t the ffer f dental appintments and appintment attendance wuld be mnitred Criteria used The telephne calls were made by Health Issues Centre researchers ne week after the letters f invitatin and prject infrmatin were psted t the cnsumers. The fllwing criteria were used fr the telephne calls: 1. Every cnsumer n the list was called nce during business hurs n a weekday. A message was left with an answering machine if the cnsumer was nt available. 2. Cnsumers wh did nt answer the first call were called again at a different time f day and a different day f the week, within business hurs. The calls that were respnded t by an autmatic message r where the line culd nt be cnnected were als tried again fr a secnd time. 3. Thse wh did nt answer the secnd call were called again utside business hurs; that is, evening r the weekend. The culd nt be cnnected lines were nt tried again. 4. If an autmatic message indicated that the number culd nt be reached, r the number given was wrng, r the cnsumer did nt have the phne number n the recrd, the researchers searched fr crrect telephne numbers frm the White Pages telephne directry and repeated steps 1 t If cnsumers culd nt be reached after all the steps abve, n mre attempts were made. A study abut peple waiting fr public dental care 19

20 6. Cnsumers wh respnded t the telephne call with limited English were ffered a telephne interpreter in their language. Once a telephne interpreter was arranged, anther call was made t the cnsumers. An interpreter in the cnsumer s language was als ffered fr face-t-face interviews with cnsumers with a limited understanding f English Respnses t recruitment The number f pre-interview telephne cntacts finally reached 107 cnsumers. Frty-seven cnsumers were fund after ne call, 36 in the secnd call and 24 were fund after calling three t six times. Althugh a frmal Arabic interpreter was nt used in these phne calls, family members were recruited n fur ccasins t relay infrmatin and t assist in setting up an interview with an interpreter. It seemed that the Arabic infrmatin included in the invitatin letter prvided an adequate intrductin t the study. The respnse t recruitment was slw in December but imprved in January. Yet at the cnclusin f the last batch f the recruitment in February, the number f participants had nt reached the required number f 60. The researchers made additinal effrts t recruit mre cnsumers. The White Pages were searched fr crrect telephne numbers f peple wh were nt riginally reached and new letters sent if addresses had changed. We went back t cnsumers wh had indicated in the early rund that they culd participate at a later time. We als ffered in-depth interviews by telephne t cnsumers wh wanted t be part f the study but were unable t cme t Dianella. In the meantime, interviews with cnsumers recruited early in the third batch revealed that data had reached saturatin. That is, that there was n further new infrmatin being discvered as the interviews prgressed (Strauss & Crbin, 1998). Tgether with the rich infrmatin cllected at the pre-interview telephne call, it was decided t stp recruiting. In ttal, 50 cnsumers agreed n the phne t take part in the in-depth interviews, but ne failed t attend, ne was sick and ne had t attend t her sick mther. Finally, 47 cnsumers (31% f all ptential cnsumers and 43.5% f cnsumers spken t n the telephne) tk part in the interviews. Five f these had taken part in the previus Dental Csts Study. Eleven interview participants (23%) came frm Middle Eastern backgrunds, where peple speak r understand Arabic; these included eight frm Iraq and three frm Lebann. 2.5 In-depth interviews The date and time f the interview were arranged n the telephne with cnsumers wh agreed t take part in the study. Cnsumers reprted t Dental Receptin n arrival and/r were met by a Health Issues Centre researcher in the waiting area. Interviews were cnducted in a private ffice at Dianella Cmmunity Health, by the researchers experienced in in-depth interviews. The researcher explained prject infrmatin t the cnsumers and answered any questins they may have had. Cnsent t the interview and digitally recrding the interview was then btained. Thugh structured, the interview was nevertheless infrmal. Rating scales as well as penended questins were used. The researchers prmpted interview participants fr extensive infrmatin where apprpriate. Of the 47 interviews, fur interviews were cnducted via an Arabic interpreter, and fur were cnducted ver the telephne. Three cnsumers did nt want t have an interpreter and brught a partner r a family member t assist with the interview. Interviews were recrded in a digital recrder and hand-written ntes. Interview participants were remunerated $30 fr their participatin. The fcus f these interviews is described in sectin 2.7 belw. A study abut peple waiting fr public dental care 20

21 2.6 Respnses t ffer f appintment and appintment attendance Abut fur weeks after the study recruitment began, Dianella Cmmunity Health started t send letters t cnsumers n the dental waiting list wh were ptential participants f the study (the interventin grup) and whse recrds nly wuld be mnitred fr the study (the cntrl grup). The letter infrmed cnsumers they had reached the tp f the waiting list and that they culd nw make an appintment with the dentist. These letters were sent in three batches, with appintments t be made within fur weeks. An appintment time wuld be allcated immediately r within fur weeks. The Dental Services at Dianella systematically recrded evidence f cnsumers making appintments and appintment attendance with clinical infrmatin n their electrnic database. The appintment data was analysed fr study participants after eight weeks (fur weeks fr cnsumers t make an appintment after receiving their letter and anther fur weeks t attend a given appintment, befre accessing the recrds). The researcher retrieved the cnsumers recrd f respnses t an ffer f an appintment and appintment attendance twice. Frm the database we checked when the letter f ffer was sent t the cnsumers, whether they made an appintment, attended, cancelled, re-bked r never attended the appintment. Recrds f all 210 cnsumers n the recruitment list were created. These included: interview participants; cnsumers wh were reached by telephne but did nt participate in face-t-face interviews; cnsumers wh were nt reached by telephne; and thse in the cntrl grup wh were nt cntacted by the researcher. Only the first appintment, the dental examinatin, was cnsidered in this study. 2.7 Fllw-up telephne calls The attendance r nn-attendance f the 47 interview participants was cmpared with their initial intentin, as stated in their face-t-face interviews. Ten peple (21%) seemed t behave differently frm their intentin. All said that they wuld like t make an appintment but the recrds shwed that they did nt respnd t letters f ffer f appintment. The researchers made a shrt telephne call t the 10 cnsumers t ask abut the circumstances that made them change their mind (see Appendix 5). 2.8 Data Items In-depth interviews with study participants cllected the fllwing data: Cnsumer demgraphic infrmatin, including: gender; level f educatin attained; main life ccupatin (either current r previus); cuntry f birth; year f arrival in Australia (if relevant); and language spken at hme. Oral Health Impact Prfile (OHIP)-14, a validated 14 item measure develped t rate the perceptins f scial impact relating t ral health ver the preceding fur weeks (Slade, 1997). It is a shrtened frm f the riginal 49-item OHIP instrument (Slade & Spencer, 1994). It includes the dimensins f functinal limitatin, physical pain, psychlgical discmfrt, physical disability, psychlgical disability, scial disability and handicap. It uses a five-pint Likert-type scale with the respnse categries: never; hardly ever; ccasinally; fairly ften; and very ften, t assess the frequency f symptms. Open-ended questins included: perceptins f ral health care needs; knwledge f ral health services; previus experience f service use; intentins t make appintment with public dental health services; reasns underlying their appintment intentins; and experiences f waiting fr a public dental appintment. Pst-interview telephne calls prvided qualitative data abut reasns fr using r nt using public dental services that vary frm cnsumers intentin. Pre-interview telephne calls cllected data abut cmmunicatin and literacy levels f cnsumers and reasns fr nt taking part in the study. A study abut peple waiting fr public dental care 21

22 2.9 Data Analysis Mst data were analysed using qualitative research methd strategies f cntent analysis (that asks wh, what, where and hw questins) tgether with grunded thery strategies f cnstant cmparisn, pen cding and the identificatin f emergent themes. Interview data was reviewed and transcribed as required by the researchers fr the purpse f the analysis. Open cding invlved the develpment f cding categries t reflect the cntent f the data cllected rather than the interview questins. Themes, patterns, categries, descriptive examples and qutatins emerged thrugh the analysis frm interpretatin f the findings. Data frm the structured questins such as the OHIP-14 was statistically analysed. A simple statistical analysis was undertaken n respnses t letters ffering appintments and attendance rates. This included recrds f cnsumers in the interventin grup (thse wh participated in the face-t-face interviews) being cmpared against recrds f the cntrl grup (thse nt cntacted by the study in any frm), and thse wh were cntacted by letters r telephne calls but did nt participate in the interviews. A study abut peple waiting fr public dental care 22