Understanding pre-school children’s Community Dental Service appointment failure: a mixed-methods study
Thesis DisciplineHealth Sciences
Degree GrantorUniversity of Canterbury
Degree NameMaster of Health Sciences
Background Disengagement is the active avoidance of a group or situation. Patient disengagement is an ongoing problem for health services and governments, as it reduces efficiency, generates additional financial costs, and reduces early identification and management of health problems. Patients who frequently disengage from preventive care services often require secondary care. Patient disengagement is an ongoing issue for oral health services. Cost, past experience, perceptions, and accessibility are key determinants to oral health service disengagement. Moreover, child disengagement is likely to follow into adolescence and adulthood. However, oral health disengagement is under researched, and what research has been conducted, predominately utilises quantitative methods. These methods identify disengagement characteristics, including who, when and how often, but fails to uncover why patients disengage from oral health services. In contrast, qualitative research methods usefully augment the current evidence-base by providing rich insights into disengagement rationalisation. Disengagement is often the result of a combination of complex circumstances occurring in a patient’s life. These complexities make disengagement difficult to clearly define. However, appointment failure is considered as one important component of disengagement, and for the purpose of this research, was used as a proxy measure of disengagement. The study investigates appointment failure at the Canterbury District Health Board’s (CDHB) Community Dental Service (CDS). The CDS is a preventative dental service providing free dental care for eligible children between the age of 6 months to 13 years, in Canterbury and South Canterbury. Objectives Set with the Canterbury District Health Board’s (CDHB) Community Dental Service (CDS), the primary research objectives are to identify the characteristics of pre-schooler appointment failure, identify the frequency of appointment failure per Community Dental Clinic (CDC), and discover parent and caregiver reasons for disengagement and their recommendations to the CDS to ameliorate it. Methods The study was granted ethics approval from the CDHB research office and the University of Canterbury (UC), Human Ethics Committee. A mixed methods sequential research design was employed to meet the research objectives. Phase one, a quantitative epidemiological investigation, utilised a retrospective closed cohort of eligible CDHB CDS pre-schoolers born in 2010 and their 2010-2014 appointment history. Eligibility required pre-schoolers to be enrolled with the CDS for the duration of the study period. A descriptive and analytical epidemiological approach was taken to characterise the population and factors associated with appointment failure. Phase two, the qualitative component, involved undertaking two parent and caregiver focus groups. Focus group participants were recruited from CDS clinic locations identified as having high failure rates in Phase one. To be eligible for the focus group, parents and caregivers had to have at least one pre-schooler currently enrolled in the CDS, who had missed a minimum of two appointments. Focus group transcripts were transcribed and analysed to uncover the factors that influence appointment failure. Results Overall, in Phase one, 6,986 pre-schoolers were born in 2010 and eligible for CDS enrolment. Male pre-schoolers accounted for 50.4% of the study population, while females made up 49.6%. The majority of pre-schoolers were European (77.6%), followed by Māori, Asian, Pacific Islands and Other, 9.2%, 7.7%, 3.9% and 1.6% respectively. Of the total number of pre-schoolers, 49.8% were living in the least deprived areas (quintiles one and two), 19.3% were living in moderate deprivation areas (quintile three) and 30.9% were living in the most deprived areas (quintiles four and five). Of the 18,933 scheduled appointments, 12.3% ended in appointment failure. The odds of failing an appointment were significantly greater for pre-schoolers with a Māori or Pacific Islands ethnicity (4.3 and 4.8 respectively), living in high deprivation areas (3.0 and 5.6 respectively), or aged 3 or 4 years at their scheduled appointment (0.6 and 0.5 respectively). Appointment type and pre-schooler sex did not increase the odds of failing an appointment. In Phase two, focus group participants identified four factors that influence appointment failure: waiting room and dental surgery ambience, staff attitude, physical resources that inhibit accessibility, and communicating with technology. Participants did not associate their childhood and current dental anxiety and fear with their pre-schooler’s failed appointments. Participants made several recommendations to reduce future appointment failure; these recommendations ranged in implementation difficulty. Seemingly simple recommendations involved enhancing the clinic environment, issuing parents with fridge magnets with the services contact details, and clinical staff communication. Potentially more difficult recommendations involved changing the clinic hours to offer late night and weekend appointments, and changing the services care delivery model so pre-schoolers can be screened in CDS mobile dental vans instead of CDC’s. Conclusions Consistent with New Zealand oral health literature, Māori and Pacific Islands pre-schoolers, pre-schoolers living in high deprivation areas and pre-schoolers aged 3 or 4 experienced greater odds of failing an appointment at the CDS. However, unique to New Zealand oral health disengagement literature, four factors were identified by participants as influencing their pre-schoolers appointment failure. These factors did not include a participant’s own childhood dental perceptions and experiences as influencing their pre-schoolers failed appointments; a factor considered to be a barrier in the international literature. The strengths of the research were the selected research methods and analysis. The mixed methods approach brought an innovative complementary perspective to an important but poorly understood topic. The opportunity to use a large, prospectively collected database systematically captured from a reliable patient data information system to inform strengths based focus groups, was also important. Talking to parents and caregivers and uncovering the reasons for non-attendance provided fresh insight, outside the routinely collected quantitative variables, and is another salient strength of this study. The research findings demonstrate the complexity and intricacies of pre-school appointment failure. Furthermore, there are clear cultural, socio-economic and age disparities associated with CDS disengagement. The CDS needs to address these disparities by targeting and promoting a service that will best meet the needs of vulnerable parents and caregivers. To improve utilisation for vulnerable pre-schoolers, the CDS should begin by incorporating the recommendations made by participants into the services model of care and future service development.