|Year : 2013 | Volume
| Issue : 1 | Page : 5-11
Quality of care at a pediatric dental clinic in Ibadan, Nigeria
OO Bankole1, JO Taiwo2
1 Department of Child Oral Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Periodontology and Community Dentistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Acceptance||05-Sep-2011|
|Date of Web Publication||2-Feb-2013|
O O Bankole
Department of Child Oral Health, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The quality of healthcare has become a topical issue in recent years and the introduction of quality assurance that constitute some of the tools for change is now an important development in healthcare practice.
Objectives: This study aims at evaluating the quality of care provided at the Paediatric Dental Clinic of the University College Hospital (UCH), Ibadan.
Materials and Methods: A descriptive study was conducted among 141 parents of children who attended the clinic over a 3-month period using a modified quality of care questionnaire by Ygge and Arnetz (2001).
Results: Majority of the parents (93.6%) were pleased with the registration process, while 81.6% and 66.7% were satisfied with the waiting arrangements and social amenities such as light and water respectively. Ratings of the quality of care indices revealed that 50.4% and 41.1% of the parents were happy with the information process and accessibility respectively. Over 80.0% of the respondents were pleased to a great degree with the dental treatment their children received. However, 44 (31.2%) said that they felt that they could not especially/not at all contact their dentist by telephone. About a fifth, (21.2%), felt they had not especially/not at all received information about how to prevent their child's dental problem. Inability of the dentists to introduce themselves was reported by 56.8% of the parents. The mean waiting time spent before being attended was 64.9 minutes while the desired average waiting time was 20.1 minutes.
Conclusion: Parents were extremely satisfied with the dental treatment their children received at the UCH and had great confidence in staff competence even though they complained of long waiting time. However, there is a communication gap between the dentist, patients, and parents, since some of the dentists failed to introduce themselves and give information on prevention of dental diseases. For this reason, patients' appointments should be spread out to reduce waiting time. Furthermore, staff should introduce themselves and efforts must be made to improve health education given to parents. The dental curriculum should emphasize patient-dentist relationships.
Keywords: Child, pediatric dental clinic, quality of care
|How to cite this article:|
Bankole O O, Taiwo J O. Quality of care at a pediatric dental clinic in Ibadan, Nigeria. Niger J Clin Pract 2013;16:5-11
| Introduction|| |
The quality of healthcare has become a topical issue in recent years and pressure is increasing for a change in the healthcare delivery system in many countries.  The introduction of quality assurance and medical audit constitutes some of the tools for the change and is now an important development in healthcare.
Patient satisfaction has become an accepted indicator of quality of care today. , However, for patient populations such as small children or elderly individuals with mental impairment who may have difficulties in expressing their views directly, the view of close relatives usually takes precedence.
Parental satisfaction with pediatric services , and pediatric dental care , has been the subject of a number of studies. Literature on quality of care of pediatric dental services in Nigeria appears scarce. This study aims at evaluating parental satisfaction with services provided at the Paediatric Dental Clinic of the University College Hospital (UCH), Ibadan, Nigeria.
| Materials and Methods|| |
The study was conducted at the Dental Clinic, University College Hospital, a teaching hospital in Ibadan, Southwestern Nigeria. All parents, of children who attended the clinic over a 3-month period consenting to fill the questionnaires, participated in the study.
A 48-item questionnaire was developed which was a modification of the quality of the pediatric care questionnaire by Ygge and Arnetz.  The original questionnaire was modified based on the culture and local environment of the study site.
Basic demographic data were collected and the parents were asked if they had previous contacts with the dental clinic. The study instrument sought to enquire about the quality of care received and items were grouped under the following domains: Information (3 items), accessibility (4 items), dental treatment (4 items), caring process (6 items), staff attitudes (4 items), participation (3 items), staff work environment (5 items), and satisfaction with associated services and facilities (8 items).
A social class was determined by using the three category version of the National Statistics Socioeconomic Classification.  The dental treatment received was a one-visit treatment. The parents scored their overall rating of quality of care at the dental clinic using a visual analog scale from 1 to 10.  The final question asked them to offer suggestions for improved services at the clinic.
The level of satisfaction of the various items was evaluated using a 4-point Likert-type scale (yes to great degree, yes to a certain degree, no not especially and no not at all). Each item was scored and higher scores indicated greater satisfaction. Scores were grouped into percentiles and they were used to grade performance under each domain into "good," "fair," and "poor."
The developed questionnaire was given to three dentists at the Dental Clinic UCH, Ibadan, who read through to evaluate for clarity, ambiguity, and appropriateness to the objectives of the study. The questionnaire was pretested among 10 parents who brought children to the clinic.
Computer data entry was done after the required number of questionnaires had been collected. Statistical analysis was done using the statistical package SPSS 15. Reliability estimates were obtained using Cronbachs alpha.
| Results|| |
A total of 149 questionnaires were filled but 8 were discarded due to missing information. Cronbachs alpha was 0.773.
Many of the respondents 85 (60.3%) were between 30 years and 39 years of age. Twenty-three (16.3%) of them were under 30 years of age while 33 (23.4%) were 40 years and above. Majority of the parents 134 (95.0%) were females while only seven (5.0%) were males. Forty-one (29.1%) of the respondents belonged to the high social class. Sixty-seven (47.5%) and 33 (23.4%) of them were in the middle and lower social classes respectively. Majority of the respondents 94 (66.7%) had children between 7 years and 12 years while 15.6% and 17.7% had children between 1-6 years and 13-15 years, respectively. Seventy-four (52.5%) of the respondents were first timers to the dental clinic [Table 1].
Many of the parents, 132 (93.6%) were satisfied with the registration process while 115 (81.6%) and 94 (66.7%) were pleased with the waiting arrangements and social amenities such as light and water respectively [Table 2].
The mean waiting time that parents claimed they spent before being attended in the pediatric dentistry clinic was 64.9 ± 35.8 minutes while the average waiting time desired was 20.1 ± 10.2 minutes and the difference was significant (P=0.04). Thirty-five (24.8%) of the respondents said that the waiting time they spent before seeing the dentist was too long.
Scores regarding information showed that half (50.4%) of the parents were pleased with the information process [Figure 1], while a fifth (21.2%) felt that they had not especially/not at all received information about how to prevent their child's dental problem [Table 3]. A total of 45% of respondents with primary education in comparison with 17.0% with university education were displeased with the information process (P=0.010) [Table 5].
|Table 3: Respondents responses to some of the items related to information, accessibility, dental treatment, and the caring process|
Click here to view
|Table 4: Respondents responses to some of the items related to the staff attitude, participation, and the staff work environment|
Click here to view
|Table 5: Influence of respondents educational level on the various quality of care indices|
Click here to view
Ratings concerning accessibility revealed that 41.1% and 36.2% believed that it was good and fair respectively [Figure 1]. A fifth (19.1%) had to a certain degree/great degree experienced difficulty in getting to the clinic in terms of transportation. Majority of the parents 132 (93.6%), believed that the charges to a certain/great degree were alright. Furthermore, 44 (31.2%) said that they felt they could not especially/not at all contact their dentist by telephone [Table 3].
Generally, over half (58.9%) of the respondents rated dental treatment as good while 16.3% thought it was fair [Figure 1]. Specifically, 118 (83.7%) of the parents had confidence to a great degree in the staff competence while 113 (80.1%) stated that they were extremely pleased with their child's dental treatment [Table 3]. Three quarters (73.2%) of respondents from the high social class were very pleased with the dental treatment process comparison to over a third (39.4%) from the lower social class (P=0.045) [Table 6].
|Table 6: Influence of respondents socioeconomic status on the various quality of care indices|
Click here to view
On the whole 33.3% and 43.3% of the respondents claimed that the caring process was good and fair respectively [Figure 1]. About half of the parents, 80 (56.8%) and 66 (46.8%) reported that the dentists had not especially/not at all introduced themselves to them or their children respectively. However, majority of the staff (133 (94.3%)) had said things that reduced their worries to a great degree/to a certain degree [Table 3]. Fourteen (42.4%) of the respondents from the lower social class and 7 (17.1%) from the high social class claimed the caring process was poor (P=0.030) [Table 6].
Concerning the staff attitude, three-quarters (75.9%) were pleased while less than a 10 th (7.8%) considered it as poor [Figure 1]. However, 127 (90.1%) of the parents said that they were treated with respect to a great degree while 118 (83.7%) of the respondents reported that their children were treated very kindly by the staff they came in contact with [Table 4]. Six (30.0%) of the respondents with primary education in comparison with 4 (4.5%) with university education were unhappy with the staff attitude (P=0.005) [Table 5].
Ratings about participation revealed that half, 49.6% of the parents felt it was good while a third (34.8%) rated it as fair [Figure 1]. Three-quarters 102 (72.3%) of the respondents claimed they had a great opportunity to ask questions about their child's dental problem [Table 4]. Forty-five percent of the parents with primary education and a 12.5% of those with university education were unhappy with the participation process (P=0.001) [Table 5].
The staff work environment was assessed as good and fair by 41.8% and 37.6% of the respondents respectively. A fifth (20.6%) of the parents were however dissatisfied [Figure 1]. Majority of the parents (138 (97.9%)) believed that the staff had to a great degree/certain degree a positive attitude to their work. However, 38 (26.9%) and 57 (40.4%) respondents felt that the staff worked under stress and had a heavy workload respectively to a great degree/certain degree [Table 4].
Influence of age on the various indices of quality of care was not significant (information P=0.595, accessibility P=0.109, dental treatment P=0.072, caring process P=0.899, staff attitude P=0.724, participation P=0.365, and staff work environment P=0.084).
Overall assessment on a visual analog scale revealed an average score of 7.3 out of 10.
| Discussion|| |
This study has revealed that parents generally reported high levels of satisfaction (7.3 out of 10) with the dental care their children received at the University College Hospital, Ibadan, which is commendable. Satisfaction with healthcare services is known to be associated with patient behavior, including compliance to treatment plans and the use of preventive health services. 
The information process is an important aspect in dental care and dentists must observe the basics of informed consent with parents seeking dental treatment for their children.  Research revealed that the important factors influencing parent satisfaction in a children's emergency department were a clear explanation of the child's diagnosis and treatment plan. ,, This study has demonstrated that the basic of informed consent was adhered to by the dental staff. However, 21.2% of the parents felt that they needed more information on how to prevent the occurrence of dental diseases in their children, corroborating the study by Lahti et al. Emphasis on prevention is pertinent to forestall recurrent oral health problems in patients.
Accessibility to dental care is an important facilitator of dental clinic attendance. Majority of the parents in this study did not have difficulty in reaching the dental clinic. This may be due to the fact that the clinic is accessible, being located on a major as well as popular road (Queen Elizabeth Road) with easy access to public transportation. Similarly, many of the respondents considered the charges reasonable. High hospital fees usually discourage parents from bringing children to the clinic in this environment especially when they are not emergency cases, as is the case with many dental diseases. In recent times, the introduction of the National Health Insurance Scheme in Nigeria has been helpful in relieving parents of payment of some aspects of dental care. It was noted from the findings of this study that about a third of parents claimed that they did not really feel they could contact the dentist by phone. The advantage of contact by phone includes informing the dentist about appointment changes and also reconfirming or receiving instructions on what to do in emergency. It also provides the dentist the opportunity to remind parents of their children's appointment.
Waiting time has been found to be significantly correlated with overall patient satisfaction. ,,,, In this study, the average waiting time spent before seeing the dentist was 64.9 minutes. Surprisingly, this did not appear to affect the overall rating of UCH dental services (7.3 out of 10). This may be as a result of the high public opinion generally held in association with the hospital. Waiting time is sometimes prolonged because some procedures in children can be lengthy, especially when they are uncooperative. Furthermore, an insufficient number of dental units reduces the number of patients that can be seen at a certain time. When waiting time is prolonged the parents become impatient and the children become restless and may exhibit decreased level of compliance during treatment. Spreading out patient's appointments will reduce waiting time.
Technical competence of dentists is often cited as a key determinant to client satisfaction placing it at or near the top of contributory factors.  It is commendable to know that over 80% of parents were extremely satisfied with the dental treatment their children received and had confidence in staff competence reflecting the findings of Haulkai and Paulsen.  The high standards revealed in this study could be adduced to the fact that the dental clinic is part of a teaching hospital where strict standards are kept. With increased confidence in the staff, there may be a higher probability that patients and parents will be willing to return.
Technical expertise may not be the standard for judgment to quality of care for many parents and their children. Less technical aspects of treatment especially the human and psychological aspects of care are recognized as being barometers of quality of care  and as such it is imperative that dentists show a high level of care and empathy for their child patients. However, this study has shown that half of the dentists did not introduce themselves to their patients and parents. This is one of the things that can create a communication gap and could have been responsible for the reduced satisfaction scores in the caring process domain. Introduction by staff members improves patient and parents' confidence and trust and also helps them to feel more relaxed. Perhaps the simplest and most profound of all human interactions is kindness. However, it is sometimes absent from healthcare environments. Staff attitude has been found as an important factor for satisfaction while patients receive hospital care. ,, This study reveals that over three-quarters of the parents were extremely pleased with the staff attitude. The staff who show kindness and compassion can go a long way toward assuring patients that they are in the right place.
Many researchers have identified parental participation in children's healthcare and decision making as important elements of parental satisfaction.  It is laudable to note that majority of the parents in this study had the possibility of participating in discussions pertaining to their children's treatment. Parental participation will not only increase the knowledge and understanding of their child's dental condition but also foster a trusting relationship between the parent and the dentist.
The relationship between employee satisfaction, patient satisfaction, and quality of care is an interactive and reinforcing one and satisfied employees deliver better care resulting in higher patient satisfaction.  Over a quarter of the parents in this study felt that the staff worked under stress and had a heavy workload. An individual experiencing work stress finds the job taxing, exceeding his or her resources, and endangering their well being. 
The environment is reported as an important contributor to patient satisfaction. , Over four-fifths of the respondents in this study were pleased with the waiting arrangements and this may have influenced their overall satisfaction score.
This study has revealed that the respondents with lower educational levels tended to be more displeased with the information process, staff attitude, and the participation process in comparison with those with higher educational levels. Furthermore, parents from the lower social class were not as satisfied with the dental treatment and caring process in comparison with those from the higher social class. This implies there could be a communication gap between the staff and respondents with lower educational levels as well as those from the lower social class. It could also mean that the dental workers were giving differential treatment and attention in favor of the more affluent and more educated parents. For this reason, adequate care and a greater deal of patience should be taken when dealing with parents particularly with less education and those from the lower social class. It is imperative that the dental curriculum should emphasize patient-dentist relationship.
| Recommendations|| |
The respondents recommended the following improvement in the services in the clinic:
Waiting time should be shorter and the clinics contact numbers should be available. Waiting arrangements should include a separate play area with games and toys for children and a television with children's channels such as cartoons. Oral health instruction posters for children should adorn the walls. Staff should introduce themselves and there should be a greater degree of interaction between the parents and the dentist concerning dental treatment of their children. The number of dental units and assistants in the clinic should be increased to reduce waiting time. Furthermore, the authors recommend small-scale furniture for the children in exiting colors. Reading materials should also be made available to accompanying parents.
| References|| |
|1.||Grol R, Wensing M. Implementation of quality assurance and medical audit: General practioners' perceived obstacles and requirements. Br J Gen Pract 1995;45:548-52. |
|2.||Vuori H. Patient satisfaction-does it matter? Qual Assure Health Care 1991;3:183-9. |
|3.||Avis M, Bond M, Arthur A. Satisfying solutions? A review of some unresolved issues in the measurement of patient satisfaction. J Adv Nurs 1995;22:316-22. |
|4.||Ygge B, Arnetz JE. Quality of paediatric care: Application and validation of an instrument for measuring parent satisfaction with hospital care. Int J Qual Health Care 2001;13:33-43. |
|5.||Margaret ND, Clark TA, Warden CR, Magnusson AR, Hedges JR. Patient satisfaction in the emergency department-a survey of pediatric patients and their parents. Acad Emerg Med 2002;9:1379-88. |
|6.||Haukali G, Poulsen S. User satisfaction at a paediatric dentistry teaching department. Eur J Paediatr Dent 2000; 5 th Congress of EAPD Bergern June 7-11 Abstract 162. |
|7.||Quinby DJ, Sheller B, Williams BJ, Grembowski D. Parent satisfaction with emergency dental treatment at a children's hospital. J Dent Child (Chic) 2004;71:17-23. |
|8.||The National Statistics Socio-economic Classification User Manual Office for National Statistics. edition. Hampshire and New York: Palgrave Macmillan; 2005. p. 10. |
|9.||Crichton N. Visual analogue scale (VAS). Available from: http://www.cebp.nl/vault_public/filesystem/. [Last accessed on 2011 Aug 14]. |
|10.||Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Do patients treated with dignity report higher satisfaction adherence and receipt of preventive care? Ann Fam Med 2005;3:331-8. |
|11.||American Academy of Pediatric Dentistry. Definitions, Oral Health Policies, and Clinical Guidelines. 2008-09; p. 268-70. Available from: http://www.aapd.org/media/policies.asp. [Last accessed on 2011 Aug 14]. |
|12.||Pagnamenta R, Benger JR. Factors influencing parent satisfaction in a children's emergency department: Prospective questionnaire-based study. Emerg Med J 2008;25:417-9. |
|13.||Lahti S, Tuutti H, Hausen H, Kääriäinen R. Comparison of ideal and actual behaviour of patients and dentists during dental treatment. Community Dent Oral Epidemiol 1995;23:374-8. |
|14.||Brown K, Sheehan E, Sawyer M, Raftos J, Symth V. Parent satisfaction with services in an emergency department located at a paediatric teaching hospital. J Paediatr Child Health 1995;31:435-9. |
|15.||Bar-dayan Y, Leiba A, Weiss Y, Carroll JS, Benedek P. Waiting time is a major predictor of patient satisfaction in a primary military clinic. Mil Med 2002;167:842-5. |
|16.||Ajayi IO, Olumide EA, Oyediran O. Patient satisfaction with services provided at a general outpatients clinic, Ibadan, Oyo State, Nigeria. Afr J Med Med Sci 2005;34:133-40. |
|17.||Ierado Ierardo G, Luzzi V, Vestri A, Sfasciotti GL, Polimeni A. Evaluation of customer satisfaction at the Department of Paediatric Dentistry of "Sapienza" University of Rome. Eur J Paediatr Dent 2008;9:30-6. |
|18.||Newsome PR, Wright GH. A review of patient satisfaction: 2. Dental patient satisfaction: An appraisal of recent literature. Br Dent J 1999;186:166-70. |
|19.||Abrams R, Ayers CS, Vogt Petterson M. Quality assessment of dental restorations: A comparison by dentists and patients. Community Dent Oral Epidermiol 1986;14:317-9. |
|20.||Sur H, Hayran O, Yildirim C, Mumcu G. Patient satisfaction in dental outpatient clinics in Turkey. Croat Med J 2004;45:651-4. |
|21.||Able-Boone H, Dokecki PR, Smith MS. Parent and health care provider communication and decision making in the intensive care nursery. Child Health Care 1989;18:133-41. |
|22.||Wolf D. Patient satisfaction linked to hospital employee satisfaction. Code Green. 2008. p. 1. Available from: http://www contextrules.typepad.com. [Last accessed on 2011 Aug 14]. |
|23.||Lazarus RS, Folkman S. Stress Appraisal and Coping. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses Agency for Healthcare Research and Quality. Chapter 26. New York: Springer; 1984. p. 1. |
|24.||Muzondo BN, Muzondo N, Mutandwa E. Determinants of parents choice of a paediatric dentist: An application of factor analysis. Afr J Bus Manage 2007;1:154-65. |
|25.||Ukpong MO, Oziegbe EO. Creating a child friendly clinic. The experience of OAUTHC over the last 10 years. 7 th Faculty Conference. Faculty of Dentistry, Nigeria: Obafemi Awolowo University, Ile-Ife; 2008. p. 23. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]