Patient satisfaction with access to a student-run free-service dental clinic

Abstract

Background:

The Student Health Initiative for the Needs of Edmonton (SHINE) dental clinic is a student-volunteer-operated clinic offering free oral care to low-income individuals. However, little is known about how SHINE impacts access to care. Drawing on Penchansky and Thomas’ theory of access, this study assessed patient satisfaction to measure access. For further context, patient-reported oral health concerns and alternative oral care options if SHINE were not available were recorded.

Methods:

The University of Alberta’s Research Ethics Board (Pro 00101981) approved the study. Surveys adapted from Penchansky and Thomas were distributed over 12 weeks to all presenting patients. Survey data were triangulated with observations. Data were represented using descriptive statistics, and variables were compared using Chi-squared tests of independence.

Results:

A response rate of 77% (140/170) was achieved. The survey revealed that patients were generally satisfied with access to SHINE. However, observations revealed physical accessibility barriers. Dissatisfaction was correlated with attending SHINE without receiving treatment. Patients primarily presented to SHINE for pain (55%, 76/139). If SHINE were not available, 38% (46/121) of patients reported they would seek care from an alternative oral health professional, 32% (39/121) through an emergency department or physician, and 27% (33/121) would not attain oral health care at all.

Conclusion:

SHINE could be seen as addressing the need for access to oral health care services. The remaining barriers to care include long waiting times and clinic capacity to deliver care. A faster triage process may reduce waiting times. However, SHINE cannot provide more oral health care due to clinic capacity. Lastly, access to clinics such as SHINE may reduce visits to emergency departments for oral health care.

PRACTICAL IMPLICATIONS OF THIS RESEARCH.

• Volunteer dental clinics provide needed access to affordable oral health care. However, they are not keeping up with demand.

• Continuous quality improvement strategies are essential to ensure volunteer initiatives are meeting the needs of the target population.

• Access to oral health care in community clinics may reduce the utilization of emergency departments for such services.

INTRODUCTION

Canada’s privatized approach to oral health care increases inequities in society by privileging the wealthy and those with dental insurance.¹ Due to the high cost of privatized dental care in Canada, nearly one quarter of Canadians avoided going to a dentist in 2018.² Income and dental insurance are the 2 most significant predictors of a person’s likelihood of seeking oral health care.^{2, 3} Individuals classified as low-income earners face the greatest structural and social barriers to care, such as affordability and stigma, and are among those most at risk of poor oral health.^{1, 3, 4, 5} An affordable oral health care option is needed to address the oral health concerns of this group.

Recognizing the gaps in access to oral health care among marginalized population groups in Edmonton, Alberta, Canada, the Student Health Initiative for the Needs of Edmonton (SHINE) dental clinic was established in 2004. SHINE is a student initiative operated by volunteer undergraduate dentistry and dental hygiene students from the School of Dentistry, Faculty of Medicine & Dentistry at the University of Alberta.⁶ It is managed independently from the school by the dental students' association and funded via corporate sponsorship and other fundraising efforts. Volunteer preceptors, who are licensed dentists and registered dental hygienists, supervise the student volunteers who provide patient care.

The primary objective of SHINE is to reduce inequities in oral health by equalizing the utilization of oral health services among low-income groups that face significant barriers to care, such as experiencing homelessness, poverty, addictions, and poor mental health.⁷ Free-of-charge services offered at SHINE include dental hygiene care, pediatric dentistry, restorative dentistry, tooth extractions, and emergency services, such as open and drain endodontic procedures. Even though these services are provided free of charge, evidence suggests that some low-income groups struggle to attend scheduled appointments.⁸ Therefore, patients at SHINE are treated exclusively on a walk-in basis and are triaged and managed based on their level of pain and infection. Furthermore, to serve patients as best as possible, dental and dental hygiene services are offered on Saturdays, which SHINE patients have deemed optimal.⁹ Priority is given to youth but services are available to all age groups. Demand often exceeds SHINE’s capacity and not all attending individuals are able to receive oral health care. Often, patients with multiple oral health conditions or who are unable to be seen due to capacity limits on a given day may have to return to SHINE multiple times to have all their issues addressed. A referral process to the University of Alberta School of Dentistry clinic has been established for patient cases deemed too complex to be managed onsite at the SHINE clinic. Patients aged 16 and under who are referred from SHINE to the School of Dentistry clinic are seen free of charge; adults pay on a sliding income-based scale.

A study completed in 2011 about the SHINE clinic reported patient demographics, patient satisfaction, and perceived value of the services.⁹ Patients participating in that study (58%, 62/106) indicated strong perceived satisfaction with and value of the treatment they received at SHINE.⁹ In 2021, a qualitative study was conducted to gather insight from community,health brokers who worked with individuals who may or could be patients at SHINE.¹⁰ It was found that health brokers were not aware of the dental and dental hygiene services offered through SHINE. The study also identified potential barriers to care for clients with whom the brokers worked.¹⁰ Following that study, health brokers were given a presentation on SHINE and the service it offers. After completion of the 2 studies on SHINE, the clinic was relocated but remained within the same inner-city neighbourhood, within 550 metres of the original location.

The aim of the current study was to investigate patient satisfaction with access to the newly expanded and relocated clinic. It explored access from the perspective of patients attempting to obtain care through SHINE. The study used Penchansky and Thomas’ 1981 theory of access, which assumes problems with access influence patient satisfaction. Therefore, patient satisfaction was used as a measure of access to SHINE. The guiding research question was, “How satisfied are you with access to SHINE?” For further context, patient-reported oral health concerns and alternative care options sought when SHINE was not available were also recorded.

METHODS

This study utilized a descriptive study design implementing a survey and observations for data collection. Ethics approval was granted from the University of Alberta’s Research Ethics Board (Pro 00101981).

Survey

A survey comprising 8 three-point Likert scale questions, 3 multiple response (MR) questions, and 6 multiple choice (MC) questions was developed by the research team to answer the research questions. The Likert scale questions were modified from Penchansky and Thomas’ theory of access patient satisfaction questions.¹¹ Penchansky and Thomas’ patient satisfaction survey explores access defined as the fit between the patients and the service. While originally used to measure satisfaction with access to medical care, the survey was adapted by the research team to align with an oral health care setting. Questions not relevant to SHINE, such as those concerning affordability, were removed. The remaining questions were adapted to a grade 4 reading level to improve readability for participants. Further, Cronbach’s Alpha of listwise cases was conducted on the satisfaction questions, which were considered ordinal data, to check for internal consistency. Data were also interpreted using descriptive statistics.

MR and MC questions were developed by the research team to provide context for patient satisfaction, explore oral health concerns, and identify alternative care options. MR and MC were treated as categorical data and interpreted using descriptive statistics, contingency tables, and a Chi-squared test of independence where applicable. All analyses were performed using JASP 0.14.1 or Excel (Microsoft), considering a critical significance value p < 0.05.

The survey was presented to all patients attending SHINE over a 12-week period from October 3 to December 19, 2020, inclusive. Patients were given the options of completing the survey independently or having the primary researcher read it to them. Return drop boxes for surveys were affixed outside the clinic door and inside the clinic.

Inclusion criteria were all consenting patients attending SHINE between the aforementioned dates regardless of whether they proceeded to receive treatment to remove any potential bias based on receiving treatment. Participation in the survey was entirely voluntary and consent was obtained by overt action of completing the survey and returning it. Patients who returned to SHINE for follow-up appointments during the data collection period were not asked to repeat the survey.

Observation

While distributing the surveys, the primary researcher engaged with patients awaiting care to give them an opportunity to verbalise their experience with the clinic and observe any access barriers to the clinic. The researcher was clearly identified; implied consent was sought via a poster affixed to the dental clinic door announcing the researcher’s presence. The poster further detailed instructions for patients wishing to be omitted. Observations and conversations were documented retrospectively, within 48 hours. Observation notes were written to provide contextual data and inform data analyses,¹² such as daily air temperature, patient complaints, and counts of presenting individuals and families. Families were considered as any grouping of people presenting together who considered themselves a family.

RESULTS

Over the 12 weeks of data collection, 183 individuals and families presented to SHINE. Eleven individuals and 2 families refused the survey. Of the 170 surveys distributed 140 were returned, for a response rate of 77% (140/183). However, many respondents skipped questions resulting in different response rates for each question. Survey respondents consisted of individual adults completing the survey on their own behalf (69%, 83/120), adult family members completing the survey on behalf of children (12%, 14/120), family groups including children and adults (9%, 10/120), family groups consisting of only adults (6%, 7/120), and health brokers completing the survey on behalf of clients (5%, 6/120).

Oral health concerns

Of the 140 respondents, 101 were new patients and 39 had attended SHINE on at least 1 prior occasion, some of whom reported that they had previously attended SHINE without receiving care (21%, 29/140). Patients indicated their primary reason to seek oral health care through SHINE was dental pain (55%, 76/139) (Figure 1). Twenty-four percent (24%, 33/139) of patients reported pain alone, while 31% (43/139) of patients linked the dental pain to other concerns, such as broken teeth. Twenty-five percent (25%, 35/139) of patients presented for dental hygiene treatment.

Figure 1.

Patient reported oral health concerns

Note: Patients (n = 139) were able to choose multiple responses (tallied counts = 229)

Awareness of SHINE

Patients were primarily made aware of SHINE by their family and friends (52%, 67/128). Online platforms such as Google and social media were the second most common way that patients learned about SHINE (22%, 28/128). Thirteen percent of patients (13%, 16/128) were referred to SHINE through health brokers and social workers. When asked where they felt SHINE should advertise its services, the most common response was “where people gather” (73%, 94/128), including community centres, schools, and food banks. Lastly, 41% (52/128) of patients indicated SHINE should advertise through health brokers and social workers.

Alternative dental care options

If patients were unable to attain dental or dental hygiene care through SHINE, 38% (46/121) responded they would seek care through a community dental office. In addition, 32% (39/121) of patients indicated that they would attend an emergency department or a family physician, 27% (33/121) of patients reported that they would not seek any care for their oral health concerns, and 2% (3/121) said they would travel to another country for oral health care.

Patient satisfaction with access to SHINE

Internal consistency (α = 0.724) within the satisfaction questions was deemed adequate. Therefore, the 8 satisfaction Likert responses items were aggregated for each respondent and interpreted as a sum score of satisfaction.

Patients were generally satisfied with their ability to access SHINE: 77.6% (95/125) of respondents indicated that SHINE improved their ability to access oral health care, and the mean aggregated satisfaction score was 12.9/16 (SD 1.4), whereby a higher score indicated greater satisfaction. Patients who sought treatment through SHINE but were unable to receive care that day were significantly less satisfied with access to SHINE compared to those who indicated always receiving care on the day they attended SHINE (χ² = 19.5, p = 0.03). No other statistically significant relational data were found regarding patient satisfaction.

Patients reported the most dissatisfaction with the time spent waiting to obtain care (11%, 13/116) and their ability to access dental or dental hygiene care when needed (16%, 22/123) (Figure 2). The observation exercise revealed that patients were dissatisfied with the time spent waiting to be triaged. Multiple patients spoke about difficulties they faced standing in line, outside, to access SHINE. Patients reported injuries, disabilities, and medical conditions such as rheumatoid arthritis, which prevented them from standing for long periods particularly in cold weather. There was one small bench outside the SHINE clinic building entrance, but it did not help individuals further back in the line. In cold weather, some family groups left one family member to wait in line while the rest of the family waited in a vehicle to keep warm. Although many patients complained of the cold, with temperatures fluctuating between –8°C and +5°C during the 12-week period of data collection, temperature did not seem to affect the number of patients seeking care during any given week. Individuals began lining up as early as 7:00 AM to secure an appointment at SHINE. The clinic opened its doors to commence triage at 8:15 AM. Depending on the number of patients presenting to SHINE, triage took between 15 and 70 minutes. Individuals towards the back of the line waited the longest for triage, often to be told that it was unlikely they would receive treatment that day due to capacity limits. Once triaged, patients unable to be immediately seated within the clinic were free to leave but were required to return within 30 minutes of a call back. Patients who provided a phone number would be contacted once there was availability for them.

Figure 2.

Summary of patient satisfaction responses^a

^aPatient responses were recorded on a 3-point Likert scale; the proportion of respondents is displayed as the size of each respective bar

During the observation, numerous individuals expressed angst, to the primary researcher, about the wait times for triage and treatment. Some individuals reported that they could not wait to be treated later in the day or could not return at a later date because of work commitments. Others indicated that SHINE was difficult to reach on public transit and that the lack of appointment times and capacity in the waiting room made it difficult to access the clinic, particularly if they left and returned for a call back. However, more patients expressed gratitude for SHINE as a service, indicating that they would wait as long as required to be able to receive care. This finding was reflected in a count of 36 repeat patients over the course of the 12 weeks of data collection. Some individuals returned as many as 4 times to address their oral health needs either because they had multiple needs or were unable to be treated previously.

DISCUSSION

Populations that have the greatest need for oral health care face the most structural barriers.^{1, 3} SHINE is a laudable advocacy initiative, providing free dental and dental hygiene care for low-income individuals and tailoring itself to meet the needs of these people. SHINE is centrally located near other community outreach services, which literature shows improves access.^{10, 13} SHINE operates on Saturdays as SHINE patients indicated it was the most convenient day of the week.⁹ Lastly, SHINE provides walk-in dental and dental hygiene services, as the evidence shows appointment-based care does not work for all low-income groups.^{5, 8} Although there is evidence to support the provision of oral health care in outreach clinics on a walk-in basis,^{5, 8} 11% of SHINE patients expressed dissatisfaction with resulting wait times to obtain care.

Of note, surveys were distributed while SHINE had protocols in place in response to the COVID-19 pandemic. Social distancing restrictions limited waiting room capacity. Patients unable to be seated immediately awaited triage outside the building and were dismissed and called back once there was a clinical operatory available in which they could be seen. Loss of space in the waiting room may have created a barrier for individuals without mobile phones, potentially impacting who utilized SHINE. Those unable to respond to their call back were passed over and the next individual was called in. Prior to the pandemic, the waiting room held more patients and prioritised seating for those without mobile phones.¹⁴

Patients in this study reported oral health concerns that align with previous studies where it was found that pain is the primary motivator for patients seeking care.^{8, 10} Although patients were satisfied with access to SHINE for such conditions, because of extended wait times and capacity limits, some were unable to obtain care. Many patients indicated that if SHINE were not available, they would seek oral health care through a physician or emergency department (32%). Emergency departments, though easily accessible in Canada, are ill-equipped to manage oral health concerns.¹⁵ Emergency departments are not staffed with oral health professionals; treatments often consist of pharmacological interventions to relieve pain and fail to resolve underlying conditions, potentially resulting in repeated visits.¹⁵ The benefit of patients seeking care through a community dental office, such as SHINE, rather than an emergency department or physician is the clinic’s ability to provide care beyond pain management and address the primary cause of the oral health concern.¹³

The first step to improving access to care and diverting community members from urgent care or emergency departments is to increase awareness of existing community dental clinics such as SHINE. Earlier research showed that the primary channel through which patients were informed of SHINE was family and friends. Despite patients’ reporting that advertising through health brokers and social workers (41%) was desirable, the number of patients actually referred by them was limited (12%). This finding may indicate that, despite informing health brokers of SHINE following data collection from Kallal et al.¹⁰ awareness of SHINE among local outreach services remains limited.

Three recommendations to improve accessibility can be drawn from the study findings. First, SHINE could strategize ways to improve wait times and triaging logistics to reduce the time patients spend waiting outside, particularly in colder months. Second, expanded discussion with health brokers and social workers who engage with community members may further an understanding of barriers in the referral process and increase awareness of SHINE for the intended population. Third, there is more demand for affordable oral health care than SHINE can accommodate. Although SHINE refers complex patient cases to the university-based student dental clinic, student volunteers could also consider promoting the Radius Community Health & Healing Dental Clinic within which SHINE operates. The Radius Community Health & Healing Dental Clinic is an inner-city facility associated with Radius Community Health & Healing, a service that offers interdisciplinary health services for individuals experiencing homelessness, addictions or substance use disorders, as well as oral care on a sliding income-based scale.⁶ Furthermore, the clinic offers both walk-in and appointment-based treatment, which may resolve access concerns about appointments. If patients are directed to other clinics through an effective referral process, they may receive more timely care and may also further reduce the burden on physicians and emergency departments.

Lastly, a key component of ensuring optimal health outcomes and improved health care delivery is quality improvement.¹⁶ SHINE does not currently have a formalized, ongoing quality improvement plan in place. Thus, a final recommendation would be to create a quality improvement initiative to ensure continued high-standard care.

Limitations

Due to the COVID-19 pandemic, patients had to complete surveys while waiting in line outside the clinic prior to receiving treatment. This measure was taken to reduce time spent in the clinic, which was associated with higher risk of COVID transmission. Many patients had not previously received treatment at SHINE, which may have,affected their responses. Furthermore, patients often completed their survey prior to being triaged and would not have known whether they would receive care that day. Satisfaction with SHINE may be overrepresented. There is evidence of acquiescence or social desirability bias within patient satisfaction surveys irrespective of question content.¹⁷

CONCLUSIONS

Patients were generally satisfied with access to SHINE, which indicates that it is generally meeting patient needs. Remaining barriers include wait times and limited capacity to receive treatment. The primary reason patients presented to SHINE was dental pain. However, dental hygiene care was the third most common oral health concern, which may indicate a desire for preventive oral care through SHINE. If unable to attain care through SHINE, 32% of patients reported they would seek care through a physician or emergency department. Therefore, access to dental clinics such as SHINE may reduce the utilization of emergency departments for oral health concerns.

Beyond the removal of financial barriers in free-of-charge clinics such as SHINE, improved awareness of such services and understanding how best to refer patients from the community to these services are vital. Additionally, evaluating logistical processes for wait times and triaging may contribute to improved accessibility.

CONFLICTS OF INTEREST

The authors have declared no conflicts of interest.