Abstract
Aim:
Transfer from a wheelchair and discomfort in dental chair are two important barriers for access to dental care among wheelchair-bound patients. The authors have devised an automated wheelchair recliner that helps to mimic the dental chair functioning at wheelchair itself. The aim of this study was to analyze the performance and acceptability of wheelchair recliner among wheelchair-bound patients.
Settings and Design:
Tertiary care settings, cross-sectional design.
Materials and Methods:
A total of 100 wheelchair-bound adult patients (aged >21 years) were evaluated for acceptability of the recliner. The patients were assessed using eight-item covering patient comfort/acceptability related to positioning, reclining, repositioning, fear of falls, joy, discomfort, perception regarding dentist’s discomfort, and use in future on a scale of 0–4 with 0 indicating least satisfying and four indicating most satisfying experience. Overall, patient experience was graded as poor, fair, good, very good, and excellent. The Chi-square test was used to compare the results.
Statistical Analysis Used:
IBM Stats package 21.0 was used. Mean ± standard deviation, Numbers/percentages and Chi-square test were used to compare results. The confidence level of the study was 95%.
Results:
The age of patients ranged from 22 to 83 years (mean age 52.26 ± 18.58 years). Majority were males (58%) and had temporary (60%) disability. On a 4-point scale, the mean scores of patients ranged from 2.47 ± 1.23 (positioning) to 3.40 ± 0.74 (intent to use in future). Overall experience was rated as good to very good by 77% of patients. No significant association of age, sex, or type of disability was seen with overall patient experience.
Conclusion:
The acceptability rates were good to very good among wheelchair-bound patients and were unaffected by their age, sex, and type of disability.
Keywords: Disability, geriatric, satisfaction, special care, wheelchair recliner
INTRODUCTION
Providing dental care to wheelchair-bound patients is a challenging task as the patients have various fears related to transfer from wheelchair to dental chair. Most of the dental practices generally do not have specialized facilities for patient transfer from wheelchair to dental chair. The accompanying caregivers are also mostly untrained for this task and are frightened of possible injuries during this process.[1] Transferring from wheelchair to dental chair is a complex process requiring specialized skills and a thorough assessment of patient’s medical status, mobility level, endurance, ability to balance, and comprehend the given commands and factors that could motivate him for such transfer.[2]
Transferring into dental chair and overcoming the discomfort on the dental chair remain to be the most important factors affecting the access to dental care among wheel-chair bound patients.[3] A possible alternative to this is the treatment of a wheelchair-bound patient on wheelchair itself. However, this alternative also has ergonomic issues on the part of dental practitioners.
To overcome this difficulty, the most viable alternative is to develop such aids that help offer dental treatment in the wheelchair itself without compromising the ergonomic issues and facilitating the easy accessibility of required dental instruments. To meet this objective, several alternatives have been offered by different workers from time to time, namely, development of modified dental chair to ease the accommodation of wheelchair-bound patients,[4] wooden lifts,[5] using a specialized reclinable wheelchair,[6] etc. However, most of these aids are costly, lack mass scalability, and have limited patient acceptability.
To overcome this issue, the authors developed an innovative wheelchair recliner that helps provide the dental care to the patient in the wheelchair itself. This innovation is a simple DC battery-operated portable device that enables to convert the wheelchair into a working dental chair at demand and also overcomes the ergonomic issues [Figures 1 and 2].
Figure 1.
Wheelchair recliner
Figure 2.
Recliner being placed under wheelchair and tilting the wheelchair to enable the dentist to provide dental care at wheelchair itself
The success of an innovation could be gauged if it helps to fulfill the need of the patient. In this article, we describe the patient acceptability, experience, and feedback on this novel innovative attempt.
MATERIALS AND METHODS
The present study was carried out as an extended part of a research project funded by the Department of Science and Technology and was approved by the institutional ethics committee (vide Letter No. 949/Ethics/R. Cell, Ref. No. 80th ECM II-A/P8).
The assessment was made on 100 wheelchair-bound patients with the Glasgow Coma Scale >12 requiring short-term dental procedures (not lasting more than 30 min), mainly prophylactic procedures, scaling, and Class 1 fillings visiting outpatient departments of the faculty of dental sciences, were included in the study, and were offered facility to avail treatment in the wheelchair itself without requiring transfer to dental chair using the reclining device developed by the authors.[7] Sample size estimations for this descriptive study were made at 95% confidence and 10% precision error using the formula n = z2 [p (1 − p)]/e2 (where P = 0.5 for descriptive studies with no proposed hypothesis, z is a constant with value 1.96 at 95% confidence, and e = 0.10 at 10% precision error), the calculated sample size was 96. After making a contingency provision of 5% and rounding off, we proposed a sample size 100.
Patients unwilling to participate in the study, mentally unstable patients or those supposed to have procedures longer than 30 min were excluded from the assessment. At the time of enrolment, age, sex, and type of wheelchair dependence (permanent disability/temporary dependence) were noted. Permanent disability was defined as the physical condition of the patient where wheelchair dependence was lifelong (permanent lower limb disability, paraplegic/hemiplegic, and stroke patients requiring wheelchair support). In contrast, temporary dependence was defined as the physical condition where the patient was wheelchair dependent for a short period (such as patients having lower limb fractures, having undergone surgical procedures that require immobilization for a limited period).
Patient’s feedback was collected on an eight-item structured inventory that assessed feeling while the positioning of recliner, feeling while being reclined, feeling during repositioning, fear of fall during positioning/reclining/repositioning, idea of wheelchair conversion into dental chair, discomfort during the entire procedure, noticing discomfort felt by the doctor during the procedure and intent to recommend this utility for use in a dental practice while treating wheelchair-bound patients. For all the items, the responses were collected on a 5-point Likert scale, where the most negative response was scored 0 and the most positive response was scored as 4. Total scores were obtained by summing the item scores for all the eight items.
The overall experience of patients was also assessed as – Poor, fair, good, very good, and excellent.
Data analysis
Data were analyzed using IBM SPSS ver. 21.0, IBM SPSS Statistics Inc., Chicago, Illinois, USA. Item-wise scores have been shown in numbers/percentages and mean scores. Total scores have been shown as mean ± standard deviation. The overall experience has been depicted as numbers/percentages. Gender and age differences for overall experience were compared using the Chi-square test. The confidence level of the study was 95%.
RESULTS
The age of patients ranged from 22 to 83 years. Maximum number of patients were aged between 21 and 40 years (33%), followed by 41–60 years (32%), 61–80 years (26%), and >80 years (9%), respectively. The mean age of patients was 52.26 ± 18.58 years. Majority of patients were males (58%). There were 60 patients having temporary wheelchair dependence, whereas 40 had permanent dependence [Table 1].
Table 1.
Age and sex profile of the study population
| Characteristic | n (%) |
|---|---|
| Age (years) | |
| 21–40 | 33 |
| 41–60 | 32 |
| 61–80 | 26 |
| >80 | 9 |
| Mean age±SD (range) | 52.26±18.58 (22–83) |
| Sex | |
| Male | 58 |
| Female | 42 |
| Type of wheelchair dependence | |
| Temporary | 60 |
| Permanent | 40 |
SD: Standard deviation
Item-wise scores on feedback inventory showed 50% or more responses with scores 3 and 4 for all the items. Among different items, the maximum number of 3/4 were obtained for the items use in the future (85%), followed by enjoyment (74%), repositioning (72%), discomfort (66%), fear of fall (64%), dentist’s discomfort (56%), reclining (54%), and positioning (50%), respectively. There were only three items on which score 0 was accorded by some patients – these included reclining (8%), positioning (7%), and fear of falls (2%), respectively. Mean item-wise scores ranged from 2.47 ± 1.13 (positioning) to 3.40 ± 0.74 (use in future). For four-item, mean scores were above 3; these included repositioning (3.15 ± 0.85), enjoyment (3.10 ± 0.81), discomfort (3.03 ± 0.85), and use in the future (3.40 ± 0.74). For the other four items, mean scores ranged from 2.47 ± 1.13 (positioning) to 2.86 ± 0.99 (fear of fall). The total mean score was 23.42 ± 3.11 out of a maximum possible 32. The median score was 24 [Table 2].
Table 2.
Item-wise scores on feedback inventory
| Item number | Item | Score | Mean±SD | ||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| 0 | 1 | 2 | 3 | 4 | |||
| 1 | Positioning | 7 | 15 | 28 | 24 | 26 | 2.47±1.13 |
| 2 | Reclining | 8 | 11 | 27 | 24 | 30 | 2.57±1.25 |
| 3 | Repositioning | 0 | 1 | 27 | 28 | 44 | 3.15±0.86 |
| 4 | Fear of fall | 2 | 5 | 29 | 33 | 31 | 2.86±0.99 |
| 5 | Enjoyment | 0 | 1 | 25 | 37 | 37 | 3.10±0.81 |
| 6 | Discomfort | 0 | 0 | 34 | 29 | 37 | 3.03±0.85 |
| 7 | Dentist’s discomfort | 0 | 0 | 44 | 28 | 28 | 2.84±0.84 |
| 8 | Use in future | 0 | 0 | 15 | 30 | 55 | 3.40±0.74 |
| Overall mean score±SD (range) [median score] | 23.42±3.11 (15–29) [24] | ||||||
SD: Standard deviation
Overall, subjective experience was reported to be good/very good by 77% of patients. There were 2% of patients who reported it as poor and 3% reported it as excellent. There were 18% of respondents who found it to be fair [Table 3].
Table 3.
Overall subjective experience
| Overall subjective experience | n (%) |
|---|---|
| Poor | 2 |
| Fair | 18 |
| Good | 37 |
| Very good | 40 |
| Excellent | 3 |
No significant difference in overall subjective experience was seen among patients in different age groups, between two sexes and between the temporary and permanent nature of disability [Table 4].
Table 4.
Association of overall experience with age, sex, and type of disability
| Variable | Overall experience | ||||
|---|---|---|---|---|---|
|
| |||||
| Poor | Fair | Good | Very good | Excellent | |
| Age (years) | |||||
| 21–40 (n=33) | 0 | 6 (18.2) | 11 (33.3) | 14 (42.4) | 2 (6.1) |
| 41–60 (n=32) | 1 (3.1) | 4 (12.5) | 13 (40.6) | 14 (43.8) | 0 |
| 61–80 (n=26) | 0 | 6 (23.1) | 9 (34.6) | 11 (42.3) | 0 |
| >80 (n=9) | 1 (11.1) | 2 (22.2) | 4 (44.4) | 1 (11.1) | 1 (11.1) |
| χ2, P | 13.344, 0.345 | ||||
| Sex | |||||
| Male (n=58) | 1 (1.7) | 8 (13.8) | 20 (34.5) | 28 (48.3) | 1 (1.7) |
| Female (n=42) | 1 (2.4) | 10 (23.8) | 17 (40.5) | 12 (28.6) | 2 (4.8) |
| χ2, P | 4.761, 0.313 | ||||
| Type of disability | |||||
| Temporary (n=60) | 2 (3.3) | 11 (18.3) | 21 (35.0) | 25 (41.7) | 1 (1.7) |
| Permanent (n=40) | 0 | 7 (17.5) | 16 (40.0) | 15 (37.5) | 2 (5.0) |
| χ2, P | 2.498, 0.645 | ||||
DISCUSSION
An innovation to decrease the inconvenience of patients through the help of indigenous efforts is the mainstay of health-care delivery system. However, it is ultimately the patients who decide whether these innovations are useful and acceptable in the form being delivered to him. In the present study, an attempt was made to develop a wheelchair recliner that could help resolve the problems of wheelchair-bound patients seeking dental care. Incidentally, the wheelchair-bound patients reportedly give heightened importance to oral health as they tend to use their mouth as a “third hand,” however, accessibility to dental care is a big barrier for them.[3] Among various factors related to accessibility to dental care, transfer from wheelchair and discomfort in dental chair emerge as issues of concern for these patients.[3] Innovations to provide dental care to wheelchair-bound patients have also been done in the past;[4,8,9] however, most of these devices could not become part of routine dental practice as they merely remained some technological innovations for academic purposes that failed to achieve clinical applicability owing to lack of dentist/patient acceptability. In fact, the roles of patients in diffusing innovations are highly under-recognized.[10] Unfortunately, previous developments in the related area did not include the patient perspective on their innovations.[4,8,9] In the present study, patient feedback and experience were gathered for our innovative development as the essential part of the overall innovation program. As such, new product development is a continuous process that requires a constant match between the user expectations and the capability of the product to deliver the same.[11-13]
In the present study, overall positive feedback was received from the patients on the issues such as positioning, reclining, repositioning, fear of fall, enjoyment, discomfort, perception of dentist’s discomfort, and intent to use in the future, obtaining scores of higher order. Overall, the median feedback score was 24 out of a maximum of 32, thus showing that the extent of positive feedback was up to 75% in our study population. Overall, the subjective experience of the patient was also good to very good in 77% of cases. These findings are encouraging.
However, the acceptability of technological innovation is also dependent on the profile and type of patient needs. Patient characteristics hold the key to the overall patient experience toward an innovation.[11] If differences in patient characteristics have an influence on their overall experience, then the innovation in question might have a variable acceptance among patients with different characteristics, and hence universal acceptability and application of this innovation may be jeopardized. In the present study, the impact of age, sex, and type of disability was analyzed on the overall patient experience and found it to be statistically not different across patient groups differentiated by different characteristics in question, thus showing that the recliner developed by us had a universal homogeneous acceptability.
The feedback achieved from the patients, however, highlighted some gaps – such as feedback areas such as positioning, reclining, fear of fall, and perception of dentist’s discomfort that were identified with low mean scores. The findings of the study thus reflected that not only the physical recliner product developed by us affect the patient feedback, but it somehow lagged behind some psychological issues. It must be understood that the patient feedback recorded by us was on first-time use of this device and recurring use of this recliner during subsequent dental visits of the patients may help improve their feedback on these issues too. The significance of patient feedback on existing and newly developed services and products is essential and has been highlighted in earlier studies too.[14,15] Such exercises help improve the quality of patient care.
The findings of the present study showed that the innovative reclining device developed by us was in general acceptable to the patients. This feedback will help improve the device further and to make it a popular, clinically acceptable product that could help make dental care access for wheelchair-bound patients easier.
CONCLUSION
The patient feedback and overall experience to the innovative reclining device to provide dental care to wheelchair-bound patients was satisfactory and highlighted some gaps. Taking care of these gaps would help increase the overall acceptability of the product, which would help make dental care access easier for wheelchair-bound patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Claunch R. Dentistry and the Wheelchair-Bound Patient. Dental IQ. 2009. [[Last accessed on 2023 May 11]]. Available from: https://www.dentistryiq.com/dental-hygiene/patient-education/article/16356053/dentistry-and-the-wheelchairbound-patient .
- 2.Felder RS, Gillette VM, Leseberg K. Wheelchair transfer techniques for the dental office. Spec Care Dentist. 1988;8:256–9. doi: 10.1111/j.1754-4505.1988.tb00752.x. [DOI] [PubMed] [Google Scholar]
- 3.Rashid-Kandvani F, Nicolau B, Bedos C. Access to dental services for people using a wheelchair. Am J Public Health. 2015;105:2312–7. doi: 10.2105/AJPH.2015.302686. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lakshmi K, Madankumar PD. Development of modified dental chair to accomodate both wheelchair bound patients and general population. Disabil Rehabil Assist Technol. 2020;15:467–70. doi: 10.1080/17483107.2019.1710775. [DOI] [PubMed] [Google Scholar]
- 5.Napierski GE. Positioning wheelchair patients for dental treatment. J Prosthet Dent. 1982;47:217–8. doi: 10.1016/0022-3913(82)90194-9. [DOI] [PubMed] [Google Scholar]
- 6.Quart AM. Dental treatment for spinal cord injury patients in a specialized reclinable wheelchair. Spec Care Dentist. 1982;2:252–6. doi: 10.1111/j.1754-4505.1982.tb00074.x. [DOI] [PubMed] [Google Scholar]
- 7.Agarwal B. A portable wheelchair recliner. Pat off J. 2017;33:26926. [Google Scholar]
- 8.Tamazawa Y, Watanabe M, Kikuchi M, Takatsu M, Tamazawa K, Yumoto N, et al. Anew dental unit for both patients in wheelchairs and general patients. Gerodontology. 2004;21:53–9. doi: 10.1111/j.1741-2358.2004.00011.x. [DOI] [PubMed] [Google Scholar]
- 9.McGhay RM. A simple headrest for patients confined to wheelchairs. J Prosthet Dent. 1980;44:347–9. doi: 10.1016/0022-3913(80)90026-8. [DOI] [PubMed] [Google Scholar]
- 10.Barber S, French C, Matthews R, Lovett D, Rollinson T, Husson F, et al. The role of patients and carers in diffusing a health-care innovation: A case study of “my medication passport”. Health Expect. 2019;22:676–87. doi: 10.1111/hex.12893. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Safi S, Thiessen T, Schmailzl KJ. Acceptance and resistance of new digital technologies in medicine: Qualitative study. JMIR Res Protoc. 2018;7:e11072. doi: 10.2196/11072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ringen G, Welo T. The product development learning process and its relation to performance indicators. Procedia Manuf. 2018;26:107–16. [Google Scholar]
- 13.Rochford L, Rulelius W. New product development process: Stages and successes in the medical products industry. Ind Mark Manage. 1997;26:67–84. [Google Scholar]
- 14.Kumah E, Osei-Kesse F, Anaba C. Understanding and using patient experience feedback to improve health care quality: Systematic review and framework development. J Patient Cent Res Rev. 2017;4:24–31. doi: 10.17294/2330-0698.1416. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Berger S, Saut AM, Berssaneti FT. Using patient feedback to drive quality improvement in hospitals: A qualitative study. BMJ Open. 2020;10:e037641. doi: 10.1136/bmjopen-2020-037641. [DOI] [PMC free article] [PubMed] [Google Scholar]