Abstract
Objectives: The status of the dental health care workforce in Shanghai was investigated in order to support and improve regional planning of this workforce. Methods: Questionnaires were used to survey all dental medical units in Shanghai. Data were collected on the quantity, structure and levels of dental health personnel. Results: A total of 852 dental medical units and 3,218 dentists were identified in Shanghai. The ratio of dentists to population is 1 : 5,201. Conclusions: Presently, the total dental health workforce in Shanghai is relatively sufficient, but its distribution is inequitable because there are fewer dental health personnel employed in the suburbs. Moreover, the structure of the dental health workforce in Shanghai is inequitable and specialists in preventive dentistry are lacking. The results of this study can be applied to help Shanghai achieve the rational distribution and efficient utilisation of the dental health workforce available.
Key words: Dental workforce, Shanghai, survey
INTRODUCTION
Shanghai, China is a large city with a population of 16 million people. As the standard of living is rising in China, demand for dental health care is increasing and the dental health sector has shown vigorous growth. However, to date, no investigations into the structure and distribution of the dental health care workforce in Shanghai have been conducted. We carried out a general investigation into the dental workforce across all dental medical units in Shanghai in 2007. This study aimed to describe the quantity, structure, levels and distribution of the dental health workforce, and the level of equipment and status of dental outpatient services at all medical units in Shanghai. We investigated the problems existing in the dental health workforce in order to help Shanghai achieve a rational distribution and efficient utilisation of the dental health personnel resources available1. Additionally, we investigated the need for particular dental specialists in dental medical units in Shanghai2.
MATERIALS AND METHODS
Regional divisions of Shanghai
The Shanghai Municipal Statistics Bureau uses population census data to divide Shanghai into central urban and suburban areas. The central urban areas of Shanghai include the 10 districts of Luwan, Huangpu, Hongkou, Yangpu, Putuo, Jing’an, Changning, Xuhui, Zhabei and Pudong. The suburbs of Shanghai include the nine districts of Minhang, Baoshan, Jiading, Nanhui, Qingpu, Fengxian, Jinshan, Songjiang and Chongming.
Collection of data on registered dental medical units
Data were collected on all registered dental medical units in Shanghai. Relevant data on public dental medical units were obtained from the Shanghai Municipal Health Bureau. Relevant data on non-public dental medical units were obtained from the Shanghai Health Supervision Station.
Questionnaire and survey methods
A questionnaire survey was used to collect data on all dental medical units in Shanghai. The survey methods included direct on-site interviews and telephone interviews. Direct and telephone interviews accounted for 66.2% and 33.8% of data, respectively. In order to protect the interests of respondents, the questionnaires were completed anonymously.
Data collection
The questionnaire collected data on the quantity of dental health care personnel in Shanghai and their characteristics, including professional title, age, education and specialty of each dental health professional. Moreover, data were collected on the levels of dental health care personnel in Shanghai. In China, dental health personnel are classified as doctors, nurses or technicians, respectively. We investigated the distribution of dental health personnel according to the types of dental health personnel employed by each district and by the dental service organisations. Additionally, we collected data on the quantity of comprehensive dental treatment equipment and the status of dental outpatient services, including annual outpatient quantity and outpatient workload.
Statistical analysis
spss 16.0 for Windows (SPSS, Inc., Chicago, IL, USA) was used to perform statistical analyses. Summary statistics were used to calculate proportions as percentages. A correlation analysis was performed to evaluate the quality of the survey between repeated investigations. Comparison analyses were performed using the chi-squared test or the Mann–Whitney U-test to make comparisons between groups. A probability value of P < 0.05 was considered to indicate statistical significance.
RESULTS
The study took place over a 1-year period during January–December 2007. Questionnaires were provided to 852 dental medical units in Shanghai. Of the 852 questionnaires distributed, 833 valid responses were received; 19 dental medical units refused to participate in interviews, giving an omission rate of 2.2%. The quality of completed questionnaires was evaluated using a repeated test procedure, whereby repeated inquiries were conducted on a random selection of 88 units (10.3% of the total sample) which agreed to be interviewed. The results of the repeated tests were positively associated with one another (r = 0.9327, P = 0.0003).
Quantity and distribution of dental health care personnel in Shanghai
According to public statistics, 852 medical units with dental departments were registered in 2007. Of these, 42.7% (n = 364) were public dental medical units and 57.3% (n = 488) were non-public dental medical units (Table 1). In China, public medical units are divided into three categories, namely: first-class hospitals (municipal hospitals); second-class hospitals (district hospitals), and third-class hospitals (community hospitals). The public medical units with dental departments (Table 1) included 26 first-class hospitals (7.1%), 99 second-class hospitals (27.2%) and 239 third-class hospitals (65.7%). Of the public first-class dental medical institutions, 88.3% were located in the central urban areas of Shanghai. Of the 488 non-public dental medical units, 321 (65.8%) were located in central urban areas and 167 (34.2%) were located in the suburbs.
Table 1.
Profile of the dental health care workforce in dental medical units in Shanghai in 2007
| Dental medical resources | P-value | |||
|---|---|---|---|---|
| Public, n (%) | Non-public, n (%) | Total, n (%) | ||
| Dental medical units | 364 (42.7) | 488 (57.3) | 852 (100) | |
| Hospital level | ||||
| First class | 26 (7.1) | – | – | |
| Second class | 99 (27.2) | – | – | |
| Third class | 239 (65.7) | – | – | |
| Dental professionals | ||||
| Dentists | 2,046 (69.1) | 1,172 (55.8) | 3,218 (63.6) | < 0.001 |
| Dental nurses | 634 (21.4) | 848 (40.4) | 1,482 (29.3) | |
| Dental technicians | 281 (9.5) | 79 (3.8) | 360 (7.1) | |
Types of dental health care personnel in Shanghai
A total of 5,060 dental health professionals were identified. These included 3,218 dentists (63.6%), 1,482 dental nurses (29.3%) and 360 dental technicians (7.1%) working in dental medical units in Shanghai (Table 1). The ratio of dentists to dental nurses to dental technicians was 1 : 0.46 : 0.11. China’s fourth population census in 2000 measured the population of Shanghai as 16,737,700. The ratio of dentists to population was 1 : 5,201. More dentists and dental technicians but fewer dental nurses were employed in public dental medical units than in non-public dental medical units (69.1% vs. 55.8%, 9.5% vs. 3.8%, 21.4% vs. 40.4%, respectively; P < 0.001). Of the 3,218 dentists, 2,243 (69.7%) dentists practised in central urban areas and 975 (30.3%) practised in the suburbs. The ratio of dentists to population in the central urban areas was 1 : 4,161, whereas the ratio of dentists to population in the suburbs was only 1 : 7,590.
Structure of the dental health workforce in dental medical units in Shanghai
Professional title structure
In China, doctors and nurses in medical units are divided into three grades according to their professional titles, namely, senior, intermediate and junior. The demographic backgrounds of surveyed dentists in Shanghai are shown in Table 2. Of the 3,218 dentists employed in dental medical units in Shanghai, 410 (12.7%) dentists held the senior professional title, 1,250 (38.8%) held the intermediate professional title and 1,558 (48.4%) held the junior professional title or no professional title. The distribution of professional titles was equitable across public and non-public dental medical units (P > 0.05). Of the 1,482 dental nurses employed in dental medical units in Shanghai, only nine (0.6%) nurses held the senior professional title, 280 (18.9%) held the intermediate professional title, 1,118 (75.4%) held the junior professional title and 75 (5.1%) held no professional title.
Table 2.
Characteristics of dentists identified within the dental health care workforce in dental medical units in Shanghai in 2007 (n = 3,218)
| Dental medical resources | P-value | |||
|---|---|---|---|---|
| Public, n (%) | Non-public, n (%) | Total, n (%) | ||
| Professional level | ||||
| Senior professional | 291 (14.2) | 119 (10.2) | 410 (12.7) | 0.170 |
| Intermediate professional | 724 (35.4) | 526 (44.9) | 1,250 (38.8) | |
| Junior professional | 1,031 (50.4) | 527 (45.0) | 1,558 (48.4) | |
| Age group | ||||
| < 30 years | 472 (23.1) | 307 (26.2) | 779 (24.2) | < 0.001 |
| 30–50 years | 1,107 (54.1) | 712 (60.8) | 1,819 (56.5) | |
| ≥ 50 years | 467 (22.8) | 153 (13.1) | 620 (19.3) | |
| Education | ||||
| Doctor’s degree or above | 99 (4.8) | 28 (2.4) | 127 (4.0) | 0.031 |
| Master’s degree | 286 (14.0) | 98 (8.4) | 384 (11.9) | |
| Bachelor’s degree | 864 (42.2) | 601 (51.3) | 1,465 (45.5) | |
| Others | 797 (39.0) | 445 (38.0) | 1,242 (38.6) | |
| Specialty | ||||
| Oral medicine | 176 (8.6) | 21 (1.8) | 197 (6.1) | < 0.001 |
| Prosthodontics | 202 (9.9) | 43 (3.7) | 245 (7.6) | |
| Dental surgery | 74 (3.6) | 13 (1.1) | 87 (2.7) | |
| Orthodontics | 108 (5.3) | 34 (2.9) | 142 (4.4) | |
| Preventive dentistry | 52 (2.5) | 0 | 52 (1.6) | |
| Paediatric dentistry | 21 (1.0) | 1 (0.1) | 22 (0.7) | |
| Oral implantology | 21 (1.0) | 10 (0.9) | 31 (1.0) | |
| General dentistry | 1,392 (68.0) | 1,050 (89.6) | 2,442 (75.9) | |
Age structure
Of the dentists employed in dental medical units in Shanghai, over half (56.5%) were middle-aged (aged 30–50 years) and around one quarter (24.2%) were aged < 30 years. Dentists who practised in non-public dental medical units tended to be younger than those practising in public dental medical units (P < 0.001).
Education structure
Of the 3,218 dentists employed in dental medical units in Shanghai, 1,242 (38.6%) were college graduates, 1,465 (45.5%) had obtained a bachelor’s degree, 384 (11.9%) had obtained a master’s degree, and 127 (4.0%) had obtained a doctor’s degree or higher qualification. Dentists who practised in public dental medical units tended to have a higher level of education than those who practised in non-public dental medical units (P = 0.031).
Specialty structure
The body of dentists employed in dental medical units in Shanghai was mainly composed of general dentists. Overall, 2,442 (75.9%) dentists practised general dentistry, 197 (6.1%) were employed in oral medicine, 245 (7.6%) in prosthodontics, 87 (2.7%) in dental surgery, 142 (4.4%) in orthodontics, 52 (1.6%) in preventive dentistry, 22 (0.7%) in paediatric dentistry and 31 (1.0%) in oral implantology. The number of specialists practising in public dental medical units was higher than in non-public dental medical units (P < 0.001).
Quantity of comprehensive treatment instruments
The investigation also evaluated the quantity of comprehensive treatment instruments available in dental medical units. There were 3,387 treatment chairs available in dental medical units in Shanghai. The ratio of dental treatment chairs to dentists in dental medical units in Shanghai was 1.05 and the number of dental chairs every 10,000 people was 2.02.
Quantity of outpatients
The number of outpatients seen in dental medical units in Shanghai in 2007 was 6,123,150. Each dentist was consulted by seven patients daily. We also examined the status of outpatient workload. 57.1% of dental units in Shanghai considered the outpatinets workload to be moderate, 8.6% considered to be excessive, and 34.3% considered to be deficient.
Shortages by specialty in dental medical units in Shanghai
We examined whether dental medical units in Shanghai were in need of additional dentists and which specialties were most needed. Our results indicated that 23.1% of units considered themselves to be in need of dentists. Among these units, 67.4% reported that they required more general dentists. Additionally, 28.5% of units reported a need for more orthodontic dentists. The need for orthodontic dentists was significantly greater than the need for other specialties.
DISCUSSION
Quantity of dental health care personnel in Shanghai
There were 3,218 dentists registered in Shanghai in 2007. The ratio of dentists to population was 1 : 5,201, which is close to the 1 : 5,000 ratio reported in moderately developed countries3. Thus, the total quantity of dental health personnel in Shanghai was relatively sufficient.
Distribution of dental health care personnel in Shanghai
Although the total quantity of dental health personnel in Shanghai in 2007 was relatively sufficient, the distribution of the dental health workforce was not equitable. Dental health personnel were mainly distributed in central urban areas of Shanghai, where 69.7% of dentists practised. The ratio of dentists to population in central urban areas was 1 : 4,161, whereas the ratio of dentists to population in suburban areas was only 1 : 7,590. Most of the dental medical institutions in Shanghai were located in central urban areas. For example, 55.4% of dental medical units and 23 of the 26 public first-class dental medical institutions were located in central urban areas, whereas only three public first-class dental medical institutions were located in suburban areas and thus the availability of dental services in the suburbs was lower4. Moreover, inherent economic incentives lead non-public dental medical institutions to select business locations in central urban areas5., 6.. Our results indicated that 321 (65.8%) non-public dental medical units were located in central urban areas and only 167 (34.2%) non-public dental medical units were based in the suburbs. This results in an unbalanced distribution of dental health personnel in Shanghai, in which the general suburban population does not have access to good dental services7., 8., 9.. Because public first-class dental medical institutions are mainly located in central urban areas, patients with high levels of need for dental health care choose to see doctors in dental medical institutions in central urban areas. Thus, suburban dental medical institutions have a lower quantity of patients, which results in the wasting of dental health human resources in these regions. Meanwhile, dental health personnel resources are relatively insufficient in central urban areas and thus both underutilisation of resources and insufficiency of resources exist in parallel. This irrational distribution has seriously restricted the provision of dental health services to Shanghai residents10., 11., 12., 13..
Irrational workforce structure
The present study identifies many irrational factors in the structure and distribution of the dental health workforce in Shanghai. Previous studies have shown that the ideal profile of a dental health workforce should include dentists, stomatologists, chairside assistants, dental laboratory technicians, dental therapists, dental hygienists, denturists and dental nurses14., 15., 16., 17.. In most countries, the dental health workforce is composed of three types of professional, including dentists, chairside assistants and dental laboratory technicians. This three-type structure of the dental health workforce is not perfect. The ratio of dentists to nurses to technicians in dental medical units in Shanghai was identified in the present study as 1 : 0.46 : 0.11, which is lower than the recommended ratio of 1 : 2 : 118. Current numbers of dental nurses and technicians are relatively insufficient. Thus, dentists must undertake more work, which is then completed by dental nurses or technicians, reducing dental service efficiency and wasting dental health professional resources19.
Therefore, it is necessary to improve the structure of the dental health workforce by strengthening the training of supporting personnel and assistants in order to enable these personnel to undertake simple routine treatments and to help dentists waste less time20. Additionally, it is important to strengthen the training of support personnel in prevention and community projects in order to increase production capacity by improving work efficiency. These initiatives will gradually rationalise the structure of the dental health workforce in China.
Unbalanced specialty distribution
As a result of recent changes in the medical model, many dental health personnel have not developed the dental medical services they provide to include dental disease prevention and health care services21. Therefore, they cannot provide communities with dental disease prevention, health protection, medical treatment and rehabilitation services21. Presently, these deficiencies in dental care are mainly attributable to the irrationalities in the specialty-associated structure of the dental health workforce. Our results demonstrate that the structure of doctor specialties in dental medical units in Shanghai is simple. Dentists were mainly engaged in the provision of comprehensive dentistry; personnel engaged in preventive dentistry and paediatric dentistry accounted for only 1.6% and 0.7%, respectively, of the dentist population22.
CONCLUSIONS
Our results demonstrate that the total quantity of dental health personnel employed in dental medical units in Shanghai in 2007 was sufficient, but the distribution of dental health personnel was unbalanced. Fewer dental health personnel were employed in the suburbs, which resulted in both the wasting and insufficiency of dental health personnel resources in Shanghai. These deficiencies in the distribution of dental health personnel seriously restrict the provision of good dental services to the general suburban population. Moreover, the structure of the dental health workforce in Shanghai is irrational, which reduces dental service efficiency and wastes a considerable amount of dental health human resources. Additionally, the specialty structure of the dental health workforce in Shanghai was simple and personnel in preventive dentistry were lacking. Therefore, dental medical units were unable to provide communities with systematic preventive dentistry, health care, medical treatment and rehabilitation services. The results of this investigation can be applied to help Shanghai achieve the rational distribution and efficient utilisation of dental health human resources.
Acknowledgements
This work was supported by the Science and Technology Commission of Shanghai (11411950900) and the Shanghai Natural Science Fundation (12ZR1446100).
Conflicts of interest
None declared.
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