A thesis submitted to fulfill the requirements for the degree of Doctor of Dental Science

Thesis (M.S.P.H.)--University of Michigan, 1942.

Thesis (M.S.P.H.)--University of Michigan, 1942.

BACKGROUND: Data about the interaction of different predictors for the use of dental services among representative samples of Brazilian children are scarce. Understanding the effect of psychosocial, clinical, sociodemographic, and context factors on inequalities in the use of oral health services provides important data for the implementation of measures to promote health. AIM: To assess the influence of socioeconomics and psychosocial factors and contextual covariates for use of dental services in 12-years old schoolchildren in Brazil. METHODS: An epidemiological survey was conducted in 12-years old schoolchildren in Santa Maria, Brazil. A two-stage cluster sampling was used. Data about the oral conditions were collected through clinical exams at school and contextual data related to the location of the school where the child studies were obtained through official publications of the municipality. Socioeconomic conditions were evaluated by a questionnaire answered by their parents. This questionnaire was used to assess whether the child had visited any dental care service in the previous 6 months and the reasons for dental visit (preventive/others than preventive). Psychosocial factors were collected by using the Brazilian version of Child Perceptions Questionnaire (CPQ 11-14). The study of association used multilevel models of Poisson regression analysis. RESULTS: The prevalence of use of dental services was 47.43%; 69.84% of the subjects used the dental services for preventive reasons. Participants from lower family income, those who rated their oral health as "fair / poor / very poor" and students of schools with low rates of approval were less to have gone to the dentist in the last six months. The reasons for dental services varied across socioeconomic groups. Moreover, those who perceived their oral health as "fair / poor / very poor", and those from schools with low approval rates were more likely to use dental services in an emergency / treatment. CONCLUSION: This study showed that psychosocial factors, and socioeconomic context are important predictors for the use of dental services, emphasizing the need for public intervention to consider the effect of social determinants in reducing inequities in use of services. / Justificativa: Dados sobre a interação de diferentes preditores na utilização de serviços odontológicos em amostras representativas de escolares no Brasil são escassos. Portanto, entender o efeito dos fatores psicossociais, clínicos, sociodemográficos e do contexto nas iniquidades em termos de utilização de serviços de saúde bucal provê dados importantes para a implementação de medidas de promoção de saúde, especialmente em crianças. Objetivo: Avaliar a influência de fatores socioeconômicos, psicossociais e de ordem contextual no uso de serviços odontológicos em escolares de 12 anos de idade em Santa Maria, RS, Brasil. Metodologia: Um levantamento epidemiológico foi realizado em escolares de 12 anos de Santa Maria, RS. A amostra foi obtida através de um processo de conglomerado em duplo estágio. Dados sobre condições bucais foram coletados a partir de exames clínicos realizados na própria escola e dados contextuais, referentes ao local da escola onde a criança estuda, através de publicações oficiais do município. Um questionário estruturado foi respondido pelos responsáveis para verificar características sociodemográficas da criança. Esse questionário foi utilizado para coletar a variável dependente, através da pergunta Seu filho procurou dentista nos últimos seis meses? . Fatores psicossociais foram coletados através do questionário Child Perceptions Questionnaire (CPQ11-14). O estudo de associação utilizou modelos multinível de análise de regressão de Poisson. Resultados: A prevalência de uso de serviços odontológicos foi 47,43%; e para uso de serviços por razões preventivas foi de 69,84%. Participantes com menor renda familiar, com percepção de sua saúde bucal como regular/ruim/péssima e alunos de escolas com baixo fluxo de aprovação apresentaram probabilidade significativamente mais elevada de não terem usado os serviços nos últimos seis meses. A procura por serviços odontológicos por razões não preventivas variou de acordo com nível socioeconômico. Ainda, participantes que perceberam sua saúde bucal como regular/ruim/péssima e estudantes de colégios com fluxo de aprovação escolar baixo tiveram uma maior probabilidade de usar os serviços odontológicos por motivos de emergência/tratamento. Conclusão: Este estudo mostrou que fatores psicossociais, socioeconômicos e do contexto são importantes preditores para o uso de serviços odontológicos, ressaltando a necessidade de intervenções públicas considerando o efeito de determinantes sociais na redução das inequidades de uso dos serviços.

Philosophiae Doctor - PhD / In order to manage public dental services, information is required about what work is being performed by the staff at the various clinics. Tally sheets have been used in the past to record treatment procedures but this is not an effective method of recording the amount of work done by staff at public dental clinics. But tally sheets are inaccurate, open to abuse, and fail to provide the necessary information for managers. Nor is it of any real value for providing feedback to staff on their performance. This inhibits a core aspect of job satisfaction for the staff, which is feedback. The staff just persevere, continue doing the same thing and feel frustrated. This contributes to poor work performance. Instead of using a tally sheet, 4 digit treatment codes are used for all treatment procedures (as used in the private sector for billing purposes) and additional codes were developed for services such as brushing programmes for which billing codes do not exist. These are recorded for each patient, together with a code for the patient category. A relative value unit (RVU) has been developed for each treatment code that has been weighted according to policy guidelines and the amount of time and effort required to provide the service. This was done for clinical treatment procedures as well as for community-based preventive activities. A computer program has been developed that captures the treatment codes which are saved in a number of databases that are linked to Excel pivot tables. The data can therefore be easily manipulated by the user to obtain the required information in the form of counts of procedures, monetary cost of the same clinical services in the private sector (useful with the proposed advent of National Health Insurance) and also in the form of relative value units. iii This is available for the current reporting period as well as for previous periods, allowing a detailed analysis of services rendered and staff performance over a period of time to show trends. Use is also made of an Objectives Matrix where the performance of each staff member can be measured according to seven objectives (Key Performance Areas) (five in the case of oral hygienists) to produce an overall Performance Index – which is a score out of ten. This enables performance appraisal to be carried out much easier than by comparing performance based on a number of diverse treatments provided. The data for all the public dental clinics in the Western Cape Province has been analysed for the period 1994 to 2012 using this system, and it has been shown that the system is sensitive enough to highlight problem areas as well as provide a balanced overall view of the service, as measured by a number of variables. The system is “low tech” in that it runs on a “stand alone” personal computer, but it could easily be applied to an integrated, networked information system provided the latter contained the treatment codes, and certain other patient, staff and clinic identifiers. It is therefore suitable for developing countries, such as South Africa, that may later develop a comprehensive Health Information System based on an electronic medical record. The emphasis is not on the information technology, it is focussed on the concepts behind the processing of the data into meaningful information for managing public dental services.

Philosophiae Doctor - PhD / In order to manage public dental services, information is required about what work is being performed by the staff at the various clinics. Tally sheets have been used in the past to record treatment procedures but this is not an effective method of recording the amount of work done by staff at public dental clinics. But tally sheets are inaccurate, open to abuse, and fail to provide the necessary information for managers. Nor is it of any real value for providing feedback to staff on their performance. This inhibits a core aspect of job satisfaction for the staff, which is feedback. The staff just persevere, continue doing the same thing and feel frustrated. This contributes to poor work performance. Instead of using a tally sheet, 4 digit treatment codes are used for all treatment procedures (as used in the private sector for billing purposes) and additional codes were developed for services such as brushing programmes for which billing codes do not exist. These are recorded for each patient, together with a code for the patient category. A relative value unit (RVU) has been developed for each treatment code that has been weighted according to policy guidelines and the amount of time and effort required to provide the service. This was done for clinical treatment procedures as well as for community-based preventive activities . A computer program has been developed that captures the treatment codes which are saved in a number of databases that are linked to Excel pivot tables. The data can therefore be easily manipulated by the user to obtain the required information in the form of counts of procedures, monetary cost of the same clinical services in the private sector (useful with the proposed advent of National Health Insurance) and also in the form of relative value units. This is available for the current reporting period as well as for previous periods, allowing a detailed analysis of services rendered and staff performance over a period of time to show trends. Use is also made of an Objectives Matrix where the performance of each staff member can be measured according to seven objectives (Key Performance Areas) (five in the case of oral hygienists) to produce an overall Performance Index - which is a score out of ten. This enables performance appraisal to be carried out much easier than by comparing performance based on a number of diverse treatments provided. The data for all the public dental clinics in the Western Cape Province has been analysed for the period 1994 to 2012 using this system, and it has been shown that the system is sensitive enough to highlight problem areas as well as provide a balanced overall view of the service, as measured by a number of variables. The system is "low tech" in that it runs on a "stand alone" personal computer, but it could easily be applied to an integrated, networked information system provided the latter contained the treatment codes, and certain other patient, staff and clinic identifiers. It is therefore suitable for developing countries, such as South Africa, that may later develop a comprehensive Health Information System based on an electronic medical record. The emphasis is not on the information technology, it is focussed on the concepts behind the processing of the data into meaningful information for managing public dental services.

Aim: To describe and analyze the demographic profile and the dental treatment needs, workload and costs of the 2007 and 2008 CF recruit population (N=10,641). Method: Treatment procedures and costs were aggregated and calculated, beginning from the date of a member’s enrolment, over a period that ranged between 13 to 36 months. Associations between treatment services and the demographic variables were tested using one-way ANOVA and chi-square tests. Independent samples T-test was used to compare means. Linear regression models were used to determine the influence of demographic variables on treatment cost. Results: Treatment needs and costs varied with recruit age, gender, rank, first language (French/English), birthplace (Canada/Foreign), tobacco use, province and census tract. The cost of treatment for the entire population was $13.9M. Mean cost per recruit was $1224 over an average period of 26 months. Outsource costs ($2.9M) were driven by referrals for restorative, endodontic and oral surgery procedures.

Aim: To describe and analyze the demographic profile and the dental treatment needs, workload and costs of the 2007 and 2008 CF recruit population (N=10,641). Method: Treatment procedures and costs were aggregated and calculated, beginning from the date of a member’s enrolment, over a period that ranged between 13 to 36 months. Associations between treatment services and the demographic variables were tested using one-way ANOVA and chi-square tests. Independent samples T-test was used to compare means. Linear regression models were used to determine the influence of demographic variables on treatment cost. Results: Treatment needs and costs varied with recruit age, gender, rank, first language (French/English), birthplace (Canada/Foreign), tobacco use, province and census tract. The cost of treatment for the entire population was $13.9M. Mean cost per recruit was $1224 over an average period of 26 months. Outsource costs ($2.9M) were driven by referrals for restorative, endodontic and oral surgery procedures.

The aim of this study is to analyse and compare the delivery of oral health care services based on the prevailing curative paradigm and WHO-treatment norms for the school-going community of Mitchells Palin district in relation to selected alternative methods of dental care delivery. The optimal use of auxiliary personnel, purchasing care from private dental practitioners and intriducing water fluoridation was examined.

The aim of this study is to analyse and compare the delivery of oral health care services based on the prevailing curative paradigm and WHO-treatment norms for the school-going community of Mitchells Palin district in relation to selected alternative methods of dental care delivery. The optimal use of auxiliary personnel, purchasing care from private dental practitioners and intriducing water fluoridation was examined.