Self-Perception of Dental Surgeons Regarding Academic Training for Oral Health Care of People with Disabilities: A Cross-Sectional StudyABSTRACT
Objective: To investigate the self-perception of dental surgeons regarding academic training for oral health care of people with disabilities (PWD).
Material and Methods: This cross-sectional analytical study was conducted with a sample of 160 public and private dental surgeons from a Brazilian municipality. A semi-structured questionnaire with open and closed questions was administered to investigate the socioeconomic and demographic aspects, professional training, professional knowledge of the health rights of PWD, and relationships with PWD. Chi-square or Fisher's exact tests, along with a multiple logistic regression model, were used for data analysis at a significance level of 5%.
Results: Almost 70% (n = 112) of professionals had training in the care of PWD. Professionals who had specific training during their undergraduate studies (AOR = 3.660; 95% CI = 1.169-11.467; p=0.026), who developed community activities in this period (AOR = 9.968; 95% C I= 1.887-52.639; p=0.007), who showed aptitude for providing oral health services (AOR = 4.155; 95% CI = 1.563-11.045; p=0.004), as well as for the behavioral management of these people (AOR = 2.808; 95% CI = 1.096-7.195; p=0.031) were more likely to have their self-perception regarding professional training being adequate for oral health care for PWD.
Conclusion: Self-perception of academic training in caring for people with disabilities was associated with some variables related to training during undergraduate studies and work experience, but there are still gaps in knowledge of the rights of people with disabilities to oral health among Brazilian dentists.
Keywords:
Persons with Disabilities; Right to Health; Health Care Quality; Access; and Evaluation.
Introduction
People with disabilities (PWD) represent a vulnerable group within the population and are crucial social opinion makers and consumers of services [1]. Data from the World Health Organization [2] show an estimate of 600 million PWD, while in Brazil, the population with disabilities is around 18.6 million aged two or over according to the 2022 demographic census, which corresponds to 8.9% of the population in this age group [3].
Epidemiological studies generally show that there is a higher prevalence of oral diseases, such as cavities, edentulism, trauma, and the presence of periodontal disease in PWD compared to the general population [4-6]. These people are at greater risk of developing oral diseases due to the difficulty in cleaning the area, a soft diet rich in carbohydrates, daily use of medications that promote decreased salivary flow, and limited access to health services [7].
In relation to the provision of dental services, for dental professionals, academic training in the area is necessary, given the various challenges in oral health care for PWD. However, it is observed that there are still a few studies that portray and deepen the importance of this theme [8]. So, undergraduate dental professional training with an emphasis on care for PWD is needed. This enables the development of different skills and competencies that are essential for providing comprehensive care for PWD. Technical skills underpinned by a scientific foundation are essential in undergraduate curricula and are key to graduating safe and empathetic general dental practitioners. Prioritizing better interpersonal relationships between professionals, patients, and guardians/caregivers is also invaluable [9].
Brazil has established health protection policies for PWD [1,10]. The 1988 Constitution of the Federative Republic of Brazil has a specific chapter about it and the National Health Policy for People with Disabilities and the Viver Sem Limites (Living Without Limits) plan proposes the transversal inclusion of PWD in different programs of the Ministry of Health and the creation of a Care Network for this population within the scope of the Unified Health System (SUS) [11]. Furthermore, the policy facilitates coordination with the National Oral Health Coordination, ensuring that dental care for these patients is provided under the Brasil Sorridente Program, a Brazilian federal oral health program, on a special outpatient basis or, in cases of greater need, within the hospital system [12]. However, numerous barriers against oral health access on public services remain, such as insufficient health care professional training, geographical factors, and social and biological challenges, including issues with health service infrastructure [13].
Knowledge regarding the healthcare rights of PWD and their access to healthcare may influence clinical relationships between dental professionals and PWD. A broader awareness of PWD priorities may enhance technical, emotional, and logistical aspects of care delivery, leading to more customized case management and better patient outcomes. Explicit efforts are necessary to guarantee effective oral health care for PWD. Even with regulations in place and the rights to access health, implementation limitations of the protection granted by law are observed in clinical practice. Oral health professionals must recognize the priorities and understand accessibility to care as a right to facilitate comprehensive health care for PWD in the public and private spheres [14].
This study aimed to investigate self-perception of academic training in caring for PWD and the variables related to the care and knowledge of the rights of PWD to oral health among Brazilian dentists from both the public and private services.
Material and Methods
Study Design and Ethical Clearance
This cross-sectional analytical study was conducted in accordance with the guidelines recommended by Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [15]. This study was approved by the institutional research ethics committee (CAAE: 67541522.6.0000.5626).
Study Location
The study was conducted in the municipality of Araruama, Rio de Janeiro, Brazil. Araruama is a municipality in the countryside of Rio de Janeiro, with a territorial area of 638.276 km2, a demographic density of 203.16 inhabitants/km2, and a population of 129.621 inhabitants, according to IBGE estimates for 2022. It is the second largest population in the lake region [16].
Sample Definition
Identification and selection of establishments and dental professionals in public and private networks in the municipality. Sixty-two dental surgeons were identified from the National Registry of Health Establishments (NRHE) as working in the public system of Araruama. One hundred and fifty-one dental surgeons worked within the private system, specifically those who work in clinics and dental offices, according to the Federal Council of Dentistry [17].
First, the number of private establishments (clinics and dental offices) and public health units was mapped to estimate the number of professionals in each neighborhood of the municipality. Subsequently, the Regional Council of Dentistry (RCD) provided a list of all professionals in the city. Finally, all identified dental professionals were invited to participate in the study.
The sample size was calculated using the GPower 3.0 software [18]. A sample of 160 participants was determined as adequate for a test power of 96% (β = 0.04), a significance level of 5% (α = 0.05), and a size of medium effect according to Cohen (1988) [19]. It was calculated later, based on the number reached and not on the base population.
Data Collect
The study was conducted in two phases. The preparatory phase included a pilot study and researcher training. First, a pilot study was conducted with a sample of ten participants, five from each type of network (public and private) in the municipality. A semi-structured questionnaire with closed and open questions was delivered to the participants in person for completion. This aimed to ensure the participants’ understanding of the questions and provide opportunities for modifications, if necessary. Then, a semi-structured questionnaire was administered.
A semi-structured questionnaire with open and closed questions, based on studies by Amorim et al. [20], Raldi et al. [21], and Xavier [22], was developed to understand the relationship between dentists’ self-perception of their training to care for PWD and their knowledge of the laws, rights, and principles relevant to PWD. The outcome question was, “Do you consider that your academic training in dentistry provided adequate learning and training for caring for PWD?”.
The questionnaire was delivered in person by a researcher to the clinics and offices of dentists who agreed to participate in the research. The participants were given one week to complete the instrument, which was then collected for analysis. The approach without interviews was chosen to avoid a possible bias in the results, due to the non-influence of a possible subjectivity of the researcher on the answers given by the participants [23], in addition to promoting a broader approach to data collection. During the field phase, the questionnaire was reapplied. The questionnaire was reapplied one week later to 10% of the sample to measure reproducibility.
Self-perception of academic training to care for PWD was considered a dependent variable, dichotomized into Yes and No responses. The independent variables were divided into general aspects related to dentistry training and work activity, experience in caring for PWD in public or private networks, working conditions to care for PWD, knowledge about the right to health/oral health of PWD, access to oral health in public and private networks, knowledge about the structuring of the Health Care Network (HCN) for oral health care for PWD, and the user's journey through the network.
Data Analysis
The Chi-square or Fisher's exact test was used to test the association of independent variables with the dependent variable (academic training for care for PWD). The variables that presented p < 0.20 in the individual (bivariate) analysis were tested in the multiple logistic regression model using a stepwise procedure. The Adjusted Odds Ratios (AOR) and the respective 95% confidence intervals (CI) were estimated for the variables that remained in the final model at the 5% significance level. All statistical tests were performed using Jamovi version 2.3.28. Regarding the open-ended question (access barriers to public oral health care services experienced by PWD), the categories related to the participants' responses were quantified as percentages.
Results
The Flowchart showed that 213 dentists worked in the city of Araruama, RJ. Due to difficulties in locating the dentists, 198 questionnaires were delivered, of which 36 were incomplete. However, 160 professionals signed the Consent Form and were eligible to participate in the study, which was sufficient for the study's testing power (96%) (Figure 1). The questionnaire was highly reproducible (kappa: 0.97), with 11.9% of the participants repeating the instrument. The response rate of participants was 75.12%.
Table 1 presents the sample characteristics in relation to the variables investigated. Of the total sample, 95.9% (n = 140) were undergraduates after the establishment of the 2002 National Curricular Guidelines for dentistry courses in Brazil, and only a minority had updated (5.6%) or specialized and or master's/doctoral courses (6.9%) in PWD/ pediatric dentistry. A total of 69.4% received training for PWD during graduation, and 57.5% of them felt able to provide services, while 49% identified as having a good aptitude for behavioral management of PWD. Forty percent (n = 64) considered their academic training for oral health care for PWD satisfactory, and one hundred and twenty-six (79%) professionals care for PWD in their practice. One hundred and thirty-two participants (82.5%) observed improvements in working conditions and access to care, despite a minority of professionals having knowledge about the functioning of the public health network in most of the issues addressed, as well as on some topics pertinent to the health rights of PWD.
The outcome variable Self-perception about academic training to care for PWD was associated with the respective variables: place of work (p<0.001), undergraduate training to care for PWD (p<0.001), community activities during undergraduate degree (p<0.001), aptitude for behavioral management of PWD (p<0.001), aptitude for providing services to PWD (p<0.001), observation of improvements in working conditions and access to care of PWD (p=0.002), knowledge about some principle or right of PWD in Brazil (p<0.001), knowledge about the central role of SUS primary care in guaranteeing the health of PWDs (p=0.012), knowledge about the articulation of the oral health network for care for PWDs (p<0.001), knowledge about how PWD navigate the public oral health network (p<0.001) and perception about the presence of equity in care for PWD (p=0.011).
In the multiple analysis, it was observed that professionals who had specific training for PWD during undergraduate course (AOR = 3.660; 95% CI = 1.169-11.467; p=0.026), who developed community activities during undergraduate program (AOR = 9.968; 95% CI = 1.887-52.639; p=0.007), who showed aptitude for providing oral health services aimed at this population (AOR = 4.155; 95% CI = 1.563-11.045; p=0.004), as well as for the behavioral management of these people (AOR = 2.808; 95% CI = 1.096-7.195; p=0.031) were more likely to have their self-perception regarding professional training being adequate for oral health care for PWD (Table 2).
The multiple logistic regression for the association between self-perception of adequate professional training for oral health care for PWD and independent variables.
Discussion
In this study, it was found that approximately one-third of dental surgeons did not obtain training related to caring for PWD during their undergraduate studies. This may be because, in some universities, study subjects that focus on caring for PWD are not mandatory. Conversely, the majority of dental professionals had PWD training as part of the academic curriculum, even in dental schools that provide annual content related to care for PWD. This may have been directly reflected in some aspects, such as greater aptitude for the service and dealing with the behavioral management of these patients. However, contrary to Ferreira et al. [24], it was also noted that a minority of dentists were capable of providing oral health care to PWD, as most of them considered that their academic training was not proper for this.
For dentistry students, contact with PWD during their undergraduate studies guarantees the experience of different clinical situations that require equally different approaches, whether in internships or extracurricular activities [25]. These prevent the neglect of PWD in the future professional practice of academics [26]. However, this was what our participants reported. The majority of dental practitioners did not think that their training was adequate, and their insecurity in providing care for PWD may be the result of inexperience caused mainly by the absence or little contact with PWD during their undergraduate and postgraduate studies.
The literature shows that the resolutions of the National Curricular Guidelines (NCG) [27] for undergraduate dental degrees support that dental surgeons must have generalist training and be competent in the provision of comprehensive health care. Mota et al. [28], in 2012, stated that it is essential for dentists' training to include diversity technically and humanly. This can be acquired through complementary training during undergraduate studies. Although training during undergraduate studies influenced the self-perception of adequate academic training on PWD, the fact that the dental surgeon had completed a postgraduate course was not of significance, nor was it related to the type of area studied, nor whether it was updated courses or specialization/master's/doctorate courses. Considering these findings, we suggest that more than continued training, clinical professional experiences during the dental surgeon's own work process may have been a more decisive factor related to the aptitude and awareness of caring for PWD from this minority of dental surgeons, as well as knowledge about the principles and rights of PWD.
The Brazilian public health system, known as SUS (Unified Health System), encompasses a comprehensive healthcare network (HCN) with universal access. However, many people do not understand their fundamental health rights or how the HCN is articulated in the provision of public services [24]. The possible reasons for this lack of knowledge and consequent obstacles in access to oral health are related to barriers such as communication and dissemination of information to users, as observed by their lack of knowledge about the possibility of offering public services in oral health based on the availability of infrastructure and trained professionals to care for PWD [29]. This statement was also reported by dentistry professionals in our study, where there is evidence of some constituent factors as barriers to PWD access to the system. Among them, a minority of professionals know about the functioning of the public health network in a large part of the issues addressed, as well as some topics pertinent to the right to health of PWD, the ability to provide services to them, and many dental surgeons cite locomotion/transport to access places of care as obstacles to health care for these people. Some of these problems have also been identified by other authors, such as Silva and Goes [30] in 2021 and Alves et al. [31] in 2018. Another obstacle addressed by Barros and da Cunha [32] is the lack of incentives and investments by the public network, which leaves professionals without a support network to assist them.
There is still a long way to go for PWD to live and feel included in an ideal, fair, and equitable scenario because of the barriers present in everyday life. However, government actions have sought to improve oral health related to the quality of life of these people by ensuring inclusive education, accessibility, and expanding access to social assistance policies that are important for these individuals. These actions seek to provide equity and justice for PWD [33].
The study has some limitations. Despite a high test power (96%), non-adherence to the study protocol due to a lack of time to complete the questionnaire and difficulties in locating the professional led to a smaller sample for analyses. This also used a questionnaire that has yet to be validated, although the questionnaire was based on three validated instruments. Hence, our results may not be directly comparable to those from previous studies. Furthermore, the study was a local study, and external validity was not considered. Additionally, we failed to specify the type of disability in the questionnaire items.
The study also has some strengths, including originality. Few studies [26, 34, 35] have attempted to verify the hypothesis developed in this research. Notably, we strived for internal validity of the entire process through a pilot study, researcher training, assessment of the reproducibility of the measurement instrument, and control of the whole data collection and analysis phase.
Our findings are relevant to researchers, managers, and professionals who work with PWD, not only in the municipality of Araruama, but also in other Brazilian municipalities. Moreover, the insights gained facilitate the elaboration and implementation of public policies whose objective is to ensure equity in care by improving health services for PWD.
Finally, the inclusion of PWD aspects in undergraduate dental training is an indicator of professional awareness for the care of PWD. As such, future investments, such as mandatory inclusion of PWD considerations in the dental curriculum and increasing extracurricular activities, among other learning and teaching strategies, may be beneficial. Ultimately, equipping dental professionals to ensure greater confidence in providing care to the public, including PWD, is paramount, especially in the face of a dental surgeon shortage in PWD care.
Conclusion
Self-perception of academic training in caring for people with disabilities was associated with some variables related to training during undergraduate studies and work experience. However, there are still gaps in knowledge of the rights of people with disabilities to oral health among Brazilian dentists.
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Financial Support
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alidianne Fábia Cabral Cavalcanti
