JOURNAL OF DENTISTRY AND DENTAL MEDICINE (ISSN:2517-7389)

Dental services have been operational in Seychelles for many decades now but to date no research has ever been undertaken dental service users and staffs to express their opinions about existing services.
Objectives: the aim of this research is to ascertain staff and patient perception of public dental services in Seychelles and proposed areas of improvement.
Methods: Questionnaire survey of dental staffs and patients attending eight public dental clinics in Seychelles.
Results: 45% of dental staffs and 370 adult patients completed the respective questionnaire. More than 80% of patients were satisfied with the quality of dental care received at their respective government dental clinic although 54% of participants reported of visiting their dentist only when they have a dental problem and 45% of participants stating their preference to attend without an appointment. Dental staffs’ responses generated some concern; only 44% believed their department to be providing quality dental services and 54% felt the department lacks good long term goals. 76% of dental staffs perceived that their clinic facilities are not well suited for their needs and 70% advocated for recruitment of more qualified dental staffs.
Conclusion: In this study, most of the complaints came from dental staffs and not from patients. The Oral Health Services Division and Health Department should consider counteracting measures directed at dental staff in any proposed plans to improve the public dental service instead of only focusing on dental infrastructure, equipment and dental service users.

Dental service; Satisfaction; Perception; Challenges 

Any service which is made available to the general public is conceptualized from an identified need and is set in place with a clear purpose and objectives. Similarly to any project, services have to be constantly evaluated in order to assess their effectiveness in terms of predefined aims, objectives and resultant outcome. Service evaluation provides valuable information about whether or not to continue or amend an existing service delivery.

Dental services in Seychelles have undergone many changes over the years, in terms of manpower and infrastructure development. The governmental dental department has transitioned from the single rudimentary dental clinic at the Victoria Hospital in the 1930s to a much larger unit comprising of 10 school- based dental clinics, 12 health centre-based dental clinics treating both adults and children. Dental personnel has also expanded in terms of skill mix and number of staff. Aside from clinical dental care, the Seychelles public dental service also implements three preventive dental programs; the Ante Natal Care and Child Oral Health dental program designed for expectant mothers and their young infants, and the school dental program targeting school children. There is no specific program targeting the adult population. Additionally, the dental clinics operating hours are maintained from 8am to 4pm and there is a provision for an on-call after working hour dental service, of which many people are unaware. Alternatively the Seychellois public can also access dental care service at six private dental clinics. However, this questionnaire survey was only conducted within public dental clinic only.

The literature is substantiated with reports from various studies evaluating communityspecific dental services or overall changes to national dental services. England is one such country whereby health service evaluation ranks high. In order to improve access to dental services outside normal working hours, NHS England proposed a weekend dental service and triage line, for which patients expressed high satisfaction (97%, 90%) [1].  Similarly, in 2003, the Department of Health, England commissioned a national evaluation of the Personal Dental Service (PDS) pilots, which compared the salaried model versus the capitation system of remunerating general dental practitioners [2]. This evaluation reported an improvement in access to NHS dental service and also uncovered that patients were not well aware of the changes piloted to the dental service and were confused about the cost and availability of treatment under the NHS.

Dental service evaluations equally allow the performing dentists to express their personal views about any proposed services. For example, the dentists who were involved in the weekend dental service believed that the vast majority of the patients seen at the weekend service had problems which warranted the urgent appointment they had been given [1]. On the other hand, other service evaluation reported on the reservations and concerns of dental care providers; the dentists of the 2003 PDS pilot felt an improvement in working conditions but nonetheless were concerned about cost and that this piloted system would not be a substitute for general dental service.

Other service evaluations tend to focus on dental intervention program targeting specific groups or communities. These researches have the capacity to uncover social issues, which impact on the quality of life and attitude to oral health of less disadvantaged groups of the population. Caton et al. [3] reported on a service evaluation done on a community outreach for homeless and hard-to-reach patients. They found that most participants had not seen a dentist for years and barriers to care included fear, embarrassment, lack of money, living chaotic lifestyle, not prioritizing dental care and difficulty finding an NHS dentist that would take on homeless people. These barriers to dental care are not comparable to the lack of knowledge about cost and availability of dental care reported in Hill et al. [2] evaluation.

Dental service evaluation not only reports on the immediate outcome of a program at hand but also reports on other inherent and unaddressed issues. An evaluation of a dental volunteer program designed for Aboriginal and Torres Strait Islander found the program to be both effective and appropriate but also highlighted that such volunteering programs should not take the place of sustainable, accessible oral health care services in remote and regional Australia [4].

Any proposed changes to a dental care services must be evaluated in relation to initial context and aims and needs to consider the perspectives of staffs, dental service users and other relevant stakeholders. In Seychelles, the Oral health services Division has been providing dental care services for all age groups for many years now, and to date no formal research has been undertaken to ascertain whether patients are satisfied with availability and delivery of existing dental services and whether the staff themselves may have alternative suggestions for better service delivery. A well-executed evaluation exercise will provide health authority with valuable information on which to base actions directed to improve quality of service, patient satisfaction as well as employee performance and retention.

Aims and objectives

The aim of this study is to ascertain dental staffs and patients’ views and opinions of the Seychelles public dental service.

Objectives

1. To find out whether dental service users are satisfied with the existing dental services provided at public dental clinics.
   
2. To understand how dental staff feel about the current dental service and their work environment
   
3. To uncover specific areas that dental service users and dental staff would like to be improved
   

The survey adopted a quantitative approach, for which separate questionnaires were issued to both groups of study participants. Questionnaire is one of the most commonly used data collection tool as it facilitates the collection of data from a large number of study participants and at a relatively lesser cost compared to other mode of data collection such as interviews.

The dental staff questionnaire comprised of two sections; section one included demographic questions whilst section two listed specific statements about career progression, variety on the job, recognition and compensation, communication, identification with organizational goals, working condition as well as attitude to patient satisfaction. The statements were measured on a five-point Likert scale (‘strongly agree’ to ‘strongly disagree’). The Likert scale, named after Rensis Likert, is a multiple-item measure of a set of attitudes relating to a particular area [5]. The goal was to measure the intensity of feelings about the area in question.

The dental staff satisfaction questionnaire inclusive of a consent letter and form was sent to all 113 clinical dental staffs and dental laboratory staffs. The consent letter outlined the purpose of the evaluation and provided specific instruction on how to return the completed questionnaire in the self- addressed envelope through the Health Department’s internal mailing system. The dental staffs were allowed a six weeks period to return completed questionnaires.

Phase two of the dental service evaluation involved adult dental service users. A total of 370 adult dental service users completed the dental patient satisfaction questionnaires at 8 adult dental clinics on Mahe and La Digue. The school-based dental clinics were excluded from this study since school children were not intended as study participants. The dental patient questionnaire was adapted from the patient satisfaction questionnaire of Safety Net Dental Clinic Manual [6]. 8 dental hygienist students and 3 dental therapists collected data from adult participants at a specified week interval at each dental clinic. However, because of data collector issues and time constraints, the initial target of 695 dental service users was not attained.

The dental service user participants were selected through both criterion and convenience sampling. Criterion sampling applies in that all participants who completed the dental patient satisfaction questionnaire had to be an adult dental service user. On the other hand, convenience sampling which is defined as the selection of participants that are both easily accessible and willing to participate in the study, applies because only participants present in the waiting area of the 8 dental clinics were invited to participate [7]. The participants were explained the purpose of this evaluation and that their participation was voluntary. They were issued a dental patient satisfaction questionnaire inclusive of a consent letter and form, which they had to complete prior to completing the questionnaire. A creole version of the consent letter and questionnaire was also made available to non-English speaking participants.

The dental patient satisfaction questionnaire equally comprised of two sections. Section one included background questions about the participants and their dental visit behaviour. Section two of the questionnaire contained specific statements about the dental clinic reception, dental visit, attitude of dental staff and dental treatment received, for which the categories of responses for the statements were Agree, Unsure and disagree. All questionnaires were completed and collected by the data collectors on site and returned to the main researcher at the central office.

Data from both sets of questionnaires were entered into separate excel database for categorical data analysis. Simple descriptive statistics was used to tabulate the demographic information and perspective of dental service users and dental staffs. 

Section One: Results of dental staff questionnaire (Table 1-4, Figure 1-3)

The dental staff questionnaire survey had a response rate of 45% of which 92% of the respondents were female, which is also indicative of the present gender distribution of staff of the dental department. A total of 370 adult dental service users, primarily made up of 68% females completed the questionnaire.

The bulk majority (82%) of patients expressed satisfaction with the reception and waiting area of their respective public dental clinics. 54% of adult patients reported of visiting their dentist only when they have a dental problem with toothache and pain emerged as the most common reason (44%) for visiting the dentist. This problem-driven dental visit seemed to predominate in all surveyed public dental clinics and across all age groups. Inevitably, this pattern of service usage dictates the operation of the adult dental service. In this case, the barrier to preventive dental visit in Seychelles is patient attitude, which is non-comparable to the social barriers uncovered in Caton et al. [3] study. When asked about the accessibility to dental services, the majority of patient participants agreed that it is relatively easy to book a dental appointment and that this process was facilitated by a helpful and polite dental staff, which was also supported by 60% of dental staffs themselves. With regards to dental visit preference, 45% of participants preferred to see the dentist without an appointment which is in line with dental problem-driven being the most common reason for dental visit. But on individual clinic level, some clinics had more participants advocating for more dental appointment.

The dental staffs also had the opportunity to comment on their current work environment, availability of resources and departmental operation. Most dental staffs were unanimous in their responses about the lack of suitable work resources and adequate work facilities. 76% of participants disagreed that their clinic facilities are well suited for their needs and 70% advocated for recruitment of more qualified dental staff and more than 80% disagreed about the availability of dental materials and number of qualified dental staff presently employed in the government dental service.

This impact of lack of human resource on service delivery also emerged in the patient participants’ responses. The questions about waiting time generated mix responses; overall less than 50% of participants agreed that they did not have to wait too long to see the dentist whilst 35% disagreed. The Oral Health Directorate may need to re-evaluate the dentist to patient ratio and other factors to strategize on how to reduce waiting time and enhance patient satisfaction. The questions about patients’ perception of the dental treatment which they received yielded mostly positive answers; 81% of all participants agreed that they were given adequate information about their proposed dental treatment and a large majority felt that all of their questions were answered efficiently, with only 3% disagreeing to that. A slightly lower percentage (67%) of participants said that they were given different alternatives of dental treatments but the remainder responses were not total disagreement but mostly uncertainty (26%). This may be indicative of memory recall problems or genuine uncertainty as to what constitutes alternative dental treatments.

Overall more than 70% of all participants believe that their dental treatment was completed efficiently and in a timely manner. And again in all dental clinics surveyed, the remainder responses tended more towards uncertainty than displeasure. 83% of participants wish to continue their dental treatment at their respective dental clinic and 76% are satisfied with the quality of dental services which they have received, as oppose to only 4% who disagreed. However, the dental staff’s perception of quality of work emanating from their department is not as optimistic. 44% of respondents agreed that their department is providing quality dental services whilst 24% were unsure and 22% disagreed. It is of great concern when employees themselves express such level of doubt and disagreement about the quality of service delivery within the Seychelles government dental service.

Despite some of their negative perception, 52% of participating dental staffs believe that their respective dental clinic does not have a poor reputation for customer service. In a way, this translates to what the patients themselves had to say about dental staffs. More than 80% of participants believed dentists to be professional in their work and behaved considerately and sensitively to their needs. Similar responses were also obtained in relation to the perceived attitude of dental surgery assistants, and this pattern was also noted in all dental clinics. A slightly lower percentage (74%) of respondents was in agreement of the positive attitude of dental hygienist, whilst the remainder responses tended mostly towards uncertainty. This is most probably due to the fact that the dental hygienist cadre is not as well- known as the other dental cadres in Seychelles and also because the dental hygiene services is not provided in all government dental clinic.

It appears that all dental staffs are highly positive about their job and are unanimous in their responses about how they feel responsible for their patient’s care and their daily work commitment. However 28% were indecisive about their future career intention, whilst 30% agreed that if they were offered another job tomorrow, they would resign from the dental profession and 42% of participants disagreed. These responses suggest that some dental staffs are mostly committed to doing their best for their customers on a daily basis but their level of commitment to their respective dental career itself is much lower.

42% of dental staff believe that they have input into clinic goals and policies and 40 % of respondents agreed that their supervisor is receptive to their suggestions. However, other result infer that the majority of dental staff also believe that the associated reverse communication from management to staff is not satisfactory; 84% of participating dental staffs feel that they are not well informed of activities and changes occurring in the dental department.

The associated questions about work development and career progression also produced conflicting results. 68% of participants believe that they have control over their professional career and yet 60% of participants contested that they were not offered opportunities to advance in their dental field. This generates a concern as to how the dental staffs view the concept of professional career, for which appropriate training opportunity is crucial to its development. There is a possibility that participating dental staff were merely thinking about their daily work duties when answering that question about control over their work instead of reflecting about their overall career. This adds to the earlier finding about the dental staffs’ future work intention; if most of the participants view their work simply as a job instead of a career, then it is easier to consider switching to another job. Additionally an almost equivocal number of participants agreed, disagreed and were unsure about whether they have receive their share of continuing education opportunities. Again this triggers questions about the scope of continuing education provided to those staff in agreement, which may suggest that such training opportunities may have not been fully dentally related. This serves as a point of action to the Oral Health Services Division to review its continuing education and professional development strategy.

The last part of both questionnaires required the study participants to comment on specific areas of improvement which would make their work or dental experience better. In almost all dental clinics, patients want more dental health and service information, and in some instances the participants specified a need to inform patients about the number of dentists available to attend to their dental needs. In selected districts, the participants’ wants the government dental service to give priority to patients in pain, when clearly the emphasis should be on dental prevention and asymptomatic dental visit. This is further reinforcement to the Oral Health Division that it needs to re- evaluate its health education and overall oral health promotion strategy. On the other hand, the participating dental staffs’ responses varied from basic work resources and environment factors to management and leadership suggestions. 25% of dental staff highlighted a need for more dental material, equipment and human resource for better dental service delivery, whilst 24% of responses focused on the leadership and management of the government dental department.

Overall, this study has highlighted key areas whereby the Oral Health Services Division may need to address in order to better the Seychelles government dental service. Nonetheless, this study had some limitations in terms of scope and sampling size; the responses of more adults and also that of service users of the school dental service would have added to the findings of this study and thus provided a more comprehensive overview of patients’ perception of the Seychelles public dental service. Furthermore the findings from this evaluation are not easily comparable to the studies presented in the literature review, because of distinct differences in the dental care system employed. 

This study has evaluated what adult dental service users and dental staffs themselves perceive of the Seychelles public dental service. Overall, patients are satisfied with the existing dental service, in terms of treatment provided and staff attitude. However, patients have highlighted particular issues mostly at specific clinic level such as the need for waiting area and overall dental clinic renovation and a reduction in waiting time for dental treatment. It is generally expected that dental service users would express more complaints about service delivery but surprisingly in this study, most of the complaints came from dental care providers. The dental staffs did not necessarily describe any problems with patient care but mostly complained about their working condition and environment and of particular concern, is their level of motivation and commitment to their profession. Thus, the Oral Health Services Division and Health Department may wish to consider including counteracting measures directed at dental staff in any proposed plans to improve the government dental service instead of only focusing on dental infrastructure, equipment and dental service users. Most importantly, health authorities need to understand that the wellbeing of existing staffs is pivotal and influential to effective service delivery.

This research was supported by the Health Care Agency of Seychelles. A special thank you goes to all the dental hygienists and dental therapists who facilitated data collection at the public dental clinics.

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