An experimental test of adolescents' compliance with dental appointments

J O U R N A L OF A D O L E S C E N T H E A L T H 1993;14:384-389

ORIGINAL ARTICLE

An Experimental Test of Adolescents' Compliance with Dental Appointments K A R E N P. WEST 1 D . M . D . , M . P . H . I ROBERT H . D u R A N T , Ph.D.~ F . S . A . M . r A N D ROBERT P E N D E R G R A S T r M.D.~ M . P . H .

This study assessed factors associated with adolescents' compliance with dental appointments. Patients (n = 162) attending an adolescent clinic were administered a pretest questionnaire assessing health locus of control, selfesteem, and beliefs and attitudes about dental health from the Health Belief Model. Adolescents needing dental care were randomly assigned to groups for whom their dental appointment was made by a health professional or one in which the patient made his or her own appointment and to groups receiving an appointment reminder card versus not receiving a reminder card. Dental records were then reviewed to examine previous experiences with dental treatment. Neither the method used for making the appointment nor the use of reminder cards had a significant effect on compliance with the dental appointments. Also, compliance was not associated with health locus of control, self-esteem, or variables from the Health Belief Model. Older patients were more noncompliant than younger patients (x = 0.14). Noncompliance was negatively correlated with the number of previous dental visits and previous dental procedures, oral hygiene instruction, and x-rays. Number of previous x-rays and previous broken appointments explained 5.1% of the variation in noncompliance. The Health Belief Model was not successful in predicting compliance behavior in this sample of adolescents. KEY WORDS:

Patient compliance Dental appointment keeping From the Department of Oral Health Practice, Collegeof Dentistry, University of Kentucky, Lexington, Kentucky (K.P. W.), Sectionof General Pediatricsand AdolescentMedicine, Departmentof Pediatrics,Medical College of Georgia, Augusta, Georgia (R.H.D.), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland (R.P.).

Address reprint requests to: Robert H. DuRant, Ph.D., F.S.A.M., Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, CE 112, Medical College of Georgia, Augusta, GA 30912. Manuscript accepted February 18, 1993. 384

1054-139X]93/$6.00

Reminder cards Health locus of control Self-esteem Health belief model

Adolescents' noncompliance with therapeutic regimens has been a source of concern to health professionals for many years (1-3). Unfortunately, the systematic study of noncompliance behavior has occurred primarily during the past 15 years and has focused primarily on adherence to medical regimens (1-18). Limited research has been directed at adherence to dental regimens, with even less research addressing adolescents' compliance in the area of dental health (7-14,19-26). Nonadherence to dental recommendations is considered to be a significant problem, as suggested by the low percentage of patients following recommended preventive regimens (8,10). For example, one survey indicated that less than 25% of those sampled brushed their teeth after every meal while less than 40% used dental floss. Only one-third of those surveyed brushed once a day (8). Another common problem is the failure of adolescents to be compliant with dental appointments recommended by health-care professionals, especially among youth from lower socioeconomic backgrounds (1921,26). The problem of compliance with medical or dental therapy is multifaceted, depending partly on the disease being treated, the age of the patient, and various other social and psychological factors (1-4). Although the usefulness of psychosocial factors, such as self-esteem and locus of control, in predicting health behavior has been questioned (27,28), there is both empirical and theoretical evidence sug-

© Society for Adolescent Medicine, 1993 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010

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gesting that adolescents' compliance with dental regimens may be related to factors such as selfesteem and health locus of control (1-3,11,13,29-31). An alternative theoretical approach to explaining adolescents' compliance behavior is the Health Belief Model (1). Based on the Health Belief Model, compliance with health-care advice is more likely among those who feel susceptible to a health problem which they perceive as serious and who feel their adherence to medical or dental recommendations is likely to have beneficial effects (22). The Health Belief Model also specifies that a cue-to-action is necessary to trigger this cost-benefit decision process. In terms of seeking dental care, cues-to-action may be: (a) having a health professional recommend a dental visit, (b) making the dental appointment for the patient, and (c) sending a reminder card by mail. The purpose of our study was to evaluate currently used methods of patient referral from an Adolescent Medicine Clinic at a medical university to an adjacent Children and Youth Project dental clinic. We compared the level of compliance with dental appointments between adolescents who make their own appointments with adolescents whose appointments are made for them by a health-care provider, such as a physician or nurse. We also tested the influence of utilizing reminder cards on compliance with appointments. Finally, we assessed the effects of health locus of control, self-esteem, and health beliefs from the Health Belief Model on the compliance of this sample of adolescents.

Methods Sample The sample consisted of 162 adolescent patients aged 12-19 years receiving routine medical care in the Adolescent Medicine Clinic of a medical university's Children and Youth Project. Every patient who had not been to a dentist during the previous year or who was found to need dental treatment for either preventive or emergency care during the 2-year study, was invited to participate. Fewer than 10% refused to participate. Reasons for refusal most often included not wanting to take the extra time to fill out the questionnaire. The gender distribution of the sample is described in Table 1. Of the 162 subjects, 157 (97%) were black. All of the adolescents lived in one of six HUD'housing projects and were enrolled in the Children and Youth Project.

COMPLIANCEWITH DENTALAPPOINTMENTS

385

Table 1. Gender, Ethnic, Experimental Conditions, and Purpose of Dental Visit Distributions of Black Adolescents Who Were Compliant and Noncompliant with Their Dental Appointments Compliant Males Females Method of appointment Patient Health professional Reminder card Yes No Purpose of visit Check-up Pain Visible caries Malocclusion Other

Noncompliant

n

%

n

%

18 31

26.9 32.6

49 64

73.1 67.4

21 28

25.3 35.4

62 51

74.7 64.6

24 25

32.9 28.1

49 64

67.1 71.9

89 2 7 0 1

47.8 40.0 53.8 0.0 14.3

97 3 6 1 6

52.2 60.0 46.2 100.0 85.7

Study Design The study protocol was approved lJy the university's Human Assurance Committee. After receiving written informed consent from the adolescent, a questionnaire was administered. In addition to demographic information, the questionnaire contained the Wallston Health Locus of Control scale (32) and the Coopersmith Self-Esteem Inventory (33). Beliefs and attitudes about dental health including perceptions of susceptibility to dental disease, barriers to dental care, seriousness of dental diseases, and general health perception/motivation, were evaluated through the use of Chen and Land's indicators of dental health beliefs (22). The adolescents' dental health behavior was assessed through their responses to questions using 6-point Likert scales ranging from strongly agree to strongly disagree. These instruments have been used extensively in studies of lower income black adolescents. The validity and reliability coefficients of these scales have been previously reported (22,32,33). All subjects were found to have acceptable reading levels prior to administering the questionnaires. Upon completion of the questionnaire, subjects were randomly assigned to two of four possible conditions using a computer-generated random numbers table. Assignment was made either to a group in which the dental appointment was made by a health-care professional or to one in which the pa-

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W E S TET AL.

tient made his or her own appointment at the adjacent dental clinic, and either to a group receiving a reminder card or one not receiving a reminder card (Table 1). When appointments were made by either the health-care professional or the patient, the time and date were placed on an appointment card for the adolescents. All appointments were within 2 weeks of the time the appointment was made, and the reminder cards were sent to the adolescent patients 5 days after the appointment had been made. None of the reminder cards were returned owing to incorrect addresses. Patient dental records were then blindly reviewed by one investigator (a dentist) to examine previous experiences and compliance with dental treatment. Appointment keeping was measured on a 5-point ordinal scale. The scale consisted of the following: (a) being on time for the appointment (within 15 min), (b) showing up for the appointment more than 15 rain late, (c) canceling appointment, but calling to reschedule the appointment, (d) no show, but calling after appointment time to reschedule, and (e) no show.

Statistical Analysis Because compliance was measured on an ordinal scale, nonparametric tests were used to assess bivariate relationships. Parametric statistical tests were used for multivariate analyses of significant bivariate relationships. Kendall's -¢ correlation coefficients were used to test the correlation between compliance and health locus of control, self-esteem, health beliefs, and previous experiences with dental treatment. Variables found to significantly correlate with compliance were then analyzed with multiple regression. Kruskall-Wallis analysis of variance (ANOVA) test was initially used to assess differences in compliance between method of referral and use of reminder cards. A two-way ANOVA was used to assess any interaction effects between method of referral and reminder cards. Because of the distribution of the compliance scale (skewness = -0.92, SE = 0.14), compliance was reduced to a dichotomous scale and the experimental effects tested with ×2 tests. Subjects scoring 1, 2, or 3 on the compliance scale were considered compliant and those scoring 4 or 5 were classified as noncompliant. Differences between compliant and noncompliant groups in the other variables were assessed with Kruskall-Wallis ANOVA and ×2 tests.

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Results Only 30.2% of the adolescent patients were compliant with their dental appointments. Neither the method for making the appointment nor the use of reminder cards had a significant effect on keeping the dental appointment (Table 1). There was not a significant interaction effect on compliance between appointment method and appointment card. There were no significant differences in the purpose of the dental visit, number of previous dental visits, broken appointments, or number of previous dental procedures among compliant and noncompliant patients (Tables I and 2), Also, the mean levels of internal health locus of control, powerful others health locus of control, chance health locus of control, self-esteem, or variables from the Health Belief Model were not different in the compliant and noncompliant groups (Table 2). Age was weakly correlated with noncompliance, with older patients slightly more likely to be noncompliant (Tables 2 and 3). Noncompliance was also weakly and inversely correlated with the number and types of previous dental visits and procedures performed, such as having had x-rays or oral hygiene instruction (Tables 2 and 3). Compliance was recoded as a dichotomous variable and analyzed with multiple regression. Number of previous x-rays explained 2.8% (adjusted R2) of the variation in compliance, followed by number of broken appointments (partial r = 0.17) explaining an additional 2.2% of variation in the model (adjusted R2 = 0.051). No other variables explained a

Table 2. A Comparison of Variables in Compliant and Noncompliant Adolescent Patients compliant Mean SD Age (years) Number of previous dental visits Previous broken appointments Number of previous dental procedures Internal health locus of control Powerful others" locus of control Chance health locus of control Self-esteem

Noncompliant Mean

SD

14.8

1.7

15.3

1.6

9.9

9.6

8.0

9.9

2.7

2.9

2.9

3.9

2.9

1.8

2.3

2,1

26.8

5.3

27.4

5.3

23.7

6.1

24.3

5.8

20.7 15.3

5.2 3.9

20.1 15.8

5.8 4.2

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COMPLIANCE WITH DENTAL APPOINTMENTS

Table 3. ×2 Analysis and Kendall's • Correlation

Coefficients Between Noncompliance and Previous Dental History

Age Number of clinic visits X-rays Oral hygiene instructions Number of previous dental

procedures

X2

p

T

p

4.4 51.1 5.9 5.5

NS 0.0095 0.015 0.019

0.14 -0.16 -0.17 -0.16

0.049 0.027 0.0076 0.01

22.4

0.001

- 0.15

0.014

significant amount of variation in compliance. There were no interaction effects between the experimental variables and any other independent variable.

Discussion Few studies have investigated behavioral factors associated with the noncompliant adolescent dental patient (1-5). Previous studies have focused primarily on compliance with dental advice such as in recommendations given by the dentist for preventive behavior (12,23-25) or compliance with orthodontic therapy (11-14). The Health Belief Model has been used extensively to evaluate patient compliance with medical advice (1), but has been found to be inconsistent in predicting dental health behavior (7). Kuhner and Raetzke (10) found that "motivation", "'perceived severity", and "perceived benefits", significantly affected dental health behavior. Chen and Tatsuoka (25) reported that white adult females' preventive dental behavior was directly related to their health beliefs. In contrast, our study of a lower socioeconomic status (SES), predominantly black sample of adolescents found no relationship between variables from the Health Belief Model and dental appointment compliance. The differences in both the study samples and the research designs may partially account for this apparent inconsistency. Previous studies have been based on cross-sectional data, whereas we tested our primary hypothesis using an experimental design. Our findings agree with the study by DuRant et al. (6) that "experience with therapy" was weakly related to compliance (5). Our findings were also consistent with Kegeles and Lund (23), w h o reported the absence of a relationship between adolescents' health beliefs and preventive dental practices, and Weisenberg et al. (24), who found that children's health beliefs and their participation in a school-based preventive dental program were not

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correlated with variables from the Health Belief Model. A specific area of the model that has not been thoroughly investigated is the "cue-to-action" component. The Health Belief Model states that a cueto-action must occur to stimulate the appropriate behavior by making the patient aware of his feelings regarding the health threat (22). It has been shown that patient satisfaction with the dentist is very important in promoting positive dental habits (26). Therefore, the health-care provider can act as a cueto-action by affecting patient motivation (1,34). In our experimental study, two forms of cues-toactions, the patient reminder cards and the healthcare providers making the subject's appointment, were found not to have an effect on compliance. While the Health Belief Model has been used in samples of black adolescents (1), it does not appear to be useful in predicting lower SES black adolescents' dental health behavior. Other theoretical models, such as the health-communication model (34) need to be tested in this population of adolescents. For example, Zimmerman (35) examined the relationship of the similarity of practitioner and patient preferences for a dental appointment, and assessed the impact of their similarity on patient satisfaction with the appointment and adherence to the reco m m e n d e d treatment regimen among predominantly white 15- to 19-year-old dental patients. He found that the similarity of patient and dental student preferences for an appointment was a very significant predictor of patient satisfaction with the appointment, reported improvement in oral hygiene behavior, and actual improvement in objective dental health. Patient satisfaction was, in turn, an independent predictor of reported behavior change and objective improvement in dental health. Based on previous research (13,29,30), we hypothesized that adolescents' compliance would also be associated with self-esteem or self-concept. Lewit and Virolainen (29) had reported patient compliance was higher among patients who viewed their orthodontic problems as severe. Egolf et al. (13) found that the degree to which the patient was selfconscious about his malocclusion was related to cooperation with treatment. We assumed that the relationship between compliance with orthodontic therapy and dental appointment keeping would be the same. However, use of the Coopersmith SelfEsteem Inventory (33) failed to find a significant relationship between self-esteem and compliance in our sample of adolescents. This is in agreement with

388

W E S TET AL.

studies by Allen and Hodgson (36) and Klima et al. (37), who also failed to find a relationship between a patient's self-esteem and dental compliance. Obman et al. (38) found no relationship between locus of control and plaque scores. In contrast, in an investigation of 60 office workers, Galgut et al. (31) found that subjects who perceived their susceptibility to disease being influenced by "powerful others" or who believe that they can control their own susceptibility to a disease, respond more positively to a plaque control regime than those who believe disease is a result of "chance." When we evaluated whether such an association was present among adolescent patients, compliance was not associated with internal health locus of control, powerful others' health locus of control, or chance health locus of control. We also assessed the influence of past dental experiences on compliance and found that the number of past dental visits, number of x-rays, oral hygiene instruction, and previous dental procedures were weakly correlated with compliance with dental appointments. Based on multiple-regression analysis, the number of previous x-rays and the number of previous broken appointments explained 5.1% of the variation in compliance. These findings agreed with the Kegeles and Lund study (12) that suggested that compliance with new preventive dental activities was higher for children who had practiced similar activities previously. We had considered the possibility of noncompliance being related to anxiety resulting from past dental experiences. We found, however, that noncompliance was not associated with any particular type of previous dental treatment or the reason for the next dental visit. In support of this finding, Brown et al. (39) have suggested that one's fear of dental treatment may reflect a more generalized feeling rather than a response to past dental situations. It may be that the more frequently a patient visits a dentist, the more opportunity there is of being constantly educated by the dentist and staff regarding the importance of good oral health. Therefore, the patient is aware of the importance of his/her role in maintenance and is more likely to seek regular care and be more compliant. Lower SES blacks have a much lower rate of dental compliance than the general population (19). Only 38% of the people in the near-poverty group receive yearly dental treatment with blacks having the lowest percentage among ethnic groups. Fazio and Boffa (20) also found that failed appointments occurred more frequently among Medicaid patients

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than among private patients. Broken appointment rates range from 20% to 50% in public health dental clinics (21). It is very important to evaluate possible causes for the poor compliance rate whether they be psychosocial factors, methods of referral, or reminders. Most dental disease can be virtually eliminated if people would be compliant with dental advice. Without patient compliance, even the most elaborate and costly prevention and treatment programs will fail.

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