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Some motives for seeking Preventive dental care
Job
Benefits Anxieties Seriousness Fear of pain Susceptibility Attitudes about dentists Travel distance Anticipations Prepayment Education Esthetics Costs Fata
Some motives for seeking Preventive dental care
S. Stephen K eg eles,* Ph.D. Ann Arbor, M ich.
Interview s with 50 supervisory and 380 nonsupervisory em ployees o f the EndicottJohnson Corp. ( which has a com panyfinanced plan fo r dental care) established that am ong the m otives prom pting per\sons to seek preventive dental care are the I follow ing: a belief that one is susceptible to dental disease, a belief that dental problem s are serious, a belief that dental treatm ent is beneficial, a belief in natural causality, an esthetic concern for on e’s teeth, a lack of anxiety about dental treatm ent, no fear o f pain, and a positive appraisal of the dentist.
*Assistant director of public health practice, research program, University of Michigan, Ann Arbor, Mich.; formerly, chief, social studies branch, Division of Dental Public Health and Resources, U.S. Public Health Service, Washington, D.C.
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Data collected over the past few years and summarized recently1 show that about 36 per cent of the general popula tion visits dentists during any one year period. An even smaller percentage makes the twice yearly visits for examination advocated by the dental health worker. People offer cost as one of the most im portant factors which influence their fre quency of dental visits. The present study is an attempt to un derstand how frequently and for what purpose dental visits are made when the direct cost is not borne by the individual for himself and his family. Further, it is an attempt to understand what differen tiates persons who make preventively oriented visits (for examination and pro phylaxis) from those who visit dentists only when their symptoms become promi nent enough to demand relief. In order to understand these differences, answers to the questions: (1) what motivates people to seek dental care? and (2) what keeps people from making dental visits? will be examined. M ETHOD
Employees of the Endicott-Johnson Cor poration who are eligible for dental care for themselves and their families under a company-financed plan were used as the study population. Two samples were se lected from employees at the Endicott and Owego, N. Y ., plants of the corpora tion. The first sample consisted of all employees in managerial or supervisory positions. A second sample, consisting of employees without supervisory or man agerial duties, was randomly selected from the company’s payroll lists. Though the study was performed during a time of company vacation, 430 of the original 450 persons selected, including 50 super visory and 380 nonsupervisory employees, were interviewed. The interview was the free answer variety, requiring between 45 and 90 minutes to complete. Each respondent was asked a series of questions about his health beliefs and attitudes, and about his
last two dental visits. Respondents with children were asked about their health beliefs and attitudes concerning children, and about the dental visits of their eldest child under 15. In many instances, how ever, questions were asked only if the re spondent had answered previous ques tions in specified ways. As a result, the data to be presented will include a differ ent number of respondents for each vari able. All of the material from the inter view was coded and placed on punch cards for computer analysis. V IS IT F R E Q U E N C Y A N D P U R P O S E
Every person in the sample had visited a dentist at some time in his life. Sixty per cent had visited dentists during the year preceding the study; 24 per cent had made at least two visits during the oneyear period; 55 per cent indicated that their last two dental visits had been within the preceding three years. Fifty-six per cent of the study popula tion used for intensive analysis stated they had visited dentists at least once in three years for examination or prophylaxis. Whether the respondents considered those visits as preventive is irrelevant because the dentist, seeing the patient at frequent intervals, can often control the course of a disease before gross symptoms appear. Our intention is to look at differences be tween the population who made dental visits for examination and prophylaxis and the population who made dental vis its only for symptom relief. (Eighty-one of the 430 people interviewed could not be classified as preventive or symptom oriented. Three hundred and forty-nine respondents formed the base for compari sons. ) R O L E O F M O T IV A T IN G F A C T O R S
The term motivation, as used in this study, needs to be defined more clearly. Studies have shown that a person’s be liefs have a direct bearing on whether or not he will take preventive actions— chest roentgenograms for tuberculosis,2 Papani
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T a b le 1 • Per cent o f individuals who made preventively oriented dental visits, according to their feelings about susceptibility, seriousness or benefits of dental actions Variable
Persons who made preventive dental visits
Felt susceptible
63.7 per cent o f 102
Did not feel susceptible
49.4 per cent of 156 p*(X2 = 5.26) < .05
Felt dental problems serious
69.9 per cent of 73
Did not feel dental problems serious
47.1 per cent of 17 p (Fisher) f = .069 p (T och er)< .05
Felt beneficial dental actions possible
59.8 per cent of 224
Felt beneficial dental actions not possible
47.1 per cent of 85 plX2 = 4.03 < .05
*Since the hypotheses^ tested indicate the direction of the expected differences, chi-square tests of significance were combined with a sign test, with a consequent halving of the significance level here and in subsequent tables. In all tables, chi-square contingency tests are fourfold, with one degree of freedom. tThe rule followed for testing relationships in this table and in subsequent tables was: where all obtained cells were 10 or greater, a chi-square was used; where any obtained cell was between 6 and 10—if the expected frequency for that cell was 10 or greater, a chi-square with Yates' correction was used—'if the expected frequency was less than 10, Fisher's Exact Test was used; in instances where any obtained cell was smaller than 6, Fisher's Exact Test was used, regardless of the expected frequency. In certain cases where Fisher's Exact Test was used, Tocher's modification of the Fisher test was also used (see Siegel,10 pages 101-3).
colaou smears for cervical cancer,3 and inoculations for Asian influenza4— in mass health campaigns. The relation of such beliefs to dental action has been discussed in detail in two previous publications.5,6 It was hypothesized in this study that a person, in order to want to make a pre ventively oriented dental visit (to be called p.o.d. visits hereafter), would need to believe: 1. That he was susceptible to a par ticular dental problem. (An individual was categorized as believing he was sus ceptible or not susceptible by the way he answered the questions: “How likely do you think it will be that [worst dental problem mentioned that the respondent had experienced] will happen to you again?” “Why do you think that?” and “How likely do you think it will be that [worst dental problem which he could anticipate] will ever happen to you?” ) 2. That being affected by the problem would be serious for him. (An individual was categorized as believing that dental problems were or were not serious by the way he answered the questions: “ If any of the dental problems [mentioned earlier by the respondent as problems which he
had experienced] happened, how serious would it be?” and “ If any of the dental problems [mentioned by the respondent as problems which he could anticipate] happened, how serious would it be?” ) 3. That there were actions which he could take to prevent or alleviate the seri ous effects of the problem. (An individual was categorized as believing or not be lieving in the effectiveness of actions which he might take by the way he an swered the questions [both for worst prob lem experienced and for worst problem anticipated]: “D o you know of anything a person could do that would make it less likely that he would get [worst dental problem]?” “ What could he do?” ; if the individual said “ no” to the first of these questions, he was asked, “Do you mean there is absolutely nothing a person can do to make it less likely that [worst dental problem] would happen?” ) In addition, an individual was cate gorized as believing that dental problems were serious if he stated that such prob lems could detract from one’s esthetic ap pearance. The hypothesis was made that an individual would see p.o.d visits as an effective method of deterring dental prob-
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Table 2 • Per cent o f Individuals who made preventively oriented dental visits, as related to combination o f three motivating factors* Group
Persons who made preventive dental visits
A.
78 per cent o f 18 high on all three variables
B.
66 per cent o f 38 high on two, and low on one variable
C.
61 per cent o f 18 high on one, and low on two variables
D.
0 per cent o f 3 low on all three variables p(ABC compared to D) (Fisher) = .040 = .042 p(test o f order)f
*Factors are susceptibility, seriousness, and benefits. tThe probability of these four relationships occurring in the predicted order and direction is I in 24, or .042.
Iems if he believed that such problems occurred through a natural process. The relation of these hypotheses to the behavior which occurred is presented in Table 1. Almost two thirds of the respondents who believed themselves highly suscep tible to dental problems made p.o.d visits as compared with half of the respondents who believed themselves barely suscep tible. (All findings presented were signifi cant at better than the .05 probability level unless otherwise specified.) Over two thirds of those who believed that dental problems which they had not experienced would be serious if they oc curred made p.o.d. visits as compared with less than half of those who did not hold this belief. (The significant relation between seriousness and p.o.d. visits holds only if seriousness is considered for dental problems not previously experienced by the individual. It seems that having ex perienced a dental problem, even if it were considered serious, does not produce behavior oriented to prevent the same problem. A comparable finding is re vealed in data collected by Robbins.7) Almost two thirds of those who be lieved that they could take generally ben eficial actions against dental problems made p.o.d. visits. Less than half of the individuals who either did not know of such actions or who did not believe that the actions would be beneficial made p.o.d. visits. It had been presumed that persons
who were categorized as scoring high on all of the motivational variables, suscepti bility, seriousness, and beneficial actions, would be most likely to take preventive health actions. Conversely, it was pre sumed that the likelihood of preventive actions would decrease as the number of motivational factors on which a person was scored high decreased. These vari ables are shown in combinations of three in Table 2. As is apparent, the greater the number of motivational factors on which the individual was high, the more likely he was to make p.o.d. visits. Seventyeight per cent of those who ranked high on all three factors made p.o.d. vis its. None of the individuals categorized as low on these variables made p.o.d. visits. Since a different number of persons were asked each question, it was very dif ficult to find persons who had combined scores for susceptibility, seriousness, and actions. Therefore, no test was possible of persons who were, for example, high on susceptibility and seriousness and low on actions, as compared to individuals high on seriousness and actions and low on susceptibility. This same problem pro duced the exceedingly small number of cases in the various cells. Concern with esthetic appearance and belief in natural causality, two other mo tivational factors presumed to be exten sions of the theoretical model, and thereby in turn related to p.o.d. visits, were measured separately. Almost two thirds of those who believed in natural
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Causation made p.o.d. visits, compared with only half of those who believed that dental problems “just happened,” or that “nothing could be done.” Two thirds of the individuals concerned with the rela tion of dental problems to their own “esthetic appearance” made p.o.d. visits as compared with slightly over half of the individuals who did not express con cern about a relation between dental problems and their esthetic appearance. This relationship shows a trend which is not statistically significant. However, 65 per cent of the parents concerned about the esthetic significance of their chil dren’s teeth made p.o.d. visits. Only half of the parents who did not express es thetic concern about their children’s teeth made p.o.d. visits (Table 3 ). (Individu als who mentioned esthetic concern about their teeth, gums, or mouth anywhere in the interview were defined as concerned with esthetic problems; individuals who did not mention esthetic concern any where in the interview were the “no es thetic concern” group.) It has been shown, therefore, that the motivational factors related to taking pre ventive actions for diseases normally con sidered more clinically severe than dental problems— polio, cancer, and tuberculosis — seem equally relevant for explaining why people will seek preventive dental care. Belief in susceptibility to dental
problems, belief in the seriousness of den tal problems, and belief in the efficacy of actions which can be taken, whether an alyzed individually or in combination, seem appropriate for understanding p.o.d. visits. In fact, persons lacking such be liefs, or having such beliefs to only a slight degree, seem to seek only symptom oriented care. Moreover, one additional motivational factor, a belief in normal causation as opposed to more fatalistic belief about cause, was found to be im portant for expanding the original theory, and thereby helping to explain p.o.d. visits. Are these various motivational factors the same phenomenon under different titles? This study showed no relation among the three major motivational fac tors. (Phi-correlations were computed between all of the variables.) People who felt that dental problems were serious may or may not have believed they would be afflicted; persons who believed them selves susceptible may or may not have believed that there were actions they could take to ameliorate or prevent den tal problems. ROLE OF BARRIERS IN SEEKING DENTAL CARE
It is conceivable that an individual who sees the need for dental care may be de
Table 3 • Per cent o f individuals who made preventively oriented dental visits, according to their belief in natural causation, concern about esthetic problems o f their teeth, or concern about esthetic problems o f their children’s teeth Variable Believed in natural causation Believed in non-natural causes or in causes about which no actions can be taken
Persons who made preventive dental visits 60.8 per cent o f 125 50.9 per cent o f 165 p(X2 = 2.82) < .05
W ere esthetically concerned about own teeth
65.1 per cent o f 63
W ere not concerned esthetically about own teeth
54.3 per cent of 282 p(X2 = 2.50) < .10
W ere esthetically concerned about child’s teeth
64.5 per cent o f 76
W ere not concerned esthetically about child's teeth
51.0 per cent o f 192 ptX2 = 3195) < .05
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Table 4 • Per cent o f individuals who made preventively oriented dental visits, according to their anxiety about treatment, fear o f pain, or appraisal o f dentist Variable
Persons who made preventive dental visits
W ere anxious about dental treatment
49.3 per cent of 201
W ere not anxious about dental treatment
64.9 per cent of 148 p (X2 = 8.691 < .01
Had fear of pain
50.9 per cent of 212
Had no fear o f pain
63.5 per cent of 137 p
Gave negative appraisal o f dentist
51.Ì per cent of 133
Gave positive appraisal o f dentist
58.8 per cent of 216 plX2 = 2.03) < .10
terred from seeking it by psychological barriers unless relatively severe symptoms occur. Three psychological factors were seen as potential barriers to seeking pre ventive care: 1. The individual might simply fear pain and postpone a dental visit until the pain from not going became stronger than the fear of the pain he expected to experience in the dental office. (Individu als who responded in ways which could be coded as fearful of dental pain to any of 20 questions in the interview were classified in the “fear of pain” group; all others were classified as the “no fear” group.) 2. The individual might be extremely anxious about the treatments he would receive in the dental office (for instance, the feeling of being completely under the dentist’s power) and put off visits until they were absolutely essential. (Anxiety about treatment was derived from re sponses coded as either expressing anxiety or not expressing anxiety for each of 18 separate questions. Individuals who were coded as expressing anxiety in any of the 18 questions were placed in the “ anxiety” group; all other persons made up the “no anxiety” group.) 3. The individual might see dentists as having primarily negative characteristics. (The data for this analysis came from two sources in the interview. The first was a rating scale filled out by the re
spondent concerning his way of rating dentists. The second source of data for this factor was based on the respondent’s analysis of a picture showing a dentist and a patient. The respondent was asked a series of questions about the relation ship. One item coded was explicit note that the pictured dentist was “brutal, cruel, callous, or incompetent.” There was also added any negative appraisal of dentists from six other questions. Indi viduals who answered negatively to any of the questions were coded as the “nega tive” group; individuals who made no negative statements about dentists were coded as the “positive” group.) How much did the study of these psy chological factors help in understanding why certain persons made p.o.d. visits and others made visits only for the relief of symptoms? These data are presented in Table 4. Half of the individuals who feared pain made p.o.d. visits as com pared with two thirds of those with no fear. Half of the persons with anxiety about treatment made p.o.d. visits as compared with two thirds of those with no anxiety; half of those who expressed negative feelings about dentists made p.o.d. visits as compared with less than three fifths of those who expressed only positive feelings. As will be noted in Table 4, the relation between appraisal of dentists and p.o.d. visits does not reach the .05 probability level of significance.
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Table 5 • Per cent o f Individuals w ho made preventively oriented dental visits, as related to combination o f three p sychological barriers*
Group A.
Persons who made preventive dental visits 40 per cent o f 73 highf on all three barriers
B.
56 per cent of 94 high on two, and low on one barrier
C.
59 per cent of 139 high on one, and low on two barriers
D.
72 per cent o f 43 low on all three barriers p(ABC compared to D) (X2 = 5.38) < .05 p(test o f order) = .042
*Barriers are anxiety about dental treatment, fear of pain, and negative appraisal of dentist. tHigh indicates any presence of barrier; low indicates no presence of barrier.
However, removing individuals who made only one negative statement about den tists, and thereby comparing those who made two or more negative comments and those who made only positive state ments shows a significant relation. The interrelation of the psychological barriers to making p.o.d. visits is shown in Table 5. As is apparent, the fewer the strong barriers, the more likely were p.o.d. visits. Again, the independence of the vari ables must be considered. Are fear of pain, treatment anxiety, and expression of negative feelings about dentists all the same phenomenon with different titles? There is a small positive correlation be tween fear of pain and the expression of negative feelings about dentists on one hand, and a small positive correlation be tween anxiety about treatment and the expression of negative feelings on the other hand. There is no relation between treatment anxiety and fear of pain. Thus, the three factors need to be considered together for maximal understanding. R O L E O F S O C IO E C O N O M IC A N D S IT U A T IO N A L FA C T O R S
A variety of studies reviewed recently1 showed a direct relation between fre quency of dental visits and social class among the general population. A recent paper by Kriesberg and Treiman8 re vealed that socioeconomic status is di rectly related to seeking preventive dental
care. The present study provided an op portunity to determine whether social and economic status would be related to seeking dental care when cost was eliminated as a factor. The socioeconomic factors considered were education (high school graduation or below high school graduation), income (6,000 dollars per year or above, and below 6,000 dollars per year), and position (supervisory po sition or nonsupervisory position). As is shown in Table 6, two thirds of the high school graduates made p.o.d. visits as compared with about half of those with less than a high school educa tion. Two thirds of those with high in comes made p.o.d. visits as compared with about half of those with low in comes. Ninety per cent of the supervisory group made p.o.d. visits as compared with half of those in nonsupervisory positions. Eighty-eight per cent of the persons categorized as high on all three socioeco nomic variables made p.o.d. visits, as did 77 per cent of those high on two of the three factors. Slightly less than half of the individuals low on all three factors made p.o.d. visits. The distance a person had to travel to get care was also found to influence the frequency of p.o.d. visits made. Thirty-six per cent of the people who lived more than ten miles from the city where the clinic was located made p.o.d. visits as compared with 59 per cent of those who lived within ten miles of the clinic city.
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Table 6 • Per cent o f individuals w ho made preventively oriented dental visits, accordin g to education, income, or position
Variable
Persons who made preventive dentai visits
W ho were high school graduates
64.4 per cent o f 118
Had less than high school education
51.5 per cent o f 229 p(X2 = 5.37) < .05
Had incomes o f $6,000 or more
64.7 per cent o f 85
Had incomes less than $6,000
52.7 per cent of 256 p(X2 = 3.741 < .05
W ere in supervisory positions
90.2 per cent of 41
W ere in nonsupervisory positions
51.3 per cent of 308 p (Fisher) = .000001
MOTIVATIONS AND BARRIERS IN CHILDREN’ S DENTAL VISITS
Each respondent with children was asked the reasons for dental visits made by his oldest child under 15 years of age. Fiftynine per cent of the children’s visits were, by parental statement, for preventive pur poses. No relationship was found between the type of dental visit made by children and motivational and barrier beliefs held by parents. This was true not only with respect to parental beliefs about them selves but also in regard to parental belief about their children. Children of high school graduates, however, made more p.o.d. visits than did children of nonhigh school graduates. Moreover, children of supervisory parents made more p.o.d. visits than children of nonsupervisory parents. DISCUSSION
Utilization of dental services is higher among Endicott-Johnson employees than among the general population. Families not only use the plan, but they also use it in ways that promote oral health and seem to have the correct motivation for dental visits. More surprising, however, was the fact that as many employees went to private dentists in the Endicott-Johnson area, for preventive purposes, as to the clinic (about 55 per cent). Whether
utilization automatically increases when in a situation where a prepayment plan exists is questionable, however. Utiliza tion was lower in the clinics of the St. Louis Labor Health Institute, for ex ample.9 Additional studies of utilization in various types of prepayment programs are needed. If the Endicott-Johnson situ ation is unusual, studies should then be made to determine what the plan offers which produces such great utilization and to pattern new prepayment programs after the Endicott-Johnson plan. Further, the influence of such plans even on per sons who do not use the plan should be known. Research is underway to assess utilization in a voluntary combined fee for service-prepayment dental plan and to examine the motivational and barrier forces which relate to dental visits under that plan. The finding that such variables as in come, education, and supervisory position were significantly related to making pre ventive dental visits substantiates similar findings in other studies. The duplication in this study is important because (1) al though these individuals did not have to pay directly for services, the desire for preventive care seemed to increase or de crease with the family’s general economic and educational state, and (2) although the particular sample studied probably consists mostly of individuals who could be classified in lower (the nonsupervisory
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group) and middle (the supervisory group) socioeconomic classes, there are sharp differences in preventive actions even within this relatively narrow popu lation range. Because of the smallness of the sample, it was not possible to determine the rela tive effects of the socioeconomic factors, the barrier factors, and the motivational factors on p.o.d. visits. We cannot specify whether persons with high motivation who also have great fear or anxiety about dental care are more or less likely to seek p.o.d. care than persons with low motiva tion with little or no fear or anxiety. Neither can it be specified whether the motivation and barrier factors are more or less important for p.o.d. visits than the socioeconomic factors. It is essential that research findings, which shed light on these interrelations be gathered. From the public health point of view, however, the influence of the barrier and motivational factors studied presents more implications for action programs than the socioeconomic findings. The socioeco nomic findings indicate groups to which action programs should be directed, not what should be done to increase utiliza tion of dental services. The barrier and motivational factors, on the other hand, suggest a need for ac tion programs which will increase feel ings of susceptibility or seriousness and reduce both the fear of pain and general anxiety about dental treatment. Tw o types of programs seem most worthy of research, and thereby, eventu ally action. The first is a careful experi mental manipulation of communications having greater or lesser motivational or barrier intent, so that it will be possible to control for the effects of one or an other inducement on behavior. Such studies have already begun; junior high school students are being used as the sample population. The second direction, not yet started, is to look carefully at the technics and tools of dental practice to assess their
emotional impact. Thus, it is conceivable that certain increased engineering gains in dental offices may lead to greater emo tional detachment by the dentist from the patient, and thereby, less patient security. Investigations of such innovations as the effectiveness of hypnosis, music, and white noise in decreasing patient fear and anxiety seem worth while. The finding that knowledge about the beliefs and attitudes of parents seems not to increase understanding of why chil dren make dental visits is provocative. Parents either take their children for den tal visits for reasons other than those which make the parents seek care, or children have much more to say about when, and for what reasons they will seek dental care than is ordinarily be lieved. To test the idea that children may partially determine their own dental ac tions, studies have begun which will at tempt to directly influence junior high school students to seek p.o.d. care and to perform a variety of necessary dental health practices. 122 South First Street
1. Kegeles, S. Stephen. Why people seek dental care: a review of present knowledge. Am, J. Pub. Health 51:1306 Sept. 1961. 2. Hochbaum, S. M. Public participation in medical screening programs—a socio-psychologlcal study. PHS publication 572. Washington, D.C., Government Printing Office, 1958. 3. Flack, Elizabeth G. Participation in case finding program for cervical cancer. In preparation, 1961. 4. Rosenstock, Irwin M., and others. Impact of Asian influenza on community life: a study of five cities. PHS publication 766. Washington, D.C., Government Printing Office, I960. 5. Kegeles, S. Stephen. An interpretation of some be havioral principles in relation to acceptance of dental care. In Proceedings of 1959 biennial conference of state and territorial dental directors with Public Health Serv ice and Children's Bureau. PHS publication 698. Wash ington, D.C., Government Printing Office, 1959, p. 21-30. 6. Rosenstock, Irwin M.; Hochbaum, G. M., and Kegeles, S. Stephen. Determinants of health behavior. Prepared for I960 White House Conference on Children and Youth. Washington, D.C., Division of Dental Public Health and Resources, Public Health Service. 7. Robbins^ Paul. Some explorations into nature of anxieties relating to illness. Provincetwon, Mass., Genetic Psychology Monographs 66:91-141, 1962. 8. Kriesberg, Louis, and Treiman, Beatrice. Socio economic status and utilization of dentists' services. J. Am. Col. Den. 27:147 Sept. I960. 9. Dental care in grojp purchase plan. Survey of atti tudes and utilization at the St. Louis Health Institute. PHS publication 684. Washington. D.C. Government Printing Office, 1959. 10. Siegel, Sidney. Nonparametric statistics: for the behavioral sciences. New York, McGraw-Hill, 1956.
Benefits Anxieties Seriousness Fear of pain Susceptibility Attitudes about dentists Travel distance Anticipations Prepayment Education Esthetics Costs Fata
Some motives for seeking Preventive dental care
S. Stephen K eg eles,* Ph.D. Ann Arbor, M ich.
Interview s with 50 supervisory and 380 nonsupervisory em ployees o f the EndicottJohnson Corp. ( which has a com panyfinanced plan fo r dental care) established that am ong the m otives prom pting per\sons to seek preventive dental care are the I follow ing: a belief that one is susceptible to dental disease, a belief that dental problem s are serious, a belief that dental treatm ent is beneficial, a belief in natural causality, an esthetic concern for on e’s teeth, a lack of anxiety about dental treatm ent, no fear o f pain, and a positive appraisal of the dentist.
*Assistant director of public health practice, research program, University of Michigan, Ann Arbor, Mich.; formerly, chief, social studies branch, Division of Dental Public Health and Resources, U.S. Public Health Service, Washington, D.C.
KEGELES . . . VOLUME 67, JULY 1963 • 111/91
Data collected over the past few years and summarized recently1 show that about 36 per cent of the general popula tion visits dentists during any one year period. An even smaller percentage makes the twice yearly visits for examination advocated by the dental health worker. People offer cost as one of the most im portant factors which influence their fre quency of dental visits. The present study is an attempt to un derstand how frequently and for what purpose dental visits are made when the direct cost is not borne by the individual for himself and his family. Further, it is an attempt to understand what differen tiates persons who make preventively oriented visits (for examination and pro phylaxis) from those who visit dentists only when their symptoms become promi nent enough to demand relief. In order to understand these differences, answers to the questions: (1) what motivates people to seek dental care? and (2) what keeps people from making dental visits? will be examined. M ETHOD
Employees of the Endicott-Johnson Cor poration who are eligible for dental care for themselves and their families under a company-financed plan were used as the study population. Two samples were se lected from employees at the Endicott and Owego, N. Y ., plants of the corpora tion. The first sample consisted of all employees in managerial or supervisory positions. A second sample, consisting of employees without supervisory or man agerial duties, was randomly selected from the company’s payroll lists. Though the study was performed during a time of company vacation, 430 of the original 450 persons selected, including 50 super visory and 380 nonsupervisory employees, were interviewed. The interview was the free answer variety, requiring between 45 and 90 minutes to complete. Each respondent was asked a series of questions about his health beliefs and attitudes, and about his
last two dental visits. Respondents with children were asked about their health beliefs and attitudes concerning children, and about the dental visits of their eldest child under 15. In many instances, how ever, questions were asked only if the re spondent had answered previous ques tions in specified ways. As a result, the data to be presented will include a differ ent number of respondents for each vari able. All of the material from the inter view was coded and placed on punch cards for computer analysis. V IS IT F R E Q U E N C Y A N D P U R P O S E
Every person in the sample had visited a dentist at some time in his life. Sixty per cent had visited dentists during the year preceding the study; 24 per cent had made at least two visits during the oneyear period; 55 per cent indicated that their last two dental visits had been within the preceding three years. Fifty-six per cent of the study popula tion used for intensive analysis stated they had visited dentists at least once in three years for examination or prophylaxis. Whether the respondents considered those visits as preventive is irrelevant because the dentist, seeing the patient at frequent intervals, can often control the course of a disease before gross symptoms appear. Our intention is to look at differences be tween the population who made dental visits for examination and prophylaxis and the population who made dental vis its only for symptom relief. (Eighty-one of the 430 people interviewed could not be classified as preventive or symptom oriented. Three hundred and forty-nine respondents formed the base for compari sons. ) R O L E O F M O T IV A T IN G F A C T O R S
The term motivation, as used in this study, needs to be defined more clearly. Studies have shown that a person’s be liefs have a direct bearing on whether or not he will take preventive actions— chest roentgenograms for tuberculosis,2 Papani
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T a b le 1 • Per cent o f individuals who made preventively oriented dental visits, according to their feelings about susceptibility, seriousness or benefits of dental actions Variable
Persons who made preventive dental visits
Felt susceptible
63.7 per cent o f 102
Did not feel susceptible
49.4 per cent of 156 p*(X2 = 5.26) < .05
Felt dental problems serious
69.9 per cent of 73
Did not feel dental problems serious
47.1 per cent of 17 p (Fisher) f = .069 p (T och er)< .05
Felt beneficial dental actions possible
59.8 per cent of 224
Felt beneficial dental actions not possible
47.1 per cent of 85 plX2 = 4.03 < .05
*Since the hypotheses^ tested indicate the direction of the expected differences, chi-square tests of significance were combined with a sign test, with a consequent halving of the significance level here and in subsequent tables. In all tables, chi-square contingency tests are fourfold, with one degree of freedom. tThe rule followed for testing relationships in this table and in subsequent tables was: where all obtained cells were 10 or greater, a chi-square was used; where any obtained cell was between 6 and 10—if the expected frequency for that cell was 10 or greater, a chi-square with Yates' correction was used—'if the expected frequency was less than 10, Fisher's Exact Test was used; in instances where any obtained cell was smaller than 6, Fisher's Exact Test was used, regardless of the expected frequency. In certain cases where Fisher's Exact Test was used, Tocher's modification of the Fisher test was also used (see Siegel,10 pages 101-3).
colaou smears for cervical cancer,3 and inoculations for Asian influenza4— in mass health campaigns. The relation of such beliefs to dental action has been discussed in detail in two previous publications.5,6 It was hypothesized in this study that a person, in order to want to make a pre ventively oriented dental visit (to be called p.o.d. visits hereafter), would need to believe: 1. That he was susceptible to a par ticular dental problem. (An individual was categorized as believing he was sus ceptible or not susceptible by the way he answered the questions: “How likely do you think it will be that [worst dental problem mentioned that the respondent had experienced] will happen to you again?” “Why do you think that?” and “How likely do you think it will be that [worst dental problem which he could anticipate] will ever happen to you?” ) 2. That being affected by the problem would be serious for him. (An individual was categorized as believing that dental problems were or were not serious by the way he answered the questions: “ If any of the dental problems [mentioned earlier by the respondent as problems which he
had experienced] happened, how serious would it be?” and “ If any of the dental problems [mentioned by the respondent as problems which he could anticipate] happened, how serious would it be?” ) 3. That there were actions which he could take to prevent or alleviate the seri ous effects of the problem. (An individual was categorized as believing or not be lieving in the effectiveness of actions which he might take by the way he an swered the questions [both for worst prob lem experienced and for worst problem anticipated]: “D o you know of anything a person could do that would make it less likely that he would get [worst dental problem]?” “ What could he do?” ; if the individual said “ no” to the first of these questions, he was asked, “Do you mean there is absolutely nothing a person can do to make it less likely that [worst dental problem] would happen?” ) In addition, an individual was cate gorized as believing that dental problems were serious if he stated that such prob lems could detract from one’s esthetic ap pearance. The hypothesis was made that an individual would see p.o.d visits as an effective method of deterring dental prob-
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Table 2 • Per cent o f Individuals who made preventively oriented dental visits, as related to combination o f three motivating factors* Group
Persons who made preventive dental visits
A.
78 per cent o f 18 high on all three variables
B.
66 per cent o f 38 high on two, and low on one variable
C.
61 per cent o f 18 high on one, and low on two variables
D.
0 per cent o f 3 low on all three variables p(ABC compared to D) (Fisher) = .040 = .042 p(test o f order)f
*Factors are susceptibility, seriousness, and benefits. tThe probability of these four relationships occurring in the predicted order and direction is I in 24, or .042.
Iems if he believed that such problems occurred through a natural process. The relation of these hypotheses to the behavior which occurred is presented in Table 1. Almost two thirds of the respondents who believed themselves highly suscep tible to dental problems made p.o.d visits as compared with half of the respondents who believed themselves barely suscep tible. (All findings presented were signifi cant at better than the .05 probability level unless otherwise specified.) Over two thirds of those who believed that dental problems which they had not experienced would be serious if they oc curred made p.o.d. visits as compared with less than half of those who did not hold this belief. (The significant relation between seriousness and p.o.d. visits holds only if seriousness is considered for dental problems not previously experienced by the individual. It seems that having ex perienced a dental problem, even if it were considered serious, does not produce behavior oriented to prevent the same problem. A comparable finding is re vealed in data collected by Robbins.7) Almost two thirds of those who be lieved that they could take generally ben eficial actions against dental problems made p.o.d. visits. Less than half of the individuals who either did not know of such actions or who did not believe that the actions would be beneficial made p.o.d. visits. It had been presumed that persons
who were categorized as scoring high on all of the motivational variables, suscepti bility, seriousness, and beneficial actions, would be most likely to take preventive health actions. Conversely, it was pre sumed that the likelihood of preventive actions would decrease as the number of motivational factors on which a person was scored high decreased. These vari ables are shown in combinations of three in Table 2. As is apparent, the greater the number of motivational factors on which the individual was high, the more likely he was to make p.o.d. visits. Seventyeight per cent of those who ranked high on all three factors made p.o.d. vis its. None of the individuals categorized as low on these variables made p.o.d. visits. Since a different number of persons were asked each question, it was very dif ficult to find persons who had combined scores for susceptibility, seriousness, and actions. Therefore, no test was possible of persons who were, for example, high on susceptibility and seriousness and low on actions, as compared to individuals high on seriousness and actions and low on susceptibility. This same problem pro duced the exceedingly small number of cases in the various cells. Concern with esthetic appearance and belief in natural causality, two other mo tivational factors presumed to be exten sions of the theoretical model, and thereby in turn related to p.o.d. visits, were measured separately. Almost two thirds of those who believed in natural
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Causation made p.o.d. visits, compared with only half of those who believed that dental problems “just happened,” or that “nothing could be done.” Two thirds of the individuals concerned with the rela tion of dental problems to their own “esthetic appearance” made p.o.d. visits as compared with slightly over half of the individuals who did not express con cern about a relation between dental problems and their esthetic appearance. This relationship shows a trend which is not statistically significant. However, 65 per cent of the parents concerned about the esthetic significance of their chil dren’s teeth made p.o.d. visits. Only half of the parents who did not express es thetic concern about their children’s teeth made p.o.d. visits (Table 3 ). (Individu als who mentioned esthetic concern about their teeth, gums, or mouth anywhere in the interview were defined as concerned with esthetic problems; individuals who did not mention esthetic concern any where in the interview were the “no es thetic concern” group.) It has been shown, therefore, that the motivational factors related to taking pre ventive actions for diseases normally con sidered more clinically severe than dental problems— polio, cancer, and tuberculosis — seem equally relevant for explaining why people will seek preventive dental care. Belief in susceptibility to dental
problems, belief in the seriousness of den tal problems, and belief in the efficacy of actions which can be taken, whether an alyzed individually or in combination, seem appropriate for understanding p.o.d. visits. In fact, persons lacking such be liefs, or having such beliefs to only a slight degree, seem to seek only symptom oriented care. Moreover, one additional motivational factor, a belief in normal causation as opposed to more fatalistic belief about cause, was found to be im portant for expanding the original theory, and thereby helping to explain p.o.d. visits. Are these various motivational factors the same phenomenon under different titles? This study showed no relation among the three major motivational fac tors. (Phi-correlations were computed between all of the variables.) People who felt that dental problems were serious may or may not have believed they would be afflicted; persons who believed them selves susceptible may or may not have believed that there were actions they could take to ameliorate or prevent den tal problems. ROLE OF BARRIERS IN SEEKING DENTAL CARE
It is conceivable that an individual who sees the need for dental care may be de
Table 3 • Per cent o f individuals who made preventively oriented dental visits, according to their belief in natural causation, concern about esthetic problems o f their teeth, or concern about esthetic problems o f their children’s teeth Variable Believed in natural causation Believed in non-natural causes or in causes about which no actions can be taken
Persons who made preventive dental visits 60.8 per cent o f 125 50.9 per cent o f 165 p(X2 = 2.82) < .05
W ere esthetically concerned about own teeth
65.1 per cent o f 63
W ere not concerned esthetically about own teeth
54.3 per cent of 282 p(X2 = 2.50) < .10
W ere esthetically concerned about child’s teeth
64.5 per cent o f 76
W ere not concerned esthetically about child's teeth
51.0 per cent o f 192 ptX2 = 3195) < .05
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Table 4 • Per cent o f individuals who made preventively oriented dental visits, according to their anxiety about treatment, fear o f pain, or appraisal o f dentist Variable
Persons who made preventive dental visits
W ere anxious about dental treatment
49.3 per cent of 201
W ere not anxious about dental treatment
64.9 per cent of 148 p (X2 = 8.691 < .01
Had fear of pain
50.9 per cent of 212
Had no fear o f pain
63.5 per cent of 137 p
Gave negative appraisal o f dentist
51.Ì per cent of 133
Gave positive appraisal o f dentist
58.8 per cent of 216 plX2 = 2.03) < .10
terred from seeking it by psychological barriers unless relatively severe symptoms occur. Three psychological factors were seen as potential barriers to seeking pre ventive care: 1. The individual might simply fear pain and postpone a dental visit until the pain from not going became stronger than the fear of the pain he expected to experience in the dental office. (Individu als who responded in ways which could be coded as fearful of dental pain to any of 20 questions in the interview were classified in the “fear of pain” group; all others were classified as the “no fear” group.) 2. The individual might be extremely anxious about the treatments he would receive in the dental office (for instance, the feeling of being completely under the dentist’s power) and put off visits until they were absolutely essential. (Anxiety about treatment was derived from re sponses coded as either expressing anxiety or not expressing anxiety for each of 18 separate questions. Individuals who were coded as expressing anxiety in any of the 18 questions were placed in the “ anxiety” group; all other persons made up the “no anxiety” group.) 3. The individual might see dentists as having primarily negative characteristics. (The data for this analysis came from two sources in the interview. The first was a rating scale filled out by the re
spondent concerning his way of rating dentists. The second source of data for this factor was based on the respondent’s analysis of a picture showing a dentist and a patient. The respondent was asked a series of questions about the relation ship. One item coded was explicit note that the pictured dentist was “brutal, cruel, callous, or incompetent.” There was also added any negative appraisal of dentists from six other questions. Indi viduals who answered negatively to any of the questions were coded as the “nega tive” group; individuals who made no negative statements about dentists were coded as the “positive” group.) How much did the study of these psy chological factors help in understanding why certain persons made p.o.d. visits and others made visits only for the relief of symptoms? These data are presented in Table 4. Half of the individuals who feared pain made p.o.d. visits as com pared with two thirds of those with no fear. Half of the persons with anxiety about treatment made p.o.d. visits as compared with two thirds of those with no anxiety; half of those who expressed negative feelings about dentists made p.o.d. visits as compared with less than three fifths of those who expressed only positive feelings. As will be noted in Table 4, the relation between appraisal of dentists and p.o.d. visits does not reach the .05 probability level of significance.
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Table 5 • Per cent o f Individuals w ho made preventively oriented dental visits, as related to combination o f three p sychological barriers*
Group A.
Persons who made preventive dental visits 40 per cent o f 73 highf on all three barriers
B.
56 per cent of 94 high on two, and low on one barrier
C.
59 per cent of 139 high on one, and low on two barriers
D.
72 per cent o f 43 low on all three barriers p(ABC compared to D) (X2 = 5.38) < .05 p(test o f order) = .042
*Barriers are anxiety about dental treatment, fear of pain, and negative appraisal of dentist. tHigh indicates any presence of barrier; low indicates no presence of barrier.
However, removing individuals who made only one negative statement about den tists, and thereby comparing those who made two or more negative comments and those who made only positive state ments shows a significant relation. The interrelation of the psychological barriers to making p.o.d. visits is shown in Table 5. As is apparent, the fewer the strong barriers, the more likely were p.o.d. visits. Again, the independence of the vari ables must be considered. Are fear of pain, treatment anxiety, and expression of negative feelings about dentists all the same phenomenon with different titles? There is a small positive correlation be tween fear of pain and the expression of negative feelings about dentists on one hand, and a small positive correlation be tween anxiety about treatment and the expression of negative feelings on the other hand. There is no relation between treatment anxiety and fear of pain. Thus, the three factors need to be considered together for maximal understanding. R O L E O F S O C IO E C O N O M IC A N D S IT U A T IO N A L FA C T O R S
A variety of studies reviewed recently1 showed a direct relation between fre quency of dental visits and social class among the general population. A recent paper by Kriesberg and Treiman8 re vealed that socioeconomic status is di rectly related to seeking preventive dental
care. The present study provided an op portunity to determine whether social and economic status would be related to seeking dental care when cost was eliminated as a factor. The socioeconomic factors considered were education (high school graduation or below high school graduation), income (6,000 dollars per year or above, and below 6,000 dollars per year), and position (supervisory po sition or nonsupervisory position). As is shown in Table 6, two thirds of the high school graduates made p.o.d. visits as compared with about half of those with less than a high school educa tion. Two thirds of those with high in comes made p.o.d. visits as compared with about half of those with low in comes. Ninety per cent of the supervisory group made p.o.d. visits as compared with half of those in nonsupervisory positions. Eighty-eight per cent of the persons categorized as high on all three socioeco nomic variables made p.o.d. visits, as did 77 per cent of those high on two of the three factors. Slightly less than half of the individuals low on all three factors made p.o.d. visits. The distance a person had to travel to get care was also found to influence the frequency of p.o.d. visits made. Thirty-six per cent of the people who lived more than ten miles from the city where the clinic was located made p.o.d. visits as compared with 59 per cent of those who lived within ten miles of the clinic city.
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Table 6 • Per cent o f individuals w ho made preventively oriented dental visits, accordin g to education, income, or position
Variable
Persons who made preventive dentai visits
W ho were high school graduates
64.4 per cent o f 118
Had less than high school education
51.5 per cent o f 229 p(X2 = 5.37) < .05
Had incomes o f $6,000 or more
64.7 per cent o f 85
Had incomes less than $6,000
52.7 per cent of 256 p(X2 = 3.741 < .05
W ere in supervisory positions
90.2 per cent of 41
W ere in nonsupervisory positions
51.3 per cent of 308 p (Fisher) = .000001
MOTIVATIONS AND BARRIERS IN CHILDREN’ S DENTAL VISITS
Each respondent with children was asked the reasons for dental visits made by his oldest child under 15 years of age. Fiftynine per cent of the children’s visits were, by parental statement, for preventive pur poses. No relationship was found between the type of dental visit made by children and motivational and barrier beliefs held by parents. This was true not only with respect to parental beliefs about them selves but also in regard to parental belief about their children. Children of high school graduates, however, made more p.o.d. visits than did children of nonhigh school graduates. Moreover, children of supervisory parents made more p.o.d. visits than children of nonsupervisory parents. DISCUSSION
Utilization of dental services is higher among Endicott-Johnson employees than among the general population. Families not only use the plan, but they also use it in ways that promote oral health and seem to have the correct motivation for dental visits. More surprising, however, was the fact that as many employees went to private dentists in the Endicott-Johnson area, for preventive purposes, as to the clinic (about 55 per cent). Whether
utilization automatically increases when in a situation where a prepayment plan exists is questionable, however. Utiliza tion was lower in the clinics of the St. Louis Labor Health Institute, for ex ample.9 Additional studies of utilization in various types of prepayment programs are needed. If the Endicott-Johnson situ ation is unusual, studies should then be made to determine what the plan offers which produces such great utilization and to pattern new prepayment programs after the Endicott-Johnson plan. Further, the influence of such plans even on per sons who do not use the plan should be known. Research is underway to assess utilization in a voluntary combined fee for service-prepayment dental plan and to examine the motivational and barrier forces which relate to dental visits under that plan. The finding that such variables as in come, education, and supervisory position were significantly related to making pre ventive dental visits substantiates similar findings in other studies. The duplication in this study is important because (1) al though these individuals did not have to pay directly for services, the desire for preventive care seemed to increase or de crease with the family’s general economic and educational state, and (2) although the particular sample studied probably consists mostly of individuals who could be classified in lower (the nonsupervisory
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group) and middle (the supervisory group) socioeconomic classes, there are sharp differences in preventive actions even within this relatively narrow popu lation range. Because of the smallness of the sample, it was not possible to determine the rela tive effects of the socioeconomic factors, the barrier factors, and the motivational factors on p.o.d. visits. We cannot specify whether persons with high motivation who also have great fear or anxiety about dental care are more or less likely to seek p.o.d. care than persons with low motiva tion with little or no fear or anxiety. Neither can it be specified whether the motivation and barrier factors are more or less important for p.o.d. visits than the socioeconomic factors. It is essential that research findings, which shed light on these interrelations be gathered. From the public health point of view, however, the influence of the barrier and motivational factors studied presents more implications for action programs than the socioeconomic findings. The socioeco nomic findings indicate groups to which action programs should be directed, not what should be done to increase utiliza tion of dental services. The barrier and motivational factors, on the other hand, suggest a need for ac tion programs which will increase feel ings of susceptibility or seriousness and reduce both the fear of pain and general anxiety about dental treatment. Tw o types of programs seem most worthy of research, and thereby, eventu ally action. The first is a careful experi mental manipulation of communications having greater or lesser motivational or barrier intent, so that it will be possible to control for the effects of one or an other inducement on behavior. Such studies have already begun; junior high school students are being used as the sample population. The second direction, not yet started, is to look carefully at the technics and tools of dental practice to assess their
emotional impact. Thus, it is conceivable that certain increased engineering gains in dental offices may lead to greater emo tional detachment by the dentist from the patient, and thereby, less patient security. Investigations of such innovations as the effectiveness of hypnosis, music, and white noise in decreasing patient fear and anxiety seem worth while. The finding that knowledge about the beliefs and attitudes of parents seems not to increase understanding of why chil dren make dental visits is provocative. Parents either take their children for den tal visits for reasons other than those which make the parents seek care, or children have much more to say about when, and for what reasons they will seek dental care than is ordinarily be lieved. To test the idea that children may partially determine their own dental ac tions, studies have begun which will at tempt to directly influence junior high school students to seek p.o.d. care and to perform a variety of necessary dental health practices. 122 South First Street
1. Kegeles, S. Stephen. Why people seek dental care: a review of present knowledge. Am, J. Pub. Health 51:1306 Sept. 1961. 2. Hochbaum, S. M. Public participation in medical screening programs—a socio-psychologlcal study. PHS publication 572. Washington, D.C., Government Printing Office, 1958. 3. Flack, Elizabeth G. Participation in case finding program for cervical cancer. In preparation, 1961. 4. Rosenstock, Irwin M., and others. Impact of Asian influenza on community life: a study of five cities. PHS publication 766. Washington, D.C., Government Printing Office, I960. 5. Kegeles, S. Stephen. An interpretation of some be havioral principles in relation to acceptance of dental care. In Proceedings of 1959 biennial conference of state and territorial dental directors with Public Health Serv ice and Children's Bureau. PHS publication 698. Wash ington, D.C., Government Printing Office, 1959, p. 21-30. 6. Rosenstock, Irwin M.; Hochbaum, G. M., and Kegeles, S. Stephen. Determinants of health behavior. Prepared for I960 White House Conference on Children and Youth. Washington, D.C., Division of Dental Public Health and Resources, Public Health Service. 7. Robbins^ Paul. Some explorations into nature of anxieties relating to illness. Provincetwon, Mass., Genetic Psychology Monographs 66:91-141, 1962. 8. Kriesberg, Louis, and Treiman, Beatrice. Socio economic status and utilization of dentists' services. J. Am. Col. Den. 27:147 Sept. I960. 9. Dental care in grojp purchase plan. Survey of atti tudes and utilization at the St. Louis Health Institute. PHS publication 684. Washington. D.C. Government Printing Office, 1959. 10. Siegel, Sidney. Nonparametric statistics: for the behavioral sciences. New York, McGraw-Hill, 1956.