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Dentists and the institutionalized elderly : issues in long term care dental services Weiss, Rachel Tobiasz 1986

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DENTISTS AND THE INSTITUTIONALIZED ELDERLYUSSUES IN LONG TERM CARE DENTAL SERVICES by RACHEL TOBIASZ WEISS A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE F A C U L T Y OF GRADUATE STUDIES Department of Interdisciplinary Studies , . ( D e p a r t m e n t o f H e a l t h Ca r e and E p i d e m i o l o g y ) ( D e p a r t m e n t o f R e s t o r a t i v e D e n t i s t r y ) We accept this thesis as conforming to the required standard 'THE UNIVERSITY OF BRITISH COLUMBIA October 1986 ® Rachel Tobiasz Weiss, 1986 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of r c U T e g P \^Q\ P L j uA^< S T U I P l £ ^ The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date OcJ\ °l , I ^ g>& ABSTRACT A r e c e n t s u r v e y o f t h e o r a l h e a l t h o f t h e i n s t i t u t i o n a l i z e d e l d e r l y i n G r e a t e r V a n c o u v e r r e v e a l e d t h a t d e s p i t e a number of d e n t a l p r o b l e m s amongst t h e c h r o n i c a l l y i l l , few had been s e e n by a d e n t i s t s i n c e t h e i r a d m i s s i o n t o t h e f a c i l i t i e s . A m a j o r i s s u e i n e s t a b l i s h i n g d e n t a l s e r v i c e s i s t h e w i l l i n g n e s s o f d e n t i s t s t o p r o v i d e s e r v i c e s i n t h e l o n g t e r m c a r e f a c i l i t i e s . T h r e e t h e o r e t i c a l m o d e l s were d e v e l o p e d t o p r e d i c t d e n t i s t s ' i n t e r e s t i n l o n g t e r m c a r e d e n t a l p r a c t i c e . The s o c i o - c u l t u r a l m o d e l , w h i c h e m p h a s i z e s c u l t u r a l p r e j u d i c e s t o w a r d s t h e e l d e r l y , was b a s e d on a number of a t t i t u d i n a l s t u d i e s o f t h e p r o f e s s i o n ( e g . t h e b e l i e f t h a t t h e e l d e r l y a r e u n c o m m u n i c a t i v e and u n g r a t e f u l o r t h e a v e r s i o n t o d e p r e s s i n g a t m o s p h e r e s o f f a c i l i t i e s ) . The p r o f e s s i o n a l model f o c u s e d on p r o f e s s i o n a l t r a i n i n g a n d s o c i a l i z a t i o n and t h e i d e o l o g i c a l f o c u s o f d e n t i s t r y on r e p a r a t i v e t h e r a p y ( e g . u n d e r g r a d u a t e t r a i n i n g w i t h t h e d i s a b l e d , o r t h e p e r c e p t i o n o f l i m i t e d t r e a t m e n t o p t i o n s f o r t h e c h r o n i c a l l y i l l ) . The e c o n o m i c model p r e d i c t e d t h a t o p p o r t u n i t y c o s t s , t h a t i s , p r i v a t e p r a c t i c e and l e i s u r e t i m e , w o u l d be c r i t i c a l i n t h e d e c i s i o n t o t r e a t t h e i n s t i t u t i o n -a l i z e d e l d e r l y . Q u e s t i o n s r e l a t i n g t o e a c h o f t h e s e m o d els were i n c l u d e d i n a s u r v e y q u e s t i o n n a i r e . The s u r v e y , m a i l e d t o 603 d e n t i s t s i n t h e g r e a t e r V a n c o u v e r a r e a , a s k e d d e n t i s t s a b o u t t h e i r e x p e r i e n c e and i n t e r e s t i n w o r k i n g w i t h b o t h t h e w e l l and i i d i s a b l e d e l d e r l y . Over h a l f t h e p o p u l a t i o n r e s p o n d e d t o t h e s u r v e y , and t h e r e s u l t s were a n a l y z e d t o d e t e r m i n e w h i c h model b e s t p r e d i c t e d i n t e r e s t i n i n s t i t u t i o n a l d e n t a l d e l i v e r y . I n t h e f i n d i n g s , 37% o f t h e d e n t i s t s i n d i c a t e d d e f i n i t e i n t e r e s t i n p r a c t i s i n g a t a f a c i l i t y i f c a l l e d upon by t h e a d m i n i s t r a t o r , and 19% o f t h e s u r v e y r e s p o n d e n t s had p r a c t i s e d a t a f a c i l i t y p r e v i o u s l y . l t was c o n c l u d e d f r o m a m u l t i p l e c l a s s i f i c a t i o n a n a l y s i s t h a t b o t h p r o f e s s i o n a l and e c o n o m i c , b u t n o t s o c i o - c u l t u r a l , f o r c e s g u i d e t h e s e r v i c i n g d e c i s i o n s o f d e n t i s t s w i t h r e s p e c t t o l o n g t e r m c a r e s e r v i c e . P r o f e s s i o n a l s a t i s f a c t i o n i n t r e a t i n g t h e e l d e r l y was t h e most s i g n i f i c a n t p r e d i c t o r o f i n t e r e s t . T h i s s a t i s f a c t i o n was l i n k e d t o s e v e r a l e n a b l i n g f a c t o r s , s u c h a s t h e a v a i l a b i l i t y o f a d e n t a l o p e r a t o r y a t an i n s t i t u t i o n , a n d e x p e r i e n c e and t r a i n i n g w i t h m e d i c a l l y c o m p r o m i s e d p a t i e n t s . T hose d e n t i s t s who had e x t e n s i v e i n s t i t u t i o n a l e x p e r i e n c e , a n d young d e n t i s t s who were b e g i n n i n g a p r a c t i c e and who were n o t b u s y , were t h e d e n t i s t s most l i k e l y t o be i n t e r e s t e d i n e x t e n d i n g t h e i r p r a c t i c e t o l o n g t e r m c a r e f a c i l i t i e s . C o n v e r s e l y , t h o s e d e n t i s t s who were b u s y i n t h e i r p r i v a t e p r a c t i c e , a n d who had l i t t l e t r a i n i n g i n t r e a t i n g t h e c h r o n i c a l l y i l l , were t h e l e a s t l i k e l y t o show i n t e r e s t i n t h i s a r e a . The f i n d i n g s i n d i c a t e t h a t i n o r d e r t o e x t e n d d e n t a l s e r v i c e s t o t h o s e e l d e r l y i n n u r s i n g homes and h o s p i t a l s , an a p p r o p r i a t e e d u c a t i o n , b o t h d i d a c t i c and c l i n i c a l , and an a c c e p t a b l e f i n a n c i a l a r r a n g e m e n t f o r s u c h s p e c i a l i z e d s e r v i c e s s h o u l d be i n t r o d u c e d i n t o t h e d e n t a l community. i v TABLE OF CONTENTS TITLE . i A b s t r a c t i i L i s t of Tables v i i ACKNOWLEDGEMENTS ix 1. I n t r o d u c t i o n . 1 1 .1 Overview 1 1.2 Statement of the Question 3 1.3 T h e s i s O u t l i n e 4 2. T h e o r e t i c a l Models of D e n t i s t s ' I n t e r e s t s 6 2.1 Overview 6 2.2 The S o c i o - c u l t u r a l Model 6 2.3 The P r o f e s s i o n a l Model 9 2.4 Economic Model 11 2.5 Hypotheses 15 3. METHODS FOR DENTISTS' SURVEY 19 3.1 Development of the Survey 19 3.2 The Q u e s t i o n n a i r e 22 3.3 A d m i n i s t r a t i o n 29 3.4 Coding 30 3.5 Recoding 31 3.6 Sampling B i a s 33 4. INTERESTS OF DENTISTS IN TREATING ELDERLY:RESULTS 37 4.1 Overview 37 4.2 F i r s t Stage:Frequency D i s t r i b u t i o n s of V a r i a b l e s .... 37 v 4.3 Second S t a g e : P r e d i c t i n g D e n t i s t s ' I n t e r e s t : B i v a r i a t e A n a l y s i s 47 4.4 T h i r d S t a g e : M u l t i v a r i a t e A n a l y s i s 56 4.5 A Summary of the F i n d i n g s 60 5. DENTISTS WHO PRACTICED AT LTCS-A SECONDARY STUDY 62 5. 1 Overview 62 5.2 Methods f o r the Secondary Study 63 5.3 R e s u l t s of Secondary Study 64 5.4 C o n c l u s i o n s of the Secondary Study 72 6. DISCUSSION 74 6.1 L i m i t a t i o n s of the Survey 74 6.2 P r a c t i c a l A p p l i c a t i o n s 75 REFERENCES 80 Appendix A 84 Appendix B 87 Appendix C 95 v i LIST OF TABLES Table Page 1 Independent Variables in the Three Models 27 2 Coding of Continuous Variables 30 3 Recoding of Practice C h a r a c t e r i s t i c s 32 4 Recoding of Importance of S p e c i f i c Considerations for LTC Service 33 5 Demographic C h a r a c t e r i s t i c s of Respondents and Population 35 6 Interest in LTC Service 38 7 Perceptions of Work with Eld e r l y 39 8 G e r i a t r i c Dental Training of Respondents 41 9a Practice C h a r a c t e r i s t i c s of Respondents 42 9b Practice C h a r a c t e r i s t i c s Relevant to E l d e r l y 42 10 Common Proceedures for E l d e r l y Patients 43 11 Important Considerations for LTC service 44 12 Threshold Variables in LTC Decision 45 13 Reasons for Not Providing LTC Services 46 14 Socio-cultural Variables S i g n i f i c a n t l y Associated with Interest 49 15 Professional Variables S i g n i f i c a n t l y Associated with Interest 51 16 Economic Variables S i g n i f i c a n t l y Associated with Interest 54 17 Multiple C l a s s i f i c a t i o n Analysis:Socio-cultural Variables 57 18 Multiple C l a s s i f i c a t i o n Analysis:Professional Variables . 58 19 Multiple C l a s s i f i c a t i o n Analysis: Economic Variables .... 59 20 Questions and Responses of LTC Practitioner Study 65 v i i 21 G e r i a t r i c T r a i n i n g Among T h r e e S u b - g r o u p s 68 22 I n t e r e s t i n LTC S e r v i c e Among Two S u b - g r o u p s 69 23 Home V i s i t s Among T h r e e S u b - g r o u p s 70 24 C o n s i d e r a t i o n s o f Time L o s s Among T h r e e S u b - g r o u p s 71 C:1 I n t e r e s t by P e r c e p t i o n s o f Work w i t h t h e E l d e r l y 96 C:2 I n t e r e s t by S e l e c t e d P r a c t i c e C h a r a c t e r i s t i c s R e l e v a n t t o E l d e r l y 97 C:3 I n t e r e s t by G e r i a t r i c T r a i n i n g of D e n t i s t s 98 C:4 I n t e r e s t by Age and Y e a r s o f P r a c t i c e 99 C:5 I n t e r e s t by S t a t u s o f P r a c t i c e and B u s y n e s s 100 C:6 I n t e r e s t by C o n s i d e r a t i o n s f o r LTC S e r v i c e 101 C:7 I n t e r e s t by R e a s o n s f o r Not P r o v i d i n g S e r v i c e s 101 v i i i ACKNOWLEDGEMENTS I w o u l d l i k e t o a c k n o w l e d g e t h e t e a c h i n g s a n d s u p p o r t o f t h e members o f my t h e s i s c o m m i t t e e - P r o f . Mary H i l l , D r . M i c h a e l M a c E n t e e , D r . B r e n d a M o r r i s o n , D r . Nancy W a x i e r - M o r r i s o n and D r . James T h o r n t o n . I am g r a t e f u l t o t h e n u r s i n g s t a f f o f t h e E x t e n d e d C a r e U n i t a t t h e H e a l t h S c i e n c e s C e n t r e H o s p i t a l a t U.B.C. f o r t h e i r g u i d a n c e d u r i n g my y e a r o f r e s e a r c h t h e r e . I am d e e p l y i n d e b t e d t o my s u p e r v i s o r , D r . Nancy W a x i e r - M o r r i s o n , who t a u g h t me t h e t h e o r e t i c a l f o u n d a t i o n s o f m e d i c a l s o c i o l o g y , and who was t h e m i d w i f e o f e v e r y c h a p t e r i n t h i s t h e s i s . I w o u l d a l s o l i k e t o t h a n k D r . M i c h a e l M a c E n t e e , who i n i t i a t e d t h e s t u d i e s on t h e d e n t a l h e a l t h o f t h e i n s t i t u t i o n a l i z e d e l d e r l y i n G r e a t e r V a n c o u v e r , f o r g i v i n g me t h e o p p o r t u n i t y t o p a r t i c i p a t e i n t h e r e s e a r c h a t a l l t h e s t a g e s o f i t s d e s i g n , o p e r a t i o n and a n a l y s i s . The B r i t i s h C o l u m b i a H e a l t h C a r e R e s e a r c h F o u n d a t i o n and t h e C o l l e g e o f D e n t a l S u r g e o n s have p r o v i d e d f i n a n c i a l s u p p o r t f o r t h i s p r o j e c t a n d I e x t e n d my g r a t i t u d e t o t h e s e o r g a n i z a t i o n s f o r t h e i r c o n t r i b u t i o n s . i x CHAPTER 1 INTRODUCTION 1.1 O v e r v i e w In 1984, an i n v e s t i g a t i o n o f t h e o r a l h e a l t h needs o f t h e i n s t i t u t i o n a l i z e d e l d e r l y i n t h e g r e a t e r V a n c o u v e r a r e a was c o n d u c t e d by s e v e r a l members of t h e D e n t a l and M e d i c a l f a c u l t i e s a t U B C ( 1 9 ) . T was a member of t h e i n v e s t i g a t i v e team and had p r e v i o u s l y a s s i s t e d i n a p i l o t o r a l h e a l t h s u r v e y i n t h e E x t e n d e d C a r e U n i t a t t h e H e a l t h S c i e n c e s C e n t r e H o s p i t a l a t U B C ( 2 0 ) . F o r t y - o n e l o n g t e r m c a r e f a c i l i t i e s i n V a n c o u v e r , Burnaby and N o r t h and West V a n c o u v e r p a r t i c i p a t e d i n t h e m a j o r s t u d y , and 653 r e s i d e n t s r e p r e s e n t i n g t h e p o p u l a t i o n a t a l l l e v e l s o f n u r s i n g c a r e were examined by a d e n t i s t and i n t e r v i e w e d a b o u t t h e i r d e n t a l n e e d s and o r a l h e a l t h h i s t o r y . As was f o u n d i n t h e e x t e n d e d c a r e u n i t s t u d y , t h e m a j o r i t y o f r e s i d e n t s h a d n o t s e e n a d e n t i s t i n 5 y e a r s o r more. O n l y 9 o f t h e 41 f a c i l i t i e s had s t r u c t u r e d d e n t a l p r o g r a m s , and most o f t h e s e i n v o l v e d l i t t l e more t h a n f o r m a l a r r a n g e m e n t s between a d m i n i s t r a t o r s a n d a d e n t i s t i n t h e community t o t r a n s p o r t r e s i d e n t s t o h i s / h e r o f f i c e when n e c e s s a r y . F o r t h e most p a r t , r e s i d e n t s a n d t h e i r f a m i l i e s were l e f t t o l o o k a f t e r d e n t a l a f f a i r s d 9 ) . 1 The i n a d e q u a c y o f t h i s s i t u a t i o n became a p p a r e n t i n t h e f i n d i n g s o f t h e s t u d y . About 1/3 o f t h e r e s i d e n t s i n t e r v i e w e d c o m p l a i n e d o f d e n t a l p r o b l e m s , u s u a l l y r e l a t i n g t o d e n t u r e s . O r a l m u c o s a l p a t h o s e s were o b s e r v e d i n 37% o f t h e sample and most o f t h e l e s i o n s were i n f l a m m a t o r y a n d s p e c i f i c t o d e n t u r e w e a r e r s . A r e l a t i v e l y h i g h p r o p o r t i o n o f t h e e l d e r l y r e s i d e n t s had t h e i r own t e e t h ( 4 1 % ) , b u t t h e m a j o r i t y ( 5 9 % ) o f t h e s e d e n t a t e i n d i v i d u a l s had c a r i e s , most commonly r o o t and p u l p a l l e s i o n s , and 18% had p e r i o d o n t a l d i s e a s e ( l 9 ) . O t h e r s t u d i e s c o n f i r m t h e i n c r e a s e d r i s k o f c a r i e s a n d p e r i o d o n t a l d i s e a s e i n o l d a g e . In t h e i r s t u d y , B a n t i n g e t a l . ( 2 ) n o t e d t h a t 89% o f t h e d e n t a t e i n d i v i d u a l s i n an O n t a r i o g e r i a t r i c i n s t i t u t i o n had r o o t c a r i e s . M a r t i n e l l o and L e a k e , r e p o r t i n g on t h e i r o r a l h e a l t h s u r v e y o f t h r e e O n t a r i o homes f o r t h e a g e d s t a t e d t h a t " a l m o s t w i t h o u t e x c e p t i o n , a l l i n d i v i d u a l s i n t h e p a r t i a l l y e d e n t u l o u s g r o u p were i n n e e d o f r e s t o r a t i v e , p e r i o d o n t a l a n d s u r g i c a l t r e a t m e n t " ( 2 2 ) . N e i t h e r a r e t h e d e n t u r e - w e a r i n g e d e n t a t e e l d e r l y f r e e f r o m o r a l d i s e a s e . S m i t h ' s ( 2 9 ) r e v i e w o f t h e A m e r i c a n s t u d i e s o f o r a l c a n c e r r e v e a l e d a h i g h e r f r e q u e n c y o f c a n c e r o u s and p r e c a n c e r o u s l e s i o n s , o f t e n a s s o c i a t e d w i t h a h i s t o r y o f s m o k i n g , amongst t h e e l d e r l y . I n a l o n g i t u d i n a l s t u d y o f 70 y e a r o l d s i n G o t h e n b u r g , S w e den, O s t e r b e r g ( 2 5 ) n o t e d homogenous l e u k o p l a k i a i n 21% o f t h e s t u d y s a m p l e . In a 1980 Iowa s u r v e y o f t h e o r a l h e a l t h s t a t u s o f t h e s t a t e ' s p o p u l a t i o n , o v e r a h a l f of t h e d e n t u r e s o f t h e o v e r 60 age g r o u p e x a m i n e d were i n need o f 2 r e p a i r o r r e l i n e . The i n c i d e n c e o f m u c o s a l l e s i o n s amongst t h e d e n t u r e w e a r e r s was 32%, and t h e o v e r a l l r a t e o f m u c o s a l l e s i o n s i n t h i s age g r o u p was 140 p e r 1000, i n marked c o n t r a s t t o 46 p e r 1000 f o r t h e e n t i r e s t a t e p o p u l a t i o n ( 3 4 ) . In t h e l i g h t of t h e s e f i n d i n g s , i t was i m p e r a t i v e t o l o o k a t t h e a v a i l a b i l i t y of d e n t a l s e r v i c e s t o t h e i n s t i t u t i o n a l i z e d e l d e r l y i n B.C. T h e r e a r e no s u c h p r o v i n c i a l l y s u b s i d i z e d s e r v i c e s t o t h e e l d e r l y and no s p e c i a l c a r e d e n t i s t s who r e g u l a r l y d i a g n o s e and t r e a t r e s i d e n t s , w i t h t h e e x c e p t i o n o f V a l l e y v i e w H o s p i t a l , a p s y c h o - g e r i a t r i c i n s t i t u t i o n , and S h a u g h n e s s y H o s p i t a l , a v e t e r a n ' s i n s t i t u t i o n . The f r a i l e l d e r l y , many o f whom have l i m i t e d m o b i l i t y , must a r r a n g e d e n t a l a p p o i n t m e n t s j u s t l i k e t h e r e s t o f us when we r e c o g n i z e a n eed f o r t r e a t m e n t . The q u e s t i o n w h i c h a r i s e s i s one o f a c c e s s i b i l i t y o f d e n t a l c a r e t o t h i s p o p u l a t i o n , and t o a l l i n s t i t u t i o n a l i z e d and homebound i n d i v i d u a l s . B e c a u s e d e n t i s t s a r e t h e o n l y p r o f e s s i o n w i t h l e g a l a u t h o r i t y t o d i a g n o s e an d t r e a t d e n t a l p r o b l e m s ( e g . even d e n t a l m e c h a n i c s must have a p r e s c r i p t i o n f r o m a d e n t i s t b e f o r e making d e n t u r e s ) , i t i s c r u c i a l t o d e t e r m i n e w h e t h e r t h e y a r e w i l l i n g and a b l e t o u n d e r t a k e t r e a t m e n t o f t h i s s p e c i a l c a r e g r o u p . T h i s i s s u e i s t h e s u b j e c t o f t h i s t h e s i s . 1 .2 S t a t e m e n t o f t h e Q u e s t i o n The q u e s t i o n t h i s s t u d y a t t e m p t s t o answer i s , " W h a t a r e t h e m a j o r d e t e r m i n a n t s o f i n t e r e s t i n l o n g t e r m c a r e ( L T C ) d e n t a l 3 s e r v i c e ? " . Three models of i n t e r e s t i n LTC d e n t a l s e r v i c e have been gleaned from the l i t e r a t u r e , each w i t h a d i f f e r e n t r a t i o n a l e f o r the s e r v i c i n g d e c i s i o n s of p r o v i d e r s r e g a r d i n g LTC p a t i e n t s . These models are t e s t e d by a survey q u e s t i o n n a i r e of d e n t i s t s i n the LTC o r a l h e a l t h survey study area. T h i s q u e s t i o n n a i r e asks d e n t i s t s about t h e i r experience and i n t e r e s t i n working with the w e l l and d i s a b l e d e l d e r l y . 1 . 3 T h e s i s O u t l i n e Chapter 2 i s a l i t e r a t u r e review of the s t u d i e s conducted on the p e r c e p t i o n s of the e l d e r l y by d e n t a l and medical p r o f e s s i o n a l s . The s o c i o - c u l t u r a l , p r o f e s s i o n a l and economic t h e o r e t i c a l models are o u t l i n e d and the hypotheses i n each model which w i l l be t e s t e d are d e f i n e d . Chapter 3 i s an account of the e v o l u t i o n of the survey q u e s t i o n n a i r e . The format of the q u e s t i o n n a i r e i s d e s c r i b e d . The q u e s t i o n s and the independent v a r i a b l e s they represent are i t e m i z e d under the three models e x p l a i n i n g i n t e r e s t i n LTC s e r v i c e . Chapter 4 p r e s e n t s the data from the survey. A b i a s study i s conducted to determine whether the demographic c h a r a c t e r i s t i c s of the respondents d i f f e r s i g n i f i c a n t l y from the t o t a l p o p u l a t i o n of d e n t i s t s i n the study a r e a . The data are a n a l y z e d i n t hree stages of i n c r e a s i n g c o m p l e x i t y , with the s p e c i f i c goal of determining which model i s the s t r o n g e s t i n p r e d i c t i n g 4 i n t e r e s t i n LTC s e r v i c e . Chapter 5 i s a secondary study of those d e n t i s t s who have p r a c t i s e d i n LTC f a c i l i t i e s . The i n c e n t i v e s and d i s i n c e n t i v e s of LTC d e n t a l p r a c t i c e are examined i n order to v a l i d a t e the c o n c l u s i o n s of the primary study. Chapter 6 i s a d i s c u s s i o n of the t h e o r e t i c a l l i m i t a t i o n s and p r a c t i c a l a p p l i c a t i o n s of t h i s study. 5 CHAPTER 2 THEORETICAL MODELS OF DENTISTS' INTERESTS 2.1 O v e r v i e w T h e r e a r e t h r e e t h e o r e t i c a l p e r s p e c t i v e s t h a t a r e p o t e n t i a l l y u s e f u l i n u n d e r s t a n d i n g t h e i n t e r e s t s o f d e n t i s t s i n p r o v i d i n g s e r v i c e s t o t h e e l d e r l y . They may be b r o a d l y c l a s s i f i e d a s s o c i o - c u l t u r a l , p r o f e s s i o n a l , and ec o n o m i c p e r s p e c t i v e s , w i t h some d e g r e e o f o v e r l a p amongst them. T h e s e w i l l be d i s c u s s e d i n d i v i d u a l l y i n t h e f o l l o w i n g p a r a g r a p h s . 2.2 The S o c i o - c u l t u r a l M o d e l The t e r m " a g e i s m " was c o i n e d by R o b e r t B u t l e r ( 2 4 ) t o r e f e r t o t h e s t e r e o t y p i n g o f t h e e l d e r l y and t h e s u b s e q u e n t s o c i a l d i s c r i m i n a t i o n a g a i n s t them. The d e g r a d a t i o n o f t h e e l d e r l y i s p e r v a s i v e i n W e s t e r n s o c i e t y , where t h e c u l t u r e i s r e g a r d e d a s " y o u t h o r i e n t e d " , and a g i n g i s a c t i v e l y c a m o u f l a g e d . N e u g a r t e n ( 1 8 ) d e s c r i b e d t h e s t e r e o t y p e o f t h e o l d as e i t h e r p o o r , i s o l a t e d o r unhappy o r p o w e r f u l , r i g i d o r r e a c t i o n a r y . The gap between young and o l d i s p e r p e t u a t e d by s u c h s t e r e o t y p e s . As B u t l e r ( 2 4 ) s t a t e d ; A g e i s m a l l o w s t h e y o u n g e r g e n e r a t i o n s t o see o l d e r p e o p l e a s d i f f e r e n t f r o m t h e m s e l v e s . Thus, t h e y s u b t l y c e a s e t o i d e n t i f y w i t h t h e i r e l d e r s a s human b e i n g s . 6 The s o c i o - c u l t u r a l l i t e r a t u r e h a s y i e l d e d a p l e t h o r a o f s t u d i e s on l a y and p r o f e s s i o n a l a t t i t u d e s t o w a r d s t h e e l d e r l y . A s t u d y by S i g n o r i , B u t t , and Kozak o f t h e UBC P s y c h o l o g y D e p a r t m e n t i s t y p i c a l o f s u r v e y s c o n d u c t e d t o gauge s o c i e t a l " a g e i s m " ( 2 8 ) . The r e s e a r c h e r s p r o v i d e d a 7 p o i n t b i p o l a r d e s c r i p t i v e a d j e c t i v e s c a l e , f o c u s i n g on 30 t r a i t s , t o 456 v o l u n t e e r s between 14 and 40 y e a r s o f a g e . The e l d e r l y were r a t e d t o be weaker, more d e l i c a t e a n d u n h e a l t h y , p o o r e r , l e s s p o w e r f u l , r i g i d , s t u b b o r n , f r i g i d a n d g o s s i p y and more s u b j e c t i v e l y o r i e n t a t e d t h a n t h e g e n e r a l p o p u l a c e . On t h e o t h e r hand, t h e r e s e a r c h e r s n o t e d a b r o a d e r i m p r e s s i o n by t h e s u b j e c t s t h a t r e c o g n i z e d a g r e a t e r h u m a n i t y , u n d e r s t a n d i n g , s e n s i t i v i t y , e x p e r i e n c e , w i l l i n g n e s s t o c o n t r i b u t e a n d p e r s i s t e n c e i n a t t a i n m e n t o f w o r t h w h i l e o b j e c t i v e s . The a u t h o r s b e l i e v e t h e m a j o r i t y of a t t i t u d i n a l s t u d i e s w h i c h r e v e a l a g e i s m e x a g g e r a t e and m i s c o n s t r u e t h e s a m p l e d g r o u p ' s v i e w s . They c l a i m t h a t t h e s e s t u d i e s r a t e a t t i t u d e s on a s m a l l number o f p r e s e l e c t e d t r a i t s w h i c h f o c u s on t h e " n a t u r a l f a i l i n g s " o f t h e e l d e r l y . N o n e t h e l e s s , t h e h e a l t h p r o f e s s i o n a l s have been f o u n d t o be s i g n i f i c a n t l y more n e g a t i v e i n t h e i r a p p r o a c h t o e l d e r l y p a t i e n t s t h a n t h e g e n e r a l p o p u l a c e ( 8 , 17,23,35) . Most commonly, i n m e d i c a l s c h o o l s t u d i e s ( 3 , 5 , 7 , 1 4 , 1 5 , 3 0 , 3 1 , 3 2 ) , s t u d e n t s were handed o u t a b i p o l a r , d e s c r i p t i v e s c a l e a n d / o r d i c h o t o m o u s g e r o n t o l o g i c a l knowledge q u e s t i o n n a i r e b e f o r e and a f t e r g e r i a t r i c c o u r s e s and c l i n i c a l e x p e r i e n c e w i t h t h e e l d e r l y . J u s t a s commonly, no d i f f e r e n c e s were f o u n d i n t h e p e r c e p t i o n s o f 7 s t u d e n t s , w h i c h were s i m i l a r t o s t e r e o t y p i c a l i m p r e s s i o n s n o t e d by N e u g a r t e n a b o v e , o v e r t h e d i d a c t i c and c l i n i c a l t r a i n i n g p e r i o d ( 3 , 1 4 , 1 5 ) . I n d e e d , t h e i m p r e s s i o n s o f t h e d e t e r i o r a t i n g image and f u n c t i o n a l l o s s o f e l d e r l y p a t i e n t s f r o m l i m i t e d t r e a t m e n t e n c o u n t e r s may have h e i g h t e n e d t h e n e g a t i v e image o f o l d age t h e s t u d e n t s h e l d ( 3 ) . The two s t u d i e s o f d e n t i s t s ' a t t i t u d e s , one by C o e ( 8 ) i n 1967, and t h e o t h e r 15 y e a r s l a t e r by K i y a k e t a l . ( l 7 ) , e m p l o y e d t h e s e two g e n e r a l i z e d a t t i t u d e s c a l e s t o a s s e s s d e n t i s t s ' p e r c e p t i o n s o f t h e e l d e r l y . I n b o t h s t u d i e s , d e n t a l p r o f e s s i o n a l s r e g a r d e d p h y s i o l o g i c a l and p s y c h o l o g i c a l d e t e r i o r a t i o n a s c o n c o m i t a n t s o f a g i n g , and d i s p l a y e d a p r o s t h o d o n t i c o r i e n t a t i o n i n g e r i a t r i c t h e r a p y . The r e l i a n c e o f K i y a k e t a l . on knowledge q u e s t i o n n a i r e s f o r t h e r e v e l a t i o n o f s t e r e o t y p e s l e d t o a f o c u s on t h e c h a r a c t e r i s t i c s o f d e n t i s t s w h i c h would p r e d i c t e i t h e r p o s i t i v e o r n e g a t i v e s t e r e o t y p e s o f t h e e l d e r l y , and t h o s e d e n t i s t s w i t h t h e h i g h e s t number o f e l d e r l y i n t h e i r p r a c t i c e p r o d u c e d t h e most n e g a t i v e e v a l u a t i o n s . T r a i n i n g i n g e r i a t r i c d e n t i s t r y h a d no s i g n i f i c a n t i m p a c t on t h e e v a l u a t i o n s o f t h e e l d e r l y . Of s i g n i f i c a n c e were t h e a g e - s p e c i f i c r e s p o n s e p a t t e r n s t o t h e e l d e r l y t h a t K i y a k ( l 7 ) a n d v a r i o u s a u t h o r s a t t e m p t e d t o d e l i n e a t e i n m e d i c a l - d e n t a l p r o f e s s i o n a l s u r v e y s . K i y a k c o n c l u d e d t h a t e l d e r l y d e n t i s t s have a "more r e a l i s t i c " a p p r a i s a l o f t h e a g e d and c o r r e s p o n d i n g l y , a more f a v o u r a b l e a t t i t u d e . B e c k ( 3 ) h y p o t h e s i z e d t h a t i n i t i a l r e s p o n s e s t o t h e 8 v i s i b l y p o o r o r a l h e a l t h s t a t u s o f t h e c h r o n i c a l l y i l l i n n u r s i n g homes e n g e n d e r an e v e n s t r o n g e r a n t i p a t h y amongst d e n t a l s t u d e n t s . However, t h e f i n d i n g s i n t h e M i l l e r e t a l . ( 2 3 ) s t u d y ru n c o n t r a r y t o t h i s s t r e a m o f t h o u g h t . H e r e , t h e o l d e r p h y s i c i a n s c o n s i d e r e d m e n t a l l y i n c o m p e t e n t and i n c o n t i n e n t c l i e n t s t h e most d i f f i c u l t t o t r e a t . W a l k ( 3 5 ) s p e c u l a t e d t h a t t h e n e g a t i v e e v a l u a t i o n s o f t h e i n s t i t u t i o n a l i z e d e l d e r l y by o l d e r p r o f e s s i o n a l s r e f l e c t a p e r s o n a l d e n i a l o f t h e t h r e a t e n i n g f u n c t i o n a l l o s s e s o f a d v a n c i n g y e a r s . The e x p o s u r e t o r e m i n d e r s o f one's m o r t a l i t y i n t h e f o r m o f e n c o u n t e r s w i t h d e b i l i t a t e d , a d v a n c e d a g e d c a n n o t be o v e r l o o k e d i n a d i s c u s s i o n o f p r o f e s s i o n a l a g e i s m . The m a j o r i t y o f s t u d i e s o f p s y c h o l o g i c a l m o t i v e e m p h a s i z e t h e a g e i s m endemic i n t h i s s o c i e t y and i t s r e a f f i r m a t i o n i n t h e l a c k o f e x p e r i e n c e w i t h and f e a r o f t h e c o m p l i c a t e d p h y s i o l o g i c a l a n d p s y c h o l o g i c a l t r e a t m e n t r e s p o n s e s o f t h e e l d e r l y . 2.3 The P r o f e s s i o n a l M o d e l T h i s s o c i a l p e r s p e c t i v e c a n be t a k e n one s t e p f u r t h e r i n e x a m i n i n g d e n t i s t r y ' s " o c c u p a t i o n a l i d e o l o g y " . W i t h a p r e d o m i n a n t f o c u s on c o s m e t i c and r e p a r a t i v e t e c h n o l o g i e s , t h e c h r o n i c c o n d i t i o n s o f c a r i e s a n d p e r i o d o n t a l d i s e a s e amongst t h e e l d e r l y r e m a i n u n a t t e n d e d u n t i l t h e s e p r o b l e m s r e a c h an a c u t e p h a s e . O n l y t h e n d o e s t h e s p e c i f i c d i s e a s e o r i e n t e d t h e r a p y w i t h 9 i t s m a s s i v e i n f r a s t r u c t u r e become a v a i l a b l e t o t h i s g r o u p , and w i t h u n d e r s t a n d a b l y l i m i t e d r e s u l t s . T r e a t m e n t o f t h e c h r o n i c and d e g e n e r a t i v e c o n d i t i o n s o f t h e e l d e r l y i n m e d i c i n e i s by and l a r g e r e g a r d e d as a p a l l i a t i v e measure, a waste o f t h e h i g h l y t r a i n e d p r o f e s s i o n a l ' s s k i l l s . Lower s t a t u s has been a c c r u e d by p r o f e s s i o n a l s when t h e e l d e r l y c o n s t i t u t e a l a r g e p r o p o r t i o n o f t h e i r p r a c t i c e ( 3 5 ) . A l a r g e number o f p h y s i c i a n s ( 8 5 % ) , i n a s u r v e y o f t h e i r e v a l u a t i o n s o f n u r s i n g homes and t h e i r r e s i d e n t s i n W e s t c h e s t e r , N e w Y o r k S t a t e , b e l i e v e d t h a t t h e y s h o u l d n o t be i n v o l v e d i n t h e i r p a t i e n t ' s c a r e a f t e r p l a c e m e n t i n a n u r s i n g h ome(23). T h i s f i n d i n g h i g h l i g h t s t h e o c c u p a t i o n a l a v e r s i o n t o m a i n t e n a n c e of t h e c h r o n i c a l l y i l l . I n t r a c i n g t h e emergence o f t h e o r g a n i z e d d e n t a l p r o f e s s i o n i n The Soc i a l C o n t e x t o f D e n t i s t r y , D a v i s ( 9 ) o u t l i n e s t h e h i s t o r i c a l d e v e l o p m e n t o f t h e s o c i a l i d e o l o g y o f d e n t i s t r y . In E u r o p e a n s o c i e t i e s , s u c h a s Denmark, t h e w o r k i n g c l a s s p o l i t i c a l c o n s t i t u e n c i e s p u s h e d t h r o u g h s t a t e h e a l t h ( i n c l u d i n g d e n t a l ) i n s u r a n c e p r o g r a m s i n t h e l a t e n i n e t e e n t h c e n t u r y . N o r t h A m e r i c a n d e n t i s t s , however, were a b l e t o e s t a b l i s h p r i v a t e s o l o p r a c t i c e s s u p p o r t e d on a f e e f o r s e r v i c e b a s i s by a g r o w i n g and a f f l u e n t m i d d l e c l a s s . The t r e n d d a t a i n d i c a t e t h a t t h e i n e q u a l i t i e s i n f e e f o r s e r v i c e u t i l i z a t i o n have p e r s i s t e d t o t h e p r e s e n t . W i t h o u t c a s t i n g a s i d e t h e p r i n c i p l e o f " u s e r p a y " ( 9 ) , t h e p r o f e s s i o n has i n d u l g e d t h e i n s t i t u t i o n a l i z e d e l d e r l y a l o n g w i t h t h e d e p e n d e n t and v u l n e r a b l e g r o u p s where i t became p o l i t i c a l l y e x p e d i e n t t o 10 do s o , t o a p p e a r t o e a s e t h e p r o b l e m o f a c c e s s . The o v e r a l l r e s p o n s e o f t h e p r o f e s s i o n t o e x t e r n a l p r e s s u r e s t o r e s t r u c t u r e t h e d e l i v e r y s y s t e m h a s been t o s t r e s s t h e r e s p o n s i b i l i t y o f i n d i v i d u a l s f o r t h e i r own h e a l t h a n d t o a t t r i b u t e s o c i a l s t r a t a i n e q u i t i e s t o t h e p r o b l e m a t i c a t t i t u d e s and m o t i v a t i o n s o f t h e d i s a d v a n t a g e d g r o u p s - t h e p o o r , t h e i n d i g e n t , t h e e l d e r l y . C o n t r a s t i n g p h i l o s o p h i e s o f t r e a t m e n t a r e e v i d e n t i n t h e p r o f e s s i o n a l c u l t u r e a c c o r d i n g t o t h e p r e d o m i n a n t s o c i a l c l a s s o f t h e i r d e n t a l c l i e n t e l e , w i t h t h e h i g h e r s t r a t a r e c e i v i n g more r e s t o r a t i v e work ( i . e . crown and b r i d g e ) and l o w e r s t r a t a h a v i n g a g r e a t e r number o f c o m p l e t e mouth e x t r a c t i o n s a n d d e n t u r e s f i l l e d ( 1 6 , 2 6 ) . The i d e o l o g y o f t h e d e n t a l p r o f e s s i o n becomes t r a n s l a t e d i n t h e t r a i n i n g o f d e n t i s t s t o s e r v i c e t h e nee d s p r e d o m i n a n t l y o f t h e a f f l u e n t and h e a l t h y a d u l t a n d young p o p u l a t i o n s , t o t h e e x c l u s i o n of t h e f r a i l e l d e r l y and t h e c h r o n i c a l l y i l l , many o f whom l i v e on l i m i t e d means. 2.4 Ec o n o m i c M o d e l The e c o n o m i c l i t e r a t u r e has m i n i m i z e d p s y c h o l o g i c a l and s o c i a l i s s u e s i n a n a l y z i n g t h e s u p p l y b e h a v i o u r o f d e n t i s t s . T r a d i t i o n a l l y , e c o n o m i s t s have compared d e n t a l p r a c t i c e s a s p r o f i t a n d / o r u t i l i t y m a x i m i z i n g f i r m s . W i t h t h e e s t a b l i s h m e n t o f p r i c e - f i x i n g a n d s e l f - r e g u l a t i n g p r o f e s s i o n a l b o d i e s , a monopoly s i t u a t i o n began t o r e p l a c e t h e c l a s s i c s u p p l y / d e m a n d p r i c e a d j u s t i n g m o d e l s ( 4 , 1 3 , 2 7 ) . E v a n s ( l 2 ) and o t h e r s have p r o p o s e d t h e c o n c e p t o f t h e " n o t - o n l y - f o r - p r o f i t " p r o v i d e r f i r m s 1 1 where o t h e r c o n s i d e r a t i o n s t h a n c o s t m i n i m i z a t i o n a n d t e c h n i c a l e f f i c i e n c y g u i d e d e n t i s t s ' s e r v i c i n g b e h a v i o u r , s u c h a s w o r k l o a d t a r g e t s , l e i s u r e r e q u i r e m e n t s and p r o f e s s i o n a l r e s p o n s i b i l i t y . E v a n s ( l 2 ) , i n w r i t i n g on t h e h i s t o r y o f m e d i c i n e i n Canada, c o n c l u d e d t h a t o v e r t h e p a s t f o u r d e c a d e s a c l e a r p a t t e r n o f p r o f e s s i o n a l e c o n o m i c o r g a n i z a t i o n emerges. E x p e n d i t u r e s i n m e d i c i n e and d e n t i s t r y have been d e t e r m i n e d by u t i l i z a t i o n , w h i c h i s t h e outcome o f p a t i e n t demand and p r o v i d e r b e h a v i o u r . The p r o v i d e r ' s s e r v i c i n g r e s p o n s e s a r e p a r t i a l l y a t t r i b u t a b l e t o t h e d i s c r e p a n c y between a c t u a l and t a r g e t i n c o m e s . The d e g r e e t o w h i c h income t a r g e t s g u i d e s u p p l i e r b e h a v i o u r i s c u r r e n t l y a c o n t r o v e r s i a l i s s u e . F o l l o w i n g E v a n ' s h y p o t h e s i s , t h e p r o v i d e r ' s r e s p o n s e t o an " o v e r s u p p l y " o f p r o f e s s i o n a l s i s n o t t o o p t o u t of t h e p r o f e s s i o n , b u t r a t h e r t o r e a d j u s t h i s / h e r p r o d u c t l i n e s t o m a i n t a i n a c t i v i t y l e v e l s and m i n i m i z e c a p i t a l l o s s e s . The C o l l e g e o f D e n t a l S u r g e o n s hopes t o r e d r e s s t h e p e r c e i v e d d e c l i n e i n incomes a s s o c i a t e d w i t h an o v e r s u p p l y o f p r o v i d e r s by means o f i n c r e a s i n g " d e m a n d " ( 1 0 ) . T h i s i s t o be a c h i e v e d by more a d v e r t i s i n g a n d p r o m o t i o n o f t h i r d p a r t y i n s u r a n c e , b u t more i m p o r t a n t l y t o t h i s argument, by t r a n s f o r m i n g "unmet need" f o r p e r i o d o n t i c , o r t h o d o n t i c and p r o s t h o d o n t i c t r e a t m e n t i n t o demand. The i s s u e o f a c c e s s i b i l i t y o f s e r v i c e s t o t h e e l d e r l y may be a s s e s s e d w i t h i n s u c h an economic c o n t e x t . D e n t i s t s have i n v e s t e d a g r e a t d e a l o f human and p h y s i c a l c a p i t a l i n u n d e r g r a d u a t e and s p e c i a l t y t r a i n i n g and i n s e t t i n g up a p r a c t i c e . T h e r e f o r e 1 2 g e n e r a l p r a c t i t i o n e r s a r e i n t e r e s t e d i n m a x i m i z i n g t h e i r l i f e - s p a n e a r n i n g s by d e v e l o p i n g a p r a c t i c e w i t h a r e g u l a r c l i e n t e l e who have t h e a b i l i t y t o pay f o r d e n t a l s e r v i c e s e i t h e r o f a g e n e r a l o r s p e c i a l i z e d n a t u r e and who w i l l u t i l i z e t h e s e s e r v i c e s o v e r a l o n g p e r i o d o f t i m e and r e c r u i t o t h e r s , m o s t l y t h e i r c h i l d r e n , i n t o t h e d e n t i s t ' s p r a c t i c e . F o r s p e c i a l i s t s i n o r t h o d o n t i c s and e n d o d o n t i c s , who c h a r g e h i g h e r r a t e s f o r t h e i r e x p e r t i s e , s h o r t t e r m c l i e n t s a r e t h e r u l e , a n d t h e o p t i m a l f l o w o f c l i e n t s t h r o u g h t h e i r o f f i c e t h r o u g h t h e r e f e r r a l network i s o f g r e a t e r c o n c e r n . The c h r o n i c a l l y i l l e l d e r l y a r e a p o o r i n v e s t m e n t i n a d e n t a l p r a c t i t i o n e r ' s t i m e and s p e c i a l i z e d l a b o u r b e c a u s e t h e y o f t e n do n o t have t h e f i n a n c i a l means t o r e c e i v e s o p h i s t i c a t e d t r e a t m e n t . I n B r i t i s h C o l u m b i a , t h e r e a r e no government o r t h i r d p a r t y i n s u r a n c e schemes f o r t h e e l d e r l y , u n l e s s t h e y have r e c e i v e d s o c i a l a s s i s t a n c e p r i o r t o t h e i r 6 5 t h b i r t h d a y . A p p r o x i m a t e l y 50% o f t h e s i n g l e e l d e r l y s u b s i s t on t h e Canada P e n s i o n P l a n ( 6 ) . The o p p o r t u n i t y c o s t i n l o s t income p o t e n t i a l may be t o o h i g h f o r t h e b u l k o f p r a c t i t i o n e r s t o c o n s i d e r an a r r a n g e m e n t t o p r a c t i s e i n LTC f a c i l i t i e s . K e e p i n g i n mind t h e s u b s t i t u t i o n o f p r o d u c t l i n e s when t h e mar k e t c a n n o t b e a r t h e s e r v i c e s o f a h i g h p e r c a p i t a number o f p r o v i d e r s a t f e e s c h e d u l e p r i c e s , t h e i n s t i t u t i o n a l i z e d e l d e r l y may p r o v e t o be a s u f f i c i e n t l y p r o f i t a b l e m a r k e t f o r n o v i c e s as a t e m p o r a r y income s o u r c e u n t i l t h e i r p r i v a t e p r a c t i c e i s e s t a b l i s h e d . F o r r e t i r i n g d e n t i s t s , L T C s may r e p r e s e n t a 1 3 p a r t - t i m e p r a c t i c e o p p o r t u n i t y without the h i g h overhead c o s t s of a u x i l i a r i e s and equipment. For these two groups at e i t h e r end of the d e n t a l p r a c t i c e , o p p o r t u n i t y c o s t s i n p r o f e s s i o n a l and l e i s u r e time are low, u n l i k e the bulk of p r a c t i o n e r s . In p u t t i n g f o r t h t h i s argument, I acknowledge the fundamental importance of the i n t r i n s i c q u a l i t i e s of h e a l t h care that p l a c e i t o u t s i d e the range of orthodox economic a n a l y s i s r t h e assymetry of i n f o r m a t i o n between p r o v i d e r and consumer; the u n c e r t a i n t y of i l l n e s s and the l i m i t s of i t s i n s u r a b i l i t y ; the d i f f e r e n t i a l d i s t r i b u t i o n of d i s e a s e along c l a s s l i n e s and a c r o s s age groups; and the e x t e r n a l e f f e c t s of h e a l t h c a r e , i . e . the e f f e c t of the d i f f e r e n t i a l access to h e a l t h care on the community of i n d i v i d u a l s ( 9 ) . The Canadian medical d e l i v e r y system has as i t s u n d e r l y i n g o b j e c t i v e the matching of h e a l t h care "needs" to the improvement and maintenance of the h e a l t h s t a t u s of i n d i v i d u a l s , and not to t h e i r " w i l l i n g n e s s " to p a y ( l 2 ) . U n f o r t u n a t e l y , the d e n t a l d e l i v e r y system doe*s not come under the n a t i o n a l h e a l t h p l a n . The concept of need may have no normative s i g n i f i c a n c e i n the orthodox model, but the e x t e r n a l e f f e c t s of h e a l t h are such that there e x i s t s an o b l i g a t i o n on the p a r t of s o c i e t y to a s s i s t i n d i v i d u a l s i n a c q u i r i n g i t . As Davis p o i n t s o u t ( 9 ) , the major s o c i a l i s s u e i n d e n t i s t r y i s i n c r e a s i n g l y the r e l a t i o n s h i p between those who provide s e r v i c e s and those who have a r i g h t to r e c e i v e them. At present there i s no s o c i a l c o n t r a c t i n d e n t i s t r y t o match s e r v i c e s to need and t h i s i s s u e w i l l 1 4 u n d o u b t e d l y a r i s e i n an a t t e m p t t o r e s o l v e t h e i n e q u i t i e s i n a c c e s s t o d e n t a l s e r v i c e s . 2.5 H y p o t h e s e s E a c h o f t h e s e t h r e e p e r s p e c t i v e s l e n d s i t s e l f t o t h e d e v e l o p m e n t o f s e v e r a l w o r k i n g h y p o t h e s e s on t h e i s s u e o f a c c e s s i b i l i t y o f d e n t a l s e r v i c e s t o t h e e l d e r l y . From t h e s o c i o - c u l t u r a l p e r s p e c t i v e i t may be h y p o t h e s i z e d t h a t t h e p e r c e p t i o n s o f t h e e l d e r l y , a s w e l l as t h e age o f t h e p r o f e s s i o n a l , a r e t h e most c r i t i c a l f a c t o r s i n t h e m o t i v a t i o n t o p r o v i d e d e n t a l s e r v i c e s t o t h e e l d e r l y . By i n t r o d u c i n g q u e s t i o n s a s k i n g d e n t i s t s t o d e s c r i b e t h e i r w o r k i n g r e l a t i o n s h i p w i t h t h e e l d e r l y and w h e t h e r t h e y d i s t i n g u i s h between t h e e l d e r l y and t h e o t h e r age g r o u p s , t h i s h y p o t h e s i s may be e x a m i n e d . B e c a u s e p r o f e s s i o n a l i s m p r e c l u d e s t h e o v e r t s u g g e s t i o n o f a g e i s m , t h e q u e s t i o n s w o u l d have t o be p h r a s e d d e l i c a t e l y . The s e c o n d t h e o r e t i c a l model opens up s e v e r a l a r e a s o f i n q u i r y . I t s t a t e s t h a t t h e o c c u p a t i o n a l s o c i a l i z a t i o n o f d e n t i s t s d o e s n o t l e n d i t s e l f t o t r e a t m e n t o f t h e f r a i l e l d e r l y . T h i s w o u l d be e v i d e n t i n c o n c e r n s a b o u t t h e l a c k o f g e r i a t r i c d e n t a l t r a i n i n g i n d e a l i n g w i t h t h e c h r o n i c a l l y i l l , t h e l i m i t a t i o n s o f t r e a t m e n t i n t h i s g r o u p , t h e p o s s i b l e m e d i c a l c o m p l i c a t i o n s o f d e n t a l o p e r a t i o n s a n d t h e i n a p p r o p r i a t e f a c i l i t i e s t o t r e a t t h e i n s t i t u t i o n a l i z e d . D e n t i s t s have grown a c c u s t o m e d t o t h e m a s s i v e i n f r a s t r u c t u r e o f t h e i r p r i v a t e 1 5 o f f i c e , w i t h o u t w h i c h many f e e l i n a d e q u a t e i n h a n d l i n g p a t i e n t s . F o r e x a m p l e , i t i s n e c e s s a r y t o gauge t h e i r i n t e r e s t i n u s i n g p o r t a b l e e q u i p m e n t , i f o f f e r e d . F i n a l l y , t h e r e a r e t h e e c o n o m i c i s s u e s o f d e n t a l p r a c t i c e s t h a t l e a d t o t h e h y p o t h e s i s t h a t o p p o r t u n i t y c o s t s w i l l p r e d i c t m o t i v a t i o n t o e n t e r i n t o LTC p r a c t i c e . The i m p o r t a n c e o f f i n a n c i a l r e i m b u r s e m e n t may be a s k e d o u t r i g h t l y . However, t h e o p p o r t u n i t y c o s t s i n t r e a t i n g t h e e l d e r l y may be gauged w i t h q u e s t i o n s r e g a r d i n g t h e i r c o n c e r n f o r l o s s o f p r a c t i c e and l e i s u r e t i m e i n d e c i d i n g whether t h e y w o u l d p r a c t i c e i n L T C s , an d m a t c h i n g t h e r e s p o n s e s t o t h e b u s y n e s s of t h e i r p r i v a t e p r a c t i c e - be i t a new, an e s t a b l i s h e d o r a p a r t - t i m e r e t i r e d p r a c t i c e . 2.5.1 Independent and Dependent Variables I n o r d e r t o measure t h e r e l e v a n c e o f t h e t h r e e b r o a d p e r s p e c t i v e s i n t h e a c c e s s i b i l i t y o f d e n t a l h e a l t h c a r e , a number o f i n d i c a t o r s have been d e v e l o p e d . I n a l l t h e a n a l y s e s , w i l l i n g n e s s o r i n t e r e s t i n p r o v i d i n g s e r v i c e s t o t h e e l d e r l y l i v i n g i n LTC f a c i l i t i e s i s t h e d e p e n d e n t v a r i a b l e . T h i s v a r i a b l e i s measured by t h e r e s p o n s e o f t h e d e n t i s t s t o a d i r e c t q u e s t i o n on t h e i r i n t e r e s t i n p r a c t i s i n g a t LTC f a c i l i t i e s i f an a d m i n i s t r a t o r makes s u c h a r e q u e s t r e g a r d i n g a r e s i d e n t . I n t h e f i r s t model, t h e b r o a d i n d e p e n d e n t v a r i a b l e s a r e t h e s o c i a l p e r c e p t i o n s of t h e e l d e r l y . T h e s e p e r c e p t i o n s o f e l d e r l y c l i e n t s w i l l i n f l u e n c e i n t e r e s t i n w o r k i n g i n LTC f a c i l i t i e s . 1 6 The s o c i a l p e r c e p t i o n o f t h e e l d e r l y , a r a t h e r amorphous c o n c e p t , may be d e f i n e d and m e a s u r e d by a s e r i e s of c o n c r e t e v a r i a b l e s : t h e d e n t i s t ' s age, e x p e r i e n c e w i t h e l d e r l y c l i e n t s , e x p e r i e n c e w i t h e l d e r l y i n l o n g t e r m c a r e , enjoyment of s o c i a l i z i n g and c o m m u n i c a t i n g w i t h e l d e r l y c l i e n t s , and t h e p e r c e p t i o n o f d i s t i n c t i o n s between e l d e r l y o r o t h e r age g r o u p s i n t h e i r p r a c t i c e . I n t h e model of p r o f e s s i o n a l v a l u e s , a g r o u p o f d e t e r m i n a n t v a r i a b l e s may be u s e d : g e r i a t r i c t r a i n i n g , s p e c i a l i z a t i o n , y e a r s of p r a c t i c e , p r a c t i c e e x p e r i e n c e w i t h w e l l and f r a i l e l d e r l y , a v a i l a b i l i t y o f o p e r a t o r y o r a p p r o p r i a t e d e n t a l e q u i p m e n t i n LTC f a c i l i t i e s , t h e p e r c e p t i o n o f l i m i t a t i o n s o f t r e a t m e n t o f t h e e l d e r l y , and p r o f e s s i o n a l s a t i s f a c t i o n i n t r e a t i n g t h e e l d e r l y . I n t h e e c o n o m i c model, i n w h i c h o p p o r t u n i t y c o s t s a r e t h e i n d e p e n d e n t v a r i a b l e s , s u c h f a c t o r s a s t h e i m p o r t a n c e o f t h e l o s s o f p r a c t i c e o r l e i s u r e t i m e , and l e s s s i g n i f i c a n t l y , f i n a n c i a l r e i m b u r s e m e n t a r e a s s e s s e d . The d i s t a n c e t h a t must be t r a v e l l e d ( i . e . t i m e l o s s ) and c a p i t a l o u t l a y f o r p o r t a b l e e q u i p m e n t a r e t h r e s h o l d c o s t v a r i a b l e s w h i c h may d e t e r m i n e w h e t h e r a d e n t i s t w i l l d e c i d e o p p o r t u n i t i e s l o s t a r e t o o h i g h t o i n i t i a t e an LTC p r a c t i c e . In t h i s s t u d y , t h e e m p i r i c a l a n a l y s i s o f d e n t i s t s ' i n t e r e s t s i n w o r k i n g w i t h t h e i n s t i t u t i o n a l i z e d e l d e r l y w i l l t e s t t h e s t r e n g t h o f t h e t h r e e m o d e l s : t h e s o c i o - c u l t u r a l , t h e p r o f e s s i o n a l and t h e e c o n o m i c . S p e c i f i c h y p o t h e s e s under e a c h 1 7 model a r e p r e s e n t e d i n L i s t 1 . 2.5.2 List 1: Explicit Hypotheses of the Three Models Soc i o - c u l t u r a l model H y p o t h e s e s : D e n t i s t s who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i l l be: 1) t h o s e who e n j o y s o c i a l i z i n g a n d c o m m u n i c a t i n g w i t h e l d e r l y p a t i e n t s 2) t h o s e who do n o t d i s t i n g u i s h between t h e e l d e r l y a n d o t h e r s 3) t h o s e who a r e o l d e r and by a s s u m p t i o n more e m p a t h e t i c w i t h t h e p r o b l e m s o f t h e e l d e r l y P r o f e s s i o n a l model H y p o t h e s e s : D e n t i s t s who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i l l be: Othose who have s p e c i a l i z e d t r a i n i n g a n d / o r e x p e r i e n c e i n g e r i a t r i c and s p e c i a l c a r e d e n t i s t r y 2) t h o s e w i t h a h i g h p r o p o r t i o n o f e l d e r l y i n t h e i r p r a c t i c e 3) t h o s e who i n d i c a t e p r o f e s s i o n a l s a t i s f a c t i o n i n t r e a t i n g t h e e l d e r l y 4) t h o s e who make home v i s i t s 5) t h o s e who do n o t v i e w t h e o r a l h e a l t h p r o b l e m s o f t h e a g e d a s h a v i n g l i m i t e d t r e a t m e n t p o t e n t i a l 6) t h o s e who a r e w i l l i n g t o use p o r t a b l e e q uipment and l e s s c o n c e r n e d w i t h t h e a v a i l a b i l i t y o f a s t a t i o n a r y o p e r a t o r y E c o n o m i c Model H y p o t h e s e s : D e n t i s t s who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i l l be: 1) t h o s e who a r e b e g i n n i n g a p r a c t i c e o r r e t i r i n g a s o p p o s e d t o t h o s e w i t h an e s t a b l i s h e d p r a c t i c e 2) t h o s e f o r whom t h e o p p o r t u n i t y c o s t s i n l o s s o f p r i v a t e p r a c t i c e and l e i s u r e t i m e a r e low 3) t h o s e who a r e l e s s c o n c e r n e d w i t h f i n a n c i a l r e i m b u r s e m e n t a n d c a p i t a l e x p e n s e s ( s u c h a s p o r t a b l e e q u i p m e n t ) 18 CHAPTER 3 METHODS FOR DENTISTS' SURVEY 3 .1 D e v e l o p m e n t o f t h e S u r v e y A m a i l s u r v e y , i n t h e f o r m o f a m u l t i p l e c h o i c e q u e s t i o n n a i r e , was c h o s e n t o t e s t t h e s i g n i f i c a n c e o f t h e t h r e e d i f f e r e n t t h e o r e t i c a l c o n s t r u c t s on t h e d e n t i s t - d i s a b l e d e l d e r l y r e l a t i o n s h i p . P r e v i o u s s u r v e y s o f h e a l t h p r o f e s s i o n a l s were e x a m i n e d i n o r d e r t o e s t a b l i s h g u i d e l i n e s f o r an e x p e d i t i o u s and e c o n o m i c a l a c q u i s i t i o n o f s o c i o - c u l t u r a l , p r o f e s s i o n a l and e c o n o m i c i n f o r m a t i o n f r o m a g r o u p o f d e n t i s t s . The p r o b l e m s o f a c q u i r i n g p e r s o n a l i n f o r m a t i o n f r o m d e n t a l p r o f e s s i o n a l s were d i s c u s s e d w i t h t h e p r e s i d e n t o f t h e C o l l e g e o f D e n t a l S u r g e o n s ( C D S ) , D r . J . S i l v e r , and s e v e r a l p r o f e s s o r s f r o m t h e d e p a r t m e n t o f R e s t o r a t i v e D e n t i s t r y . I was a d v i s e d t h a t d e n t i s t s o f t e n d i s c a r d any r e q u e s t s f o r f i n a n c i a l i n f o r m a t i o n , e v e n f r o m t h e CDS, w h i c h n e g o t i a t e s on t h e i r b e h a l f w i t h g overnment a g e n c i e s . As w e l l , d e n t i s t s a r e r e l u c t a n t t o answer l e n g t h y q u e s t i o n n a i r e s w h i c h may i n t r u d e on t h e i r p r i v a t e p r a c t i c e s c h e d u l e . The g o a l was an anonymous q u e s t i o n n a i r e , l a c k i n g any d i r e c t r e q u e s t s f o r f i n a n c i a l i n f o r m a t i o n , w h i c h would t a k e most d e n t i s t s l e s s t h a n 10 m i n u t e s t o c o m p l e t e . F o r t h e s a k e o f b r e v i t y and c l a r i t y t h e q u e s t i o n n a i r e was a l m o s t e x c l u s i v e l y m u l t i p l e c h o i c e . 1 9 The q u e s t i o n n a i r e was s u b d i v i d e d i n t o two separate s e c t i o n s . The f i r s t s e c t i o n ( h e n c e f o r t h SECTION 1) was c o n s t r u c t e d to measure d i f f e r e n t a t t i t u d i n a l , s t r u c t u r a l , and f i n a n c i a l v a r i a b l e s which c o u l d be d e c i s i v e i n the w i l l i n g n e s s of d e n t i s t s to engage i n a LTC d e n t a l program. The second s e c t i o n ( h e n c e f o r t h SECTION 2) was d i r e c t e d to d e n t i s t s who were now or who p r e v i o u s l y had p r a c t i s e d at L T C s. I t asked f o r l o g i s t i c a l i n f o r m a t i o n ( f i n a n c i a l reimbursement, d i s t a n c e t r a v e l l e d , equipment a v a i l a b i l i t y , e t c ) . T h i s i n f o r m a t i o n was thought to be of value i n the f u t u r e development of treatment programs, and i n f u r n i s h i n g a b r i e f d e s c r i p t i o n of c u r r e n t LTC d e n t a l p r a c t i c e s i n Vancouver. 3.1.1 Pretesting of the Questionnaire The completed two p a r t q u e s t i o n n a i r e was sent to the s u p e r v i s o r s of the study and s e v e r a l members of the d e n t a l f a c u l t y f o r comment. A f t e r some minor a l t e r a t i o n s i n wording and s t r u c t u r e , the p i l o t t e s t q u e s t i o n n a i r e was mailed out to 50 d e n t i s t s p i c k e d at random from the C o l l e g e of Dental Surgeons' r e g i s t e r . T h i s p i l o t study began i n November,1984, and by January, 1985, twenty-nine q u e s t i o n n a i r e s were mailed back to the F a c u l t y of D e n t i s t r y . These were examined f o r q u e s t i o n s which d i d not e l i c i t responses or were m i s l e a d i n g and ambiguous. T h i s p r e t e s t r e s u l t e d i n some f u r t h e r changes i n the q u e s t i o n n a i r e (See Appendix B). Question 7, an open-ended q u e s t i o n on the l o c a t i o n of p r a c t i c e was now a m u l t i p l e - c h o i c e 20 l i s t i n g b e c a u s e t h e a n s w e r s had v a r i e d i n t h e i r d e g r e e o f p r e c i s i o n . Q u e s t i o n 16 o f f e r e d i n t e r e s t e d d e n t i s t s o p t i o n s i n e s t i m a t e s o f t h e t i m e t h e y c o u l d d e v o t e t o LTC p r a c t i c e i n weeks p e r y e a r , d a y s p e r month, o r h o u r s p e r week. T h i s was c h a n g e d t o a s i n g l e f o r m a t , h o u r s p e r month, b e c a u s e t h e o p t i o n s p r o v e d t o o c o n f u s i n g f o r t h e d e n t i s t s , who o f t e n l e f t a q u e s t i o n mark i n p l a c e o f number. The t a b l e f o r m a t i n SECTION 2 was a b a n d o n e d b e c a u s e i t was s e l d o m f i l l e d i n c o r r e c t l y . I n s t e a d , t h e f i n a l q u e s t i o n n a i r e p r e s e n t s t h i s s e c t i o n e n t i r e l y i n r e g u l a r l i n e a r s e n t e n c e f o r m a t w i t h m u l t i p l e c h o i c e r e s p o n s e o p t i o n s . The l o g i s t i c a l i n f o r m a t i o n p o r t i o n i s now r e p e a t e d t h r e e t i m e s so t h a t t h r e e s e p a r a t e f a c i l i t i e s i n t h e d e n t i s t ' s e x p e r i e n c e may be a c c o u n t e d f o r . 3.1.2 The population A p o p u l a t i o n o f 603 d e n t i s t s , whose o f f i c e s were s i t u a t e d i n t h e LTC o r a l h e a l t h s u r v e y s t u d y a r e a ( V a n c o u v e r , B u r n a b y , N o r t h and West V a n c o u v e r ) , were s e l e c t e d f o r t h e s u r v e y . F i n a n c i a l and t i m e c o n s t r a i n t s q u a s h e d any a m b i t i o n s f o r a l a r g e r p r o v i n c i a l s u r v e y . T h i s g r o u p o f d e n t i s t s were s p e c i f i c a l l y c h o s e n w i t h a . p i l o t t r e a t m e n t p r o g r a m f o r t h e LTC f a c i l i t i e s i n mind. T h e r e f o r e , t h o s e s p e c i a l t y g r o u p s who have l i t t l e o r no c o n t a c t w i t h t h e h a n d i c a p p e d a n d e l d e r l y were o m i t t e d . Of t h e 691 d e n t i s t s r e g i s t e r e d w i t h t h e CDS, 88 were i n o r t h o d o n t i c s , p e d o d o n t i c s o r o r a l r a d i o l o g y , and t h e y were e l i m i n a t e d f r o m t h e s t u d y . 21 T h e r e were t h r e e r e a s o n s f o r s u r v e y i n g t h e e n t i r e r e m a i n i n g p o p u l a t i o n . E a r l i e r i n t h e y e a r , a l e t t e r c i r c u l a t e d by t h e S e c r e t a r y o f t h e V a n c o u v e r D i s t r i c t D e n t a l A s s o c i a t i o n r e q u e s t i n g t h e names of d e n t i s t s w i l l i n g t o o f f e r s e r v i c e s t o t h e i n s t i t u t i o n a l i z e d e l d e r l y y i e l d e d a r e s p o n s e o f 4 names. T h i s p o o r s h o w i n g on t h e p a r t o f t h e p r o f e s s i o n and o t h e r p r e l i m i n a r y d a t a s u g g e s t e d t h a t t h e number o f p o s i t i v e r e s p o n s e s on some q u e s t i o n s m i g h t be so low i f a sample were c h o s e n t h a t e s t i m a t e s o f t h e p a r e n t p o p u l a t i o n m i g h t have h i g h s t a n d a r d e r r o r s . S e c o n d l y , t h e p o p u l a t i o n was s m a l l enough t h a t t h e c o s t s w ould n o t be e x c e s s i v e i f t h e e n t i r e g r o u p w o u l d be s u r v e y e d . T h i r d l y , t h e q u e s t i o n n a i r e i n t r o d u c e d t h e c o n c e p t o f a p i l o t p l a n t o s e r v i c e L T C s , and e a c h d e n t i s t w o u l d be g i v e n t h e o p p o r t u n i t y t o p a r t i c i p a t e . 3.2 The Q u e s t i o n n a i r e 3. 2. 1 St r uct ur e See A p p e n d i x B The f i r s t s e c t i o n ( S E C T I O N 1 ) , w h i c h a p p l i e s t o a l l d e n t i s t s , may be d i v i d e d i n t o f o u r p a r t s . T h e s e p a r t s w i l l be o u t l i n e d b e low. The f i r s t p a r t r e q u e s t s d e m o g r a p h i c , p r a c t i c e , a n d e d u c a t i o n a l d a t a f r o m t h e r e s p o n d e n t s . The age, y e a r s o f g e n e r a l and s p e c i a l t y p r a c t i c e , a v e r a g e w o r k i n g h o u r s p e r week, t y p e and l o c a t i o n o f p r a c t i c e , and g e r i a t r i c d e n t a l t r a i n i n g ( r a n g i n g 22 from f o r m a l u n i v e r s i t y c o u r s e s t o p o s t - g r a d u a t e c o n t i n u i n g e d u c a t i o n ) a r e i n c l u d e d h e r e . B e c a u s e a r e q u e s t f o r h o u r l y income was c o n s i d e r e d t o o a u d a c i o u s by a d v i s o r s t h e i n v e s t i g a t o r s u b s t i t u t e d " b u s y n e s s " a s a r o u g h gauge o f t h e p r o x i m i t y o f a c t u a l incomes t o t a r g e t i n c o m e s . T h u s , t h e d e n t i s t i s a s k e d whether h i s / h e r p r a c t i c e i s "busy enough". The s e c o n d p a r t o f t h e q u e s t i o n n a i r e a d d r e s s e s t h e t r a i n i n g , and e x p e r i e n c e w i t h e l d e r l y c l i e n t e l e , and t h e i m p r e s s i o n s made by e l d e r l y c l i e n t e l e . D e n t i s t s a r e a s k e d what p e r c e n t a g e o f t h e i r p a t i e n t s a r e e l d e r l y ( o v e r 6 5 ) , w hether t h e y make home v i s i t s , and a r e a s k e d t o c h o o s e from a l i s t t h e emergency and e l e c t i v e p r o c e d u r e s most common t o e l d e r l y p a t i e n t s . T h i s p a r t i n c l u d e s t h e t r a d i t i o n a l l y " a t t i t u d i n a l " component of t h e s t u d y . I was p a r t i c u l a r l y c o n c e r n e d a b o u t a means of m e a s u r i n g t h e d e n t i s t ' s s a t i s f a c t i o n w i t h t r e a t i n g t h e e l d e r l y . A p e r u s a l o f r e c e n t r e v i e w s o f t h e a t t i t u d e and knowledge m e a s u r i n g i n s t r u m e n t s t y p i c a l l y e m p l o y e d i n t h e a t t i t u d e s t u d i e s ( d i s c u s s e d i n C h a p t e r 2) r e v e a l e d t h a t t h e y have f a l l e n o u t o f f a v o u r f o r s e v e r a l r e a s o n s . B o t h M c T a v i s h ( 2 l ) and K o g a n ( l 8 ) a d d r e s s t h e l a c k o f d i s t i n c t i o n between knowledge and a t t i t u d e amongst t h e s e m e a s u r i n g i n s t r u m e n t s . Many o f t h e s e i n s t r u m e n t s i m p l y t h a t t h e more a c c u r a t e one's knowledge o f t h e e l d e r l y ( t h e fewer t h e i n c o r r e c t s t e r e o t y p e s ) , t h e more p o s i t i v e o n e ' s a t t i t u d e t o w a r d them. In u s i n g s e m a n t i c d i f f e r e n t i a l t e c h n i q u e s , r e s e a r c h e r s assume t h a t t h e r e i s a c o n s e n s u s on t h e p a r t o f t h e p e r c e i v e r s o f t h e meaning o f c e r t a i n a d j e c t i v e s s u c h 23 as "happy" o r " i n d e p e n d e n t " . I have a l r e a d y m e n t i o n e d t h e c r i t i c i s m l e v e l e d by S i g n o r i e t a l . ( 2 8 ) , i n t h e u s e o f l i m i t e d and c o n t r o v e r s i a l t r a i t s w h i c h p r e c l u d e t h e d e s c r i p t i o n o f t h e e l d e r l y a s whole p e o p l e . Of g r e a t e r i m p o r t a n c e i s t h e c o n t i n u o u s o v e r g e n e r a l i z a t i o n o f t h e e l d e r l y , who a r e t r e a t e d as an homogenous g r o u p w i t h o u t s o c i o - e c o n o m i c c l a s s , r a c e , h e a l t h s t a t u s o r i n d i v i d u a l d i f f e r e n c e s . The v a l i d i t y o f s u c h a t t i t u d i n a l i n s t r u m e n t s i s f u r t h e r p u t i n t o d o u b t b e c a u s e t h e y l e n d t h e m s e l v e s t o a r t i f i c i a l r e s p o n s e e f f e c t s , s u c h a s r e s p o n s e s e t s and s o c i a l p r e s s u r e t o d i s g u i s e one's a g e i s m , p a r t i c u l a r l y amongst h e a l t h c a r e p r o f e s s i o n a l s ( 3 6 ) . I n any e v e n t , few s t u d i e s have s u b s t a n t i a t e d l i n k s between t h e v e r b a l e x p r e s s i o n s o f a t t i t u d e and c o n g r u e n t b e h a v i o u r s t o w a r d t h e e l d e r l y ( 1 8 ) . I c r e a t e d my own m e a s u r i n g i n s t r u m e n t o f p e r s o n a l / p r o f e s s i o n a l s a t i s f a c t i o n w i t h e l d e r l y p a t i e n t s w i t h two q u e s t i o n s . The f i r s t q u e s t i o n a s k s d e n t i s t s t o r e p o r t t h e p o s i t i v e and n e g a t i v e a s p e c t s o f t h e i r work w i t h t h e e l d e r l y on s p e c i f i c i s s u e s . T h e s e i n c l u d e e njoyment i n s o c i a l i z i n g and c o m m u n i c a t i n g w i t h t h e e l d e r l y , t h e l a c k o f d i s t i n c t i o n between t h e e l d e r l y and o t h e r age g r o u p s , d i f f i c u l t i e s w i t h m e d i c a l p r o b l e m s , c o n f u s i o n a n d / o r t h e u n g r a t e f u l o r u n c o m m u n i c a t i v e b e h a v i o u r s o f e l d e r l y , b a r r i e r s t o improvement o f o r a l h e a l t h s t a t u s b e c a u s e o f l i m i t a t i o n s t o i n t e r v e n t i o n o r l a c k o f f o l l o w - u p p r e v e n t i v e t h e r a p y and f i n a l l y , t h e t i m e c o n s u m i n g and f i n a n c i a l l y u n r e w a r d i n g n a t u r e o f s u c h work. The s e c o n d q u e s t i o n a s k s t h e d e n t i s t s t o w e i g h b o t h t h e p o s i t i v e a n d t h e n e g a t i v e 24 a s p e c t s t h e y h a v e n o t e d , t o d e t e r m i n e w h i c h o f t h e two c a t e g o r i e s p r e d o m i n a t e s i n t h e i r work w i t h t h e e l d e r l y . In t h i s manner, an e v a l u a t i o n o f s a t i s f a c t i o n d e r i v e d f r o m g e r i a t r i c d e n t i s t r y , a l t h o u g h somewhat l i m i t e d i n d e p t h , c a n l a t e r be u s e d as an i n d e p e n d e n t v a r i a b l e . The t h i r d p a r t f o c u s e s on t h e main i n d e p e n d e n t v a r i a b l e , i n t e r e s t i n p r a c t i s i n g a t LTC f a c i l i t i e s . A f t e r t h i s q u e s t i o n i s p o s e d , t h e d e n t i s t i s a s k e d how many h o u r s and how l o n g a d r i v e h e / s h e i s w i l l i n g t o g i v e t o s u c h a s e r v i c e . The f o u r t h p a r t o f t h e q u e s t i o n n a i r e i n c l u d e s t h e c o n s i d e r a t i o n s i n v o l v e d i n a r r i v i n g a t t h e d e c i s i o n t o t r e a t t h e i n s t i t u t i o n a l i z e d e l d e r l y . I t i s p r i m a r i l y a t a b l e o f s e v e n c o n s i d e r a t i o n s w h i c h a r e r a n k e d on a f o u r p o i n t o r d i n a l s c a l e f r o m v e r y i m p o r t a n t t o n o t i m p o r t a n t . E a c h o f t h e s e c o n s i d e r a t i o n s by i t s e l f , o r i n c o n j u n c t i o n w i t h o t h e r s , r e f l e c t s one o f t h e h y p o t h e s e s o f t h e s o c i o - c u l t u r a l , p r o f e s s i o n a l a n d e conomic m o d e l s . They a r e : l o s s o f l e i s u r e a n d / o r p r i v a t e p r a c t i c e t i m e ; d i s t a n c e t o f a c i l i t y ; f i n a n c i a l r e i m b u r s e m e n t an d c a p i t a l e x p e n s e s ; a v a i l a b i l i t y o f d e n t a l o p e r a t o r y ; p r o f e s s i o n a l and p e r s o n a l s a t i s f a c t i o n i n w o r k i n g w i t h e l d e r l y p a t i e n t s ; and e x p e r i e n c e and t r a i n i n g i n t r e a t i n g t h e d i a s a b l e d a n d c h r o n i c a l l y i l l e l d e r l y . Below t h i s t a b l e , c e r t a i n q u a l i f y i n g c o n d i t i o n s , s u c h a s p r e f e r r e d payment a r r a n g e m e n t s a s w e l l a s t h e u n d e r w r i t i n g o f c a p i t a l e x p e n s e s by t h e CDS o r t h e government a r e t a k e n i n t o a c c o u n t . 25 F i n a l l y , t h e d e n t i s t i s a s k e d t o mark t h e r e a s o n s why s u c h a s e r v i c e has n o t been a p a r t o f h i s / h e r p r a c t i c e b e f o r e . The r e s p o n s e o p t i o n s a r e s i m i l a r t o t h e c o n s i d e r a t i o n s , but a l s o r e f e r t o t h e l a c k o f s e r v i c e r e q u e s t by t h e a d m i n i s t r a t i o n , and t o t h e a d m i n i s t r a t i v e b a r r i e r s t o p r o p e r t r e a t m e n t . T h i s q u e s t i o n e n d s t h e f i r s t s e c t i o n . SECTION 2, w h i c h i s f i l l e d o u t o n l y by t h o s e d e n t i s t s who have p r a c t i s e d a t LTC f a c i l i t i e s , c o n s i s t s o f two p a r t s . t The f i r s t p a r t o f t h i s s e c t i o n i s d e s c r i p t i v e . The d e n t i s t i s a s k e d t o mark o f f t h e most common p r o c e d u r e s u n d e r t a k e n a t t h e f a c i l i t i e s . T h i s l i s t i n g i s f o l l o w e d by a q u e r y as t o how c l o s e l y t h e d e n t i s t f o l l o w e d t h e f e e g u i d e . The a n s wers may be o f v a l u e i n p o l i c y g u i d e l i n e s f o r a LTC p r o g r a m . The n e x t s e r i e s o f q u e s t i o n s a r e e x t e n s i o n s o f t h e p r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n m e a s u r i n g i n s t r u m e n t d e v e l o p e d f o r t h e f i r s t q u e s t i o n n a i r e . I n t h i s c a s e , t h e p o s i t i v e a n d n e g a t i v e a s p e c t s a r e l i s t e d i n two s e p a r a t e q u e s t i o n s ( S e e A p p e n d i x B ) . The d e n t i s t a g a i n must weigh t h e two l i s t s a n d d e c i d e w h i c h p r e d o m i n a t e s . T h i s r e t r o s p e c t i v e a p p r a i s a l i s o n l y o f t h e i n s t i t u t i o n a l i z e d e l d e r l y t h i s t i m e . F o l l o w i n g t h i s l i n e o f i n q u i r y , two q u e s t i o n s p r o b e i n t o t h e i n c e n t i v e s and d i s i n c e n t i v e s o f s u c h a p r a c t i c e . Amongst t h e i n c e n t i v e s , t h e d e n t i s t may n o t e s o c i a l c o n t a c t s ; p u b l i c s e r v i c e ; p r i v a t e p r a c t i c e o p p o r t u n i t y ; p r o f e s s i o n a l r e s p o n s i b i l i t y a n d / o r s e m i - r e t i r e m e n t p r a c t i c e . Amongst t h e 26 d i s i n c e n t i v e s , t h e d e n t i s t may mark o f f any one o f t h e f o l l o w i n g : a d m i n i s t r a t i v e d i f f i c u l t i e s ; f i n a n c i a l o r l e i s u r e t i m e l o s s ; p r i v a t e p r a c t i c e commitments; and p e r s o n a l / p r o f e s s i o n a l d i s a t i s f a c t i o n . T h i s s e r i e s o f q u e s t i o n s a r e i m p o r t a n t a d j u n c t s t o SECTION 1 i n d e d u c i n g t h e u n d e r l y i n g e l e m e n t s i n t h e i n t e r p l a y o f t h e d e n t a l p r o f e s s i o n and l o n g t e r m c a r e p a t i e n t s . The s e c o n d p a r t o f SECTION 2 i s a t h r e e s e r i e s r e p e t i t i o n o f q u e s t i o n s d e s c r i b i n g t h e p r a c t i c e s t r u c t u r e w i t h e a c h f a c i l i t y . T h e s e q u e s t i o n s i n c l u d e name or t y p e o f f a c i l i t y , t i m e span o f p r a c t i c e and f r e q u e n c y o f s e r v i c e v i s i t s , d i s t a n c e t r a v e l l e d , t y p e o f e q u i p m e n t a v a i l a b l e , a n d r e i m b u r s e m e n t a r r a n g e m e n t s . 3. 2. 2 Var i abi es As d i s c u s s e d e a r l i e r , t h e m o d e ls c o n s i s t o f one i n d e p e n d e n t v a r i a b l e , i n t e r e s t i n LTC s e r v i c e , w h i c h i s p r e d i c t e d by a l i n e a r c o m b i n a t i o n o f i n d e p e n d e n t v a r i a b l e s . The f o l l o w i n g t a b l e s u m m arizes t h e i n d e p e n d e n t v a r i a b l e s under t h e u m b r e l l a o f e a c h of t h e t h r e e t h e o r e t i c a l m o d e l s . T a b l e 1:Independent V a r i a b l e s i n t h e T h r e e M o d e l s Q u e s t i o n number i s d e n o t e d by (Q ) S o c i o - c u l t u r a l M o d e l I n d e p e n d e n t v a r i a b l e : Age(Q1) P e r s o n a l / p r o f e s s i o n a l s a t i s f a c t i o n : ( Q 1 3 ) a) e n j o y s o c i a l i z i n g w i t h e l d e r l y b) d o n ' t see a d i s t i n c t i o n between e l d e r l y a n d o t h e r s d ) e l d e r l y o f t e n u n g r a t e f u l o r u n c o m m u n i c a t i v e 27 e) do n o t f o l l o w up p r e v e n t i v e t h e r a p y Summary o f p o s i t i v e and n e g a t i v e a s p e c t s ( Q 1 4 ) C o n s i d e r a t i o n s : ( Q 1 8 ) f ) P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n i n w o r k i n g w i t h t h e e l d e r l y P r o f e s s i o n a l M o d e l I n d e p e n d e n t v a r i a b l e : Type o f p r a c t i c e ( Q 6 ) T r a i n i n g i n g e r i a t r i c d e n t i s t r y : ( Q 9 ) a) f o r m a l u n i v e r s i t y c o u r s e w i t h c l i n i c a l e x p e r i e n c e b) f o r m a l u n i v e r s i t y c o u r s e o n l y c ) c l i n i c a l i n s t i t u t i o n a l e x p e r i e n c e d) o c c a s i o n a l l e c t u r e s i n c u r r i c u l u m e) p o s t - g r a d u a t e c o n t i n u i n g ed f ) no f o r m a l t r a i n i n g P e r c e n t a g e e l d e r l y i n p r a c t i c e ( Q 1 0 ) Home v i s i t s ( Q 1 1 ) P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n : ( Q 1 3 ) c ) e l d e r l y p r e s e n t d i f f i c u l t i e s due t o m e d i c a l c o m p l i c a t i o n s e) e l d e r l y do n o t f o l l o w up p r e v e n t i v e t h e r a p y f ) d i f f i c u l t t o i m p r o v e o r a l h e a l t h ( l i m i t e d t r e a t m e n t o p t i o n s ) Summary o f P o s i t i v e and n e g a t i v e a s p e c t s ( Q 1 4 ) C o n s i d e r a t i o n s : ( Q 1 8 ) e) a v a i l a b i l i t y o f d e n t a l o p e r a t o r y f ) p r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n i n w o r k i n g w i t h e l d e r l y g) e x p e r i e n c e / t r a i n i n g w i t h c h r o n i c a l l y i l l o r d i s a b l e d R e a s o ns f o r n o n - p r o v i s i o n : ( Q 2 1 ) b ) i n a d e q u a t e t r a i n i n g and e x p e r i e n c e e ) l a c k o f a p p r o p r i a t e t r e a t m e n t f a c i l i t i e s E c o nomic M o d e l I n d e p e n d e n t v a r i a b l e : Age(Q1) Y e a r s i n p r a c t i c e ( Q 2 ) Y e a r s i n s p e c i a l t y p r a c t i c e ( Q 3 ) S t a t u s o f p r a c t i c e ( Q 4 ) H o u r s worked p e r week(Q5) B u s i n e s s ( Q 8 ) P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n ( Q 1 3 ) g ) g e r i a t r i c work t i m e c o n s u m i n g a n d f i n a n c i a l l y u n r e w a r d i n g C o n s i d e r a t i o n s ( Q 1 8 ) : a) l o s s o f p r i v a t e p r a c t i c e t i m e b) l o s s o f l e i s u r e t i m e c ) d i s t a n c e t o f a c i l i t y 28 d ) f i n a n c i a l r e i m b u r s e m e n t and c a p i t a l e x p e n s e s I m p o r t a n c e o f c o s t of p o r t a b l e e q u i p m e n t ( Q 1 9 ) I m p o r t a n c e o f f o r m o f r e i m b u r s e m e n t and p r e f e r e n c e s ( Q 2 0 ) N o n - p r o v i s i o n of d e n t a l s e r v i c e s : ( Q 2 1 ) a ) t o o busy i n p r i v a t e p r a c t i c e c ) f i n a n e i a l l y c o s t l y and u n r e w a r d i n g 3.3 A d m i n i s t r a t i o n The m a i l - o u t p a c k a g e was p r e p a r e d t o e n s u r e a n o n y m i t y . A c o v e r l e t t e r i n t r o d u c e d t h e s u r v e y and t h e r e s e a r c h i t c o m p l e m e n t e d ( S e e A p p e n d i x A ) . The d e n t i s t was i n s t r u c t e d t o f i l l o u t t h e a p p r o p r i a t e s e c t i o n s o f t h e q u e s t i o n n a i r e and m a i l them i n a l a r g e brown p r e - p a i d e n v e l o p e . A b l u e s l i p w i t h t h e d e n t i s t ' s name on i t was t o be r e t u r n e d i n a n o t h e r p r e - p a i d w h i t e e n v e l o p e . T h i s was t o i n f o r m me a s t o w hether o r n o t s/he h a d r e p l i e d . On t h i s s l i p , t h e d e n t i s t was a s k e d i f s/he w o u l d l i k e more i n f o r m a t i o n on LTC f a c i l i t i e s r e q u e s t i n g d e n t a l s e r v i c e s . T h o s e who r e s p o n d e d f a v o u r a b l y were l i s t e d f o r a p i l o t p r o j e c t i n p r o g r e s s t o match d e n t a l needs t o demand i n L T C s . F u r t h e r , i f a g r e e d upon, t h e i r names w i l l be a d d e d t o a c u r r e n t f i l e a v a i l a b l e t o LTC a d m i n i s t r a t o r s . In a d d i t i o n , on t h e b l u e s l i p , t h e d e n t i s t was i n v i t e d t o p a r t i c i p a t e i n an i n t e r v i e w o v e r v i e w i n g h i s / h e r e x p e r i e n c e w i t h t h e e l d e r l y a t h i s / h e r c o n v e n i e n c e . The m a i l - o u t s were s e n t o u t o v e r a two month p e r i o d b e g i n n i n g i n F e b r u a r y , 1985. By J u l y , 334 o r 55% o f t h e d e n t i s t s had r e t u r n e d q u e s t i o n n a i r e s , w h i c h was a s u b s t a n t i a l l y l a r g e r r e t u r n r a t e t h a n was e x p e c t e d f o r a s t u d y of t h i s n a t u r e . 29 3.4 C o d i n g When t h e m a j o r i t y o f r e s p o n s e s a p p e a r e d t o have been r e t u r n e d s t a t i s t i c a l t e s t s were i n i t i a t e d . S u b s e q u e n t t o a f r e q u e n c y r u n , s e v e r a l o f t h e c o n t i n u o u s v a r i a b l e s , i . e . age, y e a r s o f g e n e r a l and s p e c i a l t y p r a c t i c e , and h o u r s c o m m i t t e d t o LTC s e r v i c e were r e c o d e d f o r t h e p u r p o s e s o f c r o s s t a b u l a t i o n ( T a b l e 2 ) . The number o f h o u r s e a c h d e n t i s t was w i l l i n g t o p r a c t i s e i n LTCs was r e c o d e d f r o m t h e o r g i n a l d a t a c a l c u l a t e d i n h o u r s p e r m o n t h ( Q l 6 ) . Such c a t e g o r i z a t i o n s i m p l i f i e s t h e d e g r e e of p r a c t i c e commitment by e a c h d e n t i s t ( T a b l e 2 ) . T a b l e 2 t C o d i n g o f C o n t i n u o u s V a r i a b l e s V a r i a b l e C o d i n g Age:(Q1) a . under 35 b. 36 t o 45 c . 46 t o 55 d . 56 t o 65 e. 65 p l u s Y e a r s o f p r a c t i c e ( Q 2 ) & s p e c i a l t y p r a c t i c e : ( Q 3 ) a . l e s s t h a n b. 6 t o 15 c . 16 t o 25 d . 26 t o 35 e. above 35 5 Commitment t o LTC p r a c t i c e : ( h o u r s p e r month)(Q16) a . l e s s t h a n 8 ( l e s s t h a n a day) b. 8 t o 16(1 t o 2 d a y s ) c . 17 t o 32(2 t o d a y s d. 33 t o 56(4 t o 7 d a y s ) e. more t h a n 56(more t h a n 7 d a y s ) 30 3.5 R e c o d i n q When t h e c o d i n g was c o m p l e t e d c r o s s t a b u l a t i o n s were r u n w i t h a l l t h e v a r i a b l e s a g a i n s t t h e d e p e n d e n t v a r i a b l e , i n t e r e s t i n LTC s e r v i c e . B e c a u s e many o f t h e v a r i a b l e s were n o m i n a l , a n o n - p a r a m e t r i c method, P e a r s o n ' s c h i - s q u a r e , was c h o s e n f o r e v a l u a t i o n o f t h e c r o s s t a b u l a t i o n r e s u l t s . C h i - s q u a r e t a b l e s were computed u s i n g t h e S p s s : x s t a t i s t i c a l p a c k a g e . A f t e r an i n i t i a l r un o f c r o s s t a b u l a t i o n s , i t was f o u n d t h a t f r e q u e n c y i v a l u e s f o r c e r t a i n v a r i a b l e s s e l d o m o c c u r r e d , a n d c o n s e q u e n t l y t h e s e c r o s s t a b u l a t i o n s i n c l u d e d a l a r g e number o f empty c e l l s . The number o f o f f i c e l o c a t i o n s ( Q 7 ) was r e d u c e d f r o m 22 t o 4 ( T a b l e 3 ) . A l l t h e V a n c o u v e r l o c a t i o n s were g r o u p e d i n t o a s i n g l e c a t e g o r y . N o r t h and West V a n c o u v e r were u n i t e d i n t o one g r o u p , b e c a u s e t h e numbers were t o o few t o be o f v a l u e a s s e p a r a t e c a t e g o r i e s . A l l l o c a t i o n s w h i c h f e l l o u t s i d e t h e s t u d y a r e a were g r o u p e d t o g e t h e r . O n l y t h e V a n c o u v e r , B u r n a b y , a n d N o r t h and West V a n c o u v e r c a t e g o r i e s were u s e f u l f o r a d e m o g r a p h i c c o m p a r i s o n o f t h e r e s p o n d e n t s and t h e p o p u l a t i o n . I n d e t e r m i n i n g t h e e f f e c t s o f t h e s t a t u s o f p r a c t i c e ( Q 4 ) , t h e 8 c a t e g o r i e s were r e c o d e d t o r e f l e c t o p p o r t u n i t y c o s t s o u t l i n e d i n t h e e c o n o m i c m o d e K T a b l e 3 ) . They were now: a new p r a c t i c e (low o p p o r t u n i t y c o s t s ) ; an e s t a b l i s h e d p r a c t i c e ( h i g h o p p o r t u n i t y c o s t s ) ; a p a r t - t i m e o r a s s o c i a t e p r a c t i c e ( l o w e r o p p o r t u n i t y c o s t s t h a n f u l l - t i m e , e s t a b l i s h e d p r a c t i c e ) ; a n d f u l l t i m e p u b l i c s a l a r i e d p r a c t i c e ( w h i c h e l i m i n a t e d t h e i r 31 T a b l e 3 : R e c o d i n g o f P r a c t i c e C h a r a c t e r i s t i c s R e c o d i n g O r i g i n a l C o d i n g S t a t u s o f P r a c t i c e : ( Q 4 ) a. New p r a c t i c e = b. E s t a b l i s h e d p r a c t i c e = c . P a r t - t i m e p r a c t i c e = b.new p r i v a t e p r a c t i c e b. e s t a b l i s h e d p r i v a t e p r a c t i c e e. f u l l - t i m e p u b l i c s a l a r i e d p r a c t i c e c . r e t i r e m e n t p a r t - t i m e p r a c t i c e d. p a r t - t i m e p r i v a t e p r a c t i c e f . p a r t - t i m e p u b l i c s a l a r i e d p r a c t i c e g. a s s o c i a t e p r a c t i c e Type o f P r a c t i c e : ( Q 6 ) a . G e n e r a l = b. S p e c i a l t y = a . G e n e r a l a l l o t h e r c a t e g o r i e s P r a c t i c e L o c a t i o n : ( Q 7 ) a . V a n c o u v e r b. B u r naby c . N o r t h and West V a n c o u v e r = d. o t h e r V a n c o u v e r s u b u r b s = a l l a r e a s under V a n c o u v e r m u n i c i p a l i t y ( d . t o s.) a. Burnaby b. West V a n c o u v e r c . N o r t h V a n c o u v e r a l l o t h e r l o c a t i o n s , ex.Richmond,New W e s t m i n i s t e r , C o q u i t l a m Home v i s i t s : ( Q 1 1 ) a .No= b . y e s = a. no b. y e s , o n l y i n e m e r g e n c i e s c . y e s a v a i l a b i l i t y f o r LTC s e r v i c e ) . The t y p e o f p r a c t i c e (Q6) was r e d e f i n e d a s g e n e r a l p r a c t i c e o r s p e c i a l t y p r a c t i c e . T h i s was c o n s i d e r e d t o be s u f f i c i e n t t o d e l i n e a t e t h e e c o n o m i c and p r o f e s s i o n a l c o n s i d e r a t i o n s o f t h e two g r o u p s i n t r e a t i n g t h e 32 e l d e r l y . Home v i s i t s (Q11) were r e c o d e d t o combine t h e r e s p o n s e s of " y e s " and " o n l y i n e m e r g e n c i e s " t o " y e s " , t h u s i n d i c a t i n g w i l l i n g n e s s t o p r a c t i s e o u t s i d e o f a d e n t a l o p e r a t o r y ( T a b l e 3 ) . The i n t e r v a l r a n k i n g o f i m p o r t a n c e of s e v e r a l c o n s i d e r a t i o n s (Q18) had o r i g i n a l l y c r e a t e d 4 v a l u e s . However, many empty c e l l s o c c u r r e d i n t h e c r o s s t a b u l a t i o n s . F o r t h e p u r p o s e s o f t h e s t u d y , t h e f i r s t two a n d l a s t two c a t e g o r i e s were c o m b i n e d . I n t h i s way, a g e n e r a l s t a t e m e n t o f i m p o r t a n c e i n d e c i d i n g t o p r a c t i s e a t LTCs c o u l d be u s e d i n s t a t i s t i c a l c o m p u t a t i o n s ( T a b l e 4 ) . T a b l e 4 i R e c o d i n g o f I m p o r t a n c e o f S p e c i f i c C o n s i d e r a t i o n s f o r LTC S e r v i c e R e c o d i n g O r i g i n a l c o d i n g a. i m p o r t a n t = a . v e r y i m p o r t a n t b . m o d e r a t e l y i m p o r t a n t b. n o t i m p o r t a n t = c . m i n i m a l l y i m p o r t a n t d . n o t i m p o r t a n t 3.6 S a m p l i n g B i a s In o r d e r t o f i n d o u t i f t h e r e was a b i a s i n t h e s t u d y g r o u p as a r e s u l t o f n o n - r e s p o n s e , t h e i n v e s t i g a t o r o b t a i n e d s t a t i s t i c a l d a t a f r o m t h e CDS on t h e d e m o g r a p h i c s o f t h e d e n t i s t 33 p o p u l a t i o n . The d e m o g r a p h i c d a t a were r e c o d e d , and a g o o d n e s s - o f - f i t t e s t was c o n d u c t e d u s i n g f o u r v a r i a b l e s : age, y e a r s o f p r a c t i c e , t y p e o f p r a c t i c e and l o c a t i o n o f p r a c t i c e , i n o r d e r t o compare t h e r e s p o n d e n t s t o t h e p o p u l a t i o n . 3.6.1 Results of the Bias Study Of t h e 305 r e s p o n d e n t s i n t h e major s t u d y , c o m b i n e d w i t h t h e 29 i n t h e p i l o t s t u d y , 2 7 1 d e n t i s t s a n s w e r e d t h e f i r s t s e c t i o n o n l y , and 63 r e s p o n d e d t o b o t h s e c t i o n s . T h i s w o u l d i n d i c a t e t h a t a p p r o x i m a t e l y 19% o f t h e lo w e r M a i n l a n d d e n t i s t s i n Bur n a b y , N o r t h a n d West V a n c o u v e r and V a n c o u v e r , have o r a r e c u r r e n t l y i n v o l v e d i n some form o f d e n t a l s e r v i c e d e l i v e r y t o t h e i n s t i t u t i o n s r e s i d i n g i n t h o s e b o u n d a r i e s . The d a t a on t h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e r e s p o n d e n t s and t h e p o p u l a t i o n a r e p r e s e n t e d i n T a b l e 5 below. The age of t h e r e s p o n d e n t s r a n g e d f r o m 26 t o 77 y e a r s , w i t h an a v e r a g e o f 42 y e a r s . T h e r e was no s i g n i f i c a n t d i f f e r e n c e i n age between t h e t o t a l p o p u l a t i o n and and t h e r e s p o n d e n t s ( x 2 = 6 . 6 3 , p=.1). The d e n t i s t s i n t h e s t u d y had p r a c t i s e d between 1 and 54 y e a r s i n t h e i r p r o f e s s i o n . The mean number o f y e a r s o f p r a c t i c e was 16. F o r t h o s e who h a d embarked upon s p e c i a l t y p r a c t i c e s t h e range was 1 t o 38 w i t h an a v e r a g e o f 11 y e a r s . The g o o d n e s s - o f - f i t X 2 showed no s i g n i f i c a n t d i f f e r e n c e s between t h e p o p u l a t i o n a n d t h e sample w i t h r e g a r d s t o y e a r s o f d e n t a l 34 p r a c t i c e ( x 2 = 2 . 9 2 , p=.6). TABLE 5:Demographic C h a r a c t e r i s t i c s o f R e s p o n d e n t s and P o p u l a t i o n V a r i a b l e R e s p o n d e n t s ( % ) P o p u l a t i o n ( % ) A g e g r o u p : ( Q 1 ) 35 o r l e s s 36-45 46-55 56-65 65 + x 2=6.63 p=. 1 d f = 4 120(37) 103(31) 49(15) 41(13) 14(4) 327(100) 216(31) 214(31) 117(17) 105(15) 39(6) 691(100) Y e a r s o f P r a c t i c e : ( Q 2 ) 6 o r l e s s 6-15 16-25 26-35 36 + x 2=2.92 p=. 6 d f = 4 61(19) 129(39) 72(22) 44(14) 21(6) 327(100) 125(18) 232(34) 177(26) 92(13) 65(9) 691(100) Type o f P r a c t i c e : ( Q 6 ) G e n e r a l Spec i a l t y x 2 = 0 p=1 df = 1 277(85) 48(15) 325(100) 586(85) 105(15) 691(100) L o c a t i o n o f P r a c t i c e : ( Q 7 ) V a n c o u v e r N o r t h and West V a n c o u v e r Burnaby x 2=.15 p=.99 224(72) 56(17) 33(11) 313(100) d f = 2 501(72) 120(18) 70(10) 691(100) 35 About 85% o f t h e d e n t i s t s i n t h e s u r v e y were i n g e n e r a l p r a c t i c e . T h i s p e r c e n t a g e i s n o t s i g n i f i c a n t l y d i f f e r e n t f r o m t h e p e r c e n t a g e i n g e n e r a l p r a c t i c e f o u n d i n t h e t o t a l p o p u l a t i o n ( x 2 = 0 , p=1) A p p r o x i m a t e l y 70% o f t h e d e n t i s t s p r a c t i s e d i n V a n c o u v e r , w i t h t h e h i g h e s t number o f d e n t i s t s l o c a t e d i n V a n c o u v e r E a s t ( l 2 % ) , Downtown V a n c o u v e r ( 1 0 % ) , K i t s i l a n o and F a i r v i e w S l o p e s ( 8 % ) . Ten p e r c e n t o f t h e d e n t i s t s p r a c t i s e d i n B u r n a b y , and 18% i n N o r t h and West V a n c o u v e r . T h e s e f i g u r e s p a r a l l e l t h e p r o p o r t i o n s o f t h e t o t a l d e n t i s t p o p u l a t i o n i n t h e t h r e e s t u d y a r e a s ( x 2 = . 1 5 , p=.99). T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n age, y e a r s o f p r a c t i c e , t y p e o f p r a c t i c e and l o c a t i o n o f p r a c t i c e between t h e r e s p o n d e n t s a n d t h e p o p u l a t i o n . T hus we s h o u l d be a b l e t o g e n e r a l i z e t h e f i n d i n g s f r o m t h e r e s p o n d e n t s t o t h e p o p u l a t i o n o f a l l d e n t i s t s i n G r e a t e r V a n c o u v e r ( w i t h t h e e x c e p t i o n o f t h e s p e c i a l t y g r o u p s o m i t t e d f r o m t h e s u r v e y ) . 36 CHAPTER 4 INTERESTS OF DENTISTS IN TREATING ELDERLY:RESULTS 4.1 O v e r v i e w The a n a l y s i s o f t h e d a t a was p e r f o r m e d t o s e l e c t t h e model w h i c h b e s t e x p l a i n e d t h e main d e p e n d e n t v a r i a b l e , i n t e r e s t i n LTC s e r v i c e . T h e r e were t h r e e d i s t i n c t s t a g e s i n t h i s a n a l y s i s . In t h e f i r s t s t a g e , f r e q u e n c y t a b l e s o f t h e d a t a p r o v i d e d a g e n e r a l d e s c r i p t i o n o f d e n t i s t s and t h e i r p e r c e p t i o n s o f w o r k i n g w i t h b o t h t h e w e l l and f r a i l e l d e r l y . The f o c u s o f t h e s e c o n d s t a g e was more s p e c i f i c . H e r e , t h e r e l a t i o n s h i p between a l l t h e i n d e p e n d e n t v a r i a b l e s , s u c h as t r a i n i n g and e x p e r i e n c e w i t h t h e e l d e r l y , a n d t h e d e p e n d e n t v a r i a b l e was e x a m i n e d t h r o u g h b i v a r i a t e a n a l y s i s , and t h e s i g n i f i c a n t v a r i a b l e s were s i n g l e d o u t . In t h e f i n a l a n d most complex s t a g e , a m u l t i v a r i a t e a n a l y s i s o f t h e c o m b i n e d , s i g n i f i c a n t p r e d i c t o r s i n e a c h model was c o n d u c t e d t o r a n k t h e m o d e l s a c c o r d i n g t o t h e i r a b i l i t y t o p r e d i c t i n t e r e s t . 4.2 F i r s t S t a g e : F r e q u e n c y D i s t r i b u t i o n s o f V a r i a b l e s Of p r i m a r y i m p o r t a n c e t o t h i s s t u d y were t h e r e s p o n s e s t o t h e q u e s t i o n w h i c h a s k e d , "Would yo u be i n t e r e s t e d i n p r o v i d i n g on g o i n g s e r v i c e s t o r e s i d e n t s o f a l o n g t e r m c a r e f a c i l i t y ? " . T h i r t y - s e v e n p e r c e n t of t h e d e n t i s t s s a m p l e d r e s p o n d e d t h a t t h e y were i n t e r e s t e d , a n o t h e r 37% i n d i c a t e d no i n t e r e s t and 26% were 37 u n c e r t a i n . A t t h e f i r s t s t a g e o f a n a l y s i s , t h e f r e q u e n c y d i s t r i b u t i o n s o f t h e r e s p o n s e s c o n t r i b u t e t o o u r knowledge o f who t h e s e d e n t i s t s a r e and what t h e y have t o s a y a b o u t t h e e l d e r l y a n d t h e p o s s i b i l i t y o f a l o n g t e r m c a r e d e n t a l s e r v i c e . T h i s i n f o r m a t i o n c a n be d i s c u s s e d w i t h r e f e r e n c e t o t h e i n d e p e n d e n t v a r i a b l e s i n t h e t h r e e m o d e l s . T a b l e 6 : I n t e r e s t i n LTC S e r v i c e V a r i a b l e # ( d e n t i s t s ) % I n t e r e s t i n LTC s e r v i c e : ( Q 1 5 ) Not i n t e r e s t e d 120 37 U n c e r t a i n 86 26 I n t e r e s t e d j_2J_ 37 327 100 Time committment t o LTC s e r v i c e ( h r s . p e r mo.):(Q16) L e s s t h a n 8 83 40 8-16 1 1 17-32 3 2 33-56 24 1 1 More t h a n 56 96 46 207 100 4.2.1 Univariate Anal ys i s : Soci o-cul t ur al Model Most o f t h e s o c i a l and c u l t u r a l components o f p r o f e s s i o n a l v i e w s o f t h e e l d e r l y a r e f o u n d i n q u e s t i o n 13, w h i c h o f f e r s v a r i o u s d e s c r i p t i o n s o f t h e e l d e r l y i n p r a c t i c e t o mark o f f , and q u e s t i o n 14, w h i c h a s k s t h e d e n t i s t t o u s e t h e s e v a r i o u s d e s c r i p t i o n s i n a s s e s s i n g s a t i s f a c t i o n w i t h t h e e l d e r l y i n t h e i r 38 p r a c t i c e . The r e s u l t s , l i s t e d i n T a b l e 7, c o n t r a d i c t t h e e a r l i e r f i n d i n g s o f K i y a k ( l 7 ) , C o e ( 8 ) , H o l t z m a n e t a l ( 1 4 , 1 5 ) , who u n c o v e r e d f a i r l y n e g a t i v e s t e r e o t y p e s o f e l d e r l y p a t i e n t s . O n l y 5% r e g a r d e d t h e e l d e r l y a s u n g r a t e f u l o r u n c o m m u n i c a t i v e , y e t 31% o f t h e r e s p o n d e n t s f e l t t h a t t h e e l d e r l y d i d n o t f o l l o w up p r e v e n t i v e t h e r a p y . In t h e i r a s s e s s m e n t o f s a t i s f a c t i o n i n w o r k i n g w i t h t h e e l d e r l y , 52% were p o s i t i v e , 8% were n e g a t i v e and 32% c o n s i d e r e d b o t h t h e p o s i t i v e a n d n e g a t i v e a s p e c t s t o be e q u a l l y b a l a n c e d . T a b l e 7 P e r c e p t i o n s o f Work w i t h E l d e r l y D e s c r i p t i o n s n o t e d : ( Q 1 3 ) # ( d e n t i s t s ) % E n j o y s o c i a l i z i n g w / e l d e r l y No d i s t i n c t i o n s between e l d e r l y a n d o t h e r s D i f f i c u l t i e s - m e d i c a l p r o b l e m s U n g r a t e f u l / u n c o m m u n i c a t i v e P r e v e n t i v e t h e r a p y n o t f o l l o w e d L i m i t e d t r e a t m e n t o p t i o n s Time c o n s u m i n g / f i n a n c i a l l y u n r e w a r d i n g 182 125 109 18 1 02 90 56 33 5 31 28 1 7 56 39 n = 334 Summary o f p o s i t i v e and n e g a t i v e a s p e c t s : ( Q I 4 ) P o s i t i v e o u t w e i g h n e g a t i v e N e g a t i v e o u t w e i g h p o s i t i v e B o t h t h e same U n c e r t a i n 167 24 103 2_7 321 52 8 32 8 1 00 39 T h e s e f i n d i n g s i n d i c a t e a f a i r l y p o s i t i v e v i e w o f e l d e r l y p a t i e n t s , w h i c h l e a d s us t o q u e s t i o n a model i n w h i c h t h e l a c k of s e r v i c e i s a t t r i b u t e d t o s o c i a l p r e j u d i c e s t o w a r d s t h e e l d e r l y . Whether t h e s e v i e w s p r e d i c t a d e n t i s t ' s i n t e r e s t i n w o r k i n g w i t h e l d e r l y i n LTCs w i l l be t e s t e d t h r o u g h b i v a r i a t e a n a l y s i s . 4.2.2 Univariate Anal ys i s: Pr ofe s s i onal Model T h e r e a r e two p r o c e s s e s w h i c h u l t i m a t e l y shape p r o f e s s i o n a l i d e o l o g i e s and b o t h a r e e x a m i n e d i n t h e s u r v e y . The f i r s t i s t h e t r a i n i n g o f d e n t i s t s , w h i c h g e n e r a t e s t h e i r d e f i n i t i o n s o f h e a l t h and d i s e a s e and t h e i r o u t l o o k on c u r e a n d p r e v e n t i o n , p a t h o l o g y and a g i n g . The s e c o n d i s t h e e x p o s u r e i n t h e i r p r a c t i c e t o t h e o r a l p r o b l e m s o f t h e e l d e r l y a n d t h e t r e a t m e n t o f e l d e r l y p a t i e n t s , w h i c h i s g u i d e d by t h e p r o f e s s i o n ' s i d e o l o g y . T h i s e x p e r i e n c e d e v e l o p s t h e d e n t i s t s ' a p p r a i s a l o f t h e w e l l a n d d i s a b l e d e l d e r l y a n d t h e r o l e o f d e n t a l s e r v i c e s f o r them. The t r a i n i n g d a t a o f t h e sample a r e l i s t e d i n T a b l e 8 , t h e i r e x p e r i e n c e w i t h t h e a g e d i s summarized i n T a b l e 9 b and t h e i r p r o f e s s i o n a l v i e w s a r e r e p o r t e d i n T a b l e 7 . The d a t a i n T a b l e 8 on t h e t r a i n i n g h i s t o r y of t h e r e s p o n d e n t s p o i n t s t o a r e l a t i v e l a c k o f f o r m a l c o u r s e s w i t h c l i n i c a l t r a i n i n g ( 6 % ) . Most commonly, t h e d e n t i s t s were i n t r o d u c e d t o t h e d e n t a l p r o b l e m s of t h e e l d e r l y t h r o u g h c l i n i c a l i n s t i t u t i o n a l e x p e r i e n c e ( 1 2 % ) , s u c h a s t h e p r o s t h o d o n t i c c l i n i c a l s e s s i o n h e l d a t t h e H e a l t h S c i e n c e s 4 0 T a b l e 8 : G e r i a t r i c D e n t a l T r a i n i n g o f R e s p o n d e n t s T r a i n i n g : ( Q 9 ) # ( d e n t i s t s ) % F o r m a l c o u r s e s and c l i n i c a l e x p e r i e n c e F o r m a l c o u r s e s C l i n i c a l i n s t i t u t i o n a l e x p e r i e n c e O c c a s i o n a l l e c t u r e s ( u n d e r g r a d u a t e c o u r s e s ) P o s t g r a d u a t e c o n t i n u i n g e d u c a t i o n No f o r m a l t r a i n i n g 22 159 n=334 13 41 107 21 7 48 4 1 2 32 6 C e n t r e H o s p i t a l - E x t e n d e d C a r e U n i t . O c c a s i o n a l l e c t u r e s ( 3 2 % ) , a s o p p o s e d t o f o r m a l c o u r s e s ( 4 % ) , f o r m e d t h e i r t h e o r e t i c a l k nowledge o f g e r i a t r i c d e n t i s t r y . About 7% o f t h e g r o u p had a t t e n d e d a p o s t - g r a d u a t e c o n t i n u i n g e d u c a t i o n c o u r s e i n g e r o d o n t o l o g y . N o n t h e l e s s , 48% h a d n o t r e c e i v e d any t r a i n i n g , e i t h e r f o r m a l o r i n f o r m a l , d u r i n g t h e i r u n i v e r s i t y p r o g r a m . T h i s l a s t f i n d i n g i s n o t s u r p r i s i n g i n t h e l i g h t o f t h e f a c t t h a t t h e e l d e r l y a r e a f a i r l y s m a l l p o r t i o n o f a d e n t i s t ' s c l i e n t e l e . The e l d e r l y c o n s t i t u t e d e i t h e r 10% o r l e s s o f most o f t h e p r a c t i o n e r ' s p a t i e n t s . T h i r t y - s i x p e r c e n t o f t h e d e n t i s t s had t r e a t e d t h e e l d e r l y a t home; 12% had done so o n l y i n e m e r g e n c i e s ( T a b l e 9 b ) . 41 T a b l e 9 a : P r a c t i c e C h a r a c t e r i s t i c s o f R e s p o n d e n t s V a r i a b l e # ( d e n t i s t s ) % S t a t u s o f P r a c t i c e : ( Q 4 ) N e w d e s s t h a n 5 y r s . ) 48 15 E s t a b l i s h e d o r s a l a r i e d 253 75 P a r t - t i m e 32 10 333 100 A v e r a g e w o r k i n g w e e k ( h r s ) : ( Q 5 ) L e s s t h a n 10 5 2 11-25 20 6 26-40 263 79 More t h a n 40 ' i i 11 332 100 B u s y n e s s o f p r a c t i c e : ( Q 8 ) Not b u s y 153 46 Busy 170 53 U n c e r t a i n 2 j_ 325 100 T a b l e 9 b : P r a c t i c e C h a r a c t e r i s t i c s R e l e v a n t t o E l d e r l y V a r i a b l e # ( d e n t i s t s ) % E l d e r l y i n p r a c t i c e ( a s % ) : ( Q 1 0 ) None 15 5 5 140 42 6-10 83 25 11-24 64 19 25+ 29 9 331 100 Home v i s i t s : ( Q 1 1 ) Do n o t v i s i t 211 64 Do v i s i t 80 24 O n l y i n e m e r g e n c i e s 4J_ J_2 332 100 42 The most common emergency p r o c e e d u r e s n o t e d f o r t h i s age s e c t o r were d e n t u r e a d j u s t m e n t s ( 7 5 % ) and e x t r a c t i o n s ( 7 0 % ) . A p r o s t h o d o n t i c o r i e n t a t i o n i s e v i d e n t i n t h e d a t a on e l e c t i v e p r o c e d u r e s . F i l l i n g s / c r o w n s ( 6 5 % ) , d e n t u r e f a b r i c a t i o n s ( 6 7 % ) and r e l i n e s ( 6 5 % ) were c l o s e l y f o l l o w e d by e x a m i n a t i o n s ( 7 3 % ) and p r o p h y l a x i s ( 6 9 % ) , i n f r e q u e n c y o f p r o c e d u r e s . About one h a l f o f t h e d e n t i s t s were commonly t r e a t i n g p e r i o d o n t a l c o n d i t i o n s and a s i m i l a r number(44%) were p e r f o r m i n g e n d o d o n t i c p r o c e d u r e s on e l d e r l y c l i e n t e l e ( T a b l e 1 0 ) . T a b l e 10:Common P r o c e e d u r e s f o r E l d e r l y P a t i e n t s P r o c e e d u r e s R e p o r t e d : # ( d e n t i s t s ) % Emergency:(Q12) E x t r a c t i o n s 234 70 D e n t u r e a d j u s t m e n t s 249 75 E n d o d o n t i c s / P e r i o d o n t i c s 167 50 D i a g n o s i s o f o r a l p a t h o s e s 79 24 B i o p s i e s 34 10 n=334 E l e c t i v e : ( Q 1 3 ) E x a m i n a t i o n s 242 73 O r a l h y g i e n e 230 69 F i l l i n g s / c r o w n 216 65 D e n t u r e f a b r i c a t i o n 224 67 D e n t u r e r e l i n e s 217 65 P e r i d o n t a l t h e r a p y 163 49 E n d o d o n t i c t h e r a p y 148 44 n=334 The e m p h a s i s on c u r a t i v e p r o c e d u r e s i n d e n t i s t r y , a c c o m p a n i e d by i m p l i c i t a s s u m p t i o n s a b o u t t h e p r o g r e s s i v e d e t e r i o r a t i o n o f t h e a g e d p e r s o n , i s c l e a r l y i n f l u e n t i a l i n t h e 43 d e n t i s t s ' e v a l u a t i o n s o f t h e e l d e r l y i n p r a c t i c e . About 1/3 o f t h e r e s p o n d e n t s b e l i e v e d t h a t t h e e l d e r l y p r e s e n t e d d i f f i c u l t i e s b e c a u s e o f t h e i r m e d i c a l p r o b l e m s and c o n f u s i o n , a n d a n o t h e r 28% t h o u g h t improvement o f t h e i r o r a l h e a l t h w o u l d be q u i t e l i m i t e d ( T a b l e 7 ) . The l a c k o f e x p e r i e n c e i n t r e a t i n g t h e m e d i c a l l y c o m p r o m i s e d p a t i e n t ( 2 4 % ) and t h e a b s e n c e o f a p p r o p r i a t e t r e a t m e n t f a c i l i t i e s ( 3 5 % ) were c i t e d a s r e a s o n s f o r n o t e x t e n d i n g t h e i r p r a c t i c e t o L T C s ( T a b l e 1 3 ) . The r e q u i r e m e n t o f a d e n t a l o p e r a t o r y c l e a r l y i n f l u e n c e d t h e i r d e c i s i o n t o t r e a t p a t i e n t s i n f a c i l i t i e s ( 9 l % ) , a s d i d t r a i n i n g a n d e x p e r i e n c e w i t h c h r o n i c c a r e p a t i e n t s ( 5 l % ) ( T a b l e 1 1 ) . T a b l e 1 1 : I m p o r t a n t C o n s i d e r a t i o n s f o r LTC S e r v i c e C o n s i d e r a t i o n s r a n k e d # ( d e n t i s t s ) % i m p o r t a n t : ( Q 1 8 ) P r i v a t e p r a c t i c e t i m e l o s s , n=293 217 74 L e i s u r e t i m e l o s s , n=292 163 56 D i s t a n c e , n=289 193 67 R e i m b u r s e m e n t / e x p e n s e s , n=289 220 76 D e n t a l o p e r a t o r y , n=295 269 91 P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n , 243 85 n=286 E x p e r i e n c e a n d t r a i n i n g , n=213 108 51 The p r o m i n e n c e o f t h e s e p r o f e s s i o n a l c o n c e r n s i n t h e d e n t i s t s ' d e c i s i o n making p r o c e s s i s a t t e s t e d t o by t h e g r e a t number o f d e n t i s t s who gave h i g h o r m o d e r a t e i m p o r t a n c e t o p r o f e s s i o n a l and p e r s o n a l s a t i s f a c t i o n i n t r e a t i n g e l d e r l y p a t i e n t s amongst t h e c o n s i d e r a t i o n s l i s t e d i n d e t e r m i n i n g i n t e r e s t ( 8 5 % ) . 44 T a b l e 1 2 : T h r e s h o l d V a r i a b l e s i n LTC d e c i s i o n V a r i a b l e # ( d e n t i s t s ) C o s t o f p o r t a b l e e q u i p m e n t : ( Q 1 9 ) R e l e v a n t U n c e r t a i n I r r e l e v a n t 21 1 48 44 303 70 16 I i 100 Use o f g o v t , p o r t a b l e e q u i p m e n t : ( Q 1 9 ) W i 1 1 i n g : U n c e r t a i n U n w i l l i n g 1 98 24 18 240 83 10 7 100 Form o f r e i m b u r s e m e n t : ( Q 2 0 ) R e l e v a n t U n c e r t a i n I r r e l e v a n t 73 68 1 54 295 25 23 52 100 Pay p r e f e r e n c e : ( Q 2 0 ) Fee f o r s e r v i c e Fee f o r t i m e S e s s i o n a l f e e R e t a i n e r f e e 85 88 31 1 4 n = 295 28 29 10 4 4.2.3 Univariate Anal ys i s : Economi c Model I u s e d s e v e r a l i n d i c a t o r s t h a t e i t h e r d i r e c t l y o r i n d i r e c t l y m e a s u r e d t h e r o l e o f income e x p e c t a t i o n s i n g u i d i n g t h e b e h a v i o u r o f d e n t i s t s . O p p o r t u n i t y c o s t s a r e d i r e c t l y r e l a t e d t o t h e c u r r e n t s t a t e o f a p r i v a t e p r a c t i c e . I f a p r a c t i c e i s a t c a p a c i t y , l e a v i n g t h e 45 o f f i c e w i l l r e s u l t i n l o s s o f p r a c t i c e t i m e and h e n c e p r o f i t s . I f t h e d e n t i s t c h o o s e s t o a v o i d any l o s s o f p r i v a t e o f f i c e income, t h e n any s e r v i c i n g c o n d u c t e d o u t s i d e o f t h e o f f i c e w i l l by n e c e s s i t y i n f r i n g e on h i s / h e r l e i s u r e t i m e . The d e n t i s t s were e v e n l y d i v i d e d i n t h e i r c a p a c i t y t o t a k e on new c l i e n t s . O v er h a l f o f t h e g r o u p r e g a r d e d t h e i r p r a c t i c e a s " b u s y " ( T a b l e 9 a ) . " B u s y n e s s " i n t h e i r p r i v a t e p r a c t i c e was c i t e d by 31% o f t h e r e s p o n d e n t s a s one o f t h e i r r e a s o n s f o r not e x t e n d i n g t h e i r p r a c t i c e t o L T C s ( T a b l e 1 3 ) . The l o s s o f p r a c t i c e t i m e was r a n k e d o f h i g h o r m o d e r a t e i m p o r t a n c e by 74% o f t h e g r o u p i n t h e i r d e c i s i o n r e g a r d i n g i n t e r e s t . L o s s o f l e i s u r e t i m e was r a n k e d o f h i g h i m p o r t a n c e amongst t h e c o n s i d e r a t i o n s by a l i t t l e more t h a n h a l f t h e d e n t i s t s ( 5 6 % ) ( T a b l e 1 1 ) . T h e s e f i g u r e s i n d i c a t e t h a t t h e e c o n o m i c t h e o r y has some w e i g h t i n e x p l a i n i n g p r o f e s s i o n a l m o t i v a t i o n s . T a b l e 13;Reasons f o r n o t P r o v i d i n g LTC S e r v i c e s R e a s o n s f o r no s e r v i c e : ( Q 2 1 ) # ( d e n t i s t s ) % Too b usy i n p r a c t i c e I n a d e q u a t e t r a i n i n g F i n a n c i a l l y c o s t l y B u r e a u c r a t i c b a r r i e r s I n a p p r o p r i a t e t r e a t m e n t f a c i l i t i e s Not a s k e d f o r s e r v i c e s O t h e r 85 64 42 33 95 1 52 28 31 24 15 12 35 56 10 n = 271 46 T h e s e i n d i r e c t i n d i c a t o r s a r e f u r t h e r b a c k e d by d i r e c t s t a t e m e n t s o f f i n a n c i a l c o n c e r n . Amongst t h e l i s t o f c o n s i d e r a t i o n s i n d e c i d i n g on s e r v i c i n g L T C s , f i n a n c i a l r e i m b u r s e m e n t and c a p i t a l e x p e n s e s r e c e i v e d a r e s p o n s e o f h i g h o r m o d e r a t e i m p o r t a n c e from 76% o f t h e d e n t i s t s s u r v e y e d , and 25% o f t h e d e n t i s t s a c k n o w l e d g e d t h a t t h e f o r m o f payment w o u l d d i r e c t l y e f f e c t t h e i r d e c i s i o n ( T a b l e 1 2 ) . S l i g h t l y o v e r one q u a r t e r o f t h e d e n t i s t s p r e f e r r e d t h e t r a d i t i o n a l f e e f o r s e r v i c e , and a s i m i l a r number p r e f e r r e d a f e e p e r t i m e a r r a n g e m e n t ( T a b l e 1 2 ) . Two t h r e s h o l d v a r i a b l e s , t h e d i s t a n c e t o a f a c i l i t y ( T a b l e 1 1 ) , and t h e c o s t o f p u r c h a s i n g p o r t a b l e e q u i p m e n t ( T a b l e 1 2 ) , were o f i m p o r t a n c e t o t w o - t h i r d s o f t h e g r o u p ( T a b l e s 11 and 1 2 ) . A t t h i s p r e l i m i n a r y s t a g e , t h e n , t h e e c o n o m i c m o d e l , w h i c h e m p h a s i z e s t h e f i n a n c i a l i n c e n t i v e s a n d d i s i n c e n t i v e s o f LTC s e r v i c e , a p p e a r s t o be i n f l u e n t i a l i n p r e d i c t i n g i n t e r e s t i n s u c h a d e n t a l s e r v i c e . 4.3 S e c o n d S t a g e : P r e d i c t i n g D e n t i s t s ' I n t e r e s t i B i v a r i a t e  A n a l y s i s 4.3.1 Ov er v / ew In t h e f i r s t s t a g e o f a n a l y s i s , I s i m p l y l o o k e d a t t h e i n d e p e n d e n t v a r i a b l e s , i . e . t h e c h a r a c t e r i s t i c s o f t h e d e n t i s t s and t h e i r comments on b o t h t h e e l d e r l y i n t h e i r p r a c t i c e a n d work a t LTC f a c i l i t i e s . In t h e s e c o n d s t a g e o f a n a l y s i s , I 47 e s t a b l i s h e d w h i c h o f t h e s e c h a r a c t e r i s t i c s a nd p e r s p e c t i v e s w o u l d p r e d i c t t h e i r i n t e r e s t i n LTC p r a c t i c e . T h i s was a c h i e v e d by s e t t i n g up b i v a r i a t e t a b l e s r e l a t i n g e a c h i n d e p e n d e n t v a r i a b l e t o t h e d e p e n d e n t v a r i a b l e , i n t e r e s t i n LTC s e r v i c e . In an e x p l o r a t o r y a n a l y s i s s u c h a s t h i s , a 10% or l e s s p r o b a b i l i t y l e v e l was c o n s i d e r e d s i g n i f i c a n t t o e n s u r e t h a t t h e r e was a h i g h p r o b a b i l i t y o f a p r e d i c t o r v a r i a b l e b e i n g d e t e c t e d . The f o l l o w i n g d i s c u s s i o n o r g a n i z e s t h e s e f i n d i n g s a r o u n d t h e t h r e e m o d e l s . S p e c i f i c c r o s s t a b u l a t i o n s on w h i c h t h e d i s c u s s i o n i s b a s e d a r e f o u n d i n A p p e n d i x C. 4.3.2 Bivariate Anal ys i s: Sbci o-cul t ur al Model The p a t t e r n t h a t emerges i n t h e s e c o n d s t a g e o f a n a l y s i s o f s o c i o - c u l t u r a l v a r i a b l e s d o e s n o t r e s e m b l e any o f t h o s e o f e a r l i e r s t u d i e s on d e n t a l s t u d e n t and p r o f e s s i o n a l a t t i t u d e s . In K i y a k ' s s t u d y ( 1 7 ) , age was a s i g n i f i c a n t f a c t o r i n d e t e r m i n i n g d e n t i s t s ' v i e w s o f t h e e l d e r l y , f o r t h e o l d e r t h e d e n t i s t s t h e more f a v o u r a b l e t h e i r p e r c e p t i o n o f o l d age a n d t h e more p o s i t i v e t h e i r v i e w o f t r e a t i n g t h e e l d e r l y . However i n t h i s s t u d y , t h i s t r e n d was n o t d i s p l a y e d . In f a c t , o v e r 50% o f t h o s e u n d e r 35 were i n t e r e s t e d i n LTC d e n t a l s e r v i c e s i n c o m p a r i s o n t o 29% o f t h o s e d e n t i s t s o v e r 55 y e a r s o f a g e ( T a b l e 1 6 ) . C l e a r l y t h e n , t h e i s s u e o f p e r s o n a l empathy and c o n c e r n f o r t h e e l d e r l y , i f i t d o e s i n c r e a s e w i t h age, has no imp a c t on i n t e r e s t i n w o r k i n g w i t h t h e g r o u p . 48 T a b l e 1 4 ; S o c i o - c u l t u r a l V a r i a b l e s S i g n i f i c a n t l y A s s o c i a t e d w i t h I n t e r e s t V a r i a b l e x 2 S i g . D.F. l e v e l 1 . P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n : ( Q 1 3 ) a . E n j o y s o c i a l i z i n g w i t h 12.46 .01 2 e l d e r l y b. no d i s t i n c t i o n between 5.84 .05 2 e l d e r l y a n d o t h e r s 2. Summary o f p o s i t i v e and 14.81 .02 6 n e g a t i v e a s p e c t s ( Q 1 4 ) S o u r c e : A p p e n d i x C - T a b l e C:1 Two o t h e r s o c i o - c u l t u r a l v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d t o i n t e r e s t i n t r e a t i n g d i s a b l e d e l d e r l y a c c o r d i n g t o t h e c r o s s t a b u l a t i o n s ( T a b l e 1 4 ) . E n joyment i n s o c i a l i z i n g w i t h t h e e l d e r l y ( Q 1 3 ) was n o t e d by 45% o f t h o s e who d i d e x p r e s s i n t e r e s t ( x 2 = 1 2 . 4 6 , p =.0l) T h e r e was a s i g n i f i c a n t a s s o c i a t i o n between w h e t h e r t h e d e n t i s t d i d o r d i d n o t d i s t i n g u i s h t h e e l d e r l y f r o m o t h e r s ( Q 1 3 ) and h i s / h e r i n t e r e s t i n LTC s e r v i c e . T h o s e who do n o t d i s t i n g u i s h a r e u n i n t e r e s t e d i n w o r k i n g w i t h t h e c h r o n i c a l l y i l l e l d e r l y ( x 2 = 5 . 8 4 , p=.05). T h i s f i n d i n g s u g g e s t s t h a t a g e i s m , o r t h e s t e r e o t y p e d s e p a r a t i o n o f t h e e l d e r l y f r o m t h e r e s t o f s o c i e t y , i s n o t a s n e g a t i v e a f o r c e i n p r o f e s s i o n a l b e h a v i o u r as had p r e v i o u s l y been b e l i e v e d . The w e i g h t o f e i t h e r t h e p o s i t i v e and n e g a t i v e a s p e c t s o f work w i t h t h e e l d e r l y c l e a r l y i n f l u e n c e s t h e d e c i s i o n o f t h e p r a c t i t i o n e r s t o t r e a t t h e d i s a b l e d e l d e r l y ( x 2 = 1 4 . 8 l , p = . 0 2 ) ( T a b l e 14). T h o s e f o r whom t h e p o s i t i v e s i d e w e i g h e d more i n d i c a t e d i n t e r e s t , and 49 t h o s e who p l a c e d t h e w e i g h t on t h e n e g a t i v e a s p e c t s d i d n o t i n d i c a t e i n t e r e s t . 1 The s o c i o - c u l t u r a l m o d e l, as me a s u r e d i n t h i s s t u d y , f a l l s i n t o d i f f i c u l t y i n e x p l a i n i n g i n t e r e s t i n LTC d e n t a l s e r v i c e , s i n c e o n l y 1 o u t o f 3 s p e c i f i c h y p o t h e s e s a r e s u p p o r t e d ( L i s t 1, p. 1 8 ) . 4.3.3 Bivariate Analysis .Professional Model The p r o f e s s i o n a l model t r a c e s i n t e r e s t i n LTC s e r v i c e t o t h e t r a i n i n g a n d p r a c t i c e e x p e r i e n c e o f d e n t i s t s . In t h i s s t u d y , t h e r e was a s i g n i f i c a n t a s s o c i a t i o n between i n t e r e s t i n LTC s e r v i c e a nd c l i n i c a l i n s t i t u t i o n a l e x p e r i e n c e ( Q 9 ) ( x 2 = 9.54, p=.C)1) o r o c c a s i o n a l l e c t u r e s i n t h e d e n t a l u n d e r g r a d u a t e c u r r i c u l u m ( Q 9 ) ( x 2 = 7.51, p=.02). C o n v e r s e l y , t h o s e who had no f o r m a l t r a i n i n g were l e s s l i k e l y t o be i n t e r e s t e d i n t h i s t y p e o f s e r v i c e ( Q 9 ) ( x 2 = 2 0 . 6 9 , p = . 0 l ) ( T a b l e 1 5 ) . N o t a b l y , t h o s e who c i t e d i n a d e q u a t e t r a i n i n g a n d e x p e r i e n c e w i t h m e d i c a l l y c o m promised p a t i e n t s a s a r e a s o n f o r no t p r o v i d i n g LTC s e r v i c e b e f o r e ( Q 1 3 ) were n o t i n t e r e s t e d i n s u c h a s e r v i c e a t p r e s e n t (X 2=16.42, p = . 0 l ) ( T a b l e 1 5 ) . ^ h e w e i g h i n g o f p o s i t i v e and n e g a t i v e a s p e c t s f o l l o w e d s p e c i f i c d e s c r i p t i o n s o f work w i t h t h e e l d e r l y w h i c h were t o a c t a s c u e s i n t h e o v e r a l l a s s e s s m e n t o f p o s i t i v e a n d n e g a t i v e a s p e c t s , and t h e s e d e s c r i p t i o n s f e l l i n t o b o t h t h e s o c i a l a n d p r o f e s s i o n a l m o d e l s . When t h e summary q u e s t i o n o f o v e r a l l s a t i s f a c t i o n was c r o s s t a b u l a t e d w i t h e a c h o f t h e s e d e s c r i p t i o n s , s i g n i f i c a n t c o r r e l a t i o n s were f o u n d w i t h a l l t h e d e s c r i p t i v e v a r i a b l e s e x c e p t f o r t h e v i e w t h a t t h e e l d e r l y d i d n o t f o l l o w up p r e v e n t i v e t h e r a p y . Thus, I have i n c l u d e d t h e s u m m a r i z i n g q u e s t i o n i n b o t h t h e s o c i o c u l t u r a l a nd p r o f e s s i o n a l m o d e l s . 50 T a b l e 1 5 : P r o f e s s i o n a l V a r i a b l e s S i g n i f i c a n t l y A s s o c i a t e d w i t h I n t e r e s t V a r i a b l e x 2 S i g . D.F. L e v e l 1. T r a i n i n g i n g e r i a t r i c d e n t i s t r y : ( Q 9 ) c . C l i n i c a l i n s t i t u t i o n a l 9.54 .01 2 e x p e r i e n c e d. o c c a s s i o n a l l e c t u r e s i n 7.51 .02 2 c u r r i c u l u m f.No f o r m a l t r a i n i n g 20.69 .01 2 2. P e r c e n t a g e o f e l d e r l y i n 14.12 .08 8 p r a c t i c e ( Q 1 0 ) 3. Home v i s i t s 16.39 .01 2 4. P r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n : ( Q 1 3 ) f . d i f f i c u l t t o improve o r a l 8.30 .02 5 h e a l t h 5. Summary o f p o s i t i v e and 14.81 .02 6 n e g a t i v e a s p e c t s ( Q 1 4 ) 6. C o n s i d e r a t i o n s i n LTC s e r v i c e : ( Q 1 8 ) f . p r o f e s s i o n a l s a t i s f a c t i o n 19.08 .01 2 w i t h e l d e r l y 7. N o n - p r o v i s i o n o f s e r v i c e s : ( Q 2 1 ) b . i n a d e q u a t e t r a i n i n g and 16.42 .01 2 e x p e r i e n c e S o u r c e : A p p e n d i x C - T a b l e s C:1, C:2, C:3, C:5, C:6 The i d e o l o g i c a l v i e w s o f t h e d e n t a l p r o f e s s i o n have i n f o r m e d t h e s e n s e o f p u r p o s e d e n t i s t s have a b o u t t h e d i s a b l e d e l d e r l y . T h o s e who b e l i e v e d t h e r e were l i m i t s t o i m p r o v i n g t h e h e a l t h o f t h e e l d e r l y ( Q 1 3 ) were not i n t e r e s t e d i n e x t e n d i n g t h e i r p r a c t i c e t o t h i s g r o u p ( x 2 = 8 . 3 0 , p=.02). However, t h e r e was a r e l a t i o n s h i p b etween t h e p r o p o r t i o n o f e l d e r l y i n p r a c t i c e ( Q 1 0 ) and i n t e r e s t i n LTC s e r v i c e ( x 2 = 1 4 . 1 2 , p=.08). As w e l l , t w i c e a s many d e n t i s t s who h a d c o n d u c t e d home v i s i t s ( Q 1 1 ) were i n t e r e s t e d a s were n o t 5 1 ( x 2 = 1 6 . 3 9 , p=.0O ( T a b l e 1 5 ) . T h e s e f i n d i n g s i l l u s t r a t e t h a t f a m i l i a r i t y w i t h and p r a c t i c a l knowledge o f t h e d e n t a l p r o b l e m s o f t h i s m e d i c a l l y c o m promised g r o u p may o f f s e t t h e b a r r i e r s o f t h e c u r a t i v e i d e o l o g y o f t h e p r o f e s s i o n a n d a p p r e h e n s i o n i n t r e a t i n g t h e c h r o n i c a l l y i l l . F i n a l l y , p r o f e s s i o n a l s a t i s f a c t i o n i n t r e a t i n g t h e e l d e r l y ( Q 1 8 ) was a s i g n i f i c a n t p r e d i c t o r o f i n t e r e s t i n LTC s e r v i c e . T h o s e who f e l t s u c h s a t i s f a c t i o n was an i m p o r t a n t c o n s i d e r a t i o n i n d e c i d i n g t o e x t e n d t h e i r p r a c t i c e t o t h e i n s t i t u t i o n a l i z e d e l d e r l y were more l i k e l y t o i n d i c a t e i n t e r e s t ( x 2 = 1 9 . 0 8 , p = . 0 l ) ( T a b l e 1 5 ) . 2 The f i n d i n g s a t t h e s e c o n d s t a g e o f a n a l y s i s s u g g e s t t h a t p r o f e s s i o n a l v a r i a b l e s have a s u b s t a n t i a l e f f e c t on LTC d e n t a l p r a c t i c e . A l l o f t h e 6 s p e c i f i c h y p o t h e s e s t e s t e d were s t a t i s t i c a l l y s u p p o r t e d ( L i s t 1, p. 1 8 ) . 2 P r o f e s s i o n a l s a t i s f a c t i o n ( Q 1 8 ) , w h i c h w o u l d p r o v e t o be so c r i t i c a l i n p r e d i c t i n g i n t e r e s t , p r e s e n t e d a p r o b l e m a t t h i s s e c o n d a r y s t a g e of a n a l y s i s . B e c a u s e t h i s c o n s i d e r a t i o n i n t h e d e n t i s t ' s d e c i s i o n was b a s e d on b o t h p e r s o n a l and p r o f e s s i o n a l s a t i s f a c t i o n i n w o r k i n g w i t h t h e e l d e r l y , t h i s i n d e p e n d e n t v a r i a b l e c o u l d not i n i t i a l l y be p l a c e d i n one s p e c i f i c m o d e l . I t was e s s e n t i a l t h e n , t o f i n d o u t w h e t h e r t h i s c o n s i d e r a t i o n was l i n k e d t o o t h e r p e r c e p t i o n s o f work w i t h t h e e l d e r l y w h i c h c o u l d be c a t e g o r i z e d a s e i t h e r s o c i o - c u l t u r a l o r p r o f e s s i o n a l . I p e r f o r m e d a s e r i e s o f c r o s s t a b u l a t i o n s o f t h i s v a r i a b l e w i t h o t h e r c o n s i d e r a t i o n s and p r e d i c t o r s o f i n t e r e s t t o f i n d t h e model t h i s v a r i a b l e most r e a d i l y f i t , i . e . w h i c h of t h e two g r o u p s o f v a r i a b l e s was i t most c l o s e l y a s s o c i a t e d w i t h . The c r o s s t a b u l a t i o n s showed t h a t p r o f e s s i o n a l / p e r s o n a l s a t i s f a c t i o n was s i g n i f i c a n t l y l i n k e d t o t h e a v a i l a b i l i t y of a d e n t a l o p e r a t o r y and e x p e r i e n c e and t r a i n i n g w i t h c h r o n i c a l l y i l l p a t i e n t s . S u b s e q u e n t l y , i t was i n c l u d e d i n t h e p r o f e s s i o n a l model a t t h i s s e c o n d a r y l e v e l o f a n a l y s i s . 52 4.3.4 Bivariate anal ys i s : Economi c variables The e c onomic t h e o r y s u g g e s t s t h a t t h e p r o f e s s i o n a l m a r k e t has become i n c r e a s i n g l y s a t u r a t e d , a n d young, r e c e n t g r a d u a t e s a r e n o t p e r m i t t e d e a s y a c c e s s t o t h e w o r k i n g f a m i l i e s t h a t make up t h e b u l k o f c u r r e n t p r a c t i c e s . T h e s e new e n t r a n t s a r e more l i k e l y t o e x p r e s s i n t e r e s t i n LTC s e r v i c e , w h i c h i s an a l t e r n a t i v e market f o r t h e i r s e r v i c e s . T h i s t h e o r y a l s o p r e d i c t s t h a t t h o s e d e n t i s t s who a r e b u s y , and who a r e c o n c e r n e d w i t h p o t e n t i a l l o s s of p r i v a t e p r a c t i c e t i m e and hence income w i l l d i s m i s s t h e i d e a o f i n s t i t u t i o n a l p r a c t i c e . The f i n d i n g s a t t h i s s t a g e o f a n a l y s i s b e a r o u t t h e s e a s s u m p t i o n s . T h r o u g h c r o s s t a b u l a t i o n s u s i n g P e a r s o n ' s c h i - s q u a r e a n a l y s i s o f e c o n o m i c v a r i a b l e s w i t h i n t e r e s t i n LTC s e r v i c e , a number o f s i g n i f i c a n t a s s o c i a t i o n s a r o s e ( T a b l e 1 6 ) . T h o s e w i t h an e s t a b l i s h e d p r a c t i c e ( Q 4 ) were l e s s l i k e l y t o e x p r e s s i n t e r e s t i n LTC s e r v i c e ( x 2 = 1 5 . 5 7 , p = . 0 l ) . W h i l e 51% o f t h o s e p r a c t i s i n g d e n t i s t r y 5 y e a r s ( Q 2 ) o r l e s s were i n t e r e s t e d , t h e p e r c e n t a g e d r o p s t o 22% f o r t h o s e p r a c t i s i n g 1 6 - 2 5 y e a r s ( x 2 = 1 8 . 0 6 , p = . 0 2 ) ( T a b l e 1 6 ) . Most o f t h e n e o p h y t e s o f t h e p r o f e s s i o n were u n d e r 35 y e a r s ( x 2 = 4 4 4 . 6 5 , p = . 0 1 , d . f . = 6 ) , and t h e d e n t i s t s i n t h i s age g r o u p i n d i c a t e d t w i c e a s much i n t e r e s t a s t h o s e f r o m any o t h e r g r o u p ( x 2 = 2 3 . 5 4 , p = . 0 l ) . By c r o s s t a b u l a t i n g a ge ( Q 1 ) w i t h b u s y n e s s ( Q 8 ) , i t was e s t a b l i s h e d t h a t t h e s e d e n t i s t s were t h e l e a s t busy o f a l l t h e d i f f e r e n t age g r o u p s ( x 2 = 2 2 . 5 0 , p=. 0 1 , d . f . = 3 ) . The y o u n g e s t d e n t i s t s i d e n t i f i e d t h e c o s t o f p o r t a b l e e q u i p m e n t ( Q 1 9 ) a s a f a c t o r i n t h e i r d e c i s i o n t o e x t e n d p r a c t i c e 53 T a b l e 16:Economic V a r i a b l e s S i q n i f i c a n t l y A s s o c i a t e d w i t h I n t e r e s t V a r i a b l e x 2 S i g . D.F. L e v e l 1. A g e ( Q l ) 23.54 .01 6 2. Y e a r s o f P r a c t i c e ( Q 2 ) 18.06 .02 8 3. S t a t u s o f P r a c t i c e ( Q 4 ) 15.57 .01 4 4. B u s y n e s s o f P r a c t i c e ( Q 8 ) 7.26 .02 2 5. C o n s i d e r a t i o n s i n LTC s e r v i c e : ( Q 1 8 ) f . L o s s o f p r i v a t e p r a c t i c e t i m e 15.51 .01 2 b. L o s s o f l e i s u r e t i m e 14.98 .01 2 6. C o s t o f p o r t a b l e e q u i p m e n t ( Q 1 9 ) 15.82 .01 4 7. N o n - p r o v i s i o n o f d e n t a l s e r v i c e s : ( Q 2 1 ) a . t o o busy i n p r i v a t e p r a c t i c e 17.84 .01 2 c . f i n a n c i a l l y c o s t l y a n d 14.16 .01 2 u n r e w a r d i n g S o u r c e : A p p e n d i x C - T a b l e s C:4, C:5, C:6 t o L T C S ( X 2 = 1 9 . 7 6 , P=.01, d . f . = 6 ) . The d e n t i s t s who were b u s i e r ( Q 8 ) were l e s s i n t e r e s t e d i n LTC p r a c t i c e ( x 2 = 7.26, p=.07) ( T a b l e 1 6 ) . Those d e n t i s t s who i n d i c a t e d e i t h e r p r i v a t e p r a c t i c e ( Q 1 8 ) ( X 2 = 1 5 . 5 1 , p = . 0 l ) o r l e i s u r e t i m e l o s s ( x 2=14.98, p-,01) were f a i r l y i m p o r t a n t c o n s i d e r a t i o n s c h o s e n o t t o p a r t i c i p a t e i n a LTC p r o g r a m m a b l e 16). D e n t i s t s who had n o t p r a c t i s e d i n i n s t i t u t i o n s p r e v i o u s l y b e c a u s e t h e work was f i n a n c i a l l y c o s t l y and u n r e w a r d i n g were n o t p r e p a r e d t o do so n ow(x 2 = 14.16 , p = . 0 1 ) ( T a b l e 1 6 ) . The d i r e c t and i n d i r e c t m e a s u r e s o f t h e e c o n o m i c i m p a c t o f i n s t i t u t i o n a l p r a c t i c e on income d e m o n s t r a t e s t h a t t h e e c o n o m i c t h e o r y has a g r e a t d e a l o f r e l e v a n c e i n e x p l a i n i n g t h e 54 m o t i v a t i o n s of d e n t i s t s to work at LTC f a c i l i t i e s , s i n c e 2 out of the 3 hypotheses were s t a t i s t i c a l l y supported ( L i s t 1 , p . 1 8 ) . 4.3.5 Results of Testing of Hypotheses of the Three Models Soc i o - c u l t u r a l model Hypotheses:Dentists who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i l l be: Othose who enjoy s o c i a l i z i n g and communicating with e l d e r l y p a t i e n t s - accepted 2 ) those who do not d i s t i n g u i s h between the e l d e r l y and o t h e r s i n t h e i r work - r e j e c t e d 3 ) those who are o l d e r and by assumption more empathetic w i t h the problems of the e l d e r l y - r e j e c t e d P r o f e s s i o n a l model Hypotheses:Dentists who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i11 be: Othose who have s p e c i a l i z e d t r a i n i n g and/or experience i n g e r i a t r i c and s p e c i a l c a r e d e n t i s t r y - accepted 2 ) those with a h i g h p r o p o r t i o n of e l d e r l y i n t h e i r p r a c t i c e -accepted 3 ) those who i n d i c a t e p r o f e s s i o n a l s a t i s f a c t i o n i n working with the e l d e r l y -accepted 4) those who make home v i s i t s -accepted 5) those who do not view the o r a l h e a l t h problems of the aged as having l i m i t e d treatment p o t e n t i a l -accepted 6) those who are w i l l i n g to use p o r t a b l e equipment and l e s s concerned with the a v a i l a b i l i t y of a s t a t i o n a r y o p e r a t o r y -accepted Economic Model Hypotheses:Dentists who i n d i c a t e i n t e r e s t i n LTC d e n t a l s e r v i c e s w i l l be: Othose who are begin n i n g a p r a c t i c e or r e t i r i n g as opposed to those with an e s t a b l i s h e d p r a c t i c e - accepted 2 ) those f o r whom the o p p o r t u n i t y c o s t s i n l o s s of p r i v a t e p r a c t i c e and l e i s u r e time are low -accepted 3 ) those who are l e s s concerned with f i n a n c i a l reimbursement and c a p i t a l expenses(such as p o r t a b l e equipment)- r e j e c t e d 55 4 . 4 T h i r d S t a g e : M u l t i v a r i a t e A n a l y s i s 4. 4.1 Overv/ew In order to determine the s t r e n g t h of each model to p r e d i c t i n t e r e s t i n LTCs, I chose a m u l t i v a r i a t e a n a l y s i s which allowed f o r a l a r g e number of v a r i a b l e s with nominal c a t e g o r i e s . M u l t i p l e c l a s s i f i c a t i o n analysis(MCA) i s a m u l t i p l e r e g r e s s i o n a n a l y s i s which permits the use of nominal c a t e g o r i e s through the c r e a t i o n of a r t i f i c i a l v a r i a b l e s ( 1 ) . The main dependent v a r i a b l e , i n t e r e s t i n LTC s e r v i c e , can be a dichotomy or can be based on an i n t e r v a l s c a l e . In each m o d e l , a l l the v a r i a b l e s f o r which the t e s t of a s s o c i a t i o n r e s u l t e d i n a p r o b a b i l i t y of 1 0 % or l e s s were c o n s i d e r e d s i g n i f i c a n t , and subsequently run through the MCA progam. Each v a r i a b l e i s o r d e r e d with an adjustment f o r the e f f e c t s of other independent v a r i a b l e s w i t h i n that model, to produce a beta c o - e f f i c i e n t . T h i s c o - e f f i c i e n t i s s i m i l a r to a p a r t i a l c o r r e l a t i o n c o - e f f i c i e n t , and i n d i c a t e s the s t r e n g t h of the e f f e c t s of changes i n the independent v a r i a b l e upon the dependent v a r i a b l e , having c o n t r o l l e d f o r a l l other independent v a r i a b l e s . The combined e f f e c t of the v a r i a b l e s i n each model on the v a r i a t i o n i n i n t e r e s t , a d j u s t i n g f o r the number of v a r i a b l e s i n each model, i s g i v e n by the squared m u l t i p l e c o r r e l a t i o n ( R e a d j u s t e d c o e f f i c i e n t . T h i s c o e f f i c i e n t i s an i n d i c a t o r of the o v e r a l l s t r e n g t h of the model in p r e d i c t i n g i n t e r e s t . The r e s u l t s of the MCA a n a l y s i s are l i s t e d and d i s c u s s e d below. 56 4.4.2 Multi-vari at e Anal ysi s : Soci o-cul t ural Model T a b l e 1 7 : M u l t i p l e C l a s s i f i c a t i o n A n a l y s i s : S o c i o - c u l t u r a l V a r i a b l e s V a r i a b l e : B e t a : 1 e n j o y s o c i a l i z i n g w i t h e l d e r l y .138 2 p o s i t i v e and n e g a t i v e a s p e c t s w e ighed .132 3 no d i s t i n c t i o n between e l d e r l y and o t h e r s .103 m u l t i p l e R 2 ( a d j u s t e d ) = . 0 5 At t h i s s t a g e o f a n a l y s i s , t h e enjo y m e n t o f s o c i a l i z i n g w i t h t h e e l d e r l y i s t h e most i m p o r t a n t v a r i a b l e i n t h e m o d e l , b u t none o f t h e t h r e e s u b s t a n t i a l l y i n f l u e n c e i n t e r e s t i n LTC s e r v i c e . T h i s model o n l y e x p l a i n s 5% o f t h e t o t a l v a r i a t i o n o f i n t e r e s t , a n d t h i s low p r o p o r t i o n a t e f i g u r e r e v e a l s t h e e s s e n t i a l weakness o f t h i s m o d e l . T h e r e f o r e , t h e s o c i o - c u l t u r a l t h e o r y i s n o t v a l i d i n e x p l a i n i n g t h e d e n t i s t s ' w i l l i n g n e s s t o work i n L T C . 4.4.3 Multivariate Anal ys i s : Pr of es s i onal Model The s e c o n d model, t h a t o f p r o f e s s i o n a l t r a i n i n g a n d s o c i a l i z a t i o n , i n c l u d e s 9 v a r i a b l e s whose r a n k i n g i s l i s t e d b elow. 57 T a b l e 18 t M u l t i p l e C l a s s i f i c a t i o n A n a l y s i s ; P r o f e s s i o n a l V a r i a b l e s V a r i a b l e : B e t a : 1 . 2. 3. 4. 5. 6. 7. 8. 9. p r o f e s s i o n a l s a t i s f a c t i o n i n t r e a t i n g e l d e r l y .384 l i m i t e d t r e a t m e n t o p t i o n s t o improve h e a l t h .271 o c c a s i o n a l l e c t u r e s i n u n d e r g r a d u a t e p r o g r a m .166 p r o p o r t i o n o f e l d e r l y i n p r a c t i c e .128 l a c k o f e x p e r i e n c e i n d e a l i n g w i t h d i s a b l e d .123 l a c k o f t r a i n i n g a s r e a s o n f o r no s e r v i c e .111 c l i n i c a l i n s t i t u t i o n a l e x p e r i e n c e o n l y .075 no f o r m a l t r a i n i n g .066 make home v i s i t s t o t h e e l d e r l y .055 m u l t i p l e R 2 ( a d j u s t e d ) = . 2 8 The s t r o n g e s t v a r i a b l e , by f a r , i n t h i s model i s p r o f e s s i o n a l s a t i s f a c t i o n i n w o r k i n g w i t h t h e e l d e r l y . The s e c o n d h i g h e s t r a n k i n g v a r i a b l e , t h e v i e w o f l i m i t e d t r e a t m e n t o p t i o n s f o r t h i s g r o u p , h i g h l i g h t s t h e t r a d i t i o n a l r e s i s t a n c e o f t h e p r o f e s s i o n t o t h e management o f c h r o n i c c o n d i t i o n s amongst t h e e l d e r l y . The m o d e l ' s power i n p r e d i c t i n g t h e v a r i a t i o n o f i n t e r e s t i s a t t e s t e d t o by a m u l t i p l e - R 2 f i g u r e o f .28, i e . 28% o f t h e v a r i a t i o n i n i n t e r e s t i s a t t r i b u t a b l e t o t h e v a r i a b l e s w i t h i n t h i s m o d e l . 4.4.4 Multivariate Anal ysi s : Economi c Model The t h i r d m o d e l , w h i c h i s t h e eco n o m i c r a t i o n a l i z a t i o n o f t h e d e n t i s t s ' i n t e r e s t i n LTC s e r v i c e , c o n t r i b u t e s 11% t o t h e v a r i a t i o n i n r e s p o n s e . The r a n k i n g o f t h e v a r i a b l e s i s l i s t e d 58 below. T a b l e 1 9 : M u l t i p l e C l a s s i f i c a t i o n A n a l y s i s ; E c o n o m i c V a r i a b l e s V a r i a b l e : B e t a : l . l o s s o f l e i s u r e t i m e .215 2. age .171 3. f i n a n e i a l l y u n r e w a r d i n g a s r e a s o n f o r no s e r v i c e .155 4. k i n d o f p r a c t i c e .141 5. y e a r s o f p r a c t i c e .132 6. t o o busy i n p r i v a t e p r a c t i c e a s r e a s o n f o r no s e r v i c e .131 7 . l o s s o f p r i v a t e p r a c t i c e t i m e .131 8 . b u s y n e s s .116 m u l t i p l e R 2 ( a d j u s t e d ) = . 1 1 Amongst t h e s e 8 v a r i a b l e s , c o n c e r n o v e r l e i s u r e t i m e c o n t r i b u t e s f a r more t o i n t e r e s t i n LTC s e r v i c e t h a n c o n c e r n o v e r l o s s of p r i v a t e p r a c t i c e t i m e ( r a n k e d 7 t h ) , w h i c h , i n t h e econ o m i c model, w o u l d be t h e c r i t i c a l d e t e r m i n a n t o f i n t e r e s t . When l e i s u r e t i m e l o s s ( Q l 8 ) w a s c r o s s t a b u l a t e d w i t h o t h e r i n d e p e n d e n t v a r i a b l e s , t h e t a b l e s showed t h a t i t was most s t r o n g l y l i n k e d w i t h home v i s i t s ( Q 1 1 ) (X 2=10.09, p = . 0 l , d . f . = l ) . F o r d e n t i s t s who h a d u n d e r t a k e n home v i s i t s , t h e l o s s o f l e i s u r e t i m e was a c o n s i d e r a t i o n o f p a r t i c u l a r i m p o r t a n c e . I t a p p e a r e d t h a t many d e n t i s t s i n t h i s s t u d y t h o u g h t s e r v i c e s a t LTCs were t o be c o n d u c t e d o u t s i d e o f r e g u l a r o f f i c e h o u r s . F o r t h i s r e a s o n , l e i s u r e t i m e c o n c e r n i s a l s o s t r o n g l y a s s o c i a t e d w i t h t h e number o f h o u r s d e n t i s t s a r e w i l l i n g t o c o n t r i b u t e t o LTC p r a c t i c e ( Q 1 6 ) ( x 2 = 9 . 5 6 , p=.01, d . f . = 2 ) , and t h e d i s t a n c e t h e y 59 a r e w i l l i n g t o t r a v e l t o t h e f a c i l i t y ( x 2 = 1 7 . 9 1 , p = . 0 l , d . f . = 3 ) . The d e n t i s t s who a r e w i l l i n g t o d e v o t e o n l y a m i n i m a l amount of t i m e o r no t i m e a t a l l t o LTC p r a c t i c e a r e t h o s e f o r whom l e i s u r e t i m e c o s t s a r e paramount. W i t h a m u l t i p l e R 2 f i g u r e o f .11, t h e e c o n o m i c model i s n o t a s s t r o n g a p r e d i c t o r o f i n t e r e s t as t h e p r o f e s s i o n a l m o d e l . 4.5 A Summary o f t h e F i n d i n g s I t may be c o n c l u d e d f r o m t h e m u l t i p l e c l a s s i f i c a t i o n a n a l y s i s , t h a t b o t h p r o f e s s i o n a l a n d e c onomic f o r c e s g u i d e t h e s e r v i c i n g d e c i s i o n s o f d e n t i s t s w i t h r e s p e c t t o LTC p r a c t i c e . In t h e p r o f e s s i o n a l m o d e l , t h e e m p h a s i s i s on s a t i s f a c t i o n i n w o r k i n g w i t h t h e e l d e r l y , and t h i s s a t i s f a c t i o n h a s been c l e a r l y l i n k e d t o s e v e r a l e n a b l i n g v a r i a b l e s . The c a p a b i l i t y o f a d e n t i s t t o p r a c t i s e s u c c e s s f u l l y w i t h t h e c h r o n i c a l l y i l l o r d i s a b l e d p a t i e n t , e i t h e r e l d e r l y o r o t h e r w i s e , i s p r e d i c a t e d by h i s / h e r t r a i n i n g i n t h i s s p e c i a l i z e d a r e a , h i s / h e r e x p e r i e n c e w i t h t h i s g r o u p o f c l i e n t s , and w i t h h i s / h e r a b i l i t y t o o p e r a t e o u t s i d e t h e t r a d i t i o n a l c o n f i n e s o f t h e p r a c t i c e o f f i c e . T h e r e i s a t e n d e n c y amongst t h o s e d e n t i s t s who have n o t h a d any t r a i n i n g i n managing c h r o n i c c o n d i t i o n s amongst t h e e l d e r l y , o r an u n d e r s t a n d i n g o f t h e p h y s i o l o g i c a l and p s y c h o l o g i c a l c o m p l i c a t i o n s o f t h i s k i n d o f work, t o d i s m i s s s u c h d e n t i s t r y a s b e i n g o f l i m i t e d v a l u e t o t h e e l d e r l y p a t i e n t . 60 While the independent variables in the professional model are for the most part enabling variables, the independent variables in the economic model r e f l e c t the predisposing factors that influence the decision to work at LTCs. The decision to undertake such work requires that the dentist weighs the cost and benefits. If the costs are too high in terms of income or l e i s u r e time, then the dentist i s predisposed to declining the opportunity. However, i f the benefits in terms of income, c l i e n t recruitment, and continuation of a former patient's treatment outweigh these costs, then the dentist i s predisposed to accept th i s service opportunity. The s o c i o - c u l t u r a l model, which was employed in a series of studies with often c o n f l i c t i n g r e s u l t s , has l i t t l e bearing on t h i s matter. It may be that the instruments to measure "ageism" or c u l t u r a l values around the disabled e l d e r l y are not well refined enough to bring out.the s o c i o - c u l t u r a l influences in the servicing behaviours of dentists. Nontheless, the analysis conducted in t h i s study discounts the primacy of s o c i a l values, and places the issue of motivation in the arena of professional and economic concerns. The next step in t h i s study i s the t e s t i n g t h i s conclusion. The second section of the questionnaire(SECTION 2) was addressed to those dentists who had undertaken LTC service. These dentists, who have discussed the incentives and disincentives of LTC service, are the group which validates or invalidates the study's findings. 61 CHAPTER 5 DENTISTS WHO PRACTICED AT LTCS-A SECONDARY STUDY 5.1 O v e r v i e w We have been shown t h a t p r o f e s s i o n a l a n d economic f a c t o r s , but n o t s o c i o - c u l t u r a l f a c t o r s , p r e d i c t i n t e r e s t i n LTC d e n t a l s e r v i c e . The s e c o n d s e c t i o n o f t h e q u e s t i o n n a i r e was a d d r e s s e d t o t h o s e d e n t i s t s who have u n d e r t a k e n LTC s e r v i c e . T h e s e d e n t i s t s w i l l be t h e g r o u p who v a l i d a t e o r i n v a l i d a t e t h e s t u d y ' s f i n d i n g s . T h e s e d e n t i s t s ( h e n c e f o r t h LTC p r a c t i t i o n e r s o r LTC d e n t i s t s ) were a s k e d a number o f q u e s t i o n s a b o u t t h e n a t u r e o f t h e i r i n s t i t u t i o n a l p r a c t i c e , i . e . f e e a r r a n g e m e n t s , e q u i p m e n t a v a i l a b l e t o them, common emergency and e l e c t i v e p r o c e e d u r e s , f r e q u e n c y o f v i s i t s , d i s t a n c e t r a v e l l e d t o f a c i l i t y , e t c . Of r e l e v a n c e t o t h e p r i m a r y s t u d y a r e f o u r q u e s t i o n s f o c u s i n g on t h e m o t i v a t i o n s and c o n s e q u e n c e s o f t h i s p r a c t i c e . S i x t y - t h r e e d e n t i s t s ( l 9 % o f t h e r e s p o n d e n t s ) a n s w e r e d t h e s e p a r a t e q u e s t i o n n a i r e , h a v i n g had some i n v o l v e m e n t i n t h e p a s t o r a t p r e s e n t w i t h LTC d e n t a l s e r v i c e . The i n f o r m a t i o n t h e s e d e n t i s t s p r o v i d e d had two p u r p o s e s i n t h e o v e r a l l s t u d y . The f i r s t was t o e v a l u a t e t h e r e a s o n s d e n t i s t s gave f o r t h e i r m o t i v a t i o n and s u b s e q u e n t e n t r y i n t o LTC s e r v i c e . The s e c o n d p u r p o s e f o r e x a m i n i n g t h i s s u b - g r o u p o f d e n t i s t s was t o f i n d o u t i n what r e s p e c t s t h e y were s i m i l a r t o o r d i f f e r e n t f r o m t h e 62 d e n t i s t s who a r e i n t e r e s t e d i n LTC s e r v i c e b u t had n e v e r u n d e r t a k e n t h i s t y p e o f work, and f r o m t h e d e n t i s t s who were n o t i n t e r e s t e d . T h e s e two forms o f a n a l y s i s e n a b l e d me t o v a l i d a t e t h e f i n d i n g s o f t h e major s t u d y . They s p e c i f i e d t h e most c r i t i c a l f a c t o r s , and h e n c e , t h e model t h a t has t h e b e s t p r e d i c t i v e v a l u e f o r t h e m o t i v a t i o n f o r work i n L T C s . I n t h i s manner, t h e v a l i d i t y o f t h e a n a l y t i c a l p r o c e s s w h i c h r a n k e d t h e t h r e e m o d e l s t h r o u g h d e d u c t i v e s t a t i s t i c a l t e s t s was a s s e s s e d . 5.2 Methods f o r t h e S e c o n d a r y S t u d y The c r u x o f t h e i s s u e o f m o t i v a t i o n i s a d d r e s s e d i n q u e s t i o n 7,(SECTION 2) w h i c h a s k s d e n t i s t s t o i d e n t i f y t h e r e a s o n s t h e y e n t e r e d LTC s e r v i c e f o r any l e n g t h o f t i m e . A l l t h r e e t h e o r e t i c a l m o d e ls a r e c o v e r e d t o some d e g r e e by t h i s q u e s t i o n . In a d d i t i o n , q u e s t i o n s 4 and 5 i n q u i r e a b o u t what d e n t i s t s have l i k e d and d i s l i k e d i n s u c h a s p e c i a l i z e d p r a c t i c e . The i n c e n t i v e s a n d d i s i n c e n t i v e s o f f e r e d a s o p t i o n s t o be marked o f f by r e s p o n d e n t s c a n be s i m i l a r l y a l l o c a t e d t o t h e t h r e e m o d e l s . By a n a l y z i n g t h e r e s p o n s e s t o t h e s e i n q u i r i e s , t h e f a c t o r s w h i c h d e n t i s t s w e i g h when t h e q u e s t i o n o f l o n g t e r m c a r e p r a c t i c e a r i s e s were a s c e r t a i n e d ( T a b l e 2 0 ) . The q u e s t i o n i s whether t h e s i g n i f i c a n t f a c t o r s i n t h e t h e o r e t i c a l m o d e l s would be e v i d e n t , i . e w h ether t h e p r i m a r y s t u d y h a s r e a l i s t i c a p p l i c a t i o n s . A n o t h e r i s s u e t o i n v e s t i g a t e was t h e r e a s o n i n g f o r d i s c o n t i n u i n g s e r v i c e . I f , a s t h e e c o n o m i c model p r e d i c t s , 63 o p p o r t u n i t y c o s t s play a major r o l e i n i n t e r e s t , then a tre n d would be apparent when a p r i v a t e p r a c t i c e became e s t a b l i s h e d . The time l o s t from p r i v a t e p r a c t i c e and l e i s u r e would i n c r e a s i n g l y d i m i n i s h the v i a b i l i t y of LTC p r a c t i c e , and e v e n t u a l l y l e a d to i t s d i s c o n t i n u a t i o n . By a n a l y z i n g the responses of those who no longer o f f e r t h i s s e r v i c e , the re l e v a n c e of t h i s theory was t e s t e d . 5.3 R e s u l t s of Secondary Study 5.3.1 Incentives and Disincentives Those d e n t i s t s who had p r a c t i s e d at LTC f a c i l i t i e s , i . e . LTC p r a c t i t i o n e r s , were asked q u e s t i o n s f o c u s i n g on the i n c e n t i v e s and d i s i n c e n t i v e s of t h i s p r a c t i c e . The r e s u l t s are l i s t e d i n Table 20. The f o l l o w i n g d i s c u s s i o n compares these r e s u l t s to the c o n c l u s i o n s of the study. The LTC p r a c t i t i o n e r s were asked why they had p r o v i d e d s e r v i c e s to the i n s t i t u t i o n a l i z e d e l d e r l y . Over one h a l f of the group o r i g i n a t e d t h e i r p r a c t i c e at LTCs as par t of t h e i r p r o f e s s i o n a l r e s p o n s i b i l i t y . The m a j o r i t y of LTC p r a c t i t i o n e r s w i t h a d d i t i o n a l comments to t h e i r responses wrote t h a t o l d e r p a t i e n t s and r e l a t i v e s of p a t i e n t s had requested t h e i r s e r v i c e s . Four other i n d i v i d u a l s were s a l a r i e d i n e i t h e r a government p o s i t i o n or a h o s p i t a l r e s i d e n c y , and another two d e n t i s t s r e p o r t e d that LTC f a c i l i t i e s were p a r t of t h e i r s a l a r i e d p u b l i c p r a c t i c e i n England. Three i n d i v i d u a l s had worked as a s s o c i a t e s 64 T a b l e 20:Questions and Responses of .LTC P r a c t i t i oner Study ( ) r e f e r s to percentage of LTC p r a c t i t i o n e r s r e s p o n d i n g p o s i t i v e l y to statement n=63 SOCIO-CULTURAL PROFESSIONAL Why d i d you d e c i d e to p r o v i d e s e r v i c e s to LTCs?:(%)(Q7) a ) s o c i a l c o n t a c t s ( 2 2 ) a ) p u b l i c s e r v i c e ( 4 0 ) b ) p r o f . r e s p o n s i b i 1 i t y ( 5 2 ) ECONOMIC a) i n c r e a s e p r a c t i c e ( 1 8 ) b) p a r t time p r a c t i c e ( 8 ) c) semi r e t i r e d p r a c t i c e ( O ) What have you l i k e d about working i n LTCs?:(%)(Q4) a ) s o c i a l i z i n g ( 4 3 ) a)broadened scope(29) a)expand p r a c t i c e ( 1 3 ) b) p u b l i c s e r v i c e ( 5 1 ) b ) p a r t - t i m e p r a c t i c e ( 8 ) c) p r o f . r e s p o n s i b i 1 i t y ( 6 5 ) d) i n t e r a c t i o n w i t h o t h e r ( 2 4 ) h e a l t h c a r e workers What have you d i s l i k e d about working at LTCs:(%)(Q5) a) e l d e r l y d i f f i c u l t ( 1 8 ) b) p e r s o n a l l y unrewarding(8) c) f a c i l i t i e s s m e l l , ( 1 8 ) depress i ng a) inadequate treatment f a c i 1 i t i e s ( 6 7 ) a ) t i m e consuming(41) b) l i m i t e d treatment o p t i o n s ( 5 0 ) b ) f i n a n c i a l 1 y unrewarding(37) c) medical c o m p l i c a t i o n s ( 2 2 ) d) a d m i n i s t r a t i v e b a r r i e r s ( 1 3 ) Why d i d you s t o p : ( % ) ( Q 8 ) a ) o t h e r ( 3 2 ) a) p r o f e s s i o n a l l y and p e r s o n a l l y unrewarding(18) b) admi n i s t r a t i ve d i f f i c u l t i e s ( 1 2 ) a) i n c r e a s i n g commitment to p r i v a t e , p r a c t i c e ( 3 8 ) b) l o s s of l e i s u r e time(15) c) no demand(32) d) f i nanci al1y unrewardi ng(9) 65 f o r d e n t i s t s who had i n c o r p o r a t e d i n s t i t u t i o n a l i z e d d e n t a l work i n t o t h e i r p r a c t i c e . T h e s e comments h e l p e d t o d e f i n e t h e t e r m " p r o f e s s i o n a l r e s p o n s i b i l i t y " a s a d u t y t o e x i s t i n g p a t i e n t s i n a p r i v a t e o r p u b l i c p r a c t i c e , o r a s p a r t o f a l a r g e r j o b t h e y t o o k on. The s e n s e o f p r o f e s s i o n a l r e s p o n s i b i l i t y t o w a r d s t h e i n s t i t u t i o n a l i z e d e l d e r l y a s a s p e c i a l g r o u p r e q u i r i n g d e n t a l c a r e was e x p r e s s e d by t h e w i s h t o p e r f o r m a " p u b l i c s e r v i c e " . T h i s commitment t o p u b l i c d u t y was s p e c i f i e d by 40% o f t h e LTC p r a c t i t i o n e r s . E c onomic r e a s o n s were c i t e d by 18% who hoped t o i n c r e a s e t h e s i z e o f t h e i r p r a c t i c e and a n o t h e r 8% who r e c o g n i z e d a p a r t - t i m e p r a c t i c e o p p o r t u n i t y . O n l y 22% i n i t i a t e d t h e p r a c t i c e f o r s o c i a l c o n t a c t s w i t h t h e e l d e r l y . As t h e f i g u r e s d e m o n s t r a t e , p r o f e s s i o n a l m o t i v a t i o n s were paramount i n i n i t i a t i n g LTC p r a c t i c e , f o l l o w e d by e c o n o m i c o p p o r t u n i t i e s and f i n a l l y by s o c i o - c u l t u r a l c o n s i d e r a t i o n s . T h i s r a n k i n g a g r e e s w i t h t h e MCA r a n k i n g o f t h e m o d e l s . The LTC d e n t i s t s ' v i e w s on LTC p r a c t i c e a r e e l a b o r a t e d i n t h e d i s c u s s i o n o f l i k e s and d i s l i k e s i n LTC s e r v i c e . The m a j o r i t y ( 6 5 % ) o f d e n t i s t s were s a t i s f i e d t h a t t h e y had met t h e i r p r o f e s s i o n a l r e s p o n s i b i l i t y t o e l d e r l y c l i e n t s and had p e r f o r m e d a p u b l i c s e r v i c e ( 5 1 % ) . L e s s t h a n 1/3 had b r o a d e n e d t h e s c o p e o f t h e i r p r a c t i c e by e n g a g i n g i n s e r v i c e s t o L T C s . T h i s f i g u r e t e l l s us t h a t o n l y a m i n o r i t y o f d e n t i s t s i n c o r p o r a t e d i n t o t h e i r p r a c t i c e c h r o n i c a l l y i l l p a t i e n t s on an o n g o i n g b a s i s . 66 The r e l u c t a n c e t o u n d e r t a k e LTC p r a c t i c e i s p a r t l y e x p l a i n e d by t h e i d e n t i f i c a t i o n o f t h e d i s i n c e n t i v e s i n t h i s p r a c t i c e . O v e r 2/3 o f t h e d e n t i s t s were d i s s a t i s f i e d w i t h t h e i n a d e q u a t e t r e a t m e n t f a c i l i t i e s a t t h e i n s t i t u t i o n s . H a l f o f t h e g r o u p e x p r e s s e d t h e b e l i e f t h a t t h e r e were o n l y l i m i t e d t r e a t m e n t p o s s i b i l i t i e s f o r t h e i n s t i t u t i o n a l i z e d . They showed no r e l u c t a n c e i n a c k n o w l e d g i n g t h e t i m e consuming(41 %) and f i n a n c i a l l y u n r e w a r d i n g (37%) n a t u r e o f t h i s work. Then, t h e most c r i t i c a l f a c t o r s i d e n t i f i e d by t h e s t u d y a s i m p e d i m e n t s t o i n t e r e s t , i . e . t h e p r o f e s s i o n ' s p e r c e p t i o n o f t h e l i m i t a t i o n s o f t h i s l i n e o f work, and t h e o p p o r t u n i t y c o s t s i n t i m e t h a t c o u l d more a p p r o p r i a t e l y be u s e d e l s e w h e r e , were r e i t e r a t e d i n t h i s a u x i l l i a r y s t u d y . The s i g n i f i c a n c e o f o p p o r t u n i t y c o s t s was u n d e r l i n e d i n t h e e x p l a n a t i o n s f o r t h e d i s c o n t i n u a t i o n o f t h i s s e r v i c e . The most common e x p l a n a t i o n LTC p r a c t i t i o n e r s put f o r t h f o r d i s c o n t i n u i n g s e r v i c e was t h e i r i n c r e a s i n g commitment t o p r i v a t e p r a c t i c e ( 3 8 % ) . T h i s t r e n d was p r e d i c t e d by t h e e c o n o m i c m o d e l . A n o t h e r 32% o f t h e d e n t i s t s s t a t e d " o t h e r " a s a r e a s o n . Of t h o s e who s p e c i f i e d t h i s r e s p o n s e , q u i t e a few had moved o r l e f t a l o c u m a s s o c i a t e s h i p w h i c h i n c l u d e d LTC p r a c t i c e . B e c a u s e t h e s e d e n t i s t s d i d n o t mark o f f t h e o p t i o n "no demand", t h e argument t h a t t h e y were w i l l i n g , b u t f o u n d no i n t e r e s t e d f a c i l i t i e s , c o u l d n o t be a d v a n c e d . We c a n h y p o t h e s i z e t h a t t h e new p r a c t i c e had no room f o r LTC p a t i e n t s , i . e . t h e o p p o r t u n i t y c o s t s were t o o h i g h . 67 5.3.2 A Comparison of LTC dent i s t s wi t h t he s tudy gr oup From t h e t o t a l g r o u p o f d e n t i s t s , t h r e e s u b - g r o u p s were s e l e c t e d : t h o s e who had p r e v i o u s l y o r were c u r r e n t l y p r a c t i s i n g a t L T C s , i . e . LTC p r a c t i t i o n e r s ( 1 9 % ) , t h o s e who were i n t e r e s t e d i n LTC s e r v i c e b u t had n o t u n d e r t a k e n i t p r i o r t o t h e s t u d y , i . e i n t e r e s t e d d e n t i s t s ( 2 5 % ) , a nd t h o s e who were n o t i n t e r e s t e d , i . e . u n i n t e r e s t e d d e n t i s t s ( 3 2 % ) . 1 T a b l e 2 1 : G e r i a t r i c T r a i n i n g Among T h r e e S u b - g r o u p s ( Q 9 ) V a r i a b l e Number o f D e n t i s t s LTC I h t e r e s t e d d e n t i s t s ( % ) D e n t i s t s ( % ) C l i n i c a l i n s t i t u t i o n a l t r a i n i n g : no 44(70) 74(87) y e s 19(30) 11(13) T o t a l 63(100) x 2=21.81 P=.01 85(100) d . f .=2 U n i n t e r e s t e d D e n t i s t s ( % ) 102(95) 5(5) 107TT00) T o t a l ( % ) 220(86) 35(14) 255(100) 2 F o r m a l t r a i n i n g : no 21(28) y e s 42(72) T o t a l 63(100) x 2=17.4 P=.01 53(62) 32(38) 85(100) d.f.=2 68(64) 39(36) 107(100) 142(56) 113(44) 255(100) A c o m p a r i s o n between t h e LTC p r a c t i t i o n e r s a nd t h e two o t h e r g r o u p s s u g g e s t s t h a t a c r u c i a l e n a b l i n g f a c t o r i n d e v e l o p i n g a 1 I o m i t t e d t h o s e d e n t i s t s who were u n c e r t a i n a b o u t LTC s e r v i c e when e x a m i n i n g t h e g r o u p t h a t h ad n o t a t t e n d e d f a c i l i t i e s . 68 w o r k i n g r e l a t i o n s h i p w i t h t h e i n s t i t u t i o n a l i z e d e l d e r l y i s t h e f o r m a l t r a i n i n g o f d e n t i s t s . W h i l e 30% o f t h e LTC p r a c t i t i o n e r s had c l i n i c a l g e r i a t r i c t r a i n i n g , o n l y 13% o f t h e i n t e r e s t e d d e n t i s t s and 5% o f t h e d i s i n t e r e s t e d d e n t i s t s had s i m i l a r t r a i n i n g (X 2=21.81, p=.01). A l t h o u g h 64% o f t h e d i s i n t e r e s t e d d e n t i s t s and 62% o f t h e i n t e r e s t e d d e n t i s t s had no f o r m a l t r a i n i n g , t h i s p e r c e n t a g e f e l l t o 28% amongst LTC p r a c t i o n e r s ( x 2 = 1 7 . 4 0 , p = . 0 l ) ( T a b l e 2 1 ) . T h i s d a t a s u p p o r t s t h e f i n d i n g s of t h e s t u d y - t h a t p r o f e s s i o n a l t r a i n i n g f u n d a m e n t a l l y e f f e c t s c u r r e n t i n t e r e s t i n t r e a t i n g t h e e l d e r l y . T h r e e g r o u p s o f d e n t i s t s e x h i b i t e d s i g n i f i c a n t d i f f e r e n c e s i n t h e i r i n t e r e s t i n p o t e n t i a l LTC d e n t a l s e r v i c e : w h i l e o n l y 44% o f t h e 192 d e n t i s t s who h a d n e v e r p r a c t i s e d a t L T C s were i n t e r e s t e d , t h i s p e r c e n t a g e i n c r e a s e d t o 74% amongst LTC p r a c t i t i o n e r s ( x 2 = 1 4 . 5 2 , p = . 0 l ) ( T a b l e 2 2 ) . T a b l e 2 2 : I n t e r e s t i n LTC S e r v i c e Among Two S u b - g r o u p s ( Q 1 5 ) V a r i a b l e LTC D e n t i s t s ( % ) I n t e r e s t e d and D i s i n t e r e s t e d D e n t i s t s ( % ) T o t a l I n t e r e s t i n LTC s e r v i c e : y e s 3 7(74) no 13(26) T o t a l 50(100) 85(44) 107(56) 192(100) 122(50) 120(50) 242( 11 00) x 2=14.52 p=.01 d.f.=1 69 A n o t h e r d i f f e r e n c e i n s e r v i c i n g b e h a v i o u r was i n t h e a r e a of home v i s i t s . W h i l e 69% o f t h e LTC d e n t i s t s make home v i s i t s , o n l y 42% o f i n t e r e s t e d d e n t i s t s do s o . T h i s p e r c e n t a g e f a l l s q u i t e low amongst d i s i n t e r e s t e d d e n t i s t s ; o n l y 1/5 o f t h i s g r o u p u n d e r t a k e home v i s i t s ( x 2 = 3 9 . 0 3 , p =.0l) ( T a b l e 2 3 ) . Some s t u d i e s (7,35) have s u g g e s t e d t h a t t h e d e b i l i t a t i n g c o n d i t i o n s o f t h e e l d e r l y may n e g a t i v e l y r e i n f o r c e t h o s e who a r e p u t i n a p o s i t i o n o f t r e a t i n g them. T h i s s t u d y s u g g e s t s t h a t s u c h e x p o s u r e and e x p e r i e n c e d e v e l o p s a more p o s i t i v e a p p r o a c h t o t h i s s p e c i a l i z e d c a r e a s w e l l a s t h e a b i l i t y t o move away f r o m d e p e n d e n c y on t h e i n f r a s t r u c t u r e i n t h e d e n t i s t ' s o f f i c e . T a b l e 23:Home V i s i t s Among T h r e e S u b - g r o u p s ( Q 1 1 ) V a r i a b l e : Number o f d e n t i s t s Home v i s i t s : y e s no T o t a l x 2=39.03 LTC I n t e r e s t e d U n i n t e r e s t e d D e n t i s t s ( % ) D e n t i s t s ( % ) D e n t i s t s ( % ) 43(69) 19(31) 62(100) P=.01 36(42) 49(58) 85(100) d.f.=2 21(20) 8 5 ( 8 0 ) 106(100) T o t a l ( % ) 100(43) 133(57) 233(100) LTC p r a c t i o n e r s c o n s i d e r e d t h e l o s s o f b o t h l e i s u r e t i m e ( x 2=13.16, p=.03) and p r i v a t e p r a c t i c e t i m e ( x 2 = 9 . 9 5 , p = . 1 ) t o be l e s s c r i t i c a l i n t h e i r c u r r e n t d e c i s i o n t o p r a c t i c e a t LTCs t h a n d i d t h e r e s t o f t h e d e n t i s t s ( T a b l e 2 4 ) . T h i s f i n d i n g , a t f i r s t g l a n c e , a p p e a r e d t o r e a f f i r m t h e r o l e o f o p p o r t u n i t y c o s t s . We 70 T a b l e 2 4 ; C o n s i d e r a t i o n s o f Time L o s s Among T h r e e S u b - g r o u p s ( Q I 8 ) V a r i a b l e Number o f D e n t i s t s LTC I n t e r e s t e d D e n t i s t s ( % ) D e n t i s t s ( % ) L o s s o f p r i v a t e p r a c t i c e t i m e : i m p o r t a n t n o t i m p o r t a n t T o t a l X 2=9.95 35(61) 22(39) 57(100) p=.1 54(63) 27(37) 81(100) d.f.=2 U n i n t e r e s t e d D e n t i s t s ( % ) 6 9(67) 14(33) 8 3 ( 1 0 0 ) T o t a l ( % ) 158(71) 63(29) 221 (100) L o s s o f l e i s u r e t i m e : i m p o r t a n t n o t i m p o r t a n t T o t a l • 2 _ 13.16 25(45) 31(55) 56(100) p=.03 35(43) 46(57) 81(100) d . f = 2 58(70) 25(30) 83(100) 1 18(54) 102(46) 220( 1 00) w o u l d have e x p e c t e d t o f i n d t h a t t h o s e d e n t i s t s who d i s c o n t i n u e d s e r v i c e w o u l d i n d i c a t e l o s s o f l e i s u r e and p r i v a t e p r a c t i c e t i m e t o be more s e r i o u s c o n s i d e r a t i o n s t h a n t h o s e who c o n t i n u e work a t L T C s . T h o s e who s t i l l p r a c t i c e a t L T C s w o u l d be e x p e c t e d t o have f a r l e s s c o n c e r n f o r l e i s u r e and p r i v a t e p r a c t i c e t i m e l o s s . However, a c h i - s q u a r e a n a l y s i s showed t h a t when t h e LTC p r a c t i t i o n e r s were s u b d i v i d e d i n t o two g r o u p s , t h o s e who c o n t i n u e d and t h o s e who d i s c o n t i n u e d s e r v i c e a t L T C s , t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e two g r o u p s i n t e r m s o f l o s s o f e i t h e r p r a c t i c e o r l e i s u r e t i m e ( x 2 = . 0 0 7 , p=.94, d . f . = 1 ) . LTC p r a c t i t i o n e r s , who had d i s c o n t i n u e d s e r v i c e b e c a u s e 71 o f t h e demands on t h e i r p r a c t i c e and l e i s u r e t i m e , d i d n o t r e l a t e t h e s e c o n c e r n s when a s k e d a b o u t t h e i r c o n s i d e r a t i o n s a t p r e s e n t w i t h r e g a r d s t o f u t u r e LTC s e r v i c e . T h e s e a p p a r e n t l y i n c o n g r u e n t r e s u l t s p o i n t t o o t h e r f a c t o r s i n v o l v e d i n d i s c o n t i n u i n g s e r v i c e s w h i c h t h i s s t u d y has f a i l e d t o show up. 5.4 C o n c l u s i o n s o f t h e S e c o n d a r y S t u d y W i t h i n t h e l i m i t a t i o n s o f t h i s s e c o n d a r y s t u d y , t h e r e a r e r e l e v a n t f i n d i n g s t o v a l i d a t e t h e e a r l i e r a n a l y s i s . T h i s s t u d y shows t h a t p r o f e s s i o n a l t r a i n i n g and e x p o s u r e t o t h e i n s t i t u t i o n a l i z e d e l d e r l y i s a p r e r e q u i s i t e f o r t h i s s p e c i a l i z e d d e n t i s t r y r o l e . F u r t h e r , t h e n eed t o f u l f i l l o n e ' s p r o f e s s i o n a l r e s p o n s i b i l i t i e s t o c u r r e n t and f o r m e r p a t i e n t s a t L T C s i s i m p l i c i t i n u n d e r t a k i n g s u c h a s e r v i c e . The p r o f e s s i o n a l model, w h i c h i n d i c a t e d t h a t p r o f e s s i o n a l s a t i s f a c t i o n e f f e c t s m o t i v a t i o n i n LTC s e r v i c e , t a k e s p r e c e d e n c e i n t h i s s t u d y . But t h i s model d o e s n o t s t a n d a l o n e . The e c o n o m i c m o d e l , w i t h i t s e m p h a s i s on o p p o r t u n i t y c o s t s , c omplements t h e p r o f e s s i o n a l m o d e l . The o p p o r t u n i t y c o s t s i n l e i s u r e t i m e , so h i g h i n t h e p r i o r i t i e s o f t h o s e who have not s e r v i c e d LTC f a c i l i t i e s , a r e l e s s o v e r r i d i n g i n t h e d e c i s i o n m a king p r o c e s s e s o f LTC p r a c t i t i o n e r s . T h o s e who have d i s c o n t i n u e d s e r v i c e , e i t h e r b e c a u s e t h e y h a v e moved o r a r e c u r r e n t l y t o o b u s y i n p r i v a t e p r a c t i c e , r e a l i s t i c a l l y have shown t h a t i n c r e a s i n g commitments t o new o r g r o w i n g p r i v a t e p r a c t i c e s 72 no l o n g e r make LTC s e r v i c e a s a t t r a c t i v e a s i t had been f o r m e r l y . N o n t h e l e s s , t h e l a r g e number o f LTC p r a c t i t i o n e r s who were s t i l l i n t e r e s t e d i f t h e i r s e r v i c e s were r e q u e s t e d l e a d s t o a p o s i t i v e c o n c l u s i o n . G i v e n t h a t t h e e c o n o m i c c o s t s a r e n o t p r o h i b i t i v e , a p p r o p r i a t e t r a i n i n g and e x p e r i e n c e i n d e n t i s t r y f o r t h e c h r o n i c a l l y i l l e l d e r l y may i n c r e a s e t h e p o t e n t i a l f o r e f f e c t i v e manpower i n s p e c i a l c a r e p r o g r a m s . 73 CHAPTER 6 DISCUSSION 6 . 1 L i m i t a t i o n s of t h e S u r v e y S o c i a l s c i e n c e s u r v e y s a r e f r a u g h t w i t h numerous s h o r t c o m i n g s w h i c h l i m i t t h e a c c u r a c y o f t h e i r r e f l e c t i o n o f s o c i a l r e a l i t y . T h i s s t u d y has n o t c i r c u m v e n t e d t h e v a r i o u s p i t f a l l s . To b e g i n , I must assume t h a t t h e d e n t i s t s a r e r e p o r t i n g t h e i r p e r c e p t i o n s and e x p e r i e n c e s a s a c c u r a t e l y and h o n e s t l y a s p o s s i b l e , b u t t h e r e i s no means o f v e r i f y i n g t h i s . The r e s u l t s a r e b a s e d on " h e a r s a y " e v i d e n c e . S e c o n d l y , t h e q u e s t i o n s a n d answer o p t i o n s , a l t h o u g h p r e - t e s t e d and honed t o be a s c l e a r a s p o s s i b l e may c a r r y enough a m b i g u i t y t o p r e c l u d e any u n i v e r s a l meaning amongst d e n t i s t s . One example i s t h e t e r m " p r o f e s s i o n a l / p e r s o n a l s a t i f a c t i o n " , w h i c h p o t e n t i a l l y has d i f f e r e n t c o n n o t a t i o n s . D e n t i s t s a r e a s k e d w h e t h e r t h e y a r e busy enough. F o r some b u s y n e s s i s a c o n t i n u o u s s t r e a m o f c l i e n t s t h r o u g h t h e i r doors', f o r o t h e r s i t i s a m a t c h i n g o f a c t u a l and t a r g e t i n c o m e s . T h i s l e a d s t o t h e t h i r d l i m i t a t i o n o f t h e s u r v e y . W i t h o u t q u a l i f y i n g c l a u s e s , a n s w e r s a r e open t o t h e i n t e r p r e t a t i o n o f t h e i n v e s t i g a t o r , a n d m u l t i p l e c h o i c e a n s w e r s , r e g a r d l e s s o f how t h e y a r e c o n s t r u e d , r a i s e t h e q u e s t i o n o f how m e a n i n g f u l s u c h a s u p e r f i c i a l a n a l y s i s c a n be. 74 6.2 P r a c t i c a l A p p l i c a t i o n s The r e s u l t s o f t h e s t u d y have a number of p r a c t i c a l a p p l i c a t i o n s i n t h e p l a n n i n g o f d e n t a l s e r v i c e s f o r t h e i n s t i t u t i o n a l i z e d e l d e r l y . B o t h t h e c l i n i c a l l y and s u b j e c t i v e l y d e f i n e d " n e e d s " o f t h e i n s t i t u t i o n a l i z e d e l d e r l y r e q u i r e a d e n t a l s e r v i c e w h i c h o p e r a t e s o u t s i d e t h e c o n f i n e s o f a d e n t a l o f f i c e . T h i s p r a c t i c e must t a k e i n t o a c c o u n t t h e m e d i c a l c o m p l i c a t i o n s o f d e n t a l t r e a t m e n t f o r t h i s s p e c i a l i z e d g r o u p and t h e f i n a n c i a l and p s y c h o l o g i c a l c o n s t r a i n t s o f t h e i n d i v i d u a l s r e q u i r i n g t r e a t m e n t . T h e r e a r e a number o f i m p e d i m e n t s t o t h e e s t a b l i s h m e n t o f s u c h a d e n t a l s e r v i c e , and t h e f u l l f i l l m e n t o f manpower r e q u i r e m e n t s i s one o f t h e most f u n d a m e n t a l . D e n t i s t s have a c q u i r e d a monopoly p o s i t i o n i n d i a g n o s t i c and o p e r a t i v e p r o c e e d u r e s . U n t i l t h e l e g a l and e d u c a t i o n a l c h a n g e s w h i c h l e g i t i m i z e t h e use o f d e n t a l h y g i e n i s t s , d e n t a l n u r s e s , and d e n t a l m e c h a n i c s f o r b a s i c r e s t o r a t i v e and d e n t u r e work a r e f o r t h c o m i n g , i t i s t h i s g r o u p o f s e n i o r p r o f e s s i o n a l s who must be r e c r u i t e d f o r a LTC d e n t a l s e r v i c e . As t h i s s t u d y h a s shown, d e n t i s t s a r e r e l u c t a n t t o u n d e r t a k e t h i s s e r v i c e ( 3 7 % s a i d no, and a n o t h e r 26% were u n c e r t a i n ) . T h e i r r e l u c t a n c e i s t o a l a r g e d e g r e e b a s e d , a c c o r d i n g t o b o t h b i v a r i a t e a n d m u l t i v a r i a t e a n a l y s i s , on a g e n e r a l i z e d p e r c e p t i o n o f l i m i t e d t r e a t m e n t p o s s i b i l i t i e s f o r t h e i n s t i t u t i o n a l i z e d e l d e r l y . T h i s v i e w p a r t l y stems from t h e i r l i m i t e d t r a i n i n g and e x p e r i e n c e w i t h t h e p h y s i o l o g i c a l c h a n g e s o f t h e o r a l c a v i t y i n 75 o l d age a n d t h e o r a l p a t h o s e s common t o t h e e l d e r l y . As w e l l , d e n t i s t s a r e n o t r e a d y t o a c c e p t a w o r k i n g e n v i r o n m e n t d e v o i d o f t h e s o p h i s t i c a t e d , s t a t i o n a r y e q u i p m e n t t h e y have become a c c u s t o m e d t o f o r even m i n o r r e p a r a t i v e work s i n c e t h e b e g i n n i n g o f t h e i r t r a i n i n g . T h e s e two p r o b l e m s may be r e c t i f i e d by b r o a d e n i n g t h e e d u c a t i o n o f d e n t i s t s i n s p e c i a l i z e d c a r e d e n t i s t r y . As t h e f e d e r a l d e m o g r a p h e r s a n t i c i p a t e t h e " g r e y i n g " o f t h e C a n a d i a n n a t i o n ( 5 ) , i t i s o f b e n e f i t t o t h e d e n t a l p r o f e s s i o n t o e x t e n d t h e i r t h e o r e t i c a l b a c k g r o u n d i n t h e p h y s i o l o g i c a l and p s y c h o l o g i c a l c h a n g e s i n o l d age so t h a t t h e y may be a b l e t o d i s t i n g u i s h between n o r m a l and p a t h o l o g i c a l c h a n g e s i n t h e mouth. D i d a c t i c and c l i n i c a l c o u r s e s on t h e r a t i o n a l c a r e o f m e d i c a l l y c o m p r o m i s e d p a t i e n t s , i n v o l v i n g p a t i e n t management a n d m o d i f i c a t i o n o f s t a n d a r d t r e a t m e n t t e c h n i q u e s , would be v a l u a b l e t o b o t h u n d e r g r a d u a t e s and t o d e n t i s t s t h r o u g h t h e c o n t i n u i n g e d u c a t i o n p r o g r a m ( 1 1 ) . One c o n s e q u e n c e o f s p e c i a l i z e d d e n t a l c a r e f o r t h e c h r o n i c a l l y i l l i s t h e i n t e r a c t i o n w i t h o t h e r h e a l t h c a r e p r o f e s s i o n a l s . T h i s a p p l i e s n o t o n l y t o t h e i n s t i t u t i o n a l i z e d e l d e r l y b u t o t h e r c h r o n i c a l l y i l l p a t i e n t s a s welKthe h a n d i c a p p e d , e t c . ) . D e n t i s t s have enough o f a g r o u n d i n g i n t r a d i t i o n a l m e d i c i n e t h a t t h e i r i n c o r p o r a t i o n i n t o t h e h e a l t h c a r e team a t an i n s t i t u t i o n w ould f a c i l i t a t e t h e exch a n g e o f knowledge on t h e m e d i c a l a n d p s y c h o l o g i c a l c o m p l i c a t i o n s o f d i f f e r e n t t h e r a p i e s . F a m i l i a r i t y w i t h p h a r m a c e u t i c a l s and 7 6 s u r g i c a l proceedures would enable d e n t i s t s to p r e d i c t i a t r o g e n i c e f f e c t s of s p e c i f i c proceedures so that the h e a l t h care team may weigh the b e n e f i t s and disadvantages of d e n t a l therapy f o r s p e c i f i c pathoses. The i s s u e of a p p r o p r i a t e d e n t a l equipment at f a c i l i t i e s i s not l i m i t e d to the c h r o n i c a l l y i l l , but extends to other s p e c i a l i z e d care groups who are c o n f i n e d to w h e e l c h a i r s or beds i n f a c i l i t i e s . D e n t i s t s adopt the f i x e d s t a t i o n a r y o p e r a t o r i e s f o r t h e i r p r i v a t e p r a c t i c e s that are s i m i l a r to those of t h e i r d e n t a l s c h o o l s . I t i s not s u r p r i s i n g d e n t i s t s , when d e c i d i n g on long term care s e r v i c e , i n d i c a t e d great concern f o r the presence or absence of a d e n t a l o p e r a t o r y . In the past few decades, p o r t a b l e d e n t a l u n i t s with compressed a i r vacuum systems, hi g h and low speed hand p i e c e s , a i r / w a t e r s y r i n g e s and o r a l e vacuators have become more than adequate f o r b a s i c d e n t a l procedures. T h i s new technology c o u l d be a c t i v e l y employed i n the t r a i n i n g of d e n t i s t s to f a m i l i a r i z e them with p o r t a b l e equipment. The f i n d i n g s of the study show that the u n d e r w r i t i n g of c a p i t a l expenditures i s of importance to d e n t i s t s who are i n t e r e s t e d i n long term care s e r v i c e . I t would be h e l p f u l to the e s t a b l i s h m e n t of a program i f these u n i t s would be made a v a i l a b l e by the sponsoring government b o d i e s ( 3 3 ) . The p r o f e s s i o n a l p r e p a r a t i o n f o r s p e c i a l i z e d d e n t a l care f o r the e l d e r l y i s not the only remedy f o r the l a c k of c u r r e n t 77 i n t e r e s t i n p r o v i d i n g s e r v i c e s . The economic c o n s t r a i n t s t h e d e n t i s t s have i d e n t i f i e d s h o u l d be a d d r e s s e d . D e n t a l p r o c e d u r e s i n LTC f a c i l i t i e s , a s LTC p r a c t i t i o n e r s have p o i n t e d o u t , a r e f a r more t i m e c o n s u m i n g a n d c o m p l i c a t e d t h a n t h o s e p e r f o r m e d i n a p r i v a t e o f f i c e . P a t i e n t s must be p r e p a r e d f o r t h e d e n t i s t ' s a r r i v a l , and t h e t o i l e t i n g a n d f e e d i n g of p a t i e n t s c a n n o t be p r e c i s e l y t i m e d n o r t h e a p p o i n t m e n t p r e c i s e l y s c h e d u l e d . I n e v i t a b l y c o m p l i c a t i o n s a r i s e ; t h e p a t i e n t may be i l l t h a t day, or may be i n c o n t i n e n t d u r i n g t r e a t m e n t . The p a t i e n t o r t h e s t a f f may have f o r g o t t e n a b o u t t h e a p p o i n t m e n t o r t h e p a t i e n t may become a v e r s e t o t r e a t m e n t p r e v i o u s l y d e c i d e d upon. T h e s e p a r t i c u l a r c i r c u m s t a n c e s , a l o n g w i t h t h e l o n g e r p r o c e e d u r e t i m e i n managing t h e c h r o n i c a l l y i l l p a t i e n t , r e n d e r t h e f e e - f o r - s e r v i c e a r r a n g e m e n t u n a c c e p t a b l e t o many d e n t i s t s . They c a n e a r n more, a t l e s s c o s t and l e s s i n c o n v e n i e n c e , i n p r i v a t e p r a c t i c e . F i n a n c i a l a r r a n g e m e n t s must t a k e i n t o a c c o u n t t h e s p e c i a l i z e d management o f p a t i e n t s and t h e t i m e c o n s u m i n g n a t u r e o f LTC d e n t a l work. The p r o f i t a b i l i t y o f new p r a c t i c e s has d e c l i n e d i n r e c e n t y e a r s ( l O ) , a n d w i t h t h a t t h e s e c u r i t y o f n o v i c e d e n t i s t s h a s d e t e r i o r a t e d . T h i s i s e v i d e n t i n t h e w i l l i n g n e s s o f t h e y o u n g e r d e n t i s t s , who a r e j u s t b e g i n n i n g a p r a c t i c e , t o e n t e r i n t o LTC s e r v i c e . A l t h o u g h an LTC p r a c t i c e may n o t be a s p r o f i t a b l e a s a p r i v a t e p r a c t i c e , a g u a r a n t e e d r e t a i n e r f e e o r a s a l a r i e d p o s i t i o n may make t h i s a l t e r n a t i v e more a t t r a c t i v e and f e a s i b l e f o r n o v i c e s ( 3 3 ) . As t h e s t u d y 78 i n d i c a t e s , t h o s e who have p r a c t i s e d a t LTCs a r e more l i k e l y t o i n d i c a t e c o n t i n u e d i n t e r e s t i n t h i s work. By o p e n i n g t h e d o o r t o s p e c i a l c a r e d e n t i s t r y t h r o u g h f i n a n c i a l i n c e n t i v e s , a p r o f e s s i o n a l b a s e o f LTC p r a c t i t i o n e r s may be e s t a b l i s h e d a f t e r a p e r i o d o f t i m e so t h a t s p e c i a l c a r e d e n t i s t r y c a n e v o l v e a s a v i a b l e s p e c i a l t y o p t i o n . 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R e s e a r c h on  A g i n g 1 9 7 9 : 1 ( 1 ) , pp.11-36. 19. MacEntee,M.I., R. W e i s s , N. W a x i e r - M o r r i s o n and B . M o r r i s o n . An o r a l h e a l t h s u r v e y o f t h e i n s t i t u t i o n a l i z e d e l d e r l y i n t h e G r e a t e r V a n c o u v e r a r e a . S u b m i t t e d f o r p u b l i c a t i o n t o Community D e n t i s t r y and O r a l  E p i d e m i o l o g y . May, 1986. 20. MacEntee,M.I., J.G. S i l v e r , G. G i b s o n and R. W e i s s . O r a l h e a l t h i n a l o n g t e r m c a r e f a c i l i t y e q u i p p e d w i t h a d e n t a l s e r v i c e . Community D e n t i s t r y and O r a l  E p i d e m i o l o g y 1985:13, pp.260-263. 21. M c T a v i s h , D . G . P e r c e p t i o n s o f o l d p e o p l e , i n R e s e a r c h I n s t r u m e n t s i n Soc i a l G e r o n t o l o g y : v o l I . e d s . J . D . Mangen an d W.A. P e t e r s o n . M i n n e a p o l i s . 1983. 22. M a r t i n e l l o , B . P . a n d J . L . L e a k e . O r a l h e a l t h s t a t u s i n t h r e e O n t a r i o homes f o r t h e a g e d . J o u r n a l o f t h e C a n a d i a n  D e n t a l A s s o c i a t i o n 1976:37, pp.329-432. 23. M i l l e r , D . B . , R. L a u e n s t e i n and R. W i n s t o n . P h y s i c i a n s ' a t t i t u d e s t o w a r d t h e i l l a g e d and n u r s i n g homes. J o u r n a l o f t h e A m e r i c a n G e r i a t r i c S o c i e t y 1 9 6 8 : 1 6 ( 9 ) , pp.976-983. 24. N e u g a r t e n , B . M i d d l e Age and A g i n g C h i c a g o . 1968. 25. O s t e r b e r g , T . , A. Ohman, B. H e d e g a r d , and A. S v a n d b o r g . A c o n d i t i o n o f t h e o r a l mucosa a t age 70. An o d o n t o l o g i c a l r e p o r t f r o m t h e l o n g i t u d i n a l s t u d y o f 70 y e a r o l d s i n Gothenburg,Sweden. 1981. D e p t . o f P r o s t h e t i c D e n t i s t r y , U n i v e r s i t y o f G o t e b o r g , S w e d e n . 82 26. R o z i r , R . G . , J . T . Hughes and D. Ramsey. The e p i d e m i o l o g y o f d e n t a l d i s e a s e s i n N o r t h C a r o l i n a . J o u r n a l o f P u b l i c  H e a l t h D e n t i s t r y 1981:41, pp.14-24. 27. S c h e f f l e r , R . M . , and J . E . Kushman. A p r o d u c t i o n f u n c t i o n f o r d e n t a l s e r v i c e s : e s t i m a t i o n and e c o n o m i c i m p l i c a t i o n s . S o u t h e r n E c o n o m i c J o u r n a l 1 9 7 7 : 4 4 ( 1 ) , pp.25-35. 28. S i g n o r i , E . I , S.D. B u t t , and J . F . K o z a k . A t t i t u d e s t o w a r d s t h e a g e d . P a p e r p r e s e n t e d a t t h e A n n u a l M e e t i n g o f t h e  C a n a d i a n A s s o c i a t i o n o f G e r o n t o l o g y . O c t . 1 3 - 1 6 , 1 9 7 7 . 29. S m i t h , E . E p i d e m i o l o g y o f o r a l and p h a r y n g e a l c a n c e r s i n t h e U.S. Review o f r e c e n t l i t e r a t u r e . J o u r n a l o f t h e  N a t i o n a l C a n c e r I n s t i t u t e 1979:63, pp.1189-1198. 30. Spence D.L., M.D. F e i g e n b a u m , F. F i t z g e r a l d and J . R o t h . M e d i c a l s t u d e n t s ' a t t i t u d e s t o w a r d t h e g e r i a t r i c p a t i e n t . J o u r n a l o f t h e A m e r i c a n G e r i a t r i c s S o c i e t y 1 9 6 8 : 1 6 ( 9 ) , pp.976-983. 31. S t e e l e , L . P . D e n t a l s t u d e n t s a t t i t u d e s a n d knowledge a b o u t e l d e r l y p e o p l e . M.Sc. T h e s i s . U n i v e r s i t y o f London. 1985. 32. S t i f f , R . H . a n d G.T. P h i p p s . A t t i t u d e s o f d e n t a l s t u d e n t s t o w a r d s t h e c h r o n i c a l l y i l l , a g e d an d d i s a b l e d p e r s o n s . J o u r n a l o f D e n t a l E d u c a t i o n 1 9 6 4 : 2 8 ( 2 ) , pp.149-154. 33. T e r r i l l , A . J . , a n d J . E l l i o t . The Montana A d v i s o r y P rogram. J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n 1979: 98, pp.402-406. 34. The Iowa S u r v e y o f O r a l H e a l t h 1980. M onograph. U n i v e r s i t y o f Iowa C o l l e g e o f D e n t i s t r y and t h e Iowa D e n t a l A s s o c i a t i o n . 35. W a l k , R . I . and R.B. Wolk. P r o f e s s i o n a l w o r k e r ' s a t t i t u d e s t o w a r d s t h e a g e d . J o u r n a l o f t h e A m e r i c a n G e r i a t r i c  S o c i e t y 1 9 71:19(7):pp.624-639. 36. W i n g a r d , J . A . an d C.L. Dorman. A t t i t u d e s t o w a r d s t h e e l d e r l y : c u l t u r a l v a r i a t i o n s and m e t h o d o l o g i c a l i s s u e s . I n t e r d i s c i p l i n a r y T o p i c s i n G e r o n t o l o g y 1983:17, pp.157-169. 83 APPENDIX 84 T H E UNIVERSITY OF BRITISH C O L U M B I A . 2199 WE5BROOK MALL V A N C O U V E R , B . C . , C A N A D A V 6 T 1Z7 Dear I am i n v e s t i g a t i n g the a v a i l a b i l i t y o f den t a l s e r v i c e s t o the e l d e r l y r e s i d i n g i n l ong term ca r e f a c i l i t i e s ( h o s p i t a l s and n u r s i n g homes) i n G r e a t e r Vancouver . Th i s s tudy , wh ich i s p a r t o f my M a s t e r ' s t h e s i s , i s p a r t i a l l y funded by the B r i t i s h Co lumbia Hea l th Care Research Foundat ion and i s c a r r i e d out i n c o l l a b o r a t i o n w i t h D r . M i chae l MacEntee of the Department o f R e s t o r a t i v e D e n t i s t r y . R e su l t s w i l l be l i n k e d to a l a r g e r survey on the o r a l h e a l t h of i n s t i t u t i o n -a l i s e d e l d e r l y i n G r e a t e r Vancouver . I would be g r a t e f u l i f you c ou l d complete the f o l l o w i n g q u e s t i o n n a i r e which i n q u i r e s about y o u r expe r i ence w i t h the e l d e r l y and y o u r i n t e r e s t i n p r o v i d i n g den ta l s e r v i c e s to the i n s t i t u t i o n a l i s e d e l d e r l y . T h i s shou ld take no more than 10 - 15 minutes o f y o u r t ime . I would l i k e everyone to f i l l out the f i r s t s e c t i o n . P l e a se f i l l out the second s e c t i o n on l y i f you have p r o v i d e d den ta l s e r v i c e s to l ong term ca re f a c i l i t i e s . The q u e s t i o n n a i r e i s anonymous and shou ld be ma i l ed i n the r e t u r n stamped brown enve l ope . I t i s a l s o impo r tan t to ma i l i n the b lue shee t s e p a r a t e l y i n the r e t u r n stamped wh i t e enve l ope . A summary o f the f i n d i n g s w i l l be submi t t ed f o r p u b l i c a t i o n t o the B.C. C o l l e g e o f Den ta l Su rgeons ' n e w s l e t t e r . Thank you f o r y o u r h e l p . Yours s i n c e r e l y , RW/lg Rachel Weiss Dept. o f R e s t o r a t i v e D e n t i s t r y 86 APPENDIX 87 SECTION 1 To be f i l l e d out by everyone What Is your age? How many years have you been practicing dentistry? How many of those years have been in specialty practice? What kind.of practice do you have? a) new private practice (less than 3 years), b) established private practice, c) retirement part-time private practice, d) part-time private practice ei ful l -t ime public salaried practice, f) part-time public salaried practice e) other, specify On the average, how many hours a week do you practice? a) less than 10, b) 11-25, c) 26-40, d) over 40 What type of practice do you have? a). General b) Prosthodontlc c) Endodontic d) Periodontic e) Orthodontic f) Pedodontlc g) Oral Surgery h)Hosp1tal 1) Other, specify What parts of the city or what suburb do you practice in? a) Burnaby b) West Vane, c) North Vane, d) Downtown Vane, e) Point Grey f) Kitsllano g) Kerrisdale h) Dunbar i) Marpole j) Vane. South ki Oakridge DSouth Granville m) Mt. Pleasant n) Lower East Side o) Strathcona p) Vane. East q) Fraserview r) Fairview slopes s) Champlain Heights. Is your practice busy enough? a) yes, b) no Did you have training in geriatric dentistry at university? (Circle appropriate responses) a) formal university course (minimum 10 lectures) with cl inical institutional experience b) formal university course (minimum 10 lectures) only c) c l in ical Institutional experience only d) occasional lectures during undergraduate program e) post-graduate continuing education course f) no formal training What percentage of your practice consists of patients aged 65 years or older? a) none, b) 5%, c) 6-10%, d) 11-25%, e) 25%+ Have you treated elderly patients at their home? a) no, b) yes, only in emergency, c) yes 8 8 12. What services have you most commonly provided to e l d e r l y patients 1n your practice? C i r c l e a l l applicable Items. Emergency: a) e x t r a c t i o n s , b) denture adjustments, c) endodontic or periodontic emergencies, a) diagnosis of o r a l pathosls, e) biopsies, f) other (specify) E l e c t i v e : a) examinations, b) oral hygiene assistance/scaling, c) f i l l i n g s / c r o w n s d) denture-fabrication, e) denture r e l l n e s , f) periodontal therapy, g) endodontic therapy, h) other (specify) 13. How would you decrlbe your work with the e l d e r l y ? Please c i r c l e appropriate items. a) I enjoy s o c i a l i z i n g with 4 treating e l d e r l y p a t i e n t s . b) I don't see a d i s t i n c t i o n between e l d e r l y patients and patients In other age groups c ) E l d e r l y patients present d i f f i c u l t i e s due to such factors as medical problems and confusion. d) E l d e r l y patients are often ungrateful or uncommunicative e) E l d e r l y often do not follow up preventive therapy f) I t 1s d i f f i c u l t to improve t h e i r oral health status due to l i m i t e d treatment options. g) Treating the e l d e r l y Is time consuming and f i n a n c i a l l y unrewarding. h) Other, specify 14. Do you think the p o s i t i v e aspects of working with e l d e r l y outweigh the negative aspects, or 1s 1t the other way around? a) p o s i t i v e aspects outweigh negative aspects, b) negative aspects outweigh p o s i t i v e aspects c ) both p o s i t i v e and negative aspects are about the same d) uncertain 15. Would you be Interested In providing on-going services to residents of a long tens care f a c i l i t y ? a) no, b) uncertain, c ) yes 16. I f YES, about how many hours can you make a v a i l a b l e to long term care f a c i l i t i e s ? per month 17. How much time would you be prepared to take to t r a v e l to a f a c i l i t y ? a) none, b) 10-15 minutes, c ) h a l f an hour, d) more than h a l f an hour 89 18. How Important are the f o l l o w i n g considerations i n a r r i v i n g at your decision regarding future services to long terra care f a c i l i t i e s ? Very Imoortant Moderately Imoortant a) Loss of p r i v a t e p r a c t i c e time 1 2 3 4 b) Loss of l e i s u r e time 1 2 3 4 c) Distance to f a c i l l t y ( l e s ) 1 2 - 3 4 d) F i n a n c i a l reimbursement 4 c a p t l a l expenses 1 2 3 4 e) A v a i l a b i l i t y - of dental operatory A equipment at f a c i l i t y 1 2 3 4-f) Profession 4 personal s a t i s f a c t i o n In working with e l d e r l y p a t i e n t s I 2 3 4 g) Experience 4 t r a i n i n g In t r e a t i n g d i s a b l e d and/or c h r o n i c a l l y 111 p a t i e n t s 1 2 3 4 Minimally Imoortant 19. Would the cost of purchasing portable equipment a f f e c t your decision? a) no, b) u n c e r t a i n , c) yes I f YES, would you consider using portable equipment purchased by the College o f Dental Surgeons, the f a c i l i t y or the government? a) no, b) uncertain, c) yes 20. Would the form of reimbursement a f f e c t your decision? a) no, b) u n c e r t a i n , c) yes I f YES, how would you p r e f e r to be paid? C i r c l e one or more responses. a) fee per s e r v i c e , b) fee per time, c) sessional fee, d) r e t a i n e r fee (on c a l l 21. I f you have not provided dental services to long term care f a c i l i t i e s why not? C i r c l e appropriate answers. a) too busy i n p r i v a t e p r a c t i c e • b) inadequate t r a i n i n g and experience with medically compromised patients c) f i n a n c i a l l y c o s t l y and unrewarding d) bureaucratic b a r r i e r s would hinder proper treatment of patients e ) lack of appropriate treatment f a c i l i t i e s at I n s t i t u t i o n s f) have not been asked by residents or administrators . • g) other (specify) I f you have not seen patients i n a long term care f a c t l l t y please stop here and return the questionnaire. I f you have provided t h i s type of s e r v i c e , please, proceed to s e c t i o n I I . Thank you f o r your help. - -• -90 SECTION II To be f i l l e d out ONLY by dentists who have pract iced in Long Term Care Fac i l i t y ( i e s ) If you have not pract iced in a Long Term Care F a c i l i t y , then you can discard th is s e c t i o n . 1. What were the most common dental services you nave provided to residents of long tern care f a c i l i t i e s ? Eneroency E lect ive ly extract ions I, oral examinations 2) denture adjustments 2) oral nygiene ass is tance, 3 endodontic S per iodont ic emergencies scal ing 4) d iagnosis of oral patnosis 2 ) fi11ings/c-cwns 5) b iops ies 4) denture f ab r i ca t i on 6) otner (spec i fy) 5) denture re i ines 6) periodontic tnerapy 7) enaocontic tnerapy 8) other (specify) 2. For pat ients under long term care, do you charge more or less than the fee guide recommended by the CO.3.S.C? 1) I fo l low the guide 2) I cnarge more than the guide 3) I sometimes charge less wnen indiv idual considerations involved 4) I always cnarge less 3. IF you charge more or l e s s , by what percentage do your fees vary from the guide? 1) 10S 2) 205 3) 20'. 4) 405 5) i n d i v i d u a l l y set fees 4. What have you l i k e d about working in long term care f a c i l i t i e s ? C i r c l e the appropriate responses. 1) found s o c i a l i z i n g witn e lder ly patients rewarding 2) provided opportunity to increase the s ize of my pract i ce 3) broadened the scooe of my practice 4) permitted part-t ime pract ice 5) pub l i c serv i ce opportunity 6) met my profess iona l r e s p o n s i b i l i t i e s to e lde r l y 7) provided i n t e r a c t i o n with otner health care worxers 8) other (spec i fy) 9 1 5. What have you d i s l i k e d about working in long term care f a c i l i t i e s ? C i r c l e the appropriate resoonses. 1) inaoeauate treatment f a c i l i t i e s 2) time consuming 3 ) f i n a n c i a l l y unrewarding 4) l imi ted treatment p o s s i b i l i t i e s 5) medical and osycnological comolications of dental tnerapy 6) e lae- ly d i f f i c u l t to work with ex. veroal ly aousive 7) personal ly unrewarding 8) f a c i l i t i e s unpleasant, environments smel l , depressing atrospnere 9) administrat ion erects D a r n e r s to pat ient management ana long tern tnerapy 10) otner (spec i fy) 6. have the p o s i t i v e aspects outweighed tne negative aspects of t reat ing e lde r l y 1n long term care f a c i l i t i e s , or i s i t tne ctne'- way around? 1) pos i t i ve aspects outweign negative aspects 2) negative aspects cutwiegn pos i t ive aspects 3) pos i t i ve and negative aspects aDout tne same 4) uncertain 7. 'why did you o r i g i n a l l y decide to provide dental services to long term care f a c i l i t i e s ? C i r c l e one or more tnan one. 1) opportunity to increase s ize of pract i ce ' 2! socia l contacts witn e loer ly are rewarding 3) wanted to pe r form a pus l i c serv ice i ) part of profess ional r e s p o n s i a i l i t i e s 5) part-time pract i ce opportunity 6/ part of a se">i-reti rement pract ice 7) otner i spec i fy) 8. For tnose who no longer work in f a c i l i t i e s , wr,y did you stop? C i r c l e one or more tnan one. 1) no demand 2) administrat ive d i f f i c u l t i e s in patient management and working environment 2) f i n a n c i a l l y unrewarding 4) loss of l e i sure time 5) increasing conrnitments to pr ivate o f f i c e pract ice 6) pro fess iona l ly ano personal ly unsa t i s f i ed witn work 7) other, (spec i fy) 92 B ) Tne f o l l o w i n g Q u e s t i o n s have been c o n s t r u c t e d f c r more d e t a i l s of y o u r d e n t i l p r a c t i c e 1n l o ng t e rm f a c i l i t i e s . The q u e s t i o n s a re r e p e a t e d 3 t imes i n o r d e r f o r you to i n c l u d e up t o t n r e e f a c i l i t i e s i n wh i ch y ou have p r a c t i c e d F a c i l i t y fl 1. Name o f f a c i l i t y o r t ype i f you cannot remeTOtr name: ~ a) r e n a o i 1 i t a t i o n c e n t r e b) p r i v a t e h o s p i t a l c) ex t ended c a r e p u b l i c n c s p i t a l d) n o n - p r o f i t n u r s i n g nome e) p r i v a t e n u r s i n g home 2. Over now l o n g a p e r i o d o f t ime d i d you p r a c t i c e a t t h i s f a c i l i t y ? 2. A p p r o x i m a t e l y how o f t e n d i d you work t n e r e ? a: wnen c a l l e d f o r emergency b) once a week c ) b i - m o n t h l y d) once a 1/4 y e a r e) once a 1/2 y e a r f ) once a y e a r g) o o n ' t rememoer 4. A p p r o x i m a t e l y how mucn t ime d i d you spend pe r s e s s i o n , i . e . l e n g t h c f v i s i t ? a) 1/2 hour b) 1 hour c) f u l l M y i) 2 o- more days e; one wee* f; t r o ouch v a r i a t i o n t o g i v e an ave rage h) d o n ' t rememper 5. Ho» f a r was t h e f a c i l i t y f r o r y ou r o f f i c e ? a) 5-10 m i n u t e s 0) 10-15 m inu tes c ! 1/2 hou r d) > i /2 nour e) o o n ' t remencer 6. wnat t r e a t m e n t a r r angemen t s d i d tne f a c i l i t y nave? C i r c l e a l l a) d e n t a l o o e r a t o r y b) exam in ing room c ) p o r t a D l e eau ipment d) h i g h i n t e n s i t y e) d o n ' t rememoer f ) none 7. wnat t y p e o f r e i m p j r s e m e n t was made? P l e a s e c i r c l e more tnar, one r e sponse f o r c o m p i l a t i o n s , e . g . f e e per i t em 4 s e s s i o n a l f ee a) f ee p e r i t e m b) f ee p e r t ime c ) s e s s i o n a l f e e d) r e t a i n e r f ee (on c a l l a v a i l a b i l i t y ) e) o t h e r f ) o o n ' t rememoer g) no re imbursement F a c i l i t y 12 1. Mame o f F a c i l i t y o r t ype 1f y ou c a n n c : r e m e r o e r name: a) r e n a b i 11 t a t i on c e n t r e b) p r i v a t e h o s p i t a l c) e x t ended c a r e p u b l i c h o s p i t a l d) n o n - p r o f i t n u r s i n g nome e j p r i v a t e n u r s i n g home 2. Over how l o n g a p e r i o d o f t ime d i d you p r a c t i c e a t t h i s f a c i l i t y ? 3 . A p p r o x i m a t e l y how o f t e n d i d you work t h e r e ? a) wnen c a l l e d f o r emergency b) once a week c ) b i - m o n t h l y d) once a month e) once a 1/4 y e a r f ) once a 1/2 y e a r g) once a y e a r h) o o n ' t rememoer 4. A p p r o x i m a t e l y how much t ime d i d you spend p e r s e s s i o n . I . e . l e n g t h o f v i s i t ? a) 1/2 hou r b) 1 hou r c) 1/2 day d) f u l l day e) 2 o r more days f ) one week g) t o o much v a r i a t i o n t o g i v e an average h) o o n ' t rememper 93 5. How far was the faci l i ty from your office? a) 5-10 minutes b) 10-15 minutes c) 1/2 nour d) > 1/2 hour e) don't rememoer 6. What treatment arrangements did the fac i l i ty have? Circle all a) dental ODeratory b) examining room c) portaole equipment d) hign intensity light e) don't rememoer f) none 7 . What tyoe of reimbursement was made? Please circle more than one response for combinations, e.g. fee per item & sessional fee a) fee per item D ) fee per time c) sessional fee d) retainer fee ( on call availability) e) other f) don't rememoer g; no reimoursement Faci l i ty « 1. Name of faci l i ty or type If you cannot rememoer narce: a) renabllitation centre b) private hospital c) extended care public hospital d) non-profit nursing nome e) private nursing home 2. Over how long a period of time did you practice at this faci l i ty? 3. Aoproximately how often did you work there? a) wnen called for emergency b) once a week c) bi-monthly d) once a month e) once a 1/4 year f) once a 1/2 year g) once a year h) don't rememper 4 . Approximately how much time did you spend per session, i .e . length of visit? a) 1/2 nour b) 1 nour c) 1/2 day d) full day e) 2 or more days f) one week g) too mucn variation to give an average h) aon't rememoer 5. How far was the faci l i ty from your office? a) 5-10 minutes b) 10-15 minutes c) 1/2 hour d) > 1/2 hour e) don't remember 6. What treatment arrangements did the faci l i ty have? Circle a l l . a) dental operatory b) examining room c) portable equipment d) high intensity l ight e) aon't rememoer f) none 7 . What type of reimbursement was made? Please circle more than one response for combinations, e.g. fee per Item 4 sessional fee. a) fee per item b) fee per time c) sessional fee d) retainer fee (on call availabil ity) e) other f) don't rememoer g) no reimbursement 94 APPENDIX 95 T a b l e C : 1 : I n t e r e s t by P e r c e p t i ons of Work wi t h t h e E1 d e r1 y I n t e r e s t Var i a b i e s D e s c r i p t i o n s of work:(Q13) Enjoy s o c i a l i z i n g w / e l d e r l y No d i s t i n c t i o n s L i m i t e d t r e a t m e n t o p t i o n s No(%) 54(30) 52(41) 44(41 ) Uncertain^/.) Y e s (%) 46(25) 37(30) 21(25) 82(45) 36(29) 25(34) T o t a l ( % ) C h i - s q u a r e 182(100) 12.46 125(100) 5.84 90(100) 8 . 30 .01 .05 .02 Deg. Freedom 2 2 2 (u)Summary of p o s i t i v e and n e g a t i v e aspects:(Q14) P o s i t i v e outweigh n e g a t i v e 49(30) 43(26) 72(44) 164(100) N e g a t i v e outweigh p o s i t i v e 15(62) 3(13) 6(25) 24(100) Both the same 42(41) 27(27) 33(32) 102(100) U n c e r t a i n 12(45) 9(33) 6(22) 27(100) T o t a l 118(37) 82(26) 117(37) 317(100) 14.81 .02 96 T a b l e C : 2 : I n t e r e s t by S e l e c t e d P r a c t i c e C h a r a c t e r i s t i c s R e l e v a n t t o E1der1y I n t e r e s t Var i a b l e s No(%) UncertainC/.) Yes(%) T o t a l ( % ) C h i - s q u a r e P Deg. Freedom Pe r c e n t a g e e l d e r l y i n p r a c t i c e : :(Q10) 0 10(84) K8) 1(8) 12(100) l e s s than 5 53(38) 34(25) 51 (37) 138(100) 6-10 29(35) 22(27) 32(38) 83(100) 1 1-25 19(30) 21(33) 24(37) 64(100) 25+ 9(33) 6(22) 12(45) 27(100) T o t a l 120(37) 84(26) 120(37) 324(100) 14.12 .08 8 Home v i s i ts:(Q11) Do not make home v i s i t s Make home v i s i t s T o t a l 90(44) 54(26) 61(30) 205(100) 29(24) 31(26) 60(50) 120(100) 119(37) 85(26) 121(37) 325(100) 16.39 .01 97 Tab! e C: 3 : I n t e r e s t by Ger i a t r i c T r a i n i ng of Dent i s t s I n t e r e s t V a r i a b l e s No( % ) U n c e r t a i n ( % ) Yes( % ) T o t a l (%) C h i - s q u a r e p Deg. Freedom T r a i n i n g : ( Q 9 ) I n f o r m a l undergraduate l e c t u r e s 28(27) 29(28) 48(45) 105(100) 7.51 .02 2 C l i n i c a l i n s t i t u t i o n a l t r a i n i n g 7(17) 11(27) 23(56) 41(100) 9.54 .01 2 No formal t r a i n i n g 76(49) 37(24) 42(27) • 155(100) 20.69 .01 2 98 Table C : 4 : I n t e r e s t by Age and Years of P r a c t i ce V a r i a b l e s Age of d e n t i s t : ( Q 1 ) l e s s than 35 36-45 46-55 56 p l u s T o t a l No(%) 26(22) 45(44) 22(45) 27(49) 120(37) I n t e r e s t U n c e r t a i n ( % ) Y e s ( % ) 32(27) 29(28) 13(27) 12(22) 86(26) 62(51 ) 29(28) 14(28) 16(29) 121 (37) T o t a l ( % ) C hi -square 120(100) 103(100) 49(100) 55(100) 327(100) 23.54 Deg. Freedom .01 Years of P r a c t i c e : ( Q 2 ) l e s s than 5 14(23) 16(26) 31(51) 61(100) 6-15 41 (32) 35(27) 53(41) 129(100) 16-25 35(49) 21(29) 16(22) 72(100) 26-35 19(43) 10(23) 15(34) 44(100) 36 + 11(52) 4( 19) 6(29) 21(100) T o t a l 120(37) 86(26) 121(37) 327(100) 99 T a b l e C : 5 : I n t e r e s t by S t a t u s of P r a c t i ce and Busyness V a r i a b l e s No(%) S t a t u s of p r a c t i c e : ( Q 4 ) News ( l e s s than 5 y r s . ) 11(23) F u l 1 - t i m e ( e s t a b l i s h e d , s a l a r i e d ) 97(39) P a r t - t i m e 11(36) T o t a l 119(37) I n t e r e s t U n c e r t a i n ( % ) Y e s (%) 8( 17) 72(29) 6( 19) 86(26) 29(60) 78(32) 14(45) 121(37) T o t a l ( % ) C h i - s q u a r e 48(100) 247(100) 31(100) 326(100) 15.57 Deg. Freedom .01 Busyness: Busy Not busy T o t a l 71(43) 44(26) 52(31) 167(100) 45(30) 38(26) 67(44) 150(100) 116(36) 82(26) 119(38) 317(100) 7.26 .02 100 Tabl e C:6 : I n t e r e s t by Cons i d e r a t i ons f o r LTC Serv i ce V a r i a b l e s No(%) C o n s i d e r a t i o n s of importance:(Q18) Loss of p r i v a t e p r a c t i c e time 78(36) Loss of l e i s u r e time 64(40) Persona 1 / p r o f e s s i o n a l s a t i s f a c t i o n 63(26) Cost of p o r t a b l e equipment(Q19) 56(27) I n t e r e s t Uncerta inC/,) Yes(%) 67(31 ) 50(31) 71(29) 64(31 ) 71 (33) 48(29) 108(45) 90(42) T o t a l ( % ) C h i - s q u a r e p Deg. Freedom 216(100) 15.51 .01 2 162(100) 14.98 .01 2 242(100) 19.08 .01 2 210(100) 15.82 .01 4 T a b l e C : 7 : I n t e r e s t by Reasons f o r Not P r o v i d i ng S e r v i c e s Reasons:(Q21) Too busy i n p r i v a t e p r a c t i c e 41(49) 28(33) 15(18) 84(100) 17.84 Inadequate t r a i n i n g and e x p e r i e n c e 34(53) 20(31) 10(16) 64(100) 16.42 F i n a n c i a l l y c o s t l y and unrewarding 26(62) 9(21) 7(17) 42(100) 14.16 Have not been asked 38(25) 53(35) 60(40) 151(100) 18.53 .01 .01 .01 .01 101 

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