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Dental care of the aged patient: Implications of attitudes toward aging among dental students and dental hygiene students

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Dental care of the aged patient: Implications of attitudes toward aging among dental students and dental hygiene students

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Content DENTAL CARE OF THE AGED PATIENT: IMPLICATIONS OF ATTITUDES TOWARD AGING AMONG DENTAL STUDENTS AND DENTAL HYGIENE STUDENTS by Linda Louise Cook A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY June 1978 UMI Number: EP58853 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertalton PuDiisreng UMI EP58853 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UNIt/ERSny OF SOUTHERN CALIFORNIA LEONARD VAnS SCHOOL OF GERONTOLOGy UNlVERSjry PARK LOS ANGELES, CALIFORNIA 90007 J ) S T ( vl6 theéÂA, WAxctte/i b t / Linda Louise Cook U L vid zn . tk z dOizcXoK T/ie4X4 CommLtto,z, ’ and appKovdd by a t t â M> mmbejià, ken been pAe- 6ented to and accepted by the Vean The Leona'td Vavtô SchoaZ GeAontoZogy, tn poAttaZ ^itZ^tZlment th e AequtAements ioA the degAee of, Veoun Vate THESIS COmiTTEE ChaZmmi 1 TABLE OF CONTENTS I LIST OF TABLES . ill I CHAPTER I I I INTRODUCTION ......................... 1 I Statement of the Problem and Hypotheses Rationale ' Definition of Terms Delimitations ! II REVIEW OF THE LITERATURE..............14 Alternatives Within the Dental Service Delivery System j Attitudes of Health Care I Providers I Dental Practitioners' Attitudes j Attitudes Toward Aging ; III PROCEDURES AND METHODOLOGY 2 2 Sample and Administration Instrument Statistical Analysis IV RESULTS AND DISCUSSION................27 V CONCLUSIONS AND RECOMMENDATIONS . , 3 8 Summary : Findings ! Conclusions I Recommendations ' BIBLIOGRAPHY....................................... 44 APPENDIX A - SURVEY INSTRUMENT ................. 50 1 APPENDIX B - CODE BOOK............................61 11 LIST OF TABLES TABLE 1 Scores for Several Samples on the Scale of Attitudes Toward Old People .... 21 2 Willingness to Work with Older People . . . 29 3 Willingness to Adapt Office Equipment and Procedures for the Older Patient ........... 32 4 Willingness to Advocate on Behalf of the Elderly............................. 37 111 CHAPTER I INTRODUCTION I Dental problems such as tooth decay and j periodontal disease are so widespread among the elderly that half of all per sons over 65 years of age. . . are with out any natural teeth . . . 6.2 percent have neither natural teeth nor dentures and 30 percent have dentures which are ineffective and which require refitting or replacement. . . . The elderly, the population segment which most needs dental care, receives less dental care than the rest of the population. (U. S. House of Representatives Select Committee on Aging, 1976, p. 12) The picture of the oral health status of today's older people is bleak. Not only do the elderly experience more , oral pathology than the young, the periodontal index I (number of decayed, missing, or filled teeth) markedly in- f creases with age. Contrary to popular opinion, however, this decay or loss of teeth is not a normal age change. ; There are some older people who, because of nutrition and ; hygiene factors, are able to retain many of their teeth for their entire lives. This ability to maintain oral health permeates the individual's quality of life. There is no I part of the sociological, psychological, or physiological ! 1 , ] i functioning which is not, in some way related to the con- 1 I I Î ; dition of the oral cavity. i Shanas and Maddox (19 76) have pointed out that health I ! I ,is a social resource since it facilitates the individual's i I I : interaction in society and affects how well social roles ! j I i can be carried out. Dental health can be seen in much the ! I ; same light. The loss of teeth and the physical changes i i I I that accompany poor oral health change the "face" that is i jpresented to others. When teeth are lost and not replaced, ' there is nothing to keep the upper and lower jaws apart. j I I The face may seem to collapse, with the nose and chin ap- Ipearing to meet. Without the stimulation of functioning teeth, the jaw bone resorbs, becomes very thin, and allows ,the lips and cheecks to sink even further inward contribut ing to wrinkling. What teeth do remain in the unhealthy mouth may appear longer because of excessive receding of ; gums and bone from around the root (Franks , 1973). The : range of possible facial expressions will thus change quite drastically. What is intended as a smile may look more like a grimace. This description is very similar to the popular description of a witch found in Hansel and Gretel: . . . her sharp nose bent down to meet her bristly chin. Her face, all folds and wrinkles, looked like an old shriveled pear; and she had only three teeth, two above and one below, all very long and yellow. (Gag, 1936, p. 15) Graber (1975) discusses research from Richardson, Root and Epstein, and Secord which indicates a close relation ship between oral condition and psychosocial functioning. Richardson, for example, has shown that those who have facial deformities are socially rejected more often than those with other physical handicaps except obesity. Secord, according to Graber, has found that "a good occulusion (bite) with its attendant relaxed facial features is identi fied by most people with the personality characteristics of sincerity, warm-heartedness, conscientiousness, and in telligence" (p. 13). Aside from creating a social image and thus influencing social opportunities, lack of oral I j health can create anxieties concerning interpersonal re- I < lationships within the individual. As Graber discusses, j i I i Root and Epstein have identified specific psychological I ' t I changes in children with oral disfiguration which may also I ; be found in the older adult with dental problems. Epstein | ! : I (1975) points out that "there are so many primitive feel- I : I ! ings about the importance of the teeth. . . . We often see i jolder patients who have no teeth and they walk around with ! ; their heads down. . , . . If we give these people just one j I upper denture they immediately change their posture. . . ." I I (p. 11). They stand straighter, look at others more I 1 directly, and smile and talk more. This may reflect ■ ' I ; psychological changes similar to those found in children ■ 3 ' with oral disfiguration. These changes involve "feelings ' i of inferiority and shame, modified self-expression, and j I I anti-social behavior tendencies" (Graber, 19 75, p. 14). | ! Loss or poor functioning of teeth affects the general J ! health. Franks (1973) has pointed out that acute oral in- I I feetion can spread, creating systemic complications. Re- j !sistance to these complications is, in turn, reduced by the* I I fact that nutrient intake is diminished. Oral pain and j [ loose teeth can make chewing difficult to the point that ‘ I I the persons may not eat the proper amounts or types of I , foods. Even with properly-fitting dentures, the chewing ! capacity is reduced to 20 percent of normal (Elfenbaum, , I 1971) , so that the tendency to eat softer, high-carbohydrate , foods remains a threat to the body's ability to resist ' I disease (U. S. House of Representative Select Committee on Aging, 19 76). As has been shown, oral health has importance in both i psychosocial and physiological functioning. This importance to the individual continues throughout the life span, since 'such factors as self-concept, interaction with others and 'nutrition affect the old as well as the young. In spite of the importance of oral health to the older person, there is ; generally low levels of dental care among the elderly. Whereas use of medical services increases with age, use of dental services decreases. Elderly people use considerably fewer dental services and see dentists 3 3 percent less frequently than other segments of the population. . . . 71.8 percent of the edentulous elderly pop ulation has not even visited a dentist in the past 5 years. (U.S. House of Representatives Select Committee on Aging, 1976, p. 12) There are several factors in the life of the older person which influence this lower level of dental attention. These factors include the elderly's possible past experi ences, poor attitudes toward dental care, low income, and restricted mobility. The past and present environment have an impact on a person's oral health and habits (Franks, 1973). The cohort of today's older people were raised during a time when, be- I cause of the state of dental technology, the best way to | I treat a cavity was to pull the tooth. The relationship j I between caries (decay) and bacteria was not even discovered | i 1 I until the turn of the century (Anderson in Albert, 19 76) , j : and it was some time later that preventative dentistry be- | ! ; came common. Another historical reason that today's older 1 ' i I people may have poor oral health is that it has only been j I relatively recently that "painless dentistry" has been I ! _ ! 'widespread. Once a person had had a tooth pulled without ' ! I benefit of anesthesia, it would be reasonable to want to \ ’ . i * avoid repeating the experience. Without knowledge of how ‘ i I to maintain good oral hygiene, this was difficult, so often dental disease was ignored until it became intolerable. By I the time professional attention was sought, extraction of | I j the tooth may have been the only treatment option. It is ^ I I I easy to understand why older people may feel that loss of j j teeth is inevitable and why they may fear pain with dental I treatment. Unfortunately, these attitudes keep them away j I I i from the dental office far too often (McKelvey, 196 8; I 1 Silverman, 1976). I i Other barriers can also come between the aged and the , dental care they need. According to the U. S. House of 1 Representatives Select Committee on Aging (19 76), "elderly ; Americans, frequently poor and on fixed incomes, have ' ignored their need for proper dental care because of their I ' ; lack of money" (p. 12) . Those over 65 and earning $3,000 or less yearly see the dentist only one-fourth as often as j those making $15,000 or more. Income also has been shown to be related to the type of dental care sought (Hobson & I . ; Roseman, 1953; Lerner, 1969). Preventative and restorative care which can be afforded by those with higher incomes may ; be beyond the reach of the elderly poor, who more frequently : have teeth extracted to alleviate pain. Even if the older patient wants dental care and can afford it, restricted mobility can present a barrier. The traditional practice is in-office, and those who are home- bound or have no easy access to transportation do not have 1 alternative ways to be seen by a dentist. It is estimated I I that of those over 65 in the United States, 6 percent are j I unable to leave their homes and another 6 percent are un- I able to leave the house without assistance (Franks, 1973). I ! Four percent live in nursing homes and thus have reduced I access to or ability to use transportation. Thus, 16 per- ^ cent of the older population may be at least partially re- I stricted in getting to the dentist. ! ' It has been seen that the poor oral health status of j I today's older people is based upon many factors within the : elderly and their environment. It remains important, how- , ever to recognize that the dental profession may share in I the responsibility for linking elderly patients with the ' services they need. McKelvey (1968) asserts that I . . . the obligation of caring for the ' dental needs of the . . . aged must be a responsibility of the community, in j which the dental profession, community organizations and the local government should assume their respective roles. ' Statement of the Problem and Hypotheses ' Dental health is important to the older individual in : many ways. It is an integral part of the image the person presents to others, and thus influences social opportuni ties and self-image. Acute oral infection can proliferate, : creating systemic infections. Finally, loosening or loss of teeth affects the ability to maintain proper nutrient ' levels due to reduced chewing capacity. | i I ' In spite of their importance, there is generally low ' ! I ' levels of oral health and professional dental care among , I j I the elderly. Influences in the lives of older people which | I I I may have an impact on their demand for dental attention in- I elude past experiences, poor attitudes, low income, and re- I stricted mobility. In addition to these, there may also be i [ factors within dental professionals which affect service I delivery. It becomes appropriate to inquire as to the character istics of dental practitioners which facilitate or create I barriers to service delivery. There are many factors which i , could be examined. This study will limit its scope to one: i I i : the attitudes toward aging within the profession. i I In investigating attitudes toward aging, two areas will be studied: ! 1. What are the attitudes toward aging among dental students and dental hygiene students? 2. In what ways are students* perceptions of their service delivery to older patients related to attitudes? Three specific hypotheses have been developed from the general hypothesis that more positive attitudes toward aging will be associated with a willingness to deliver ser vices to meet the special needs of the elderly. These specific hypotheses are : 8 1. willingness to work with older people will be found more often among those Ss with highly posi tive attitudes toward aging and less often among I I those Ss with highly negative attitudes, j 2. Willingness to adapt office equipment and pro- | I cedures for the older patient will be found more j often among those Ss with highly positive attitudes t toward aging and less often among those with | I highly negative attitudes. ! I i 3. Willingness to advocate for fulfillment of the ! dental needs of the elderly will be found more j i ; often among those Ss with highly positive attitudes ■ toward aging and less often among those with highly negative attitudes. ; Rationale Before examining the relationship between attitudes toward aging and service delivery to older patients, it is ! important to examine several issues relating to design of ,the study. First, is it possible to measure attitudes to- I ward aging, either as an entity itself, or in relationship I to service delivery? Second, how valid will it be to re late test results from a student sample to the population 'of practitioners ? Finally , what value will this study have for the future? "Attitudes Toward Old People" have been tested re- peatedly by Kogan (1961a, b, c) and by others using his ! I scale. These studies have shown that attitudes toward ■ I aging can, indeed be measured with reliability and valid- I I ' 1 ity. The relationship between attitudes in general and ! I ] ' I service delivery has been investigated in many fields, in- ■ ! . I eluding nursing homes (Kosberg, 1975) and community mental ' 1 ! I health services (Gentry, Veney, Kaluzny, Sprague, & Coulter; I I : 1974), as well as dental hygiene and dental assisting j I (Lobene, Fredericks, & Munday, 1970a, b and 1971a, b; < I I Fredericks, Munday, & Blanchet, 1973). The latter studies : i ; I demonstrated that willingness of dental hygiene and dental ; I I assisting students to work with or on behalf of nursing I I home residents is related to overall social attitudes. The i hypotheses of this study attempt to refine and expand upon ' knowledge of this association. I It is important in evaluating this study and the ones which have preceeded it to ask about the validity of apply-. ! ing test results from a student sample to the population of ' practitioners. Young and Smith (19 72) have pointed out I that most studies of the characteristics of dentists have used dental students as subjects. I Very little information is available for creating a description Of the practitioner of dentistry. Almost nothing is known about such factors as personality characteristics, atti tudes toward practice of the profession, or relations with patients. The best information about the graduate dentist 10 comes from data that have been gathered about future members of the profession--the student dentists — and that process by which they i achieve professional status. (p. 235) {Methodological studies are needed to assess differences and i I ' similarities between students and practitioners before re- ! . ! I suits of Student studies can be said to be valid for practi- i i : tioners. Without such studies, and being cognizant of the i I I jdifficulties in testing practitioners, researchers can only | formulate tentative conclusions regarding the applicability j ! of studies of students. ‘ < , The results of this study may prove to be of value in I giving direction to future research, and possibly in in- j I fluencing the curricula of dental schools. If, indeed, | ' service delivery is related to attitudes toward old people, ! ! it may be possible to create more favorable attitudes and i thereby increase attention to the dental needs of the aged. Definition of Terms 1. Attitudes are characterized by Shaw and Wright i (1967, p. 10) as being "a relatively enduring system of affective evaluative reactions based upon and reflecting the evaluative concepts or , beliefs which have been learned about the t characteristics of a social object or class of social objects." The attitudes discussed in this study are those which are held with reference to older people. 11 2. Dental service delivery refers to the means by j which professional dental care reaches the patient: I There are innumerable facets to service delivery, 1 but this study will consider only three: willing-j [ ness to work with older patients; to adapt office ' I procedures and equipment to benefit them; and to \ \ advocate for fulfillment of their dental needs. I 3. Dental practitioner refers to the dentist or ; dental hygienist. | i 4. Preventative treatment is any dental procedure ; which has as its goal the prevention of oral j disease. An example is cleaning the teeth. 5. Dental prosthesis is a denture, whether partial * i or full. Prosthetics is the making and fitting of dentures. 6. Re St orations are fillings. i I 7. Extraction is the removal of a tooth or teeth. Delimitations I ! The scope of this study is intentionally restricted in several ways. It examines only those attitudes toward aging 'which are measured by Kogan's scale of "Attitudes Toward Old People," and relates them only to three aspects of service delivery. Willingness to work with, adapt for, and advo cate on behalf of older people, are in turn measured by self-reporting by Ss. Subjects were selected from a single 12 j geographic area and from a single dental school (University : of Southern California). 13 ! CHAPTER II I ! I I REVIEW OF THE LITERATURE | I I * I Alternatives Within the Dental i ( Service Delivery System j : It has been suggested the sensitive response to the ! ■dental needs of older people is the responsibility of the I . ! dental profession, community organizations, and govern- i ! mental bodies (McKelvey, 1968) . There are a myriad of options for these three groups to improve service delivery 'to the elderly. ; To assist the aged in paying for dental treatment, it | has been suggested that public and private third-party pay- ! ment systems be revised to include total dental care— pre- ' 'vention, restoration, and prosthesis. Private dental in surance is the most rapidly expanding type of health in- Isurance. It is questionable how much this expanded cover age affects the elderly, though, since in 1974, only 16 per cent of the entire population had any dental insurance. Medicare authorizes only surgery related to fracture of facial bones, and no treatment of teeth or gums is covered. 14 Medicare reported a zero expenditure for dental care in j 1975 (U. S. House of Representatives Select Coimnittee on j Aging, 19 76). As of January 1976 , only 36 states offered I I dental coverage under Medicaid. Of these, 11 did not ■ ! serve the medically needy and 3 were considering dropping dental coverage entirely (U. S. House of Representatives | Select Committee on Aging, 19 76). Even in states in which , Medicaid payments are available, the type of allowable care I is extremely limited. Most states with dental plans will | i . ■ ' I pay only for extractions and dentures, not for fillings or ; I I , preventative examination and treatment. ! ; Transportation difficulties of the older patient can ' I be approached in several ways. Provision of special trans- I portation to the dental office for older patients with I limited mobility was first demonstrated in the 1950s (Andrews & Lotzkar, 1961). It was not until the mid-1970s ; I that some communities began providing such services, how- ; ever. Anguine (in Summit, 1973) suggests that "when a patient can't get to the health services he (sic) needs, i we should be able to deliver the service to the patient" I I (p. 14). A delivery system aimed toward servicing nursing ' I homes involves establishing a satellite office in the 1 I nursing home (Epstein, 1976) . This is prohibitively ex pensive unless, as has been done in some areas, the local dental society donates equipment. Radke (19 74) cites "the 15 failure of dentistry to become involved in this institu- | tional service" (p. 40) as being another reason that this , i alternative has not been more highly utilized. A final de- I I I livery system now being explored is the use of a mobile | I dental clinic. A large van or trailer can house an entire I I ■ ■ I I i office, or a smaller van can carry more portable equipment ! ' ! : 1 I to be used in the home. Total dental services could thus I ; be provided to nursing home residents and the homebound, J 1 . I I whether young or old. Precedents have been set by dental I ' schools (Andrews & Lotzkar, 1961; Waldman & Stein, 1967; i I I iMcKelvey, 1968; Reis & Layton, 1970) and practitioners have , tshown that the private mobile clinic can become a reality i (Burbach, 19 76) . If, in the future, the dental profession is to serve - the needs of older people, especially those who are poor, ill, or without transportation, it will be necessary to look seriously at some of these alternatives. Although some changes are being made in service delivery systems, the re sponse of the profession as a whole has been slow. For ex- ' ,ample, a prototype mobile service to the homebound and aged i iwas devised 20 years ago (Andrews & Lotzkar, 1961) , and still is not in common usage. Whether this low level of jattention to the special needs of the elderly may be related to attitudes toward aging is not examined in existing re- i search. 16 1 Attitudes of Health Care Providers j 1------------------ ! i There has been limited research into health care de- t ! I j livery to the older patient and providers' attitudes. } I ■ * 1 Kosberg and Gorman (19 75) have studied the perceptions | 1 1. I of patient rehabilitation potential among persons asso- * ’ elated with nursing homes (administrators, staff, volun- j , , I ; teers, relatives, and residents) and concludes only that j I "further research is suggested. . .to ascertain the out- , , comes of such perceptions" (p. 403) on service delivery. ; I Gentry et al. (19 74) have identified certain attitud- ' ; I i inal factors which can be important to community health * I services. They conclude that practitioners' limited know- | ledge of the health needs of specific populations and per- ' I ceptions of responsibility for service delivery can consti- i tute barriers to implementation. Dental Practitioners' Attitudes Drake (19 73) assessed the perceived responsibility for I meeting the needs of special populations among dental stu dents. He showed that among students of Community Dentistry over 70 percent felt that the school should sensitize stu- ’dents to the needs of children and the mentally handicapped, but only 33 percent felt that sensitization to the needs of : nursing home patients was a role of the school. This follows McKelvey's (1968) observation that the dentist's "background of training in a highly functional office in 17 the treatment of essentially healthy and younger patients j does not well orient him (sic) to the care of . . . the | I I I aged" (p. 1). Waldman and Stein (1967) also point out that' I lack of experience with the aged or ill patient can intens-' I ify any existing fears felt by the dental student. Research into dental practitioners' attitudes and ser- 1 ' vice delivery is extremely limited. Lobene et al. (1970a, i : b; 19 71a, b) surveyed students of Dental Assisting and I Dental Hygiene to determine social attitudes and profes sional concerns. Subjects were classified as being most ’ i concerned with "manpower shortages" in the field or with ! ! the needs of the "poor, aged, and other disadvantaged ■people" by their responses to a forced-choice question. It I was found that those Ss who were concerned with the poor, : aged, and disadvantaged were more likely to feel that the dentist should be concerned with the social as well as the physiological problems of the patient. They were also more' ‘ willing to work for the welfare of the disadvantaged. This ; willingness was measured in two areas. The first was type of job position acceptable to the student (dental school, ! neighborhood health center, or Appalachian community). The ' second was students' perception of their response to learn- - ing of the dental needs of a local nursing home. Those more concerned with disadvantaged people were more likely to respond to the first question that they would work in 18 i Appalachia than those concerned with manpower shortages. | i t 1 A similar difference was found in responses to the second i ; I ! question. Those Ss more concerned with disadvantaged ( ! 1 people were more likely to say they would offer their ser- j ; vices or contact the State Department of Health, whereas , 1 ' , those concerned with manpower shortages were more likely to | ■say they would leave action to the authorities. Fredericks | I et al. (19 7 3) replicated the study and confirmed that stu- j I 1 dents indicating a willingness to work with the disadvant- ' I aged "were most likely to express concern for humanitarian i ' and social action" (p. 42). In summary, overall social ; I attitudes appear to be related to willingness to work with/ ' I advocate on behalf of several disadvantaged groups (includ- i ing the elderly). It may be possible to refine and expand i upon this observation with relationship to a specific set 'of attitudes (attitudes toward aging) and a specific client i group (the elderly). This possibility forms the basis for the present research. Attitudes Toward Aging I None of the previous research dealing with health care * delivery investigated practitioners' attitudes toward aging.. I This study uses the Kogan scale of "Attitudes Toward Old People" (1961a) which Shaw and Wright (1967) describe as j 'testing Ss* perceptions of "such things as the residential 1 aspect of old people's lives, vague feelings of discomfort 19 and tension in the presence of old people, qualities of I ' old people, and interpersonal relations across age genera- | I I j tions " (p. 46 8). | : , ■ I j Table 1 depicts the means and standard deviation of j ( scores on the Kogan scale for samples from this and two ! ( ! ' Other studies. The first three samples are from research I ' I ; done by Kogan (1961a) wlaen he was developing the scales ; . i ' I I measuring positive COP+) and negative (0P-) attitudes. i I j I Subjects were taken from introductory psychology classes at| 1 Northeastern and Boston universities. The second four i ( I . , ’ samples are from a follow-up study (Kogan, 1961b) in which , young subjects were taken from introductory social science ; ! I j classes at Boston University and older subjects (women aged; 49-86, men aged 54-92) were taken from a non-profit geron— ; tological research organization in Boston. The educational ! and career levels of the older samples were high enough to approximate or exceed those of the younger sample. In i . I j Chapter IV, the scoring of these groups will be compared to , that of dental students (DS) and dental hygiene students , (DHyS) in the present study. 20 o O ) C Cl. o " O CO .-o O i 3 (/) -p s - ■ p o ■ p 4- <C C O 4- O ) o s - o O ) o to f O o to -o s- r O ■o c c o r O o c - s o o C O to ■ P 4-) C D 00 c - s C O C D to r O o o C D o C D oo + > Q _ O ) O Q C O C M to o C D 00 C'. c o C D C O r-v to 00 ra Q i C M o to C O 00 s: to to to to L O to L O c - s -o S - r O -o c O c o O 00 < ± - CO 1^ C O C M r e s C M o c - s C D C M to 00 o ■ p ■ p to ra CM o C M C D 1 ■ > o. II to to to I— c 00 c ■ p O ) C D ra O ) II C D II c C S Î- O J — ' ( L ) E - O ^ c 00 c O ) O ) II O ) 0)00 CD to O ) 3 00 II c -o ----- •1 - c O ) C M (U 00 L L . -P to c m 3 to CD'— > Q. to r— c B c ■ P C M >ï E I— II I— II -O II C L ) a ra C D —; C L ) o I— c ( U CD s:: C D 3 r d ra C l ) - o >- o Q Q to ra Xi p to to c C D C D O ) to ( U O ) s - o s z c c s - >, s - ra ra -o 3 Di CD < u 3 o o o X: P to zx H — to 21 ! CHAPTER III I PROCEDURES AND METHODOLOGY i I : Sample and Administration ! This study was conducted with Senior Dental (DS) and ' Dental Hygiene (DHyS) students from the University of Southern California School of Dentistry. Sampling of the ( ; two groups was somewhat different. Questionnaires were given to all students currently enrolled (DS, N=120 and DHyS, N=50). The Hygiene students returned their responses f ■ before leaving. Only one student failed (due to illness) to complete the survey. Originally, it was expected that DS would also complete the questionnaires during class. Due to unanticipated time restraints, however, they were ; allowed to take the questionnaire home. Twenty-six re- 'turned their responses. A possible reason for this low 'return rate was suggested by one of the students as being the fact that they are asked to be subjects for so many studies that they lose interest in participating in any one in particular. The implications of this situation to the results of the study are important. It is quite possible 22 that those DS with highly positive attitudes toward aging | ' or those already interested in dental care for the elderly j ' I I were the only ones who returned their questionnaires. This ; I would skew the results in a positive direction for both the | I . I , measures of attitude and of service delivery. Assessment 1 i of findings must, therefore, take this into account. j I I i Subjects represent practitioners who have recently , ■ I I graduated from USC or similar schools. Because overall I j I , professional orientation and development of the practitioner I _ i ' may be influenced by the milieu of the specific school ; I ! attended, this sample may not be representative of the total j population of Dentists and Hygienists. Factors within the i t I Dental School which may be important to the professional ; development of Ss include : | ‘ j ' 1. A strong emphasis on community dentistry and alternative delivery systems, typified by the operation of a mobile dental clinic; and 2. An experimental program in which certain of ; the students are trained to provide care to I I entire families rather than individual patients. Within the University there also exists a School of Geron tology, and some of the Ss have either taken specialized courses or have attended lectures on aging given at the ' Dental School. 23 1 Instrument 1 I Data collection was accomplished by means of a survey j (see Appendix A) consisting of four sections. The first section asked for certain demographic information such as ' course of study and year in school. Three open-ended ques- | I 1 ' tions were then asked in order to gather descriptive data ! ■ 1 ■concerning Ss' attitudes. These questions dealt with need | for and problems in providing dental care to the elderly, | i as well as the school's responsibilities in the area of j ! Geriatric Dentistry. Service delivery was measured by ; ; . 1 ' items which describe a hypothetical situation and ask for ; ' I the subject's most probable response in a forced-choice I categorization. Finally, attitudes toward aging were | 'measured by the Kogan scale of "Attitudes Toward Old People," which is analyzed in terms of positive (0P+) and | negative (0P-) scales. Kogan (1961a) tested the content I validity of the attitude scale used in the present study, by finding correlations with scores on scales of attitude toward ethnic minorities, the deaf, cripples, and the blind. I All correlations were significant at the .05 level. There ! was also a significant correlation found with scores on nurturing from a personality inventory. Reliability was computed for odd and even items, and depending on the ! sample, ranged from .66 to .83. 24 j Statistical Analysis j I Ss were initially segregated according to career j I category (Dentistry or Dental Hygiene) for purposes of 1 I I 1 analysis. This was done because it was felt that career ■ i i ; orientation and training may affect attitudes/service de- j I _ ! livery, and also because the method of data collection was j i different enough for the two groups that it may have in- j ' fluenced results. ] J T-tests were used to determine whether there were any ] i ' 1 ,differences between DS' and DHys' responding oh 0P+ and I OP-. Chi-square was used to determine response differences ’ fon items of the "Hypothetical Situations" section. Since , ■ there were no statistically significant differences found ' ( = .05), the two groups were combined for further I ' analysis. i t I I Means and standard deviations on the two Kogan scales : (0P+ and 0P-) were compared between the two survey groups as well as among the Ss and other groups previously tested : by Kogan (Table 1) . Data was recoded from the "Hypothetical Situations" ; responses into false dichotomies representing the willing- I ness/unwillingness referred to in the hypotheses. Both the ; original and revised coding systems are outlined in Appen- , dix B. T-tests were used to determine the presence of re lationships ( = .05) between scores on OP+/OP- and dichotomized responses. 25 Data analysis in parts of the study, is limited by the fact that frequently the N in a given cell is so small I (i.e., three or four) that it is difficult to establish I jwhether the groups are, indeed, different. In some of j these cases, the .10 level of significance was attained and is reported. These cases are noted, where they exist, and I ' recommendations for further investigation are based upon I them. Finally, it is recognized that the main value of I this study is in providing indicators for research in this ; area. Before the hypothesized relationships can be con- f firmed, it will be necessary to observe the actual be- ; havior of practitioners and their patients. 26 I CHAPTER IV I j RESULTS AND DISCUSSION j I ! ! The dental students and dental hygiene students i : sampled in this study scored the same on both 0P+ and OP- i ! of the Kogan Scale of "Attitudes Toward Old People." As i ' j can be seen from Table 1 in Chapter II, the mean scores on j Opt were 78.87 for DHyS and 78.68 for DS; the mean scores I on OP- were 45.37 and 47.72, respectively. These scores f ; are higher for 0P+ and lower for OP- than the scores found I by Kogan in his original samples. This generally more positive attitude could result from a variety of factors. : ■ Historical changes may have had an effect. The first two studies were carried out 16 years ago; and during that ’ time there has been an increasing awareness of the needs of ' older people, as exemplified by the proliferation of public, : voluntary, and private programs for the aged. Second, it is possible, since the Ss for this study are more self- I selected for interest in human services, that the more pos itive scores reflect sample differences. Third, and less ; importantly, the effects of being in a school in which aging 27 j is discussed may be expressed in more positive attitudes | I ' ( j ' I toward older people. | ' The fact that there were no differences found between j I I ; responses of DS and DHyS on either the Kogan Scale or the j I ; ’ "Hypothetical Situations" indicates that differential j career orientation and training between the two groups do I I I ■ not seem to have an effect on response patterns. | ] 1 I The general hypothesis that dental practitioners' i ! i : attitudes toward aging will affect service delivery to I ‘ older patients was divided into three more specific hypoth- i I . ' eses which were then each tested by several items of the . "Hypothetical Situations" section of the questionnaire. j I The first of the three hypotheses dealt with willing-, , ness to work with older people, and was tested by two items. The first item asked for a ranking of job preference I among private general practice, neighborhood health center, , advisor to a group of nursing homes, and teaching at a | : dental school. Table 2 shows that those Ss with more posi- i tive attitudes (signified by high 0P+ and low OP- scores) i I were those who would be more likely to rank "advisor to a group of nursing homes" either first or second choice. The ; second item asked for a ranking of patient-age preference among children, young adults, middle-aged, and elderly. The predicted relationships were found for both 0P+ and OP- , with rank value of the response, elderly. It appears that 28 C M e u X) n 3 e u C D E C +3 •1 — e u S- s- X ) 3 4 - O -O = ü_ - K -a r— to O O C O c 3 e u = S- CO eo ra o E o 5 O T3 C O zc e u "C c o 3 JX s- s- •r- O C D c T- e u U C S5 -= 4- C CC h- e u « 3 tO to O s- C C s- O CL • 1 — o 3 4- 4— 'r - z e _ > CL +3 4 - > co O 0 0 4~ O 0 3 0 0 O -a E 3 O 0 3 c cr C L Cl +3 o II e u 3 c a X : O e u e u X : o E eu = en O to 4 - > T- eu o o o •1- X : • « a = s- ' • S 3 ^ ta o 1 ". o tv. e u >0 +3 -a C O +3 to o '— o 0 3 e u +3 to CL C +J e u +3 JX to O O o .L e C D c s- E e u '1 — to »r- s- C 0 3 * 1 — D u 4 -> 0 3 1 — o oc IL +3 0 0 E 0 3 -a s- tO S 4 -> U e u e u e u O O lO > 0 3 s- C D -a Q-r— ra % 3 e u +3 < e u e u < C 1 — 1 > ) o i - X3 r— O e u 3 +3 S- JC O -O II +3 -a e u + - > 4- e u o Q S- & _ -o -a -o 3 e u S T3 *1- O 4 e 4- S LU e u > * = I I O L O e u s- o O L T ) L O s- S- d) S- 1 — = L. CL o 4 - C L e u O f'v o eo a 3 4 - . L e -a « O " 3 o lO "r- e u T3 O O e u r — L. .Le L. >) 4 - > e u (-) e u C *1- 5 -0 3 + 3 e u +3 15 -E O 0 0 0 3 Q . 0 0 o c C C h — -a to to O e u 1 e u 3 E +3 O CL 0 0 c o e u o O +3 C D > )X : Il 0 3 c ■ E '. +3 S- +3 e u • > r — CL -O X3 C — " 0 3 C +3 O T- e u o 0 3 •r— ) +3 ( Q rc a CL 3 E CL S- e u 0 3 e u e u eu “ O = en rs. C O 4 - 0 0 sz o c o o to oo o . +3 s- +3 o e u o = L. o 0 3 eu E O f'v to 0 0 S- 3 4- JX L. -a C O C L e u c -O C O e u O e u +> 3 4 - e u <c C D 0 3 +> +3 X3 Le to o e u s _ C D C f O c S- s- s- -a C D -r- >> > C D 0 3 • ! — C D C L C JX 1 — ex I I 3 o • e u S- e u e u +3 E O o 0 0 .l: CL z C D to e_ ) >- r — +3 • ! — 0 3 0 3 e u e u 4- E r — r— (u +3 cC C D U C C D •1— C to •1- Il E e u o E 3: X) E 3: C to e u c -o o S- *p- t o + - > "O fO c *1 - fO > 4 - > e u en Q i O I o . o r - +3 S- s- e u 3 -a o ■ J e 1 — Il O . L O LU C M = L. O f'v C O -a f'v e u "O Le s- C 'p- fO E D C 1 — ” >^■0 I — C S- o e u o T3 e u r— C O LU O 1 — = S- «0- L O O -O eo 00 e u +3 00 Le to c s- 0 3 *r* O C IL ~ > » E r— +3 S- S- e u 3 T3 o ■ J e 1 — I I o LU C M C M = S- O C O 1 — -a « O " p — e u "a Le L. SZ * 1 — 0 3 E ex 1 — ">>■0 p - E E O e u o -a e u 1— oo LU f'v l O = E C M r — O -a C M to e u +3 3X 0 0 E E < T 3 * p - C X IL C M e u +-> ra e u ■si CO 4-> T3 t C J C * 1 - fO > 4 - > e u en Q Lf) o >11 Q_ * 29 there are indications of a relationship between positive 1 attitudes toward aging and willingness to work with the ill i I aged as well as the elderly in general. t I A third item which tested willingness to work with i I older patients was a replication of an item used by Lobene, et al. (1970a, b; 1971a, b j, involving response to knowledge , I I of the dental needs of patients in a nursing home. Response I alternatives included both willingness to advocate by con- | 1 t tacting the State Department of Health and to offer ser- | I , vices directly. When responses were analyzed according to I I .willingness to take either alternative versus no action, a I I significant difference ( = .05) was found according to | i OP-^ Those with more negative (higher 0P-) scores were much ' more likely to "leave action to the authorities." 0P+ did not appear to be as highly related = .10). While j Lobene, et al. did not differentiate between willingness to i I : work directly with nursing home patients and willingness to ; : advocate on their behalf, this study has attempted to make t a distinction. When the answer "offer your services" was analyzed against other response options, no significant differences were found according to either 0P+ or OP-. Analysis of the option "try to contact the State Department 'of Health" did show some relationships which are discussed later in this chapter. , I The hypothesis dealing with willingness to adapt office 30 t equipment and procedures for the older patient was tested ; t i j by three items of the questionnaire. The first item asked j 1 how often the subject would accept older patients whose ! I . I j treatment was being covered by Medi-Cal. Response alterna- j I : tives were "always," "sometimes," and "never." No relation-! i ship was found between response and score on either 0P+ or | I OP- scale. Ss' written responses accompanying this item | i 1 indicate that the reason for a lack of relationship may be | i due to the problems found in the Medi-Cal system. Comments ! : . I ) associated with the response, "never" were along the lines : : I of : ; Medi-Cal is too limiting in its scope of ' I dental therapy and I don't like being ■ told how to treat my patients ! I It is too hard and takes too long to I actually get payment from Medi-Cal. ; It appears that the strength of feeling which is associated I I I ■with Medi-Cal itself may be stronger than any relationship which might exist between attitudes toward old people and the recognition of need for alternative payment systems. I Table 3 shows that significant relationships in the pre- : dieted direction were found between OP-/OP+ scores and i whether Ss stated they would or would not make changes in procedure and equipment. One item involved response to reading in the Journal of the American Dental Hygiene Association that older patients tolerate treatment better when sitting up than 31 j Table 3 | i : Willingness to Adapt Office Equipment j I and Procedures for the Older Patient ; I I I Item 1. I f you had control of your ow n practice, would you accept 1 ' older patients whose treatment was being covered by Medi-Cal? ! ^ A. Always B. Sometimes C. Never ! I ; OP- 0P+ ! Always or Always or j Sometimes Never Sometimes Never Mean 46.16 51.00 78.89 75.50 | Standard Deviation 9.77 16.00 8.60 10.53 | I Item 2. I f you read in the Journal of the American Dental Hygiene Association that a researcher has shown that many older i patients tolerate treatment better when sitting upright than when in a supine position, what would you do? : A. Treat all older patients in the upright position. | B. Begin treatment of older patients by placing them in ; the supine position, then moving them to an upright position i f signs of fatigue are exhibited. | C. Continue to treat in the supine position since i t is more efficient. D. Other. Specify: ___________ O P ^________________ 0P+______ Would adapt Would not Would adapt Would not ("A" or "B") adapt ("C") ("A" or "B") adapt ("C") . Mean 46.61 69.00* 78.02 60.00* Standard Deviation 10.54 0.00 8.40 0.00 *P±.05 32 Table 3 (Conf d. ) Item 3. A large local nursing hom e has been referring its 65 ambula tory patients to you for treatment for the past year. N ow the administrator is seeking dental care for 75 patients confined to wheelchairs. In order to serve these patients, your office w ill have to purchase special headrests for the wheelchairs and pay for widening a doorway. Of which would you be most in favor? A. Widening the door and purchasing the headrests. B. Referring the administrator to a colleague. C. Other. Specify: OP- 0P+ Would Would not Would Would not adapt ("A") adapt ("B") adapt ("A") adapt ("B") Mean 45.04 56.06* 79.23 74.82** Standard Deviation 8.46 14.12 7.79 11.73 *P ± .05 **P ± .10 33 when in the supine position ordinarily used. Response j I alternatives indicating willingness to adapt were a) treat j ■ all older patients in the upright position; and b) begin 1 I I ! treatment of older patients by placing them in the supine ! I I ; position, then moving them to an upright position if signs i I ■ i ; of fatigue are exhibited. Common responses other than those I . t I provided on the questionnaire included asking the patient | which position was more comfortable, and making an individ-; I I I I ual decision based on physiological as well as chrono- ! 1 1 logical age. I I I Those who said that they would adapt positioning had | i I I more positive scores than the subject who said he would , I 1 I "continue to treat in the supine position since it is more I efficient." The final item concerned willingness to make ! I I . adaptations in office equipment in order to treat nursing ' ! home patients confined to wheelchairs. Response options given were "widening the door and purchasing the head- ' rests," and "referring the administrator to a colleague," and "other." The comments regarding "other" fell roughly , 1 ' * into two categories : compromising with the nursing home on ; cost, and starting mobile service or a satellite office at the home. All options were dichotomized such that "refer- ; ing the administrator to a colleague" represented that the ■ subject would not make changes in order to treat the patients. All other categories of response represented 34 ! some, type of adaptation which would be made. It was found j ' i I that there was a significant relationship between OP- and ] I willingness to adapt. Less negative (lower) OP- scores | ! ' ,were associated with changes made, and more negative | ' I ! (Higher) OP- scores were found among those who would not | I * I consider alternatives. The expected relationship with 0P+ i ! scores was not found to be as strong as predicted, although} ! : ; there appears to be a relationship of some degree .10) ' ! existing. , I The hypothesis having to do with willingness to ad- > ; VOcate for fulfillment of the dental needs of the elderly ' was tested by two items of the questionnaire. The first I item asked for response to knowledge of proposal of a bill "to expand Medi-Cal dental benefits to include comprehen sive dental care for the aged." There were no significant I ' differences found between responses of those with low or high Kogan scores. The reason for this may be similar to the effect found in the earlier item dealing with Medi-Cal: Ss' feelings about the Medi-Cal system itself seemed to have a stronger influence than their attitudes toward old , people. The second item dealt with knowledge of the dental I needs of patients in a specific nursing home, and has al- ; ready been partially discussed relevant to the first hypothesis. While there did not appear to be a relation ship between OP+/OP- score and willingness to offer ser- 35 vices. Table 4 indicates that a significant ( = .05) re- j I lationship between 0P+ and willingness to advocate ("Try | J I , to contact the State Department of Health") . The relation- ] I I I ship with OP- was not as strong, although there appeared I ! I to be a tendency for those with more negative scores to be ^ ! less willing to advocate (c< = ,10), 36 Q ) E t a E ( U -O L U ( U E +3 ta E ( U C O S i ta o o > -o < a : o +3 CO CO ( U c C D -o E 4 - 3 f O C O C O E Q.C-. E 1 f O X o ej > e u <c 00 00 > -O E e u c- E < u "O JX e u C O 1 — -O f O C O o 3 +3 c Q- O 3 o O 2 O E f O E 2 O +3 +3 0.4-3 + E f O E e u (U E O ■o E S E O +3 f O +3 E •r- -O (J 4 - 3 2 e u f O C D E 1 — < o c e u Q o e u o L C o C O C l «r- O J ra ta E E +3 +3 E C D o C l 4 - 3 u O c- C O ta f O -a S E e u (U O >, 3 O E E 4- E O 3 f O 4 - 3 S e u +3 < U +3 E f O E e u E +3 1 — ( T 3 JX O E lO O f O a. o +3 E +3 E 4 ~ C O C O C D i— 3 E 1 E O ) ra +3 C O C U C D 4 - 3 E +3 O C D ra f O E C E E C O C D O t' ra (U ( U t/i ta f O o C O ■ O e u e u +3 -O e u E E C D 00 f O E zc ra E E e u fC e u O 4 - 3 0) E C l f O E e u C D o E E 4- (/? > f O X ej JX « d - O E e u "O ra E E (U U ) O -o +3 E e u 3 4 - 3 E C E o E 3 O E o E 4 - 3 ( U 0.4-3 f O O E 2 >> E S O +3 E 4- ( U +3 E C O E C O •p O E 3 O o -O ta e u E C l E C O C O E e u r O E E E E O o c = 4 - 3 C l O O ■ O e u e u i 4 - 3 e u •1- O e u E E E +3 e u E o C O C O C O C O O (J > . E O lO < U C O C O C O ra o E e u (U "O f O e u e u e u E +3 +3 lO 3 C L E E e u Q JX 3 ra +3 C D C D JX co * 0 " C D ra +3 +3 U +3 E E f O 00 C D E C O X c O O +3 E e u C O Q J • ! ” +3 ej ej O C D O +3 l O E e u e u E C O +3 -o C O E +3 E u O E ta o 3 +3 e u +3 E E E 3 O E E O > E f O +3 O 4 - 3 4 - 3 E 4 - 3 C O C D e u e u 2 e u ra O e u +3 f O e u +3 4 - 3 E E ra C O E •!- E. E O 4^ • 1 — 4 — e u o E E 3 E E e u E E 2 S O 4 - 3 O 3 +3 c >^■0 U O O fO ( U -o -o -O -o e u ta E E ■o -o o 4 4 > 3 3 3 3 E e u e u +3 E o O O O -O O 3 e u > e u e u ta 2 2 2 S E 1 — O E ra > .4 - E o fO 4 - 3 2 e u E 4- • 1 — 1 ■ O ta 1 — o C D -I— E E -r- 4 - 3 ra "O f O fO > ra "O E e u e u 4 - 3 ( U E ra 1 — * z: C O (_) o s: en Q 3 E < C O o i o Q- O e u L C ra 4 - 3 4 C 4 c +3 O o O o o E 1 — ■ a ^ r '~ . 1 — 3 < o = E O +3 U ra '—' e u o o C M JX = I— C D ra 4 - 3 E C D 00 O C- -O 3 C O O = S —' e u JX ra 4 - 3 4 e +3 C M f"- o C M f". E C D C D - o ^ LO 3 c C O = 3: — E O +3 U ta < — ' e u o L C = : C D 00 ra O +3 E O LO O ■ O r — 3 C O O = 3: -O o E •!- fO +3 T3 ta c E • ! - (C «3 > (U +3 1/ a . • J c 4 < ( U 4 - 3 C M ( U 4 - 3 ir> o 41 Q- • X 37 I CHAPTER V I ' CONCLUSIONS AND RECOMMENDATIONS I I j ; Summary , i ! ■ It was hypothesized that among dental students and | : dental hygiene students, more positive attitudes toward i aging would be associated with a willingness to deliver ser- I vices to meet the special needs of the elderly. Service I I delivery was, in turn, categorized in terms of working with, adapting for, and advocating on behalf of older patients. Students were given a written survey of which one sec tion was the Kogan Scale of Attitudes Toward Old People and another section was composed of seven questions concern- ;ing Ss' perceptions of their service delivery to older patients, I Attitude scores on the Kogan Scale of Attitudes Toward ! Old People were found to be the same for both Dental stu dents and Dental Hygiene students in this sample. As well as having similar attitude ratings, the two groups of stu dents responded to the open-ended questions and the "hypothetical situations" items similarly. This indicates 38 I that among dental practitioners the choice of dentistry or j dental hygiene as a career does not seem to affect either j attitudes toward aging or projected service delivery. ; i ; It was found that subjects' scores on the Attitudes | I ; i Toward Old People Scale were generally more positive than ] j j i those of Kogan's original sample. The reasons for this may ; be historical, motivational, or environmental. j T-Tests were used to identify differences on attitude i I I ^rating between those subjects who responded with a willing- [ness to work with, adapt for, or advocate on behalf of I I • 'older people. In five of seven cases, the hypotheses were I 'upheld. The remaining two items concerned different , i aspects of Medi-Cal, and it appeared that in those in 's tances the subject's feelings concerning government payment I : systems were stronger than any relationship which may exist : 'between attitudes toward aging and service delivery. I It was concluded that while further research is in- ;dicated, dental schools can begin now to give curriculum emphasis to issues in geriatric dentistry. I ‘Findings ' It was found that attitudes toward old people as measured by Kogan's scale was the same for DS and DHyS. The I mean scores for positive attitudes (ÔP+) were 78. 87 for Dental Hygiene Students and 7 8.68 for Dental Students; the I mean negative scores (0P-) were 45.37 and 47.72, respec- 39 j tivdly. While these scores were the same for the two groups j I of subjects tested, they were higher than those of Kogan's ! j initial samples. j I I ; Responding to the items in the "hypothetical situa- ' I I tions" was the same for both groups tested in this study. j ! I i 0P+ and OP- scores were observed to be related to per- i • . I I ceived service delivery to older people on items dealing I ! I ^with : I ! 1. job preference I Î I 2. patient-age preference | 3. knowledge of the dental needs of nursing home patients , I 4. positioning of older patients, and , ■ 5. office adaptations in order to serve patients in wheelchairs. ; Those items which showed no relationship between OP+/OP- and 1 . service delivery concerned: 1. acceptance of Medi-Cal payment, and 2. expansion of Medi-Cal dental benefits. I Conclusions From these findings, it is concluded that dentists and , hygienists have similar attitudes toward aging, and that these attitudes may be related to service delivery to older ; patients. Specifically, this relationship can be expected with respect to willingness to work with, adapt for, and 40 jadvocate on behalf of older patients. The findings also j I indicate that the relationship between service delivery and , ! i i attitudes toward aging may not always be a simple and j I i idirect relationship. For example, problems existing in j I Medicare/Medi-Cal may interfere with dental practitioners' I 1 : i willingness to accept or advocate for expansion of public i ; I ! payment systems. This is an area which definitely merits i further research. ! ! i Re comme nd at ions j It has been observed in this study that attitudes to- j ward aging may be related to willingness to work with, i 1 adapt for, and advocate on behalf of older patients. For i verification, it is recommended that further research be conducted in such a manner as to avoid the sampling problems which were found in this study. Additionally, future re- ■ search will be needed to observe behavior of practitioners with older patients in the clinical setting. Several ques- I tions concerning the observed differences are yet to be answered: . 1. Do attitudes of subjects reflect the attitudes of those who are training them? 1 I 2. Will attitudes held during schooling carry over into practice? 3. Are perceptions of service delivery reflective of actual behavior? 41 I 4. Is there a cohort effect in both attitudes toward | 1 i I old people and parameters of service delivery? j I The observation that attitudes concerning Medi-Cal seemed : I I 1 to be strongly negative may justify future research into , : i I this area. Do problems found in the present payment systems I I Stand in the way of dental practitioners' advocacy for the i I ' aged poor? : I The findings concerning relationships between atti- | ; ■ I I tudes and service delivery could have implication for future ' i I training of dental practitioners. Attitudes in general andj i ; , attitudes toward aging in particular can be changed through ; : I , education. Specific issues with which practitioners may ' want to be prepared to contend include the creation and i support of motivational change in older patients, advocacy for social and political change to support the individual's : ,desire for treatment, and the provision of services in a ■ manner sensitive to the special needs of the aged. The American Society for Geriatric Dentistry and the American Dental Association have made some steps in this direction by jointly sponsoring special meetings to discuss problems and opportunities in treating older patients. This type of material should also be presented in a form which will have wider appeal, in order to reach practitioners who are not already interested in this area. Finally, professional journals can take a role in publishing articles on dental care of the aged. 42 I The demographic descriptions of the poor level of oral 1 I health of the aged population point to the need for changes.; I [ I It will be necessary to improve the motivation for dental I care among older people themselves, and to create a service I delivery system conducive to fulfillment of their needs. : Perhaps the most effective point at which to intercede, I however, is in the area of training dental practitioners. I It is they who provide services, they who can create and I I support motivational change in patients, and they who can 1 most readily advocate for social and political intervention ! in the dental care delivery system. 43 BIBLIOGRAPHY 44 I BIBLIOGRAPHY I i I ; Albert, W. 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Community dentistry's contributions to oral i ! care of the aged and patients in terminal illness. : I Journal of the American College of Dentistry, July 19 71, ' I 38, 152-160. i i 1 1 Elfenbaum, A. Better oral health for the elderly. New i 1 York Journal of Dentistry, November 19 70, 40, 313-316. j I : I _ _ _ _ _ _ . Dentistry for the elderly in health and illness. j I In A. Chinn (Ed.) , Working with older people : Clinical < j aspects of aging. Washington, D.C.: United States | ! Government Printing Office, 19 71, 337-353. j I Epstein, S. Public relations in geriatric dentistry. ; I Journal of the American Society for Geriatric Dentistry, i I Autumn 1975, 1^, 11. I 1 I I_____ . Personal communication. May 1976. ;Folta, J., & Deck, E. (Ed.). A sociological framework for patient care. New York: John Wiley and Sons, Inc., : 1966. I Franks, A. Geriatric dentistry. Oxford, England: Black- i well Scientific Publications, 1973. Freden, K. Mobile dental clinics. Journal of the Southern i California Dental Association, June 1970, 3^, 560. Fredericks, M., Mundy, P., & Blanchet, L. Dental auxilaries and the poor: A study of expressed willingness to serve. Dental Student, February 1973, 41-43. I Gag, W. (Translator). Tales from Grimm. New York: Coward-McCan, Inc., 19 36, 15. ( Garfinkel, R. The reluctant therapist. Gerontologist, April 1975, 15, 136-137. Gentry, J., Veney, J., Kaluzny, A., Sprague, J., & Coulter, E. Attitudes and perceptions of health service pro- ' viders: Implications for implementation and delivery of community health services. American Journal of Public Health, December 1974, 64(12), 1123-1131. 46 j Goldberg, S. Dental health education via the mobile I trailer. Journal of the New Jersey Dental Association, i I Winter 1974,^(2), 32-33. ! I _ ; I Graber, L. Psychological aspects of malocclusion. Chicago | i Dental Society Review, August 1975, 68(8), 12-15. ; ! ■ I jHobson, W., & Roseman, C. A dental survey of a group of ' ^ old people living at home. British Dental Journal, ; I 1953, 21' 208. I jKendal, P., & Reader, G. Contributions of sociology to i medicine. In H. Freeman, S. Levine, & L. Reeder (Eds.) , ' I Handbook of medical sociology. Englewood Cliffs, N.J.: 1 i Prentice-Hall, Inc., 1972, 1-29. ' ! , I ! Kogan, N. Attitudes toward old people; The development of > a scale and an examination of correlates. Journal of I , Abnormal and Social Psychology, January 1961a, 6^, 44-54.' I ;_____ . Attitudes toward old people in an older sample. Journal of Abnormal and Social Psychology, May 1961b, 62(3), 616-622. Kogan, N., & Wallach, M.. Age changes in values and atti- , tudes. Journal of Gerontology, July, 1961c, , 272-280. Kosa, J. The nature of poverty. In J. Kosa, A. Antonovsky, & I. Zola (Eds.) , Poverty and health : A sociological ! analysis. Cambridge, Mass.: Harvard University Press, 1969, 1-34. Kosa, J., Antonovsky, A., & Zola, I. Health and poverty reconsidered. In J. Kosa, A. Antonovsky, & I. Zola (Eds.), Poverty and health : A sociological analysis. Cambridge, Mass.: Harvard University Press, 1969, 319- 342. Kosberg, J., & Gorman, J. Perceptions toward the rehabili tation potential of institutionalized aged. Gerontolo- gist, October 1975, 35, 39 8-403. Kurtzman, C., Freed, J., & Goldstein, C. Evaluations of treatment provided through two universities' mobile dental project. Journal of Public Health Dentistry, Spring 1974, 34(2), 74-79. 4 7 Lawton, M. P. Social ecology and the health of older people. In C. Kart, & B. Maynard (Eds.) Aging in I America. Port Washington, N.Y. : Alfred Publishing Co., j 1976, 315-323. j Lerner, M. Social differences in physical health. In I J. Kosa, A. Antonovsky, & I. Zola (Eds.), Poverty and I health; A sociological analysis. Cambridge, Mass.: ! Harvard University Press, 1969, 69-112. Lobene, R. , Fredericks, M. , & Mundy, P. Social attitudes of students of dental assisting. Dental Assistant, July 1970a, 16-19. Social attitudes of students of dental assisting. Dental Assistant, August 1970b, 32, 17-20. . Attitudes of dental hygiene students. Journal of the American Dental Hygiene Association, May-June 197la> 45, 164-168. i Social attitudes of dental hygiene students. I Journal of the American Dental Hygiene Association. I July-August 1971b, 237-241. ! Loether, H. Problems of aging. Belmont, California : Dickenson Publishing Co., Inc., 1967. McKelvey, L. (Ed.) Dental care for the Chronically ill and j aged. Washington^ D ~ , C. : United States Government ~ ; Printing Office, 1968. Radke, F. Gerodontia and the development of a gerodontist. Journal of the Alabama Dental Association, January 1974, 58, 38-42. Reis, J., & Layton, A. Dental care for the homebound. I Dental Assistant, April 1970, 2 2 , 19-20. Roeck, D., & Bernhard, M. Geriatric dentistry: Why is it ! a "special problem"? Journal of the American Society for Geriatric Dentistry, Autumn 1975, 12/ 15. Rosenstock, I. Prevention of illness and maintenance of health. In J. Kosa, A. Antonovsky, & I. Zola (Eds.) Poverty and health; A sociological analysis. Cambridge, Mass.: Harvard University Press, 1969, 168-190. Shanas, E., & Maddox, G. Aging, health, and the organiza tion of health resources. In R. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences. New York: Van Nostrand Reinhold Co., 1976. 48 ' Shaw, M., & Wright, J. Scales for the measurement of attitudes. New York; McGraw-Hill, 1967, Silverman, S. Self-image and its relation to denture acceptance. Journal of Prosthetic Dentistry. February 1976, 3^(2), 131-141. Summit, L. (Ed.) The crisis in health care for the aging. New York; Huxley Institute for Bioscoial Research, 19 73J ■ United States House of Representatives Select Committee on | I Aging. Medical appliances and the elderly ; Unmet heeds j I and excessive costs for eyeglasses, hearing aids, ! dentures and other devices. Washington, D.C.; United { i States Government Printing Office, September: 1976, 9-18. ! I ! ' Waldman, H. B. , & Stein, M. Now! For the chrdnicaTly ill | ■ and aged ; A plan for total dental services. Was hin gton ; Dl C.; United States Government Printing Office, 1967. ! I I 'Young, W., & Smith, L., Jr. The nature and organization | of the dental practice. In H. Freeman, S. Levine, & L. Reeder (Eds.), Handbook of Medical Sociology. Englewood Cliffs, N.J.; Prentice-Hall, Inc., 1972. 49 APPENDIX A SURVEY INSTRUMENT 50 DENTAL SURVEY I am conducting research into some of the attitudes and opinions of students of Dentistry and Dental Hygiene. The results of this study will be used as part of a Master's Thesis. Your answers to the questionnaire will be treated con fidentially , therefore, do not write your name anywhere on this survey form. In answering the questions, please work straight through from beginning to end. Do not skip any questions and do not go back to ones you have already answered. Part of the survey consists of your responses to hypothetical situations. If you have never encountered the situation, answer as if you had. Thank you for your assistance by participating in this survey. Sincerely, Linda Cook 51 SECTION I BACKGROUND INFORMATION Circle the letter next to the answer which identifies you. Course of Study Year in School A. Dentistry B. Dental Hygiene C. other. Spe ci fy A. Senior B. Junior C. other Specify^______ DO NOT WRITE IN THIS SPACE 1-3 SECTION II OPINIONS The following questions are concerning your opinions. There are no right or wrong answers 1. What age group(s) do you feel are in the most need of special attention from the dental profession? Why ? 2. What do you feel are the most important problems in providing dental care to the elderly? 52 SECTION III HYPOTHETICAL SITUATIONS ! This section deals with some situations you may j encounter during your professional career. ; Answer the following questions by writing the ; letter corresponding to your response in the I space provided. Additional space is provided : between items so that you can add clarifying ; comments if you wish. j 1 1. While looking for a job, you are offered ! four positions with equal financial and fringe benefits. Rank them in the spaces I provided below as to which positions you i would be most likely to accept. (1 = most ! likely, 4 = least likely) _____ A. Private general practice 2. 3. B. Neighborhood health center C. Advisor to a group of nursing homes D. Teaching at a dental school Which age groups of patients do you prefer to treat most? (1 = most prefer, 4 = least prefer) A. B. C. D. Children Young Adults Middle-Aged Elderly If you had control of your own practice, would you accept older patients whose treatment was being covered by Medi-Cal? DO NOT ' WRITE IN I THIS I SPACE I 10 11 12 13 14 15 A. Always B. Sometimes C. Never 53 If you read in the JADA that a researcher has shown that many older patients tolerate treatment better when sitting upright than when in a supine position, what would you do?____ A. Treat all older patients in the upright position. B. Begin treatment of older patients by placing them in the supine position, then moving them to an upright posi tion if signs of fatigue are exhibited. C. Continue to treat in the supine position since it is more efficient. D. Other. Specify: DO NOT I WRITE IN I THIS ! SPACE 16 17 A large local nursing home has been referring its 65 ambulatory patients to you for treat ment for the past year. Now the administrator is seeking dental care for 75 patients con fined to wheelchairs. The nursing home will provide special transportation and an at tendant to accompany the patients. In order to serve these patients, your office will have to purchase special headrests for the wheelchairs and pay for widening a doorway. Which would you be most in favor of?_____ A. Widening the door and purchasing the headrests. B. Referring the administrator to a colleague. C. Other. Specify: 18 19 54 I 6. Imagine that in the next session of the State Legislature a bill will be proposed ! to expand Medi-Cal dental benefits to in clude comprehensive dental care for the aged. What would you do? I A. I would be against it. I B. I would hope that it passed but j probably not take any action. C. I would write my congressperson to j express support. j D. I would write my congressperson and I campaign for it. ' 7. What would you be most likely to do when ! reading in the newspaper that dental ser- i vices are badly needed in a nursing homè ; near your home? DO NOT WRITE IN THIS SPACE 20_ ___ 21 22 23 A. Leave action to the authorities. B. Try to contact the State Department of Health. C. Offer your services. D. Other. Specify: SECTION IV MORE OPINIONS Do you feel that the dental school has a responsibility to sensitize students to the needs of the aged? If so, how should that role be carried out? 24 55 j The following items are not directly related DO NOT to Dentistry. They are comprised of a number WRITE IN I of statements expressing general opinions with THIS I which you may or may not agree. Following each SPACE I statement are six spaces labeled as follows : I Strongly I Disagree Slightly Slightly Strongly Disagree Disagree Agree Agree Agree You are to indicate the degree to which you agree or disagree with each statement by checking the appropriate space. Please consider each state ment carefully, but do not spend too much time on any one statement. Do not skip any items. There are no "right" or "wrong" answers— the only correct responses are those that are true for you. 5. 6. One of the most inter esting qualities of old people is their accounts of their past experiences Most old people spend too much time prying into the affairs of others and in giving unsought advice. Most old people are cap able of new adjustments when the situation de mands it. Most old people can generally be counted on to maintain a clean, attractive home. Most old people make one feel ill at ease. w D W cn > CA ft H- h - ^ I - * iQ r+ h i C O H- H- h i h i 0 LQ f D O 3 y 5- f D 3 h i ft ft h - * m h - * I - * h - > •C f D •c X X D D > > H- H- iQ vQ C O C O h i h i p j U i f D f D LQ f D f D h i f D f D f D f D 25 26 27 28 29 56 cn o cn cn > cn rt- n' H* M r t e n p - P - P P 0 fu fD O 5 vQ tr tr fD 5 f t r t iQ fD M P ' M X f D X X X O o > > H - p - vQ c n c n P P fu fD f D fD f D P f D fD fD fD WRITE IN THIS SPACE It is evident that most old people are very different from one another. 30 I 8. Most old people need no more I love and reassurance than any- t one else. 9. Most old people seem to be ' quite clean and neat in their ; personal appearance. 10. Old people have too little power in business and politics. 11. If old people expect to be liked, their first step is to try to get rid of their irritating faults. 12. One seldom hears old people complaining about the be havior of the younger genera- ^ tion. I 13. Most old people respect others' privacy and give advice only when asked. 14. Most old people make ex cessive demands for love and reassurance. 15. It would probably be better if most people lived in residential units with people their own age. 31 32 33 34 35 36 37 38 57 cn a cn cn > cn ft P O 3 iQ M X O H- C O P f D fD H- C O H- H- CD iQ iq f t f t M M X X iq P fD fD a H- C O C D iq P fD fD s p fD fD iq p fD fD r t p o 5 iq p* X S % fD DO NOT WRITE IN THIS SPACE I 16. Most old people should be j more concerned with their j personal appearance ; they're I too untidy. I 17. It is foolish to claim that ! wisdom comes with old age. I 18. Most old people would pre- : fer to quit work as soon as ; pensions or their children ! can support them. i ! 19. People grow wiser with the ■ coming of age. ! I 20. It would probably be better ' if most old people lived in residential units that also housed younger people. 21. Most old people are really : no different from anybody ! else : they're as easy to : understand as younger people. ■22. Most old people are cheerful, agreeable, and good humored. i ! 23. There is something different ' about old people : it's hard ' to figure out what makes ! them tick. 24. Most old people are irritable, grouchy, and unpleasant. 39 40 41 42 43 44 45 46 47 5 8 cn a cn cn > cn rh H- M I-* iQ f+ n CO M- M- n o C D iQ iQ C D 0 3 iQ y y C D 3 <q> > H - H- iQ iQ CO CO C D C D C D C D iQ iQ C D C D n CD C D C D C D W R IT E I N T H I S , 25. Most old people are con stantly complaining about 1 the behavior of the younger Î generation. I I 26. When you think about it, old 1 people have the same faults I as anybody else. ,27. Most old people are very re laxing to be with. I 28. Most old people would prefer ; to continue working just as i long as they possibly can ' rather than be dependent on anybody. :29. There are a few exceptions, but in general most old people are pretty much alike. 30. In order to maintain a nice residential neighborhood, it would be best if too many old people did not live in it. i 31. Most old people bore others by talking about the "good old days." 32. Old people have too much power in business and politics, 33. You can count on finding a nice residential neighborhood when there is a sizable number of old people living in it. 48 49 50 51 52 53 54 55 56 59 I ' c n a c n c n > c n i f t H - M H - *yQ r f C O H - H - H H i o P yQ yQ (D 0 5 yQ Î J * Î J * (D 5 1 yQ f t r f yQ ] M (D M M i X (D X X X D D > > H - H - yQ yQ C O C O H P p (D (D kq yQ (D C D h (D (D Q (D 34. Most old people get set in their ways and unable to change. 35. Most old people tend to let their homes become shabby and unattractive. DO NOT WRITE IN THIS SPACE 57 58 Is there anything else you would like to comment on concerning dental care of the elderly that has not been covered in this questionnaire? 59 Once again, thank you for taking the time to participate in this survey. 60 i i I APPENDIX B CODE BOOK 61 TEST ITEM COLUMN DESCRIPTION # ______________ VAROl 1-3 Identification # I background INFORMATION j I-l VAR02 4 Course of Study 1-2 VAR03 Year in school SCORING 001 through 126 ; a = 1 through c = 3 a = 1 through c = 3 : OPINIONS I II-1 VAR04 II-2 VAR05 Need for dental attention among various age groups Problems in pro viding dental care to the aged Mentions the 1 aged = 1 Does not men tion the aged =2; Mentions prob- ! lems having to do with the aged = 1 Does not men tion = 2 VAR06 Mentions prob lems having to do with the practitioner = 1 Does not men tion = 2 VAR07 Mentions prob lems having to do with the de livery system = 1 Does not men tion = 2 HYPOTHETICAL SITUATIONS III-l VAR08 VAR09 10 11 Job preference Comments By rank answer to "c. Nurs ing home con sultant," first choice = 1 through fourth choice = 4 Commented = 1; No comment = 2 62 I TEST ITEM COLUMN DESCRIPTION ' # ■ _ _ _ _ _ _ III-2 VARIO 12 Patient age pre ference SCORING By rank answer "d. Elderly." First choice = through fourth choice = 4 to ; VARll 13 Comments Commented = 1; No comment = 2 III-3 VAR12 14 Acceptance of Medi-Cal a = 1 through c = 3 VAR13 15 Comments Commented = 1 No Comment = 2 III-4 VAR14 16 Positioning patients a = 1 through d = 4 VAR15 17 Comments Commented = 1 No comment = 2 III-5 VAR16 18 Adapting office a = 1 through d = 4 VAR17 19 Comments Commented = 1 No comment = 2 III-6 VAR18 20 Medi-Cal bill a = 1 through d = 4 VAR19 21 Comments Commented = 1 No comment = 2 III-7 VAR20 22 Nursing home needs a = 1 through c = 3 VAR21 2 3 Comments Commented = 1 No comment = 2 MORE OPINIONS IV-1 VAR22 24 School responsi bility Commented = 1 Did not comment=2 63 i TEST ITEM COLUMN I # _ ' ' IV-2 VAR2 3 ■ through ; IV-35 through DESCRIPTION 25-2 8 OP Scale questions VAR56 VAR5 7 59 Other comments SCORING Strongly dis agreed = 1 Disagree = 2 Slightly dis agree = 3 No answer = 4 Slightly Agree = 5 Agree = 6 Strongly agree = 7 Commented = 1 Did not comment = 2 COMPUTE 0P+ Score VAR23 + VAR25 + VAR26 + VAR28 + VAR29 + VAR30 + VAR31 + VAR33 + VAR34 + VAR40 + VAR41 + VAR42 + VAR43 + VAR47 + VAR48 + VAR49 + VAR54 OP- Score VAR24 + VAR27 + VAR32 + VAR35 + VAR36 + VAR37 + VAR38 + VAR39 + VAR44 + VAR45 + VAR46 + VAR50 t VAR51 + VAR52 + VAR53 + VAR55 + VAR56 64</q>

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Asset Metadata

Creator Cook, Linda Louise (author)

Core Title Dental care of the aged patient: Implications of attitudes toward aging among dental students and dental hygiene students

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Degree Conferral Date 1978-06

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest,social sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Wiswell, Robert A. (committee chair)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-401667

Unique identifier UC11657591

Identifier EP58853.pdf (filename),usctheses-c37-401667 (legacy record id)

Legacy Identifier EP58853.pdf

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Document Type Thesis

Format application/pdf (imt)

Rights Cook, Linda Louise

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA