A qualitative exploration of patients’ perception regarding the comprehensive dental services availed at a primary health center

Introduction

The Dawson report first mentioned the term ‘Primary Health Care Center’ around 1920 in the United Kingdom.¹ Primary care is defined as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”² Although the World Health Organization (WHO) has recognized the importance of primary care in health service systems, there is dearth of primary care physicians compared to specialist physicians.^1,3 A similar shortage is observed in Sub-Saharan Africa, where factors such as inadequate financing and unreliable expenditure on medicines add to the challenges of providing primary health care.^4–9

In India, Primary Health Centers (PHCs) and its outreach teams constitute the “backbone” of the rural health care system with strong referral mechanisms connecting them to speciality care.¹⁰ However, in developing countries, primary health centers face challenges in delivering oral health care, necessitating programs to enhance community outreach, meet basic health requirements, and facilitate proper patient referrals.¹¹ The government of India launched the National Oral Health Programme to provide comprehensive oral health care in response to the oral health conditions in the nation. This initiative aims to improve the determinants of oral health, integrating oral health promotion and preventive services with the general health care system, and encouraging the promotion of public-private partnerships (PPP) as a means of improving oral health.¹² The provision of comprehensive oral care is a patient-centered service¹³ that encompasses various dental treatments, including examinations, consultations, prophylaxis, and restorations.¹⁴ However, it is typically observed that while the population in urban areas has limitless access to these services, those in greater need of them have restricted access.¹⁵

In an effort to address the needs of underserved populations, community health services step in to offer free dental services, bridging the gap in access to oral care.¹⁶ Despite existing barriers such as challenges related to transportation and caregiver attitudes,¹⁷ literature suggests that these programs contribute to a reduction in carious teeth, particularly in children.¹³ To optimize services, co-locating dental clinics within medical health centers proves beneficial, streamlining the referral process and providing patients with convenient access to both medical and dental care.¹⁸ The sustainability of such services can be enhanced by gaining an in-depth understanding of the perceptions of the patients regarding the services availed. Therefore, a qualitative approach is apt for comprehensively understanding the influences and contexts that affect the decision-making processes of individuals regarding their oral health care needs.

Patient satisfaction, as evidenced in various studies, plays a crucial role in ensuring compliance, improving clinical outcomes, and increasing service utilization.¹⁹ Patient satisfaction is affected by patient perception,²⁰ which is based on their dental experiences and a certain level of expectation when they avail dental services from a primary health center at a reasonable to no cost.²¹ Furthermore, it serves as a roadmap for enhancing quality,²² ensuring that patients not only have the intention to use the services in the future themselves but also to recommend them to others.^23,24 Hence, the present study was carried out to assess the patients’ perception towards comprehensive dental services availed at a Primary Health Center (PHC) located in South India.

Methods

The present qualitative research, which explores the perceptions of patients receiving comprehensive oral health care, has been reported in accordance with the COREQ (Consolidated criteria for Reporting Qualitative research) Checklist.²⁵ The materials used in this study (questionnaire, participant information sheet, interview guide, sample consent form and filled COREQ checklist for the present study) are available as extended data.²⁶

Results

A total of 12 participants were interviewed in this study with a mean age of 49.42 (±15.9) years. Among these, 8 (66.7%) were female, and 4 (33.3%) were male with the majority of participants lived in close proximity to the PHC.

The qualitative examination of the interviews resulted in the identification of three primary themes: pre-visit perspectives, visit related perspectives, and post-visit perspectives. Each theme was subsequently subdivided into two sub-themes, with further categories emerging from the respective codes. A comprehensive overview of these themes, sub-themes, categories, and codes is presented in Table 1.

Each category was assigned a distinct color to facilitate easy identification of the codes in the transcribed interviews. The color-coded chart, depicting the occurrence of codes in each participant interview, is presented in Figure 1 and aids in recognizing the frequency of each code in every participant interview. Each theme, along with illustrative quotes, are detailed below.

Figure 1. The color-coded chart depicting the occurrence of codes in each participant interview.

Discussion

The present qualitative research was conducted to delve into patients’ perception regarding the comprehensive dental services offered at the PHC through in-depth interviews. The findings illuminated that the prevailing outlook on care at the PHC was predominantly positive, indicating a favorable perception among the participants.

In this study, the most common reason for visiting the center was to obtain dentures, indicating a significant interest among in addressing their missing teeth. Following this, endodontic treatment ranked as the second most common reason. This is in contrast with a study conducted in Switzerland, where endodontic treatment was the most sought-after treatment, followed by dentures.³⁰ Some participants also mentioned that they visited because it offered free dental treatment. This suggests that the provision of free treatment increases the likelihood of patients utilizing the facility, aligning with findings of a Kerosuo et al., which notes that the treatment rate is influenced by the availability of free treatment.³¹ When inquired about their previous source of dental care, a majority of participants had previously sought oral health care at private dental clinics. The transition to the center for subsequent treatment might be attributed to the availability of free treatment, which, in comparison to the costs incurred in private clinics, is likely to be considerably lower.

Most participants did not encounter any issues concerning the treatment provided, waiting times, or the availability of appointments. However, among those who faced difficulties, waiting time emerged as the primary concern. This aspect could have influenced their perceptions of the center and its facilities, aligning with findings from a study conducted by Inglehart et al.³²

Most of the participants in this study expressed satisfaction with the care they received at the center. Additionally, participants who visited the center primarily to alleviate pain reported relief. A study by Shrestha et al. indicated that patient satisfaction hinged on meeting the expectations and needs of the population.¹¹ Similarly, another study focusing on children revealed an overall improvement in the oral and general health of children who received comprehensive care, likely contributing to their satisfaction with dental treatment.¹³ Similar results were observed in the present study with most participants expressing a positive opinion regarding the comprehensive care provided. This positive sentiment suggests that a holistic approach likely contributed to overall patient satisfaction by addressing the various facets of oral health and potentially related concerns.

The affordability of comprehensive care is a significant factor, as evidenced by a study conducted by Cruz et al, indicating that co-located clinics can enhance the cost-effectiveness of care. In line with this, a participant in our study highlighted the absence of a cost burden, emphasizing the convenience of receiving all necessary care in a single center and avoiding the expenses associated with traveling to different places for different treatments.¹⁸ This can be appreciated in the following excerpt:

Regarding recommending the center to others, all participants in this study expressed their willingness to do so, with the majority having already recommended the center to others. The reasons cited for willingness to recommend included the availability of free treatment, quality of care and the convenience of accessing all care in one location. Notably, studies on orthodontic treatment,³³ fixed dental treatment³⁴ and aesthetic crown lengthening³⁵ have reported similar outcomes, where a substantial number of participants were willing to recommend the respective treatment to others. These findings were consistently attributed to the high levels of satisfaction with the treatments received.

When questioned about potential enhancements to the center for improved care, the participants predominantly expressed the need for increased resources. This included a demand for more dentists, additional dental chairs for treatment, a shaded waiting area for patients, and provision of drinking water in the waiting area. Participants specifically emphasized the requirement for more dentists and dental chairs to alleviate waiting times, aligning with the findings in a study conducted by Nair et al.²⁰ Additionally, participants voiced a desire for free dental crowns or fixed prosthetics at a lower cost, highlighting a perceived cost barrier to accessing paid dental services. This echoes the sentiments of the same study, where participants cited the high cost as a significant challenge, leading to difficult decisions on prioritizing family members for dental care when multiple individuals required treatment.²⁰ These results highlight the complex interplay of factors that affect the accessibility and outcomes of comprehensive dental care services.

Conclusion

The overall results of this study revealed a predominantly positive outlook among the participants regarding the comprehensive dental services at the PHC. Through insightful interviews, both strengths and weaknesses of the center, as well as the oral health care provided, emerged. Although the majority of patients expressed satisfaction, a subset of participants offered constructive suggestions for improvement. The various suggestions, based on real experiences, offer potential for improvement, and can enhance the use of dental services, establishing an environment that fosters continuous enhancement and prioritizes patient-centric oral healthcare.

Acknowledgement

We thank all the staff working at the Primary Health Centre for their co-operation towards completion of this research.