INTRODUCTION

In Colombia, the services provided by health students is based on a teaching clinic model;¹ this combination of academy and practice is one of the key fundamentals in the preparation of health staff, which may reflect the efficiency or deficiency of this theoretical and practical training at the moment of treating patients. Similarly, the preparation of health staff requires institutions that allow developing health care processes, for a better interaction of Higher Education Institutions and Health Services Providers, seeking the application and evaluation of knowledge, skills, attitudes, and skills acquired during practicum, which in turn indicates the ability to perform professional duties in a safe and ethical manner.²

In recent years, the issue of quality and its perception by patients has gained considerable importance among Health Services Providers; therefore, patient satisfaction is a good predictor of treatment compliance and adherence to consultation or service provider; it is a useful tool for assessing not only treatment rooms but also communication models (for example, possible decision making); finally, patients’ opinions can be systematically used to improve the organization of services.³

Quality is conceived as the greatest possible health care benefit with the lowest risks for patients, with two intertwined and interdependent dimensions: technique and interpersonal attention. Technique refers to the application of science and medical technology to provide the maximum level of health benefits without increasing risks; interpersonal attention measures the degree of adherence to values, norms, expectations, and aspirations of patients.³

Consequently, the clinic teaching model becomes a challenge, requiring the achievement of a treatment plan established jointly by students and faculty at the dental clinic, seeking the highest possible quality. Patients in need of complex treatments increase the challenge to students, as they test the skills acquired during the theoretical and practical training process provided by dental schools and foster commitment to patients;⁴ however, due to the specific circumstances of training processes, the planned treatment is not often achieved entirely, altering the continuity of the plan, as well as the safety and timeliness of the service, thus affecting the overall perception of quality.

That being said, and considering that most studies on dental patient satisfaction are based on experiences in foreign countries,^5,6,7 while in Colombia the studies related to patient satisfaction with dental care are scarce, this study seeks to identify the key factors in the perception of quality of the dental services provided by undergraduate students, in order to help dental school provide quality health services.⁸

METHODS

This was an observational, cross-sectional study, analytical in nature, observing the sociodemographic characteristics of patients treated at the dental service of a Health Institution where dental services are provided.

Sample size was calculated at 202 patients, considering the criteria for a descriptive study: a population of 411 patients seen at a teaching clinic during the first quarter of 2015, with a 95% confidence level and assuming a proportion of 50% of patients satisfied with the service. This study included men and women aged 18 to 60 years, who initiated dental treatment between June and August 2015 and spent more than one month in the dental treatment offered by an undergraduate student, a doctor of dental medicine, or a specialist. Patients who attended priority consultation were excluded, as well as those treated by graduate students, as this can lead to variations in the perception of the health service quality. However, sample selection was not probabilistic, as patients were selected in order of attention in the month of September 2015, until reaching the sample size previously set.

The technique used for data collection from the primary source was an instrument with five domains, each containing three to five questions and four variables; this instrument was taken and modified from a survey used in the article “Validation of a survey to evaluate outpatient satisfaction”,⁹ with 0.957 Cronbach’s alpha. Validity of the appearance and content of this instrument was assessed by means of the Delphi method, by three experts in dental teaching services. This review determined if the survey’s questions were appropriate, concise and complete. This phase ended with the construction of the questionnaire, which was applied to the target population by the main researcher. This project was endorsed by the Universidad CES Ethics Committee (Statement 83/2015) ensuring confidentiality of the information provided by the population.

Univariate analysis was conducted to characterize the population of undergraduate students who provide dental services and patients receiving the services. The quantitative variables were described through the measures of central tendency, position, and dispersion, and the qualitative variables were described using percentages. To establish association with dental service quality, according to factors related to student, patient, care assessment, and teaching clinic agreements, crude and adjusted prevalence reasons (RP and RPadj respectively) we calculated through logistic regression, with their respective 95% CI. Service quality was assessed as poor, good, or excellent as a dependent variable.

RESULTS

All patients analyzed during the data collection period met the inclusion criteria, and none met the exclusion criteria. Of the 87 students seeing patients at the Dental Service, 57 were women (65.5%) and 140 of the 202 patients were women (69.3%). Concerning the perception of service quality by patients, it is worth noting that per 3.1 women who perceived quality as excellent, there is one man who perceived it as poor or good, and there was association between socioeconomic level and the perception of service quality, showing that patients in socioeconomic level 3 have 3.1 more probabilities to perceive service quality as excellent in comparison to patients with higher socioeconomic levels Table 1.

As for the perceptions of the attitude and treatment by dental students and faculty members according to service quality, 9 in 10 patients said they received a kind treatment, with no evidence of association with the perception of a poor service Table 2.

Regarding the information offered from staff at the front desk explaining that the patient was going to be seen by a student, 1 in 10 patients said that the information was clear. Similarly, per 2.8 patients who perceive quality as excellent, there is 1 who perceives it as poor or good Table 3.

Concerning quality of the dental services received in terms of disease management, 9 in 10 patients said it was excellent Table 4. As for quality of the dental services with respect to student’s knowledge, per every 10 patients who perceive quality as excellent, there is 1 who perceives it as poor or good Table 4.

It is worth noting that 9 in 10 patients said that the quality of the dental services they received was excellent with respect to the supervision of the student by a professor, and there is evidence of association between faculty supervision and service quality Table 4

In terms of comfort and cleanliness of dental units, per 2.8 patients who perceived quality as excellent, there is 1 who perceives it as poor or good, and there is evidence of association between comfort and cleanliness of the dental units with the likeliness to perceive the service as excellent. There was association between comfort and cleanliness of the waiting room and restrooms with the probability of perceiving the service as excellent Table 5.

In adjusting all the independent variables associated with factors influencing dental service quality, we found out that the perception of dental services quality increases according to patient’s sex (female) (RPadj= 6.6 [0.7-65.5]), with respect to management of the disease (excellent) (RPadj = 17.1 [2.3-124.8]), as well as the quality of dental services with respect to the supervision of the student by a professor (excellent) (RPadj = 170.2 [11.4-2540.7]), the comfort of the waiting room and restrooms (comfortable) (RPadj= 13.0 [1.6-109.0]) and cleanliness of the waiting room and restrooms (clean) (RPadj = 4.5 [1.2-17.5]). The remainder characteristics showed no significant associations, and in general there was little variation between raw and adjusted RP Table 6.

DISCUSSION

The findings of this study helped identify the factors that influence perception of the quality of the dental service provided by undergraduate dental students at Universidad CES, through the exploration of patients’ concerns. The findings suggest that a large percentage of patients are satisfied with the service provided, identifying key factors that influence the perception of the service as excellent; these include supervision of students by faculty members during dental treatment, attitude and treatment by staff, the information provided before, during, and after attention, and structural aspects in terms of waiting rooms, restrooms, and dental units.

With regard to the distribution of patients by sex, most patients seeking dental services were women, who accounted for 65.5% of the study population. This result was also found in two studies in Medellin¹⁰ and Cartagena,¹¹ where the percentage of women was 57.2% and 56.1% respectively. This is also consistent with findings by Hincapié et al¹² in a study in Medellin, where patients seen at the service of comprehensive dentistry for adolescents and the orthodontic service were 44.7% men and 55.3% women.

The present study reported that 7 out of 10 patients rated quality of the dental service provided by students as excellent. This percentage is higher than that reported by George et,¹³ who evaluated the causes of irregular dental care, finding out that only 51,54% of patients were satisfied with the service. However, the results in the present study are different from the ones in a study in Mexico, where the answer about the perception of quality by patients was very good in 23% and 45%, good in 52% and 45% and only 2% and 13% considered poor, respectively for each population.¹⁴

In domestic terms, higher percentages have been reported with regard to dental service satisfaction. A study by Hincapié et al¹² showed that 95.6% of the population was completely satisfied with dental care. Similarly, Betin et al¹¹ showed a high degree of satisfaction: 89% of patients stated that the treatment received was satisfactory, according to the comprehensive care they received and staff efficiency, which demonstrates students’ skills and abilities.

In Colombia, dental care is provided through the dental teaching clinics model, and it is challenging to fulfill the treatment plans jointly established by students and faculty members at dental clinics. This happens especially with new patients who require more complex treatments, which increases the challenge to students because it tests the skills acquired during the theoretical and practical training provided by dental schools and encourages commitment with patients.⁴

The dental care offered by students affects patient satisfaction, 12 agreeing with the results in the present study, where faculty supervision to students during dental care directly affects the perception of service quality as excellent. It is important to highlight that the teaching clinic model must guarantee a quality work by the student with supervision by a faculty member, which is critical in patient’s quality perception. All this is consistent with the findings by Orenuga et al¹⁵ in a study evaluating the level of satisfaction of patients in the Dental Department at a higher education institution in Nigeria, where dissatisfaction was expressed by 89% of respondents for receiving attention by students with no faculty supervision.

One of the rights patients have is receiving quality services based on what is diagnosed, done, and planned.¹⁰ Regarding this category, this study showed that service quality was strongly associated to patient’s perception regarding disease management, including diagnosis, treatment, and follow-up.

In the present study, the attitude and respectful treatment by both dental students and faculty members were identified as key factors in quality perception, agreeing with the findings by López-Portilla et al1 in a study carried out in Medellín, observing that most participants highlighted the respectfulness with which they were treated by students and professors as one of the strongest aspects of the service. Similarly, Lang¹⁶ reported quality of the dental treatment and student kindness as positive aspects of the dental service. This all agrees with the findings by Agudelo et al,¹⁰ as well as with the literature review by Lara Flores et al¹⁴ and Matee et al,¹⁷ who highlight interpersonal factors as key in patient satisfaction, along with other factors such as empathy and demonstrations of interest in patient.

The study by Agudelo et al¹⁰ reported that patient satisfaction with treatment by front desk personnel was 5.5%, and therefore the authors considered that this aspect must be strengthened, as it is the first impression the patient has upon entering the institution. This in turn coincides with the findings by López-Flores et al,¹⁴ whose multivariate analysis showed that patient dissatisfaction with dental service focused on the way they were treated by front desk staff, the information they received about treatment, and the cleanliness and overall organization of the office. This agrees with the results of the present study, as comfort and cleanliness of waiting room, restrooms, and dental units was one of the categories most commonly linked with patient dissatisfaction.

In terms of comfort and cleanliness of waiting rooms and restrooms, the present study showed that these aspects should be improved, as 8.2% of patients rated these spaces as either uncomfortable or dirty. This is consistent with a study in Medellín by Agudelo et,¹⁰ who emphasized the influence of these variables on user satisfaction, and with a study by Lang,¹² who pointed out that the negative aspects of the dental service at clinics of the School of Dentistry of Universidad de San Carlos de Guatemala are related to the lack of bathroom cleanliness. In Núñez’s dissertation,¹⁸ based on the level of satisfaction of patients in the dental clinic of Universidad Nacional Mayor de San Carlos, the author concluded that there was a high level of acceptance, because the dental services of this clinic were rated as good and very good in terms of infrastructure and equipment. Other results that are similar to the present study suggest that these aspects were some of the most important in patients’ perception of quality concerning dental services.

Among the possible limitations of the present study is its cross-sectional nature. The conclusions with respect to the association model do not allow establishing a causal relationship, but only a relationship of association between the independent variables and the two dependent variables: service quality, and teaching clinics agreements. In addition, participants might have felt intimidated in answering some of the questions, and the timing of each patient’s last session may have had some effect on the responses.

The scarce scientific literature available and the insufficient information on factors that influence quality of the dental service through both teaching clinics agreements and outpatient dental service were a limiting factor; however, this is a good starting point to approaching the issue. The results of this study are applicable to the sample where data were taken from, and future studies are needed to address more broadly the concept of quality in relation to clinical practicum, assessing the impact on health care quality in a differential manner.

CONCLUSIONS

The methodology used in this study allowed concluding that the factors associated to health care quality in the dentistry service, within the context of dental teaching clinics, are concentrated on dimensions such as attitude and respectful treatment, information provided to patient, supervision by faculty members, and structural aspects related to comfort and cleanliness.