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ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 236-241

Perceptions and attitudes among interns of dental colleges in Pune district toward community outreach program: A qualitative study


Department of Public Health Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission20-Mar-2018
Date of Acceptance27-Jun-2018
Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Sahana Hegde Shetiya
Department of Public Health Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr D.Y Patil Vidyapeeth, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_73_18

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  Abstract 

Background: Dental Council of India in its 3rd amendment regulations-2011 had incorporated 3 months of compulsory rural posting for the dental interns to sensitize them toward social responsibility through community outreach program. Objective: The objective of the present qualitative study was to understand in-depth the perceptions and attitudes of the interns of dental colleges in Pune district, India, toward community outreach programs. Materials and Methods: Focused group discussions were conducted for each group of ten interns separately in one college for about 1 hour, based on a well-designed but flexible topic guide through a moderator and a note-taker. Results: Most of the interns were aware of need for outreach programs in the community. It helps the interns in sharpening their clinical as well as communication skills outside the traditional dental school settings. Since most of the dentists prefer to practice in urban or financially stable areas, such programs can increase the exposure of dental students to underserved population and sensitize them toward their oral health needs. Conclusion: Thus, dental profession must develop strategies to provide new graduates with professional and personal support to retain the rural dental workforce.

Keywords: Attitude, outreach, perception


How to cite this article:
Shinde PP, Shetiya SH, Agarwal D, Mathur A. Perceptions and attitudes among interns of dental colleges in Pune district toward community outreach program: A qualitative study. J Indian Assoc Public Health Dent 2018;16:236-41

How to cite this URL:
Shinde PP, Shetiya SH, Agarwal D, Mathur A. Perceptions and attitudes among interns of dental colleges in Pune district toward community outreach program: A qualitative study. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2018 Nov 17];16:236-41. Available from: http://www.jiaphd.org/text.asp?2018/16/3/236/238591


  Introduction Top


In developing countries like India, one of the key factors contributing to oral health inequity is lopsided dental care workforce planning.[1] With the trend of rising Indian population, there is also an increase in dental colleges in India. Before 1991, there were only 49 dental colleges in India.[2] However, as of now, there are 304 dental institutions recognized or approved by the Dental Council of India (DCI).[3] With an increase in the number of dental colleges in India, there also has been improvement in the dentist to population ratio.[4] According to National Health Profile of India-2015, India's dentist-to-population ratio is 1:8022 which is more than many developed nations and few developing nations.[5] However, dentists offering oral health services usually practice in the cities and treat the affluent parts of the urban population. Thus, it is often difficult for the poor urban and the rural population to get access to basic and emergency oral health care. To address this situation, strategies need to be adopted to attract and retain dental professionals, especially in the rural areas.

Dentistry in India is a 4-year course with 1-year compulsory internship which is aimed at improving the training skills in all the different specialties of dentistry.[6] The need for dental treatment in a rural setup with compulsory posting of 3 months had been top agenda of the president of DCI which was backed by the Ministry of Health and Family Affairs for catering to patients who are underprivileged and the needy.[7] Taking this into account, the revised Bachelor of Dental Surgery course –3rd Amendment Regulations, 2011 was introduced, which incorporated 3 months of compulsory rural attachment. Dental interns, during their 3-month postings in the Department of Public Health Dentistry, mainly have to attend regular health education and treatment camps and work in satellite clinics which are sometimes far away from the main educational institute and are referred to as “outreach” or “outplacement” programs. Mobile dental clinics as well as portable dental equipment are being used to provide dental services where traditional dental setups are not available. Interns serve to be the majority health-care providers for these programs along with staff/postgraduate students of dental colleges and hospitals. However, there was limited evidence of studies related to evaluation of these services from interns' perspectives.

Hence, the present qualitative study was carried out to understand in-depth the perceptions and attitudes of the interns of dental colleges toward community outreach programs during their 3-month posting in Department of Public Health Dentistry. This assessment will provide perceived benefits related to learning as well as other skills, evidence to support increased rural exposure for dental interns; possible strategies to overcome the challenges faced by them and suggestions to refine the program from their feedback.


  Materials and Methods Top


The focus of phenomenological approach in a qualitative study is what interns experience with regard to a phenomenon, i.e., “community outreach program” and how they interpret these experiences. The present qualitative study utilized a focused group discussion among interns of the four dental colleges in Pune district. Using homogeneous sampling technique, a total of 40 interns (10 from each college) who were posted in the last week of their posting or those who have recently completed their 3-month posting in Department of Public Health Dentistry were included in the study. Ethical clearance from the Institutional Review Board was obtained (IEC/DYPDCH/PHD-TD/04). The study was conducted for a duration of 3 months from September 2015 to December 2015.

Written informed consents were obtained from respective authorities of the four dental colleges and also from all the interns participating in the study. Focused group discussions were conducted for each group of ten interns separately in one college for about 1 hour, based on a well-designed but flexible topic guide through a moderator and a note-taker. The moderator introduced the topic and guided flow of the discussion. The notetaker assisted the moderator in tracing sociogram, recording nonverbal communication, and noting the level of consensus among interns. The participants influenced each other through their ideas and contributions during the discussion.

All the discussions were audio recorded on a mobile phone after giving prior information about it to the participants. The problem of recall bias was minimal as the responses were recorded immediately after completion of posting. The recorded data were transcribed and analyzed.

Inductive analysis

The raw data were formatted, and close reading of the text was done. Segments of text were coded. Categories were created from similarly coded data. Major categories were compared with each other and consolidated into themes. The data were analyzed using software QDA Miner Lite version. The results were written in text, and no form of results was expressed quantitatively.


  Results Top


Overall, 40 interns, 12 males and 28 females, with age range from 21 to 24 years participated in the study. A rigorous and systematic reading and coding of the transcripts by chief investigator allowed major themes to emerge. Segments of text were coded using inductive analysis. The results were reported under following five themes and subthemes:

  1. Need for community outreach programs
  2. Benefits of community outreach programs


    1. Benefitting the community
    2. Benefitting interns


  3. Constraints


    1. Limitations in providing services through outreach programs
    2. Barriers in utilization of services through outreach programs


  4. Attitude of interns


    1. Toward community outreach programs
    2. Toward DCI rule of 3-month compulsory posting in Department of Public Health Dentistry


  5. Suggestions in improving community outreach programs.


Need for community outreach programs

For many participants, community outreach programs were for spreading awareness regarding oral health among people. Some were of the opinion that people may not have access to dental facilities in rural areas and even if it was available, they cannot afford dental treatment at private dental clinics.

Following responses were given by the participants when they were asked the question:

Chief Investigator – What is the need for community outreach program?

R10 – “They are not following what needs to be followed. There is lack of oral hygiene. It's their right to know. So we have to impart that knowledge to them through outreach programs.”

B7 – “I think people in rural areas consider dental problem as secondary problem. So by organizing camps at least they will come for check up and we can diagnose at an early stage. Otherwise they come to dental clinic at last stage when there is swelling or so.”

B1 – “In India, a very small percentage of population go for the high range treatment which are given in private clinics. The ones who come to the clinic are the financially stable ones.”

S9 – “The suffering is more. Oral status is poor. Some people are still using mishri (tobacco product) for cleaning their teeth.”

Benefits of community outreach programs

Benefitting the community

Almost all the interns agreed that the community gets benefitted through such community outreach programs as it increases their awareness toward oral health. Furthermore, the people prefer immediate treatment rather than traveling to far-off places. Some felt that people receive oral health education, preventive services such as sealants, and professionally applied topical fluoride as well as other basic oral health services free of cost.

Following responses were given by the participants when they were asked the question:

Chief Investigator – How are people benefitted through such programs?

D4 – “I think they are benefitted because they are ignorant of some things, like they don't know the harmful effects of tobacco or smoking. So, we tell them and provide information. But eventually it's up to them to take benefit from it or not.”

B4 – “We give them oral health lectures and demonstrations of brushing technique on models.”

Benefitting Interns

All the participants agreed that they get benefitted through the community outreach programs. It develops their skills such as confidence, patient management, clinical skills, teamwork, diagnosis, convincing power, and communication skill. Some of the participants said that they get to learn more from such programs as they get practical exposure to variety of cases in such programs than in college.

Following responses were given by the participants when they were asked the question:

Chief Investigator – What benefits do you get through such programs?

R1 – “We learn how to handle different kinds of patients like the patient is apprehensive, adamant, or cooperative.”

D3 – “We also get to know the myths related to oral cavity (among people).”

D7 – “In camps, we learn how to manage with limited resources.”

B5 – “A lot of things you read in book you don't get to see in college practically, but when you go for such camps, we came across things that we cannot identify. So you have to call the teaching faculty.”

Constraints

Limitations in providing services

When the participants were asked about the limitations, they experience during the community outreach programs, some of them said the infrastructure of the mobile dental clinic and the satellite centers should be improved. Timely maintenance of the chair and equipment in mobile dental clinic and satellite centers was necessary as when the things are not working, it leads to waste of resources. Few of them said that they have to either go with their own vehicles or through public transport to the satellite centers.

Following responses were given by the participants when they were asked the question:

Chief Investigator – What limitations do you face during such programs?

R6 – “If everything is in working condition we don't mind traveling every day.”

R1 – “The infrastructure of satellite centers and the mobile dental clinic should be improved.”

R6 – “I think outreach programs are pretty good except for the fact that when we go to rural centers, they are very far. So, college should provide us transport.”

Barriers in utilization

Most of the participants said that the people have a negative attitude toward oral health and hence there is underutilization of services which are provided.

Following responses were given by the participants:

S5 – “Until and unless children or any person don't have pain, they won't come.”

R5 – “They don't want conservative treatment, for them dental treatment is just extractions.”

D3 – “When we conduct camps we provide them with basic treatment and we refer them to college for further treatment. Less than 50% are convinced to get the treatment done because of the distance or cost. They are partially benefitted because there are many factors which affect them.”

R5 – “People come and ask for medicines (for relief of tooth pain). If we give medications they take them for that duration and after the pain has stopped they don't want any treatment. Then it repeats again.”

R2 – “They find the doctor who speaks Marathi (regional language) more convincing.”

R5 – “Even if you give pamphlets they just throw it in the dustbin.”

Attitude of interns

Toward community outreach programs

Overall, all the participants were interested more in treatment camps rather than just checkup alone. For some, these outreach programs left over a sense of satisfaction and responsibility toward community. Few of them said that they would like to provide such services in future after setting up their own private practices. For some, there was no difference between department and camp posting, instead, they would prefer department more as the things are readily available there. None of the participants preferred postgraduation in Public Health Dentistry for rendering such services in future.

Following responses were given by the participants when they were asked the question:

Chief Investigator – In future has this posting encouraged you to do anything for the community?

S9 – “We can link up with NGOs and we can conduct camps when we start our private dental clinic.”

D2 – “After we start to earn we can put some part (time/money) into public work. We should spare at least 1 day in a month for community.”

Toward DCI rule of 3-month posting in Department of Public Health Dentistry

None of the participants were really aware of the purpose of 3-month posting in Department of Public Health Dentistry. Few of them said that it was for spreading awareness about oral health among people. Some of them were of the opinion that this 3-month posting should be placed in such a way that the exposure of clinical postings has already been acquired by the candidate for a smooth and confident delivery of oral health care by the candidate at rural health-care settings. Few of the participants said that 3 months is rather too long. Following responses were given by the participants when they were asked the question:

Chief Investigator – What is your opinion about Dental Council of India rule of 3-month posting for Interns in Department of Public Health Dentistry?

B6 – “I personally feel it should be split into 1-month duration posting in Public Health Dentistry.”

B1 – “It is too long. There is not much work to do, so we become little… (starts laughing)”

Suggestions in improving community outreach programs

Some of the participants suggested that follow-up of the patients at such programs is important. Appointments can be given to the patients during the checkup itself and transport should be arranged when they are referred to the college for further treatment. More camps in distant and rural areas should be arranged.

Following responses were given by the participants when they were asked the question:

Chief Investigator – Do you have any suggestions for improving the community outreach program?

D7 – “From our side we should keep follow-up of camps, at least once. We should see. If after us educating them, are they really concerned or not.”

D10-“We should arrange transport for these people, we can send our college bus.”


  Discussion Top


The purpose behind the qualitative approach was that it can measure things such as experiences, emotions, opinions, and other nonquantifiable data. The study findings were discussed under the following five themes and their subthemes which emerged during the qualitative data analysis:

Need for community outreach programs

In the present study, it was found that, after 3-month posting in Department of Public Health Dentistry, the interns were aware about the need for community outreach programs. Results of the present study were in accordance with Strauss et al., who examined how dental curriculum can maximize the impact of community-based dental education (CBDE) on students, their values, and their career plans.[8] The author provided evidence that CBDE has positive effects on students' awareness of need of dental care for underserved patients. Furthermore, similar findings were noted in studies which reported that the dental community field experience made the students aware of the population needs and the impact of cultural, educational, and economic factors on population's dental needs.[9],[10],[11],[12],[13]

Benefits of community outreach programs

Benefitting the community

The findings of the present study were in accordance with Bazen et al., who reported that students' assessment of their experiences in rural placements helps in highlighting possible strategies for the improvement of oral health of the populations in these areas.[10] Furthermore, many studies support the finding that undergraduate rural exposure may have a positive influence on students' intention to work for underserved population, thus benefitting the community in those areas.[14]

Benefitting interns

The findings were in accordance with studies which gave evidence that outreach training provides students with valuable experience in a range of areas such as team working, confidence, holistic approach to treatment planning, and professional skills.[15],[16],[17],[18] The present study also reported that, through the outreach programs, the interns learn comprehensive patient care skills as in contrast to college where the specialized care is compartmentalized to different specialty departments. These findings were in accordance with the study by Bean et al. which showed that traditional school-based clinics remain vital for exposing students to certain treatment modalities, but community-based sites offered students' more experiences with more patients.[18]

Constraints

Limitations in providing services

The findings were in accordance with the study by Titley, who reported that the maintenance of mobile dental clinics and portable dental equipment has been very problematic due to the use of highly specialized equipment and limited access to technical and mechanical backup.[19] The findings that there were no specialists accompanying the interns at such places were similar to that reported in a study by Bazen et al., who stated that commonly perceived disadvantages of rural practice were the lack of specialist support and lower availability of equipment.[10] Transportation was an issue for some of the interns in the present study which was similar to that noted in a study by Johnson et al. in which the personal and financial cost of the placement was also important for students who reported being unhappy with additional traveling time and financial expense.[15]

Barriers in utilization of services provided through outreach programs

Community demands more of curative services in such programs rather than preventive services. Vashisth et al. also reported that the services provided in the outreach programs should be based on the felt needs of the population so that both attendance and the utilization of dental services can be increased, thereby improving the oral health status of the population.[20] Findings of the present study were supported by Kadaluru et al., who stated that community outreach programs provide an opportunity for investigating issues among groups of people who do not utilize dental services, which should help in understanding the barriers to access dental care in these populations.[21]

Attitude of interns

Toward community outreach programs

Similar findings were noted in studies by Thind et al. and Dharamsi et al., in which it was found that time spent in outreach rotations may be perceived as positive dental school experience and nurture a purposeful sense of social responsibility.[16],[22] The findings of the present study were in accordance with the study by Mofidi et al. where it was found that community outreach programs have influenced the interns to conduct such programs even after setting up their own private practices in future.[23] In the present study, interns expressed a variety of ways to contribute toward their social responsibility for underserved population. Community outreach programs motivated them to spread awareness about oral health among underserved population. None of the interns showed willingness to opt for postgraduation in Public Health Dentistry for serving the community. The probable factors reported for choosing a specialty were professional status, high income, better job options, interest in research in a particular branch, and family background.[24] The findings were, in contrast, to study by Piskorowski et al. which reported that CBDE, specifically more than 5 weeks may influence the likelihood that students will select community dental career paths as their first choice.[25]

Toward Dental Council of India rule of 3-month compulsory posting in Department of Public Health Dentistry

Compulsory rural posting may have an advantage of exposing the undergraduates to rural practice to help address the projected shortage of rural dental professionals.[10] However, it was seen that, though the interns valued the rule, hardly any of them were aware of the motive behind it.

Suggestions in improving community outreach programs

In the present study, there were suggestions by interns regarding regular evaluation and follow-up of the services provided through the outreach programs. Chances of patients visiting the dental college and hospital may be increased if free transport is arranged for them by the dental hospital and prior appointments are given during the time of referral itself. A similar finding was noted in a study by Ganesh et al. among interns of dental schools in Tamil Nadu, India, in which it was revealed that the quality of life in rural areas can be improved by conducting dental camps, running mobile dental clinics, and arrangement of transport facilities for people of rural areas.[26]

The findings of the present study should be generalized with care as the interpretation of qualitative data is inherently subjective. The participants have varying ability to reflect, express, and correlate their experiences. However, the study also did not consider the perception of interns toward underserved population before their exposure to community outreach programs.

Assessment of interns after completion of their 3-month posting showed that most of the interns were aware about the need for outreach programs in the community. Community outreach programs were perceived to be benefitting for the community as well as the interns outside the traditional dental school settings. Since most of the dentists prefer to practice in urban or financially stable areas, such programs can increase the exposure of dental students to underserved population and sensitize them toward their oral health needs. The assessment also provided challenges faced by the interns regarding infrastructure and equipment during such programs.

Limitations

The findings of the present study should be generalized with care as the interpretation of qualitative data is inherently subjective. The participants have varying ability to reflect, express, and correlate their experiences; the study also did not consider the perception of interns toward underserved population before their exposure to community outreach programs.

Recommendations

The study gave suggestions such as arrangement of transport facilities for patients and regular follow-up to refine the program. Given the lack of current state health department leadership in oral health and prevailing oral health disparities among diverse and vast population size, local community-based solutions and advocacy are crucial for improving the oral health of the public. Thus, dental profession must develop strategies to provide new graduates with professional and personal support to retain the rural dental workforce.

Further before and after studies can be conducted in these areas to assess the impact of community outreach programs on interns.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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