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Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 195-200

Assessment of trust in dentists using the dentist-trust scale in Belagavi City, Karnataka, India: A cross-sectional hospital-based study

1 Department of Public Health Dentistry, KAHER, Belagavi, Karnataka, India
2 Department of Public Health Dentistry, KCDSH, Bengaluru, Karnataka, India

Date of Submission02-Dec-2020
Date of Decision01-Feb-2021
Date of Acceptance14-Sep-2021
Date of Web Publication15-Oct-2021

Correspondence Address:
Barkha Shivkumar Tiwari
Department of Public Health Dentistry, KAHER, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_215_20

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Background: Trust is essential for a successful dentist–patient relationship. A higher trust is associated with a greater care-seeking behavior and greater adherence to the treatment regimens. Despite the importance of trust relationship of patients toward their dentist, the phenomenon is rarely studied in developing countries. Aim: The aim of the study was to determine the extent of patient's trust on dentist and to assess the factors affecting the dentist–patient trust relationship. Materials and Methods: A cross-sectional descriptive survey was carried among 397 patients visiting the outpatient department of a dental hospital in Belagavi city, Karnataka. Men and women aged above 18 years who have visited dentist at least once during the past 5 years were included in the study. A 11-item Dental Trust Scale (DTS) measuring trust in the dental profession was used. Descriptive statistics including mean scores were described for DTS. Exploratory Factor Analysis (EFA) using Principal Axis Factoring was used to explore the dimensionality of the DTS and associations between DTS mean scores and categorical variables were tested using Chi-square test. Results: The DTS had reliable internal consistency (Cronbach's alpha = 0.63) and EFA revealed a four-factor solution. Lower trust levels were associated with previously experienced pain, feeling like they were going to gag, fainting or embarrassment, and any personal problems with the dentist. Higher trust levels were associated with dentist last visited, people who visited dentist at least once a year and among higher SES. Conclusion: The majority of people appeared to exhibit trust in dentists generally.

Keywords: Dental experience, dental visiting, dentist trust, dentist–patient relationship, scale

How to cite this article:
Tiwari BS, Patil PA, Ankola AV, Kashyap BR. Assessment of trust in dentists using the dentist-trust scale in Belagavi City, Karnataka, India: A cross-sectional hospital-based study. J Indian Assoc Public Health Dent 2021;19:195-200

How to cite this URL:
Tiwari BS, Patil PA, Ankola AV, Kashyap BR. Assessment of trust in dentists using the dentist-trust scale in Belagavi City, Karnataka, India: A cross-sectional hospital-based study. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Dec 9];19:195-200. Available from: https://www.jiaphd.org/text.asp?2021/19/3/195/328275

  Introduction Top

Trust is a major driving force for all human relationships. It is defined as “an optimistic acceptance of vulnerability by the patient in the belief that the doctor will act with moral character and competence.”[1] The one-dimensional structure of trust as measured in the field of dentistry/medicine is often connected with five components which include fidelity, competence, honesty, confidentiality, and trust.[2] Furthermore, it is considered to be an integral part of respect for patient's autonomy.[3]

The patient's trust toward the dentist is directly connected with patient-reported satisfaction with their care. This would in turn determine whether the patient would retain or switch dentist or recommend a dentist to others. It is also one of the prime factors for treatment adherence.[4] Despite the importance of trust in the clinician–patient relationship, information focused on the trustworthiness of dentists in the literature is sparse.[2]

Several tools have been developed for the measurement of trust in health care. Some of these tools measure trust in physician and some in health system as a whole. All these tools have been developed and used in western developed countries, having high public investment in health care and low out-of-pocket health expenditure. Trust in health care in the low and middle-income countries like India is likely to be different wherein the availability and accessibility of health care is minimal and out-of-pocket expenditure is very high.[5] Furthermore, in these countries, the dentist–patient interaction is influenced by many factors such as social and cultural entities, diverse languages, customs, and religion.

A number of trust scales have been developed and used to assess trust in medical physicians such as “The General Trust in Physicians scale” which was developed by Hall et al.[6] This scale was recently modified by Armfield et al.[7] as “Dentist Trust Scale” to measure trust of dentist in Australian population. However, no studies assessing this scale are known to be reported in other developing countries and especially in India.[2]

Hence, the present study aims to determine the extent of patients' trust on dentists using the Dentist-Trust Scale (DTS) in a dental hospital-based setting in Belagavi city Karnataka, India, which would give an idea of the applicability of this scale for the nation and other similar developing countries.

  Materials and Methods Top

A cross-sectional descriptive survey was carried out among patients visiting the outpatient department of a dental college and hospital, Belagavi, Karnataka, India, in the month of January 2018. The patients attending the hospital come from both urban and rural areas. The ethical clearance was obtained from the Institutional Ethical Review Board. Patients were explained in detail about the study, and informed consent was obtained.

A pilot study was conducted, and the sample size was determined using G*Power software Version by assuming 80% power, 0.05 as alpha error, and medium effect size. The total sample size of 397 was determined in this manner.

Participants aged 18+ years, who have given written informed consent, not having any dental problem, have visited dentist at least once during the past 5 years were included in the study. Participants who never visited a dentist were excluded.

A 11-item DTS developed by Armfield et al.[7] measuring trust in the dental profession was used. Possible item responses were recorded on a 5-point Likert scale ranging from “Strongly disagree” (1) to “Strongly agree” (5), with higher scores indicating greater dentist trust.

A pilot study was conducted on ten subjects to check the validity and reliability for the questionnaire. The English questionnaire was translated to Kannada and Marathi by persons well versed in the respective languages. The Kannada and Marathi questionnaire was back translated to English by persons fluent in Kannada, Marathi, and English, respectively. The back translated English version was compared with the original questionnaire for grammar and comprehension. Demographic and socioeconomic status (SES) (According to Modified BG Prasad scale)[8] variables were age, gender, per capita monthly income, highest educational attainment, aversive dental experience, and visiting variables.

Trust in the dentist last visited was assessed using the question: “How much trust do you have in the last dentist visited?” with possible responses being “None at all,” “A little,” “A moderate amount,” and “A great deal.” This question allows for a comparison of trust in dentists generally, as obtained from the DTS, and trust in a specific dentist, the one last visited. Participants were also asked: “Have you ever changed dentists because you were unhappy with the care you received?” This question asks about an important potential outcome of poor trust that the patient changes their dental provider.

Patient's visit to the dentist was assessed by the question: “How frequently do you visit a dentist”? Delay or avoidance of visit was measured by the question: “Are you currently avoiding or delaying visiting the dentist?” Aversive dental experiences were measured by asking people if they had them, as a result of visiting the dentist, ever experienced: pain, discomfort, felt-like they were going to gag, fainting or felt light-headed, faced any embarrassment, or had any personal problems with the dentist during a dental visit. Response options were “Yes” or “No.” Current oral health problems were also assessed by asking the participants whether they currently experienced pain or discomfort in your teeth, gums or mouth, for which the possible responses were also either “Yes” or “No.”

Furthermore, in order to assess an overall trust in relation to medical profession in Indian population, they were asked: which medical profession do you trust the most? With options as “Medical Doctors,” “Dentist,” “Pharmacist,” and “nurses.”

The data were compiled using MS Office Excel, and the analyses were performed using statistical package SPSS for windows Version 20 (Chicago, IL, USA, SPSS Inc.). Descriptive statistics including mean scores were described for DTS. Internal consistency of the scale was tested using Cronbach's alpha and item intercorrelation was reported using Pearson r correlation coefficient. An Exploratory Factor Analysis (EFA) was used for dimension reduction and to find out the underlying structure of the variables where each factor was represented by a set of items (questions) in the DTS. Principal Axis Factoring was used to extract the least number of factors which can account for the common variance (correlation) of a set of variables. The factor model was then rotated for analysis. Associations between DTS mean scores and categorical variables related to demographic, socioeconomic, and visiting characteristics, as well as past dental experiences, were tested using Chi-square test.

  Results Top

The total number of respondents was 397 with the mean age of 39 years (49.12% males and 50.88% females). The response frequencies for DTS questionnaire are shown in [Table 1]. More than one-third of the respondents indicated the higher score, i.e. agree (4) and strongly agree (5). Means from the 11 items ranged from 3.18 to 4.33 which reflected the finding that the majority of respondents responded to the items with a score of 3 or higher, indicative of moderate to higher levels of trust. However, 23% of respondents had scores <3.0, indicating lower levels of trust.
Table 1: Descriptive statistics and frequency of individual items from the Dental Trust Scale

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The DTS had a reliable internal consistency (Cronbach's alpha = 0.63). The average measures intraclass correlation was 0.628 (95% CI: 0.57–0.68, P < 0.05). Item Pearson r correlation coefficients ranged from − 0.02 to 0.73 [Table 2]. An EFA using Principal Axis Factoring revealed a four-factor (components) solution [eigenvalue = 2.52, 22.9% of variance explained in the [[Supplementary Table 1] and [Supplementary Table 2] and [Supplementary Figure 1] provided].
Table 2: Correlations between each item of Dental Trust Scale

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Association of the responses of DTS scores was tested with the sociodemographic factors, visit to the dentist, and adverse outcome variables [Table 3]. The responses <3 (neutral) were considered to be low trust and more than 3 was considered to be higher trust. Number of responses with the neutral score 3 were equally divided into half and 50% was added to lower trust and the other 50% to higher trust values, in order to avoid under or overestimation in relation to the trust levels.
Table 3: Association between levels of trust with sociodemographic data, visiting pattern and previous experience with the dentist

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Following the Chi-square test, statistically significant associations (P < 0.05) were found for the variables, namely, SES, frequency of the dental visit and trust in the last dentist visited. Among them, those who belonged to the higher socioeconomic status and visited more frequently (within 6 months to a year) showed higher trust levels with their dentists. It was also noted that higher trust levels were exhibited by the respondents of 31–60-year age group. Referral from the family and friends ensured more trust in the dentist, when compared to advertisements. Factors such as previous painful experience, gagging, fainting, and any embarrassment that occurred during the visit to the dentist contributed to lower trust levels. However, during the end of the survey, out of 397 respondents, 169 (42.5%) of them showed higher trust levels toward their health professionals. Among these 169 participants, 103 (60.9%) of them indicted that the physicians were trust worthier than the dentists 56 (33.1%).

  Discussion Top

The dentist–patient relationship is a personal and productive partnership and any disturbance affects the quality and efficiency of care.[9],[10] As success in clinical practice is largely based on trust, it is an integral element of interpersonal relationship between individual dentist and their patient.[11] Besides the trust of individual patients, maintaining the public trust is also crucial for dentistry. The acknowledgment of the professional and ethical values of dentistry is important because they serve to maintain this trust.[12] Trust often corresponds with satisfaction, but the two are different concepts. Currently, patient satisfaction is widely used as a measure of quality of patient care. It is important to note that trust might be a better indicator as it has a strong emotional component, takes time and effort to build, and reflects a long-standing benchmark of dentist–patient relationship. Theoretically, the patient trust should serve to reinforce the functioning of clinical relationship, thereby increasing the probability of patient satisfaction.[13] Trust in dentist is a scarcely studied construct, especially in the setting of developing countries. This study looked at trust in dentist in a hospital-based setting in India. In this study, various factors associated with trust such as age, gender, SES, visiting variables, and past dental experiences were chosen, and the responses were categorized as having high or low trust. While most people indicated trust in dentists generally, about one-quarter of participants indicated a mid-point or neutral response to each item on the DTS. Less dentist trust was significantly associated with people of lower SES as individuals in this group suffer from psychological and social problems because of living in poverty, less access to dental care services, and delay to seek treatment based on high cost which further leads to complicated dental procedures influencing trust.[14] Furthermore, patients from resource poor settings, especially the marginalized communities, tend to be overwhelmed by sprawling hospital complexes and the maze of rooms, waiting areas in hospitals, and referral to several departments.[15] Whether lower trust plays a causal role in these associations is not determinable due to the cross-sectional nature of this study. On the contrary, higher SES group usually represents the people with better educational level, thus leading to a better comprehension, awareness level, and greater trust in the dentist.[16]

People with relatively less trust in dentists generally were significantly more likely to have previously experienced pain, feeling like they were going to gag, faint or embarrassment, or any personal problems with the dentist. It can be hypothesized that negative past experiences and practitioner behavior, might lead to reduced trust. This implies that interpersonal communication is more important in establishing dental trust than experiences associated with the treatment. Most of these findings were in accordance to the study done by Armfield et al.[7]

The current study was an institution-based study which assessed the immediate trust state that the patient had in the dentist in the context of illness. Further a community-based qualitative study will provide a better picture of the overall trust in health care, with particular reference to the dentist focusing on interpersonal skills of dentist and the relationship between dimensions of satisfaction and trust. The concept of trust is multifaceted and complex and its associations with other factors over time are currently poorly understood. Therefore, longitudinal studies will be required to know the causal associations. While the findings of the study are applicable to the sample population of this institution, very different findings might be apparent in other dental hospitals. The major limitation of this study was to determine the reasons behind why people might have changed dentists in the past, and how long ago such changes might have taken place. People can change their dentist for many reasons other than lack of trust or some other aspect of patient dissatisfaction which could not be assessed due to limitedness of the questionnaire used and study being cross-sectional in nature. In addition, the factors relevant to trust in dentists may vary in both type and extent from person to person, the nature, delivery, and funding of dental services. Nevertheless, the study gives a very important perspective of the need to explore the aspect of dentist–patient trust in the Indian population. The strength of this study is that it is, to our best knowledge, the first study to explore trust in dentist in the hospital-based setting in India. Research on trust is important in the developing country setting. There is increasing realization that health is a basic human right. Therefore, many developing countries are working on universal health access.[4] This health for all will be a reality only if trusting dentist–patient relationships are fostered. Therefore, there is a need to research trust and understand the dynamics of trust in dentist.

  Conclusion Top

The dentists scale used in this context has allowed for a much more detailed examination of the potentially important role of trust in significant dental outcomes, dental visiting patterns, and avoidance of the dentist. While most Indian adults surveyed indicated more agreement than disagreement with the various items of the trust scale, approximately one in five adults indicated a general lack of trust in dentists. However, validity of this needs to be explored in greater depth. More research is needed in order to better understand the basis for trust and distrust and its exact role in dental visiting behaviors. Furthermore, more number of qualitative studies intending to explore the various dimensions of patients' trust in dentist would highly help in developing a unique tool for the countries with poor resources in this regard.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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