ARTÍCULOS ORIGINALES
Social representat ions of dental treatment in a group of environmental health graduate students in Lima (Peru)
Elizabeth Pozos-Radillo1, Lourdes Preciado-Serrano1, Ana R. Plascencia1, Má Carrión-García2, María de los A. Aguilera1
1 Health Sciences Centre of the University of Guadalajara, Jalisco, Mexico.
2 Universitat Oberta Cataluya, Barcelona, Spain.
CORRESPONDENCE Dra. Elizabeth Pozos Radillo Paseo de los Virreyes 706 A-19 Virreyes Residencial, C.P. 45110 Zapopan, Jalisco, Mexico. E- mail: litaemx@yahoo.com.mx
ABSTRACT
Social representations are a type of common sense knowledge shared by different groups based on their experience. This study identified the social representations of dental practice in a group of environmental health graduate students in Lima, Peru. Method: We interviewed 25 graduate students using a "focus group" technique and a semi-structured guide. Three groups were formed with purposive sampling. The data were collected during the years 2010-2011, and analyzed using open, axial, selective coding with Atlas-Ti software. Results: Three substantive categories were identified: dental practice, characteristics of the dental care provider and dental practice setting. The social representations that the students identified with dental practice were fear and pain. Conclusions: The negative social representations of dental practice may affect viability and adherence to treatment, so it is important to identify them in time in order to intervene effectively.
Key words: Dentist-patient relationships; Social perception; Dentistry.
RESUMEN
La práctica odontológica y su representación social en un grupo de estudiantes de postgrado en salud ambiental de Lima (Peru)
Las representaciones sociales son un tipo de conocimiento de sentido comun que comparten diferentes grupos, basados en su experiencia. En este trabajo se identificaron las representaciones sociales de la practica odontologica en un grupo de estudiantes de postgrado en salud ambiental de Lima Peru. Se entrevistaron a 25 estudiantes de posgrado con la tecnica "focus group" y con una guia semi-estructurada. Se conformaron tres grupos con muestreo intencionado. Los datos se recolectaron durante los anos 2010-2011. La informacion se analizo con codificacion abierta, axial y selectiva mediante el software Atlas-ti. Se identificaron tres categorias sustantivas: practica dental, caracteristicas del profesional de odontologia y entorno de la practica dental. Las representaciones sociales que identificaron los estudiantes con la practica odontologica fueron miedo y dolor. Las representaciones sociales negativas de la practica odontologica pueden afectar la viabilidad y apego al tratamiento, por lo que es importante identificarlas oportunamente para intervenir con eficacia.
Palabras Clave: Relaciones dentista-paciente; Percepcion social; Odontologia.
INTRODUCTION
Oral diseases are a major public health concern due
to their high prevalence and incidence around the
world1. Even today, dental caries is the disease that
causes the greatest oral health problems in the
world. In the year 2000, the Ministry of Health of
Peru announced that "dental pathology" had the
third most frequent morbidity, was associated with
economic, sociocultural, environmental and behavioral
factors, and should be dealt with urgently2.
Dentistry works on the mouth, as a biological component,
and on the connections between somatic
individuality and environmental and social surroundings.
Evidence of early impact on oral morbidity
calls for a theoretical-practical discussion of
the traditional, highly prevalent approaches of current
dentistry3,4. Dental treatment as a social process
may be approached from the social representation
theory based on an epistemology of common sense
that brings meaning to everyday knowledge. This
knowledge is the fruit of social interactions based
on a mental perception of reality, which transforms
social objects in their context into symbolic categories.
Social representations thus work as a sys-
tem for interpreting reality that governs people's
relations with their physical and social surroundings
and determines their behavior or practices5.
From this standpoint, social representations (SR)
constitute cognitive systems in which we can recognize
stereotypes, opinions, beliefs, values and norms
that often lead to positive or negative feelings6. SRs
are constructed as systems of codes with values and
interpretations defining how men and women act in
the world, and are therefore a valuable tool for
explaining people's behavior in this study, which is
not limited to the particular circumstances of the
interaction but transcends to the cultural aspect and
the most widespread social structures. For example,
when people refer to social objects, they classify,
explain and assess them because they have constructed
a social representation of those objects.
Some studies on the SR of dental treatment have
established the importance of identifying beliefs,
myths, habits and behavior related to oral health7.
Some studies look at social representations of the
oral health-disease process in an underprivileged
urban population where different aesthetic, biological
and sometimes emotional aspects are involved8.
Other studies focus on the patient-dentist relationship
and the importance of communication9,10. Marin
et al. (2007) found that SR of dentists from the professional
practice perspective differed among participants:
the dentist considers anesthesia as the core,
while among patients, it is teeth for women and fear
for men11. Fear of pain is deemed one of the main
causes for refusing to seek dental health care8,12,
which according to the World Health Organization,
leads to high morbidity rates13,14.
This study contributes initial information, which
will surely be expanded on in future studies on different
groups of dental service users. No paper was
found in the literature review referring to the social
representations of healthcare graduate students and
dentistry, although there are studies on other kinds
of users and on the general population, most of
which focus on oral health, with very few focusing
on dental treatment. Thus, the aim of this study is
to identify the SRs held by a group of environmental
health graduate students from Lima, Peru.
MATERIALS AND METHODS
Population
The main inclusion criteria for participants in the
study were: to be a member of the professions, a
graduate student in environmental health, of legal
age and of either sex. Purposeful sampling was performed
based on two criteria: environmental health
graduate students who had had contact with dental
care and who studied at that time at the General
Environmental Health Directorate (DIGESA).
Twenty-five students were divided into three groups
(two groups of eight and one group of nine). Environmental
health students were chosen for the SR
study because due to the nature of their education
they had a more holistic view of the nature of health.
In addition to scientific knowledge and technical
skills, their training includes personal development
of a positive attitude that could be related to the
meaning of social representations in matters of
health.
Construct preparation
Information was gathered by using the "focus group"
technique, based on a collective semi-structured
interview of a heterogeneous group of students, during
which a participative, calm, friendly, relaxed
atmosphere prevailed. This enabled the participants
to express their opinions about, attitudes towards and
experiences with dental treatment openly.
A thematic interview guide was prepared to direct
the participants' conversation and personal disclosures,
including the subject of dental treatment. Two
assistants took notes at the sessions in order to record
behavioral information that would have been impossible
to obtain by means of audio recording only.
This study was made from a qualitative perspective
with the support of ethnographic techniques, in the
city of Lima, Peru in 2011.
Information was gathered from the interviews and
transcribed in its entirety into a text processor. Kernels
of meaning that came up during the communication
and terms of presence or frequency that were
meaningful for the analysis of the objective were
identified. In qualitative terms, the presence of certain
themes, and the behavioral models present in
the discourse were reflected by frequency values.
This enabled us to isolate patterns and processes of
common and different factors and take them to the
field in the following data-gathering stage, in a new
interview of another focus group. The interviews
were considered complete once the subject was
exhausted. The interview was conducted at the
DIGESA auditorium and lasted approximately two
hours per group.
Data analysis
The analysis strategy involved formulating and sifting
inferences and distinctions from the data as well
as identifying the major meanings in order to codify
the information into thematic categories.
The analysis process took place in two stages. The
first was the descriptive distinction (descriptive
aspects) where abstract codes were created based
on particular meanings that allowed us to learn the
dominant conceptualization of the social representations
of dental treatment and that are included in
the results.
The second stage used relational discrimination
(explanatory aspects) where relationships or connections
found in the descriptive results were established.
They will be presented in the discussion by
means of an open codification with a "line-by-line"
examination of the gathered data as well as data that
produced questions and reflections, the category
grouping and lastly selective axial15 coding until a
polished category structure was obtained and saturation
and integration were achieved. Coding and
information analysis were done with ATLAS.ti version
2.4 software.
Participants were sent personalized invitations
which included an explanation of the aims of the
study, and any questions they had were answered.
Each person was asked to specify an interview session
schedule and confirmation, which enabled us
to form groups within a minimal period of a week.
Ethical considerations
The interviews were conducted with the participants'
informed consent; the protocol was reviewed and
approved under number IISO/CI/18/08 as provided
by the 2008 Declaration of Helsinki on Ethical Principles
for Research Involving Human Subjects.
RESULTS
Three substantive areas were identified under different
categories during the distinction stage when
we looked for kernels of meaning making up the
communication and whose presence was meaningful
for the description of the social representation
about how dental treatment is understood: 1) dental
care; 2) dentists' professional demeanor; and 3)
dental practice setting. The categories were fear of
pain, economics/cost, poor attitude in the dentist,
poor dentist-patient communication, and hygiene
and annoying instruments.
This paper includes the most important results,
obtained by means of an open coding procedure,
which underscore some of the identity, performance
and understanding traits of dental treatment based
on the comments of graduate students in environmental
health.
The representations of dental treatment that they
hold and which are determinant for their day-to-day
actions with regard to dentistry are reflected by the
following statements:
1. Substantive area of dental care
"It is very important to take care of your teeth
and receive continuous dental care."
"I feel mistrustful and uncertain about dental
care when I hear other people's bad opinions
about deficient interventions and poor handling
of dental instruments."
- Connection between fear and pain as causes associated
with lack of dental care
"Dental care scares me because I think dental
treatment will hurt. I only see a dentist when I
have to, especially when I have a toothache. I
consider it a necessary evil."
"I don't go to the dentist because I'm afraid of
pain. I've always believed it's going to hurt a lot,
and that scares me and makes me feel anxiety."
- Economics/Cost as an important factor for not seeing
a dentist.
"I think dental care is quite expensive and treatments
are unaffordable. I think it is a highly
lucrative profession."
"I don't go for dental care because I don't earn
much and I can't afford dental treatment,"
Fear of pain and the high cost of dental treatment are recurrent themes in the participants' SR of dental treatment in the substantive area of dental care. These feelings lead the interviewees to refuse to seek dental and oral healthcare, preferring to avoid it and escape from what they consider a threat, even though they believe that maintaining good dental health is important.
2. Substantive area of dentists' professional
demeanor
- Aspects related to a poor patient-dentist relationship
due to poor communication.
"The dentist doesn't have a good attitude because
he has no patience and doesn't take enough time
to attend to his patients."
"I don't think there is good communication
between dentists and their patients because I
feel they don't explain the dental procedures
they're performing and their effects."
This substantive area of dentists' professional demeanor reveals the main SR surrounding the patient-dentist relationship. It highlights the need to implement individual and social strategies, to learn about bio-psycho-social alterations, the characteristics of dental patients and their management, and endeavor to improve interpersonal relations in the patient-dentist experience. Interpersonal relationships are needed to cope with the demands of a reality subject to permanent changes. A person's attitude towards a dentist may be influenced and conditioned by this reality and the dental treatments he or she has undergone. During dental treatment, patients come into contact with the dentist, assess his/her behavior and at the same time form an opinion about him/her; feelings emerge that influence the kind of relationship that will be established.
3. Substantive area of dentistry setting
- Postures regarding dental hygiene
"The dentist's office should be clean and tidy,
and disposable material should be discarded
between one patient and the next."
"There shouldn't be any kind of animals in a
dentist office for hygiene reasons."
- Important equipment and instrument aspects that
annoy patients during dental treatment
"I don't like the noise made by the equipment,
especially the handpiece."
"I dislike the lighting very much, especially
when it's in your face to light up your mouth
directly, and then to feel the water splashing
from your mouth when instruments are being
used inside it."
The above factors occasionally produce negative attitudes of mistrust and anxiety in patients, leading to fear, scant motivation, dissatisfaction and poor dentist- patient interaction. These situations should be analyzed from different perspectives in order to understand patients' demands, limitations and wishes and thus take action to adapt as much as possible to the situation and its possibilities, fostering changes both in what annoys patients and in patients' attitudes and behavior. The results of this research show that the most dominant SR is fear of pain, followed by the expensive treatment, poor dentist attitude, poor communication, hygiene and annoying dental equipment. This suggests that dentistry has developed a disturbing scientific-technical reference about the purpose of its work and about itself, without producing social and epidemiological impact on oral health and disease. Individual SRs are distanced from or contrary to the theoretical-practical principles underlying dentistry because patients perceive the atmosphere of the dental practice as the least appropriate place for the work done by dentists.
DISCUSSION
The main SR in this group of environmental health
graduate students regarding dental treatment was
fear of pain. Fear of dental procedures is common
because it has an impact on them and their quality
of life. The appearance of extreme dental fear (dental
phobia) leads to high levels of anxiety and progressive
avoidance behavior in those suffering from
it, with situations such as putting off making a dental
appointment, avoiding periodic checkups, displaying
behavior during the visit such as closing
their mouth, leaning their head away, standing up,
slapping the dentist's hand, screaming, complaining
or crying, all of which create a problem for dentists
to work. It also induces the patient to abandon preventive
habits. The patient will only visit a dentist
when he has extreme pain or dental problems16,17.
Newton4 claims that the most frequent triggers for
fear of dental work are seeing the syringe, the anesthesia
injection, and hearing the sound of the handpiece.
The most feared interventions are tooth
extractions and root canal. These emotions of fear
may have been acquired in the social environment,
particularly at home. They lead people to believe that
they should only go to the dentist when there is pain
or a serious problem. This representation is shared
by people who believe that regular visits are not
important for maintaining oral health, but rather that
they are "a waste of time and money". Most of the
people who hold these beliefs also complain about
the excessive cost of dental treatment10,11,13,18,19.
Other substantive areas present in the study population's
SR were expense, poor dentist-patient relationship, and
poor setting for practicing dentistry. These images held
by the participants condition their behavior, which in
this case may be refusal to seek dental care.
We need to recognize and differentiate contradictory
feelings that produce negative attitudes, determine
whether they are human creations due to mistaken
ideas, thoughts or beliefs, possibly acquired either
during their upbringing at home or due to negative
experiences they have undergone or heard about
related to dental procedures.
One of the most highly valued practical aspects in a
dentist's office is hygiene, which involves the personnel,
procedures and work systems. Any negligence
in this area could cause cross-infection defined
as the transmission of contagious agents between
patients and dental care providers or vice versa20-22 because the everyday work of dental care providers
involves physical contact with blood and saliva in a
septic environment..
A negative setting may be the outcome of an accumulation
of several factors such as mistrust, deficient
communication, and inadequate resources and
work environment, as found in the SR of these participants.
The idea that dental work is expensive and annoying
is based on real perception. Constant technological
developments mean that dental equipment and
instruments have to be renewed frequently, requiring
constant investments to prevent them from
falling behind and becoming obsolete. This makes
dental treatment more expensive. Some people,
especially the underprivileged, have limited access
to dental care, and the cost of dental care is a topic
that lends itself to great controversy and confusion.
The underlying causes of expensive dental care
should be studied. Some of these causes are expensive
equipment and materials, and the lack of prevention
of oral and dental problems. The avoidance
of at least a yearly dental checkup makes treatment
more complicated and increases costs. When patients
visit a dentist for an emergency or in the presence of
pain, the situations are more complex and thus more
expensive to resolve23,24. Scientific and technical
breakthroughs have not made dental care more
affordable and less bothersome, nor have they created
a pleasant, comfortable environment for patients
during treatment25,26.
Dentistry is a profession that produces sensations
of anxiety, fear, pain and discomfort in patients27.
Cortes28 claims that dentists seem to care more
about the organism than the body, the sign than the
symptom, the individual than the subject. There is
no possibility of establishing an intersubjective
encounter that would enable the body to speak
based on its symptoms, where the subject is represented
during dental treatment. During clinical
treatment, the dentist asks the patient to open his
mouth but not to talk. He only wants to hear information
related to the disease, not the history of the
person suffering from it. His attention is not focused
on the body that suffers but on the painful organism
and he becomes engaged in work resulting in biological-
mechanical reductionism.
This leads to the perception of dentists as unfeeling
and cold towards their patients during dental procedures.
Cancado29 claims that the success of a dental
practice depends on the dentist's skill in winning over
his patients. Another study suggests implementing
communication strategies: listen more and talk less.
Begin with topics brought up by the patients because
they are important to them, and implement strategies
to improve dentist-patient communication30.
One cause of poor dentist-patient relationships is
that dentists are exposed to physical and psychological
fatigue in addition to work-related, social
and personal circumstances, which affect them
more than they do other healthcare providers. This
may result in personality changes and mood swings
and in extreme situations the "hateful dentist syndrome",
causing negative feelings in patients, who
react defensively, and inevitably contaminating the
dentist-patient relationship and leading to rupture31.
Previous studies on social representations of oral
health8,32 have discovered that oral health and disease
are influenced by culture, employment, poverty,
aesthetics and emotions. Alzate33 and Romero34 claim that social representations of the mouth and
hygiene are deeply rooted in tradition and that very
little is done to promote nourishment although it is
recognized as a part of general health. Similarities
among these studies lie in the social representations
related to emotions (fear of pain) and poverty (economics).
The differences between them and our
study could be explained by the fact that they were
undertaken with different focuses and populations
and deal with different situations such as satisfaction,
aesthetics, the relationship with discourse and
institutional practices8,34-36.
CONCLUSION
This study concluded that fear of pain, costly treatment,
dentists' poor attitude, poor communication,
hygiene and annoying dental equipment make up
the social representations of the cognitive system in
environmental health graduate students. They were
discerned within an explanatory framework of opinions
and beliefs that marked their behavior.
We should note that although the formal education,
social status and economic resources of the participants
in our study differed from those in the abovementioned
studies, the same SR of fear of pain prevails
in both kinds of populations. This shows how difficult
it is to modify this SR and indicates that professional
education, even in the field of health, does not alter
the SR of dental treatment, so that the perception is
the same in professionals andh other populations.
New strategies should therefore be devised to identify
the origin of this SR, in order to intervene effectively
and change it. This would encourage patients
to seek dental care, thereby improving the oral
health of the general population.
ACKNOWLEDGEMENTS
This study was possible thanks to the participation of the General Directorate of Environmental Health Digesa. (Lima, Peru). The authors are grateful to all participants in the study.
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