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J Dent Res 83(12):961-965, 2004
© 2004 International and American Associations for Dental Research

RESEARCH REPORTS
Clinical

Information and Participation Preferences of Dental Patients

B.C. Schouten1,*, M.A.J. Eijkman2, and J. Hoogstraten2,3

1 Utrecht University, Department of Interdisciplinary Social Sciences, Heidelberglaan 2, Postbox 80140, 3508 TC Utrecht, The Netherlands;
2 Academic Centre of Dentistry Amsterdam, Department of Social Dentistry, Louwesweg 1, 1066 EA, Amsterdam, The Netherlands; and
3 University of Amsterdam, Department of Psychological Methods, Amsterdam, The Netherlands;

* corresponding author, b.c.schouten{at}fss.uu.nl


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS & METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Dutch dentists have a moral and legal obligation to inform their patients and involve them in the decision-making process. It is unclear, though, to what extent patients prefer information and involvement in decision-making. Therefore, the aim of this study was to determine levels of preference for information and participation in decision-making among emergency patients (n = 96) and regular patients (n = 245). It was hypothesized that female gender, higher education, younger age, and a monitoring coping style are positively associated with higher preferences for information and participation. The results demonstrated that emergency and regular patients have high preferences for information, but that their preferences for actual involvement are significantly lower. Only weak associations were found between the antecedent variables and patients’ preferences. It is concluded that, in the study of the etiology of patients’ preferences for information and participation, future research should incorporate factors such as dental anxiety and seriousness of the dental condition.

KEY WORDS: decision-making • need for information • informed consent • patient autonomy • social dentistry


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS & METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Although several studies have demonstrated that many patients desire considerable information about their condition (Waitzkin, 1985; Blanchard et al., 1988; Ende et al., 1989; Sutherland et al., 1989; Beisecker and Beisecker, 1990; Fallowfield et al., 1995; Nease and Brooks, 1995; Davis et al., 1999), the results regarding patients’ desire to participate in dental decision-making are not that clear-cut. Only a few studies have been carried out assessing dental patients’ need for information. These studies indicated that dental patients desire detailed information on a variety of dental topics, and that they are not always satisfied with the amount of information they receive from their dentist (Eijkman et al., 1984; Harych and Völkel, 1990; Adekoya-Sofowora et al., 1996).

Deber (1994) has argued that many studies in this research domain have confused two dimensions of choice, which she terms ‘decision-making’ and ‘problem-solving’. She defines problem-solving as identifying the correct solution to a problem, whereas decision-making involves making a choice between several alternatives. Because problem-solving tasks require medical expertise and knowledge, patients seldom will be involved in this phase. On the other hand, the ultimate choice of action to be taken lies in the hands of the patient, because values and preferences of patients determine which decision will be taken. Confirmation for Deber’s hypotheses comes from a study in which patients undergoing an angiogram indicated that they wished to be involved in decision-making tasks as opposed to problem-solving tasks (Deber et al., 1996). Therefore, one of the aims of this study is to determine dental patients’ need for involvement in problem-solving as well as decision-making tasks.

Another aspect complicating conclusions regarding patients’ need for information and their desire for participation in decision-making tasks is the influence of patients’ personality and demographic characteristics. Older age, lower education, and male gender are more likely to be associated with less need for information and participation. Moreover, these groups of patients tend to search for and receive less information and involvement in the decision-making process (Waitzkin, 1985; Ende et al., 1989; Weisman and Teitelbaum, 1989; Beisecker and Beisecker, 1990; Degner and Sloan, 1992; Fallowfield et al., 1995; Nease and Brooks, 1995; Street et al., 1995; Deber et al., 1996; Turk-Charles et al., 1997; Davis et al., 1999). A personality trait much studied in the present context is patients’ coping style—that is, the tendency either to seek information about potentially threatening situations (monitoring) or to distract oneself and avoid information (blunting). The Threatening Medical Situations Inventory (TMSI) does assess patients’ coping style within the domain of threatening medical situations (Miller, 1987). In a study on cancer patients’ coping styles, it was found that a monitoring coping style was positively correlated with a preference for detailed information and participation in medical decision-making (Ong et al., 1999).

The main purpose of this study was to determine levels of preference for information and participation in dental decision-making among emergency dental patients and the intermediate effect of patients’ coping style and demographics. To enhance the generalizability of the results, we decided to replicate this study among regular dental patients. In line with previous research, we hypothesized that female gender, higher education, younger age, and a monitoring coping style are positively associated with higher preferences for information and participation in dental decision-making. Furthermore, we hypothesized that patients’ desire for participation in general will be lower than their desire for information, but that patients do prefer involvement in decision-making tasks as opposed to involvement in problem-solving tasks. No differences with regard to these preferences between emergency and regular dental patients were expected.


   MATERIALS & METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS & METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
The survey among emergency patients was conducted in 13 Dutch dental private or group practices. Mean age of the 13 participating dentists was 45.4 yrs (SD, 5.2; range, 38–60 yrs), they had been practicing dentistry for, on average, 19.0 yrs (range, 8–34 yrs), and worked an average of 32.9 hrs per wk (range, 23–45 hrs). The mean number of patients visiting them at least once a year was 1903. Seven dentists had completed post-graduate courses on dentist-patient communication.

To be enrolled in the study, patients had to be older than 16 yrs, and had to be able to speak and read the Dutch language. When these criteria were met, patients visiting the dentist for emergency treatment were recruited, in the waiting room before undergoing treatment, to participate in the study. All patients signed consent forms indicating their willingness to participate and their understanding of the procedure and general aim of the study. After the consultation, patients were given a questionnaire to take home and return, completed, within 2 wks.

The second survey was carried out in five of the same dental practices from the first survey. Each practice received 100 questionnaires. The dental assistant or receptionist was instructed to administer these questionnaires to their patients over the course of 1 wk. Regular patients who were visiting their dentist for treatment or routine check-up were asked to complete the questionnaire after treatment. The mean age of these five dentists was 47.2 yrs (SD, 5.1; range, 38–51 yrs), they had practiced dentistry for, on average, 20.1 yrs (range, 8–26 yrs), and worked an average of 36.1 hrs per wk (range, 32–45 hrs). The mean number of patients visiting these dentists at least once a yr was 2309. Three dentists had taken or were taking post-graduate courses on dentist-patient communication. The sampling methods and procedures were reviewed and approved by the Netherlands Institute for Dental Sciences (IOT).

Questionnaires
The questionnaire included the following scales: the Threatening Medical Situations Inventory (TMSI; Miller, 1987), the subscale ‘Information’ of the Krantz’ Health Opinion Survey (HOS; Krantz et al., 1980), and the subscale ‘Information-seeking preference’ of the Autonomy Preference Index (API; Ende et al., 1989), part of the subscale ‘Decision-making preference’ of the API and the Deber-Kraetschmer Problem-Solving Decision-Making scale (PSDM; Deber et al., 1996). The reason for the use of these scales was two-fold. First, within dentistry, no instruments are available to measure these variables. Second, these questionnaires are among the most widely used instruments for the assessment of information-seeking and decision-making preferences of patients, thereby enhancing the possibility for results to be compared among studies. Furthermore, the PSDM scale is the sole available instrument which makes a distinction between problem-solving and decision-making tasks within the decision-making process.

The TMSI consists of four scenarios of threatening medical situations, followed by three monitoring and three blunting alternatives. Each of the alternatives must be answered on a five-point Likert scale, ranging from 1 (‘not at all applicable to me’) to 5 (‘strongly applicable to me’). Total monitoring and blunting scores are obtained by adding the relevant items (range for both scales, 12–60).

The subscale ‘Information’ of the HOS consists of seven items. Responses are rated in a binary, agree-disagree format. The reported reliability of the subscale is good (Kuder-Richardson reliability around 0.75 [Krantz et al., 1980]). The subscale ‘Information-seeking preference’ of the API includes eight items. Response choices range from 1 (‘strongly disagree’) to 5 (‘strongly agree’). Total scores are linearly adjusted to range from 0 to 100. The reported test/re-test reliability is 0.83; the internal consistency coefficient (Cronbach’s alpha) is 0.82 (Ende et al., 1989).

Five items from the ‘Decision-making preference’ subscale of the API were used in this study. Total scores were obtained in the same way as with the ‘Information-seeking preference’ subscale. The PSDM scale contains two vignettes, followed by six series of tasks, four of them relating to problem-solving activities, and two relating to decision-making activities. Respondents are asked to indicate, on a five-point scale, who should decide for each task: 1, the dentist alone; 2, mostly the dentist; 3, both equally; 4, mostly me; or 5, me alone. Reported internal consistency of the scales is satisfactory (Cronbach’s alpha > 0.70) (Deber et al., 1996). For the purpose of the present study, the following vignettes were used: (1) "Suppose you had mild tooth pain for some days during toothbrushing. Besides that, the tooth doesn’t trouble you. You decide to visit your dentist about this"; and (2) "Suppose that, for the last couple of days, one of your teeth is becoming increasingly looser. You decide to visit your dentist about this". The first vignette corresponds with a relatively minor dental problem, most probably followed by non-invasive treatment. The second vignette corresponds with a more serious dental problem, which is likely to be followed by a more invasive treatment. Data analysis included correlation coefficients, t tests, ANOVAs, and reliability tests.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS & METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 96 emergency patients participated in the study. Of the 119 patients asked to participate in the study, 10 patients refused, and 13 initially agreed but failed to return the post-appointment questionnaire. With regard to the regular patient sample, a total of 245 patients participated, which corresponds approximately with the number of questionnaires distributed. (According to the participating dentists, almost no patients refused to complete the questionnaire when asked.) Regular and emergency dental patients did not differ significantly on demographics such as age, gender, and educational background.

Desire for Information and Participation
The internal consistencies of the scales are—with the exception of the API ‘Decision-making’ (range, Cronbach’s alpha, 49–57) and HOS ‘Information’ scales (range, KR20, 61–65)—in the moderate to high range (range, Cronbach’s alpha, 73–87).

Table 1Go presents the demographics of both samples as well as mean test scores and standard deviations on the HOS, API, and Deber-Kraetschmer scales (differences in sample size are due to missing values).


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  		Table 1. Patient Demographics and Mean Test Scores
 
No differences in scores on the five subscales were found as a function of gender, or, among emergency patients, as a function of being in pain. Among emergency patients, no differences were found on these scales between patients who were treated by a dentist who had taken post-graduate courses on dentist-patient communication, and patients who were treated by a dentist who did not. With respect to regular patients, patients treated by a dentist who did pursue post-graduate courses on dentist-patient communication scored significantly lower on the HOS-scale (p = 0.003) and significantly higher on the API ‘Decision-making preference’ subscale (p = 0.03). Among both samples, significant differences were found on the HOS and the Deber-Kraetschmer decision-making scale as a function of patients’ education. With regard to emergency patients, scores on the HOS were significantly higher among patients with higher education than among patients with intermediate levels of education (p = 0.04) or among patients with lower levels of education (p = 0.002). The reverse pattern of results was found among regular patients. Regular patients with lower levels of education scored significantly higher on the HOS than either patients with intermediate levels of education (p = 0.05) or patients with higher levels of education (p = 0.001). In the emergency patient sample (p = 0.001) and in the regular patient sample (p = 0.03), scores on the Deber-Kraetschmer decision-making scale were significantly higher among more highly educated patients compared with patients with less education.

The API and HOS information subscales scores were not correlated, and scores on the API subscale were significantly higher than those on the HOS subscale (scores on the HOS scale were adjusted to API scores) (paired-samples t test; p < 0.001). Scores on the API ‘Decision-making’ subscale were significantly lower than patients’ scores on the API ‘Information-seeking preference’ subscale (paired-samples t test; p < 0.001). Spearman rho correlations between the various information and decision-making measures are shown in Table 2Go.


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  		Table 2. Spearman Rho Correlations between Information and Decision-making Measures
 
All Deber-Kraetschmer PS scores were significantly higher than Deber-Kraetschmer DM scores (p < 0.001). For both samples, scores on the problem-solving task ‘treatment options’ were significantly higher for vignette 1 than for vignette 2 (paired-samples t test; p = 0.003 and p = 0.003, respectively), and for emergency patients, the mean score on the problem-solving task ‘diagnosis’ was higher for vignette 1 than for vignette 2 (p = 0.003). Frequencies of the scores on the PSDM scale are shown in Table 3Go.


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  		Table 3. Distribution of PSDM Scale Scores
 
Relationship of Patients’ Demographic Variables and Coping Style to Subscale Scores
Table 4Go shows the results of the univariate analyses of patients’ coping style, their age, and education on each of the five subscale scores. As can be seen from this Table, results are not consistent across the two patient samples. Most correlations are weak and do not reach significance.


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  		Table 4. Correlations of Patient Variables with Desire for Information and Participation
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS & METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of the present study demonstrate that regular as well as emergency dental patients have high preferences for information, a finding consistent with the results of other studies among different patient samples (e.g., Fallowfield et al., 1995; Nease and Brooks, 1995; Davis et al., 1999). Among both samples, patients’ scores on the HOS information subscale were substantially lower than their responses on the API ‘Information-seeking preference’ scale. Both instruments are regularly used in research on patients’ information preferences, but the validity of the HOS scale in assessing patients’ desire for information is questionable. According to Nease and Brooks (1995), the HOS does focus on past behaviors of the patient to obtain information, and not as much on the patient’s desire for information. Moreover, three items of the HOS scale are strongly related to decision-making tasks. Hence, the HOS scale may actually measure patients’ information-seeking behaviors instead of their desire for information. Moreover, this diversity in the HOS items may result in relatively low internal consistency, which was indeed the case in the present study.

The second question this study addressed was the extent to which dental patients wished to be involved in decisions concerning their own care. The results of this study clearly indicate that patients’ preferences for involvement are lower than their wish to be informed. However, when problem-solving tasks are distinguished from decision-making tasks, another picture emerges. It is clear that patients do wish to be involved in decision-making tasks. In general, though, they do think that the dentist should be responsible for problem-solving tasks. Thus, if a true partnership between practitioner and patient is to be reached, it is necessary that both medical expertise and patient values be integrated into the decision-making process.

Only weak associations were found between the antecedent variables and patients’ preferences for information and participation. Moreover, results were not consistent among the two samples. Whereas the associations were in the expected direction among emergency patients, this was not the case for the regular patient sample. In particular, correlations between some antecedent variables and HOS scores were the opposite of what was expected and what is found in the literature. However, correlations were generally quite weak, and possible problems with the validity and internal consistency of the HOS scale make it difficult for these results to be explained. It should be noted, however, that other studies also failed to find strong associations between patients’ characteristics and their need for information and participation in medical decision-making. It is possible that situational factors—such as previous health care experiences of patients and the seriousness of the dental condition—are at least as important in determining patients’ preferences and should be taken into account in future studies. Another factor which could be an important predictor is patients’ anxiety during the dental treatment. Therefore, future research should incorporate these factors into any study of the etiology of patients’ preferences for information and participation. In the meantime, explicitly asking patients about their preferences for information and involvement in decision-making remains the best clinical approach—not only because Dutch dentists have a moral obligation, rooted in the principle of patient autonomy, to inform their patients and involve them in their own dental care, but also because they have a legal obligation to obtain the patients’ informed consent to treatment. Even more important, it is crucial, for the enhancement of patient satisfaction and compliance, that dentists inform their patients and involve them in their own dental care.


   ACKNOWLEDGMENTS
 
This study was supported by funds from the Netherlands Institute for Dental Sciences (IOT).

Received May 26, 2004; Last revision August 4, 2004; Accepted September 7, 2004


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS & METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Adekoya-Sofowora CA, Lee GTR, Humphris GM (1996). Needs for dental information of adolescents from an inner city area of Liverpool. Br Dent J 180:339–343.[Medline]

Beisecker AE, Beisecker TD (1990). Patient information-seeking behaviors when communicating with doctors. Med Care 28:19–28.[ISI][Medline]

Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB (1988). Information and decision-making preferences of hospitalized adult cancer patients. Soc Sci Med 27:1139–1145.

Davis MA, Hoffman JR, Hsu J (1999). Impact of patient acuity on preference for information and autonomy in decision making. Acad Emerg Med 6:781–785.[ISI][Medline]

Deber RB (1994). Physicians in health care management: 8. The patient-physician partnership: decision making, problem solving and the desire to participate. Can Med Assoc J 151:423–427.[Abstract]

Deber RB, Kraetschmer N, Irvine J (1996). What role do patients wish to play in treatment decision making? Arch Intern Med 156:1414–1420.[Abstract]

Degner LF, Sloan JA (1992). Decision making during serious illness: what role do patients really want to play? J Clin Epidemiol 45:941–950.[ISI][Medline]

Eijkman MAJ, van Riel CBM, van Dijk RJ (1984). 873 questions of Dutch dental patients: a challenge to dental health education. Community Dent Oral Epidemiol 12:308–314.[Medline]

Ende J, Kazis L, Ash A, Moskowitz MA (1989). Measuring patients’ desire for autonomy: decision making and information-seeking preferences among medical patients. J Gen Intern Med 4:23–30.[ISI][Medline]

Fallowfield L, Ford S, Lewis S (1995). No news is not good news: information preferences of patients with cancer. PsychoOncology 4:197–202.[Medline]

Harych I, Völkel J (1990). Kommunikation zwischen zahnarzt und patient. Stomatology 40:313–315.

Krantz DS, Baum A, Wideman M (1980). Assessment of preferences for self-treatment and information in health care. J Pers Soc Psychol 39:977–990.[ISI][Medline]

Miller SM (1987). Monitoring and blunting: validation of a questionnaire to assess styles of information seeking under threat. J Pers Soc Psychol 52:345–353.[ISI][Medline]

Nease RF, Brooks WB (1995). Patient desire for information and decision making in health care decisions: the autonomy preference index and the health opinion survey. J Gen Intern Med 10:593–600.[ISI][Medline]

Ong LML, Visser MRM, v. Zuuren FJ, Rietbroek RC, Lammes FB, de Haes JCJM (1999). Cancer patients’ coping styles and doctor-patient communication. PsychoOncology 8:155–166.[Medline]

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Sutherland HJ, Llewellyn-Thomas HA, Lockwood GA, Tritchler DL, Till JE (1989). Cancer patients: their desire for information and participation in treatment decisions. J R Soc Med 82:260–263.[Abstract]

Turk-Charles S, Meyerowitz BE, Gatz M (1997). Age differences in information-seeking among cancer patients. Int J Aging Hum Dev 45:85–98.[ISI][Medline]

Waitzkin H (1985). Information giving in medical care. J Health Soc Behav 26:81–101.[ISI][Medline]

Weisman CS, Teitelbaum MA (1989). Women and health care communication. Patient Educ Couns 13:183–199.[ISI][Medline]




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