Impact of fees on access to dental care: evidence from France.

BACKGROUND: For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. METHODS: Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. RESULTS: Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35; P value = 0.024; 95% CI 1.04-1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. CONCLUSIONS: The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform.

Translation and validation of the French version of the Child Perceptions Questionnaire for children aged from 8 to 10 years old (CPQ 8-10).

BACKGROUND: The Child Perceptions Questionnaire (CPQ) belongs to a set of questionnaires measuring Child Oral Health Quality of Life (COHQOL). The CPQ is used to collect the perceptions of children on the impact of oral diseases on their quality of life. This cross-sectional study was aimed to translate the CPQ8-10 into French language and evaluate its psychometric properties. METHODS: The translation process complied with international recommendations. The final French version was tested on children aged 8-10 years old attending consultations in a Parisian public hospital and divided into three groups: children with oral-facial clefts, children with dental anomalies linked to a rare disease other than clefts and children presumed to be healthy and without anomalies. The internal consistency relating to the reliability of CPQ8-10 was evaluated by Cronbach's alpha. The intra-class correlation was used to measure reproducibility at the test-retest level. Construct validity was evaluated by Spearman's correlation and tested using factor analysis. The discriminant validity was assessed using Kruskall Wallis test. Criterion validity was calculated using Spearman's correlation. RESULTS: One hundred seventy-six children participated in this study. During the translation process, minor changes were made. The French version showed good reliability with a Cronbach's alpha of 0.81 for the total scale. The ICC of the test-retest was excellent (=0.90) demonstrating good reproducibility. The construct validity was acceptable with a statistically significant correlation between the scores of the French-CPQ8-10 and the evaluation of oral health (r = 0. 381 and p < 0.001) and its impact on oral health quality of life (r = 0.363 and p < 0.001). The loading weights obtained in the Exploratory Factor Analysis showed that this model revealed seven factors with eigenvalue greater than 1, explaining the 63,89% of the cumulative variance. The differences observed between the scores of the study groups revealed good discriminant validity. Criterion validity was supported by significant association between CPQ scores and pain. CONCLUSION: The French-CPQ8-10 is reliable and valid for use with the children of this age group.

Parental-Caregivers Perceptions Questionnaire (P-CPQ): translation and evaluation of psychometric properties of the French version of the questionnaire.

BACKGROUND: The Parental-Caregivers Perceptions Questionnaire (P-CPQ) is a measure of parental/caregivers' perceptions of the impact of children's oral health on quality of life. The aim of the study was evaluate the psychometric properties of the French version of the P-CPQ. METHOD: The original P-CPQ was developed in English language and has 31 items divided into four sub-scales. This cross-sectional study used the translation-back translation method. The translated questionnaire was pretested on 14 parents-caregivers to obtain the final French version. The psychometric properties were tested on 142 parents/caregivers of three clinical groups of children from 8 to 10 years old without dental/facial anomalies (presumed healthy), with oral-facial clefts and with oral-dental anomalies linked to a rare disease other than cleft, approached in the waiting room of the Centre of the Hospital Rothschild in Paris, France, where the children attended treatment. Internal consistency was assessed by Cronbach's alpha and test-retest reliability by Intra-class Correlation Coefficient (ICC). Construct validity was measured by correlations between the total scores and the global ratings of oral health and overall wellbeing, and tested using exploratory factor analysis (EFA) and the factorial structure was evaluated by the partial confirmatory factor analysis (PCFA). Discriminant validity was determined using Kruskall-Wallis test. RESULTS: The mean (standard deviation) P-CPQ score was 18.73(18.79). Internal consistency was confirmed by a Cronbach alpha of 0.85. The test-retest reliability revealed that the responses to items were satisfactorily stable (ICC = 0.88). Construct validity was demonstrated by significant correlation coefficients between the total scale and the global ratings (r = 0.54 and 0.46; p < 0.001). Factor analysis with Principal Component Analysis extracted seven factors explaining 65.23% cumulative variance. Goodness-of-fit indices for partial confirmatory factor analysis were satisfactory for the 7-factors model of the French-PCPQ version. There were statistically significant differences between clinical groups regarding the total scale, thus demonstrating discriminant validity (p < 0.001). CONCLUSION: This French P-CPQ version showed reliability and validity comparable to the previous versions. However, the cross-cultural structure of the subscales should be further evaluated.

[An illustrated guide to dental screening: a school survey]. / Support photographique et dépistage bucco-dentaire?: étude en milieu scolaire.

AIM: Marked social inequalities in oral health are observed right from early childhood. A mandatory complete health check-up, including dental screening, is organized at school for 6-year-old children. School healthcare professionals are not well trained in dental health. The aim of this study was to assess the relevance of an illustrated guide as a simple and rapid dental screening training tool in order to ensure effective, standardized and reproducible screening. METHODS: A cross-sectional study was conducted in the context of the dental examination performed as part of the health check-up. Two examiners (Doctor E1 and Nurse E2) were trained in dental screening by means of the illustrated guide. This reference guide, comprising pictures and legends, presents the main oral pathology observed in children. RESULTS: 109 consent forms for oral screening were delivered, and 102 children agreed to participate (93.57%). The sensitivity of detection of tooth decay by examiners E1 and E2 was 81.48% with a specificity of 96%. No correlation was observed between the child's age (+/- 6 years) and correct detection rates. CONCLUSIONS: The illustrated guide is an appropriate and rapid tool for dental screening that can improve the quality of dental check-up and increase the number of children detected.

[Health literacy and patient education interventions: a review]. / Interventions en littératie en santé et éducation thérapeutique : une revue de la littérature.

INTRODUCTION: Low health literacy (HL) is an obstacle to therapeutic patient education (TPE), especially for people in a vulnerable situation, who are also at greater risk of chronic illnesses and their complications. It therefore seems essential to rethink TPE programmes in order to ensure greater equity based on analysis of the characteristics of HL interventions and their possible relationships with TPE. METHODS: A scoping review of the literature was performed from November 2014 to January 2016 using the following search engines: MEDLINE/PubMed, EMBASE, PsycINFO, ERIC, OpenGrey, SUDOC, thèses.fr and BDSP and the following search terms: ?health literacy?, ?Littératie en santé?, ?literacy?, ?Littératie?, ?numeracy?, ?numératie?, ?compétence en santé? combined with the keywords: ?programme?, ?program?, ?intervention?, ?méthode?, ?method?, ?technique?, ?outil?, ?tool?. RESULTS: After selecting forty out of 206 studies, interventions were classified into two main types of specific interventions to promote comprehension of resources intended for patients and generally complex interventions designed to support and improve HL skills. DISCUSSION: While the level of health literacy has an impact on TPE programme accessibility, TPE programmes need to be made more accessible and TPE must constitute an opportunity to address health literacy needs via its own specific modalities. Creating partnerships between social/educational and health settings might be an effective strategy to strengthen the interrelationships between HL and TPE, as might training that prepares caregivers-educators to improve patient HL. CONCLUSION: Interrelationships between HL and TPE are possible. Research should question the pedagogical modalities to be used to adapt TPE programs to the HL.

[Oral health status, supply of oral and dental care among Senegalese children: a review of available data]. / État de santé, offre et recours aux soins bucco-dentaires chez les enfants sénégalais?: synthèse des données disponibles.

INTRODUCTION: Oral and dental diseases are a major public health problem due to their high prevalence and their impact on general health. OBJECTIVE: This article reviews the oral health status and oral health care supply and uptake in children. METHOD: The available literature were reviewed. The Medline and Embase databases, and the Senegal Ministry of Health and Social Action and National Agency of Statistics and Demography (ANSD) websites were consulted. A total of 7 articles, 3 PhD theses and 8 reports were selected for analysis. The review was supplemented by interviews. RESULTS: Overall, children have poor oral health status. Health care supply is insufficient (1 dentist/38,000 residents) and poorly distributed (mostly in the capital) with unequal oral health care uptake. CONCLUSION: This systematic review of the literature revealed a lack of reliable data on the oral health of children. It also concluded on a generally poor oral health status.

Oral Health Knowledge, Attitudes, Practices, and Literacy of Pregnant Women: A Scoping Review.

PURPOSE: Pregnancy is a state particularly sensitive to oral pathologies (periodontal and decay). The oral health status of pregnant women can have an impact on the outcome of the pregnancy and the oral health of the child to come. As in the general population, the oral health of pregnant women is socially determined and dependent on psychosocial factors, including factors related to health behaviours. Research into the determinants of oral health in pregnant women will allow a better understanding of the mechanisms of action specific to this period of perinatality. MATERIALS AND METHODS: The methodology of a scoping review was selected with the objective of investigating the contribution of knowledge, attitudes, practices (KAP) and oral health literacy on pregnant women's oral health. RESULTS: Of the 67 articles selected, 52 studied the 'knowledge' component, 27 the 'attitude' (including the perception and beliefs concerning health), and 54 the 'practice' component, while 6 articles examined literacy. The KAP components were studied in relation to socioeconomic determinants, oral health status, healthcare utilisation and oral health literacy. The level of oral health literacy of pregnant women is strongly related to their living environment and socioprofessional level which influences their attitudes and practices. Woman's oral health practices before pregnancy can be a predictor of her practices during pregnancy. CONCLUSION: The complex nature of the attitude component (locus of control, sense of self-efficacy, perceived importance) is little discussed. The heterogeneity and exhaustiveness of topics related to KAP raises the question of how to more accurately assess KAP in pregnant women in a valid, reproducible, and transferable manner and the need to build a structured oral health consensus body of work. This review is a first step towards identifying the psychosocial factors that are essential for developing a model of educational intervention in oral health that combines the process of behavioural change and decision making while taking into account the concept of empowerment, and with the aim of reducing social inequalities in health.

Determinants of maternal and household social inequalities of dental caries among Senegalese children in the Department of Pikine.

Introduction: the problematic of social Inequalities in oral health remains a global concern; it constitutes evidence of social injustice. The present work aims to study the determinants of maternal and household social inequalities of children´s dental caries in Pikine. Methods: cross-sectional epidemiological survey has been conducted in the department of Pikine, Senegal on 315 children aged 3 to 9 and their mothers. The clinical data on children´s caries have been obtained by clinical examination and the socio-economic data by a questionnaire submitted to mothers. Pearson chi-square and trend tests as well as a logistic model were used in the data analysis. Results: the prevalence of dental caries in children was 64.8% and the mixed decayed, filled, missing (DFM) index was 2.5 (±2.7). The trend test showed significant inequalities in the prevalence of dental caries according to level of studies (p<0.001), profession (p<0.010) and contacts frequency (p<0.001) of mothers; the level of wealth (p<0.001) and structure (p<0.005) of households. According to the logistic regression model, the level of secondary or university education [OR (IC 95%) = 0.59 (0.33'>OR (IC 95%) = 0.59 (0.33-0.93)] or social network dynamism [OR (IC 95%) = 0.32(0.15'>OR (IC 95%) = 0.32(0.15-0.67)] of mothers; as well as wealthy families [OR (IC 95%) = 0.23(0.08'>OR (IC 95%) = 0.23(0.08-0.64) were associated to fewer risks of dental caries among children. Conclusion: some socio-economic characteristics of the mother and the household social conditions are identified as determinants of dental caries social inequalities in Children. Proportionate universalism may be a good approach to reduce this problematic in Pikine.

Socio-Economic Determinants of Dental Service Expenditure: Findings from a French National Survey.

(1) Background: This study investigated how individual enabling resources influence (i) their probability of using dental services and (ii) consumers' expenditure on dental treatment. (2) Methods: Data were derived from a self-administered national health survey questionnaire and from expenditure data from national health insurance. Multiple linear regression methods were used to analyze entry into the dental health system (yes/no) and, independently, the individual expenditure of dental care users. (3) Results: People with the highest incomes were more likely to use dental service (aOR = 1.59; 95% CI = 1.28, 1.97), as were those with complementary health insurance and the lowest deprivation scores. For people using dental services, good dental health status was associated with less expenditure (-70.81 EUR; 95% CI = -116.53, -25.08). For dental service users, the highest deprivation score was associated with EUR +43.61 dental expenditure (95% CI = -0.15; 87.39). (4) Conclusion: Socioeconomic determinants that were especially important for entry into the dental health service system were relatively insignificant for ongoing service utilization. These results are consistent with our hypothesis of a dental care utilization process in two steps. Public policies in countries with private fees for dentistry should improve the clarity of dental fees and insurance payments.

Characteristics of oral health literacy in Senegal: A cross-sectional study among women in the Department of Pikine.

Senegal having a significant prevalence of socially differentiated oral diseases, oral health literacy (OHL), an individual and social resource, should be considered alongside a remedial response. This work aimed to analyze women's OHL characteristics. A cross-sectional study on 315 women in Pikine County was carried out, using the Oral Health Literacy-Adult Questionnaire (OHL-AQ) for the OHL data collection and a questionnaire for the women's socioeconomic characteristics data. These women had an OHL average score of 6.5±3.1 and a median of 6. Among them, 56.5% had a seemingly low OHL level, a little over 68.9% had a score above the median as regards the "listening, communication and understanding" aspect, 58.4% to "decision making", 55.2% to "understanding numbers" and 33% to "reading and understanding". According to a multivariate analysis, secondary and higher educated women (p<0.001) with an active social network (p<0.023), in a wealthy household (p<0.0001) and of nuclear household type (p<0.036) had a higher OHL level. Women in Pikine have low OHL and are from working- class households. Therefore, oral health policies must take into account the women's social network contribution to the OHL improvement.

Health Literacy throughout adolescence: Invariance and validity study of three measurement scales in the general population.

OBJECTIVE: To simultaneously investigate the psychometric properties of three recently developed health literacy measurement scales throughout adolescence in the general population. METHODS: French versions of the Health Literacy for School-Aged Children (HLSAC, unidimensional) scale, the Health Literacy Assessment Scale for Adolescents (HAS-A, multidimensional) and the 16-item European Health Literacy Survey questionnaire (HLS-EU-Q16, unidimensional) were completed by 1 444 adolescents in 8th, 9th, 11th grade in general school and 11-12th grade in vocational school. Psychometric properties were studied using confirmatory factor analysis, McDonald's omega coefficient and hypothesis testing. RESULTS: Structural validity was acceptable (HLS-EU-Q16) to good (HAS-A and HLSAC), no measurement invariance issue was found and internal consistency was acceptable for the three scales (0.68-0.84). Convergent validity was low (Pearson correlation coefficients<0.5) and the only scale for which results were in agreement with a priori hypotheses was the HLSAC. CONCLUSIONS: Our results were supportive of the use of HLSAC to assess health literacy during adolescence but the HAS-A, with a slightly better structural validity, can also be promoted due to its three measured dimensions. PRACTICE IMPLICATIONS: The use of these scales in practice will help to focus on health literacy, a critical factor for prevention and health promotion in adolescence.

Which determinants should be considered to reduce social inequalities in paediatric dental care access? A cross-sectional study in France.

Better access to dental care through systemic and educational strategies is needed to lessen the burden of disease due to severe early caries. Our study aims to describe family characteristics associated with severe early caries: parental knowledge, attitudes, practices in oral health and socio-demographic factors. For this cross-sectional study, 102 parents of children aged under 6 years with severe early caries and attending paediatric dentistry service in France completed a questionnaire during face-to-face interviews. Caries were diagnosed clinically by calibrated investigators, using the American Academy of Paediatric Dentistry criteria, and dental status was recorded using the decayed, missing, and filled teeth index. The majority of children were from underprivileged backgrounds and had poor oral health status, with a median dmft index of 10. Parents highlighted the difficulty of finding suitable dental care in private practices. Parents appeared to have good oral health knowledge and engaged in adapted behaviours but showed a low sense of self-efficacy. They perceived the severity of early caries as important but the susceptibility of their child as moderate. The study affirmed the importance of improving the accessibility of paediatric dental care and developing educational strategies to enhance the knowledge, skills, and oral health practices of families.

Mothers' oral health literacy and children's oral health status in Pikine, Senegal: A pilot study.

CONTEXT AND OBJECTIVE: As elsewhere, disadvantaged children in Senegal are those most affected by dental diseases and difficulties in obtaining dental care. Studies conducted mainly in developed countries suggest that a low level of mothers' OHL is correlated with poor oral health of their children. The objective of this study is to estimate the level of mothers' OHL in Senegal and its relationto the dental health of their children. METHODS: This cross-sectional epidemiological survey took place among 315 children aged from 3 to 9 years old and their mothers. It estimated the children's dental health status by clinical examination which used a disposable examination kit and a headlamp, took place at the child's home, in the mother's presence. Examiners interviewing the mothers administered the Oral Health Literacy-Adult Questionnaire to determine their OHL and questioned them further about their social characteristics and their children's dental health behaviour. Logistic regression and correlations were used for the statistical analysis. RESULTS: The OHL score ranges from 0 to 17; mothers' mean score was 6.5 (±3.1) and 56.5% had a low score (below the median). The prevalence of dental caries in children was 64.8%. Mothers' high OHL is associated with children caries free and low prevalence of dental caries. The logistic regression showed a significantly protective relation between children's dental caries and mothers' high OHL scores (mean score 12-17) (OR = 0.51, 95% CI: 0.29-0.88), high educational level (OR = 0.42, 95% CI: 0.23-0.76) and a high level of social contact (OR = 0.31, 95% CI: 0.15-0.63). The structural analysis showed that OHL was significantly correlated with both the mothers' social position (r = 0.61 and P<0.001) and the children's caries (r = -0.26 and P<0.001). CONCLUSION: The OHL level of Senegalese mothers was significantly associated with their children's dental caries. Improving mothers' OHL might therefore help strengthen their capacities to promote oral health, thus helping to improve their children's dental health and reduce inequalities.

Implementation of a Medical Ethics Course in Undergraduate Dental Education and Assessment of Knowledge and Attitudes.

OBJECTIVES: A medical ethics course was launched in 2012 in a French University Dental School. We compared knowledge and attitudes, before and after implementation of that course. The aim of this study was to compare students who received an ethics course (third year) to those who did not have such training, however, most of them did have some clinical traineeship. MATERIALS AND METHODS: An anonymous questionnaire was sent to the second-, third-, and sixth-year students. It comprised questions with Likert item format answers and clinical vignettes with open responses. The results were analyzed by two approaches: a statistical analysis (chi-square or Fischer exact tests) and a content analysis using a predefined grid. RESULTS: A total of 299 respondents replied (75% students) the questionnaire. The analysis showed a statistically significant association between knowledge of the law and information procedures (P < 0.0001), access to medical files (P = 0.004), and recording consent (P = 0.049). It was also significant between knowledge of the law and the principles of biomedical ethics (P < 0.0001 for autonomy and beneficence). The third-year students could state the principles of medical ethics with their percentage always greater than the sixth-year students. After the third year, the students' attitudes switched from a social to a medical emphasis, and their point of view regarding patient's autonomy evolved. Patient's refusal of care raised potential conflicts between autonomy, professional judgment, information, and consent. CONCLUSION: Ethics teaching could offer a way to turn positive attitudes into real competencies and should be considered at an early stage.

Evaluation of children's participation in a national dental programme in France.

OBJECTIVES: The current national oral health programme for children in France, called the DHE "Dental Health Examination," began in 2007. The aims of the current study were to evaluate the efficiency and effectiveness of the DHE programme in improving resource allocation to preventive dental services and providing access to dental care, especially for the children who need it most. The main questions were as follows: How many children participate in it? Does it reach the children who need it most? And does it save dental care costs? METHODS: The study examined data for 1937 children aged 6-16 years. Data came from two data sets: (a) a 2010 French self-reported survey on health, health care and insurance; and (b) the data set of the National Health Insurance Fund on healthcare consumption, based on reimbursement data to families and payments to providers; this data set contains information on healthcare expenditures. We investigated participation in the DHE programme, the wider use of dental care services and the total amount spent on dental care in 2010, by dental health status and socio-demographic characteristics. Data analysis used multiple logistic and linear regressions. RESULTS: Children in households with higher income were more likely to participate in the DHE programme (OR = 3.09, 95% CI [1.78, 5.36]). Families with higher incomes were more likely to use dental care (OR = 2.23, 95% CI [1.40, 3.55]). Households with private complementary health insurance utilized more children's dental care services than households without it (OR = 2.79, 95% CI [1.04, 7.49]). Families that were aware of the DHE prevention programme were more likely to utilize dental care (OR = 1.77, 95 % CI [1.34, 2.33]) and had lower dental care expenses (coeff. = -142.93, 95% CI [-207.68, -78.18]). CONCLUSION: Financial barriers remain the major obstacle to dental care utilization in France, even with DHE, a free secondary prevention programme aimed at all French children. Participation in the DHE programme is associated with better access to dental care and with lower costs for both the National Health Insurance Fund and participating households.

Sociodemographic factors associated with the dental health of persons with diabetes in France.

This paper describes and compares the oral health status among people with and without diabetes in France, and analyzes the related socioeconomic factors. The study is based on data from the cross-sectional national health survey conducted in France from 2002 to 2003, which included 19,231 people over 35 years of age, among whom 1,111 reported having diabetes. Data were collected through interviews that inquired about oral health status and use of dental care services, income, educational level, health insurance, place of residence, and birthplace. The prevalence of oral health problems was higher among subjects who had diabetes, compared with those who were nondiabetic (16.4% vs. 13.4%). Dental care utilization during the survey period was reported to be 8.7% among subjects who were diabetic versus 12.9% among those who were nondiabetic. The subjects with diabetes were more likely to have dental problems (OR = 1.47, CI = 1.03-2.08) and wear removable dentures (partial and complete) when their income was lower (OR = 2.17, CI = 1.52-3.10). There were social inequalities in oral health among people with diabetes in France according to income level.