EJovpetm Journal of Orlhodonlia 13(1991) 15-21

© 1991 European Orthodontic Society

Subjective appraisal of orthodontic practices. An investigation into perceived practice characteristics associated with patient and parent treatment satisfaction Gerd Sahm, Axel Bartsch, Rolf Koch, and Emil Witt Poliklinik fur Kieferorthopadie der Universitat Wurzburg, Federal Republic of Germany SUMMARY Based on a comprehensive in-practice questionnaire survey among 254 schoolage patients and their parents, the subjective perception and evaluation of orthodontic care was investigated. By means of refined statistical analysis, three types of practice showing significantly distinct image profiles were identified. Likewise, the set of discriminating variables was reduced and assigned to the fundamental concepts of 'interpersonal satisfaction' and 'perceived efficacy' which appeared to play a crucial part in the crystalization of both patients' and parents' contentedness with the treatment received. To take account of the interdependence of instrumental and social factors, a model of perceived practice similarity is suggested; its significance regarding treatment decisions and future research efforts is pointed out.


Although several interview studies have been carried out into the scope of orthodontic patient attitudes for the last twenty years (Oliver and Knapman, 1985; Sergl and Furk, 1982; Roller and Droschl, 1976-1979; Dausch-Neumann, 1967; Ebert, 1977; Sahm et al, 1988), most of them did not reach beyond reporting the response distributions of single items. Preparatory to a major project on patient compliance in removable appliance wear, we completed a questionnaire survey which was designed to enquire into differential characteristics of orthodontic practices in the eyes of patients and parents. Involving nine resident orthodontists, this was the first such study carried out in Germany. While a comparative and detailed appraisal of the topics studied is beyond the scope of this paper, our present intention is three-fold: (1) to identify variables which produce differences between orthodontic practices in the eyes of patients and parents; (2) to assemble a number of practices into

subgroups according to their degree of similarity; (3) to derive a preliminary structural pattern which may help to conceptualize and integrate future approaches in the area of orthodontic patient attitudes. Furthermore, such an approach might contribute to opening up the issue of'practice image' to scientific discussion. Subjects and methods

/. Assessment of data Our sample comprised 254 cases who were randomly selected from all nine practices. The children, who were treated with functional appliances, mostly bionators, ranged from 9 to 14 years of age with a mean duration of treatment of 14.7 months (Table 1). Besides the patients, the accompanying parents and the operators were enrolled in the interviews, which were carried out by two of the authors (G.S., A.B.) at the respective practice. To guarantee a trustful and anonymous atmosphere, patients



Table 1 Sample attributes. Total number of cases Patients male female accompanied by mother accompanied by father accompanied by both by themselves

254 97 157 198 12 19 25

38.2% 61.8% 78.0% 4.7% 7.5% 9.8%


mean s.d. duration of treatment mean s.d.

11.3 yrs 1.6 yrs 14.7 mos 9.6 mos

and parents completed their forms in separate rooms. The operator was not present during the interviews. The importance of frank answering was stressed. Based on a pretest and subsequent psychometric examination (Sahm et ai, 1988) with special respect to the clearness and comprehensibility of the item contents, the questionnaire employed consisted of a 92-item patient version and a 66-item parent version (Table 2a). According to the varying complexity of the latter, the interviewees were offered various response formats to ensure a maximum of adequate information. In general, overall attitudes were assessed by 6-point visual rating scales (Table 3), while more detailed questions on special behaviour were provided with dichotomous (yes/no) or categorical formats including multiple responses. The vast majority of topics was referred to within both the patient and parent questionnaire and can be classified into the following groups: (1) (2) (3) (4)

treatment motivation and satisfaction; dentofacial aesthetic standards; peer responses; parental attitudes and controlling behaviour; (5) patient-orthodontist relationship (including office atmosphere); (6) patient co-operation and knowledge about treatment.

From the questionnaire items on patient-operator interaction and parental control, we developed psychometric scales (Sahm et al., 1990) replacing the original variables within the subsequent analyses. Table 2a

Questionnaire modules. Questionnaires

Topic Treatment motivation and satisfaction Dentofacial aesthetic standards Peer responses Parental attitudes and control Patient-orthodontistinteraction Office atmosphere Knowledge on treatment Patient compliance



n= 8 n= 4

ft =^


71 =


71 =

7 1 7 4


n= 1


71 =



71 =



71 =

Note. The mere number of items can be misleading in that multiple response formats contain more information than dichotomous questions. Table 2b Semantic differential (28 pairs of polar adjectives/6-grade-rating scale). Underlying dimensions ( + / —)

Interpersonal concepts Patient by himself (PP)—

-Activity Patient by provider (BP) - Lilceability Patient by parent (EP) — -Dominance Provider by patient (PB) -Sociability

Provider by parent (EB)

Table 3

very well

very tense

Example of graphic rating scale.

A. Patient questionnaire: 'How did you wear your appliance . . .7' fairly slightly slightly fairly very well





B. Semantic differential: 'How do you judge your orthodontist .. .T fairly slightly slightly fairly very relaxed

Note. Data analysis is based on the assumption of equalinterval measurement



Since the operators were requested to complete their forms immediately after the respective treatment session, the orthodontist questionnaire was confined to seven basic items on treatment schedule (n = 2), required daily wear (n= 1), perceived patient compliance and amiability (n = 2), dentofacial appearance, and urgency of treatment (n = 2). In addition, we developed a 'Semantic Differential' (Osgood et ai, 1957) consisting of 28 bipolar adjective rating scales (Table 2b) which proved valid for all age groups. This was completed by all parties to ascertain the reciprocal perception of personality attributes. From separate principal component analyses and subsequent orthogonal rotation, a homogeneous and stable dimensional structure throughout all concepts was established, which allowed developing the following psychometric scales: (1) (2) (3) (4)

likeability; sociability; activity; dominance.



//. Data analysis The stepwise process of data analysis comprised various statistical procedures aiming at an appropriate selection of variables and classification of cases (cf. Fig. 1). As a preliminary screening, bivariate correlations between all inventory items and scales from the three treatment parties were computed. As there were significant differences in the distributions of patient age and treatment duration between the practices studied, analyses of questionnaire variables was based on residuals with the variance of age and duration being partialed out. Items appearing to make a significant contribution were transformed to an appropriate level of measurement, whenever necessary, and entered into a discriminant analysis. This multivariate procedure aims at a maximum discrimination of the criterion groups (i.e. the nine practices attended) by linear combinations of predictor variables. Like multiple regression analysis, it allows the determination of weighting coefficients for the single predictors by taking account of their mutual relationship.

Perceived treatment characteristics ( stepvrise selection of predictor variables )

Correlational and discriminant analyses

Cluster analysis

> > > > > >

Number of complaints Overall rating Perceived treatment progress Regularity of wear Overall rating Supposed wear required

> > > > > >

Overall rating Waiting interval Boredom factor Overall personal relationship Extent of verbal communication Feelings of rejection/ anxiety


Basic concepts

Technical > satisfaction Perceived > compliance > Supposed directive -> Office atmosphere -> Quality of interaction

Interpersonal Satisfaction

> > > >


-> •>

Patient-perc. Parent-perc. Patient-perc. Parent-perc.

operator operator operator operator

likeability likeability sociability sociability

Personality judgement

Original item was selected Scale was assembled for selection

Figure 1 Perceived treatment characteristics (stepwise selection of predictor variables).


We thereby arrived at an average of 79.1 per cent of correct classifications throughout the nine practices studied (classification sample: «c = "total*0.6, 83.4 per cent; cross-validation sample: nv = «loui * 0.4, 74.7 per cent). The variables still contributing significantly to the prediction of the groups were z-standardized (i.e. transformed to the same scale with mean = 0, s.d. = l) and entered into a cluster analysis combining the hierarchical WARD-procedure with subsequent &-means method (Ward, 1963; Blashfield, 1980). Starting off" with the maximum number of clusters possible ( = number of cases), the WARD algorithm successively fuses those clusters which lead to the minimal possible increase of the total sum of squares of errors. The partition of k clusters thus produced can be further improved: for all cases Euclidean distances to the centres (means) of all clusters are repeatedly computed. Any case found to be closer to the centre of the next cluster that to its own is moved to the former. Based on the discriminant factor patterns and theoretical considerations on concept similarity, indices were then developed from variables of homogeneous content. For this purpose, the standardized variable scores of the cluster centres were averaged and classified into five categories [below (mean —2 s.d.)/below (mean—1 s.d.)/(mean± 1 s.d.)/above (mean-I-1 s.d.)/above (mean+ 2 s.d.)], so that the variable positions within a single cluster (e.g. number of complaints within Cluster I: z= —1.32) in comparison to the whole-sample mean contribute to the global attribute grades considered characteristic of each practice in this group (e.g. technical satisfaction within Cluster I above average). In order to avoid confusion which might result from contradictory attitudes of patient and parent within the same 'case' all variables diverging by more than one grade were excluded from further analyses. Results Within our sample, we were able to reliably identify three types of practice. They represent groups differing by characteristic patterns of perceived attributes which are respectively composed of several questionnaire items (Fig. 1). The first group (Table 4) is made up of two practices comprising 22.8 per cent of our


patients. They are characterized by an aboveaverage level of perceived compliance with requirements which were considered fairly high. Overall treatment satisfaction of patients and parents is above average, although in their eyes the treatment lacks observable progress. This impression might be due to an increased aspiration level resulting from their comparatively greater self-perceived efforts. On the other hand, the orthodontist's personal relationship with his patients appears to be quite poor. Neither do they appreciate his overall practice atmosphere, nor are they satisfied with the operator's social behaviour. Their complaints concerning a lack of time and perceived efforts culminate in the parents' strong wish to establish better communication with the orthodontist. Briefly characterized, these practices may well be considered functional and effective, but the patients do not enjoy their orthodontic visits. Face to face with their operator, they choose not to voice any complaints, but rather do or at least pretend to comply with his stated demands. The second group is characteristic of how most of the practices are imaged by their clients. Comprising five practices with 58.4 per cent of cases altogether, this is the largest cluster. The patients are generally satisfied, since the orthodontist's requirements are not too difficult to meet. Furthermore, the treatment partners seem to have come to terms with a sufficient level of cooperation through a process of negotiation. Table 4 Image profile of nine orthodontic practices Ouster no. Office no. Number (%) Mean age pts (yrs.) Mean duration (mos.) Mean wear required* Standard scores jc.f: Supposed directive^ Technical satisfaction Perceived compliance Office atmosphere Interaction quality Personality judgement§

I 1,7 22.8 11.04 8.7 15.8

1:1) (±0)

II 2, 3, 5, 6,9 58.4 11.29 15.7 13.9


(t) +)

III 4,8 18.8 11.50 15.5 16.1


* Stated by orthodontist (hours per day), t Standard scores: xt; e.g. ( + ) above average within 1 standard deviation (grand mean+ Iff) S x s ^ ( g r a n d mean). I Stated by clients. § Scored ( + ) for socially desired attributes, etc.


APPRAISAL OF PRACTICES Table 5 Selected variable profile of two offices applying classical activators (ranks in overall sample*). Requir. Regular. Treatm. Removal Interpers. Verbal No. HPD's of wear satisf. wh. speak, climate activity

It • Rank T = highest value observed. t Average hours per day required 18.6 according to operator. i Average hours per day required 13.8 according to operator.

Thus, there is no reason for conflicts between operator and patient which might undermine the personal atmosphere. In that they get along well with each other, at least sufficient progress of treatment is achieved. The remaining two practices make up the third cluster. Unlike the groups characterized previously, there are many complaints about the appliances, as the orthodontist's requirements seem to be too difficult to fulfil. Thus, reported compliance with required time remains poor, especially with respect to regularity of wear. Moreover, the operator apparently fails to resolve this discontent through a sociable personal interaction with the patient; rather, he is considered unfriendly and aloof which is likely to evoke resentment. He is viewed as an insecure and 'difficult' personality who does not care much about his patients. That is precisely how the operator judges his patients which provides clear evidence of the interdependence of all treatment partners' behaviours. Two out of the nine orthodontists (Nos IV and VI) treated patients with classical activators. Our findings thus far outlined have been reflected in miniature by the image profiles of these two practices (Table 5).

Discussion Several studies concerning patient-perceived quality of medical care (Davies and Ware, 1981; Hornung and Massagli, 1979; Koslowsky et al., 1975) suggest two basic dimensions of patient satisfaction which can be characterized as socioemotional comfort and evaluation of technical ability. Our findings point to a similar pattern: the psychological attributes finally proving important for the appraisal of practices (such as

Technical satisfaction, Office atmosphere, etc.) can easily be assigned to these concepts. Hence, interpersonal satisfaction and perceived treatment efficacy appear to be generalized criteria by which patients judge their treatment. There is evidence, however, that these aspects are not independent of each other, in that they were not consistently represented by orthogonal discriminant factors. A close examination of the image patterns given in Table 4 apparently provides further validity for this conclusion. Each of the groups is characterized by an intricate web of mutual social perceptions and evaluations which modulate the overall appraisal of treatment. In particular, the impact of merely technical measures on patient feelings and behaviour is largely controlled by psychological factors. As patients are rarely able to determine the professional's technical competence, they are prone to confuse perceived efficacy with their interpersonal contentedness. In particular, this appears to happen more often in younger children. Likewise, patients with a lower level of education are more likely to amalgamate affective and instrumental components in perception of their relationship with the operator (Ben-Sira, 1980). Certainly, the interpersonal skills of the operator become crucial when conflicts arise from demands which are not well understood and considered untenable. In this case, they serve as a facilitating factor. Evidence of what has been claimed regarding technical measures is provided by comparing the two practices using activators. The latter have the reputation of being rather bulky and less comfortable to wear compared to bionators. One of these practices belongs to the second group, with a rank of overall satisfaction being among the highest within our sample. Virtually all of these patients are required to wear their


G. SAHM, A. BARTSCH, R. KOCH AND E. WITT Perceived Treatment Efficacy

Cluster 1

Cluster 3

Legend: Cluster

Group of Practices


Basic Aspects of Appraisal


Positive / Negative Pole


No. of Practice

for maximum scores on the one dimension by lower scores on the other. Notwithstanding the adequacy of such a model for the present sample, it has been devised for heuristic purposes and still awaits scrutinization through replication and validation studies. The latter should include external criteria of satisfaction (such as recommendations, discontinuation of treatment, regular attendance) and quality of care (such as expert ratings of treatment progress, duration, and intensity of verbal activity). Regarding the 'types' of practice, the stability and external validity of our solution need to be tested. As a more practical conclusion, we maintain that if—and only if—the orthodontist successfully conveys the proper impression of spending considerable time in caring for his patients, he can expect them to respond to exacting requirements with sufficient compliance and general treatment satisfaction.

Figure 2 Circular representation of practice similarity with primary discriminatory factors.

Address for correspondence

appliances at night only. Thus, any conflicts which might result in a deterioration of the interpersonal atmosphere can be avoided. On the contrary, the other practice employing activators belongs to group III. For most patients, a 20-hour demand has been imposed. They fail to comply with these requirements. Discontented patients backed up by their parents consider the orthodontist either too inflexible and non-communicative, or he appears too insecure to enforce his demands authoritatively. Thus, both perceived efficacy and interpersonal satisfaction are dimensions of equal importance, though the proportions may vary from one individual to another in the course of the treatment process. As a visual clue to this conclusion, we arranged the practices studied on a circle representing the degree of mutual resemblance (Fig. 2). The circle is crossed by two axes intersecting at the centre. With the two axes representing the interpersonal and the efficacy factors, this scheme takes account of their interdependence. It is impossible to move a point around the circle without changing its position in both dimensions. Rather, a curvilinear relationship between them is implied. In other words, you might have to pay

Dr Gerd Sahm Poliklinik fur Kieferothopadie der Universitat Wurzburg Pleicherwall 2 D-8700 Wurzburg F. R. Germany Acknowledgements

This study was supported by a grant of Deutsche Forschungsgemeinschaft. References Ben-Sira Z 1980 Affective and instrumental components in the physician-patient-relationship: an additional dimension of interaction theory. Journal of Health and Social Behavior 21: 170-180 Blashfield R K 1980 The growth of cluster analysis: In: Tryon, Ward, Johnson (eds). Multivariate Behavioral Research Vol. 15 439-458 Dausch-Neumann D 1967 Die Einstellung des Kindes zu seiner kieferorthopadischen Plattenapparatur. Fortschritte der Kieferorthopadie 28: 91-101 Davies A R, Ware J E 1981 Measuring patient satisfaction with dental care. Social Science and Medicine 15A: 751760 Ebert K-P 1977 Probleme und Ziele kieferorthopadischer Behandlung aus Patientensicht. Fortschritte der Kieferorthopadie 38: 452-468

APPRAISAL OF PRACTICES Hornung C A, Massagli M 1979 Primary care physicians' affective orientation toward their patients. Journal of Health and Social Behavior 20: 61-69 Roller S, DroschJ H 1976-79 Die kieferorthopadische Behandlung aus der Sicht der Patienten und deren Eltern, Teil 1-4. Osterreichische Zeitschrift fur Stomatologie 1976,73: 205-210; 1977,74:62-73,428^*40; 1979,76:436444 Koslowsky M, Bailit H, Valluz2o P 1975 Satisfaction with care and the utilization of dental services at a neighborhood health center. Journal of Public Health Dentistry 35: 170-176 Oliver R G, Knapman Y M 1985 Attitudes to orthodontic treatment. British Journal of Orthodontics 12: 179-188 Osgood C E, Suci G J, Tannenbaum P H 1957 The measurement of meaning. University of Illinois, Urbana

21 Sahm G, Bartsch A, Koch R 1988 How do patients feel about their orthodontic treatment? Unpublished paper presented at the 64th EOS-Congress London Sahm G, Bartsch A, WitrE 1990 Reliability of patient reports on compliance. European Journal of Orthodontics 12: 438-446 Sergl, H G, Furk E 1982 Untersuchungen fiber die personlichen und familiaren Schwierigkeiten der Patienten bei kieferorthopadischen Behandlungen, Teil I—III. Fortschritte der Kieferorthopadie 43: 207-215, 319-324, 345-351. Ward J H 1963 Hierarchical grouping to optimize an objective function. Journal of the American Statistical Association 58: 236-244.

Subjective appraisal of orthodontic practices. An investigation into perceived practice characteristics associated with patient and parent treatment satisfaction.

Based on a comprehensive in-practice questionnaire survey among 254 school-age patients and their parents, the subjective perception and evaluation of...
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