The social validation of pharmacological approaches to the management of dental anxiety in adults: Impact of treatment urgency, method of intervention and treatment outcome
Main Article Content
One hundred and twenty-eight adult patients attending a clinic at a United Kingdom dental hospital rated vignettes describing the management of an adult who was severely dentally anxious. There were 8 vignettes, which varied systematically along three dimensions: treatment urgency (presence or absence of pain), method of Intervention (psychological approach versus use of sedation) and treatment outcome (good outcome - individual overcame dental anxiety to attend regularly, or poor outcome - individual did not attend following the treatment). Participants were assigned one vignette at random and rated the acceptability and humaneness of the treatment approach using the Treatment Evaluation Inventory (Kazdin, French, & Sherick, 1981). Overall the psychological intervention was rated as more acceptable than the use of sedation (F = 7.60, p < 0.01), and interventions which resulted in good outcomes were rated as more acceptable (F = 148.8, p < 0.001). There was no significant effect of treatment urgency. Ratings of acceptability are strongly influenced by the outcome of the treatment regardless of the urgency of treatment need.
Researchers working within the framework of applied behavior analysis have often been concerned to determine the social validity of their interventions. Wolf (1978) suggested that data on social validity can be collected by answering three questions:
Does society deem the program goals to be desirable and appropriate for the client?
Are the client and the significant people in his/her life satisfied with the change that occurred during treatment?
Are the procedures used to achieve change acceptable to the client, his/her significant others and the broader community?
There has been relatively little attention paid to the social validation of treatment, despite a great deal of emphasis being placed on consumer involvement in the design of treatments and services (Worcester, 2003). The third of Wolf’s questions, concerning the acceptability of treatment, is interesting given that acceptability as a concept appears in many aspects of public health. It is enshrined in the Primary Health Care Approach (WHO, 1978), it is included as a dimension of access (Penchansky & Thomas, 1981) and definitions of health need (Matthew, 1972).
A limited number of recent studies have addressed the acceptability of behavior management techniques for dentally anxious children, but there have been no published studies on behavior management for adults who fear dental treatment. Behavior problems among children receiving dental treatment are relatively common. Holst, Hallonsten, Schroder, Ek, and Edlund (1993) reported that among a sample of 273 3-year-olds attending the dentist for the first time 13% acted reluctantly and 11% negatively. A number of restrictive and nonrestrictive techniques for managing anxious children are available, including pharma- cological approaches and a range of behavior management approaches (American Academy of Pediatric Dentistry, 2004). Murphy, Fields, and Machen (1984) assessed the attitudes of parents towards 10 different behavior management techniques employed in pediatric dentistry, the acceptability of which they ranked after they had viewed them on video. General anesthesia, sedation and the use of Hand-Over-Mouth (where a dentist places his or her hand over a child’s mouth, restraining the child, and explains that he/she wishes the child to act appropriately) were generally viewed as the most unacceptable techniques. In a further study by Fields, Machen, and Murphy (1984) the same methodology was used but additionally parents were provided with information on the nature of the dental treatment to be performed. They found that the acceptability of the behavior management technique was related to the nature of the treatment performed. Pharmacological treatments (general anesthesia and sedation) were judged unacceptable except when used for extractions and restorations. Physical restraint by the assistant was viewed as acceptable for a wider range of treatments than restraint by the dentist, which was viewed as acceptable only for giving an injection. Voice control, mouth props, positive reinforcement, and tell-show-do were judged to be acceptable for nearly all procedures. The Papoose board (the child is placed on the board and restrained by being wrapped in a sheet around the arms and legs) and Hand-Over-Mouth were unacceptable to the majority of parents for all dental procedures.
More recent studies have similarly demonstrated the lower ratings of acceptability given to techniques such as Hand-Over-Mouth, the Papoose Board and sedation in comparison to nonpharmacological treatment approaches (Newton, Naidu, & Sturmey, 2003; Newton & Sturmey, 2003; Sturmey, Thomsett, Sundaram, & Newton, 2003). However these latter studies also demonstrated a strong effect of the efficacy of treatment – effective treatments are generally rated as more acceptable and humane than noneffective treatments (Morgan, 1989). There has been to date no study which has examined the impact of treatment urgency and treatment outcome on ratings of acceptability. The aim in this study is to determine the impact of treatment urgency, method of behavior management and outcome of management technique on the perceived acceptability of behavior management techniques amongst adult dental patients. Adult patients are included in this study since there has been no previously published study examining treatment of adult patients, and because adult patients were perceived as allowing a greater range of treatment urgency (it was felt by the researchers that children with dental treatment need would be routinely viewed as “urgent” cases).
Method
The experimental design was a three-factor cross-sectional design employing opportunistic sampling. There were two levels for each factor. The three factors were: method of intervention (sedation vs. tell-show-do); treatment urgency (Low - patient has no pain but is in need of an extraction vs. High - patient suffers from pain and requires an extraction) and outcome (Good - adult became less anxious following treatment vs. Poor - adult remained highly anxious). Participants were randomly assigned to one of 8 cells. Each participant received a pack containing a cover letter explaining the purpose of the study, demographic questions, a case vignette and a copy of the Treatment Evaluation Inventory (TEI; Kazdin, French, & Sherick, 1981) to complete after they had read the vignette.
Participants
Participants were volunteers recruited from the out-patient clinics of King’s College Dental Hospital, London, United Kingdom. All adult dental patients were approached regardless of age, gender, ethnicity or any other related factors until a sample size of 128 volunteers had been gathered. A sample size of 128 was chosen on the basis of previous experience using the TEI, which suggested that differences between mean ratings for the vignettes would be in the region of 7.0 points with a standard deviation of 7.0. On the basis of this and using Altman’s nomogram (Altman, 1997), a sample size of 16 participants per vignette was determined to be necessary to identify this difference with the usual assumptions of power and significance. A researcher approached each participant and explained the aim of the study, and written consent was obtained from those willing to participate. Participants’ responses were anonymous and all participants were informed that they could withdraw from the study at any point. The volunteers were then asked to read one of eight vignettes (randomly allocated) in which management of an adult with severe dental anxiety was described. There were 59 (46%) male and 69 (54%) female participants. The mean age of the sample was 46.5 years (SD = 16.8).
Materials
Vignettes There were eight vignettes, which were designed following the guidance of Neff (1979) to maximize their social validity. Each described a standardized scenario of 31-year-old Mike working in a bank, who was fit and healthy but has severe fear of attending the dental clinic. The variation between the vignettes was in the method of intervention, the severity of the disease and the level of outcome of the treatment.
The second paragraph described the severity of the disease, that is Mike suffering from pain and needing an extraction, or Mike having no pain but also needing an extraction. The third paragraph described the method of intervention. One method described the dentist explaining the procedure step-by-step to Mike, using “Tell-Show-Do”. The other method was the dentist making a referral to the local hospital for treatment under sedation by injecting midazolam into his arm. The treatment outcome for each scenario varied by either Mike’s being able to have regular six-monthly check-ups following this extraction or by Mike’s never being able to go to the dentist following this appointment. An example of one vignette is given as an Appendix.
Treatment Evaluation Inventory The TEI is a 19-item questionnaire designed to measure the perceived acceptability of interventions for behavioral problems (Kazdin et al., 1981). Respondents indicated their agreement or disagreement with a series of statements on a 5-point Likert scale with markers at each end and at the mid-point. Each item is scored with increasing scores indicating greater acceptability. The items were then summed to give a total score which indicates the perceived acceptability of the treatment ranging from 19 (low acceptability) to a maximum of 95 (high acceptability). Cronbach’s alpha for the TEI has previously been reported as high (a = 0.96) and the scale has previously been shown to discriminate between behavioral treatments (Newton & Sturmey, 2004). An example of a TEI item is, “Please give an overall rating of the way in which the dentist dealt with Mike’s behavior, taking into account all aspects of the treatment.” The anchors of the scale were Very Poor and Very Good.
Statistical Analysis
Mean values of the TEI-Acceptability scale (and SD) were calculated for each vignette, and the significance of differences between vignettes was analyzed using one-way Analysis of Variance. Subsequently a full factorial General Linear Model analysis was performed, with each of the three factors entered as independent variables, and with age as a covariate.
Results
The demographic characteristics of the participants are shown in Table 1. There was no difference in the proportion of males and females who completed the eight different vignettes (χ2 = 3.99, ns). However, there were significant differences in the mean age of the participants across the eight vignettes (F = 3.96, p < 0.001).
The mean (and standard deviation) of TEI scores for the eight vignettes are summarized in Table 2. A between-groups one-way Analysis of Variance revealed there were significant differences in ratings across the vignettes (F = 22.90, p < 0.001), post hoc Tukey B tests were calculated to reveal where the differences between groups lay. A three-way analysis of variance model was calculated, which is summarized in Table 3. None of the interaction terms were significant; there was a significant effect of the outcome of the intervention and the type of intervention. Tell-Show-Do was rated significantly more acceptable than the use of sedation, but the largest effect was that of treatment outcome – participants rated effective treatments as more acceptable than ineffective treatments. Treatment urgency had no significant effect on ratings of treatment acceptability.
Conclusions
The social validity of two techniques for the management of dental anxiety in adults was compared amongst adults attending dental treatment. The impact of treatment urgency (as defined by the presence of pain), and the outcome of the anxiety management were systematically varied. A psychological approach to management (Tell-Show-Do) was rated as more acceptable than the use of sedation, and as established previously (Newton et al., 2003; Newton & Sturmey, 2003; Sturmey et al., 2003) the outcome of the anxiety management technique had a strong effect on ratings of acceptability. The urgency of the treatment required did not have an effect on ratings of acceptability, in sharp contrast to the work of Fields et al. (1984) where the acceptability of the behavior management technique was related to the nature of the treatment performed. This discrepancy is possibly the result of the research methods adopted. In the present study a standardized approach to the assessment of acceptability was adopted using a previously validated tool, whereas studies by Murphy et al. (1984) and Fields et al. used a ranking procedure that would accentuate differences between methods. Age had a weak impact on ratings of acceptability that was not significant in the full ANOVA model. It is possible that the apparent effect of age was related to differences in the age distribution across the vignettes.
Table 1. Sociodemographic Characteristics of Participants Shown by Vignette
Table 2. Mean Scores (and Standard Deviation) for Treatment Evaluation Inventory Shown by the Eight Vignettes
Table 3. Means (and Standard Deviations) of TEI Acceptability Scores for Terms in ANOVA Model
Several limitations of the present study may be identified. The study was cross-sectional therefore it is possible that individual difference factors may have influenced participants’ judgments including dental anxiety. Participants’ own fear of dental treatment may have influenced their judgment of the treatments described in the vignettes. The sample size was based on the ability to detect a difference identified in previous studies, but may have been insufficient to detect the interaction effects in the present study. Respondents were adults attending for dental treatment and had not directly experienced the approaches to the management of dental anxiety described in the vignettes. Experience of treatment has been shown to have an impact on perceived acceptability (Fields et al., 1984; Murphy et al., 1984), however the primary goal of the research was to address the third of Wolf’s aspects of social validation – that is judgments of the acceptability of the intervention by the broader community.
The acceptability of approaches to the management of dental anxiety is related to the efficacy of treatment. This supports the current emphasis on evidence- based healthcare (Gray, 2001), and has implications for the communication of treatment options to patients - information on the outcome of interventions is an important determinant of patients’ views. The present study suggests that a principal influence on patients’ judgments of treatment will be the anticipated outcome of the treatment. Clinicians should provide realistic information regarding the outcome of treatment.
References
Altman, D. E. G. (1997). How large a sample? In S. M. Gore & D. G Altman (Eds.), Statistics in Practice. Oxford: Blackwell Science.
American Academy of Pediatric Dentistry. (2004). Guidelines 2002-2003. AAPD, Chicago.
Fields, H. W., Machen, J. B., & Murphy, M. G. (1984). Acceptability of various behavior management techniques relative to types of dental treatment. Pediatric Dentistry, 6, 199-203.
Gray, J. A. M. (2001). Evidence-based healthcare (2nd ed.). London: Churchill Livingstone, Harcourt Publishers Ltd.
Holst, A., Hallonsten, A. L., Schroder, U., Ek, L., & Edlund, K. (1993). Prediction of behaviour- management problems in 3-year-old children. Scandinavian Journal of Dental Research, 101, 110-114.
Kazdin, A. E., French, N. H., & Sherick, R. B. (1981). Acceptability of alternative treatments for children: Evaluation by inpatient children, parents and staff. Journal of Consulting and Clinical Psychology, 49, 900-907.
Matthew, G. K. (1972). Measuring need and evaluating services. In G. McLachlan (Ed.), Portfolio for health. Oxford: Oxford University Press.
Morgan, R. L. (1989). Judgments of restrictiveness, social acceptability and usage: Review of research on procedures to decrease behavior. American Journal on Mental Retardation, 101, 121-133.
Murphy, M. G., Fields, H. W., & Machen, J. B. (1984). Parental acceptance of pediatric dentistry behavior management techniques. Pediatric Dentistry, 6, 193-198.
Neff, J. (1979) Interaction versus hypothetical other: The use of vignettes in attitude research. Sociology and Social Research, 64, 105-125.
Newton, J. T., Naidu, R., & Sturmey, P. (2003). The acceptability of the use of sedation in the management of dental anxiety in children: Views of dental students. European Journal of Dental Education, 7, 72-76.
Newton, J. T., & Sturmey, P. (2003). Students’ perceptions of the acceptability of behavior management techniques. European Journal of Dental Education, 7, 97-102.
Newton, J. T., & Sturmey, P. (2004). Development of a short form of the Treatment Evaluation Inventory for the acceptability of psychological interventions. Psychological Reports, 94, 475- 481.
Penchansky, R., & Thomas, J. W. (1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19, 127-140.
Sturmey, P., Thomsett, M., Sundaram, G., & Newton, J. T. (2003). The effects of behavior management, child characteristics and outcome on public perceptions of intervention acceptability in paediatric dentistry. Behavioral and Cognitive Psychotherapy, 31, 169-176.
Wolf, M. M. (1978). Social validity, the case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203-214.
World Health Organization / UNICEF (1978). Primary health care, Alma Ata 1978. ‘Health for All’ Series No. 1. Geneva, World Health Organisation.
Worcester, R. (2003). Patient choice. London: MORI / London School of Economics.
Appendix An Example of One of the Vignettes: Urgent Treatment, Tell-Show-Do Intervention, Good Outcome
Mike is a 31-year-old-man. He is fit and healthy and works in a bank as a mortgage advisor.
About ten years ago, Mike developed a severe fear of going to the dentist. He gets so frightened that he feels physically sick when he goes into a dental surgery. He has put off going to the dentist for two years and now he is in constant pain. He went to a dentist who looked in Mike’s mouth and told him he needed an extraction. Mike was too scared to have the treatment and left the surgery.
Mike then felt very desperate; he went to another dentist and asked for his help. The dentist spent a much longer time talking to Mike about the dental procedure than the first dentist. He explained the procedure step by step and then showed Mike what he was going to do. This procedure is called ‘Tell-Show-Do’.
At the end of the treatment Mike felt a lot better about going to the dentist. He was able to go to his local dentist to have his treatment done. The local dentist did not use the psychological treatment. Since then Mike has been to the dentist every six months for a regular check up.
Altman, D. E. G. (1997). How large a sample? In S. M. Gore & D. G Altman (Eds.), Statistics in Practice. Oxford: Blackwell Science.
American Academy of Pediatric Dentistry. (2004). Guidelines 2002-2003. AAPD, Chicago.
Fields, H. W., Machen, J. B., & Murphy, M. G. (1984). Acceptability of various behavior management techniques relative to types of dental treatment. Pediatric Dentistry, 6, 199-203.
Gray, J. A. M. (2001). Evidence-based healthcare (2nd ed.). London: Churchill Livingstone, Harcourt Publishers Ltd.
Holst, A., Hallonsten, A. L., Schroder, U., Ek, L., & Edlund, K. (1993). Prediction of behaviour- management problems in 3-year-old children. Scandinavian Journal of Dental Research, 101, 110-114.
Kazdin, A. E., French, N. H., & Sherick, R. B. (1981). Acceptability of alternative treatments for children: Evaluation by inpatient children, parents and staff. Journal of Consulting and Clinical Psychology, 49, 900-907.
Matthew, G. K. (1972). Measuring need and evaluating services. In G. McLachlan (Ed.), Portfolio for health. Oxford: Oxford University Press.
Morgan, R. L. (1989). Judgments of restrictiveness, social acceptability and usage: Review of research on procedures to decrease behavior. American Journal on Mental Retardation, 101, 121-133.
Murphy, M. G., Fields, H. W., & Machen, J. B. (1984). Parental acceptance of pediatric dentistry behavior management techniques. Pediatric Dentistry, 6, 193-198.
Neff, J. (1979) Interaction versus hypothetical other: The use of vignettes in attitude research. Sociology and Social Research, 64, 105-125.
Newton, J. T., Naidu, R., & Sturmey, P. (2003). The acceptability of the use of sedation in the management of dental anxiety in children: Views of dental students. European Journal of Dental Education, 7, 72-76.
Newton, J. T., & Sturmey, P. (2003). Students’ perceptions of the acceptability of behavior management techniques. European Journal of Dental Education, 7, 97-102.
Newton, J. T., & Sturmey, P. (2004). Development of a short form of the Treatment Evaluation Inventory for the acceptability of psychological interventions. Psychological Reports, 94, 475- 481.
Penchansky, R., & Thomas, J. W. (1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19, 127-140.
Sturmey, P., Thomsett, M., Sundaram, G., & Newton, J. T. (2003). The effects of behavior management, child characteristics and outcome on public perceptions of intervention acceptability in paediatric dentistry. Behavioral and Cognitive Psychotherapy, 31, 169-176.
Wolf, M. M. (1978). Social validity, the case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203-214.
World Health Organization / UNICEF (1978). Primary health care, Alma Ata 1978. ‘Health for All’ Series No. 1. Geneva, World Health Organisation.
Worcester, R. (2003). Patient choice. London: MORI / London School of Economics.
Table 1. Sociodemographic Characteristics of Participants Shown by Vignette
Table 2. Mean Scores (and Standard Deviation) for Treatment Evaluation Inventory Shown by the Eight Vignettes
Table 3. Means (and Standard Deviations) of TEI Acceptability Scores for Terms in ANOVA Model
Appreciation is due to reviewers including
Sarah Barker
CPsychol AFBPsS
Department of Oral Health and Development
School of Clinical Dentistry
University of Sheffield
Claremont Crescent
S10 2TA
UK
Karl Woodmansey
PhD
4312 McKinney
no. 3
Dallas
TX 75205
USA