The facilitating factors and barriers influencing change in dental practice in a sample of English general dental practitioners

AIM

The objective of this study was to investigate the barriers and facilitators to change in dental practices among a sample of general dental practitioners (GDPs) from three regions of England.

METHOD

In-depth face-to-face interviews with 60 GDPs were undertaken. The sample was selected from a group of 317 GDPs who had completed a questionnaire in the first phase of this study. The participants were selected to reflect diversity regarding the number and extent of self-reported changes reported in the questionnaire, and personal and practice characteristics. Of the 92 attempted contacts, 60 (65%) of the interviews were successfully completed. The interview schedule formed the basis of the interview. All the interviews and notes were transferred on to NUD*IST QSR version 4, a qualitative analysis package.

RESULTS

No single factor was identified as being more important than another in facilitating change. The main facilitators for change were: financial factors, regular patient attendance, particularly a core patient group, staff loyalty, having regular staff meetings and open communication and having access to peer support. The main barriers to change were the reverse of the facilitators plus not having a financial stakehold in the practice.

CONCLUSIONS

A range of factors were identified as influencing change in general dental practice. These include GDPs' attitudes and experience of change, patient factors, organisational issues, contact with peers and access to appropriate training courses.

The prevalence and nature of recent self-reported changes in general dental practice in a sample of English general dental practitioners

OBJECTIVE

To determine the extent and types of change in seven domains of dental practice in a sample of English general dental practitioners (GDPs).

METHODS

A postal questionnaire was sent to 561 GDPs on the dental lists of three health authorities in diverse regions of England. Information collected included demographic details on personal and practice characteristics, self-rating of amount of change in the seven domains of practice and factors influencing change.

RESULTS

The response rate was 60%. Fifty-six per cent of the sample were under 40 years old. Over a third of respondents reported "changing a lot or completely" certain clinical activities, practice management arrangements and practice amenities. The highest self-reported level of change was in clinical activities. Of the GDPs who reported changing their clinical activities, 56% reported an increase in preventive care, followed by crown and bridge (44%), periodontics (44%) and endodontics (43%). Practice management rated second in the mean rank scores for self-reported change. The main changes reported were the introduction of computer systems and employment of practice managers. A sizeable percentage (66%) reported increasing the amount of information they provided to patients and the time spent discussing care. Quality assurance activities were the area of practice least likely to have changed over a 5-year period. Over half the sample reported not being involved in any quality assurance activities in the previous 5 years. Those respondents who were younger, had a postgraduate qualification and earned more than 20% of their income from private practice reported higher levels of change.

CONCLUSIONS

General dental practitioners' work patterns are dynamic and appear to be responding to changing needs and demands on their service. The main changes were in the types of clinical procedures being carried out. The low prevalence of changes reported in auditing and peer review activities needs to be investigated further.

143DIETARY CARBOHYDRATES AND LIPIDS AFFECT IN VITRO EMBRYO PRODUCTION FOLLOWING OPU IN HEIFERS

The superstimulation protocol of Blondin et al. (2002; Biol. Reprod. 66, 38–43) produces cumulus-oocyte complexes (COCs) of high developmental competence for IVP. Using a similar protocol we assessed the affects of alterations in oocyte donor carbohydrate and lipid metabolism during ovarian stimulation on the production and viability of blastocysts in vitro. A 2×2 factorial experiment offered two diets: Fiber (F) and Starch (S) alone (0) or with 6%w/w (6) protected lipid (calcium soaps of fatty acids). Thirty-two heifers ranked by body condition score (scale: 1=thin, 5=obese) were allocated within score to one of the 4 treatments: F0, F6, S0 and S6. COCs were collected 5 days after estrus by OPU for lipid analysis. Ovarian stimulation (4 doses of FSH (9mg NIADDK oFSH) given 12h apart) commenced 2 days later. COCs were collected 40h after the last FSH injection. GnRH (0.012mg Buserelin) was administered i.v. 6h prior to OPU. A second period of ovarian stimulation and OPU then followed. Following IVM/IVF, zygotes were cultured in SOF with 0.3%w/v fatty acid-free BSA under oil (38.8°C, 5% CO2, 5% O2, 90% N) until Day 8 of development, when blastocysts were subjected to total cell counts and TUNEL analysis. Data were analyzed by ANOVA. Neither follicles aspirated (25.9±1.87) nor oocytes recovered (12.1±0.92) differed between treatments. Total fatty acids in plasma were greater (P<0.001) for the F than for the S diets and increased with the inclusion of protected lipid (0.75, 1.82, 0.50 and 1.39μgmL−1 for F0, F6, S0 and S6, respectively; SED=0.076). The dietary lipid-induced increase in plasma fatty acids was reflected in an increase (P<0.05) in total fatty acids within the oocyte (70.4, 74.7, 69.9 and 78.4 ng/oocyte; SED=3.41). Retrospective analysis by body condition indicated that S diets reduced (P=0.006) blastocyst yields in thin heifers and reduced (P=0.02) cleavage rates in fat heifers (Table 1). Blastocyst yields were lower (P=0.1) for fat heifers on the F0 diet. Total cell numbers were greater for thin heifers on S0 than F0 diet. TUNEL-positive cells averaged 4.2±0.48% and did not differ between treatments. In conclusion, modification of oocyte donor carbohydrate and lipid metabolism prior to OPU can influence IVP outcome in a complex manner dependent on body composition. Supported by Defra and The Perry Foundation. Table 1 In vitro blastocyst yields and total cell numbers

Evidence-based dentistry: an overview of the challenges in changing professional practice

A great deal of effort and resources are currently being directed at developing an evidence-based approach to healthcare delivery. The success of the evidence-based movement will depend upon the provision of necessary support to help GDPs achieve change. This paper aims to give an overview of current knowledge on what types of interventions are most effective at changing health professionals' clinical practices. Barriers to change are highlighted and the implications for the development of evidence-based dentistry are considered. Further research on organisational, social and personal influences affecting the application of evidence-based practice is necessary.

Oral health promotion evaluation--time for development

Increasing emphasis is now being placed upon the evaluation of health service interventions to demonstrate their effects. A series of effectiveness reviews of the oral health education and promotion literature has demonstrated that many of these interventions are poorly and inadequately evaluated. It is therefore difficult to determine the effectiveness of many interventions. Based upon developments from the field of health promotion research this paper explores options for improving the quality of oral health promotion evaluation. It is essential that the methods and measures used in the evaluation of oral health promotion are appropriate to the intervention. For many oral health promotion interventions clinical measures and methods of evaluation may not be appropriate. This paper outlines an evaluation framework which can be used to assess the range of effects of oral health promotion programmes. Improving the quality of oral health promotion evaluation is a shared responsibility between researchers and those involved in the provision of programmes. The provision of adequate resources and training are essential requirements for this to be successfully achieved.

Obesity, NIDDM, Adipogenesis and Insulin Resistance - IBC's Ninth International Conference

Approximately 70 representatives from industry and academia attended IBC's Ninth International Conference on Obesity, NIDDM, Adipogenesis and Insulin Resistance. It was characterized by intense and in-depth presentations on topics ranging from the costs (both human and financial) associated with obesity and diabetes and their complications to the use of animal models and progress in the identification/characterization of new drugs and/or drug targets. The conference was divided into three, distinct sessions, each of between six and eight talks, including an opening keynote address by Dr Susan Jebb on the etiology and implications of obesity treatment.

Photoassembly of the manganese cluster and oxygen evolution from monomeric and dimeric CP47 reaction center photosystem II complexes

Isolated subcomplexes of photosystem II from spinach (CP47RC), composed of D1, D2, cytochrome b(559), CP47, and a number of hydrophobic small subunits but devoid of CP43 and the extrinsic proteins of the oxygen-evolving complex, were shown to reconstitute the Mn(4)Ca(1)Cl(x) cluster of the water-splitting system and to evolve oxygen. The photoactivation process in CP47RC dimers proceeds by the same two-step mechanism as observed in PSII membranes and exhibits the same stoichiometry for Mn(2+), but with a 10-fold lower affinity for Ca(2+) and an increased susceptibility to photodamage. After the lower Ca(2+) affinity and the 10-fold smaller absorption cross-section for photons in CP47 dimers is taken into account, the intrinsic rate constant for the rate-limiting calcium-dependent dark step is indistinguishable for the two systems. The monomeric form of CP47RC also showed capacity to photoactivate and catalyze water oxidation, but with lower activity than the dimeric form and increased susceptibility to photodamage. After optimization of the various parameters affecting the photoactivation process in dimeric CP47RC subcores, 18% of the complexes were functionally reconstituted and the quantum efficiency for oxygen production by reactivated centers approached 96% of that observed for reconstituted photosystem II-enriched membranes.

An alarming lack of public awareness towards oral cancer

OBJECTIVE

To determine public awareness and knowledge of oral cancer in Great Britain.

DESIGN

The respondents were selected according to a systematic probability sample designed to be representative of all adults in Great Britain (GB). The overall design was similar to previous omnibus surveys carried out by National Opinion Poll (NOP). The survey was carried out in ten regions of GB in September 1995 and was commissioned by the Health Education Authority (HEA).

SUBJECTS AND METHODS

A random sample of 1,894 members of the public over the age of 16 years were asked in face-to-face interviews their knowledge relating to cancer, with particular reference to oral cancer, its causes and those at high risk and general attitudes to cancer.

RESULTS

Oral cancer was one of the least heard of cancers by the public with only 56% of the participants being aware, whereas 96% had heard of skin cancer, 97% lung cancer and 86% cervical cancer. There was a 76% awareness of the link between smoking and oral cancer but only 19% were aware of its association with alcohol misuse. Whereas 94% agreed that early detection can improve the treatment outcome, a disheartening 43% believed that whether a person developed a cancer or not was a matter of chance and therefore was unavoidable.

CONCLUSIONS

This survey highlights a general lack of awareness among the public about mouth cancer and a lack of knowledge about its causation especially the excess risk associated with alcohol.

RECOMMENDATIONS

There is a clear need to inform and educate the public in matters relating to the known risk factors associated with oral cancer. A media campaign informing the public about oral cancer is clearly required. The need for the reduction in the incidence of oral cancer should be included in 'Our healthier nation' targets. An overall health promotion strategy to reduce cancers should include oral cancer as a priority. In addition the European Code against Cancer which aims to improve prevention, the early detection of oral cancer and the necessity for fast track referral should be made more widely known. Recognition of oral cancer in local strategies for oral health should be encouraged.

Inequalities in oral health: a review of the evidence and recommendations for action

Reducing inequalities in health has become one of the main health policy issues in the late 1990s. The Labour Government set up an independent inquiry into inequalities in health under Sir Donald Acheson to make recommendations on approaches to reducing health inequalities. This paper reviews the evidence on inequalities in oral health in Britain. Dramatic improvements in dental health in children and young adults have taken place in the past 30 years. The levels of caries in permanent teeth of children is low. Widening inequalities in oral health however exist between social classes, regions of England, and among certain minority ethnic groups in pre-school children. The main social class and minority ethnic differences in dental caries is in pre-school children. Wide district and regional differences also exist in prevalence of caries in young children. The area differences relate very strongly to deprivation. In adults the differences in decay experience is less unequal than in children but there are marked social class inequalities in edentulousness. Dental caries decreased in all social classes in the United Kingdom. The main causes of the inequalities are differences in patterns of consumption of non milk extrinsic sugars and fluoridated toothpaste. Improvements in oral health that have occurred over the last 30 years have been largely a result of fluoride toothpaste and social, economic and environmental factors. Oral health inequalities will only be reduced through the implementation of effective and appropriate oral health promotion policy. Treatment services will never successfully tackle the underlying cause of oral diseases.

UBI4, the polyubiquitin gene of Saccharomyces cerevisiae, is a heat shock gene that is also subject to catabolite derepression control

Carbon and nitrogen regulation of UBI4, the stress-inducible polyubiquitin gene of Saccharomyces cerevisiae, was investigated using a UBI4 promoter-LacZ fusion gene (UBI4-LacZ). Expression of this gene in cells grown on different media indicated that the UBI4 promoter is more active during growth on respiratory than on fermentable carbon sources but is not subject to appreciable control by nitrogen catabolite repression. UBI4-LacZ expression was virtually identical in cells having constitutively high (ras2, sra1-13) or constitutively low (ras2) levels of cyclic AMP-dependent protein kinase activity, indicating that this kinase does not exert a major influence on UBI4 expression. Catabolite derepression control of the UBI4 promoter was confirmed by measurements of UBI4-LacZ expression in hap mutant and wild-type strains before and after transfer from glucose to lactate. Mutagenesis of the perfect consensus for HAP2/3/4 complex binding at position -542 resulted in considerable reduction of UBI4 promoter derepression with respiratory adaptation in HAP wild-type cells and abolished the reduced UBI4-LacZ derepression normally seen when aerobic cultures of the hap1 mutant are transferred from glucose to lactate. This HAP2/3/4 binding site is therefore a major element contributing to catabolite derepression of the UBI4 promoter, although data obtained with hapl mutant cells indicated that HAP1 also contributes to this derepression. The HAP2/3/4 and HAP1 systems are normally found to activate genes for mitochondrial (respiratory) functions. Their involvement in mediating higher activity of the UBI4 promoter during respiratory growth may reflect the contribution of UBI4 expression to tolerance of oxidative stress.

Psychophysical Discrimination of Spatial Structure in Natural Images

We report a series of experiments in which subjects were required to make spatial discriminations about naturally obtained images, as follows. Subjects were shown two natural images on a computer screen, side by side and for a period of 500 ms. Subjects were then shown, on a separate part of the computer screen, a small patch of one of the images selected at random. Subjects were required to decide which of the two full images the patch comes from, and whereabouts in that image it is taken from. They indicated their response by clicking the mouse cursor at the appropriate point on the screen.

The proportion of trials on which the subjects selected the correct image and the accuracy of the spatial position of their correct responses were calculated. These two measures independently indicate the general discriminability of the two image sets, and the extent to which the spatial layout of the image has been perceived. By comparing response accuracy for images that are from different sets (such as mountain or town scenes) with response accuracy when the two images are from the same set it is possible to establish the image properties that underlie coarse scene apprehension. By using sets of images that are perhaps best described as being natural textures (such as patterns of foliage or rock surface) it is possible to measure the extent to which texture is processed spatially. Our results are interpreted in the light of statistical differences between the image sets that we have used.

Statistical Analysis of Spatial Structure in Natural Images

When a sample of natural images is taken and compared with a set of noise images, the two are obviously distinguishable. Even when the noise images are set to have the same power spectral characteristics as the natural images, there is no doubt which is a normal image and which is a noise image. In the study to be reported, we have examined the nature of the spatial characteristics of natural images that allow them to be so discriminated from noise images.

The approach is to process large sets of images belonging to various categories through mechanisms that have some similarities to known operations in biological visual systems. Thus, the images are filtered at various spatial scales and at various orientations; the filter outputs are combined into local energy maps; and features are detected in such processed images. The result of these calculations is the distribution of values of some parameter which describes a particular image characteristics for each set of images. Parameters that could support adequate discrimination between two sets of images, for example natural images and noise images, will have largely non-overlapping distributions.

In practice it is found that no simple parameters can distinguish obviously different sets of images, but parameters that encapsulate spatial patterns, especially those related to non-accidental image properties, can do so. It is concluded that filter outputs must be followed by nontrivial spatial operations. Suggestions are made as to what are the most plausible.