Shared Partnership for Care: A Mixed-Methods Evaluation of Métis Access to Dental Services at the Mike Petryk School of Dentistry

Introduction

Driven by a strong commitment to collaborating with the community and enhancing the educational experiences of its students, the Mike Petryk school of dentistry (MPSoD) at the University of Alberta in Edmonton, Alberta, recognized the need to create diverse learning experiences and promote the development of cultural sensitivity among dental students.^1,2 Exposure to these learning opportunities during training may also help to improve dentistry students’ clinical preparedness to provide dental care to underserved populations.²

The MPSoD has actively explored opportunities to modify its clinical program and develop functional relationships with community groups. It is well documented that in Canada, Indigenous children incur higher rates of early childhood caries than non-Indigenous children.^3-5 Until the recent implementation of the Canadian Dental Care Plan, Métis citizens did not have access to publicly funded dental insurance programs, such as the Non-Insured Health Benefits program, that are available to other Indigenous groups.⁶ The MPSoD initiated strategic discussions with the Otipemisiwak Métis Government of the Métis Nation within Alberta (MNA), a self-governing body that aims to advance the overall well-being of its more than 70 000 citizens through socioeconomic and cultural support.^7,8 A shared partnership agreement between the MPSoD and the MNA was developed to provide a broad range of oral health services for all Métis children (excluding orthodontics) and for selected adults with emergency needs.

The partnership’s clinical program began in 2020, whereby a designated individual from the MNA coordinated with the MPSoD to schedule appointments for each Métis citizen. Children were eligible for comprehensive dental care, including restorations, extractions, dental hygiene therapy, space maintainers and pulpotomies. Adults were eligible for emergency care, including extractions and open-and-drain endodontics; however, when time permitted, periodontal debridement was occasionally performed for adults.

This study primarily aimed to understand the dental services provided to Métis citizens attending the dentistry student clinic at the MPSoD. Secondarily, the study aimed to gather perspectives from Métis citizens regarding their experiences with dentistry students at the clinic.

Methods

Study design

A concurrent mixed-methods design guided this study.⁹ The Health Research Ethics Board at the University of Alberta approved this study (Pro00110090).

Quantitative phase

Data were retrieved from electronic dental charts for all available Métis patients who attended the MPSoD clinic between July 1, 2020, the partnership start date (when the clinic was first reopened during the pandemic) and July 8, 2021, the end of the intersession term for students. Fourth-year dentistry students provided dental care under the supervision of University of Alberta dental instructors. Anonymity of the patients’ chart data was maintained by having an administrative custodian in the MPSoD, external to the research team, extract the patient data, eliminate identifying information and deliver the anonymized data to the research team. The retrieved data included patient demographic characteristics (e.g., age and postal code), the number of dental visits and the dental services received at each visit.

Data analysis involved generating descriptive statistics to summarize the treatments and patients’ demographic information. Data were compared in terms of numbers of visits and the treatments required, patients’ age and sex, distance travelled to the clinic (based on postal code) and frequency of services provided. Participants’ age was stratified using guidelines from the Canadian Health Measures Survey.¹⁰ To analyze the dental services provided, dental procedure codes were categorized according to the nature of the service (diagnostic, preventive or treatment), as displayed in Table 1. All analyses were completed using the JASP statistical software platform (version 0.19.3; University of Amsterdam, Amsterdam, The Netherlands).

Qualitative phase

Individual interviews with Métis patients were conducted between May and August 2022 to explore their experiences in the student dental clinic. The overall sample from the chart audit consisted of children and adults in a ratio of about 4 to 1; therefore, it was decided to recruit the parents of 8 pediatric patients and 2 adult patients for the interviews, to represent similar proportions of participants.

Recruitment of participants for interviews was completed by the MNA health programs administrator, who also facilitated collaborative activities with the MPSoD to support Métis citizens in terms of informing them about the dental services available and scheduling appointments. Interviews were scheduled with the first 10 people who responded to the invitation and fit our criteria for the interview sample. The purpose of interviewing participants was to gain some perspective on receipt of dental services in the clinic and was not meant to be an exhaustive exploration. Therefore, the number of interviews was predetermined to minimize the burden of participation for participants and to respect the community relations that had been built with the MNA. The interviews were conducted by 2 female members (S.D., P.D.) of the research team, who are Métis citizens and clinical instructors in the university’s dental and dental hygiene programs, respectively.

Each interview participant was given a $50 gift card, as per recommended practices.^11,12 The interviews were completed and audio-recorded online (Zoom collaboration platform, version 5.11.6; Zoom Video Communications, San Jose, CA) or by telephone. The use of virtual interviews aimed to enhance accessibility for participants. The participants provided oral consent, which was documented in the transcript of each interview. The research team developed a script of open-ended questions for the semistructured interviews (see Table 2).

The interviews were transcribed verbatim by a transcription company (Transcript Heroes, Toronto, ON). One research team member (S.M.C.) verified transcription accuracy. Inductive thematic analysis was used to analyze the data. Four members of the research team (S.M.C., S.D., P.D., M.N.Y.) read each transcript independently and developed initial data codes. The same people worked together to develop a coding scheme based on these initial codes, and the research team as a whole confirmed the coding scheme following discussion and consensus. The codes were then grouped into broader themes and subthemes to describe participants’ experiences in the MPSoD dentistry student clinic.

Results

A total of 216 patients, 45 adults and 171 children, were referred through the MNA and scheduled for dental appointments at the MPSoD clinic during the study period. Table 3 shows the patient distribution by age for both adult and pediatric cohorts.

Patient characteristics and dental services provided

Adult emergency patients

The 45 patients who attended the adult emergency program ranged in age from 19 to 79 years. Overall, 66.7% (n = 30) of the patients lived within the Edmonton and metro areas, meaning they had to travel by car for 60 minutes or less to reach the clinic (Table 4). The remaining 33.3% (n = 15) of patients travelled from outside the Edmonton area, meaning that one-way driving time by car was more than 60 minutes.

The average number of clinic visits per adult patient was 3.0. More specifically, 51.1% (n = 23) of the adult patients visited the clinic 1 or 2 times, 26.7% (n = 12) visited 3 or 4 times, and 22.2% (n = 10) visited more than 4 times (Table 4). Of the 372 dental procedure codes for adults, 9.1% (n = 34) were for prevention, 62.4% (n = 232) were for diagnosis, and 28.5% (n = 106) were for treatment (Table 4). The most common dental services were extraction of root tips, extraction or removal of impacted teeth, and open-and-drain endodontic procedures. The program for adults aimed to address emergency dental needs; however, some case-specific procedures were also completed for preventive purposes.

Pediatric patients

In the pediatric program, 171 patients received dental services during the study period. The proportion of pediatric patients who travelled to the clinic from a location within the Edmonton and metro areas (a one-way drive of 60 minutes or less) was 59.1% (n = 101) (Table 4). The proportion who travelled from outside the Edmonton area (a one-way drive of more than 60 minutes) was 40.4% (n = 69). For one patient, distance could not be determined because postal code information was missing.

Of the 171 pediatric patients, 64.3% (n = 110) visited the student dental clinic 1 or 2 times, 28.1% (n = 48) visited 3 or 4 times, and 7.6% (n = 13) visited more than 4 times (Table 4). Of the 1732 dental procedure codes recorded, 41.6% (n = 721) were for preventive services, 40.6% (n = 704) were for diagnosis, and 17.7% (n = 307) were for treatment (Table 4).

Experiences at the MPSoD clinic

Ten individual interviews were completed. Eight of the interviews were conducted with parents of pediatric patients, and 2 interviews were conducted with adult patients. All of the parents were mothers. Of the 8 mothers, one each had 1, 3 and 4 children receiving care, and the remaining 5 mothers each had 2 children. Of the 2 adult patients interviewed, one identified as female and the other as male.

Three themes were identified: interactions with dentistry students, clinical environment and processes, and accessing dental services at the dentistry student clinic. Table 5 displays these themes, their subthemes and representative quotes for each.

Within the first theme, interactions with dentistry students, 2 subthemes were identified: the perceived clinical ability of the students and increased anxiety about receiving clinical care from students. The parents and patients perceived the quality of care provided by the students to be professional, kind and appropriate for building rapport with patients. Some participants initially expressed apprehension about receiving services from dental students, but this anxiety quickly subsided once they interacted with the student and the procedure commenced. Participants realized that the students were competent and felt they were in good hands for themselves or their children. One parent reported the following experience:

Um, the only thing I would have been concerned about is like if they [students] were just learning. Like, you know, when they’re just learning on kids, that was my only concern. But, after we came, I felt that there was no concern.

The second theme, clinical environment and processes, had 3 subthemes: clinical staff and dentistry instructors, challenges in completing multiple clinic forms when more than one child was receiving dental care and length of time for the appointment relative to private clinics. Participants reported positive interactions with clinic staff and were further reassured about being in a student clinic when they interacted with the clinical instructors, who were readily available to guide the students. One parent stated the following:

It seemed like, you know they [clinical dental instructors] were constantly walking around and checking and asking questions to the students. And the students would wait until the instructor came around.

A few participants with more than one child in the clinic described some challenges completing multiple clinic forms, but also recognized that, overall, it was not a significant issue. Some participants also found the long appointment times to be a bit challenging. However, in the overall experience, they understood why the sessions were more extended and why multiple appointments might be required. One parent shared the following:

If I had to make one comment, it would just be that the appointment was lengthy. But I understand the learning process and waiting for an instructor to come and give feedback …

The third theme, accessing dental services at the MPSoD, had 4 subthemes: navigating the city of Edmonton and the university campus, parking, time required to travel to the clinic and coverage for dental services. Navigating the unfamiliar university campus and the Kaye Edmonton Dental Clinic building, as well as the city (since some study participants were from out of town), created some anxiety. Finding and paying for parking was a common issue reported by participants, despite the parking cost being an expected expense. Some participants reported driving long distances one way to attend the MPSoD dental clinic; however, the longer drive was offset by numerous advantages. These advantages included the efficiency of dental care in the clinic, the compassion shown by students and dental instructors, decreased or no fees for dental services, and support from the MNA, including hotel and gasoline vouchers.

All participants cited the cost of dental services and dental coverage as a barrier to receiving dental care at a private dental clinic. Most participants cited not having dental insurance, having recently lost coverage, and being financially unable to afford dental care services for themselves or their children. They were appreciative of the opportunity to receive care for their children or themselves, made possible through the collaboration between the MNA and MPSoD. One parent explained the situation as follows:

We’re right on the cusp where we don’t have extended health coverage, being self-employed. And we’re like $2000 above the government program for dentistry. So affordable care has been difficult, financially, to access and yes, we decided that we should probably … do it [come to the MPSoD through the MNA].

Discussion

In this study, we aimed to understand the dental services provided to Métis citizens and their perspectives on receiving dental care from dentistry students at the University of Alberta’s MPSoD clinic. Most of the patients were children, and nearly half had to travel more than 60 minutes one-way to access dental services. Most of the procedures were diagnostic services, followed by preventive services. The Métis patients at the MPSoD clinic perceived their experiences as positive, although they reported some barriers associated with accessing the clinic (e.g., travel time and parking).

As noted above, after diagnostic procedures, preventive services were the most frequently provided type of dental service, followed by treatments such as pulpotomies, extractions and periodontal therapy. Previous literature has primarily focused on the promotion of oral health and preventive services for children from Indigenous communities, more specifically registered Métis, First Nations and Inuit children, with a high number of atraumatic restorative procedures being reported among these populations.^1,3,4

For adult patients, treatments were primarily for emergency care, given the nature of the partnership with the MNA. The dental services delivered are aligned with the primary emergency care needs of general adult populations, which are often associated with pain-related experiences.¹³ However, in some cases, the diagnosis revealed an urgent need for periodontal debridement; therefore, if time permitted, this treatment was completed along with preventive measures, including fluoride application.

Although the dental services provided to both children and adults were essentially the same as those provided to the general population,^13,14 the Métis community has faced some barriers to accessing care, as highlighted by the qualitative phase of the present study. Also, many of the patients attended the relevant program 3 or more times (48.9% of adult patients, 35.6% of pediatric patients). Some adult and pediatric patients required multiple visits to complete complex dental care. These results may suggest the need to understand how accessibility challenges affect the dental care received by members of these communities, particularly among those requiring multiple visits. Previous studies have shown that frequent visits combined with travelling large distances increase the potential for lost wages, the travel costs for parents and individuals, and the number of school days missed for children and youth.^15,16

Data shown in Table 4 indicate that 40.4% of children and 33.3% of adults seen at the MPSoD had to travel more than one hour to attend their appointments. Similar to the impact of having to return multiple times for treatment, travelling long distances represents a significant accessibility barrier to dental care.¹⁵ The challenge associated with long trips has previously been identified among children from Métis and First Nations communities in Manitoba, Canada.¹⁷ However, strategies to enhance rural and remote care services are challenging and complex.

This study’s secondary aim explored Métis citizens’ perspectives on their experiences with the dental clinic and dentistry students, revealing 3 key themes: interactions with dentistry students, the clinical environment and processes, and accessing dental services at the dentistry student clinic. Interactions with dentistry students were perceived as overwhelmingly positive. Interview participants consistently pointed to students’ kindness, professionalism and thorough explanations. This finding aligns with previous research on patient satisfaction in student-provider clinics.^17,18 Initial parental apprehension about students providing care was often alleviated after positive interactions and observations of the guidance provided by clinical instructors, which echoes findings of reduced patient anxiety after treatment in student-provider settings.¹⁹ The clinical environment and its processes were also discussed in the interviews. Participants commented positively on the clinic staff and instructors, but also noted challenges related to managing multiple children and the extended appointment durations inherent in a teaching clinic. These aspects reflect the distinct nature of a dental school clinic, which by necessity must prioritize student learning and rigorous protocols, differentiating it from private practice.²⁰ Finally, accessing dental services at the MPSoD, in terms of travel and related aspects, emerged as a significant barrier. Families reported that the location of the clinic on the university campus impeded their ability to receive care, consistent with access challenges faced by other Indigenous communities in Canada.^3,21 Strategies to mitigate these barriers, such as providing previsit parking information and financial assistance for travel and accommodation, were identified as beneficial. These findings underscore the critical need to develop targeted strategies to enhance dental care accessibility for diverse populations.

Although this study is not generalizable to the entire Métis population, it provides insight into the dental services required by patients and their experience receiving care from dentistry students at a large dental clinic within an educational setting. This study also demonstrates how a dental school can engage with the community to bring learning experiences to students while providing needed services. Future studies could explore how the partnership has been sustained over time, how additional treatment services are incorporated and how the involvement of dental hygiene students could affect service delivery for Métis patients. Additionally, students’ perspectives on their preparedness for and confidence in providing care to Metis patients could be explored. Lastly, a future study could explore how students’ cultural sensitivity was affected through engagement with Métis patients.

Conclusion

The partnership between the Otipemisiwak Métis Government of the MNA and the MPSoD provided a new pathway for access to care for Métis citizens. The patients had positive perceptions of the care they received. Through this collaborative partnership, MNA citizens received needed dental services, while students benefited from learning experiences with Métis citizens.

Acknowledgements

The Alberta Indigenous Mentorship in Health Innovation Network (AIM-HI Network) and the University of Alberta school of dentistry undergraduate summer research student program funded Terri Ward’s participation as an undergraduate summer research student. Research funding was also provided through a seed grant from the Situated Knowledges: Indigenous Peoples and Place (SKIPP).

THE AUTHORS

	Dr. Compton is a professor, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
	Dr. Fernandes Fagundas is a research associate, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
	Dr. Depledge is a CC Director & Assistant Clinical Professor, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
	Ms. Bartel is Director of Health, Otipemisiwak Métis Government, Alberta, Edmonton, AB
	Ms. Anderson is Health Associate Director at Métis Nation of Alberta, Edmonton, AB
	Ms. Ward is a Registered Dental Hygienist, Edmonton, AB, Canada
	Dr. Lai is a Professor, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
	Ms. Dahlseide is Assistant Clinical Professor and Program Lead at Wâpanachakos Indigenous Health Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
	Dr. Yoon is Associate Professor, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada

Corresponding author: Dr. Sharon M. Compton, Mike Petryk School of Dentistry, University of Alberta, 5-555 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB T6G 1C9. Email: scompton@ualberta.ca

The authors have no declared financial interests.

This article has been peer reviewed.

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