Author's response to reviews

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1 Author's response to reviews Title:A survey of the sociodemographic and educational characteristics of oral health technicians in public primary health care teams in Minas Gerais, Brazil Authors: Mauro H.N.G Abreu Carla A. Sanglard-Oliveira Abdul R.M. Jaruche Juliana V.M. Mambrini Marcos A.F. Werneck Simone D. Lucas Version:2Date:10 November 2013 Author's response to reviews: see over

2 UNIVERSIDADE FEDERAL DE MINAS GERAIS Faculdade de Odontologia Colegiado do Programa de Pós-Graduação Av. Pres. Antônio Carlos, 6627 Pampulha Belo Horizonte MG Brasil Tel. (31) Fax: (31) Site: November 10, 2013 Mario Dal Poz, University of the State of Rio de Janeiro Editor-in-Chief Human Resources for Health Dear Professor Dal Poz, We are submitting the revised version of A survey of the sociodemographic and educational characteristics of Brazilian oral health technicians (dental hygienists) in public primary health care teams, Minas Gerais in response to the suggestions made by the three referees. This cover letter explains the details of our revision. We look forward to hearing from you regarding the result of your evaluation. Yours faithfully, Mauro Henrique N. G. Abreu, PhD, MS maurohenriqueabreu@ig.com.br

3 Reviewer 1 - Dr Sara Holmes 1 Abstract It would be helpful to explain the OHT/Dental Hygienist link which is indicted in the study title. 2 Abstract the final sentence ( There are to different clusters of OHTs..) is repeat of the earlier sentence and should be deleted. 3 Key words the key words could better reflect the exact nature of the study and OHT and education profile should be included. 4 Results It is stated that 79.9% of the participants had up to 11 years of formal schooling. Previously authors state that OHTs must have a minimum of 11 years of formal schooling. The use of the term up to is thus potentially confusing/contradictory and should be amended. 5 Discussion There is a typographical error at the end of the second paragraph should read and should be addressed by 6 Discussion (final paragraph) the term health diagnosis is likely to have wide interpretation and an alternative is advised. 7 Within the discussion the author s suggest that the data could represent the presence of a group of individuals who seem to desire a shift to other professions requiring higher qualification, could it not also be argued that it may represent opportunities for the further professionalization of this sector of the dental team? Reviewer 2 Dr.Cristiana Carvalho 1 Although the questions posed by the authors are not new, they are well defined to describe the sociodemographic and educational profiles of Brazilian OHTs in public primary health care Responses 1 We have modified the study title considering suggestions of reviewer 1 and 3. 2 We have removed this final sentence. 3 We have added these two key words. 4 Thank you for the opportunity of clarifying this issue. Despite of the obligation of at least 11 years of formal education for being OHT, in our study, there are a few OHT (n=3; 1.5%) who reported less than 11 years of formal schooling. This happened probably because the legislation is recent and some OHT may have been formed in the health service itself. We clarified this issue in the discussion section (please see page 10). 5 Thank you again. We have modified this error. 6 We have modified the term collective health diagnosis for The diagnosis of public health issues 7 We have added this discussion on 5 th paragraph. Responses Thank you for your suggestion. We have modified the title.

4 teams in the state of Minas Gerais. I suggest a small change in the title to A survey of the sociodemographic and educational characteristics of oral health technicians in public primary health care teams in Minas Gerais, Brazil, since the research takes place only in Minas Gerais. 2 As of the objectives and methods, it was not clear why the authors adopted the cluster analysis. Considering the variables presented, a descriptive analysis could have reached the same conclusions, especially if they were crossed by one of the selected variables (for example, time since graduation, or years of work as OHT ). In addition, the advantages and limitations of the use of this methodology must also be appointed. Thank you for the opportunity of clarifying this question. Our study aimed to describe the sociodemographic and educational profile of Brazilian OHTs in public primary health care teams in the state of Minas Gerais. (please, see page 4). As a descriptive study, our sample size calculation was based on the formula for description of proportions, as we presented on page 6 The sample size was calculated based on a 50% expected frequency, 95% confidence interval, 5% precision, and finite population of OHT equal to 484. Thus, the sample comprised 231 OHTs who were selected in a simple random manner. In order to maintain the methodological consistence, in the statistical analysis we should develop descriptive and exploratory techniques. So, in Table 1 we presented the descriptive analysis of our sociodemographic variables. In Table 2 we presented the cluster analysis. Cluster analysis (CA) is an exploratory data analysis tool for organizing observed data (in our case, OHT). into meaningful taxonomies, groups, or clusters, based on combinations of independent variables (in our case, sociodemographic and educational characteristics of OHT), which maximizes the similarity of cases within each cluster while maximizing the dissimilarity between groups that are initially unknown. This multivariate analysis creates new groupings without any preconceived notion of what clusters may arise. This data reduction in subgroups enables to manage subgroups in an easier way. Cluster analysis has an advantage, comparing to discriminant analysis, because in cluster analysis, you don t know who or

5 what belongs in which group. You often don t even know the number of groups. One of the difficulties of Cluster analysis is to identify the number of clusters. In our study (please see page 7), The choice of two clusters was due to a better understanding of the phenomenon. Clusters also are interpreted solely based on variables included in them. So, considering our objectives and methods, the use of descriptive (please see Table 1) and exploratory statistical techniques (please see Table 2) is justified. 3 Considering the limited number of variables included, the research lacks sufficient details to replicate the work. In fact, the data collected are not sufficient to contribute to the purposes of the study: the organization of the work process and the effective planning and management of dental primary health care. Also the background fails to give enough information to understand the role of this profession in Brazilian s dental health care team. Hereby I point out some of my concerns to the authors: 3.1 The description of the OHT role in the family health team was not clear. There are two kinds of dental auxiliary personnel in Brazil and the difference between them must be well defined. 3.2 It was not clear if the eleven years of formal education includes professional degree or if it is only basic education. How long does it take to graduate in OHT? Does the sample analyzed have a professional degree? 3.3 If the profession was recognized in 1975, and regulated in 2008, how was it recognized before? That recognition was not an element of professional regulation? Did the professional degree and requisites to be an OHT changed We add this information on page 7 and 8. We modified the presentation of these variables to enable the replication of our study (please see page 7). We agree that the measurement of more sociodemographic variables might be useful for planning and management of public health actions. However, this is the first study that measure, in a representative sample of OHT in Brazil. So as an exploratory study, others researches could be developed. We add this discussion on page 11. We had clarified the difference between this two kinks of dental auxiliary personnel in Brazil (please see page 3). Thank you for you commentary. We had modified the description of each variable. For this classification we considered the basic education (please see page 7) In our sample, 97.1% (95%CI; 93.4% 98.8%) of OHT graduated in OHT. We included this information in the results (please see page.8). Thank you for your commentary. We had changed this phrase (please see page 3).to Although accepted as an occupation since 1975, OHT was only regulated in Brazil in 2008.

6 between 1975 and 2008? This information is important to understand the dynamics of job market, income and educational requirements overtime. 3.4 It seems that the variables presented are not enough to support the conclusions. Some of the following is missing: what kind of procedures does the OHT perform in the team work? With which professions do they work? Which kind of work contract do they have? Is it a permanent or temporary one? (this variable interferes in the income and in the desire to change profession as mentioned in the discussion). Do they work in urban or rural areas? Do they work in small or big cities? How was measured the participation in continuing educational programs: one time, two times, three times; or one course, two courses? What was the extension of the course? Short or long duration courses? Could participation in congress be considered continuing education? We had already included the requisites to be an OHT between 1975 and 2008 (please see page 11). The Brazilian law maintained the old obligation of at least 11 years of formal educational for being OHT. Thank you for the opportunity of clarifying these issues. As we explain before, we agree that the measurement of more sociodemographic variables might be useful for planning and management of public health actions. However, this is the first study that measure, in a representative sample of OHT in Brazil, some useful sociodemographic and educational variables. All our conclusions are valid for Minas Gerais. We do not aim to compare small or big cities, urban or rural areas. So as an exploratory study, others quantitative researches could be developed, measuring these characteristics. We add this discussion on page 11. We also change our objective to the aim of the present study was to describe some sociodemographic and educational characteristics of Brazilian OHTs in public primary health care teams in the state of Minas Gerais. The measurement of participation in continuing educational programs was made by this question; Do you attend any continuing educational programmes in the dental field? yes/no (please see page 7). 3.5 In relation to the sample, why was it not stratified by the size of population and the geographical distribution? Does it not interfere in the data analyzed, like income and desire to change professional status? 4 In relation to the discussion presented I would add a few other considerations since some of the conclusions are not consistent with the findings: Our objective was describe some sociodemographic and educational characteristics of Brazilian OHTs in public primary health care teams in the state of Minas Gerais.. So, a simple random sample design allows us to achieve our objective. Stratified sample is adequate when the objective of the study involves comparisons and it was not important in our study.

7 4.1. First of all, that is not adequate to say that there is feminization of this specific professional category, due to the fact that it has always been feminine profession, almost everywhere It is not adequate to affirm that their low salaries indicate that little value is attributed to this profession, without given information about the salaries of all health auxiliaries and technicians that have the same educational degree and training, and without comparing it to the current salaries of the whole Brazilian economy. 4.3 There is no evidence from the data collected to say that OHTs with more than eleven years of formal education have an over education or qualifications in excess. The authors did not present which kind of education they have to make such statement. Do they have a higher degree qualification? The only fact of having more years of formal training is not a reason to suggest an over education or a possible change in the profession, especially if they have a permanent job in the public sector, as do the OHTs included in this research. 4.4 The comparison with United Kingdom OHT profession was not consistent, since they have a very different context from the Brazilian s dental health personnel regarding the access to health care services and the role of OHTs. Thank you for your commentary. We had changed the discussion (please see page 9). Thank you for the opportunity of clarifying our discussion. We have included this text in our discussion section (please see page 9). In our research, 82.4% of OHT perceived less than the mean income of the personnel without higher education in public sector [17]. Two bills on wage technical professions in healthcare are under evaluation by the Brazilian National Congress. The proposed wage for OHT is less than a half of the proposal of the nursing technician. So, the monthly wage of an OHT provides further proof of the little value attributed to this profession [18,19]. Thank you again for the opportunity of clarifying these issues. As we comment before, the categories of education was better explained on page 7. We also modified the phrase on page 10 to The percentage of OHTs with incomplete or complete university level (more than 11 years of formal schooling) indicates the phenomenon of overeducation, i.e., having educational qualifications in excess of their role [17]. As suggest by other reviewer, we add this phrase to the discussion section On the other hand we could not discard the possibility of this phenomenon may represent opportunities for the further professionalization of this sector of the dental team. (please see page 10). We removed this discussion.

8 4.5 Finally, it is expected that the OHTs with more time of work experience and age to have more opportunities to participate in continuing educational programs and to have higher salaries, particularly if they work in the public sector. In general, the Brazilian public sector provides career plans and/or permanent job s opportunities. In consequence, more time of work means more advantages with respect to the salary and the opportunities to have continuing education. This could suggest that the OHT will not change job easily, even if they have more years of formal education. It would be helpful to see some data about turning over of this profession in the public sector. One last factor to be added to this analyzes is that there is a huge salaries variation in the public sector, since it depends on the local policies and career plans from the municipalities. Reviewer 3 Dr.Yolanda Flores-Peña The research question is well defined and is relevant for to study of human resources. The methods are appropriated and well described. The statistical analysis is adequate. I considered that only mention that in Brazil, no such studies have been conducted with representative samples is no sufficient for justification of study. Thank you for your recommendations. We add these issues on the Discussion section. Considering that our study is an explanatory and descriptive one, we reinforce the need of further researches using qualitative and quantitative methodologies. Responses Thank you for your evaluation. Thank you for the opportunity of clarifying the relevance of our study. We have modified the position of this phrase and we considered that the justification of our study is now clearer (please see 3 rd paragraph in the Background section, page 4). Therefore, the present study is relevant for the Brazilian public health system (Unified Health System) [9], as more thorough knowledge of this human resource is crucial for the effective planning and management of primary health care. In addition, it might represent an effective contribution to the knowledge of personal and regional characteristics of the OHTs, thus strengthening the theoretical-practical coherence of the work process. Besides, in Brazil, no such studies have been conducted with representative samples of OHTs.

9 General comment Considering the valuable commentaries made by the reviewers, we also included acknowledgments for them in the manuscript (Please see page 14). Prof. Mauro Henrique N. G. Abreu