Dentists’ entrepreneurial intention and associated factors in public hospitals in major cities in Guangdong (South China): a cross-sectional study

Dentists traditionally have a higher level of entrepreneurship, or are more likely than other healthcare professionals (such as physicians, surgeons or nurses), to start up their own practice, or move into private practice [1, 2]. Entrepreneurship refers to the ability to identify new opportunities, the possession of executive skills to obtain resources and implement plans, as well as leadership skills, including risk attitude and tolerance [3, 4]. Specifically, the concept of entrepreneurship in dentistry involves initiating or developing a dental practice or relevant business, organizing the necessary financial and human resources, and taking the associated risks and rewards [4]. Dentists may also be engaged in the manufacturing of dental instruments, equipment or materials. During the past decades, as results of healthcare reforms worldwide, market factors (such as service competition and patient satisfaction) are playing an increasingly important role in the operation environment of dentistry. Promoting the entrepreneurship of dentists has increasingly received attention in both dentistry and dental education worldwide [1, 4, 5]. To achieve this goal effectively, it is necessary to have an in-depth understanding of dentist’ entrepreneurial intention (EI) and related influential factors.

Entrepreneurial intention (EI) is defined as “the conscious state of mind that precedes action and directs attention toward entrepreneurial behaviors such as starting a new business and becoming an entrepreneur” [6, 7]. As the first stage of a series of actions in organizational founding, EI is an important part of the business planning process [8, 9], reflecting an individual’s readiness to engage in subsequent entrepreneurial activities [10‐14]. It may also be influenced by factors, such as an entrepreneur’s demographic, professional knowledge, technical skills, entrepreneurial behaviors [15], as well as psychological characteristics [16, 17]. Employees in knowledge–intensive industries may demonstrate entrepreneurial intention and behaviors with some unique features [16‐18]. For example, in general, business entrepreneurs are more likely to be active with start-up and innovations in their 20s [19‐21], whereas dentists’ optimal time for starting a private practice may be postponed due to education and professional qualification requirements. Other factors, such as a family business background or the social-cultural environment, may also influence an individual’s EI through the channels of social skills development, confidence and business values [22, 23].

Due to traditional ignorance about oral health and past social-economic reasons, the general oral health status of Chinese residents is a serious concern and there has been a rapid growth in demand for dental service [24]. In 2017, the caries incidence of the population was greater than 50%, and less than 50% of the residents had a healthy periodontal condition [25]. The caries incidence for children at age of 5 years was 70.9%, and 34.5% at the age of 12 years [25]. For adults between the age of 35 and 44 years, the dental cavity detection frequency was 96.7% and the gingival bleeding detection frequency was 87.4% [25]. With the significantly enhanced awareness of preventive dental health and improved living standards in China during the past decade, public demand for dental care surged quickly with an annual growth rate of about 11% [26]. In 2020, China's dental care market was estimated to be worth RMB100 billion (US$14 billion) [26].

The current social health insurance scheme in China only covers minimum basic treatment-oriented dental services and does not include prevention-oriented dental care services, dental crowns with advanced materials, orthodontics or dental implants [24]. It is estimated that over 85% of the dental costs have to be paid out of pocket [24]. Many urban middle-class residents, especially those in central cities, prefer to choose private dental clinics because they are willing to and can afford to pay for the better patient experience provided by private dental clinics [27, 28]. These private clinics can provide a facility with a patient-friendly environment, patient communications with patients, advanced diagnostic and treatment equipment, a short or no waiting time, flexibility in appointments, and so on [26, 29, 30].

At the current stage, the dental care supply in China is still insufficient to meet the rising demand. By 2018, there were 314,347 trained dentistry personnel in mainland China, among whom 171,587 (54.6%) were dentists, 37.8% were dental nurses and 7.6% were dental technicians. The density of dentistry personnel (per 1000 population) was about 0.129 in 2018, while the WHO standard is 0.2 [31]. There were in total 75,399 dental service units among all healthcare providers in mainland China [31]. By institution number, 73.8% of these service units exist as dental departments of general hospitals [24].

To improve the supply of dental health care, over the past five years there has been some policy reforms in China, such as multi-sited practicing by qualified dentists and a simplified process of private clinic license application and approval. Significantly, there are favorable policies encouraging private venture capital to enter the dentistry field in China [24, 32]. Due to these reasons, investment capital has actively flowed into the private dental sector and some large oral-care companies have tried to establish chain clinics through the acquisition of existing stand-along clinics, especially those owned and operated by qualified dentists (for example, dentists who graduated from leading dental schools or who are working in top public hospitals in the region) [26, 29, 33]. The rapid growth of the private dental care market in China has created a high demand for qualified dentists with entrepreneurship from public hospitals, where most dentists practice and develop in their sophistication of practice [26]. While a career in public hospitals may provide job security and a decent professional reputation, private practice and dental entrepreneurs have the advantages of a more attractive income and the potential of a lucrative financial return from a successful dental venture business.

As employees in a knowledge–intensive industry, dentists’ entrepreneurial activities may have some unique features and associated factors. However, currently there is only a very small volume of literature studying this aspect of dentists [5, 34, 35]. Some studies focused on dental students [36‐40], but they are not yet perfectly comparable to dentists in their actual career path with various social-economic responsibilities. The recent rapid growth of private dentistry in China and the high demand for dentists in public hospitals has provided a good research opportunity.

This study focuses on the dentists in public hospitals in five major cities of Guangdong Province (Guangzhou, Shenzhen, Foshan, Zhuhai, and Zhongshan). Located in the Pearl River Delta Area in Guangdong province, Guangzhou and Shenzhen are among the top megacities of China and the studied cities are among the most economically developed areas in China with a high level of personal income. Since the private economy (especially small to medium enterprises) developed early in Guangdong across all industries, including healthcare, residents in this area accept private dental care that meets their quality and personal experience preference [26]. In industrial cities in Guangdong, such as Shenzhen, with limited public medical resources and a strong individual capacity to pay, the private dental sector has very large potential market growth opportunity [26].

In 2018, there were 20,681 certified dentistry personnel in Guangdong province [41]. The density of dentistry personnel (per 1000 population) was about 0.18, whereas the national average level was 0.129. There are in total 172 general public hospitals and specialized dental hospitals in Guangdong Province. There are 104 hospitals (60%) located in the 5 major cities selected in this study while the remaining 17 cities in total have 68 hospitals (40%) [41]. Specifically, 53 hospitals (30%) are located in Guangzhou City (the capital of Guangdong Province), 21 (12%) in Foshan, 17 (10%) in Shenzhen, 8 (5%) in Zhuhai and 5 (3%) in Zhongshan [26].

This study aims to examine the entrepreneurial intentions of dentists in the public hospitals in major cities of Guangdong Province, China, and the associated key factors, including educational background, professional qualification, years of practice, their entrepreneurial or leadership skills, family background, as well as risk aversion level.

Ethical approval of this study was obtained from the Research Ethics Committee at the School of Business, Macau University of Science and Technology (No: MUST/MSB/D/19/0128). The verbal informed consent procedure was approved by the Research Ethics Committee. The questionnaire has a brief cover letter in written form, describing the research purpose of the collected information and the confidential guarantee policy. Before starting the questionnaire, the ethics statement was disclosed to all respondents and verbal informed consents were obtained from all respondents. All responses were voluntary and anonymous.

The questionnaire adopted an established scale to measure the key concepts of entrepreneurial intention and behaviors [42] and was pre-tested for validity by collegiate faculty, dentists, and dental students randomly selected from major public hospitals in Guangzhou, China. The reliability of the scales was estimated to be 0.81. (See Additional file 1 for the full version of the questionnaire.)

A Snowball sampling method was adopted. Two or three senior dentists in the major public hospitals in each city were first randomly sampled, then each of them gave multiple referrals to other qualified dentists in their cities. This pattern was repeated until a sufficient number of dentists became available for the sample. The number of dentist respondents is proportional to the dental healthcare workforce population in each city [26, 41]. About 51% of the respondents in this sample are from Guangzhou, 20% from Foshan, 16% from Shenzhen, 8% from Zhuhai and 5% from Zhongshan.

The sampling and survey process was performed during the ten months between September 2018 and June 2019. A total of 400 questionnaires were distributed in either paper or electronic forms through WeChat (the dominant social media App in China), depending on the respondents’ preference and convenience. Eventually, 336 valid responses were received (effective return rate = 84%), equivalent to about 3.6% of the total registered dentist population in the studied area. All questionnaires were self-administrated. All data collected through the questionnaires were entered and coded.

EI is a useful and practical approach to understanding actual entrepreneurial behavior. This survey of dentists’ EI captures their objective orientation, such as plans, wishes and preference for engaging in entrepreneurial dental business activities [43].

It was measured by one single question adapted from Krueger et al. [44], “It is likely that I will start and run my business in dentistry in the near future.” Responses were measured with a 5-point Likert scale, with 1 being least likely and 5 being most likely. For logistic regression analysis, a dummy variable of EI was then created according to the number values of the answers. EI was assigned with the value of “1” if answers were “5 = most likely”, or “4 = likely”. EI took the value of “0” for other answers (3 = neutral, 2 = unlikely, 1 = very unlikely).

This study hence includes these relevant factors accordingly.

The baseline model was a multivariate logistic regression model analyzing the major factors associated with the dependent variable, the dentists’ EI, that is a dummy variable, taking the value of “1” if answering “having entrepreneurial intention”. The independent variables included basic demographic and professional characteristics of the dentists.

The full model added additional variables to capture potential influences from the dentist’s personality, personal skills and resources, such as ‘entrepreneurial behavior’, ‘risk aversion’ and ‘entrepreneurial family background’. All statistical analyses were performed with STATA (version 15).