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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 143-150

An observational study to find the patterns of out-of-pocket expenditure for oral healthcare among sanitary workers in Coimbatore, India


Department of Public Health Dentistry, Sri Ramakrishna Dental College and Hospital, Coimbatore; The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India

Date of Submission09-Jul-2019
Date of Decision11-Sep-2019
Date of Acceptance24-Feb-2020
Date of Web Publication24-Jun-2020

Correspondence Address:
Dr. Arun K Simon
Department of Public Health Dentistry, Sri Ramakrishna Dental College and Hospital, Sri Ramakrishna Arts College Road, Coimbatore - 641 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_78_19

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  Abstract 


Background: Out-of-pocket (OOP) expenditure for health care and dental care has been steadily increasing. The OOP expenditure may precipitate existing financial distress in the households and lead to unmet dental needs. In India, OOP health expenditure is on the higher side due to low public spending on health. Aim: To find the patterns of oral health-care expenditure, factors associated with catastrophic dental health expenditure (CDHE), and knowledge about health insurance of sanitary workers in Coimbatore, India. Materials and Methods: The study employed a cross-sectional design based on an interview schedule. The final sample consisted of 246 study participants, randomly selected from sanitary workers presently working in Coimbatore Municipal Corporation. Data were collected regarding demographic information, and the interview schedule oral health-care expenditure inventory consisting of 48 questions was administered. Data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS, ver. 20.0), and Chi-square test was applied for categorical variables. Results: The reported prevalence of CDHE was 15.4%. For dental care, 5.3% of the participants have spent more than Rs. 5000/month, and for dental medications, 11% have spent more than Rs. 2000/month. Respondent's monthly income (P < 0.05), number of family members (P < 0.001), socioeconomic status (P < 0.001), monthly expenditure (P < 0.001), duration of work (P < 0.001), dental problems (self-assessment) (P < 0.001), irregular dental visits (P < 0.001), self-medication (P < 0.001), and postponement of dental care (P < 0.001) were significantly associated with CDHE. Conclusions: This study provides evidence that OOP payments for dental care were high among the sanitary workers in Coimbatore putting burden on the financial security of their families, and 15.4% of the respondents were affected by CDHE.

Keywords: Cost of illness, health expenditures, occupational health, oral health


How to cite this article:
Nobelika A A, Simon AK. An observational study to find the patterns of out-of-pocket expenditure for oral healthcare among sanitary workers in Coimbatore, India. J Indian Assoc Public Health Dent 2020;18:143-50

How to cite this URL:
Nobelika A A, Simon AK. An observational study to find the patterns of out-of-pocket expenditure for oral healthcare among sanitary workers in Coimbatore, India. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Jul 7];18:143-50. Available from: http://www.jiaphd.org/text.asp?2020/18/2/143/287639




  Introduction Top


A healthy mouth is important, as it mirrors the general health of a person. The public perception of oral health problems is poor due to the fact that poor oral health affects morbidity more than mortality, and consequently, oral health programs get less priority in India.[1] Dental conditions such as pain or loss of teeth can cause a decrease in self-esteem and restrict activity.[2],[3] In India, the out-of-pocket (OOP) health expenditure is on the higher side due to the fact that public spending on health is low.[4] Dental services in India, where community-oriented oral health programs are seldom found, face a difficult situation of unequal distribution, accessibility, and affordability of dental care.[1],[5]

In most developing countries, OOP payments are the primary source of health-care financing.[6] Dental diseases are a serious public health problem with wide distribution. Despite this, very few seek dental care widening the gap between need for actual care and demand for care. In India, patients are rarely covered under any type of insurance and generally pay out of their pockets to get treatment from both public and private dentists. Increased cost of dental care dissuades people from utilization of dental care and leads to worsening of the existing conditions.[7] Using dental services can cost households a large proportion of their available income and push many into poverty and long-term debt.[8]

In, India, there has been a proliferation of private dental clinics to meet the dental needs of the population that has consequently increased the OOP expenditure for dental care. Basic dental care reduces the need for complex and expensive treatment. Catastrophic dental health expenditure (CDHE) can be termed as expenditure for dental services and/or medication for dental problems during the past year that exceeded the 10%–20% of the household income.[9] There is some evidence that OOP expenditure for dental care is associated with catastrophic health expenditure leading to impoverishment and pushes households below poverty line.[9],[10],[11]

Studies that examine the patterns of expenditure for dental care in Indian conditions are insufficient. To improve oral health outcomes, there is a necessity to find patterns of expenditure in occupational dental health in India and factors predictive of this behavior. Sanitary workers, in particular, are most often exposed to chemical and biological hazards.[12] Poor socioeconomic conditions of sanitary workers, especially women, are well documented.[13] Keeping this in mind, this study was conceptualized with the objectives to find the family background, details of work, self-reported oral health status, patterns of oral health-care expenditure, factors associated with CDHE, and knowledge about health insurance of sanitary workers in Coimbatore, India.


  Materials and Methods Top


Study design

The study employed a cross-sectional design based on an interview schedule.

Sample size

The Coimbatore Corporation is divided into five zones, namely East, West, North, South, and Central, and there are 100 wards (20 in each zone). As per data obtained from Coimbatore Municipal Corporation, the total number of sanitary workers (both permanent and outsourced) presently working in Coimbatore Municipal Corporation is 6342. The prevalence of payments for dental care in India from literature was estimated as 20%.[11] Considering 5% permissible error at 95% confidence interval, the minimum sample size was estimated to be 246 using the formula n = Z2 P(1-P)/d2, where n = sample size, Z = 1.96, P = expected prevalence or proportion (20%), and d = precision (5%). After the ethical approval, a pilot study was conducted on 15 participants to recheck the sample size obtained.

Inclusion criteria

  1. Sanitary workers who are presently working with Coimbatore Corporation
  2. Adults ≥18 years old.


Exclusion criteria

  1. Those who are unable/unwilling to give informed consent
  2. Those not able to understand English/Tamil.


Ethical considerations

Permission to conduct the study was obtained from the Coimbatore Municipal Corporation. Ethical clearance to conduct the study was obtained from the Institutional Ethics Committee (SRDCH/EC/2018/21). Informed consent was taken from all the participants.

Interview schedule

The interview schedule, oral health-care expenditure inventory (OrHEI), was used to gain insight into the expenditure patterns for oral health care among sanitary workers. The OrHEI was pretested for reliability and was designed both in English and in Tamil, the local language. General information such as gender, educational qualification, years in the occupation, income of the participant, and his household was obtained. The interview schedule consists of 48 questions. The first 4 items are about family details. The next 11 items are about details of the sanitary worker. The next 28 items are about oral health status, and the final 5 items are about health insurance.

Translation of the questionnaire

The interview schedule-based questionnaire was translated into the local language, Tamil, through two independent forward translations by bilingual translators after which the versions were compared to develop a single version of the survey. Another person, unaware of the contents of the original questionnaire, back translated the Tamil version of the questionnaire into English language and it was compared to the original document to check the validity of the translation.

Calibration of the examiners

Calibration was done to establish intra-examiner reliability for OrHEI during the pilot survey. Kappa statistic used to assess intra-examiner reliability showed that there was almost total agreement (κ = 0.96 and κ = 0.94). The investigators checked the 48 items in the interview schedule for face and content validity by expert evaluation and group discussions among the investigators and few sanitary workers and were found to be valid.

Systemizing the survey

The principal investigator made the initial visit to the Zonal offices of the Coimbatore Corporation to describe the purpose of the survey and to finalize the date of visit. A reminder through telephone was given to the sanitary supervisor 1 day before the date of visit. The sanitary workers are mandated to visit the Zonal offices daily and mark their attendance before the service supervisor. On the designated day, after acquainting with the principal investigator and the purpose of the survey, eligible participants were administered the interview schedule by the principal investigator after obtaining written informed consent. About 15 min on average was taken for administering the questionnaire to the participants. A minimum of five visits were made to the Zonal offices to include all the willing participants. Sanitary workers were excluded from the study in case of he/she was absent on the fifth visit also.

Study duration and location

Data collection was carried out over a period of 3 months from October 2018 to December 2018 at the premises of the sanitary department of Coimbatore Municipal Corporation by the principal investigator.

Data management and statistical analysis

The data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS, ver. 20.0; SPSS Inc., Chicago, IL, USA). Basic descriptive statistics were used to tabulate the results. To test the associations between categorical variables, Chi-square test was applied. The level of statistical significance was kept at P ≤ 0.05.


  Results Top


Characteristics of the study population

The interview schedule, OrHEI, was administered to 246 sanitary workers who were aged between 18 and 60 years. The distribution of males (46.3%) and females (53.7%) were similar among the participants. Around 60% of the participants had primary school or middle school education, whereas 24.4% were illiterate. Based on the modified Kuppuswamy scale,[14] 70.3% of the participants were coming under upper-lower class and the remaining under lower-middle social class [Table 1].
Table 1: Sociodemographic factors of the participants (n=246)

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Occupation-related data of sanitary workers

Among the 246 respondents, about 54.5% of them stated that their monthly expenditure was more than Rs. 10,000. More than half (57.3%) of the respondents were contract workers and around 80.1% responded that their work timings were nonspecific. Around 80.5% of the participants told that the earnings from work are not enough for the family and 49.6% of the participants borrowed to meet the monthly expenses. About 57.3% of the respondents spend most of the income on household items, followed by medications (19.9%). Tobacco usage and alcohol consumption are seen among 23.6% and 28% of the participants, respectively. Among those who consumed tobacco and alcohol, 28% spend more than Rs. 3000/month for purchase of the products [Table 2].
Table 2: Occupation.related data of sanitary workers (n=246)

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Oral health data of sanitary workers

About 39.8% of the participants self-reported that their oral health was good, whereas only 28.5% of the participants self-reported that their general health was good. Around 56.5% had never visited a dentist in their lifetime. Among the participants who had visited the dentist, 70% had a dental visit less than a year before. Majority of the participants (74%) used toothpaste and toothbrush and 72% brushed only once daily. About 16.3% had taken some form of medication for dental problems in the past year and 32.4% of the respondents practiced some form of self-medication. About 48% of the respondents preferred to visit dental clinics, followed by 30.5% who preferred government hospitals. Over 54% provided the better treatment as the reason for the choice. Around 32.5% had postponed their dental treatment during the last 1 year. Among those who postponed the dental treatment, 52.5% gave lack of money as the reason. For dental care, 5.3% of the participants have spent more than Rs. 5000/month, and for dental medications, 11% have spent more than Rs. 2000/month. Majority of the participants (99.2%) prefer cash as the preferred payment mode for dentist fee. Among the participants, 56.9% felt that the diagnostic tests component of dental treatment was the major contributor to the costs, followed by 29.7% who felt that the dentist fee cost them more. About 30.9% of the participants have lost one or more working days to dental problems during the last year. It was felt by 50.4% of the participants that the dental expenditure is affecting daily expenditures, whereas 47.6% felt that it is a burden to the family [Table 3].
Table 3: Oral health data of sanitary workers (n=246)

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Health insurance and sanitary workers

Majority (65.4%) of the participants were aware of the presence of health insurance schemes, but only 34.6% had enrolled in some form of health insurance schemes, but it did not cover dental treatments. Among the participants, 84.6% think that insurance for dental problems is necessary and 54.1% were willing to join a dental insurance scheme if available [Table 4].
Table 4: Health insurance and sanitary workers (n=246)

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Catastrophic dental health expenditure

CDHE was based on the criteria if more than 20% of income spent for dental care and medication.[9] In our study, we used income and expenditure ranges, and by including higher ranges of income, we found that 15.4% of the participants were affected by CDHE. Respondent's monthly income (P < 0.05), number of family members (P < 0.001), socioeconomic status (P < 0.001), monthly expenditure (P < 0.001), duration of work (P < 0.001), dental problems (self-assessment) (P < 0.001), irregular dental visits (P < 0.001), self-medication (P < 0.001), and postponement of dental care (P < 0.001) were significantly associated with CDHE [Table 5].
Table 5: Relationship of various factors with catastrophic dental health expenditure

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  Discussion Top


The burden of oral diseases is more in Indians when compared to their South Asian counterparts.[15] A person seeking dental care in India faces the consequence of being in a health system noted for incurring high OOP payments as majority of dental services in India are provided by the private dental practitioners.[7] Bhushan et al.[16] have reported that occupations can be a marker for limited dental care access and unmet dental care needs.

The OOP expenditure for noncommunicable diseases has increased steadily in the recent past, and the source of finance for many health conditions is mostly from the savings.[17] In the present study, a larger part of the respondents have indicated that they do not have any kind of savings that lead to OOP for dental care. The OOP payments may deepen the existing financial distress in the households and push many households below the poverty line.[18] Chokhandre et al. reported a high prevalence of morbidities among waste pickers caused by higher health-care expenditure.[19] Kashyap et al. reported that the total expenditure on health care is significantly higher among the tannery workers when compared with nontannery workers.[18] Our findings were similar, where respondents had postponed their dental treatment during the last 1 year, and among those who postponed, the dental treatment gave lack of money as the primary reason. This is also comparable to the study done by Verma et al.[20] where they reported that the cost of dental treatment and oral health-care needs acted as a significant barrier to achieve good oral health.

Barros and Bertoldi[21] reported that medicines were responsible for 47% of household expenditure associated with health and about 16% of households committed 20% or more of their income with health, which was comparable to this study where 19.9% of the respondents spent most of their income on medicines. Among the total medical expenditure, spending for medicine for nonhospitalized care was the highest in both urban and rural areas.[22] As per our study, self-medication was practiced by a significant of the participants and was associated with CDHE which can be compared to the findings of a study done in Chhattisgarh[20] where self-medication was the treatment of choice for the majority. This can be attributed to the financial constraints according to the Health In India – 71st round of National Sample Survey (2014).[22] The report also mentions that there was a high preference to allopathic treatment, which is comparable to our results for dental self-medication.

Bernabé et al.[11] noted that OOP payments for dental care posed a significant burden on households in low- and middle-income countries that may curtail spending on basic necessities and pushing families into poverty. They also reported that OOP dental expenditure might reduce the living standards. These findings are comparable to our study where almost half of the respondents agreed that dental expenditure is a burden to their family and affects their other day-to-day expenditures. Majority of the participants also had to borrow for their monthly expenses, which pushes them further into the poverty cycle. Majority of the respondents in our study preferred private sector for dental treatments that increase their dental expenditure. Increasing the confidence of the people in public health facilities by developing professionalism and delivering quality care may motivate the poor in using public health facilities and protect them from falling into health-related poverty trap.[18]

In a household survey conducted in Chhattisgarh by Verma et al.,[20] regular dental checkup was given the least priority and the dentist was visited only when there is pain. This is comparable to our study where majority of the participants had never visited the dentist and many went to the dentist only if they had any dental problem and may be the cause of emergency dental expenditure. In this study, CDHE was associated with irregular dental visits. Participants in our study reported loss of working days due to dental diseases during the past year, but loss of workdays due to hospitalization was more in tannery workers when compared to nontannery workers.[18]

In our study, a large number of participants were of the opinion that dental insurance was necessary and they were willing to join if such options were available. Dental awareness can also be one of the beneficial effects of dental insurance plans, but specific dental plans are not common in India.[7] Providing only health insurance may not be the only solution where changes in the design of health insurance packages are critical to decrease the inequities and provide access to health services.[23]

The Global Health Expenditure Database of the World Health Organization (2016) mentions that OOP health expenditure forms 64.58% of the health expenditure.[24] More recent reports of the World Health Organization[25] suggest that global spending is in a phase of transformation with increasing domestic government funding and rapid increase of total health spending in low- and middle-income countries. The report further mentions that even though there is a decrease in households paying OOP, it does not imply that larger public spending does not enhance equity in access to health services. It also points out that primary health-care spending is <40% of public spending.

Limitations of the study

Our study followed a cross-sectional design that does not throw light on causal relationships and may have some inherent bias also. Close-ended questionnaire surveys limit the options of the respondents. Although the sanitary workers represent an important part of the workforce, the study results may not be generalizable to other workers. Our study presents only the self-reporting of income and OOP payments for dental care, and there may be an overlap of expenditure, which may result in reporting error. Furthermore, since no measures were utilized for checking the accuracy of the self-reported data, there may be the presence of social desirability/participant bias. We also did not capture any OOP payments for dental care through the traditional or home care remedies.

Recommendations

We have underscored the increased expenditure for dental care among sanitary workers in Coimbatore. Prescribing generic medications which are available through Pradhan Mantri Jan Aushadhi Yojana[26] can reduce the OOP payments for medications, which form a significant part of the dental expenditure. It is established that cost of dental care is an important barrier for sanitary workers to attain better oral health. The workers can be benefitted through Ayushman Bharat Pradhan Mantri Jan Arogya Yojana[27] where dental surgical treatment costs are covered for eligible persons.


  Conclusions Top


This study provides evidence that OOP payments for dental care were high among the sanitary workers in Coimbatore putting burden on the financial security of their families and 15.4% of the respondents were affected by CDHE. We also presented findings, which showed that expenses for medicines exceed household expenses for some of the participants and that many sanitary workers had never visited the dentist.

Acknowledgment

The authors would like to acknowledge the insights provided by Dr. Jagan P, Dr. Priscilla Joys N, and Dr. Mathew MJ faculty in the Department of Public Health Dentistry, Sri Ramakrishna Dental College and Hospital, Coimbatore.

Financial support and sponsorship

The Indian Association of Public Health Dentistry (IAPHD) through IAPHD Financial Assistance for Undergraduate students (S.no-4) supported this work.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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