|Year : 2021 | Volume
| Issue : 4 | Page : 269-276
Perceived dental needs and barriers to utilization of dental services among elders in India – A cross-sectional survey
NG Bhuvaneshwari1, GV Usha2, Nagesh Lakshminarayan3
1 Public Health Dentist, Oral Cancer Screening Vertical, Indian Cancer Society, Mumbai, Maharashtra, India
2 Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India
3 Department of Public Health Dentistry, Dayananda Sagar College of Dental Sciences, Bengaluru, Karnataka, India
|Date of Submission||05-Sep-2020|
|Date of Decision||16-May-2021|
|Date of Acceptance||20-Oct-2021|
|Date of Web Publication||15-Dec-2021|
N G Bhuvaneshwari
Public Health Dentist, Oral Cancer Screening Vertical, Indian Cancer Society, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The population of geriatric patients in India is increasing, and the uneven geographic distribution of dentists and the various age-related factors are likely to pose an oral health challenge in the near future. Aim: The aim of this study was to assess perceived needs and identify and describe the barriers associated with oral health service utilization among the elderly population aged 65–74 years in Davangere city. Methodology: A cross-sectional door-to-door survey using a self-designed, structured, validated questionnaire was carried out with a sample of 1440 elders. They were randomly selected through multistage sampling technique. Information regarding demographic details, systemic conditions, oral hygiene practices, perceived need, utilization rate of dental services, and factors acting as barriers for the utilization of dental services among the elderly were collected. Chi-square test and Pearson correlation were applied. Results: About 70.5% of the subjects had utilized the dental services in their lifetime, but only 41.4% had utilized in the previous year. Fifty percent of the elders perceived a problem in their oral cavity. Most of our respondents suffered from more than one chronic disease and had utilized the dental services. The cost of treatment, nonsuitability of location of clinic, indirect cost due to transport, the appointment system, and no availability of services on weekends acted as the important barriers to utilize the dental services. Conclusion: Financial constraint and lack of perceiving dental problems as severe acted as major barriers. Preventive oral hygiene measures tailored to meet the unique needs of the individual patient are essential.
Keywords: Barriers, dental care, geriatric, perceived need, utilization
|How to cite this article:|
Bhuvaneshwari N G, Usha G V, Lakshminarayan N. Perceived dental needs and barriers to utilization of dental services among elders in India – A cross-sectional survey. J Indian Assoc Public Health Dent 2021;19:269-76
|How to cite this URL:|
Bhuvaneshwari N G, Usha G V, Lakshminarayan N. Perceived dental needs and barriers to utilization of dental services among elders in India – A cross-sectional survey. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Jan 22];19:269-76. Available from: https://www.jiaphd.org/text.asp?2021/19/4/269/332527
| Introduction|| |
Growing is a natural process. Old age should be regarded as a normal inevitable biological phenomenon. According to the WHO, the global population is increasing at the annual rate of 1.2%, while the population of those over 65 years is increasing at a rate of 2.5%. The fastest-growing population segment in most countries is adults older than 80 years, which is estimated to make up nearly 20% of the world's population. There is also a sudden increase of the 65 years plus population in the last decade, and India is no exception to that. The world population of elderly individuals is expected to reach 830 million by the year 2025, of which India alone will contribute to 110 million. This means that one out of every seven aged persons in the world will be an Indian. The increasing population of geriatric patients is the most evident changing paradigm that India witnesses, which can be phrased as the “gray tsunami.” India currently ranks fourth among countries of the world in the absolute size of the aged population.
Sociodemographic trends and characteristics of the Indian geriatric population are as follows., Eighty percent reside in rural areas. Nearly 75% are economically dependent, with little difference between the urban and rural elderly. Three-fourths of the dependent elderly population is supported by their own family members. Thirty percent are below the poverty line and only 28% are literate. In addition to demographic transition, the Indian elders face plenty of cultural, financial, and social challenges. Their health needs are often neglected by both, the family and their self.
Among the noncommunicable diseases, oral diseases account for 0.5% of India's burden of disease. Poor oral health can have an impact on oral and general comfort, cognition, behavior, quality of life, and life expectancy. Access to health care is a key factor which determines the utilization of health-care services. It is a complex issue, and the varying definitions have been proposed by Freeborn and Greenlick and Penchansky and Thomas over the years. Daly, 2002, made an observation that those definitions define one dimension of access which refers to the relationship between the health services and clients, particularly in terms of health-care usage. They do not address the sociological, psychological, financial, cultural, and behavioral aspects of the patients. These aspects reflect the health-seeking behavior. All these factors are assumed to have an intricate relationship with each other in determining the oral health outcomes. These factors along with changing trends in the elderly population, offer the oral professionals to observe unique challenges to treat them.
India with the large workforce through 313 dental colleges, uneven geographical distribution of dentists with respect to rural and urban areas, and with maximum of elders restricted in rural areas further minimizes the utilization of dental services. There are no preventive care policies and recall systems for regular checkups, and the traditional dental care is treatment oriented. In India, oral care service utilization is inversely related to age. It decreases from 51.1% to 35.5% due to poor mobility with advancement in age. The information available on dental health needs, oral health service utilization, and barriers experienced by the elderly in accessing care is relatively less in India., Hence, a study has been designed with an aim to identify the perceived oral health needs and the various barriers for utilization of dental services among the elderly population aged 65–74 years in Davangere city. The information obtained by the current research may serve as a tool to formulate the policy for utilization of multiple and complex oral health care by the gray community.
| Methodology|| |
A cross-sectional survey was conducted on elderly people aged 65–74 years in Davangere city. The total population of people aged 65–74 years was obtained through census data. Sample size was calculated using the formula.
where n = sample, N = population size, and e = precision level = 2.5% (0.025)
Using simple random sampling technique, elderly people aged 65–74 years residing in their home as well as in shelter homes within the jurisdiction of Davangere city and who gave voluntary informed written consent were included. Participants with mental disorders affecting communication and memory function were excluded.
Ethical approval (Ref. No. BDC/Exam/283/2016-17) was obtained from the Institutional Review Board. Permission for the survey was obtained from the respective in-charge persons of retirement's club, ashrams, and old-age home present in the selected locality.
Study pro forma
Data were collected using a self-designed structured questionnaire containing 37 questions. The pro forma was divided into five sections – to collect information about sociodemographic details, medications for their medical conditions, oral hygiene practices and dietary habits, perceived need for dental care, and multiple-choice questions to assess various factors influencing the utilization of dental care.
Questions were translated to local language (Kannada) and were later back translated into English by translation experts well versed in both Kannada and English by back-translation method to check the translation validity and to ensure their linguistic equivalence. Content validity was tested by three experts (one public health dentist, one periodontist, and one prosthodontist), and content validity index (CVI) for total scale was computed. A satisfactory level of agreement was found (CVI = 0.86) among the panelists.
A pilot study was conducted, and the questionnaire was administered to twenty participants. After a period of 3 days, the questionnaire was again re-administered to the same participants to check the reliability by test–retest method. The value computed was 0.89. Cronbach's α (alpha) test was used to measure the internal consistency. The value calculated was 0.82 which reflects the high level of correlation. The time period set for the data collection was from March 2017 to August 2018. Questionnaire was self/interviewers administered for the participants by three trained investigators including one principal investigator and two dental interns. The two dental interns were trained in order to maintain a standardized method for administration of questionnaire. The data obtained were analyzed using SPSS software version 20. The significant level was fixed at P < 0.05. Chi-square test and Pearson correlation were applied.
| Results|| |
The response rate was 91%. The study population consisted of 1440 elderly subjects with a mean age of 68.10 years. The participants' social status was classified using BG Prasad socioeconomic status scale, and 26.8% belonged to class V. Most of them suffered from circulatory diseases 37.9% [Table 1] and [Table 2]. Overall 97.7% (1407) of the participants brushed/cleaned their teeth/denture regularly. About 48.7% (693) of the study participants reported consumption of sugary snacks [Table 3].
|Table 1: Sociodemographic details of study participants aged between 65-74 years|
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|Table 2: Distribution of study participants according to the presence of systemic conditions|
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|Table 3: Distribution of study participants according to their oral hygiene practices and dietary habits|
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Nearly 52.3% of the participants reported dental problems and 39.1% were satisfied with their present oral health. Almost 70.5% had visited the dentist, but only 41.4% had visited within the last year, the most common reasons being toothache. Public transport was the major mode of transport to reach the dentist [Table 4] and [Table 5].
|Table 4: Distribution of study participants according to their self-reported perceived oral needs, satisfaction of oral condition, and presence of natural teeth/prosthesis|
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|Table 5: Distribution of study participants according to their utilization of dental services|
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Among the elders who had not visited a dentist, 50.5% reported no dental problems and 31.1% could not afford the expenses [Table 6]. The major factors reported as barriers for utilization of dental services by the elderly were cost of treatment (67.8%), attitude to seek dental treatment only when they no longer can bear pain (60.3%), and use of self-care or home remedy (59.7%) [Graph 1].
|Table 6: Distribution of study participants according to their self-reported reasons for not visiting the dentist|
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All the factors were significantly associated with the utilization of dental services at P < 0.001. The factors such as cost, dentist explanation, appointment system, nonavailability of service on Sundays, unbearable pain, and preference for specialist showed a fair degree of positive correlation.
| Discussion|| |
Utilization of dental services is predominantly a consequence of perceived need. Hence, perceived need has been considered as an accurate predictor of utilization of dental services. The study assessed the oral health needs and barriers for utilization of dental services among the elderly population aged 65–74 years in Davangere city. Fifty percent of the elders perceived a problem in their oral cavity, most commonly on their teeth. About 70.5% of the subjects had utilized the dental services in their lifetime, but only 41.4% had utilized in the previous year. Frequently reported barriers were the cost, need for dental treatment, location of service, failure to comprehend dentist explanation, appointments/waiting time in the dental office, unavailability of service in weekends, attitude toward seeking treatment only when they can no longer bear pain, whether any of them prevented them from accessing dental care services, use of home remedy or self-care, and preference for a specialist opinion.
In our study, it was interesting to note that majority of our participants were using toothbrush and toothpaste to clean their teeth. A study by Pankaj Goel reported the use of toothbrush or chewing sticks as cleaning aid and rinsing after every meal as a healthy cultural habit among elders. Huge gap in oral hygiene practices between rural and urban areas may be due to lack of knowledge, accessibility, and affordability of modern oral hygiene aids.
In our study, females had less utilized the dental services as compared to males. In a country like India, females do not have the freedom to make independent decisions. They are dependent on their family for all of their basic needs. The lower utilization of dental services among females could be because of less access to education and economic dependence and hence they do not have financial freedom to make health-care choices.
BG Prasad socioeconomic status scale was more appropriate and the participants were classified accordingly as data were collected only regarding total number of family members and income. The utilization of dental services among our elders increased from 23.4% to 41.9% as the socioeconomic condition improved. The study by Thomas observed that as socioeconomic condition improves, utilization of dental services among rural elders improved from 27.7% to 63.3%. Similar results were reported in the study done by Ferreira et al. People belonging to low social class do not give much importance to oral health and utilization of dental services. It may be due to poor educational status and lack of awareness about oral health.
As the multilevel Andersen behavioral model at the individual level states that the perceived need for oral health may influence their utilization. About one-half of our participants felt their oral health need to be attended and majority of them were satisfied with their oral status. However, the study by Fiske et al. described that elder satisfaction with oral health was not related to their clinical state and their perceived need for dental care was lower than the normative need. Molete et al. revealed perceived need to significantly influence future utilization among elders. The National Oral Health Survey reported that 80% of the Indian population aged 65–74 years require oral health care. This mismatch suggests the need for assessing the barriers and facilitators related to the utilization of dental services.
In the present study, only considering those with systemic conditions, it was interesting to find that most of them had utilized the dental services. Contradictory results were seen in the previously reported studies., Majority of the elders did not consider geographic location of clinic/hospital as a barrier. Similar results were reported by Molte P et al., wherein oral health services were available in the near proximity to retirement villages. As stated by Anderson and Newman model, the availability of health professionals and facilities within the community and illness level enables the utilization rate. The elders in the present study were majorly mobile, and availability of two dental institutions in the nearby vicinity with free services for the elderly would have enabled them to utilize dental services.
Amongst the study participants, overall utilization of dental services was found to be 70.5%. Similar results were reported in the study by Kadaluru Umashankar et al. and Lo ECM. The reasons for such trends among the elderly in that study were because they perceived their health status to be poor compared to younger subjects. Contrasting results were reported in a study by Vikram et al., where only 36.4% had ever visited. The utilization rate within previous year was little high (41.4%) in the present study, when compared among the elders in rural Manipal and Jonesburg. Moreover, previous surveys reported higher utilization among participants of the same age within the previous years.,,,,
In the present study, more than a third had not utilized and one-half of the elders reported that they did not experience any dental problems. This could be because dental diseases are not life threatening, and the relief can be obtained by painkillers over the counter. Similar reasons were reported in the study by Pradeep et al. and Molete et al.
In a qualitative study among elders in Hartford Connecticut, majority expressed the lack of need for dental care, because they had never experienced dental pain or any problems. Consequently, in the present study, the rate of dental care visits was moderate. As 71.6% of the subjects felt that “there is a need for dental care visit,” but only 52.3% perceived a need for dental treatment and only 41.4% had visited a dentist during the past year. These results reflect a substantial discrepancy between the needs and demands of oral health-care service among elderly people in Davangere.
Cost of the treatment was the major barrier reported, and the results are consistent with the previous studies., Whereas lack of insurance and out of pocket expenditure were reported as important barriers in a qualitative study conducted in Connecticut. Findings by Bernabe et al. indicated that out-of-pocket spending for dental care contributed to catastrophic health spending that can push households into poverty. The results suggest the need for dental insurance system or schemes so as to provide dental treatments at subsidized rates exclusively for elders, to overcome the financial barrier. Elders in the current study reported the use of self-care for dental problems. Similar behavior was observed among the adults and elders in the study by Garcha et al. and Goel et al. Self-medication is one of the important barriers for utilization of dental services. It reflects the social and traditional influences on utilization of dental services.
Toothache was the major reason for visiting a dentist among Chinese middle aged and elders. Similar behavior was also reported in the present study. In addition, majority (67.9%) of the elders in the present study were willing to visit a dentist only when they can no longer bear the pain. Similar results have been reported in the Indian adult population., However, one-third of them were not willing to seek treatment even with presence of pain. Possible explanations could be the individual perception of pain, social, and cultural factors involving past experiences and expectations. This behavior of late presentation of patients seeking treatment only when in pain, can be attributed to the low level of oral health awareness.
One-third of the elders were unable to comprehend the dentist explanation and had negative perception that dentists show less interest toward elders' oral care. Similarly, elders in Connecticut were also of the same opinion. It could be attributed to lack of soft skills, gap in knowledge, regarding the physical, socioeconomic, and psychological problems of the elders, and the complexities involved in treatment planning for patients with multiple chronic diseases and medication. Our elders felt that treatment preferences by a dentist are not according to their need. Similarly, elders reported low felt need in the study by Anehosur et al. A clinical assessment by Joyce and Smith and Sheiham among the elderly, noticed a wide discrepancy between their normative and perceived needs. Professional judgments are said to be the best means to identify the needs of the population, but the approach fails to appreciate the importance of peoples' subjective needs.
About one-third of the study participants considered language as the barrier. As stated by Hamilton et al., communication increased patient utilization of dental services by inhibiting patient treatment anxiety and by enhancing the perceived technical competence of the dentist. Majorly elders in our study preferred professional or expert opinion for dental care. Consistently, in the study by Garcha et al., participants wished to seek only expert/professional advice irrespective of their social class. Most of the people are of the opinion that a qualified doctor would know what is best.
The current study used a reliable, valid, self-modified structured questionnaire adapted from previous literature.,,, A “do not know” option was provided for the questions related to barriers for utilization of dental services, so as to reduce the biased responses, thereby allowing them to reflect their true feelings.
In the present study, the sampling frame consisted of elders aged 65–74 years, and through census data, the finite population proportion of elders was obtained (3%). A census eliminates sampling error and provides data on all the individuals in the population. Sample size was calculated using the probability proportional to size method for population. This method was used as it facilitates planning for field survey work with a predetermined number of individuals to be interviewed in each selected unit.
The strengths of our survey include scientifically calculated sample size, simple random, and population proportion sampling strategy to ensure representativeness. Overall response rate of 91% compares very favorably with the highest recommended response rate in the literature of 80%. At this level, nonresponse bias can be expected to be minimal. The questionnaire was validated for language and content. It was pilot tested and assessed for validity and reliability. The interviewer was trained for questionnaire administration. All these reduced interviewer bias, measurement, and instrument error. Despite a high response rate in the current study, the study has certain limitations. The utilization of health services was assessed by means of self-reporting, which could threaten the validity of the information, by leading to reporting and recall bias.
Specific preventive protocol tailored to meet the unique needs of the individual patient is essential. Geriatric MID focusing on the use of ART and chemomechanical caries removal is cost-effective treatment options. The access to dental care can be improvised by adopting old-age home, ashrams, and domiciliary care by nearby dental colleges.
| Conclusion|| |
The major impediments for access to dental care were low SES, nonavailability of services on weekends, underestimation of preventive oral health care, systemic conditions, lack of self-perceived need, and low oral health literacy rate.
A special debt to Dr. Savithra M (Public Health Dentist) for her scholarly language assistance and back translation of questionnaire. I extend my gratitude to Dr. Mahesh (Public Health Dentist) for statistical assistance. Special thanks to Mr. Shivakumar, Kannada teacher, for his extraordinary support and assistance with the Kannada language validation and subject experts (two prosthodontists, one periodontist, and one community dentist) for content validation of the study questionnaire. I thank all the caretakers who assisted participants during filling up of questions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]