UTILIZATION OF
DENTAL SERVICES
1
CONTENTS
• Introduction - Health care and Health Services
• Utilization of dental service
• Data on utilization
• Need, demand and utilization
• Factors Affecting Utilization
• Models Of Utilization
• Barriers of utilization
• Measurement Of Utilization
• Recommendations
• Conclusion
• References 2
INTRODUCTION
3
(1)
HEALTH CARE
• Multitude of services provided to individuals
or communities by agent of health service or
professions for the purpose of promotion
maintaining ,monitoring or restoring health.
Levels of Health Care
• Primary
• Secondary
• Tertiary
4
HEALTH SERVICES COMMUNITY AND
INDIVIDUALS
HEALTH SYSTEMS
PUBLIC SECTOR
A.PRIMARY HEALTH CARE
B.HOSPITAL / HEALTH CENTRES
C.HEALTH INSURANCE SCHEMES
D.OTHER AGENCIES
PRIVATE SECTOR
INDEGENOUS SYSTEMS
VOLUNTARY HEALTH AGENCIES
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NATIONAL HEALTH PROGRAMMES
(1)
HEALTH SERVICES
CONCEPTS PERSONS
Health and Providers
Disease and
Consumers
IDEAS OBJECTS
Equity Hospitals
Coverage Health centers
Effectiveness Health
Efficiency Programmes
Impact
6
CHANGING CONCEPTS IN HEALTH
(1)
SERVICES
• COMPREHENSIVE SERVICES (1946)
• BASIC HEALTH SERVICES (1965)
• PRIMARY HEALTH CARE SERVICES (1978)
7
IDEAL REQUISITES OF
HEALTH SERVICES
(1)
• Comprehensive
• Accessible
• Acceptable
• Provide scope for community participation
• Feasible
8
UTILIZATION OF DENTAL
SERVICES
• It is expressed as the proportion of
people in need of a service who
actually receive it in a given
period, usually a year.(2,3,4)
9
Dental utilization
Vs
Medical utilization
10
DATA AND STUDIES ON UTILIZATION
• International Collaborative Study of Oral Health
Systems (ICS) Sponsored by WHO and US Public
Health Service. (2)
• NORC/ University of Chicago Study – 1964, 1972 (3)
(3)
• USPHS/ University of Colorado Study – 1960
(3)
• Institute of Medicine Study
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BASIS OF UTILIZATION !!!!
(5,7)
NEED
DEMAND DEMAND
UTILIZATION
12
FACTORS AFFECTING
UTILIZATION
(2,3,4)
13
AGE
• Inverted “U” Pattern (Anderson & Neumann)
• Peak of utilization 6-24 years (Barem 1978)
14
80- 84 YEARS = 36%
85 AND >85 YEARS = 24%
FINANCIAL BARRIER
Daniel D S and Nancy A H (2006)
15
SEX
• More in females
• Age group 14-24years
• (Anderson &Newman 1972)
16
RACE AND ETHNICITY
• More in Whites
• Differences in preventive behaviors among Asian,
African,European,Israelic people (Shuval et al
1970)
• No difference between Caucasians & Chinese
(Sarda et al 1970)
• More Utilization by Non Whites (Neumann &
Anderson 1972)
17
INCOME
• Gross income
• Income is directly proportional to utilization
• (Anderson &Neumann 1972)
18
OCCUPATION
• Measurable dimension of socioeconomic status
• Occupation of head vital
• Professional group – Highest utilization
• More in Non shift workers than shift workers
( Peterson 1981 )
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EDUCATION
• Education of Head important predictor
• Poorly Edu Moderate Edu Highly Edu
• Education of head of family for 16 years
20
SOCIO ECONOMIC STATUS
Income , Education & Occupation
SES Patterns of Behavior Utilization
Insurance no effect on utilization in Sweden
(Barenthin 1986)
Longer enrolments intervals (9)
Utilization
21
•The UWA study of utilization with insurance
coverage – 1981 , Glasser and Hoffman. (3)
(3)
•National health interview survey – 1978-79
22
GEOGRAPHIC LOCATION
• Location of both individual and family
• More utilization in US and Far West Countries
• Urban area more utilization
• Dental services Density More utilization
(Henderson 1977)
23
COMMUNITY VARIABLES
• Low utilization in fluoridated area
(Anderson & Neumann 1975)
• Large community more utilization
(Mc Farlaine 1985)
• Health care facilities utilization
24
USUAL ACTIVITY STATUS
• Closely related to occupational status
• Difference in working people, house
keeping ,retired……
• Not a predictor of utilization
25
RELIGION
• Lack of logical theoretical reasoning of
utilization definitely influence utilization
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MARITAL STATUS
Married More utilization
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ORGANIZATIONAL
CHARACTERISTICS OF DENTAL
CARE DELIVARY SYSTEMS
28
THE ACCESS TRIANGLE
(6)
Demand Work force
ACCESS
Economics
29
REGULAR SOURCE OF CARE
• More utilization Regular Dentist
• (Kronfield 1979)
• Women regular source
• Young people regular source
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RECEIVING CARE IN SPECIAL
CLINICS
• Veterans clinics
• Navy Base and Air Craft Base clinics
• Union Sponsored work based clinics
• Pre Payment and Finance
(Bailit &Raskin 1978)
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PERCEPTION OF NEED
• Self Perceived Need More Utilization
ATTITUDES
Value of teeth Value of esthetics more utilization
Attitudes Culture Utilization
32
Subjective
ORIENTATION OF PARENTS
• Mother’s encouragement and attendance pattern
• Parent behavior and level of knowledge
• Parent attitude
• Mother’s oral health related behavior
(Raynor 1970)
33
ATTITUDE TOWARDS DENTIST AND
DENTAL CARE
• Patient Satisfaction utilization
• Dentist’ personality and ability to reduce pain
• Attitude of Dentist
• Private practitioner more utilization
(Shciekein 1998)
34
ECONOMIC FACTOR
• Major barrier of utilization
• Wide variations in utilizations
(Kegele 1963,Nikias & Kats 1970 )
• 74% - Cost barrier (William HR 2006)
• Not in concurrence (Rosamund LH et al. 2003)
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SOCIO CULTURAL FACTORS
• “The family, its kinship and friendship influences
the manner in which individuals define and act
upon symptom or life crisis”
• (MC Kinlay 1972)
• Culture ,Ethnic or Reference group affect
utilization (Zola 1966)
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IMMIGRANTS
“Healthy immigrant effect”
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DENTAL EMERGIENCIES (11)
1995-2003 Rowley et al.
Young age
Non Caucasian ethnicity
Medicaid as payer
No dentists
Proximity to any major hospitals
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SPECIAL NEEDS PATIENTS
• HIV + and high risk uninfected women (12)
• Childhood cancer treated patients – 60.4% (11)
• Geriatric population
39
Why some people regularly
attend services before
symptoms appear and others
don't ??
40
Socio – Psychological Factors
• Fear of dental treatment to inevitability of tooth
loss with age
• Motivation, perception and learning !!!!
• Mc Kinlay three major principles(1972)
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McKinlay’s Principles………
• The extent to which people see the problem as
having serious consequences.
• Behavior emerges out of the conflict among
motives and among courses of action .
• Health related motives may not always give rise
to health related behavior
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MODELS
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THEORETICAL MODELS OF
UTILIZATION
Psychological Sociological Economic
Income
Kasland Cobb(1966) Price
Time
Health behavior Distance
Illness behavior
44
• Illness Behavior – Circumstances that will lead
individual to perceive symptoms as threat.
• Health Behavior – Circumstances that will lead
an individual to value a visit to a health
professional as a way of reducing that threat.
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BEHAVIOURAL MODEL OF UTILIZATION OF
HEALTH CARE SERVICE
UTILIZATION
SOCIETY INDIVIDUAL HEALTH SERVICES
PREDISPOSING ENABLING NEED
Demographic Income Perceived
Social factors Cost Clinical
Health beliefs Availability
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Anderson and Newman
HEALTH SEEKING BEHAVIOUR
• Perceived Seriousness - Relative severity of the health problem
• Perceived Susceptibility - Nature and intensity of perceptions affect
willingness to take action.
• Perceived Benefit - Anticipated value of the recommended course of
action. Person should believe recommended health action will do
good if he/she is to comply.
• Perceived Barrier - Perception of negative conequences.Greatest
predictive value of whether behavior will be perceived
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ROSENSTOCK AND BECKER’S
(HEALTH SEEKING BEHAVIOUR (MODEL)
Individual Perceptions Modifying Factors Likehood of Action
Demographic,
Socio-Psychological variables
Perceived Seriousness
Perceived Susceptibility Preventive
Perceived Benefit Perceived Threat Health Action
Perceived Barriers
Cues To Action
Information
Reminders
Communication 48
SALUTOGENIC THEORY OF ANTONOVSKY`S
• Sense of coherence
THEORY OF COGNITIVE DISSONANCE
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•SOCIAL MODELS
•ECONOMIC MODELS
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DENTAL MANPOWER
• Geographical Distribution
• “Dentist Population Ratio Conceals utilization
more than it reveals”
• Inverse care law
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RELATIVE IMPORTANCE OF VARIABLES IN
EXPLAINING UTILIZATION (2)
Variable groups Relative importance
1) Predisposing
• social structure Medium
• attitudes- beliefs Medium
2) Enabling
• family resources High
• community resources Low
3) Need
• perceived Medium
• evaluated
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Barriers of Dental Care Utilization
(2,3,5,)
PERCIEVED NEED FOR CARE - Psycho-Social Lack of self perceived need
Lack of knowledge about systems
PRORITIES IN LIFE ACCEPTIBILITY
Access problems
Inconvenience of Appointments
Too Busy / Problem of work
Fear and Anxiety
Low priority to dentistry
Cost
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BARRIERS FOR IMMIGRANTS
1) Recent arrival
2) Lack of access
3) Insurance
4) Language barriers
5) Social and cultural barriers
Brue Newbold and Amish Patel (2006)
54
(2,3)
MEASUREMENT OF UTILIZATION
• Annual number of visits for dental care per Person
• Proportion of persons in a population group visiting a
dentist every year
• Number of visits to a dentist within certain specific period
of time
• Reported number of first visit to a dentist by patients
making a series of visits within a specified time
• Number of annual visit among persons who make at least
one visit to a dentist
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UTILIZATION
Probability of Use Level of Use Intensity of Care
% of people Number of visits Number and
visiting dentist at made by those mix of
least once within making at least services
defined period one visit received
Reisine.S 1987
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INDIAN SCENARIO (14)
PRASAD's health education efforts have increased utilization of
dental services. Previously only extractions were available, but
now Prasad Chikitsa also offers cleanings, fillings, root canals,
scaling and dental hygiene education as well. over 2,000 people
are treated each year at the clinic.
Tansa region, India.
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RECOMMENDATIONS
(2,3,7.11,12)
• National utilization studies
• Each mutable variable affecting dental health status
• Improve methodologies
• Increased attention to conceptualization and
hypothesis testing
• Regular data gathering
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RECOMMENDATIONS
• Determination of impact of continuing of care on
level of oral health.
• Focus on individual characteristics .
• Analysis of WHO International Collaborative Study
(ICS) data
• Emphasis on high utilizers who exhibit traditional
sociodemographic characteristics of poor utilization
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RECOMMENDATIONS
• Plans to monitor impact of national ,state and local
health policies
• Studies on effects of income and insurance on
utilization.
• How actual dental need influence level of perceived
need and how these two effect utilization.
• Various programme mechanisms should be utilized
and evaluated
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CONCLUSION
“Health for all”
Multiple variables
If you build they will come
Perceived need
Attitudes of dentists and dental staff
Research
61
REFERENCES
1) Geoffrey L Slack, Brian A Burt , Dowell TB. Dental Public Health –An introduction to
community dental health .Planning National Dental Health Services 2nd Ed, John.Wright &
Sons,1981: 133-148.
2) Cohen.C K and Gift H C. “Disease Prevention and Oral Health Promotion
Socio-Dental Sciences in action”. 1st Ed, Munksgaard, Copenhagen,1995:341-387.
3) Stiffler F D, Young O W, Burt A B. Dentistry, dental practice, the community,
3rd Ed, W B Saunders company, 1983:318-338.
4) Peter S. Essentials of Preventive and Community Dentistry, 2nd Ed, Arya (Medi)
publishing house, New Delhi 2004.
5) Cynthia M.Pine. “Community Oral Health”. Health needs assessment, 1st Ed,
John.Wright & Sons,1997: 40-42.
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6) Mattin D, Smith JM.
The oral health status, dental needs and factors affecting utilization of dental services in
Asians aged 55 years and over, resident in Southampton'.Br Dent J 1991 Jul 6;171(1):11-2.
7) Allyson R D,Howard C B,Susan H .“Oral Health Status in the US. Will improved health
lead to decreased demand for dental services?” Jl Dent Edu 1985;49(6):427 – 430.
8) Stahlnacke K, Soderfeldt B, Unell L, Halling A, Axtelius B “Changes over 5 years in
utilization of dental care by a Swedish age cohort. Comm Dent Oral Epidemiol 2005
Feb;33(1):64-73.
9)Damiano P et al. Longer enrollment intervals and utilizations of services. Jl Publ Healt
Dent 2006;66(2):97-103.
11) Scott T Rowley et al. Utilization of hospital for treatment of pediatric dental
emergencies. Ped dent 2006; 28:10-17.
12) Mark W Y et al. Use of dental services by adult survivors of childhood cancer. Jl Publ Healt Dent
2004;64(1):50-54.
13) Caroline H et al. factors associated with use of dental services among HIV infected and
high risk uninfected women. Jl amer dent assoc 2005;136(9):1242-55.
14) www.google/dental serv/utilization/edu.com 63
THANK YOU 64
