Barriers to access dental care services among adult population: A systematic review

INTRODUCTION

The oral health of the general population in various countries across the globe has shown an improved trend over the past few decades, but people from developing countries still continue to have profoundly high levels of dental disease mainly dental caries and periodontal disease.^[1] Literature evidences show that suboptimal utilization of dental care services has been repeatedly reported by the population from developing countries.^[2,3] In many countries, comprehensive national dental care systems have succeeded in increasing the coverage and reducing or even eliminating socio-economic differences in the use of dental services.^[4] However, inequalities in socioeconomic status lead to uneven utilization of dental services in many countries. There are also other barriers to seeking regular dental care, including the availability of dental services, dental fear, cost, income the distance a person had to travel to get care, and preference for preservation of teeth. The Federation Dentaire Internationale classifies barriers for utilizing dental services as follows: (a) Individuals themselves (such as lack of perceived need, anxiety or fear, financial considerations, and lack of access), (b) the dental profession (inappropriate workforce resources, uneven geographical distribution, training inappropriate to changing needs and demands. and insufficient sensitivity to patient’s attitudes and needs), and (c) society (insufficient public support of attitudes conducive to health, inadequate oral health care facilities, inadequate oral health workforce planning, and insufficient support for research).^[5-7] Utilization is the actual attendance by the members of the public at health-care facilities to receive care. Utilization, which measures the number of visits per year or the number of people with at least one visit during the previous year, serves as an important tool for oral health policy decision-making.^[8] The primary purpose of dental care services is to provide good dental health. An improvement in the individual level of dental health is an important indicator of the overall performance of the communities’ dental care system. Thus, a change in individual dental health will have an impact on the demand as well as the utilization of dental services across the communities and finally the nation.^[9]

India being one of the largest democracies in the world, with a population of over 1 billion is a rapidly developing nation and is making great progress in IT, finance, and living standard. In spite of these, it is alarming to know that very few people receive proper and good dental care. This could be substantiated by the fact that about a third of the population suffer from dental caries that require treatment.^[10]

Over the years, the Government of India has shown an increase of 16% in the allocation of monetary resources to the health sector from 2018 to 2019.^[11] Despite this rise, the budget allotted to oral care is very minimal. Furthermore, there are no preventive care policies and recall systems for regular checkups and the dental care provided is treatment-oriented. In our country, dental care services are mostly through out of pocket expenses by the patient, with very limited influence of private/public insurance companies. Therefore, finance becomes a huge barrier to access dental care.^[12,13]

Another problem encountered by the patients in accessing dental care can be attributed to diversity in the distribution of dental care providers. Previous studies have shown the inappropriate distribution of workforce with states in Southern and Eastern region harboring thousands of dentists whereas northeastern and northwestern regions lack adequate workforce.^[14]

Apart from all these disparities, India is also a country with great cultural diversity; its influence contributes and plays an integral part in shaping and developing good oral hygiene practice. In many cultures, the esthetic appearance of teeth may be important, but having “healthy” teeth and gums is not related to the appearance in a direct way. Health care is a cultural construct arising from beliefs about the nature of the disease and the human body, and it follows that cultural issues are a hindrance to the delivery of effective preventive care and illness intervention.^[13]

To address these problems, various bodies including Indian Dental Association, Dental Council of India work toward equitable access to oral care by conducting camps for various populations around the country, distribution of oral hygiene kits, training personnel to conduct a basic oral examination, and targeting school children through school dental programs. Despite such tremendous efforts taken by these bodies, our country still faces a huge oral disease burden. As an initiative to rectify the situation, the Ministry of Family Health and Welfare came up with national oral health policy in 1986. This policy was formulated along with National Oral health Programme to address the issues of:

1. Determinants to improve oral health

2. Integration of oral health promotion and preventive services with the general health-care system

3. Promoting of public-private partnerships (PPP) model for achieving better oral health.^[15]

Further to alleviate the problem, Ayushman Bharat or “Healthy India” is a national initiative launched by Prime Minister Narendra Modi as the part of National Health Policy 2017, to attain the goal of Universal Health Coverage. This program has been sketched in a manner to achieve SDG goals and its underlying principle which says “leaving no one behind.” Ayushman Bharat is an initiative to make headway from a segmented outlook of health- care delivery to a comprehensive need-based health-care service. Its functions focus mainly on delivering treatments, which address health in a holistic approach (covering prevention, promotion, and ambulatory care) covering all levels of prevention. This scheme will be in action through Health and Wellness Centres within the primary health center or sub-center in the village and that will be providing preventive, promotive, and curative care for non- communicable diseases, psychiatric care, geriatric care, and palliative care along with dental care.^[16] Unfortunately, all these proposals are still in a draft stage. Although it is evident that dental care access in our country encounters numerous barriers, majority of them are not rectified. A first step to any problem will be an in-depth understanding of the same, which when carried out by systematically analyzing the available literature forms the highest scientific evidence. Thus, this systematic review was done with the aim of assessing the barriers faced in utilizing dental care services by general population in age group between 20 and 60 years in India as these findings would provide evidence for making appropriate decisions in our national oral health policy which could further improve access to dental care services for people across India.

MATERIALS AND METHODS

RESULTS

Search results

The search generated a total of 91 articles from five different electronic bases: PubMed, TRIP, Cochrane, and Google Scholar. PubMed produced 17 articles, TRIP database produced six articles, Cochrane produced nine articles, and Google Scholar produced 54 articles. PRISMA 2009 guidelines regarding the paper selection are shown as a flowchart in Figure 1.

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Figure 1:

The search strategy according to the PRISMA guidelines.

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Figure 1 shows the search strategy according to the PRISMA guidelines.

The full texts of 25 articles were obtained for further review. On the basis of inclusion and exclusion criteria, nine articles were included initially in this systematic review. The bibliographical search of the selected articles yielded an additional five eligible studies for inclusion. Hence, a total of 14 articles were considered for the final review. Among those 11 articles excluded, seven articles had reported barriers reported by geriatric patients and pediatric patients. Four articles had a study population of dentists reporting on barriers encountered by them in delivering dental care services. All the studies included were cross-sectional design.

The methodological quality and risk of bias were assessed using the Modified Newcastle-Ottawa Scale. Among the 14 articles included, four articles had a moderate methodological quality and a higher risk of bias when compared to the rest ten articles which had less risk of bias and good quality of methodology. Figure 2 shows the quality assessment along with the risk of bias across the 14 articles included.

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Figure 2:

Representing the methodological assessment of the 14 included articles.

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Figure 2 represents the methodological assessment of the 14 included articles.

The author’s name with year of publication, study population, assessment tool, outcome, and summary of these included studies are tabulated in Table 2.

Table 2: Represents data extraction of included studies

S. No.	Author and Year	Population	Outcome and Result	Author’s conclusion
1.	Poudyal et al., 2010[19]	n=195 adults Age group-above 18 years	No issues in teeth – 60.7% Lack of time – 12.7% Fear – 12% Not a priority – 4.7% Long distance – 1.3% No knowledge – 5.3%	Majority reported “I have not had any problems in my teeth” as reason for not visiting a dentist
2.	Kakatkar et al., 2011[35]	n=427 Age group 25–45 years	Lack of knowledge – 11.7% No time – 27.4% No interest – 33.3% Difficulty in getting appointment – 23.2% Unpleasant experience – 41. l% Costly – 20.4% Transportation difficult – 21.3% Work restraint – 14.3% Lazy – 4% Not a priority – 19.4%	The highly reported reason for not visiting a dentist in this study was “fear toward the dentist”
3.	Randhawa et al., 2011[21]	n=1232 Age group 30–60 years	No time – 32.14% Local medicine usage – 30.6% Transportation difficulty – 36.86%	Uneven distribution of dentist ratio in urban and rural areas were the reason for nonutilization
4.	Kadaralu et al., 2011[24]	n=246 adults Age 18–55 years	Expensive – 22% Time constraint – 19.5% Fear – 8.5% Lack of transportation – 1.2% Other reasons – 2.4%	High cost was the main barrier to the utilization of dental services
5.	Devaraj et al., 2012[27]	n=180 people Age 15–65 years	Not a priority – (43.1%) Neglect – (22.4%) No teeth problems – (15.5%) Time constraint – (8.6%) Costly – (6.9%) Fear of dentist – (1.7%) More visits – (1.7%)	Majority did not prioritize oral health
6.	Verma et al., 2012[22]	n=193	Not important – (45%) No time – (22%) Usage of self-medicines – (16%)	This study has revealed the gaps in the knowledge of the respondents, about dental problems as a barrier
7.	Fotedar et al., 2013[18]	n=319 adults Age group – above 18 years	No time – 39.3% Expensive – 10.6% Not needed unless has pain – 62.5% Fear – 31.5% Long distance – 49.3% not a priority – 61.8%	Majority reported barrier for visiting a dentist was “Not needed unless has pain” indicating the low felt need of the people
8.	Jain et al., 2013[36]	n=600 Age group – 20–50 years	No issues in teeth – 25% Lack of knowledge – 65% Not a priority – 78% No interest – 14.5% Unpleasant experience – 24.5% Lack of time – 20.25% Fear – 60.3% Costly – 74% No dentist nearby – 75.3% Traveling to the dentist is too difficult – 72% Lack of adequate transport to dental care facility – 56% Time restraint – 23.6% Lazy – 10.7%	Highly reported barriers for utilization of oral health care were: Knowledge, attitude, fear, cost, and transport
9.	Gill et al., 2014[20]	n=400 Age group-older than 20 years	Lack of time – 190 Not a priority – 115 Usage of local medicines – 95	Lack of time was identified as the major barrier in this study
10.	Nagarjuna et al., 2016[25]	n=600 Age group-older than 20 years	Lack of time – (45.8) Costly – (33.3) Not a priority – (60) Fear – (48.6) Long-distance – (26.3) I do not think dental diseases are very serious – (51)	Most of them believe that visiting the dentist is necessary only for pain relief
11.	Patel et al., 2016[23]	n=450 Age group 18–60 years	Lack of knowledge6.5% More visits –35% Expensive – 61.5%	Myths and beliefs create hindrances in the effective delivery of quality preventive and corrective dental treatment
12.	Fozia et al., 2017[28]	n=120 Age 20–67 years	No issues in teeth – 46.4% (Beliefs and Myths) –8.6% Financial difficulty –6.4% Lack of time – 27.6% Anxiety and fear of dental treatment – 6.9% Transportation – 4.1%	The highly reported reasons for nonutilization of dental service in this study were “Did not have any dental problem”
13.	Francis et al., 2017[29]	n=420 Age 20–67 years	Did not have any dental problem – 46.4% The dental problem was not serious – 8.6% Financial difficulty – 6.4% Lack of time – 27.6% Anxiety and fear of dental treatment – 6.9% Transportation – 4.1%	The highly reported reasons for nonutilization of dental service in this study were “Did not have any dental problem” indicating the low felt need among study subjects in that area
14.	Vashisht et al., 2018[26]	n=545 Age group – 18–44 years	Financial constraints (42.0%) Lack of transportation facility (23.7%) Nonavailability of dentist (6.1%) Lack of time (79.4%) Lack of symptoms (82.4%) Anxiety toward dental procedures (64.1%)	Majority reported a lack of tooth symptoms as the reason for not visiting the dentist

DISCUSSION

The intent of this systematic review was to find the barriers faced by the Indian adult population within the age group of 20–60 years; through self-reported questionnaires. Population in the age group below 18 years and above 60 years were excluded as utilization of health services in both these populations are influenced by various other factors such as parental/caregivers perception, comorbid health condition or physical difficulty to access health services.^[30] The search was restricted to India because in recent years, there has been tremendous change in oral health patterns among the population, and the National Oral Health Policy has reached its second draft stage. With a deeper understanding of the barriers faced in utilizing dental services through systematically analyzing literature would prove to be a platform for the stakeholders to modify/ devise appropriate policies across the country. Despite the high number of publications in this field that was initially screened, the relatively small number of studies that were finally included in the review collaborates the idea that there is a lack of quality evidence on barriers faced by the Indian adult population in utilizing dental care services.

In the present review, the search based on PRISMA guidelines narrowed down on a set of 14 descriptive cross-sectional studies that reported an outcome on barriers faced in utilizing dental care services by the Indian adult population between 20 and 60 years of age.

Over the years, the pattern of oral health status has improved across the globe yet India faces increased dental disease burden among its residents.^[1] The reason could be due to inequalities seen in accessing dental services and poor planning and implementation of health programs. Despite numerous health schemes cropping up the surfaces, oral health still occupies a back seat. An increased unmet dental need was seen among the studies participants of the included studies with decrease in utilization pattern of oral health services.^[10]

Among the 14 included studies, seven studies had reported utilization rate of dental services among the participants, which showed a greater variation. A higher rate of nonutilization was seen among the northeastern states which could be attributed to the uneven distribution of dentists. In accordance to the above statement, all the included studies reported nonavailability of dentist as a major barrier in accessing dental services.^[21] Reasons for higher utilization rate and anticipated reason for nonutilization of dental services could be the socio-economic status of the subjects; the perception of the adult about dental service is some of the significant predictive factors of dental service utilization. Patel et al. in their study showed a significant association in income, racial ethnicity, and education with unmet needs of dental care.^[23]

Apart from these, there are also other barriers in seeking regular dental care, including dental fear, finance, lack of knowledge/time, and less importance given to the oral disease. In our systematic review, the above-mentioned barriers were the most common ones reported.

Patients’ feelings, beliefs, and attitude are some of the psycho- social determinants of dental health which modify or change the patient’s dental health-care seeking behavior but may prove to be the basis for the barriers in accessing dental health care.^[31] Several literature studies state inadequate dentist workforce distribution, poor knowledge, lack of insurance schemes for dental care, poor government policies, and fear toward dentists as potential barriers for their access to oral care, which is very well reflected in this review.^[32-36] Although dental care delivery is a two-way process, the receiving end always has an upper hand whose feedback plays a pivot role in a system. Therefore, all the articles selected for analysis had the patient’s perceptions of barriers faced in dental care service utilization as their primary outcome. Overall findings of this study suggest that the utilization of dental services among the Indian adult population shows huge variation and there are barriers at individual, interpersonal, environmental, and governmental level factors which act as barriers in accessing and utilization of dental care services. From the current literature evidence, we can conclude the geographic imbalance of dentists, lack of knowledge and time, financial constraint as profound barriers present in dental service utilization among the Indian adult population.

CONCLUSION

The lack of high-quality evidence about the barriers faced by the adult population in India will remain a challenge to many dental clinicians as the gap created between unmet dental needs and utilization of dental services still remain unbridged. Although various barriers are listed, lack of time and unavailability of the dentist seems to be more common ones faced. Henceforth, for further evaluation of the barriers to utilization of dental care services among the Indian adult population, a standardized questionnaire tool would improvise the standards of the studies in the future.