barriers in dental public health

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BARRIERS IN UTILIZATION
OF DENTAL HEALTH CARE
SERVICES

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Contents
 Introduction
 Definitions of need
 Factors affecting barriers to utilization of oral
health care services
 Classification of barriers
 Indian scenario
 How to overcome barriers
 Summary
 References

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Introduction
 The concept of need is at the core of health
planning. Planning health services is, in turn,
rooted in the ethical imperative to use resources
appropriately.
 A common assumption in the organization and
provision of health services, including dental
health services, which is being challenged, is that
the need for health care can be objectively
determined by professionals.

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 Health care needs now extend beyond a narrow
clinical interpretation to issues like:
• The impact of ill health on individuals and on
society
• The degree of disability and dysfunction that ill
health brings
• The perceptions and attitudes of patients
themselves towards ill health
• The social origins of many common illnesses.

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 All these factors are believed to influence
the utilization of health services, the
development of health care techniques
and, ultimately, the effectiveness of
treatment.

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Definitions of need
 Donabedian (1973) – states of the client that
create a requirement for care and therefore
represent a potential for service.
 Matthew (1971) – a need for medical care exists
when an individual has an illness or disability for
which there is an affective and acceptable
treatment or cure

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Bradshaw (1972)- four types of social needs:
1. Normative need: which the expert or
professional, administrator or social scientist
defines in any given situation, against which the
actual standard is compared.
 Those below the standard are said to be in need
of support and special services.

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2. Felt need: equated to what people want,
expressed as the individuals own assessment of
his or her requirement for health care.
3. Expressed need: is felt need converted into
action by seeking assistance.
4. Comparative need: assessed by comparing the
health care received by different people with
similar characteristics

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 Unmet need: it is the difference, if any, between
those services judged necessary to deal
appropriately with defined health problems and
those services actually being received (Carr and
Wolfe, 1979)
 Most commonly used type of need assessment in
dental health planning is normative need because
it seems to be relevant to the disease oriented or
bio-medical model, which is believed to identify
diseases without depending on the subjective
perception of the patient.

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 HEALTH SERVICES: Multitude of services
provided to individuals or communities by
agents of health services or Professionals for the
purpose of promotion, maintaining, monitoring
or restoring health.

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Health care delivery
Common problems: Plamping 1988
 Insufficient resources
 Insufficient emphasis on prevention and public
health
 Unclear goals

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 Inadequate organization and management
• Poor planning
• Administration not unified
• Little emphasis on evaluation
 Inequality of distribution of services regionally
 Failure in manpower planning and use of
ancillary workers

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 Inequitable access for people in certain localities
and those with disabilities, and for older and
socially disadvantaged people.
 Method of payment of dentists does not promote
high professional standards
 Lack of public accountability and public
involvement

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 Dental training is not oriented to health service
goals (attachment to a medical rather than a
social model of health)
 Dental research is not sufficiently oriented to
health care needs and prevention
 Unclear strategies for implementing policies
 Access problems

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 UTILISATION OF DENTAL SERVICES: Is the
actual attendance by members of the public at
dental treatment facilities to receive dental care.
 It is expressed as the proportion of a population
who attended a dentist within a given time,
usually a year, or as the average number of visits
per person made during a year.

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 BARRIER : (synonym: obstacle or hindrance)
 Any condition that makes it difficult to make
progress or to achieve an objective.
 Anything that prevents, hinders or controls
progress or movement.

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UTILISATION
OF DENTAL SERVICES
FACTORS AFFECTING IT

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 AGE
• Dental visits are lowest for children under 5
years and persons over 65 years of age. Highest
during the late teenage and early adulthood.
(Newman and Anderson, 1972)

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 Dental care for people over age 64 is a complex
issue with major financial and political
implications.
 The number and relative proportion of persons in
this age group are growing rapidly.
 Insurance for dental services is also growing
rapidly.

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 1977, National Medical Care Expenditure survey
(America): 68 % of 65 yrs and above did not
visit the dentist (exception under age 6).
 Possible contributing factors to this include:
• The small proportion of elderly persons with
private health insurance for dental care;
• The loss in income concomitant with retirement;
• The higher rate of edentulousness among the
elderly, significantly reducing their demand for
dental care.

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 Social gradient exists in children’s oral health
status and dental care utilization.
 For example, children who are in a racial/ethnic
minority or living in poverty are less likely to
visit the dentist than their more advantaged
counterparts.

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 GENDER:
• Women report using dental services more than
men do. (Ekanayake L and Mendis R, 2002;
Ugur ZA and Gaengler P,2002)
 More females complained of toothache than
males. (Ishak A. Razak and Mohamed M. Ali,
1988)

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 RACE AND ETHNICITY:
• Whites use dental services more than non whites
even when controlling for age and sex (Hochstim
et al, 1968).
• Variations in the use of dental services by race;
higher proportions of Whites received cleaning,
examinations, and fillings compared with non-
Whites. (Anderson and Newman 1972).

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• The Chinese were found to be high utilizers of
rehabilitative services whereas the Malays and
Indians were more frequent utilizers of
emergency services. (Ishak A. Razak and
Mohamed M. Ali, 1988)

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 PLACE OF RESIDENCE AND GEOGRAPHIC
LOCATION:
• More persons in the urban than in the rural areas
visit the dentist and the urbanites visit more
regularly. (Anderson and Newman, 1972;
Osterberg T et al, 1998; Lo ECM et al, 2001)
• Patients in the urban area reported having more
dental insurance but not better dental health.
Patients in more rural areas reported seeking
more emergency dental treatment but not more
dental fear. (Lisa J. H, Timothy A. S and Ted P.
Raybould; 2004).

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• The only dental treatment that is more
extensively used by the poor is the oral surgery
(tooth extraction) (Alexandrina P. Stoyanova,
2003)

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 EDUCATION:
• Utilization increases with increase in the level of
education and the education level of head of
house (Anderson and Newman, 1972;Salber EJ
et al, 1976).
• Approximately three quarters of non utilizing
caregivers reported no more than a high school
education, and more than half of utilizing
caregivers reported at least some college. (Susan
E. Kelly et al, 2005)

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• The majority of the people prefer private dental
offices, where the patient satisfaction is high.
(MUMCU G. et al, 2004)

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 INCOME:
• Income is directly related to utilization of dental
services. (Osterberg T et al, 1998).
• Low-income children are almost twice as likely
as high-income children to have unmet dental
needs, one of the reason being inadequate access
to dental care, not only for acute but also for
preventive services.

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 OCCUPATION:
• A direct relationship exists between occupational
status and frequency of dental visits (Douglas
CW and Cole KO, 1979).
• Measurable dimension of socioeconomic status.

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 DENTAL INSURANCE:
• People with dental insurance visit a dentist more
often than people without insurance (NHS data ,
1989).
• Children with private dental insurance had four
times higher odds of having visited a dentist
compared with those who had no dental
insurance. (Woosung Sohn, 2007).

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 GENERAL HEALTH:
• People who consider themselves in excellent
health visit the dentist more often than people
who see themselves as having good or fair
health.
• Similar distribution was seen among people who
had no restriction of activity compared with
those who were limited to some degree.

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 SOCIO-CULTURAL FACTORS:
• The family, its kinship and friendship network
influences the manner in which individuals
define and act upon symptoms or life crises
(Mc Kinlay, 1972).
• Use of dental services is learned by example,
particularly from mothers (Kriesberg and
Treiman, 1962; Rayner, 1970).

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Classification of Barriers

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PENCHANSKY AND THOMAS, 1981
 Access problems describe the difficulties
experienced with service use.
• Availability of services
• Accessibility of services
• Affordability of services
• Acceptability of services
• Accommodation

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1. Availability of services
 Refers to how well the services are distributed.
Eg. Dentist : Population Ratio
 Health services are located in areas where the
needs are low but in areas where the needs are
greatest few services are found.
“Inverse care law” ( Tudor- Hart)
 If it is perceived that services are limited then
demand for care becomes suppressed.

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2. Accessibility of services
Has two dimensions:
• Location- how far one has to travel to the nearest
dental practice.
• Spatial dimension- whether a person can
physically access the premises.

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3. Affordability of services
 Direct costs of dental treatment
 Indirect costs:
• Loss of pay due to time off work
• Travel costs
• Pay for child care while at the dentist

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 People suffer depending upon how they are paid.
 Low income workers are usually paid by the
hour, and the cost to them of taking time off
work is greater than to someone on a salary.

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4. Acceptability of services
• The expectations of users and providers of health
services about how services should look and
should be.
• Providers want to attract to their practice
‘Patients’ who speak their language, pay on time,
behave well in the waiting room and enhance the
image of practice.

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• Users would like to be made to feel welcome in
the practice, to feel information was easy to find
and to be dealt professionally but treated as an
individual.

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5. Accommodation
 Refers to the way in which care is provided in
terms of opening hours, emergency visits, late
night clinics, waiting time and ease of getting an
appointment.

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According to Finch et al, 1988 –barriers to the
receipt of dental care
 Two main barriers to dental treatment:
• Fear of dental treatment
• Cost of dental treatment

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 Other barriers
• Reception and waiting room procedures
• Loss of control
• Personality of the dentist
• Clinical smell
• Hearing the sounds of the dental treatment
• White coats and the bright lights
• Feeling vulnerable in dental chair
• Travel time and time off work

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DENTIST ORIENTED PATIENT ORIENTED
High cost of treatment Lack of perceived need
Inaccessibility of the services Fear
Difficulty of getting
appointment
Lack of time, laziness
Restricted amount of dental
services offered
Poor expectation of
treatment outcome
Dentists attitude, inexperience,
way of communicating and
knowledge
Lack of perceived
seriousness
TER HORST AND DE WIT CLASSIFICATION

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SILBERMAN AND TRYON CLASSIFICATION
• Practical barriers
• Cognitive barriers
• Psychosocial barriers

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PRACTICAL BARRIERS
 All the tangible factors which make the
attainment of dental care more difficult can be
viewed as practical barriers.
 Cons and Leatherhood listed three barriers:
• Lack of money
• Lack of transportation
• Lack of conveniently located dental services

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 Lack of child care during clinic hours.
 Inflexible work schedules.
 Unwillingness of clinic personnel to schedule
consecutive appointments.

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COGNITIVE BARRIERS
 Values, attitudes, beliefs as well as objective
information or lack of it, which stand in the way
of obtaining care.
 They include:
• Individuals needing dental care are not aware of
that need.

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• Individuals do not understand the potential
seriousness of dental problems.
• Unawareness of the individuals about the
availability of dental services

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 Persons from lower socioeconomic groups differ
from mainstream people in their attitudes, beliefs
and judgments about health, sickness and health
care facilities.
 They are less sophisticated and less acquainted
with scientific data.
 They rely on family and cultural norms for their
health care.

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 Minority and poverty groups have fatalistic
attitude towards dental diseases.
 The services of dentists are often viewed as out
of reach financially. Dentists are perceived as
greedy and self serving.

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PSYCHOSOCIAL BARRIERS
 A psychosocial barrier is experienced
 An individual’s self image is damaged
 An individual’s self esteem is decreased by
events or interactions with others during the
course of dental treatment.

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 The situations which create psychosocial barriers
can be:
• A dentist reacts with disgust to a patient’s poor
oral hygiene.
• A receptionist delays acknowledging a waiting
patient.
• Questions which are asked and answered
brusquely and without explanation.
• Unsympathetic approach to treatment.

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All these can make a patient feel:
• Ignorant
• Uncomfortable
• Out of place
• Unimportant
• Inadequate
• Acutely or embarrassingly aware of their poor
oral health or their inability to take care of their
oral health needs.
 So the people try to avoid these situations and
the result is the total avoidance of dental care.

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 For the minority and poor populations
• Dental care is not a familiar part of their lives
• Unsure of the financial obligations which may be
incurred.
• Unclear of the procedures involved in using
dental services.
 Hence their approach to dental care seeking may
be tentative.

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FEDERATION DENTAIRE INTERNATIONALE
1. Barriers referring to individuals including:
 Lack of perceived need
 Anxiety or fear
 Financial considerations
 Lack of access

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2. Barriers referring to the dental profession
including:
 Inappropriate manpower resources
 Uneven geographical distribution
 Training appropriate to changing needs and
demands
 Insufficient sensitivity to patient attitudes and
needs

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3. Barriers referring to society including:
 Insufficient public support of attitudes conducive
to health
 Inadequate oral health care facilities
 Inadequate oral health manpower planning
 Insufficient support for research

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4. Other possibilities may include:
 Cultural beliefs and rituals, especially within
ethnic groups
 Lifestyle changes in modern world
 Influences of neighboring countries
 Low value of oral health to the public
 Conditions within the clinic in relation to
professionalism

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Anxiety as a barrier to dental care
• Due to feeling of vulnerability at the dentist
• A relinquishing of control in the sensitive area of
the mouth
• Fear of pain of dental treatment
• Previous bad experiences with a dentist
• Vicarious learning
 A person who is anxious about a situation often
cope simply by avoiding it. So anxious
individuals delay or avoid visiting a dentist.
(Milsom KM et al, 2003; Schuller AA et al,
2003; Sohn W and Ismail AI,2005).

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Economic barriers
 Cost of dental treatment is seen as a major
barrier to utilization of dental services. This
barrier can exist in two ways:
• The actual price of the service is too high.
• The amount of disposable income available for
buying the service is too low.

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 ‘Income elasticity of demand’ are positive and
range from 0.1 to 1.7 (Holtman and Olsen;
Feldstein ).
 The Income Elasticity of Demand measures the
rate of response of quantity demand due to a
raise (or lowering) in a consumers income.
IEoD = (% Change in Quantity Demanded)/(%
Change in Income)

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 ‘Price elasticity of demand’ are negative and
range from -0.3 to -1.4 (Holtman and Olsen;
Feldstein ).
 The Price Elasticity of Demand measures the
rate of response of quantity demanded due to a
price change.
PEoD = (% Change in Quantity Demanded)/(%
Change in Price)

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 Cost was the major barrier for those with no
knowledge of actual cost and exemption status
(Lester V et al, 1998).
 Imagined cost is the major barrier ( Clerehugh).
 Low income adults without insurance coverage
have the lowest utilization rates ( Locker D and
LeakeJL, 1993).

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 The relationship between obtaining the target
income and providing an accessible dental
practice has been shown to influence practice
policy with regard to special needs patients.
 Dentists in general dental practice, while
providing dental care for patients with special
dental needs, only do so for those who can
access the care they provide. Hence there
remains a group of patients who are unable to
access care in the usual manner.

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 Links between running costs, time urgency and
stress are the factors prohibiting the provision of
dental care for patients with special dental needs.
 With regard to providing specific forms of dental
treatment, such as relative analgesia or
domiciliary dental care, dentist again point to
their concerns about the financial implications.

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Lack of perceived need
 These are the needs which people perceive as
being important. They are subjective feelings of
what people really want.
 Lack of perceived need is a major barrier to care
among the elderly (Konigsberg,1983; Knazan,
1986; Lester V et al, 1998).

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 Lack of interest in teeth was correlated with non
enrolment in dental care (Antoft, 1983).
 People with the most negative perception of their
teeth were the most irregular attendees ( Kari
Storhaugh, 1988).

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 The inability to recognize need for dental
treatment in oneself and a failure to see the value
of understanding dental disease, thus giving it a
low priority in life.
 People tend to overestimate their dental health
and under estimate their need for care. Such
misperceptions stand in the way of active care
seeking behavior (Reisine and Bailit).

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Access barriers
The journey to reach a dentist in terms of time and
cost.
• Difficulty in disrupting one’s routine to organize
and attend a dentist ( Finch H ; Lahiti SM et al,
1999)
• Distance from the patient to a dentist.
• Lifts and stairs are barriers to access (FDI report,
1992).
• Difficulty in finding a provider and scheduling
an appointment (Mofidi M et al,2002).

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 Time barrier -Value of the patient’s travel time,
waiting time and treatment time. Excessive wait
times are a barrier (Mofidi M et al, 2002).

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Quality of experience barriers in dental care setting
( Mofidi M et al, 2002)
 Demeaning interactions with front office staff
• Discriminatory attitude
• Rude behavior
• Disrespectful, judgmental and insensitive
behavior.

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 Negative interactions with dentists
• Impersonal and disrespectful attitude and
behavior
• Not being children oriented
 Negative relationships with the provider of
dental care results in lower rates of utilization
(Donabedian).

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The image of the dentist and attitude towards
dentistry:
 Dentists suffer from a problem of association.
 When thinking of dentists, people thought of the
potential for hurt / pain and discomfort (Finch).
 Dentists are considered impersonal in their
approach to patient.

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• Dentists are highly paid, they are concerned with
money. Therefore want to treat as many patients
as fast as possible. This is called the ‘conveyer
belt image of the dentist’.
• Lack of acceptability of the dentist
• No confidence in the dentist
• Did not believe in the need for dental treatment
(Frazier et al).

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 ‘Having no dental problem’ is the main reason
for non utilization (Man J et al, 1990; Stewart JJ,
1990).
 Dental visits for elderly represent problem
solving behavior and they would visit a dentist
only if they were experiencing problem. (Schou
L and Eadie D, 1991; Merilie DL and Heyman
B, 1992).

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Beliefs about illness and disease
• People do not seek help if they do not consider
the symptoms of dental disease important.
• Dental problems are insidious in nature.
• Low visibility of symptoms of dental diseases.
• Gradual and often painless progress
• People accommodate to low grade dental pain or
a bad taste in the mouth and an impaired
appearance.

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 The following are some taboos generally
prevalent in society
• Fasting.
• Females don’t go to male dentist for treatment.
• People of upper caste don’t go to lower castes
doctor for treatment, thinking that their religion
will be spoiled.

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• Jains of North India consider taking injection as
taboo – They get their teeth extracted with out
anesthetic injection.
• A lot of people who are required to under go
extraction of the teeth are reluctant to undergo
treatment because they are afraid that they will
loose their eye sight.

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Ill health related factors
 Systemic ill health and functional limitations are
barriers to seeking oral health care by
institutionalized, frail and home bound elderly
persons (Merilie DL and Heyman B, 1992;Jones
JA et al, 1990).
 Lack of mobility as a barrier (Fiske et al, 1990).
 Edentulousness is related to non utilization
(Tuominen R and Paunio I, 1987; Palmquist S,
1989; Slade DG et al, 1990; Hu Ez et al, 1990).

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Barriers to accessing dental care: dental
health professional factors
Occupational stress
 The idea that dentistry is the most stressful of all
of the health professions was first proposed by
Cooper et al.
 In the 1980s Cooper et al proposed that
occupational stress was due to:
• Time-related pressures
• Fearful patients

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• High case loads
• Financial worries
• Problems with staff
• Equipment breakdowns
• Defective materials
• Poor working conditions and the routine and
boring nature of the job.

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 By the 1990s Humphris and Cooper had
identified four, new, additional stressors: These
included,
• Concerns about the future of general practice in
dentistry
• Aggressive and hostile patients
• Worries about the risk of cross infection
• Fears about litigation

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 These susceptible individuals not only suffer
physical and/or emotional ill health (emotional
exhaustion) but they could also experience a
withdrawal of interest from their work (lowered
personal achievement) and a turning away from
patients and colleagues alike (depersonalization).
 A dental health professional who found
herself/himself in this position was said to be
suffering from ‘burn-out’.

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 The “burnt-out” dentist who encounters a
dentally anxious patient will be unable to deal or
help the patient cope with their dental fears.
 The patient’s dental anxiety in combination with
the dentist’s own occupational stress allows a
situation to occur in which barriers to providing
or accepting dental care result.

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 The relationship between obtaining the target
income and providing an accessible dental
practice has been shown to influence practice
policy with regard to special needs patients.

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 Perceptions of dental needs are based upon the
clinical training of dental health professionals.
 The normative need provides the basis from
which treatment plans are formulated, negotiated
and discussed with patients.
 The decision to refer the patient with severe
periodontal disease for specialist care or a small
child with an acute abscess to a centre of
excellence for a general anesthetic extraction is
consistent with the normative need.

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 In either clinical situation the decision to refer
may reduce access to the practice but facilitate
patient entry to secondary level care.
 When the patient insists that treatment is needed
which is thought to be contraindicated,
difficulties in patient management start to
emerge.

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 Lack of access as a psycho-social factor in
maintaining an accessible dental practice relates
not only to the physical characteristics of the
practice premises (ramps, lifts, wide corridors
etc.)
 but also to the provision of care for dentally
anxious patients (psychological accessibility) as
well as having the appropriate auxiliary
personnel.

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Indian scenario
 The current situation features huge unmet
treatment needs, striking inequality in delivery
systems, and absence of an adequate community-
oriented prevention system.
 People in developing countries are burdened by a
significant number of oral diseases, which are
further aggravated by poverty, poor living
conditions, lack of dental awareness, and the
absence of appropriate policies and funding to
provide basic oral health care.

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 In the wake of changing culture and lifestyle,
new dental diseases are emerging.
 While future patterns of disease and the efficacy
of future treatments are difficult to predict, the
demand for dentistry is likely to increase.

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 Despite a low mortality rate associated with
dental diseases, such diseases have a
considerable impact on self-esteem, eating
ability, nutrition, and health throughout people’s
lives.
 A mismatch exists between oral health
professionals and the population they serve. The
dentist-to-population ratio, which was 1:300,000
in the 1960s, stands at 1:10,000 (2004) in urban
areas and about 2.5 lakh persons in rural areas.

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 Like anywhere else in the world, urban bias
exists in India, with three-fourths of dentists
clustered in urban areas, which house only one-
fourth of the country’s population.
 Health service planning, health manpower
planning in India has not received adequate
attention

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 In 1990 there were 3,000 registered hygienists
and 5,000 laboratory technicians in India. This
implies that the service of one hygienist was
available to seven dentists, and one laboratory
technician renders service to four dentists,
whereas it should be a 1:1 ratio.
 There are no registered dental nurses or chairside
assistants and no denturists.
 This situation is becoming increasingly difficult
with a decrease in the number of schools for
hygienists and laboratory technicians from forty
(20+20) in 1990s to twenty (10+10) in 2000 with
the result that there has been no increase in the
efficiency of overburdened dentists.

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 Oral health services are offered by dentists, who
practice in the cities and treat the affluent parts
of the urban population.
 It is often difficult for the poor urban and the
rural population to get access to emergency care.
Community-oriented oral health programs are
seldom found.
 The major missing link causing this unfortunate
situation is the absence of a primary health care
approach in dentistry.

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 High disease burden in Tribals is due to Social
and economic barriers to utilization.
 Dental workforce shortages and geographical
barriers all aggravate oral health and access
problems.
 The issue of geographic distance is important in
a large country like ours (India) with limited
means of communication.

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 It has been shown that the effect of difficult
access to health centers is more pronounced for
mothers with less education.
 The distance from private hospitals does not
affect the health parameters but the distance
from public health centre does.
 Those who live in remote areas with poor
transportation facilities are often removed from
the reach of health systems. Incentives for
doctors and nurses to move to rural locations are
generally insufficient and ineffective.

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 Indian woman is less likely to seek appropriate
and early care for disease, whatever the socio-
economic status of family might be.
 This gender discrimination in healthcare access
becomes more obvious when the women are
illiterate, unemployed, widowed or dependent on
others.
 The combination of perceived ill health and lack
of support mechanisms contributes to a poor
quality of life.

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 There are several challenges for geriatric oral
health care delivery in India. Education in
geriatric dentistry is as not yet a recognized
specialty in India.
 The dental manpower tends to segregate in urban
areas; only 20% serve 80% of the rural elderly.
 The primary health centers, the basic unit of
primary health care, does not have the provision
for dental care.

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 Except those in organized sectors like in
government jobs, railways, defense services and
public sector companies, the majority of the
elderly population have no health security.
 Health insurance companies do not reimburse
expenses on dental treatment. Dental treatment is
expensive in the private sector and considered
optional by the majority of elderly and their care
providers.

104. 104
OVERCOMING BARRIERS
Removing practical barriers
 Improved accessibility
 Strategic placement of clinics
 Adjustment of clinic operations to meet the
needs of the people.
 Mobile dental units or integrating dental clinics
with medical clinics.
 Open surgeries

105. 105
Removal of cognitive barriers
 Educational programs
 Needs assessment
 Community participation

106. 106
 Education is a long-established determinant of
the demand for health and health care.
 Better education allows an individual to be more
effective in converting health care and other
health-enhancing goods into health. A recent
study of the empirical effects of schooling on
health found it to be the most important correlate
of good health (Grossman and Kaestner 1997).
 Education of parents, particularly the mother, is
also important in determining child health status.

107. 107
Removal of psychosocial barriers
 Improved communication
 Human relations program
 Attention should be given to the skills of
listening and communication.

108. 108
 The impact of communication messages
concerns the role of the communicator or key
user of services. It is well established that health
educators who are seen to obey their own health
messages are more likely to have impact
(antismoking messages are a good example of
this).
 Some research indicates that use of particular
services by local leaders has a positive impact on
the general uptake in the population.

109. 109
 Other salient features which should be included
are surgery hours and position and location of
the dental practice.
 It has been shown that patients use health
services which are within a 6 mile (10 kilometre)
radius of their homes, work or schools.
 The relation between access, location and
distance traveled has been identified by industry
with many of the larger multinationals providing
in-house dental care facilities—thus improving
access to care.

110. 110
 Similarly the community dental service
has provided mobile dental units for
school children and patients with special
needs.

111. 111
Removing the barrier of cost
 A clearer charging system
 Ability to get an estimate of cost prior to
treatment
 An incentive of free initial course of treatment

112. 112
Removing the barrier of anxiety
 Attention should be given to the image and
approach of dentists.
 Dentists should be trained in dealing with
people.

113. 113
 Dentists who can structure their time effectively
and can acknowledge their difficulties with
patients and staff members are in a better
position to cope with occupational stress.
 It is their awareness and ability to acknowledge
the existence of stressors in the workplace which
allows them to cope effectively with stress,
prevent ‘burn-out’ and maintain an accessible
dental service for their patients.

114. 114
 The dental team working together will also be
able to increase accessibility for dental health
care. In this regard the receptionist, the dental
nurse and hygienist are invaluable.
 The receptionist can increase accessibility by
judicious use of the appointment book. The
dental nurse can increase accessibility, not only
by her patient management but also in her
surgery work with the dentist.

115. 115
 The hygienist working with her dental
colleagues enables more patients to access
preventive health care by providing the practice
with her expert oral health promotion.

116. 116
Summary
 It has been proposed that barriers to accessing
dental health care exist not only in relation to the
patient but also in relation to the dentist together
with the characteristics of the practice.
 It has been suggested that within the two-person
endeavor which is the dentist-patient interaction
that equivalent concerns and anxieties are
experienced by both dentist and patient.

117. 117
 It has been postulated that it is this mirroring of
concerns—occupational stress and dental anxiety
for dentist and patient respectively — which
provides the ingredients for a barrier to be
erected that reduces access to regular dental care.
 Dentists, by being aware of the potential for the
construction of barriers can, by developing their
patient management skills and changing practice
policy, maintain and provide an accessible dental
health care service for their patients.

118. 118
 For adult patients the barriers include dental
anxiety, financial costs of dental treatment,
perceptions of dental need and lack of access.
 For younger children their barriers to dental care
will be affected by parental attitude and
anxieties.
 For pre-adolescents and adolescents dental
attendance and compliance with preventive
advice will be influenced by their stage of
psychological development.

119. 119
 Irrespective of the category of barrier to
accessing dental care it is the place of the dental
health professional to acknowledge that barriers
exist and assist their patients to access and accept
dental health care.

120. 120
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Public Health. 2002; 92:1816–1821

121. 121
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122. 122
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123. 123
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124. 124
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125. 125
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126. 126
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127. 127