Journal of Public Health Dentistry . ISSN 0022-4006
Cost as a barrier to accessing dental care: findings from a Canadian population-based study Brandy Thompson, RDH, MSc1; Peter Cooney, DMD, MSc, FRCD(C)2; Herenia Lawrence, DDS, MSc, PhD1; Vahid Ravaghi, DDS, MSc, PhD3; Carlos Quiñonez, DMD, MSc, PhD, FRCD(C)1 1 Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada 2 Office of the Canadian Oral Health Advisor, Public Health Agency of Canada, Ottawa, ON, Canada 3 Oral Health & Society Research Unit, Faculty of Dentistry, McGill University, Montreal, QC, Canada
Keywords health services accessibility; dental health surveys; insurance; dental; socioeconomic factors; healthcare disparities. Correspondence Mrs. Brandy Thompson, Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto, 124 Edward Street, Room 515, Toronto, ON M5G 1G6, Canada. Tel.: 416-979-4900, ext. 4489; Fax: 416-979-4936; e-mail: [email protected]. Brandy Thompson, Herenia Lawrence, and Carlos Quiñonez are with Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto. Peter Cooney is with Office of the Canadian Oral Health Advisor, Public Health Agency of Canada. Vahid Ravaghi is with Oral Health & Society Research Unit, Faculty of Dentistry, McGill University. Received: 2/2/2013; accepted: 12/5/2013. doi: 10.1111/jphd.12048 Journal of Public Health Dentistry 74 (2014) 210–218
Abstract Objective: The aim of this study is to determine the demographic and socioeconomic characteristics of Canadians who report cost barriers to dental care. Methods: An analysis of data collected from the 2007/09 Canadian Health Measures Survey was undertaken from a sample of 5,586 Canadian participants aged 6–79. Cost barriers to dental care were operationalized through two questions: “In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?” and “In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?” Logistic regressions were conducted to identify relationships between covariates and positive responses to these questions. Results: Approximately 17.3 percent of respondents had avoided a dental professional because of cost within the previous year, and 16.5 percent had declined recommended dental treatment because of cost. Adjusted estimates demonstrate that respondents with lower incomes and without dental insurance were over four times more likely to avoid a dental professional because of cost and approximately two and a half times more likely to decline recommended dental treatment because of cost. Conclusions: Nearly one out of five Canadians surveyed reported cost barriers to dental care. This study provides valuable baseline information for future studies to assess whether financial barriers to dental care are getting better or worse for Canadians.
Introduction In Canada, both public and private sectors are involved in the financing and delivery of health care; however, contrary to physician and hospital care, which are universal, dental care is not publicly covered for the general population. Dental care is almost entirely financed through private employment-based insurance and/or out-of-pocket expenditures, each representing about half of all private dental care expenditures and delivered within a private for-profit system (1). As a result, Canadians are largely responsible for securing their own dental care, which raises questions about the equitable distribution of dental services for Canadians. In particular, the privately financed nature of dentistry provokes the question, “to what extent do individuals’ 210
financial resources, including income and dental insurance coverage, affect their ability to use, or access, dental services?” Research has demonstrated that income and insurance are generally the strongest determinants of utilizing dental care, even after controlling for different sociodemographic factors. In Canada, the probability of receiving dental care increases markedly with dental insurance and household income (2-5). To illustrate, Millar and Locker found that with all other factors being equal, the highest income Canadians are almost three times more likely to visit a dentist compared with the lowest income Canadians (2). Dental insurance also has an independent effect on utilization, meaning that regardless of income level, the insured utilize more dental care than the uninsured (2-4). © 2014 American Association of Public Health Dentistry
B. Thompson et al.
In recent years, there has been renewed public interest in the affordability of dental care. It has been argued that a significant minority of the adult population experiences financial barriers in accessing dental care, especially those who do not have any form of dental insurance. In one study, 26 percent of Canadians surveyed deemed dental care costprohibitive, with 35 percent mentioning checkups, cleanings, and fillings as treatments they required but could not afford (6).A 2009 study of working poor Canadian adults confirmed that almost 30 percent of these individuals had been unable to afford dental care in the past, with 12.6 percent reporting a competing need, having to sacrifice other spending (e.g., food) to pay for care (7). Locker et al. subsequently demonstrated that 30 percent of Canadian adults reported avoiding or delaying dental visits, and 32.2 percent reported not being able to receive all of the recommended dental treatment because of cost (4). The issue of affordability has historically been a central policy issue in Canada, especially as financial barriers, particularly insurance, are some of the most mutable barriers influenced by policy decisions (4). Importantly, prior to the 2007/09 Canadian Health Measures Survey (CHMS), there was essentially no nationally representative data on Canadians experiencing cost barriers to dental care. The availability of this new data provides an opportunity to explore these barriers and their correlates. From a public health and program planning perspective, it is important to identify population subgroups experiencing barriers to access in order to determine priorities for the most effective use of resources. Thus, the aim of this study was to determine the demographic and socioeconomic characteristics of Canadians who avoided the dentist and declined recommended dental treatment because of cost.
Cost as a barrier to accessing dental care
Variables used in this study were imported from the original CHMS Wave 1 master data file. Survey weights were used to ensure data were nationally representative. Each weight corresponded to the number of people represented by the survey respondent in the population as a whole. In addition, bootstrap weights were applied to take into account of the CHMS’ complex, multistage sampling design. Further details pertaining to the study design, sampling strategy, and characteristics of the sample are available in Giroux (9).
Data collection Data collection was conducted in two stages: a questionnaire administered in respondents’ homes and a clinical examination in a mobile clinic. Consent for participation in the health interview was implied when agreeing to respond to the questions. Written consent was obtained for the physical measures collected at clinic sites, including the dental examination (10). During the household questionnaire, 34 oral health questions sought information on the respondents’ oral health, satisfaction with the appearance of teeth, oral symptoms, oral care habits including dental care utilization, and sources of funds to pay for dental care (11). The interview also gathered information on sociodemographic characteristics. Parents/guardians answered questions about their children aged 6–11, including questions from all household modules. Examining dentists were supplied by the Canadian Forces and were calibrated to World Health Organization standards (11). The dentist–examiner asked respondents 18 questions relating to dental symptoms (pain, bleeding, dry mouth, etc.) and an additional 15 medical history questions to ensure eligibility (11).
Covariates
Methods Study design & sample Data for this study were obtained from the 2007/09 CHMS conducted by Statistics Canada in partnership with Health Canada and the Public Health Agency of Canada. The CHMS is a multistage, geographically stratified survey of households collecting data from different age–sex groups sampled from several sites across Canada. A combined household and clinic response rate of 51.7 percent was achieved (8). A total of 5,604 people living in privately occupied dwellings across Canada were surveyed at 15 sites in five regions (British Columbia, the Prairies, Ontario, Quebec, and the Atlantic provinces) (9), representing approximately 97 percent of the Canadian population between 6 and 79 years of age. Eighteen respondents who did not attend the dental examination were excluded from analyses. © 2014 American Association of Public Health Dentistry
Covariates selected for this study were based on variables that have been previously explored in the literature on cost barriers to care (3,4,7,12,13) and variables in line with the groupings suggested by Andersen’s emerging model of health services (14). This study was not meant to test the Anderson model but uses it to conceptualize the choice of variables selected. The Andersen model was designed to represent the many influences that affect an individual’s utilization (or nonutilization) of health services and exhibits how access to, and use of health services, are a function of predisposing, enabling, and need factors (14). Andersen’s emerging model was modified to summarize the factors that influence cost barriers to dental care (Figure 1). Predisposing factors include demographic characteristics and one’s social structure. The predisposing characteristics in this study include age, sex, immigrant status, number of years in Canada, Aboriginal status, education, and smoking status. Immigrant status was determined by the household question 211
Cost as a barrier to accessing dental care
ENVIRONMENT
Dental Care System
External Environment
B. Thompson et al.
POPULATION CHARACTERISTICS
Predisposing Characteristics • Age • Sex • Immigrant • Years in Canada • Aboriginal • Education • Smoking Status
Enabling Resources: • Income • Adequacy • Insurance Status • • Employment Status
HEALTH BEHAVIOUR
Need: SelfReported Oral Health SelfReported Oral Pain
Use of Health Services: • •
Avoided dental professional due to cost Declined recommended dental treatment due to cost
Figure 1 Modification of Andersen’s emerging model [adapted from Andersen (14)].
that asked: “Were you born a Canadian citizen?” The number of years in Canada indicates the length of time the respondent has been in Canada since his/her immigration. The household question corresponding to his variable is: “In what year did you first come to Canada to live?” This was a continuous outcome that was dichotomized into “greater than 10 years” and “less than 10 years” to identify newer and older immigrants. Education indicates the highest level of education acquired by any member of the household. Enabling factors include both community and personal resources and must be present for use to take place. Income, insurance, and employment status, for example, are important enabling measures. A measure of income adequacy was used. Income adequacy is a derived variable classified into four categories based on the respondent’s total household income and the number of people living in the household. See Appendix for a description of how each income category was derived. Dental insurance was derived from two questions in the household questionnaire: “Do you have insurance or a government program that covers all or part of your dental expenses?” and “Is it: an employer-sponsored plan? a provincial program for children or seniors? a private plan? a government program for social service (welfare) clients? a government program for First Nations and Inuit?” The insurance variable was recoded and classified into three groups: private, public, or no insurance. Employment status was determined by the respondent’s job status over the past year and the total number of hours the respondent worked per week. Full time was classified as working more than 30 hours per week, and part-time was classified as working less than 30 hours per week. Lastly, need factors include perceived need (how individuals view their health). Self-reported oral health was the need factor in this study. Respondents were asked to rate the health of their mouth using the following categories: excellent, very good, good, fair, and poor. 212
Cost barriers Two variables were used to measure cost barriers to dental care and correspond to two questions in the household questionnaire: “In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?” and “In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?” Respondents answered “yes” or “no.” Similar questions (with slight variations in wording) have been used by previous Canadian (4,12,13) and international oral health surveys (15,16).
Analyses Descriptive frequencies were calculated to observe the socioeconomic and demographic characteristics of the sample as a whole and of each subsample (individuals who reported avoiding the dentist because of cost and individuals who reported declining recommended dental treatment because of cost). Bivariate logistic regressions were conducted to identify the independent relationship of covariates with each outcome variable (individuals who reported avoiding the dentist and individuals who reported declining recommended dental treatment). Only variables with a P-value less than 0.25 in the bivariate analyses were entered into the multivariable model. Multicollinearity among the predictive variables was assessed using the variance inflation factor (VIF). Only those variables with a VIF equal to or less than three were entered into the multivariable model. Logistic regressions were conducted for each outcome variable to determine which factors were the strongest predictors of reporting cost barriers. The crude and adjusted odds ratios, 95 percent confidence intervals (CIs) and P-values were recorded. The significance level was set at P < 0.05. Prevalence odds ratios were utilized in order to compare © 2014 American Association of Public Health Dentistry
B. Thompson et al.
results with data from other cross-sectional oral health surveys that also used odds ratios to describe the strength of the association between similar independent variables and similar outcomes (2,4,7,12,17). All statistical analyses were completed using STATA v.12 (StataCorp LP, College Station, TX, USA). All missing data were coded by Statistics Canada. Missing data were the result of nonresponse to some or all questions in the survey. In this study, records with missing values were removed from the analyses. As part of the disclosure process at Statistics Canada’s Research Data Centre, only weighted proportions and counts were permitted for release.
Results Approximately 17.3 percent (CI: 14.7, 20.3) of those surveyed reported avoiding a dental professional because of cost, and 16.5 percent (CI: 15.0, 18.2) reported declining recommended dental treatment because of cost. Eleven percent (CI: 9.37, 13.13) of the respondents reported both avoiding a dental professional and declining recommended treatment because of cost within the last year. Seventy-seven percent (CI: 74.9, 79.53) of those surveyed did not report experiencing a financial barrier to dental care. In other words, 23 percent, or nearly one in five of those surveyed, reported experiencing a cost barrier to dental care, whether it was avoiding a dentist, declining recommended dental treatment, or both.
Socio-demographic and economic factors Tables 1 and 2 describe the prevalence of avoiding dental treatment and declining treatment according to sociodemographic factors. When both the insurance and employment status of respondents were examined, cost barriers were reported most among those that were employed without insurance. Among respondents who reported avoiding a dentist, 41.7 percent (CI: 33.3, 50.6) were employed without insurance, and 35.0 percent (CI: 29.8, 40.5) were unemployed without insurance. Similarly, among respondents who reported declining recommended dental treatment, 29.6 percent (CI: 23.0, 37.1) were employed without insurance, and 28.5 percent (CI: 23.0, 35.0) were unemployed without insurance. When specifically looking at dental insurance, among those that avoided the dentist altogether (Table 1), there is no statistically significant difference between those with public and private insurance. However, when examining those that declined recommended dental treatment because of cost (Table 2), there is a difference between the privately and publicly insured. © 2014 American Association of Public Health Dentistry
Cost as a barrier to accessing dental care
Table 1 Characteristics of Respondents Avoiding Visiting a Dental Professional in the Past Year due to Cost, 2007/09
All Age 6-11 12-19 20-39 40-59 60-79 Sex Male Female Income Higher Upper middle Lower middle Lower Insurance Private Public No insurance Education >High school High school
Cost as a barrier to accessing dental care: findings from a Canadian population-based study Brandy Thompson, RDH, MSc1; Peter Cooney, DMD, MSc, FRCD(C)2; Herenia Lawrence, DDS, MSc, PhD1; Vahid Ravaghi, DDS, MSc, PhD3; Carlos Quiñonez, DMD, MSc, PhD, FRCD(C)1 1 Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada 2 Office of the Canadian Oral Health Advisor, Public Health Agency of Canada, Ottawa, ON, Canada 3 Oral Health & Society Research Unit, Faculty of Dentistry, McGill University, Montreal, QC, Canada
Keywords health services accessibility; dental health surveys; insurance; dental; socioeconomic factors; healthcare disparities. Correspondence Mrs. Brandy Thompson, Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto, 124 Edward Street, Room 515, Toronto, ON M5G 1G6, Canada. Tel.: 416-979-4900, ext. 4489; Fax: 416-979-4936; e-mail: [email protected]. Brandy Thompson, Herenia Lawrence, and Carlos Quiñonez are with Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto. Peter Cooney is with Office of the Canadian Oral Health Advisor, Public Health Agency of Canada. Vahid Ravaghi is with Oral Health & Society Research Unit, Faculty of Dentistry, McGill University. Received: 2/2/2013; accepted: 12/5/2013. doi: 10.1111/jphd.12048 Journal of Public Health Dentistry 74 (2014) 210–218
Abstract Objective: The aim of this study is to determine the demographic and socioeconomic characteristics of Canadians who report cost barriers to dental care. Methods: An analysis of data collected from the 2007/09 Canadian Health Measures Survey was undertaken from a sample of 5,586 Canadian participants aged 6–79. Cost barriers to dental care were operationalized through two questions: “In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?” and “In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?” Logistic regressions were conducted to identify relationships between covariates and positive responses to these questions. Results: Approximately 17.3 percent of respondents had avoided a dental professional because of cost within the previous year, and 16.5 percent had declined recommended dental treatment because of cost. Adjusted estimates demonstrate that respondents with lower incomes and without dental insurance were over four times more likely to avoid a dental professional because of cost and approximately two and a half times more likely to decline recommended dental treatment because of cost. Conclusions: Nearly one out of five Canadians surveyed reported cost barriers to dental care. This study provides valuable baseline information for future studies to assess whether financial barriers to dental care are getting better or worse for Canadians.
Introduction In Canada, both public and private sectors are involved in the financing and delivery of health care; however, contrary to physician and hospital care, which are universal, dental care is not publicly covered for the general population. Dental care is almost entirely financed through private employment-based insurance and/or out-of-pocket expenditures, each representing about half of all private dental care expenditures and delivered within a private for-profit system (1). As a result, Canadians are largely responsible for securing their own dental care, which raises questions about the equitable distribution of dental services for Canadians. In particular, the privately financed nature of dentistry provokes the question, “to what extent do individuals’ 210
financial resources, including income and dental insurance coverage, affect their ability to use, or access, dental services?” Research has demonstrated that income and insurance are generally the strongest determinants of utilizing dental care, even after controlling for different sociodemographic factors. In Canada, the probability of receiving dental care increases markedly with dental insurance and household income (2-5). To illustrate, Millar and Locker found that with all other factors being equal, the highest income Canadians are almost three times more likely to visit a dentist compared with the lowest income Canadians (2). Dental insurance also has an independent effect on utilization, meaning that regardless of income level, the insured utilize more dental care than the uninsured (2-4). © 2014 American Association of Public Health Dentistry
B. Thompson et al.
In recent years, there has been renewed public interest in the affordability of dental care. It has been argued that a significant minority of the adult population experiences financial barriers in accessing dental care, especially those who do not have any form of dental insurance. In one study, 26 percent of Canadians surveyed deemed dental care costprohibitive, with 35 percent mentioning checkups, cleanings, and fillings as treatments they required but could not afford (6).A 2009 study of working poor Canadian adults confirmed that almost 30 percent of these individuals had been unable to afford dental care in the past, with 12.6 percent reporting a competing need, having to sacrifice other spending (e.g., food) to pay for care (7). Locker et al. subsequently demonstrated that 30 percent of Canadian adults reported avoiding or delaying dental visits, and 32.2 percent reported not being able to receive all of the recommended dental treatment because of cost (4). The issue of affordability has historically been a central policy issue in Canada, especially as financial barriers, particularly insurance, are some of the most mutable barriers influenced by policy decisions (4). Importantly, prior to the 2007/09 Canadian Health Measures Survey (CHMS), there was essentially no nationally representative data on Canadians experiencing cost barriers to dental care. The availability of this new data provides an opportunity to explore these barriers and their correlates. From a public health and program planning perspective, it is important to identify population subgroups experiencing barriers to access in order to determine priorities for the most effective use of resources. Thus, the aim of this study was to determine the demographic and socioeconomic characteristics of Canadians who avoided the dentist and declined recommended dental treatment because of cost.
Cost as a barrier to accessing dental care
Variables used in this study were imported from the original CHMS Wave 1 master data file. Survey weights were used to ensure data were nationally representative. Each weight corresponded to the number of people represented by the survey respondent in the population as a whole. In addition, bootstrap weights were applied to take into account of the CHMS’ complex, multistage sampling design. Further details pertaining to the study design, sampling strategy, and characteristics of the sample are available in Giroux (9).
Data collection Data collection was conducted in two stages: a questionnaire administered in respondents’ homes and a clinical examination in a mobile clinic. Consent for participation in the health interview was implied when agreeing to respond to the questions. Written consent was obtained for the physical measures collected at clinic sites, including the dental examination (10). During the household questionnaire, 34 oral health questions sought information on the respondents’ oral health, satisfaction with the appearance of teeth, oral symptoms, oral care habits including dental care utilization, and sources of funds to pay for dental care (11). The interview also gathered information on sociodemographic characteristics. Parents/guardians answered questions about their children aged 6–11, including questions from all household modules. Examining dentists were supplied by the Canadian Forces and were calibrated to World Health Organization standards (11). The dentist–examiner asked respondents 18 questions relating to dental symptoms (pain, bleeding, dry mouth, etc.) and an additional 15 medical history questions to ensure eligibility (11).
Covariates
Methods Study design & sample Data for this study were obtained from the 2007/09 CHMS conducted by Statistics Canada in partnership with Health Canada and the Public Health Agency of Canada. The CHMS is a multistage, geographically stratified survey of households collecting data from different age–sex groups sampled from several sites across Canada. A combined household and clinic response rate of 51.7 percent was achieved (8). A total of 5,604 people living in privately occupied dwellings across Canada were surveyed at 15 sites in five regions (British Columbia, the Prairies, Ontario, Quebec, and the Atlantic provinces) (9), representing approximately 97 percent of the Canadian population between 6 and 79 years of age. Eighteen respondents who did not attend the dental examination were excluded from analyses. © 2014 American Association of Public Health Dentistry
Covariates selected for this study were based on variables that have been previously explored in the literature on cost barriers to care (3,4,7,12,13) and variables in line with the groupings suggested by Andersen’s emerging model of health services (14). This study was not meant to test the Anderson model but uses it to conceptualize the choice of variables selected. The Andersen model was designed to represent the many influences that affect an individual’s utilization (or nonutilization) of health services and exhibits how access to, and use of health services, are a function of predisposing, enabling, and need factors (14). Andersen’s emerging model was modified to summarize the factors that influence cost barriers to dental care (Figure 1). Predisposing factors include demographic characteristics and one’s social structure. The predisposing characteristics in this study include age, sex, immigrant status, number of years in Canada, Aboriginal status, education, and smoking status. Immigrant status was determined by the household question 211
Cost as a barrier to accessing dental care
ENVIRONMENT
Dental Care System
External Environment
B. Thompson et al.
POPULATION CHARACTERISTICS
Predisposing Characteristics • Age • Sex • Immigrant • Years in Canada • Aboriginal • Education • Smoking Status
Enabling Resources: • Income • Adequacy • Insurance Status • • Employment Status
HEALTH BEHAVIOUR
Need: SelfReported Oral Health SelfReported Oral Pain
Use of Health Services: • •
Avoided dental professional due to cost Declined recommended dental treatment due to cost
Figure 1 Modification of Andersen’s emerging model [adapted from Andersen (14)].
that asked: “Were you born a Canadian citizen?” The number of years in Canada indicates the length of time the respondent has been in Canada since his/her immigration. The household question corresponding to his variable is: “In what year did you first come to Canada to live?” This was a continuous outcome that was dichotomized into “greater than 10 years” and “less than 10 years” to identify newer and older immigrants. Education indicates the highest level of education acquired by any member of the household. Enabling factors include both community and personal resources and must be present for use to take place. Income, insurance, and employment status, for example, are important enabling measures. A measure of income adequacy was used. Income adequacy is a derived variable classified into four categories based on the respondent’s total household income and the number of people living in the household. See Appendix for a description of how each income category was derived. Dental insurance was derived from two questions in the household questionnaire: “Do you have insurance or a government program that covers all or part of your dental expenses?” and “Is it: an employer-sponsored plan? a provincial program for children or seniors? a private plan? a government program for social service (welfare) clients? a government program for First Nations and Inuit?” The insurance variable was recoded and classified into three groups: private, public, or no insurance. Employment status was determined by the respondent’s job status over the past year and the total number of hours the respondent worked per week. Full time was classified as working more than 30 hours per week, and part-time was classified as working less than 30 hours per week. Lastly, need factors include perceived need (how individuals view their health). Self-reported oral health was the need factor in this study. Respondents were asked to rate the health of their mouth using the following categories: excellent, very good, good, fair, and poor. 212
Cost barriers Two variables were used to measure cost barriers to dental care and correspond to two questions in the household questionnaire: “In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?” and “In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?” Respondents answered “yes” or “no.” Similar questions (with slight variations in wording) have been used by previous Canadian (4,12,13) and international oral health surveys (15,16).
Analyses Descriptive frequencies were calculated to observe the socioeconomic and demographic characteristics of the sample as a whole and of each subsample (individuals who reported avoiding the dentist because of cost and individuals who reported declining recommended dental treatment because of cost). Bivariate logistic regressions were conducted to identify the independent relationship of covariates with each outcome variable (individuals who reported avoiding the dentist and individuals who reported declining recommended dental treatment). Only variables with a P-value less than 0.25 in the bivariate analyses were entered into the multivariable model. Multicollinearity among the predictive variables was assessed using the variance inflation factor (VIF). Only those variables with a VIF equal to or less than three were entered into the multivariable model. Logistic regressions were conducted for each outcome variable to determine which factors were the strongest predictors of reporting cost barriers. The crude and adjusted odds ratios, 95 percent confidence intervals (CIs) and P-values were recorded. The significance level was set at P < 0.05. Prevalence odds ratios were utilized in order to compare © 2014 American Association of Public Health Dentistry
B. Thompson et al.
results with data from other cross-sectional oral health surveys that also used odds ratios to describe the strength of the association between similar independent variables and similar outcomes (2,4,7,12,17). All statistical analyses were completed using STATA v.12 (StataCorp LP, College Station, TX, USA). All missing data were coded by Statistics Canada. Missing data were the result of nonresponse to some or all questions in the survey. In this study, records with missing values were removed from the analyses. As part of the disclosure process at Statistics Canada’s Research Data Centre, only weighted proportions and counts were permitted for release.
Results Approximately 17.3 percent (CI: 14.7, 20.3) of those surveyed reported avoiding a dental professional because of cost, and 16.5 percent (CI: 15.0, 18.2) reported declining recommended dental treatment because of cost. Eleven percent (CI: 9.37, 13.13) of the respondents reported both avoiding a dental professional and declining recommended treatment because of cost within the last year. Seventy-seven percent (CI: 74.9, 79.53) of those surveyed did not report experiencing a financial barrier to dental care. In other words, 23 percent, or nearly one in five of those surveyed, reported experiencing a cost barrier to dental care, whether it was avoiding a dentist, declining recommended dental treatment, or both.
Socio-demographic and economic factors Tables 1 and 2 describe the prevalence of avoiding dental treatment and declining treatment according to sociodemographic factors. When both the insurance and employment status of respondents were examined, cost barriers were reported most among those that were employed without insurance. Among respondents who reported avoiding a dentist, 41.7 percent (CI: 33.3, 50.6) were employed without insurance, and 35.0 percent (CI: 29.8, 40.5) were unemployed without insurance. Similarly, among respondents who reported declining recommended dental treatment, 29.6 percent (CI: 23.0, 37.1) were employed without insurance, and 28.5 percent (CI: 23.0, 35.0) were unemployed without insurance. When specifically looking at dental insurance, among those that avoided the dentist altogether (Table 1), there is no statistically significant difference between those with public and private insurance. However, when examining those that declined recommended dental treatment because of cost (Table 2), there is a difference between the privately and publicly insured. © 2014 American Association of Public Health Dentistry
Cost as a barrier to accessing dental care
Table 1 Characteristics of Respondents Avoiding Visiting a Dental Professional in the Past Year due to Cost, 2007/09
All Age 6-11 12-19 20-39 40-59 60-79 Sex Male Female Income Higher Upper middle Lower middle Lower Insurance Private Public No insurance Education >High school High school
