Community Dent Oral Epidemiol 2014; 42; 591–602 All rights reserved
Ó 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental attendance among adult Finns after a major oral health care reform
Eero Raittio1, Urpo Kiiskinen2, Sari Helminen3, Arpo Aromaa4 and Anna Liisa Suominen1,4,5 1 University of Eastern Finland, Kuopio, Finland, 2Eli Lilly Finland, Helsinki, Finland, 3 Social Insurance Institution, Helsinki, Finland, 4Institute for Health and Welfare (THL), Helsinki, Finland, 5Department of Oral and Maxillofacial Surgery, Kuopio University Hospital, Kuopio, Finland
Raittio E, Kiiskinen U, Helminen S, Aromaa A, Suominen AL. Dental attendance among adult Finns after a major oral health care reform. Community Dent Oral Epidemiol 2014; 42: 591–602. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Abstract – Objectives: Between 2001 and 2002, all age limits restricting the availability of subsidized private dental care and Public Dental Services (PDS) were abolished in Finland. In addition, the reform aimed to address incomeand residence-related disparities in access to subsidized oral health care services. The aim of this study was to analyse how dental attendance and factors associated with it changed after the reform. Methods: We carried out three consecutive surveys on the use of oral health care services and perceived oral health. The surveys were conducted in 2001 (n = 2837), in 2004 (n = 2420) and in 2007 (n = 2296), and the study population comprised Finnish adults born in 1970 or earlier. Logistic regression analyses were used to examine factors associated with the use of the services. Results: The percentage of respondents who attended dental care regularly or had used oral health care services over the past 12 months rose between 2001 and 2007. In particular, there was an increase in the proportion of subjects who used PDS. The average number of visits to a private dentist decreased between 2001 and 2007. In the regression analyses, the use of services was associated with older age, perceived lack of need for care, perceived toothache during the past 12 months, perceived good oral health, lower number of missing teeth and regular dental visiting habits. The use of private dental care services was associated with perceived good oral health and perceived lack of need for care, higher household income and older age in all three study years while the use of PDS was associated with younger age, perceived good oral health and perceived lack of need for care only in 2001. Conclusions: The use of oral health care services rose and age did not seem to be a barrier to the use of oral health care services after the reform, as was the aim of the reform. No change in the association of household income with the use of oral health care services was seen after the OHCR.
Equity in access to health care services regardless of age, income or place of residence has been set as a major public health policy goal worldwide (1). In Finland, several steps have been taken to achieve the goal in the context of oral health care since 1972, when the Primary Health Care Act entered into force. Since its implementation, municipalities have provided oral health care services free for charge for children through Public Dental Services (PDS). In addition, where municipalities had suffidoi: 10.1111/cdoe.12117
Key words: access; dental health; dental services research; disparities; public health policy Eero Raittio, University of Eastern Finland, Yliopistonranta 1 C, 70211 Kuopio, Finland Tel.: +358405825708 e-mail: [email protected] Submitted 27 June 2013; accepted 26 May 2014
cient resources, they may have offered partly subsidized PDS for the adult population. In the late 1980s, the municipalities’ obligation to arrange partly subsidized PDS gradually spread, so that it then covered all those born after 1956. Since 1990, these adults (those born in 1956 or later) have also been entitled to receive a reimbursement from the tax funded National Health Insurance (NHI) maintained by the Social Insurance Institution of Finland (SII) for private dentist fees (which effectively
591
Raittio et al.
covers only 30–40% of market price fees). In the late 1990s, two-thirds of the Finnish population lived in a municipality that was not able to provide PDS for its inhabitants born in 1955 or earlier (2). Moreover, the very same people (born in 1955 or earlier) were not entitled to receive a reimbursement for private dental costs from the NHI and so, were compelled to pay the full cost of their oral health care. Studies (3, 4) showed that pro-rich inequity in the use of oral health care services was present in Finland in the late 1990s. To address these obvious income-, age- and residence-related disparities in access to subsidized oral health care services in Finland, a major Oral Health Care Reform (OHCR) was implemented between 2001 and 2002. Since the implementation of the first phase of the OHCR in 2001, those born in 1946 or later have been entitled to use PDS and to receive reimbursements for private dental costs from the NHI. In the second phase of the OHCR in 2002, all age restrictions were abolished. Since then, the whole population has been entitled to reimbursements for private dentist fees (excluding prosthetics and orthodontics) and municipalities have been obliged to provide PDS for all their inhabitants. Since the introduction of the OHCR, the only criterion for access to PDS should be the patient’s need for oral health care. Over the past decade, limited access to medical care was a main concern in public health care in Finland, including PDS. In response to this, legislative reforms aiming to guarantee access to care in a reasonable period of time (less than half a year) and to standardize medical (odontological) assessment of the need for care were introduced in 2005. This brought pressure to improve patient intake processes and care pathways particularly in those PDS units which had difficulties in meeting the increased demand for oral health care. The aim of this study was to analyse how the use of oral health care services and associated factors had changed in Finland after the OHCR. We also used this opportunity to see whether the 2005 legislative amendments relating to access to care brought about any changes.
Data and methods Data The data for this study were collected by the National Public Health Institute, KTL (later
592
renamed the National Institute for Health and Welfare, THL) and by the SII. We carried out three identical cross-sectional postal surveys conducted before (2001), between (2004) and after (2007) the legislative reforms (Table 1). Cluster sampling was used by applying the sample framework of the Health 2000 Survey. It resulted in representative samples of Finnish adults born in 1970 or earlier. Response rates for the surveys were 70% (n = 2873) in 2001, 65% (n = 2420) in 2004 and 60% (n = 2296) in 2007. In this study, the use of oral health care services was measured using (i) the following yes or no question: ‘Have you visited any oral health care services during the past 12 months?’ and (ii) the number of oral health care visits (at least one) per type of facility used during the past 12 months. The facility options given in this study were: a private dentist, a PDS dentist and a dental nurse or a dental hygienist. The latter two options were interpreted as indicating that the respondent had visited a PDS during the past 12 months. Dentate respondents were also requested to assess their dental visiting habits by choosing one of the following options: ‘regular for check-up’, ‘only when you have toothache or some other problem’ or ‘never’. The latter two options were interpreted as indicating irregular dental visiting habits while the first option was deemed to imply regular dental visiting habits. Respondents were also asked if they had received recalls from the dentist during the past 12 months. The perceived need for oral health care was gauged using the question: ‘Do you think you need dental treatment now?’ Information about perceived toothache or oral discomfort was also inquired: ‘Have you during the past 12 months had toothache or other problems related to your teeth or dentures?’ The options for both questions were either ‘yes’ or ‘no’. Perceived oral health was measured on the basis of the response to the question: ‘Is the condition of your teeth and the health of your mouth at present?’ The options were ‘good’, ‘fairly good’, ‘average’, ‘quite poor’ and ‘poor’. The perceived availability of PDS and private sector services were examined using two statements: ‘There is good availability of PDS/private dental services in the municipality where I live.’ and dental anxiety by ‘I’m scared to visit the dentist.’ The options to these statements were ‘agree’, ‘agree to some extent’, ‘not sure’, ‘disagree to some extent’ and ‘disagree’.
Dental visiting after a major oral health care reform Table 1. Number (n) and percentages (%) of respondents in the surveys 2001
Year of birth
Gender Household income per consumption unit quintiles
Education
Number of missing teeth
Perceived need for care Perceived toothache or oral discomfort during the past 12 months Perceived oral health
‘There is good availability of PDS in the municipality where I live’ ‘There is good availability of private dental services in the municipality where I live’ ‘I’m scared to visit the dentist’
1956–1970 1946–1955 10 All Total Yes No Total Yes No Total Good or fairly good Average Poor or fairly poor Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total
The background variables collected for this study were: year of birth: divided into three groups based on the execution phases of the OHCR; people born between 1956 and 1970, people born between 1946 and 1955 (first phase of the OHCR) and people born before 1946 (
Ó 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental attendance among adult Finns after a major oral health care reform
Eero Raittio1, Urpo Kiiskinen2, Sari Helminen3, Arpo Aromaa4 and Anna Liisa Suominen1,4,5 1 University of Eastern Finland, Kuopio, Finland, 2Eli Lilly Finland, Helsinki, Finland, 3 Social Insurance Institution, Helsinki, Finland, 4Institute for Health and Welfare (THL), Helsinki, Finland, 5Department of Oral and Maxillofacial Surgery, Kuopio University Hospital, Kuopio, Finland
Raittio E, Kiiskinen U, Helminen S, Aromaa A, Suominen AL. Dental attendance among adult Finns after a major oral health care reform. Community Dent Oral Epidemiol 2014; 42: 591–602. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Abstract – Objectives: Between 2001 and 2002, all age limits restricting the availability of subsidized private dental care and Public Dental Services (PDS) were abolished in Finland. In addition, the reform aimed to address incomeand residence-related disparities in access to subsidized oral health care services. The aim of this study was to analyse how dental attendance and factors associated with it changed after the reform. Methods: We carried out three consecutive surveys on the use of oral health care services and perceived oral health. The surveys were conducted in 2001 (n = 2837), in 2004 (n = 2420) and in 2007 (n = 2296), and the study population comprised Finnish adults born in 1970 or earlier. Logistic regression analyses were used to examine factors associated with the use of the services. Results: The percentage of respondents who attended dental care regularly or had used oral health care services over the past 12 months rose between 2001 and 2007. In particular, there was an increase in the proportion of subjects who used PDS. The average number of visits to a private dentist decreased between 2001 and 2007. In the regression analyses, the use of services was associated with older age, perceived lack of need for care, perceived toothache during the past 12 months, perceived good oral health, lower number of missing teeth and regular dental visiting habits. The use of private dental care services was associated with perceived good oral health and perceived lack of need for care, higher household income and older age in all three study years while the use of PDS was associated with younger age, perceived good oral health and perceived lack of need for care only in 2001. Conclusions: The use of oral health care services rose and age did not seem to be a barrier to the use of oral health care services after the reform, as was the aim of the reform. No change in the association of household income with the use of oral health care services was seen after the OHCR.
Equity in access to health care services regardless of age, income or place of residence has been set as a major public health policy goal worldwide (1). In Finland, several steps have been taken to achieve the goal in the context of oral health care since 1972, when the Primary Health Care Act entered into force. Since its implementation, municipalities have provided oral health care services free for charge for children through Public Dental Services (PDS). In addition, where municipalities had suffidoi: 10.1111/cdoe.12117
Key words: access; dental health; dental services research; disparities; public health policy Eero Raittio, University of Eastern Finland, Yliopistonranta 1 C, 70211 Kuopio, Finland Tel.: +358405825708 e-mail: [email protected] Submitted 27 June 2013; accepted 26 May 2014
cient resources, they may have offered partly subsidized PDS for the adult population. In the late 1980s, the municipalities’ obligation to arrange partly subsidized PDS gradually spread, so that it then covered all those born after 1956. Since 1990, these adults (those born in 1956 or later) have also been entitled to receive a reimbursement from the tax funded National Health Insurance (NHI) maintained by the Social Insurance Institution of Finland (SII) for private dentist fees (which effectively
591
Raittio et al.
covers only 30–40% of market price fees). In the late 1990s, two-thirds of the Finnish population lived in a municipality that was not able to provide PDS for its inhabitants born in 1955 or earlier (2). Moreover, the very same people (born in 1955 or earlier) were not entitled to receive a reimbursement for private dental costs from the NHI and so, were compelled to pay the full cost of their oral health care. Studies (3, 4) showed that pro-rich inequity in the use of oral health care services was present in Finland in the late 1990s. To address these obvious income-, age- and residence-related disparities in access to subsidized oral health care services in Finland, a major Oral Health Care Reform (OHCR) was implemented between 2001 and 2002. Since the implementation of the first phase of the OHCR in 2001, those born in 1946 or later have been entitled to use PDS and to receive reimbursements for private dental costs from the NHI. In the second phase of the OHCR in 2002, all age restrictions were abolished. Since then, the whole population has been entitled to reimbursements for private dentist fees (excluding prosthetics and orthodontics) and municipalities have been obliged to provide PDS for all their inhabitants. Since the introduction of the OHCR, the only criterion for access to PDS should be the patient’s need for oral health care. Over the past decade, limited access to medical care was a main concern in public health care in Finland, including PDS. In response to this, legislative reforms aiming to guarantee access to care in a reasonable period of time (less than half a year) and to standardize medical (odontological) assessment of the need for care were introduced in 2005. This brought pressure to improve patient intake processes and care pathways particularly in those PDS units which had difficulties in meeting the increased demand for oral health care. The aim of this study was to analyse how the use of oral health care services and associated factors had changed in Finland after the OHCR. We also used this opportunity to see whether the 2005 legislative amendments relating to access to care brought about any changes.
Data and methods Data The data for this study were collected by the National Public Health Institute, KTL (later
592
renamed the National Institute for Health and Welfare, THL) and by the SII. We carried out three identical cross-sectional postal surveys conducted before (2001), between (2004) and after (2007) the legislative reforms (Table 1). Cluster sampling was used by applying the sample framework of the Health 2000 Survey. It resulted in representative samples of Finnish adults born in 1970 or earlier. Response rates for the surveys were 70% (n = 2873) in 2001, 65% (n = 2420) in 2004 and 60% (n = 2296) in 2007. In this study, the use of oral health care services was measured using (i) the following yes or no question: ‘Have you visited any oral health care services during the past 12 months?’ and (ii) the number of oral health care visits (at least one) per type of facility used during the past 12 months. The facility options given in this study were: a private dentist, a PDS dentist and a dental nurse or a dental hygienist. The latter two options were interpreted as indicating that the respondent had visited a PDS during the past 12 months. Dentate respondents were also requested to assess their dental visiting habits by choosing one of the following options: ‘regular for check-up’, ‘only when you have toothache or some other problem’ or ‘never’. The latter two options were interpreted as indicating irregular dental visiting habits while the first option was deemed to imply regular dental visiting habits. Respondents were also asked if they had received recalls from the dentist during the past 12 months. The perceived need for oral health care was gauged using the question: ‘Do you think you need dental treatment now?’ Information about perceived toothache or oral discomfort was also inquired: ‘Have you during the past 12 months had toothache or other problems related to your teeth or dentures?’ The options for both questions were either ‘yes’ or ‘no’. Perceived oral health was measured on the basis of the response to the question: ‘Is the condition of your teeth and the health of your mouth at present?’ The options were ‘good’, ‘fairly good’, ‘average’, ‘quite poor’ and ‘poor’. The perceived availability of PDS and private sector services were examined using two statements: ‘There is good availability of PDS/private dental services in the municipality where I live.’ and dental anxiety by ‘I’m scared to visit the dentist.’ The options to these statements were ‘agree’, ‘agree to some extent’, ‘not sure’, ‘disagree to some extent’ and ‘disagree’.
Dental visiting after a major oral health care reform Table 1. Number (n) and percentages (%) of respondents in the surveys 2001
Year of birth
Gender Household income per consumption unit quintiles
Education
Number of missing teeth
Perceived need for care Perceived toothache or oral discomfort during the past 12 months Perceived oral health
‘There is good availability of PDS in the municipality where I live’ ‘There is good availability of private dental services in the municipality where I live’ ‘I’m scared to visit the dentist’
1956–1970 1946–1955 10 All Total Yes No Total Yes No Total Good or fairly good Average Poor or fairly poor Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total Agree or agree to some extent Not sure Disagree or disagree to some extent Total
The background variables collected for this study were: year of birth: divided into three groups based on the execution phases of the OHCR; people born between 1956 and 1970, people born between 1946 and 1955 (first phase of the OHCR) and people born before 1946 (
