Utilization of dental services in Southern China. Lo, ECM; Lin, HC; Wang, ZJ; Wong, MCM; Schwarz, E

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1 Title Utiliztion of dentl services in Southern Chin Author(s) Lo, ECM; Lin, HC; Wng, ZJ; Wong, MCM; Schwrz, E Cittion Journl Of Dentl Reserch, 2001, v. 80 n. 5, p Issued Dte 2001 URL Rights Cretive Commons: Attribution 3.0 Hong Kong License

2 E.C.M. Lol*, H.C. Lin2, Z.J. Wn 3, M.C.M. Wong1, nd E. Schwrz"4 'Fculty of Dentistry, The University of Hong Kong, 3/F, Prince Philip Dentl Hospitl, 34 Hospitl Rod, Hong Kong; 2Deprtment of Preventive Dentistry, Sun Yt-sen University of Medicl Sciences; nd 3Deprtment of Epidemiology, Sun Yt-sen University of Medicl Sciences; 4present ddress, 1619 Duke St., Alexndri, VA 22314, USA; *corresponding uthor, J Dent Res 80(5): , 2001 ABSTRACT A popultion's utiliztion of dentl services is n importnt prmeter in orl helth cre plnning, which hs rrely been studied in Chin. The objectives of this report were to describe the dentl service utiliztion pttern of middle-ged nd elderly Chinese nd to nlyze the influence of selected vribles on the use of dentl services. A Gungdong Province popultion of to 44-yer-olds nd to 74-yer-olds recruited from urbn nd rurl communities ws interviewed in their locl dilect. It ws found tht 23% of the middle-ged nd 24% of the elderly subjects hd visited dentist within the preceding yer. The two most commonly cited resons for not hving seen dentist for t lest 3 yers were: no perceived need, nd no serious dentl problems. Among subjects who hd visited dentist within 3 yers, the 3 most commonly received tretments were: fillings, extrctions, nd dentl prostheses. Furthermore, logistic regression nlysis showed tht women, subjects who lived in urbn res, were better educted, were welthier, nd hd better orl helth knowledge were more likely to be recent dentl service user. In conclusion, dentl service utiliztion mong the dult Southern Chinese ws found to be low, problem-driven, nd influenced by some socio-economic fctors. KEY WORDS: dult, use of dentl cre, orl helth survey, Chinese. The Orl Helth Survey in Southern Chin, 1997, ws conducted under the uspices of the Deprtment of Periodontology nd Public Helth of the Fculty of Dentistry, the University of Hong Kong, nd publiction of these ppers is mde possible by funding from The Reserch Grnts Council of the Hong Kong Specil Administrtive Region, Chin, HKU 232/95M, together with the University of Hong Kong Committee for Reserch nd Conference Grnts. Utiliztion of Dentl Services in Southern Chin INTRODUCTION It is well-estblished tht erly dignosis nd pproprite tretment, including preventive nd curtive mesures, cn prevent dentl diseses from reching stge where pin or other symptoms would force person to seek professionl dentl cre (WHO, 1984; Glvind nd Nyvd, 1986), nd tht dopting hbit of visiting dentist regulrly is one of the common messges in orl helth eduction (Ashley, 1989). There hve been mny studies on people's dentl service utiliztion behviors, but these were minly conducted in the highly industrilized countries (Petersen nd Holst, 1995). In fct, there re very few published orl epidemiologicl studies on dults in Minlnd Chin, nd none of them hs reported specificlly on the use of dentl services. Around hlf of the dult urbn residents in Hunn Province (Zhu, 1993) nd round 90% of the dults in Hubei Province (Petersen et l., 1997) stted tht their min reson for visiting dentist ws due to dentl problem. Another study in Southern Chin reported tht only 15% of the urbn residents nd 5% of the rurl residents hd visited dentist when they lst hd dentl problems (Sun, 1992). Thus, one cn speculte tht the dentl service utiliztion rte mong Chinese dults is low becuse of the bove-mentioned dentl visit behvior, very high dentist-to-popultion rtio (1:100,000), nd the poorly developed dentl cre delivery system (FDI, 1990). A survey conducted in Hong Kong, city in Southern Chin djoining Gungdong Province, found tht round one-third of the Chinese dults hd visited dentist within yer, nd few were regulr users (Lo nd Schwrz, 1994). This utiliztion rte ws low compred with tht found in most Western industrilized countries (Petersen nd Holst, 1995). The min objectives of this nlysis were to describe the dentl service utiliztion ptterns of the middle-ged nd the elderly Southern Chinese nd the influence of vrious fctors on the use of dentl services in these two ge groups. MATERIALS & METHODS The smple ws comprised of to 44-yer-old nd to 74-yerold Chinese living in different res of Gungdong Province, Southern Chin. The subjects were recruited from 16 survey sites (8 urbn nd 8 rurl) through combintion of multi-stge strtified smpling nd quot smpling. First, 4 mjor dministrtive regions of the Province were chosen for the survey, minly bsed on their geogrphic loction. Then, by two-stge strtified simple rndom smpling, 2 urbn sub-districts nd 2 rurl townships in ech region were selected to be the survey sites. With ssistnce from the locl government nd helth uthority, bout 100 subjects in ech ge group were recruited either from their work plce or from their houses. Detils of the smpling methods nd recruitment of subjects hve been described in preceding pper (Schwrz et l., 2001). Informtion for this nlysis ws collected by fce-to-fce interview conducted by mens of structured questionnire. Becuse some of the subjects, especilly the elderly, could communicte only in their locl dilect, interviewers fluent in tht dilect were recruited from stffs of the locl government or hospitl. Trining ws provided to the interviewers prior to the interviews, nd 1471

3 1472 Lo et /. the reserchers monitored their performnce throughout the survey. In the interview, besides providing informtion on their socioeconomic bckground, the subjects were sked when they lst visited dentist. Those respondents who hd not mde dentl visit within the previous 3 yers were sked to give the resons for not doing so. Respondents who hd visited dentist within 3 yers were sked to give informtion on the tretments they hd received in their lst dentl visit. Four questions were sked so tht the dentl knowledge of the subjects could be mesured. Two questions were on the cuses nd the prevention of tooth decy, nd the other two were on gum disese. Up to 3 nswers were recorded for ech question. We constructed dentl knowledge score by counting the totl number of cceptble nswers given by the subjects, excluding those responses like "do not know" nd "no nswer". Thus, the dentl knowledge score ws in n intervl scle nd rnged from 0 to 12, with higher dentl knowledge score indicting better dentl knowledge. Eight sttements conceming the importnce of orl helth, importnce of retining nturl teeth, dentl service utiliztion, nd dentl helth beliefs were designed to explore the subjects' ttitudes towrd orl helth. The subjects were sked to indicte whether they greed with, disgreed with, or hd no comment on ech of the sttements. We constructed dentl ttitude score by counting the totl number of sttements to which the subjects, in their responses, showed positive ttitude. Agin, this score ws in n intervl scle nd rnged from 0 to indicting more positive ttitude. 8, with higher score Dt Anlysis According to the nlytic model used in this study (Schwrz et l., 2001), loction of residence (urbn/rurl res), gender, eduction level, mteril welth mesured by the Fmily Mteril Possession Index (FMPI), dentl knowledge, dentl ttitudes, nd dentl fer were selected s possible fctors ffecting the subjects' use of dentl services. The study subjects were ctegorized into two groups ccording to the time lpsed since their lst dentl visit, within 3 yers nd more thn 3 yers. This ws used s the dependent vrible in the bivrite nlysis. Sttisticl nlysis ws performed by the softwre Sttisticl Pckge for Socil Sciences (SPSS). Chi-squre tests were used to detect significntly different distributions of dentl service users in reltion to the vrious independent vribles. For the nlysis Tble 1. Recency of Lst Dentl Visit in the Two Age Groups According to Loction of Residence (%) 35- to 44-yer-olds 65- to 74-yer-olds Time Since Lst Urbn Rurl Urbn Rurl Dentl Visit (n = 798) (n = 775) (n = 774) (n = 741) < 12 months yers yers > 5yers Never visited dentist Significnt between urbn nd rurl residents, p < (Chisqure test). J Dent Res 80(5) 2001 with men score vribles, two-smple t test ws used. The sttisticl significnce level ws set t For ssessment of the reltive importnce of the independent vribles in explining the use of dentl services within 3 yers, bckwrd stepwise logistic regression nlysis ws performed. The significnce level chosen for retention of vrible in the model ws 0.05, nd 95% confidence intervls of the odds rtio were clculted for ll vribles tht were retined in the finl logistic model. RESULTS Tble 1 shows the percentge distribution of the study subjects ccording to the time lpsed since their lst dentl visit, ge group, nd loction of survey site. It cn be seen in both ge groups tht less thn one-third of the urbn residents nd less thn 20% of the rurl residents hd visited dentist within the preceding yer. The dentl service utiliztion pttems of the two ge groups were similr, nd proportionlly more of the urbn residents hd mde recent dentl visit thn the rurl residents (p < 0.001). The most commonly cited reson for not hving seen dentist for t lest 3 yers ws no perceived need. This ws more commonly cited by the urbn residents (62-73%) thn by the rurl residents (43-55%) in both ge groups (p < 0.001). The second most commonly reported reson ws tht the dentl problems were not perceived s serious (25-31%). Close to one-third of the rurl elderly sid tht finncil difficulty ws brrier to receiving dentl cre, but the percentges of the urbn elderly nd the middle-ged who cited finncil difficulty s brrier were significntly smller (p < ). Among the subjects who hd visited dentist within 3 yers, the 3 most common tretments which they received in their lst dentl visit were fillings, extrctions, nd dentl prostheses (Tble 2). It ws further found tht proportionlly more of the urbn residents hd received fillings, while more of the rurl residents hd received extrctions nd fixed dentl prostheses (p < 0.05). Furthermore, rther low percentge of the subjects received scling in their lst dentl visit-less thn 20% in the middle-ged nd only few percent in the elderly. Tble 2. Tretments Received in the Lst Dentl Visit mong Those Who hd Visited Dentist within the Pst 3 Yers (multiple response nlysis; percentges totl more thn 100) 35- to 44-yer-olds 65- to 74-yer-olds Urbn Rurl Urbn Rurl Tretment Received (n = 385) (n = 265) (n = 415) (n = 268) Exmintion Sclingb Fillingb Extrction Fixed prosthesis Dentures Othersb Significnt between urbn nd rurl residents in both ge groups, p < 0.05 (Chi-squre test). 6 Significnt between urbn nd rurl residents in 35- to 44-yerolds only, p < 0.05 (Chi-squre test).

4 J Dent Res 80(5) 2001 In the 35- to 44-yer-old subjects, hving mde dentl visit within 3 yers ws more commonly found mong the urbn residents, women, those who were better educted or welthier, nd those who hd better orl helth knowledge or more positive dentl ttitudes (Tble 3). It ws interesting to find tht hving hd more recent visit to dentist ws relted to being frid of dentists. A similr pttern ws lso found in the 65- to 74-yer-olds, except tht gender nd dentl fer did not hve sttisticlly significnt reltionship with dentl service utiliztion. Results of the logistic regression nlysis (Tbles 4 nd 5) were similr to those found in the bivrite nlysis. In the 35- to 44-yerolds, 4 of the 7 independent vribles remined in the finl logistic regression model. These were loction of residence, gender, fer of dentists, nd dentl ttitudes. The vribles retined in the finl logistic regression model in the 65- to 74- yer-olds were slightly different from those in the younger ge group. Five vribles were retined: loction of residence, gender, eductionl ttinment, mteril welth, nd dentl knowledge. DISCUSSION Findings from this study confirmed the specultion tht dentl service utiliztion mong dults in Minlnd Chin ws very low. Compred with the highly industrilized countries, where bout 60 to 80% of the dults would hve visited dentist within yer (Miller et l., 1987; Todd nd Lder, 1991; Petersen nd Holst, 1995), the utiliztion rte of the study subjects ws only bout one-third. Even when compred with the sitution in Hong Kong, where most of the people re Southern Chinese (Lo nd Schwrz, 1994), the utiliztion rte of the middle-ged Gungdong subjects ws lower, while tht of the elderly subjects ws similr. The dentl service utiliztion rte of the Gungdong dults found in this study is very close to tht of dults in Centrl Chin (Petersen et l., 1997; Petersen nd Esheng, 1998). In these studies, it ws found tht the dentl utiliztion rte of the younger dults ws rther low, nd tht of the elderly ws higher. Similr to the findings of other Chinese studies (Zhu, 1993; Peng et l., 1997; Petersen et l., 1997), it ws found tht the use of dentl services mong the Southern Chinese ws very much symptom-driven, nd preventive dentl visits were rre. This pttern ws lso found mong the Chinese living in Hong Kong (Lo nd Schwrz, 1994) nd those in the United Kingdom (Kwn nd Willims, 1999). Severl mesures of dentl services utiliztion hve been used in different studies (Gift, 1984). The min mesure used in the bivrite nd multivrite nlyses in this study ws dichotomous vrible, whether the subject hd mde dentl visit within 3 yers. This mesure ws chosen becuse the low rte of utiliztion of dentl services mong the study subjects rendered the use of more sophisticted vribles e.g., the number of dentl visits within yer nd the regulrity of Use of Dentl Services in Southern Chin Tble 3. Use of Dentl Services in Adult Chinese According to Selected Demogrphic nd Socio-Behviorl Fctors Time Since Lst Dentl Visit 35- to 44-yer-olds 65- to 74-yer-olds < 3 yrs > 3 yrs < 3 yrs > 3 yrs Fctor n % % n % % Loction Urbn Rurl Gender Mle Femle Eduction Up to primry Lower secondry Upper secondry nd bove Afrid of dentists Yes No x x x x Men FMPIb Men dentl ttitude scoreb Men dentl knowledge scoreb Significnt between groups with p < (Chi-squre test). 6 Significnt between groups with p < (tctest). Tble 4. Results of Logistic Regression Anlysis on the Use of Dentl Services within 3 Yers mong the 35- to 44-yer-olds Fctor Bet (SE) Odds Rtio (95% CI) p-vlue Loction Rurl <0.001 Urbn 0.46 (0.11) 1.6 ( ) Gender Mle Femle 0.28 (0.11) 1.3 ( ) Afrid of dentists No < Yes 0.46 (0.12) 1.6 ( ) Dentl ttitude 0.13 (0.04) ) Constnt (0.28) < x2 = 71; df = 4; p < Reference ctegory dentl visits less pproprite. The reltionships between dentl service utiliztion nd the min demogrphic vribles, e.g., gender, loction of residence, eduction, nd welth, found in this study were similr to the findings of most dentl utiliztion studies, including those from Chin (Petersen et l., 1997), Hong Kong (Schwrz nd Lo, 1994), nd other prts of the world (Gift, 1984). However, the reltionship between dentl fer nd utiliztion s found in this study is worth some

5 1474 Lo et l. J Dent Res 80(5) 2001 Tble 5. Results of Logistic Regression Anlysis on the Use of Dentl Services within 3 Yers mong the 65- to 74-yer-olds Fctor Bet (SE) Odds Rtio (95% CI) p-vlue Loction Rurl Urbn 0.27 (0.13) 1.3 ( ) Gender Mle < Femle 0.49 (0.14) 1.6 ( ) Eduction No forml schooling < Primry 0.52 (0.15) 1.7 ( ) Secondry nd bove 0.84 (0.19) 2.3 ( ) Fmily Mteril Possession Index 0.02 (0.01) 1.02 ( ) Dentl knowledge score 0.06 (0.03) 1.06 ( ) Constnt (0.15) < x2= 102; df = 6; p < Reference ctegory. discussion. Being frid of dentists is usully presented s brrier to dentl service use (Feske et l., 1990; Locker et l., 1991), nd one would expect the regulr or more recent dentl service users not to be frid of dentists. This ws not the cse in this study, nd the odds rtio of 1.6 in the 35- to 44-yer-old subjects suggested tht people who were frid of dentists would more likely be recent dentl service users. This is probbly becuse the subjects in this study minly visited dentist when they hd serious dentl problems, nd one of the most common tretments received ws extrction. Thus, their dentl visits were perhps very unplesnt, which would mke the recent users frid of dentists. This proposition ws supported by the further nlysis of the survey dt which showed tht the recent users were lso more likely to hve experienced pin, to perceive their orl condition s poor, nd to hve perceived need for more tretment. Similr findings were lso obtined in recent survey of dults in Centrl Chin (Petersen et l., 1997). This kind of ttitude nd behvior hinders the development of preventive dentl visits. Orl helth eduction lone most probbly cnnot brek this vicious cycle in the Southern Chinese. Chnges in the orgniztion of dentl cre services (e.g., improving ccessibility by setting up more dentl clinics or outrech dentl services), provision of better cre (e.g., better pin control during tretment nd the use of more conservtive pproches), nd better dentist-ptient interctions (e.g., pying more ttention to ptients' feelings nd using more ptient-friendly pproch) will probbly be required to chnge this sitution. Due to severe lck of trined dentl personnel in Southern Chin nd the low utiliztion of dentl services, it would be very ineffective nd inefficient to implement dentl-clinic-bsed orl helth eduction nd promotion ctivities. The use of mss medi or collbortions with other disciplines in primry helth cre my be better wys to disseminte orl helth messges under the current sitution in Southern Chin. The orl helth policy should plce more emphsis on community-bsed preventive progrms thn on clinic-bsed curtive services. In conclusion, dentl service utiliztion mong the dult Southern Chinese ws low, problem-driven, nd influenced by some socio-economic fctors. Improvement in the dentl service utiliztion rte in this popultion will depend on the generl socil nd economic development s well s on the success of improvements in the delivery of dentl cre services nd community-bsed orl helth promotion ctivities. ACKNOWLEDGMENTS The University of Hong Kong (CRCG) nd the Reserch Grnts Council of Hong Kong finncilly supported this study. REFERENCES Ashley FP (1989). Role of dentl helth eduction in preventive dentistry. In: The prevention of dentl disese. Murry JJ, editor. Oxford: Oxford University Press, pp Federtion Dentire Intemtionle (1990). FDI bsic fcts London: Federtion Dentire Intemtionle, pp Feske J, Gelbier S, Wtson RM (1990). Brriers to dentl cre in n elderly popultion resident in n inner city re. JDent 18: Gift HC (1984). Utiliztion ofprofessionl dentl services. 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