Abstract

Background

Utilization of oral health services on a regular basis is essential for addressing any oral health problem and preventing the development of more serious concerns. However, there exist some barriers that directly impact utilization of dental services, like cost, lack of awareness, anxiety or dental fear, accessibility and availability of dental services. Therefore, this study was conducted to determine dental service utilization and perceived barriers among adults residing in Jiri, Nepal.

Methods

A cross-sectional study was conducted among 725 adult residents of Jiri who were interviewed with the help of a validated and pre-tested questionnaire. Data were analyzed in SPSS version 24. Mean and standard deviation were computed for continuous data like age. Frequency and percentage were calculated for categorical variables regarding dental service utilization and perceived barriers. Chi square test was used to determine association between demographic factors and their dental services utilization status.

Results

Out of 725 study participants, 595 (82.1%) did not visit a dentist in the past one year. Very few (87, 12%), utilized dental services in the past six months. Dental pain was the major reason for their visit to the dentist. Many aged 65 years and above (109, 87.2%) did not visit dentist in the past one year which was significantly higher than other age groups (P鈥�=鈥�0.033). Similarly, most of the unemployed residents of Jiri (331, 86.9%) had not utilized dental services than employed or self-employed residents (P鈥�=鈥�0.001).The major barrier for dental service utilization perceived by the study participants was the high cost of treatment (474, 65.4%) followed by lack of awareness to seek dental care (417, 57.5%) and difficult access to oral health services due to scarce dental facility (393, 54.2%).

Conclusions

The findings of this study showed low dental care utilization status by the adult residents of Jiri which was associated with age and employment status. High cost of dental treatment, lack of awareness and accessibility were the major perceived barriers. Utilization of dental services can be increased by tackling concerns about the affordability of oral health care, adequate accessibility of public dental facility, and oral health education and promotion at community level.

Background

The term 鈥渉ealth care utilization鈥� refers to the quantification or description of how often people utilize healthcare services to prevent and treat health issues, maintain their health and well-being, or obtain information about their current condition and prognosis [1]. Patient concerns, preferences, and attitudes should be thoroughly examined because of their potential influence on the utilization and satisfaction of health care services [2]. To ensure service utilization, ensuring sufficient availability and access to oral health services is essential, as it leads to early disease prevention, prompt diagnosis, and efficient management of oral diseases and related problems that offer opportunities for improved health promotion [3].

Oral health is an important aspect of public health. In addition to having an adverse effect on an individual鈥檚 quality of life, poor dental health presents challenges for society and health systems as a whole [4]. Dental service use is considered as the number of dental visits per person, the percentage of people who visit a dentist annually, the first dental visit in a series of visits reported, the absence of dental visits within a given period, or the total cost of dental visits or routine versus emergency care [5]. Understanding the variables influencing the use of dental health services is crucial for informing the healthcare system and for health policy decision-making targeted at enhancing oral health status, service utilization, and dental health services [6, 7].

Context-specific factors can influence the utilization of oral health services in diverse geographical locations, especially in nations with distinct cultures, economies, and social structures [8, 9]. The utilization of dental health care is also affected by the effectiveness of dental health program intervention [10]. According to the National Oral Health Policy of Nepal, the prevalence of dental caries is 78% in the rural population, and approximately 31% of those aged 35鈥�44 years have a deep periodontal pocket [11]. Moreover, in rural areas of developing countries such as Nepal, there is limited accessibility and availability of oral health care services and a lack of oral health care providers [12]. Self-medication, the use of herbal medications and homemade treatments appear to be popular practices in most rural areas [13]. Jiri is such a municipality of Dolakha District in the Bagmati Province of central Nepal which lies about 190听km from Kathmandu and is the main gateway to the Everest Region. In Jirel community, health care facilities are limited and the traditional health care is greatly contributed by medicinal plants [14].

A hospital-based study conducted in Eastern Nepal identified several barriers to the utilization of dental services, such as lack of money, perception of restoration not being a long-term solution, the inability to visit a dentist for multiple times, old age and a lack of awareness of other treatment options [15]. This study aims to determine the utilization status of oral health care services and perceived barriers to utilization among adults residing in Jiri, Nepal. Jiri is a municipality situated in Dolakha District in the Bagmati Province of Central Nepal.

Methods

Study design and participants

A cross-sectional study was conducted from 25th March to 5th April 2024 to determine oral health care utilization among the heads of households in Jiri, Dolakha, Nepal. The heads of households in wards 5 and 6 of Jiri were selected via the convenience sampling method. Wherever the head of household was not present during the time of data collection, another senior member of the family aged 18 years or older willing to participate in the study was considered. Individuals under psychiatric medication, immigrants, those with any developmental disability or under substance abuse at the time of data collection were excluded. The sample size was calculated on the basis of a similar study conducted in India [16], where 19% of the study participants had visited a dentist in the past year. This value is n鈥�=鈥塟²pq/e², where Z鈥�=鈥�1.96, p鈥�=鈥塸revalence鈥�=鈥�28%; q鈥�=鈥�100-p; e鈥�=鈥塵argin of error鈥�=鈥�3%; n鈥�=鈥�656.64; adding a 10% nonresponse rate, the total final sample obtained = 722.30鈥夆増鈥�725.

Ethical consideration

Ethical approval was obtained from the Institutional Review Committee of the Institute of Medicine [reference number: 475 (6鈥�11) E2 080/81]. Written informed consent was obtained from the study participants before data collection. They were informed about the purpose of the study, its potential risks and benefits. They were ensured that the confidentiality of data will be maintained, and their participation would be voluntary.

Study tool

The questionnaires used in the published studies [12, 17, 18] regarding dental care utilization status and perceived barriers were considered for developing a questionnaire for this study (Questionnaire in Supplementary material 1). The questionnaire developed was translated into the Nepali language via the standard back-translation method. Face and content validity of the questionnaire were ensured. Face validity of the adopted questionnaire was considered by the principal investigator who subjectively viewed the questionnaire as covering the concept it purports to measure. Content validity of the questionnaire was checked by the two community dentistry experts by reviewing the assessment items to ensure that they aligned with the content domain.

To measure the reliability of the reported findings, pretesting was performed by interviewing 26 adults twice within an interval of two weeks before final data collection. Reliability was measured using Cohen鈥檚 Kappa and the average score obtained was 0.65 indicating substantial agreement. The participants who were pretested were excluded from the main study. In the final questionnaire, minor changes were made in some of the questions based on the inappropriateness of the responses received during the pre-testing phase for clarity of questions. The questionnaire consisted of three parts. The first part included the participants鈥� sociodemographic profile, including age, sex, level of education, marital status and current occupation status. The second part included questions related to the utilization of oral health services, and the third part consisted of questions related to perceived barriers to the utilization of oral health services.

Data collection

Adults residing in Jiri, Dolakha, were interviewed about oral health service utilization in the past year and barriers to utilization of these services through home visits by fourth-year dental students of Maharajgunj Medical Campus. The time required for each interview was 10鈥�15听min. The dental students were trained in the department before final data collection. Wards no. 5 and 6 of Jiri were considered sites that were selected for the Community Health Diagnosis Program for the year by the Department of Community Dentistry, TU Teaching Hospital, Maharajgunj Medical Campus.

Statistical analysis

The data obtained were entered into a Microsoft Excel Sheet and analysed with Statistical Package for Social Sciences (SPSS) version 24 software (IBM Corp., Armonk, N.Y., USA). The means and standard deviations were computed for continuous data such as age. Frequencies and percentages were calculated for categorical variables regarding the utilization of dental services and perceived barriers. A chi-square test was performed to determine the associations between the demographic factors of the study participants and their dental service utilization status.

Results

The mean age of the study participants was 48.78鈥壜扁��15.30 years. Among the 725 participants, 375 (51.7%) were males, and 350 (48.3%) were females. Most of them (595, 82.1%), had not visited a dentist in the past year (Fig.听1), and very few (87, 12%), had a dental visit in the past six months. The major reason for visiting the hospital was dental pain (Fig.听2). Among 130 adults who visited a dentist in the past year, 112 (86.2%) reported that they were satisfied with their last dental visit.

Fig. 1

Dental visits in the past year and frequency of visits (n鈥�=鈥�725)

Fig. 2

Reasons for last dental visit (n鈥�=鈥�130)

The associations of demographic factors with the utilization of dental services in the past year are presented in Table听1. Age (P鈥�=鈥�0.033) and current occupational status (P鈥�=鈥�0.001) were significantly associated with the utilization of dental services. Most of the participants who had not visited the dentist in the past year were those aged 65 years and above (n鈥�=鈥�109, 87.2%), and those who were unemployed (n鈥�=鈥�331, 86.9%).

Table 1 Association of demographic factors with the utilization of dental services in the past year (n鈥�=鈥�725)

Out of 725 adults surveyed, 653 (90.1%) reported atleast one perceived barrier to utilization of dental services. The perceived barriers to the utilization of dental services are presented in Table听2. More than half of the study participants (474, 65.4%) perceived the high cost of dental treatment as the major barrier to the utilization of dental services, followed by a lack of awareness of seeking dental care (417, 57.5%) and difficult access to oral health services due to scarce dental facilities (393, 54.2%).

Table 2 Perceived barriers to the utilization of dental services (n鈥�=鈥�725)

Association of demographic variables with at least one perceived barrier to utilisation of dental services is presented in Table听3. Current occupational status (P鈥�=鈥�0.015) was found significantly associated with at least one perceived barrier by the adult residents of Jiri.

Table 3 Association of variables with at least one perceived barrier to utilisation of dental services (n鈥�=鈥�725)

Discussion

Oral diseases continue to be neglected and receive little attention in many nations worldwide, despite being among the most prevalent diseases affecting large populations [19]. The factors influencing the use of oral health services by rural populations in developing nations are not well understood [12]. Therefore, this study was conducted to determine the status of dental care utilization and the barriers to utilization perceived by the heads of households residing in Jiri, which is situated in Dolakha district in Bagmati Province, Central Nepal.

Among the 725 adult residents who participated in this study, only 130 (17.9%) visited a dentist in the past year, and very few (87, 12%) had a dental visit in the past six months. Additionally, according to the annual report of Nepal, 2020, there is a low record of dental visits by only 3.89% of the Nepalese population [20]. The prevalence of dental health care utilization was found to be 15.4鈥壜扁��2.9% in Kerala [4] and 36% in Nellore, India, in the past year [21]. However, 60.3% and 9.9% reported visiting a dentist for dental treatment in the past year and for 6-monthly dental check-ups, respectively, in Kermanshah city, western Iran [3]. Past dental visits show that the person has given care to his/her oral health. It reflects the individual's motivation and decision towards dental treatment. Utilization of dental services not even once a year indicates poor preventive oral health practices by people because they seek dental care only after they suffer from an acute dental problem [22]. In the current study, the utilization of dental services was low, and the major reason for the last dental visit was dental pain followed by tooth decay. Similarly, other studies reported that pain was the primary reason for visiting a dentist, followed by decayed teeth [22,23,24]. Pain and emergency care are the most common reasons for dental appointments [25].

In the present study, the associations of demographic factors with the utilization of dental services in the past year were determined. Age (P鈥�=鈥�0.033) was significantly associated with the utilization of dental services. Among different age groups, utilization of dental services was observed more (51, 24.2%) among 35鈥�49 years of age. In a study by Kakatkar et al., younger age group visited the dentist regularly in comparison to the older age group which may be because the younger age group had more knowledge and fewer barriers [26]. In the present study, many of those aged 65 years and above (109, 87.2%) had not visited a dentist in the past year. In accordance with the findings of this study, one study reported that the frequency of dental visits decreased with age [27]. The underutilization of dental services can be attributed to several factors, such as elderly people facing issues such as loss of income due to not being an active work force, increased risk of chronic diseases, loss of social support, and inadequate pensions, all of which have an impact on their general health and dental health [28]. In contrast, other studies have shown a significant association of dental service utilization with age, such that older age was observed to be an important factor for seeking and using dental health-care services [3, 25, 29,30,31]. The contrasting study findings for dental service utilization with respect to age suggest the need for both interindividual and intraindividual explanations [27].

In the present study, current occupational status (P鈥�=鈥�0.001) was significantly associated with dental service utilization in the past year, such that the number of dental visits for seeking care was lower among most unemployed individuals (331, 86.9%) than among employed individuals (179, 75.5%) or self-employed individuals (85, 79.4%) in Jiri. Similarly, a study reported that people with unemployment status are more likely to experience unmet dental care needs due to their financial constraints [32]. Additionally, in other studies, most employed adults had a higher rate of regular dental attendance than the unemployed adults [4, 33, 34].

An analysis of the perceived barriers to dental service utilization by adult residents of Jiri revealed that the most common perceived barrier was the high cost of dental treatment, followed by a lack of awareness of seeking dental care and difficult access to oral health services due to scarce dental facilities. Similarly, the most frequent barriers reported by the elders in the study conducted by Saleh et al. were the high cost of dental services, lack of awareness of the importance of dental checkups, fear of dental procedures, difficult transportation and long distances, and poor experience [35]. Similarly, Al Johara reported that the high cost of dental care was the most discouraging factor for the utilization of dental services [2].

In the present study, most of the unemployed respondents (349, 91.6%) perceived at least one barrier in utilization to dental services than self-employed or employed groups (P鈥�=鈥�0.015). This could be because career traits are consistently associated to subsequent self-perceived healthcare access barriers, with cost barriers being normally linked than service unavailability [36].

The present study provides useful information regarding the status of dental service utilization by people in the rural population of Nepal and its associations with demographic factors and perceived barriers. However, this study has several limitations that should be considered when interpreting its findings. Convenience sampling, a type of non-probability sampling method, was utilized for selecting the sample, which could have led to a high risk of causing selection as well as under coverage bias, owing to their unrepresentativeness towards the target population. Since dental visits in the past six months and one year were investigated, the probability of recall bias could not be avoided. Additionally, we could not assess whether the dental visit was limited to regular dental checkups or whether the participants sought any preventive or curative treatment measures. Furthermore, the cross-sectional nature of the study design could not reveal the temporal relationship between demographic factors and dental service utilization status.

Conclusions

The results of this study revealed that residents of Jiri, Dolakha, had a low dental service utilization status, which was associated with both age and employment status. The main perceived barriers to utilization were accessibility, lack of knowledge, and the high expense of dental care. Addressing issues such as oral health care affordability, public dental facility accessibility, and oral health education and promotion at the community level can all help to increase the use of dental services. Overcoming these challenges requires establishing public鈥抪rivate partnerships to lower out-of-pocket expenses and prioritizing the integration of basic dental care into primary health care.