Factors influencing the utilization of dental services in East Java, Indonesia

Introduction

Health is a fundamental right of every human being without discrimination related to race, religion, and socioeconomic status (World Health Organization, 2015). Oral health is integral to the overall health of human beings (Peres et al., 2019; World Health Organization, 2020). However, in most countries, access to and utilization of oral health services are limited (Glick et al., 2012; Petersen, 2003; Watt et al., 2019). Lack of access to such services can have a detrimental impact on people’s general health and quality of life (Petersen, 2003). Tooth loss is mainly the result of accumulated dental diseases as a product of low utilization of dental services (Petersen, 2003).

One of the commonly used indices to assess the utilization of dental services is the percentage of the population attending a dental visit in the previous year (Bayat et al., 2008). The utilization of dental services is varied across countries. In developing countries, the majority of people only visits the dentist for pain relief rather than preventive care (Varenne et al., 2006), while in developed countries about 40–80% of the adults visit a dentist in a given year (Bayat et al., 2008).

Previous research has indicated certain factors that influence dental service utilization (Fonseca et al., 2017; Machry et al., 2013; Vieira et al., 2019; Vujicic & Nasseh, 2014). For example, socio-demographic factors related to dental service use include age, sex, education, and residential location (Fonseca et al., 2017; Machry et al., 2013; Vieira et al., 2019). Moreover, poor health behaviors are usually clustered in the same person wherein a person with a bad tooth brushing habit also rarely accesses dental treatments (Jordao et al., 2018). Furthermore, dental clinical condition such as dental status (dentate vs edentulous) could influence the utilization of dental services as it differentiates the extent of dental treatment need. So far, utilization of dental services and factors related to it have been mainly reported in developed countries, while such reporting in developing countries has been limited.

Oral health is a much neglected field of research in developing countries, including in Indonesia. Indonesia is the fourth most populated country in the world after China, India, and the United States of America (United Nation, 2019). Cases of dental caries in this country is high; for example, more than 88% of the population has been estimated to have experienced caries, with 45% having untreated caries (The Ministry of Health, Republic of Indonesia, 2019). Currently, Indonesia is in the process of establishing universal health coverage through Jaminan Kesehatan Nasional (JKN), wherein basic dental health is included in the insurance coverage. This insurance covers seven services: 1. dental examination, medication and consultation, 2. premedication, 3. dental emergency, 4. extraction of deciduous or permanent tooth without difficulties, 5. medication after extraction, 6. glass ionomer and composite dental fillings resulting from disease (not cosmetic reasons), and 7. scaling (once a year) (Social Insurance Administration Organization, 2020). This universal health coverage program was implemented as a capitation system whereby the dentists are paid a fixed amount for the number of people who were under their care (Deloitte Indonesia, 2019). The participants in the insurance scheme include Contribution Assistance Recipients (“Penerima Bantuan Iuran,” PBI) and non-PBI members (Deloitte Indonesia, 2019). PBI include poorer citizen whose insurance is funded by the government through taxes. Non-PBI members include other citizens not categorized as poor, who need to subscribe to the insurance scheme by paying for it monthly (e.g., through deduction directly from their income) (Deloitte Indonesia, 2019). A comprehensive assessment of the JKN program conducted by the Government of Indonesia in 2017 found that JKN has managed to bring 76% of Indonesia’s population under the program; this is considered an impressive coverage rate (Social Insurance Administration Organization, 2019).

Despite the high level of dental problems and the high insurance coverage, the utilization of dental services among the Indonesian population is very low (The Ministry of Health Republic of Indonesia, 2013b). Indonesian Basic Health Research (Riset Kesehatan Dasar/RISKESDAS) 2018 showed that only 8.1% of Indonesians used dental services (The Ministry of Health Republic of Indonesia, 2013b). In Indonesia, East Java is the second most populated province with a slightly below average national dentist-population ratio (The Ministry of Health Republic of Indonesia, 2013a). The insurance coverage in this province is 80%. However, the utilization of dental services in this province is similar to the national estimate which is 8.6% (The Ministry of Health, Republic of Indonesia, 2013b). Understanding the factors influencing dental service utilization among East Java residents is needed as a fundamental step to develop policy to increase the utilization of the services.

This study aimed to explore the associations of socio-demographic characteristics, behavioral factors, and clinical condition with the utilization of dental services among East Java residents.

Methods

Results

Table 1 shows the characteristics of the total study participants and the final participants included in the multivariable analysis. From a total of 90,551 respondents, 79,322 respondents with information on all variables were included in the final analysis. The included respondents were similar in all characteristics to the total number of respondents except in the age and educational level. Those included in the final analysis had a higher education level when compared with the total respondent population.

The results from the bivariate analyses are presented in Table 2. All the indicators showed a significant relationship with the utilization of dental services. In terms of age, people over 50 years old showed the lowest utilization of dental treatment, followed by people less than 25 years old. Respondents that received the highest number of dental treatments were people between 25 and 50 years old. Furthermore, males, people with lower educational background, residents of districts, people reporting bad tooth brushing habit, and those with edentulism showed lower utilization of dental treatments compared to their counterparts.

The results of the multivariable model are presented in Table 3. The model showed that dental services utilization differed by age. Respondents less than 25 years of age received lower dental treatment than respondents ≥50 years old (PR [95% CI] = 0.74 [0.71–0.78]). However, respondents 25–<50 years old showed more utilization of dental treatments than respondents ≥50 years old (PR [95% CI] = 1.23 [1.18–1.28]). Being male and having lower education were indicators for having a lower utilization of dental treatment (PR [95% CI] = 0.81 [0.79–0.84] and PR [95% CI] = 0.89 [0.86–0.93], respectively). Similarly, people living in districts showed lower utilization of dental treatment than those living in municipalities. Respondents with bad tooth brushing habit showed lower utilization of dental treatment. Having teeth was associated higher utilization of dental treatment (PR [95% CI] = 1.39 [1.16–1.66]).

Discussion

This study showed that the utilization of dental services by East Java residents in Indonesia was very low. Only 9% of the East Java population received dental treatments during the last 12 months, which is slightly higher than the national average (8.1%) (The Ministry of Health, Republic of Indonesia, 2013b). Dental service utilization was low among respondents who were less than 25 years old, male, district residents, edentulous, and had lower education and poor toothbrushing habit.

Among Indonesians, the fact that 95.5% of the population never utilize dental services was revealed in the 2018 national health survey (The Ministry of Health. Republic of Indonesia, 2019). The percentage of the population that never accesses dental services in Indonesia was far higher than that has been reported in rural India, another developing country (Gupta et al., 2014). Research in a rural population of western Rajasthan, revealed that around 55% of the population never visited a dentist while only 1.5% visited a dentist in the last 6 months (Gupta et al., 2014). However, these estimates contradict some research findings from economically developed countries where approximately 40%–80% of the population have accessed dental services within the last 12 months (Brown & Lazar, 1999; Kiyak & Reichmuth, 2005). Lack of awareness about oral health could be a reason behind the lower utilization of dental services in East Java province, Indonesia. In Indonesia, the secondary data analysis from the National Socioeconomic Survey in 2013 also showed that a high proportion of the Indonesian people had no perceived need for dental services (98.36%) and had never utilized dental services, resulting in considerable unmet need for dental treatments (97.7%). Of those who had unmet need for dental treatments, 94.8% had no perceived need for dental services (Malik et al., 2020). Perceived need for dental care is one of the best predictors of dental service utilization (Gibson, 2013). Individuals’ perceived dental health may influence their perceived need for dental care (Morin et al., 2005). In general, people will not attend health services unless they have health problems, and they demand health care as they believe that health service can solve their health problems (Wright et al., 1998).

In East Java, utilization of dental services varied according to socio-demographic, behavioural, and clinical factors. People aged 25–<50 years had the highest utilization of dental services in this study, followed by those ≥50 year old. Those less than 25 years old had the lowest utilization of dental treatment. Among Indonesians, people in 25–<50 years of age are considered the productive workforce, at which point they have usually progressed in their careers to a point and are earning enough to allow them to have insurance or utilize dental services privately. This could be the reason for greater utilization of dental treatment in this age group. The lowest utilization of dental services among people less than 25 years old could also be influenced by dental anxiety. Previous study in the Indonesian population reveals that people less than 25 years old have higher dental anxiety than their counterparts (Prihastari et al., 2020). People aged younger than 25 years old still had limited self-control and were less focussed on long-term consequences relative to people aged 25 years and older. These characteristics lead to an increased risk of unhealthy behaviours among people in this age group (Committee on Improving the Health, Safety, and Well-Being of Young Adults, 2015), including the lack of dental service utilization to maintain their oral health. However, high levels of self-concept among people aged 25 and older may help them maintain their oral health and motivate them to improve dental service utilization. Similarly, for baby boomers (people aged 50 years and older), physical attractiveness is important, as evidenced by the growing number of people in this age group seeking cosmetic dental care (Kiyak, 2015).

This study finds that females have greater utilization of dental services, supporting previous studies (Emerich et al., 2015; Fonseca et al., 2017; Green & Pope, 1999; Honkala et al., 1997; Saintrain et al., 2014), while also contradicting another study (Akbar et al., 2019). Women’s greater use of oral health service providers is likely because they pay more attention to esthetics and oral hygiene. Research shows that women pay more attention to their appearance and health (Green & Pope, 1999). On the other hand, men tend not to seek dental service due to the lack of perception of their need (Kiyak, 1993). However, each gender’s perspectives and beliefs may differ culturally, explaining the contradictory results. Higher dental service use was also observed among working women than working men in a study in Japan (Nishide et al., 2017). One possible explanation is that working women were more likely than working men to allocate time to use dental service. Compared to men, women had a greater interest in health and literacy and put more attention to oral health (Kawamura et al., 1999).

Education is also a significant contributing factor to dental service utilization. People with lower educational background have lower access to dental treatment, supporting previous research. Considering that the analysis sample in this study were better educated than the total respondent population only underestimates this problem. A study showed that higher educated individuals visited the dentist 10 times more than those with low education (Barros & Bertoldi, 2002). A previous study has demonstrated a higher level of oral health knowledge among people with a high educational background than those with low educational background. Having adequate oral health knowledge is attributed to positive attitudes towards dental service utilization, resulting in more educated people using dental services than less educated people (Zhu et al., 2005). Our results indicate that prevention programs would benefit by specifically targeting less educated people.

East Java province is one of the provinces located in the main island, Java. Among other islands, the Java island is categorized as the most developed. Thus, socioeconomic inequality among each area in East Java could be considered lower than other less developed islands. However, this research still finds that dental service utilization is lower among the district residents than the municipality residents in East Java. This finding supports previous research (Akbar et al., 2019). It is known that public transport networks are less developed in rural areas than in urban areas. Lack of transport access to dental facilities can be an obstacle to routine dental visit (Hamano et al., 2017; Ogunbodede et al., 2015). Moreover, the use of a service also depends on the perception of user’s needs, influenced by their values, beliefs and cultures (Giordani et al., 2010). A study in Istanbul (Ozkan et al., 2011) found that more than half of the population surveyed did not feel the need or have the desire to visit a dentist, although their dental conditions were not ideal.

This study finds that people who have bad tooth brushing habit utilize dental services less, supporting previous research (Jordao et al., 2018). Jessor’s problem behaviour theory (Jessor, 1991) proposes that various risk behaviours are inter-related. Research (Jordao et al., 2018) has affirmed this theory in the dental behaviors field, finding that there are clustering patterns in dental health behaviors whereby less frequent tooth brushing is clustered with high sugar intake, current smoking, and lack of dental visits.

Moreover, dentate people in East Java utilize more dental services than edentulous people, similar with other research finding (Tuominen, 1987). In many countries, the reason for dental service use is to mainly undergo dental treatment. This is especially true in developing countries where most of the people visit dental care services only when they are in pain (Varenne et al., 2006). Edentulousness in some parts of the world has been thought of as a healthy condition without pain even though this condition could reduce the ability to chew certain types of food, reducing the quality of life. Elders were also found to be more resilient to poor clinical status compared to younger people (Slade & Sanders, 2011). The importance of dentate status in predicting dental service utilization is evident. It has also been argued that age will not be a significant predictor of dental service utilization if individuals were grouped by dentate status (Gibson, 2013).

The strength of this study lies in the nature of data collected in a national survey, allowing a representative data of the East Java population. The cross-sectional study design is a limitation as it precludes causal explanations. Self-reported utilization of dental services and lack of data on insurance coverage and income could be other limitations of this study as associations between lower socioeconomic status and decreased access to dental services have been found in several countries (Grytten et al., 2012; Hjern et al., 2001; Larson & Halfon, 2010; Listl, 2011; Murakami et al., 2014; Tchicaya & Lorentz, 2014). Some potential bias could arise due to self-reported data and residual confounder. However, the study findings are in agreement with prior research that assessed dental care utilization, and it provides avenues for future research. This study has the potential to inform guidelines, or specific changes to existing policy or practice in Indonesia. Recognizing significant indicators that influence dental care utilization may aid in the planning and provision of programs for dental services and resource allocation. Strategies for the improvements in dental care utilization may require a multidimensional approach. The results may also inform oral health practitioners and policymakers about specific target groups requiring oral health intervention programs.

Conclusions

This first detailed population-based study in the East Java province of Indonesia has demonstrated that the use of dental services is influenced by socio-demographic factors. People less than 25 years old, male, those with lower educational background, those living in a district, those with poor tooth brushing habit and being edentulous are associated with lower dental service utilization.

Data availability

Data used for this analysis are available by a written request to the Ministry of Health Republic of Indonesia.