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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 295-301

Perceived barriers in the utilization of oral health-care services among care home geriatric residents in Chennai City: A cross-sectional survey


1 Department of Dental Surgery, Government Thiruvarur Medical College and Hospital, Thiruvarur, Tamil Nadu, India
2 Department of Public Health Dentistry, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission21-Jun-2021
Date of Decision10-Jul-2021
Date of Acceptance13-Jul-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
S Sharmila
Department of Dental Surgery, Government Thiruvarur Medical College, Thiruvarur - 610 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_109_21

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  Abstract 


Aim: According to recent surveys, the elderly uses oral health services at a lower rate than any other age group which is mostly driven by their perceived need and perceived barriers. The purpose of this study is to assess the perceived barriers of care home geriatric residents in the utilization of oral health care services in Chennai city. Materials and Methods: This cross-sectional survey was conducted among 237 elders from 14 randomly selected care homes in Chennai. Anderson and Newman's, framework was used to assess the utilization of oral health-care services. A structured interview was conducted to collect the demographic data and to assess the perceived need and barriers. Data collected were analyzed using the SPSS software version 20. Multiple logistic regression analysis was done to assess the association between the various perceived barriers. Results: Among the 237 participants, 24% were male and 76% were female. The mean age was 74.1 years. The primary perceived barrier was found to be a lack of perceived need for oral health-care services (72%) despite the poor oral health status (93%). The other barriers were unacceptability (89.9%), unaffordability (39.2%), unavailability (33.3%), inaccessibility (35.4%), and lack of accommodation (8.9%). Aging was found to a major perceived barrier in the utilization of oral health services (81.4%). Conclusion: The current study highlights the importance of oral health education and promotion among institutionalized elderly, as well as the need for domiciliary oral health-care services. The need for geriatric dentistry in the curriculum of dentistry is also emphasized.

Keywords: Barriers, care home, geriatric, oral health services, utilization


How to cite this article:
Sharmila S, Sujatha A, Aswath Narayanan M B, Ramesh Kumar S G, Selvamary A L. Perceived barriers in the utilization of oral health-care services among care home geriatric residents in Chennai City: A cross-sectional survey. J Dent Res Rev 2021;8:295-301

How to cite this URL:
Sharmila S, Sujatha A, Aswath Narayanan M B, Ramesh Kumar S G, Selvamary A L. Perceived barriers in the utilization of oral health-care services among care home geriatric residents in Chennai City: A cross-sectional survey. J Dent Res Rev [serial online] 2021 [cited 2022 Jul 1];8:295-301. Available from: https://www.jdrr.org/text.asp?2021/8/4/295/332911




  Introduction Top


Old age consists of ages exceeding the average life span of human beings. There is no definite boundary to define old age as it does not have the same meaning in all societies.[1] The World Health Organization (WHO) (1963) classified “elderly” as people aged 60–74, and “aged” as anyone aged 75 and up. At the same time, the WHO acknowledged that in the developing world, old age is often defined not by years but by new roles, the loss of prior ones, or the inability to contribute actively to society.[2] The national policy on older persons (1999) of the government of India defines “senior citizen” or “elderly” as a person who is of age 60 years or above.[1]

In 2000, there were 600 million people who were aged 60 and over and this number is expected to increase to 1.2 billion by 2025 and 2 billion by 2050.[3] Seventy percent of the world's senior population lives in or will live in developing countries, according to estimates.[4] Health is a most important criterion, especially in older age groups. Poor health in old age may be due to the result of life-long exposure to health risks, denial, lack of knowledge, and access to health services.

Oral health is an essential component of general health. Good oral health is necessary for mastication, taste, weight, speech, appearance, and psychosocial behavior and has an impact on a person's quality of life during his/her entire lifespan. Poor dental health is frequently associated with various comorbidities such as metabolic dysregulations, cognitive impairment, and even an increased overall mortality rate.[5] The oral health requirements of the elderly are changing and growing and require an understanding of the medical and dental aspects of aging. The factors such as ambulation, independent living, socialization, and sensory function should also be taken into consideration.[6] The link between need, provision, and utilization of health services is addressed through access to health care. According to Aday and Anderson (1960), access refers to an individual's or a population group's perspective and actual admission into the health-care delivery system.[7],[8],[9] Patient consumption of oral health services is mostly a result of the patient's perceived need for such care, and hence, perceived need has been seen as a reliable predictor of oral health service utilization. Asking people to report their perceptions to care and barriers in the utilization of services rather than using the real patterns of service use to directly measure their true access may be a better option.

Penchansky and Thomas define the barriers in the utilization of dental services as availability, accessibility, accommodation, affordability, and acceptability.[10] The barriers in the utilization of dental services by geriatric patients can be due to inaccessibility, lack of financial support, functional disability, comorbid conditions, fear, lack of interest, dentist's knowledge, attitude, and practices toward treating the elderly. Gaszynska et al. in 2014 conducted a study on 259 care home residents aged 65 years and beyond in Lodz, Poland, the barriers to dental care for the elderly were investigated. It was discovered that more than half of the residents surveyed (59.8%) had received objective dental treatment needs and only 27% were aware of the need for treatment and 9.7% reported the need to the personnel.[5]

A review of the scientific literature indicated that there are limited studies in India to evaluate the barriers faced by the geriatric population in the utilization of oral health care services. Thus, there is a need to investigate the barriers experienced by elderly people in India in the utilization of oral health-care services to effectively address their growing demands. The present study aimed to assess the perceived barriers in the utilization of oral health-care services among care home residents in Chennai, Tamil Nadu.


  Materials and Methods Top


The purpose of this cross-sectional study was to determine the perceived barriers in the utilization of oral health services among care home geriatric residents by using a predesigned, structured questionnaire. The study has been presented following STROBE guidelines.

Study setting

The study was conducted among geriatric residents of 14 randomly selected free and paid care homes in Chennai city for 3 months.

Study size

Sampling procedure

The corporation of Chennai is divided into three regions (North Chennai, Central Chennai, and South Chennai) and 15 zones. The list of old age homes was obtained from the directory of old age homes in India 2009, published by help age India (a secular, nonprofit and nongovernmental organization in India registered under the societies registration act of 1860).[11] There were 46 old age homes in Chennai city according to the directory of old age homes in India 2009, published by help age India. Simple random sampling was done by the lottery method to select one old age home for each zone. Out of 15 zones, 14 old age homes were selected since there were no old age homes available in one zone. There were a total of 444 geriatric residents from the selected 14 old age homes. Simple random sampling was done to select the study participants who satisfied the selection criteria and voluntarily consented to the study.

Sample size

Since qualitative data were collected, the sample size was calculated using the formula n = 4(pq/L2) where n = sample size; p = population proportion of positive character, q = 1 − p and L = allowable error. For the current study, L was presumed to be 7% of p giving power of (1 − L) i.e., 93% to study. P was taken as 50%, (Macfarlane in 1997 suggested that if there was doubt about the value of p, it is best to err toward 50% as it would lead to larger sample size.). According to this formula, the sample size needed for this study was 204. With an adjustment of 10% error, the estimated sample size would be 224. In the present study, 237 participants were included with an adjustment for nonrespondents.

Participants

Inclusion criteria

  1. Participants belonging to 60 years and above age group
  2. Participants who are residing at the care home for more than 6 months.


Exclusion criteria

  1. Participants who were suffering from mental illness or under antipsychiatric medications
  2. Participants who had hearing and speech disability
  3. Participants who were severely debilitated at the time of assessment
  4. Participants who do not had the cognitive and physical condition required.


Permission was obtained from the concerned authorities of the selected institution. The selected participants were contacted in person and explained about the study. After a detailed explanation of the purpose of the study, written informed consent was obtained from the study participants.

Study variables

Outcome variable

The outcome variable measured in this study was the barriers presumed by the geriatric population in the care homes in the use of dental health care services.

Predictor variables

The main predictor variables which were used to assess the use of dental health care services were the determinants of access such as availability, accessibility, affordability, acceptability, accommodation, and perceived need.

Model covariates

Three covariates hypothesized as being associated with barriers in the use of dental health care services were the variables included in Anderson's framework:

  1. Predisposing variables include age in years, sex, marital status, presence or absence of children/attender, years of formal education, and years of accommodation
  2. Enabling variables are the factors that either facilitate or hinder access to health services which includes intrapersonal factors that affect one's propensity for using health services, source of income, total income, health insurance coverage, and level of dependency
  3. Dental need refers to the individual's illnesses or impairments that necessitate health service use, which includes the number of diagnosed dental conditions, system conditions, and functional health status.


Data sources/measurement

Data collection was done by the interview method using a predesigned and pretested structured questionnaire. Functional living was assessed by Barthel's index for assessing activities for daily living.[12] The questionnaire used in the current study was developed using the Anderson and Newman model (1981). This conceptual framework presents a set of variables that can be used to predict the use of medical, dental, and hospital services. The three domains of the model include predisposing variables (demographic and attitude), enabling variables (e.g., income, availability of health insurance), and need, all of which are interrelated, and are used to predict personal health practices, use of professional health services, and overall health and satisfaction with one's health.[13] This model is customized for the Indian population. Penchansky and Thomas criteria for the assessment of barriers in the utilization of services were also assessed through this questionnaire.

The questionnaire or instrument consisted of questions in the Guttman scale which was read aloud to the participants by the investigator. The questionnaire was named as a perceived barriers assessment instrument (PBAI) for the geriatric population. This instrument comprised of six classes: availability (3 items), accessibility (8 items), affordability (5 items), acceptability (14 items) and accommodation (6 items), and perceived need (4 items). Internal consistency using Cronbach's alpha for the PBAI was found to be 0.7. The content validity of the questionnaire was tested by a panel of experts. The validity of the questionnaire was tested with a test-retest method with a sample of 15. Data obtained from the participants were subjected to the statistical analysis.

Bias

Interviewer bias was addressed by the random selection of study participants during the interview procedure.

Data analysis

Statistical analysis was performed using the IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Cronbach's alpha was used to test the internal consistency of the questionnaire. Descriptive data were tabulated in percentages and proportions. The level of significance is set at 5% for this study, conditional probabilities of 50%–100% were considered to be a high probability of a specific barrier, and <40% was considered a low probability. Participants with similar perceived access barriers were grouped as Class I to Class IV.[14] Class I members showed a low likelihood of detecting barriers in any aspect of oral health-care access. Members of Class II had a higher probability of perceived barriers in the availability/accessibility of oral health services. Members of Class III had a high probability of perceiving problems with acceptability. Members of Class IV had a high probability in all represented dimensions of access.

Dimension of accommodation was not represented due to the low prevalence in the current study population. All relative risk ratios (RRRs) are relative to the likelihood of membership in the no barriers group. Relative risk and adjusted RRR were calculated between the covariates and predictor variables using the multinomial logistic regression with a stepwise selection method (backward elimination). Significant connections were then fitted in a logistic regression model to see if any combination of predisposing, enabling, and need variables, as well as clinical characteristics, provided a multivariate explanation of the use of oral health-care services.


  Results Top


The present study was conducted to assess the perceived barriers in the utilization of oral health-care services among the care home geriatric residents in Chennai city. Out of the selected 14 homes, two were run by the government, 12 were by private ones. Free services were available in 8 homes, paid services in 4 homes, and combined services in 2 homes.

[Table 1] reflects the demographic details of the study population. [Table 2] explains the frequency distribution of various barriers to access to oral health-care services. The study population was classified into four classes based on their perceived barrier with reference to the study done by Thorpe et al. to identify the patterns of perceived barriers to medical care in older adults. Class I had minimal constituted barriers and accounted for a very minimal percentage. Class II group (barrier of accessibility/availability) was 5.9%. Class III group (barrier of acceptability) was about 24.1% and Class IV group constituted (combined or severe barriers) 67.1%.
Table 1: Sociodemographic distribution of the care home geriatric residents

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Table 2: Frequency distribution of barrier items in the sample

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[Table 3], [Table 4], [Table 5] depicts the RRR and adjusted RRR from multinomial logistic regression predicting between Class I barrier group and Class II, III, and IV barrier group, respectively. The following variables were associated with an increased likelihood of being in the Class I barrier group: education (RRR-1.79; 95% confidence interval [CI] [1.36–2.98]); the presence of children (RRR-1.11;95% CI [1.02–1.96]); activity of daily living (RRR-1.68;95%CI [1.33–2.58]), as shown in [Table 3]. In the Class III barrier group, the following independent variables were associated with an increased likelihood: sex (RRR-3.35; 95% CI [1.19–9.44]); activity of daily living (RRR-3.82; 95%CI [1.95–7.49]), health insurance (RRR-12.189; 95% CI [4.52–32.84]), and oral health beliefs (RRR-3.77;95% CI [1.31–10.83]), as shown in [Table 4].
Table 3: Relative risk ratios and adjusted relative risk ratios from multinomial logistic regression predicting barrier class membership for Class II

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Table 4: Relative risk ratios and adjusted relative risk ratios from multinomial logistic regression predicting barrier class membership for Class III

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Table 5: Relative risk ratios and adjusted relative risk ratios from multinomial logistic regression predicting barrier class membership for Class IV

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The following variables were associated with an increased likelihood of being in the severe barrier class: sex (RRR-1.56 95% CI-[1.22–2.71]), children (RRR-2.92 95% CI [1.56–5.50]), and oral health beliefs (RRR-2.70 95% CI [1.28–5.71], as shown in [Table 5].


  Discussion Top


Oral health care is more complex and demanding for the elderly as they are associated with various comorbid conditions. Access to oral health care is a combined relationship between need, provision, and utilization of health services. Perceived need is a more reliable indicator of access to health-care services.[14]

The present study was conducted to assess the perceived barriers in the utilization of oral health-care services among care home geriatric residents. The findings of the study give an insight into the various dimensions of barriers to access perceived by the geriatric residents in care homes. In our study, the number of elderly institutionalized women (76.4%) was higher than that of men (24.6%). These findings are similar to that of other studies carried out in old-age homes in Chennai city.[15],[16]

The present study reveals that 43% of the residents were slightly dependent on their daily activities assessed by Barthel's activity of daily living index which provides an assessment of one's ability to carry out basic daily tasks. The results of the study have revealed a high prevalence of oral health problems (93%) which was similar to other studies conducted at old age homes.[17],[18] The perceived need (28.3%) for the utilization of oral health services among the care home geriatric residents was comparatively low. These results are consistent with the qualitative research of Borreani et al.[19] Similarly, Gaszynska et al. reported that only 27% of the study population were aware of the need for the treatment and about 23.3% of them had no felt need. These findings were similar to the results of the present study.[5]

The perceived barriers to utilization of oral health-care services were categorized according to Penchansky and Thomas[10] who have classified it into five barriers to access problems. Acceptability to dental treatment (89.9%) was found to be the most common barrier followed by unaffordability (39.2%), inaccessibility (35.4%), unavailability (33.3%), and accommodation being the lowest (8.9%). Health insurance, the activity of daily living, oral health beliefs, and gender were significantly associated with acceptance to oral health care among the study participants.

In a study on the pattern and factors that influence the use of dental services among 226 older adults in rural Victoria by Mariño et al., affordability was significantly associated with the utilization of dental services. The percentage of barriers to dental care reported in this study was cost of services (32.7%), fear of dentists (25.8%), length of waiting for hours (18.1%), and availability of oral health care services (11.1%). The unaffordability barrier was similar to that of the present study. However, this study was done among the community-dwelling geriatric population which is in contrast to our study.[13]

Subjects with similar perceived access barriers were grouped as class I to class IV according to a study by Thorpe et al.[14] Class IV which constituted a combined barrier to access was high (67%) followed by the Class III barrier of acceptability (24.1%). To our knowledge, this is the first study that has grouped participants with similar access problems to oral care. Acceptability to dental treatments and perceived oral health beliefs seemed to be a major barrier to the utilization of oral health care services among the study population. About 81.4% of geriatric residents believed that oral diseases are inevitable with aging. About 17.7% of the residents had fear of some form in accepting the dental treatment which was consistent with that of a previous study. A study by Palati et al.[20] showed that only 14.56% of the individuals assume that they need treatment.

The low perceived need for oral health care during aging might be due to the low and unevenly distributed oral health-care services during their childhood and adulthood.[5]

Health education, motivation, and constant reinforcement are essential in alleviating the deeply entrenched oral health beliefs and cultural barriers. Some of the cultures and beliefs have positive values while others may be useless or positively harmful. Healthy habits and practices hallowed by centuries of practice which has helped the implementation of health programs should be encouraged.[21]

When the geriatric residents were asked about the methods to enhance their utilization of oral health-care services, about 83.1% preferred a dentist to visit their care home instead of traveling to the dental setting. About 71.3% of the individuals opted for a portable dental setting in their respective care homes.

Accommodation as a perceived barrier to the utilization of oral health-care services is very low among the study population; however, about 41.8% preferred a separate waiting queue, 47.7% desired zero waiting time at the dental office, 58.6% wanted the dental office to be situated in the ground floor and 50.6% wished to have manual assistance at the dental hospital/clinic. The findings of the present study limit comparisons with previous studies as it is the first of its kind. Thus, strategies to accommodate geriatric patients in health care settings such as separate waiting queues, appointment systems with zero waiting hours, construction of ramps and lifts, manual assistance at the dental office would improve the utilization of health-care services among the geriatric population.

Limitations

  1. As the study was carried on geriatric residents in the urban area, the results of the study cannot be generalized to the geriatric population residing in the rural areas and geriatric residents who are homebound.
  2. As the data were collected by the interview method, social desirability bias would have been a possibility in the present study.


We recommend qualitative research to enlighten the deeply entrenched sociodemographic, financial, psychosocial, and structural barriers of the geriatric care home residents.

Dental care should be included in routine assessments by care home staff, and residents should have access to ongoing dental treatment. Regardless of dentate status, it is recommended that the elderly should have routine dental visits once every 6 months. Hence, the primary need is not only to educate and motivate the elderly population regarding the importance of oral health care but also the caregivers to promote frequent visits of dental health-care workers to meet the dental requirements of the elderly. For homebound and severely debilitated geriatric patients, regular home visits by the dentist with a portable and mobile dental unit should be made available to meet the demands and enhance the utilization.


  Conclusion Top


Assessment of perceived barriers in the utilization of oral health-care services among geriatric care home residents has exposed the different dimensions of barriers encountered by the geriatric population residing in care homes. The perceived barrier of acceptability is considerably very high despite the low perceived need for oral care among the geriatric population residing in care homes.

It is the combined responsibility of the caregivers, social workers, medical and dental professionals, and policymakers in bringing a comprehensive and domiciliary oral health care model for the aged. Establishing liaisons between health and social service professionals to identify the people who are unable to access dental care can be beneficial. In India, lobbying should be done to include oral diseases in the noncommunicable diseases under the national program for the elderly. Adoption of old age homes by dental institutions could help to enhance the utilization of oral health services by the geriatric population. Above all, geriatric dentistry must be incorporated in the undergraduate and dental auxiliary teaching curriculum for a better understanding of their differing needs and demands.

Acknowlegment

The authors would like to thank Mrs. Valarmathy M.Sc., M.Phil. Research officer, The TN Dr.M.G.R Medical University, Chennai, for her statistical advice and guidance in this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Central Statistics Office. New Delhi: Central Statistics Office Ministry of Statistics and Program Implementation, the Government of India; 2011. Situation Analysis of the Elderly in India. Available from: http://mospi.nic.in/sites/default/files/publication_reports/elderly_in_india.pdf [Last accessed on 2020 Aug 15].  Back to cited text no. 1
    
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Thorpe JM, Thorpe CT, Kennelty KA, Pandhi N. Patterns of perceived barriers to medical care in older adults: A latent class analysis. BMC Health Serv Res 2011;11:181.  Back to cited text no. 14
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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