Factors associated with the use of dental health services in primary care in northeastern Mexico

ISSN Online 0719-2479 ©2016 Official publication of the Facultad de Odontología, Universidad de Concepción www.joralres.com 240 1. Facultad de Odontología, Universidad Autónoma de Nuevo León, Monterrey, México. 2. Facultad de Salud Pública y Nutrición, Universidad Autónoma de Nuevo León, Monterrey, México. 3. Unidad de Investigación Epidemiológica y en Servicios de Salud, Instituto Mexicano del Seguro Social, México.


INTRODUCTION.
Health systems are responsible for managing and providing primary health care, and particularly dental care, in most countries.Health services must be available to provide an organized social response to the needs of the population in order to achieve efficiency and equality. 1he use of health care services is motivated by need.There are models that alone or combined explain that particular need.The market economy model explains dental health care, because the access and use of dental care services is regulated by market economy and involves many intervening factors. 2,3everal factors associated with the use of dental health services (UDHS) have been identified, such as "accessibility", which is the degree of fit between the characteristics of health care resources and the population in need of care. 4This may be hampered by geographical barriers such as perceived travel time and means of transport to reach the health center.There are also economic factors, such as the cost of transport and the perception of such spending, organizational barriers such as waiting time for care, the way patients are treated by the medical staff, availability of dentists, dental materials and the psychological barrier of not wanting to return to the dentist's practice. 4,5][6][7][8] In Mexico, dental health care service is available at public institutions where people find essentially basic preventive care and receive some simple treatments such as fillings and extractions, but no restorative treatments.In the field of private dental care, a wide range of services are available, but they are usually very expensive for patients.This affects the most economically vulnerable population in greater need of care 8,9 .Thus, UDHS in primary care is one of the most complex and least recognized problems, and one that exposes social inequality.
Access and use of health services has been studied in Mexico and many other Latin American countries.However, there has been very little research on UDHS 3,5 .Research in this field is essential to propose courses of action aimed at improving access to dental health services, not only for preventive care, but also for restorative treatments to respond to the needs of the population 10 .
The aim of this study was to evaluate the factors associated with UDHS in primary care by groups of epidemiological interest in dental health care in northeastern Mexico.

Study Design
A cross-sectional study was conducted in northeastern Mexico from September 2013 to January 2014.

Population and sample size
The study population consisted of four groups of interest regarding oral health.Four sample sizes were calculated using the formula to estimate an a priori ratio of 50%, in an infinite population with an expected 5% error and 95% confidence interval.A total of 368 individuals were evaluated.The distribution of the sample was proportional to each of the four groups; students of 6 to 12 years (T, n=92), pregnant women (PW, n=92), active workers (W, n=92) and people over 60 (OA, n=92).Temporary immigrants who have lived less than a year in the area were excluded.Questionnaire items were written in simple language, avoiding technical terms and subjected to expert consensus to validate their content.Prior to the final application several tests were made to make sure they would be understood by participants.
Many households were visited consecutively on different days (including Saturdays and Sundays) and at various times (morning and evening) in the previously identified geographical area.If in any given household there was more than one person eligible for the study, one of them was randomly selected to participate in the study.Three trained and standardized pollsters conducted the survey.They collected data by doing interviews after participants have signed the informed consent.In the case of students, the informant was the mother, father or guardian.

Statistical analysis
A descriptive analysis of the following sociodemographic variables was performed: mean and standard deviation for non-categorical variables, absolute and relative frequencies for categorical variables and 95% confidence intervals (CI).A bivariate analysis was performed to establish the relationship between the use of dental services in primary care with each of the sociodemographic variables using chi-square test.A multivariate analysis was conducted using binary logistic regression to control confounders.Statistical analysis was performed with SPSS 20.0 (IBM, USA).In all cases p<0.05 was considered to be significant.
*In the characteristics education, occupation, migration and speaks indigenous language, information about the person responsible for the child was considered.

RESULTS.
The mean age of all respondents was 34±21 years; 62.5% were women, and 36.7% were married.Table 1 shows demographic and socieconomic characteristics by group.
Table 2 shows the characteristics of UHDS by category for each group.Table 3 shows UHDS access barriers in the 169 respondents who reported having experienced such barriers.In the bivariate analysis, secondary or higher education (p=0.012),paid employment (p=0.03),federal support from "Programa Oportunidades" (p=0.002) and having dental health care services (p=0.0001)were identified as factors associated with UHDS.Other factors are shown in Table 4.
In multivariate analysis, secondary or higher education (p=0.033),paid employment (0.012), federal support from "Programa Oportunidades" (p=0.04) and having dental health care services (p=0.019)showed a significant effect on UHDS, independent of age, sex, marital status, income and speaking indigenous languages.

DISCUSSION.
3][14] In most of them, UDHS was less than 50%, which is different from the 60.2% observed in a study conducted in Spain in a population under 15 years of age, who lived in communities where a health care program aimed at this specific risk group was implemented. 7The most relevant factors observed in this study are related to geographical barriers, since most of the respondents used public transport and they perceived from regular to high the cost of using it.Specifically the group of PW spent on average 1.7 USD, equivalent to 60% of the local minimum daily wage.A previous study conducted in the State of Tamaulipas 14 located in the same geographic region of northeastern Mexico, revealed people had lower spending on transport, and the population included in the study did not come from an economically vulnerable group as the participants in this study.These results show evidence of inequality between populations, where those who need the most are also those who pay the highest cost.On the other hand, the PW group estimated travel time close to an hour and most of those interviewed perceived it as too long, similar to the results obtained in the study conducted in Tamaulipas. 14egarding economic access barriers, monthly family income was ranked in the fourth decile group reported for the state of Nuevo Leon, Mexico, from 391.3 to 623 USD in average. 15It was found that between 6% and 30% used private dental services, which would not be the case if a universal state coverage were implemented.The latter has not been observed in any country. 16An example of difference in access to dental care is reported by a study in Brazil. 17he study shows strong inequality in students and older adults living in marginal urban areas.The impact on dental health was directly related to their income level.9][20][21] It has been established that in high-income countries, traditional curative dental care represents a significant financial burden from 5% to 10% of public health spending. 16,22,23egarding organizational barriers, between 10% and 20% has spent more than a year without visiting a dentist, especially PW and OA.This is despite the fact that more than 35% of them were receiving federal support from "Programa Oportunidades".Beneficiaries of this program have the responsibility of visiting the dentists at least once in a year.In a similar study conducted in Spain, 39.7% of students had not attended a dental care service in a year, although this may be explained because Spanish children had healthy habits such as tooth brushing. 7lthough most of W were beneficiaries of social security, they did not use dental care services.This is probably due to geographical and organizational access barriers, considering that their employment situation is precarious.In a study in Mexican cooperatives, sociodemographic variables were associated with lack of access to dental health. 10In Brazil, it was established that about 40% of pregnant women and 67% of older adults had not used dental health services in the past three years prior to the interview.However, in Brazil, a dental health policy named "Smiling Brazil" 17 and aimed at groups of epidemiological interest was proposed and implemented.
Sometimes when patients arrive at the health center, there are not dentists or dental material available.This situation is similar to that reported in Colombia, where organizational barriers such as opening hours, lack of availability of dentists and difficulty to get an appointment were reported. 24lmost all the groups studied estimated an average of 60 minutes of waiting time at the dental practice.This contrasts with Cuba, where 77.8% of PW estimated less than 15 minutes of waiting time on average to receive treatment in each of the visits, as there is a specific medical-care program for PW. 13 Paradoxically, in the present study PW did not perceive waiting time as being too long; this may be because patients are "accustomed" to wait. 18he 72.5% of OA perceived waiting time as long, 47.5% perceived poor quality of service, and 35% said they would not return to the same health center.A similar study found that OA in Cuba were the least frequent group attending dental health services and were the most dissatisfied. 25The same was reported in Chile, where it was established that the group with the least access to UDHS was OA. 26 A high percentage of people were unschooled or had only primary education.8][29] Another associated factor was being a beneficiary of the "Programa Oportunidades", one of the most important programs in the country, which includes among its benefits, dental care.However, only one third of the PW and OA have such support.The rest of the population have only limited access to dental health services and suffer the effects of the marked inequalities in dental health care services. 11ne limitation of this study was choosing only one family member to represent each surveyed household.Another limitation was the possible recall bias regarding UDHS.However, its strength lays in having been conducted in an open population and not just users of health services.

CONCLUSION.
Geographical, economic and organizational access barriers were identified.It was established that secondary or higher education, paid employment, being a beneficiary of "Programa Oportunidades", and the availability health services were factors associated with UDHS.
Factores asociados al uso de servicio de salud dental en atención primaria en el noreste de México.

Cruz G, Núñez G, Salinas A, Ramos E & Sánchez R.
The study was approved by the local ethics and research committee of the School of Public Health and Nutrition at Universidad Autónoma de Nuevo Leon, Mexico, registration number 12-FaSPyN-SA-17.

Table 1 .
Sociodemographic and economic characteristics in groups of dental epidemiological interest in northeastern Mexico (n=368).Factors associated with the use of dental health services in primary care in northeastern Mexico.Cruz G, Núñez G, Salinas A, Ramos E & Sánchez R. J Oral Res 2016; 5(6): 240-247.DOI:10.17126/joralres.2016.053.*In the characteristics education, occupation, migration and speaks indigenous language, information about the person responsible for the child was considered.

Table 2 .
Use of dental health services in groups of dental epidemiological interest in northeastern Mexico (n= 68).

Table 3 .
Access barriers to use dental services by groups of dental epidemiological interest in northeastern Mexico (n=169).Factors associated with the use of dental health services in primary care in northeastern Mexico.

Table 4 .
Relationship between sociodemographic characteristics and associated factors for the use of dental health services in primary care (n=368).
Factors associated with the use of dental health services in primary care in northeastern Mexico.
Factors associated with the use of dental health services in primary care in northeastern Mexico.