Community
Community Dentistry
Dent. Oral Epidemiol. 1976: 4: 215-220
/j^ey words: insurance, health; public dental health)
Dental insurance and equity of access to dental services INKERI BARENTHIN Department of Social Medieine, University oj Uppsala, Uppsala, Sweden ABSTRACT - The first-year consequences of national dental insurance, introduced in Sweden in 1974, are examined here from the point of view of social justice. The concept of equity of access in medical care is discussed. In a local survey, a comparison is made between use of dental services in 1972, 1973, and 1974. The results indicate that fewer people visited the dentist after the implementation of the insurance than before. Other evidence supports this conclusion. People traditionally considered to be underprivileged as to dental care Were compared with other people. One underprivileged group, edentulous persons, received more treatment after the insurance was instituted than before. (Reeeived for publieation 20 January, aeeepted 25 April 1976)
National dentai insurance was recently introduced in Sweden. The insurance started with limited benefits at the end of 1973 and in January 1974 it began to operate in full. Since then, everyone in the country pays only half the dentist's fee and the insurance the other half. In cases of very high costs, the insurance pays a higher proportion. Patients under 17 years are treated free in the public services, as they were before. The purpose of the insuranee, to quote from the bill introducing the legislation, is "to create equal opportunities for each citizen to get good dental care at reasonable cost". This goal comprises three subgoals: (1) equal opportunities for each citizen, (2) good dental care, (3) reasonable cost. Part 1, dealing with equality, comes under social policy. Many studies (for reviews, see RICHARDS") have shown that people differ greatly in the amount of dental care they get and these differences are not only due to differences in "real" dental needs. Many socioeconomic and other factors influence the demand for dental care and have led to different people having different opportunities to get care. ;v Part 2 concerns the quality of care. Swedish dental care has always been considered of high standard internationally, and the new insurance should not cause any lowering of the standard.
, ,
,-
'
"•
Part 3, the desire for moderate cost to the individual, was fulfilled when the insurance was introduced. The cost for the patient, about half what it was before, is reasonable for the majority of people. If it still costs too much for the individual concerned, he or she can get financial help from other authorities. It is evident from the foregoing that the real situation diverges from the goal mostly in the first subgoal. The dental insurance can thus be seen as a social reform aiming to provide the "good dental care" already existing on a more equal basis than before through lowering the cost for the individual. In this paper, the consequences of the insurance 1 year after its introduction are studied mainly from the point of view of social justice. First will be examined the concept of equal opportunity, or equity of access as it is often called in current literature in health services research. A desire for social justice is embedded in the majority of the modern health programs. Access to health services is more and more considered to be a civic right for each person irrespective of income or class"''''''. It is a value beyond rational debate, but the debate on means to attain "the dream" is endless^. The debate on means is complicated by the fact that there is no general agreement on what is meant
216
BARENTHIN
by either equity or access, not to mention how these should be measured. At present many efforts are being made to clarify these concepts. Access implies, naturally, entry to the health care system. The presence of health care facilities and manpower is necessary but not in itself a guarantee of access. The distribution, volume, and organization of the facilities, as well as the characteristics of the population (e.g. attitudes, income, insurance coverage) could be expected to play a role in how people get access to health services. Separate studies of each of these conditions may give a different picture of a population's facility of access to the services'. Equity means the quality of being fair or impartial. How this should be interpreted in the field of health is not quite clear. Does it mean an equal number of visits to the doctor, a well-balanced geographical distribution of health care resources, lack of financial barriers for demanding care, or still something else? In this study of equity of access, the starting point is the first visit, i.e. the entry into the system. The changes in the distribution of entries are examined before and after the implementation of the dental insurance to try to see whether the "trend" during the first year is towards "more" ecjuity, i.e. if the changes can be considered to promote fairness, thus contributing to social justice.
MATERIAL AND METHODS The study was conducted in Tierp, a district situated 60 km north of Uppsala in Sweden. Tierp has a long tradition of agriculture and iron industry. The population of 21,000 inhabitants live in rural area or in the small eenters formed mainly around industries. In March of 1974, trained interviewers questioned a representative sample of the population in order to find out how people estimated the state of their own health and what they thought of various health-related matters, and also how they used the existing services. Dental questions, such as visits to the dentist during the past years, dental status, and ability to chew, were ineluded in the interview. Information was also obtained regarding various social characteristics and the general state of health. The persons were divided into the three social classes traditionally used in Sweden; Class 1 covers the upper elass, elass 2 the middle elass, and class 3 laborers. Information on ineome was taken from the health insurance office. The sample was selected in two stages. First, all persons aged 16 years or more, born the 10th or 20th of any month, were taken. From these (1,099 persons), 390 persons were randomly selected. Thirty of these 390 were
excluded because they had moved from Tierp, were doing military service, or were in some institution. Another eight were not interviewed beeause they could not be reached, and 13 refused to participate. This left 339 persons (87 % of 390, 94 % of 360) who were then interviewed. In order to see how well the answers to the interview questions concerning dental health agreed with the factual dental status, a subset sample of the "original" sample population of 339 persons was examined. This was done in connection with the regular health screening done ever>' 4th year in each district of the district. Seventy-six persons of the sample population lived in the districts of Karlholm and Hallnas, and 67 of these (88%) attended the health screening and could thus be examined and interviewed. The examination method is described elsewhere''. Since the introduction of the insurance, dentists must send reports to the health insurance offiee from where the insuranee is administrated. The reports include detailed information about the treatment given to each patient. This information is used as a base for the payment that the dentist receives directly from the insuranee. The information concerning all patients born the 10th or 20th of any month (constituting a national sample) is then registered at the social security data bank. Since all the persons interviewed in Tierp were born on these days, information about their visits to dentists dudng 1974 could be obtained from this national register. Information concerning persons under 17, not covered by the insurance, was obtained from school dental registers. To find out what factors were important for changes in utilization, a regression analysis was done. To this end, an auxihary variable was ealeulated for eaeh person in an attempt to operationalize the change. The auxiliary variable, q, takes into eonsideration the fact of utilization during each of the 3 years, 0 or 1, as described in Tahle 4. Thus its purpose was to show any "trend" in utilization. The q is calculated as follows; q = (utilization 1974 minus utilization 1973) minus (utilization 1973 minus utilization 1972). -
RESULTS
' " •""'-'
'
-.^
In all, 339 persons were interviewed concerning dental matters. In view of the intimate connection
Table 1. Study persons by dental status and age Total
Age
Dental status 16-44 45-64 > 6 5
n
%
8
216
64
10
23 23
56
16
67
20
Only natural teeth Both dentures and natural teeth Dentures but no natural teeth
157
2
36 29
Total
169
110 60
51
339 100
Access to dental services Table 2. Proportion of persons seeing a dentist in the different years by sex and age 1972
1973
1974
45-64 >65
67 38 11
60 49 28
58 35 11
Total
46
50
41
76 40 13
73 40 21
56 31 21
56
55
43
72
Sex and age Men (n = 182)
Women [n = 157) 16-44 45-64 >65 Total Both sexes {n = 339) 16-44 45-64 >65
39 12
67 45 25
57 34 15
Total
50
52
42
between dental status and need and use of dental services. Table 1 takes up the subjects' self-reported dental status with reference to natural teeth and removable dentures. Further analysis showed that difficulties in chewing were reported by 9 % of all persons. Among edentulous persons this proportion was 15 %. Table 2 gives the proportion of persons by age and sex who saw a dentist during each of the 3 years. As seen there, the percentage dropped distinctly during the last of these years, both for women and men. A larger percentage of women than men consulted a dentist each of the 3 years, and each year the percentages were lowest in the highest age groups. Table 3 shows the changes occurring over 19721974 in the pattern of use for groups which earlier studies have indicated get less dental care than others. All the groups were characterized by the same or lower consumption in 1974 than in 197273, except for the edentulous persons. No less than 21 % of these consulted a dentist in 1974, which is a large increase over the 2 foregoing years for these people. The dentaf insurance is particularly generous when it comes to getting new full dentures or renewing old ones. The group with poor chewing ability and the group with a poor general health
217
condition showed the same percentage visiting a dentist during 1974 as in 1973; the persons in good general condition and those with good chewing ability, on the other hand, visited dentists to a lesser extent. So far the results have dealt with the pattern of use in different groups. It is also important to study the changes in use at the individual level. Even if the proportion consulting dentists does not change from year to year, the percentage may not be made up of the same individuals each year. In other words, the question is whether it is the same people who come back for treatment from year to year. Table 4 shows the number of persons visiting or not visiting a dentist during 1972-74. As seen, this allows for eight patterns of use. Thus one person may have made no visit during these years, another only in 1974, another both in 1973 and 1974 and so on, as set forth in the Table. In order to study simultaneously the effect of the above-mentioned explanatory variables on the "trend" variable q, multiple regression analysis was employed. The variable that explained most of the varianee (although not to any signifieant degree) in the q variable was the interview answer to the question whether the person made regular visits to Table 3. Proportion of persons seeing a dentist in each of the years 1972-74 by some social and health characteristics Characteristic Education Only obligatory schooling (n = 245) More than obligatory schooling ( n = 94) Social class Low (3)
/\ *| — OHQ '^ — 4 U o I\
High (14-2)
(n=131)
Dental status Edentulous persons ( n = 67) Others (n = 272) Chewing ability Poor {n= 29] Good {n~310) General health Poor
Others Total
1972
1973
1974
44
47
36
68
66
45
50 52
53 52
41
0 63
3
21
65
61
24
17
53
56
17 45
45
{n= 23) (n = 316)
9
22
22
53
55
44
(" = 339)
50
52
42
218
BARENTHIN
Table 4. Interviewed persons by use pattern in 1972 through 1974 (0 = no visit during the year, 1 = one or more visits) Visited dentist 1972
1973
0 0 0
0
0 1 1 1 1
0
1974
•
1 1 0 0 1 1
Total
No. of persons
%
0
88
26
1 0 1 0 1
36 22 22 17 20
11 6
0 1
6
5 6
7 0 •'•
21
64
19
339
100
the dentist. Of greater interest, however, is that explanatory variables directly associated with economic circumstances, such as income or social class, did not significantly explain any variance in q. Nor did they explain the variance in utilization when each year was studied separately.
DISCUSSION The self-reports on dental status and chewing ability obtained at the interviews agreed well with the results of later clinical examination. Only in a few instances did minor deviations occur. These made no difference, however, to the way these cases were classified here. It was not possible to check the interview reports on visits to dentists during 1972 and 1973. It is known from previous investigations"'^^ that people tend tO' embellish their reports about visits to dentists. SMEDBY^'' found that persons tended to report a more recetit date for their last visit than was recorded at the dentist. It is possible that some visits which people in Tierp reported as having taken place in 1972 and 1973 actually occurred earlier than they said. As mentioned previously, institutionalized persons were not interviewed. Both these and the real absentees were old people, many in poor general condition. This probably means that they were less apt than most to go to a dentist and so less apt to get dental care. This was confirmed by a special study. Of the 51 missing persons only 14 (27 %) were noted as having consulted a dentist in the
register for 1974. Accordingly, judging by the composition of the missing persons in the sample, the proportion going to a dentist in the whole sample was probably slightly lower than calculated. The results of this study apply only to the area where the survey was done, i.e. Tierp. The district is not representative of the whole of Sweden. Tierp is an old agricultural area with some industrial traditions but without any cities. The age composition of the population differs slightly from that in Sweden as a whole, being a little "older". The social standard is rather homogeneous. As seen from the results of the regression analysis, socioeconomic factors did not play an important part in determining whether dental visits were made or not. This result is different from what is usually found in similctr studies. The percentage of people aged 17 years or over visiting dentists in 1974 was 44 for the whole country and 42 for Tierp. In 1974 there was one dentist per 1,200 inhabitants for the whole country and one dentist per 1,800 inhabitants in Tierp. The number of dentists in Tierp (12) was so small that individual variations in the dentists' practicing patterns may account for much of the variance in the patients' visits. Visits to the dentist were counted no matter where they took place, but the majority of them took place in Tierp. The number of first visits or entries does not of course alone reveal much about the adequacy of the care. Entry into the system, however, is a necessary prerequisite for receiving any kind of care. Since the first purpose of the insurance was to guarantee this ("create equal opportunities"), we have concentrated on whether or not a person visited the dentist. It might be argued that the volume of care, i.e. number of visits, should also be analyzed. Greater inequality exists, however, with regard to whether or not people ever see a dentist ("initiation", often patient's own decision) than with regard to the number of visits they make ("continuation", depending much on the physician's or the dentist's decision). Once in the system, the use rates do not differ much between different socioeconomic groups^. One group, edentulotis persons, increased its use of dental services, i.e. a greater proportion of persons in the group went to the dentist in 1974 than before. In this respect the insurance had the desired
Access to dental services 219 effect the very first year. In other respects, the insurance did not seem to have essentially increased or decreased equity betweeti different groups. The dental insurance authorities have made an investigation conceming the types of treatment given in 1974. They also compared the results with those from an earlier study analyzing the frequency of different types of treatment given in dental offices. They concluded that dentists devoted a greater proportion of their time to prosthetic work in 1974 than in 1970-7P^ Dental technicians have also reported a considerable increase in their workload. T h e fact that dentists now do more prosthetic work (hoth fixed and removable dentures) than before, undoubtedly explains some of the decrease in the number of persons visiting the dentist in 1974. Prosthetic work generally requires more titiie than other treatment. The more time devoted to one patient, the fewer the patients that can be treated. The information on visits obtained at the interview is contaminated by errors of memory and embellishment, which tend to give higher rates of utilization of the services than what is true. The insurance register may also contain errors, such as incomplete or erroneous data registration. This kind of registration error tends to reduce the true utilization rates. The insurance authorities make great efforts to avoid these errors. Although all evidence, not only in this study, indicates that there was a real reduction in the utilization rates in 1974 compared with earlier years, one must be very cautious when interpreting the size of the reduction from the results of this study since it uses different kinds of primary data for different years. The question whether the Swedish dental insurance has succeeded in creating more equity, is probably not answerable yet. Difficulties may crop up during the first year after the implementation that will disappear during the following years. It is possible that an evaluation of this reform is only meaningful after many years. However, a study of a transitional period might interest planners in other countries intending to carry out similar reforms. They may want to know what can happen immediately after the implementation of an insurance, even if it may have a different effect in the long run. In view of the many factors associated with access it is not surprising that a change in one factor is not immediately followed by great changes
in gaining access. Even the removal of fitiancial barriers known to prevent certain groups from getting care has not always altered the situation to the extent desired. The role of financial barriers in dentistry is uncertain. While many patients give cost as one of the main reasons they do not seek care", many do not go to the dentist even when they are offered free treatment'^''". No health care system can be separated from its national, cultural, and social setting. Each society expresses its own opinions on what is distributive justice through its political decisions. The Swedish dental insurance is an expression of this kind. As the results of this study indicate, however, the introduction of dental insurance does not guarantee that the desired chatiges occur rapidly. The removal of financial barriers can be said to be a necessary but not sufficient prerequisite for gaining "better" equity of access to dental services. DONABEDIAN' summarizes the difficulties: barriers are not only financial, they are also psychological, social, organizational, and of many other kinds.
REFERENCES 1. ADAY, L . A.
& ANDURSEN, R . : A framework for
the
study of access to medical care. Health Serv. Res. 1974: 9; 208-220. 2. ANDERSEN, R . : Health sei-vices distribution and equity. In:
ANDERSEN, R . , KRAVITS, J.
& ANDERSON, O .
W.
(ed.): Equity in health services: empirical analyses in social policy. Ballinger Publ. Go., Cambridge, Mass. 1975, p. 9-32. 3. ANDERSON, O . W . : Health care: can there be equity? John Wiley & Sons, New York 1972. 4. BARETSTIHIN, I.: The eoncept of health in community dentistry. / . Public Health Dent. 1975: .35; 177-184. 5. BoDNARCHUK, A.: Utilization of dental services by welfare reeipients in a private dental office. / . Can. Dent. Assoc. 1967: 33: 126-130. 6. BRESLOW, L . : Research in a strategy for health improvement. Int. J. Health Serv. 1973: 3: 7-16. 7. DoNABEDiAN, A.: Models for organizing the delivery of personal health services and criteria for evaluating them. Milbank Mem. Fund Q. 1972: 50: 103-154, part 2. 8. GoULDING, P. C.: What the public thinks of the dentist and of dental health. / . Am. Dent. Assoc. 1965: 70: 1211-1215. 9. HELOE, L . A.: Gomparison of dental health data obtained from questionnaires, interviews and clinical examination. Scand. ]. Dent. Res. 1972: 80; 495-499. 10. KEGELES, S. S.: Some motives for seeking preventive dental eare. / . Am. Dent. Assoc. 1963: 67; 90-98.
220
BARENTHIN
11. RICHARDS, N . D . : Utilization of dental serviees. In: RICHARDS, N . D . & COHEN, L . K . (ed.): Social sciences
and dentistry: a critical bibliography. Federation Dentaire Internationale, The Hague 1971, p. 209-240. 12. RiKSFOERS.aiEKRrNGSVERKET: Vissa erfarenheter
den allmdnna tandvdrdsfdrsakringen. report. Stockholm 1975. Address:
-•
^' - ' : - : -
Department of Social Medicine University oj Uppsala Akademiska sjukhuset S-750
Sweden
14 Uppsala
, *
rorande
Mimeographed
,
, , , ,.
' ' -_;
' i ,.
•;':
13. SMEDBY, B.: Bestyrelsen av vissa jaktorer for tandvdrdskonsumtionen. Socialmedicinsk tidskrifts skriftserie nr. 37. Stockholm 1972. 14. TowNSEND, p.: Inequality and the health service. Lancet 1974: i: 1179-1190. 15. WHITE, K . L . : Organisation and delivery of personal health services. Milbank Mem. Fund Q. 1968: 46: 225258.
Community Dentistry
Dent. Oral Epidemiol. 1976: 4: 215-220
/j^ey words: insurance, health; public dental health)
Dental insurance and equity of access to dental services INKERI BARENTHIN Department of Social Medieine, University oj Uppsala, Uppsala, Sweden ABSTRACT - The first-year consequences of national dental insurance, introduced in Sweden in 1974, are examined here from the point of view of social justice. The concept of equity of access in medical care is discussed. In a local survey, a comparison is made between use of dental services in 1972, 1973, and 1974. The results indicate that fewer people visited the dentist after the implementation of the insurance than before. Other evidence supports this conclusion. People traditionally considered to be underprivileged as to dental care Were compared with other people. One underprivileged group, edentulous persons, received more treatment after the insurance was instituted than before. (Reeeived for publieation 20 January, aeeepted 25 April 1976)
National dentai insurance was recently introduced in Sweden. The insurance started with limited benefits at the end of 1973 and in January 1974 it began to operate in full. Since then, everyone in the country pays only half the dentist's fee and the insurance the other half. In cases of very high costs, the insurance pays a higher proportion. Patients under 17 years are treated free in the public services, as they were before. The purpose of the insuranee, to quote from the bill introducing the legislation, is "to create equal opportunities for each citizen to get good dental care at reasonable cost". This goal comprises three subgoals: (1) equal opportunities for each citizen, (2) good dental care, (3) reasonable cost. Part 1, dealing with equality, comes under social policy. Many studies (for reviews, see RICHARDS") have shown that people differ greatly in the amount of dental care they get and these differences are not only due to differences in "real" dental needs. Many socioeconomic and other factors influence the demand for dental care and have led to different people having different opportunities to get care. ;v Part 2 concerns the quality of care. Swedish dental care has always been considered of high standard internationally, and the new insurance should not cause any lowering of the standard.
, ,
,-
'
"•
Part 3, the desire for moderate cost to the individual, was fulfilled when the insurance was introduced. The cost for the patient, about half what it was before, is reasonable for the majority of people. If it still costs too much for the individual concerned, he or she can get financial help from other authorities. It is evident from the foregoing that the real situation diverges from the goal mostly in the first subgoal. The dental insurance can thus be seen as a social reform aiming to provide the "good dental care" already existing on a more equal basis than before through lowering the cost for the individual. In this paper, the consequences of the insurance 1 year after its introduction are studied mainly from the point of view of social justice. First will be examined the concept of equal opportunity, or equity of access as it is often called in current literature in health services research. A desire for social justice is embedded in the majority of the modern health programs. Access to health services is more and more considered to be a civic right for each person irrespective of income or class"''''''. It is a value beyond rational debate, but the debate on means to attain "the dream" is endless^. The debate on means is complicated by the fact that there is no general agreement on what is meant
216
BARENTHIN
by either equity or access, not to mention how these should be measured. At present many efforts are being made to clarify these concepts. Access implies, naturally, entry to the health care system. The presence of health care facilities and manpower is necessary but not in itself a guarantee of access. The distribution, volume, and organization of the facilities, as well as the characteristics of the population (e.g. attitudes, income, insurance coverage) could be expected to play a role in how people get access to health services. Separate studies of each of these conditions may give a different picture of a population's facility of access to the services'. Equity means the quality of being fair or impartial. How this should be interpreted in the field of health is not quite clear. Does it mean an equal number of visits to the doctor, a well-balanced geographical distribution of health care resources, lack of financial barriers for demanding care, or still something else? In this study of equity of access, the starting point is the first visit, i.e. the entry into the system. The changes in the distribution of entries are examined before and after the implementation of the dental insurance to try to see whether the "trend" during the first year is towards "more" ecjuity, i.e. if the changes can be considered to promote fairness, thus contributing to social justice.
MATERIAL AND METHODS The study was conducted in Tierp, a district situated 60 km north of Uppsala in Sweden. Tierp has a long tradition of agriculture and iron industry. The population of 21,000 inhabitants live in rural area or in the small eenters formed mainly around industries. In March of 1974, trained interviewers questioned a representative sample of the population in order to find out how people estimated the state of their own health and what they thought of various health-related matters, and also how they used the existing services. Dental questions, such as visits to the dentist during the past years, dental status, and ability to chew, were ineluded in the interview. Information was also obtained regarding various social characteristics and the general state of health. The persons were divided into the three social classes traditionally used in Sweden; Class 1 covers the upper elass, elass 2 the middle elass, and class 3 laborers. Information on ineome was taken from the health insurance office. The sample was selected in two stages. First, all persons aged 16 years or more, born the 10th or 20th of any month, were taken. From these (1,099 persons), 390 persons were randomly selected. Thirty of these 390 were
excluded because they had moved from Tierp, were doing military service, or were in some institution. Another eight were not interviewed beeause they could not be reached, and 13 refused to participate. This left 339 persons (87 % of 390, 94 % of 360) who were then interviewed. In order to see how well the answers to the interview questions concerning dental health agreed with the factual dental status, a subset sample of the "original" sample population of 339 persons was examined. This was done in connection with the regular health screening done ever>' 4th year in each district of the district. Seventy-six persons of the sample population lived in the districts of Karlholm and Hallnas, and 67 of these (88%) attended the health screening and could thus be examined and interviewed. The examination method is described elsewhere''. Since the introduction of the insurance, dentists must send reports to the health insurance offiee from where the insuranee is administrated. The reports include detailed information about the treatment given to each patient. This information is used as a base for the payment that the dentist receives directly from the insuranee. The information concerning all patients born the 10th or 20th of any month (constituting a national sample) is then registered at the social security data bank. Since all the persons interviewed in Tierp were born on these days, information about their visits to dentists dudng 1974 could be obtained from this national register. Information concerning persons under 17, not covered by the insurance, was obtained from school dental registers. To find out what factors were important for changes in utilization, a regression analysis was done. To this end, an auxihary variable was ealeulated for eaeh person in an attempt to operationalize the change. The auxiliary variable, q, takes into eonsideration the fact of utilization during each of the 3 years, 0 or 1, as described in Tahle 4. Thus its purpose was to show any "trend" in utilization. The q is calculated as follows; q = (utilization 1974 minus utilization 1973) minus (utilization 1973 minus utilization 1972). -
RESULTS
' " •""'-'
'
-.^
In all, 339 persons were interviewed concerning dental matters. In view of the intimate connection
Table 1. Study persons by dental status and age Total
Age
Dental status 16-44 45-64 > 6 5
n
%
8
216
64
10
23 23
56
16
67
20
Only natural teeth Both dentures and natural teeth Dentures but no natural teeth
157
2
36 29
Total
169
110 60
51
339 100
Access to dental services Table 2. Proportion of persons seeing a dentist in the different years by sex and age 1972
1973
1974
45-64 >65
67 38 11
60 49 28
58 35 11
Total
46
50
41
76 40 13
73 40 21
56 31 21
56
55
43
72
Sex and age Men (n = 182)
Women [n = 157) 16-44 45-64 >65 Total Both sexes {n = 339) 16-44 45-64 >65
39 12
67 45 25
57 34 15
Total
50
52
42
between dental status and need and use of dental services. Table 1 takes up the subjects' self-reported dental status with reference to natural teeth and removable dentures. Further analysis showed that difficulties in chewing were reported by 9 % of all persons. Among edentulous persons this proportion was 15 %. Table 2 gives the proportion of persons by age and sex who saw a dentist during each of the 3 years. As seen there, the percentage dropped distinctly during the last of these years, both for women and men. A larger percentage of women than men consulted a dentist each of the 3 years, and each year the percentages were lowest in the highest age groups. Table 3 shows the changes occurring over 19721974 in the pattern of use for groups which earlier studies have indicated get less dental care than others. All the groups were characterized by the same or lower consumption in 1974 than in 197273, except for the edentulous persons. No less than 21 % of these consulted a dentist in 1974, which is a large increase over the 2 foregoing years for these people. The dentaf insurance is particularly generous when it comes to getting new full dentures or renewing old ones. The group with poor chewing ability and the group with a poor general health
217
condition showed the same percentage visiting a dentist during 1974 as in 1973; the persons in good general condition and those with good chewing ability, on the other hand, visited dentists to a lesser extent. So far the results have dealt with the pattern of use in different groups. It is also important to study the changes in use at the individual level. Even if the proportion consulting dentists does not change from year to year, the percentage may not be made up of the same individuals each year. In other words, the question is whether it is the same people who come back for treatment from year to year. Table 4 shows the number of persons visiting or not visiting a dentist during 1972-74. As seen, this allows for eight patterns of use. Thus one person may have made no visit during these years, another only in 1974, another both in 1973 and 1974 and so on, as set forth in the Table. In order to study simultaneously the effect of the above-mentioned explanatory variables on the "trend" variable q, multiple regression analysis was employed. The variable that explained most of the varianee (although not to any signifieant degree) in the q variable was the interview answer to the question whether the person made regular visits to Table 3. Proportion of persons seeing a dentist in each of the years 1972-74 by some social and health characteristics Characteristic Education Only obligatory schooling (n = 245) More than obligatory schooling ( n = 94) Social class Low (3)
/\ *| — OHQ '^ — 4 U o I\
High (14-2)
(n=131)
Dental status Edentulous persons ( n = 67) Others (n = 272) Chewing ability Poor {n= 29] Good {n~310) General health Poor
Others Total
1972
1973
1974
44
47
36
68
66
45
50 52
53 52
41
0 63
3
21
65
61
24
17
53
56
17 45
45
{n= 23) (n = 316)
9
22
22
53
55
44
(" = 339)
50
52
42
218
BARENTHIN
Table 4. Interviewed persons by use pattern in 1972 through 1974 (0 = no visit during the year, 1 = one or more visits) Visited dentist 1972
1973
0 0 0
0
0 1 1 1 1
0
1974
•
1 1 0 0 1 1
Total
No. of persons
%
0
88
26
1 0 1 0 1
36 22 22 17 20
11 6
0 1
6
5 6
7 0 •'•
21
64
19
339
100
the dentist. Of greater interest, however, is that explanatory variables directly associated with economic circumstances, such as income or social class, did not significantly explain any variance in q. Nor did they explain the variance in utilization when each year was studied separately.
DISCUSSION The self-reports on dental status and chewing ability obtained at the interviews agreed well with the results of later clinical examination. Only in a few instances did minor deviations occur. These made no difference, however, to the way these cases were classified here. It was not possible to check the interview reports on visits to dentists during 1972 and 1973. It is known from previous investigations"'^^ that people tend tO' embellish their reports about visits to dentists. SMEDBY^'' found that persons tended to report a more recetit date for their last visit than was recorded at the dentist. It is possible that some visits which people in Tierp reported as having taken place in 1972 and 1973 actually occurred earlier than they said. As mentioned previously, institutionalized persons were not interviewed. Both these and the real absentees were old people, many in poor general condition. This probably means that they were less apt than most to go to a dentist and so less apt to get dental care. This was confirmed by a special study. Of the 51 missing persons only 14 (27 %) were noted as having consulted a dentist in the
register for 1974. Accordingly, judging by the composition of the missing persons in the sample, the proportion going to a dentist in the whole sample was probably slightly lower than calculated. The results of this study apply only to the area where the survey was done, i.e. Tierp. The district is not representative of the whole of Sweden. Tierp is an old agricultural area with some industrial traditions but without any cities. The age composition of the population differs slightly from that in Sweden as a whole, being a little "older". The social standard is rather homogeneous. As seen from the results of the regression analysis, socioeconomic factors did not play an important part in determining whether dental visits were made or not. This result is different from what is usually found in similctr studies. The percentage of people aged 17 years or over visiting dentists in 1974 was 44 for the whole country and 42 for Tierp. In 1974 there was one dentist per 1,200 inhabitants for the whole country and one dentist per 1,800 inhabitants in Tierp. The number of dentists in Tierp (12) was so small that individual variations in the dentists' practicing patterns may account for much of the variance in the patients' visits. Visits to the dentist were counted no matter where they took place, but the majority of them took place in Tierp. The number of first visits or entries does not of course alone reveal much about the adequacy of the care. Entry into the system, however, is a necessary prerequisite for receiving any kind of care. Since the first purpose of the insurance was to guarantee this ("create equal opportunities"), we have concentrated on whether or not a person visited the dentist. It might be argued that the volume of care, i.e. number of visits, should also be analyzed. Greater inequality exists, however, with regard to whether or not people ever see a dentist ("initiation", often patient's own decision) than with regard to the number of visits they make ("continuation", depending much on the physician's or the dentist's decision). Once in the system, the use rates do not differ much between different socioeconomic groups^. One group, edentulotis persons, increased its use of dental services, i.e. a greater proportion of persons in the group went to the dentist in 1974 than before. In this respect the insurance had the desired
Access to dental services 219 effect the very first year. In other respects, the insurance did not seem to have essentially increased or decreased equity betweeti different groups. The dental insurance authorities have made an investigation conceming the types of treatment given in 1974. They also compared the results with those from an earlier study analyzing the frequency of different types of treatment given in dental offices. They concluded that dentists devoted a greater proportion of their time to prosthetic work in 1974 than in 1970-7P^ Dental technicians have also reported a considerable increase in their workload. T h e fact that dentists now do more prosthetic work (hoth fixed and removable dentures) than before, undoubtedly explains some of the decrease in the number of persons visiting the dentist in 1974. Prosthetic work generally requires more titiie than other treatment. The more time devoted to one patient, the fewer the patients that can be treated. The information on visits obtained at the interview is contaminated by errors of memory and embellishment, which tend to give higher rates of utilization of the services than what is true. The insurance register may also contain errors, such as incomplete or erroneous data registration. This kind of registration error tends to reduce the true utilization rates. The insurance authorities make great efforts to avoid these errors. Although all evidence, not only in this study, indicates that there was a real reduction in the utilization rates in 1974 compared with earlier years, one must be very cautious when interpreting the size of the reduction from the results of this study since it uses different kinds of primary data for different years. The question whether the Swedish dental insurance has succeeded in creating more equity, is probably not answerable yet. Difficulties may crop up during the first year after the implementation that will disappear during the following years. It is possible that an evaluation of this reform is only meaningful after many years. However, a study of a transitional period might interest planners in other countries intending to carry out similar reforms. They may want to know what can happen immediately after the implementation of an insurance, even if it may have a different effect in the long run. In view of the many factors associated with access it is not surprising that a change in one factor is not immediately followed by great changes
in gaining access. Even the removal of fitiancial barriers known to prevent certain groups from getting care has not always altered the situation to the extent desired. The role of financial barriers in dentistry is uncertain. While many patients give cost as one of the main reasons they do not seek care", many do not go to the dentist even when they are offered free treatment'^''". No health care system can be separated from its national, cultural, and social setting. Each society expresses its own opinions on what is distributive justice through its political decisions. The Swedish dental insurance is an expression of this kind. As the results of this study indicate, however, the introduction of dental insurance does not guarantee that the desired chatiges occur rapidly. The removal of financial barriers can be said to be a necessary but not sufficient prerequisite for gaining "better" equity of access to dental services. DONABEDIAN' summarizes the difficulties: barriers are not only financial, they are also psychological, social, organizational, and of many other kinds.
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