JECH Online First, published on March 20, 2015 as 10.1136/jech-2014-204493 Research report
The impact of the economic crisis on unmet dental care needs in Spain Silvia Calzón Fernández,1 Alberto Fernández Ajuria,2 José Jesús Martín,3 Matthew Joseph Murphy2 1
GS Córdoba Sur. Servicio Andaluz de Salud, Córdoba, Spain 2 Área de Salud Pública. Escuela Andaluza de Salud Pública, Granada, Spain 3 Facultad de Ciencias Económicas y Empresariales, University of Granada, Granada, Spain Correspondence to Dr José Jesús Martín, Facultad de Ciencias Económicas y Empresariales, University of Granada, Campus Cartuja s/n, Granada 18011, Spain; [email protected] Received 4 June 2014 Revised 29 January 2015 Accepted 2 March 2015
ABSTRACT Objectives To analyse the impact that the economic crisis and the evolution of socioeconomic inequality before (2007) and during (2011) the current crisis have had on unmet dental care needs in Spain. Methods The Living Conditions Surveys from the years 2007 and 2011 were used, including 44 138 adults aged under 65 years. A descriptive and stratified analysis was carried out along with the calculation of the concentration index and a multivariate logistic regression jointly and separately by gender. The dependent variable was unmet dental care needs and the independent variables were income, employment status, gender, age, education and chronic disease. A dummy variable was created for the year of survey completion as a proxy measure for the economic crisis. The SPSS V.20 software was used. Results During the period under analysis, the unmet needs for dental services increased (from 6.2% to 7.2%) along with the concentration index (from −0.1412 to −0.189). The main correlations with unmet needs were: unemployment (OR=1.46), lower income (OR=2.44 for the income quintile) and the year 2011 with respect to 2007 (OR 1.13). For women, the OR is greater according to income level (2.44 compared with 1.77 in men) and the year 2011 (1.21 compared with 1.06), while for men unemployment had a greater effect (OR=1.52 compared with 1.46). Conclusions There has been an increase in unmet dental care needs as well as in the social gradient for service access. The most vulnerable groups are those with less purchasing power and the unemployed. The economic crisis has also increased this unmet need.
INTRODUCTION
To cite: Calzón Fernández S, Fernández Ajuria A, Martín JJ, et al. J Epidemiol Community Health Published Online First: [please include Day Month Year] doi:10.1136/jech2014-204493
Oral health is considered a fundamental component of general health,1 with extensive evidence backing the association between bad oral health and a greater risk of mortality.2 The burden of oral disease is particularly high in disadvantaged and impoverished population groups, in developing as well as developed countries.3 The WHO describes these differences as social inequalities, and considers them to be unjust and avoidable.4 These inequalities have been observed in self-perceived oral health5 as well as through dental examinations carried out by dentists.6 These differences are observed in Spain between regions and between social groups.7 Although there is no consensus on the theory that would explain the exact origin of these inequalities, it has been suggested that patterns of dental care use constitute one of the mechanisms through which they may occur.8 Thus, those who
find it difficult to access care also have more prevalent and severe diseases.9 Social inequalities also appear in the access to dental visits in Europe, including in Spain.10 The behavioural model, proposed by Andersen,11 considers that the accessibility of health services depends on individual factors, the health system and the social context. Therefore, regarding the access to dental services we must consider, in addition to the socioeconomic level, the influence of other factors such as chronic disease,12 marital status, gender, age, education and employment status.13 The Spanish healthcare system provides basic coverage for dental care ( preventive and restorative) with public financing for children. However, unlike other health services, publicly financed dental care for adults is limited to care for acute pathologies.14 All other dental procedures are paid for by individuals, leading to significant private spending on oral health, which amounts to 97% of total dental care costs. With the exception of 4.8% of the population, which belongs to special social security plans for public employees, there are no publicly discounted plans for the rest of the population for other dental services.15 Since 2007, many countries have experienced the consequences of the economic crisis which, in the case of Spain, was accompanied by an increase in unemployment from 8.26% in 2007 to 25.03% in 2012.16 It has been suggested that the crisis could have affected the accessibility of health services through the loss of disposable household income.17 In Spain, the access to medical visits, which are publicly financed, has not decreased significantly.18 However, unmet dental care needs increased in the period between 2007 and 2011.19 Certain evidence also exists regarding the impact of the crisis on the decrease of preventive dental visits and the perception of the population that this is the principal reason for not seeing a dentist.20 21 The objectives of this study are to estimate the effects of the crisis on unmet dental care needs in Spain and to analyse the evolution of socioeconomic inequalities on these unmet needs before (2007) and during (2011) the current crisis.
METHODS Sources and variables As a source of information, the Living Conditions Surveys (ECV) from years 2007 and 2011 were used. They were administered throughout Spain by the National Statistical Institute under European Union (EU) oversight in coordination with Eurostat.22 The survey includes a sample of 16 000
Calzón Fernández S, et al. J Epidemiol Community Health 2015;0:1–6. doi:10.1136/jech-2014-204493
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Research report households in Spain. Residents of the autonomous cities of Ceuta and Melilla were excluded, as were individuals over the age of 65 and those surveys lacking data for the dependent variable (244 people, 0.66% of the sample). The data from the two transversal surveys (2007 and 2011) were combined resulting in the inclusion of 43 894 individuals in the study. A dummy variable was created for each year studied (1 for 2007 and 0 for 2011) as a proxy measure for the economic crisis. The prevalence of unmet dental care needs represents the outcome variable, a binary value defined by ‘yes’ or ‘no’ responses to whether individuals had experienced an “unmet need for dental examination or treatment during the last 12 months”. A ‘yes’ response indicated that there had been at least one occasion when the person needed a dental examination or treatment but did not receive it. Additionally, a variable related to the reason for not seeking care was included. The independent variables used were those that were commonly linked to the accessibility of dental services in previous studies: age (as continuous), gender, education level, marital status, the presence of chronic disease, employment status and income level (stratified in quintiles).10–13 Individual disposable income was calculated as household income (net income after income taxes and social security payments) divided by the number of consumption units according to the modified equivalence scale developed by the Organization for Economic Cooperation and Development (OECD). This scale, first proposed by Hagenaars et al,23 assigns a value of 1 to the household head, 0.5 to each additional adult member and 0.3 to each child. The values were changed to constant values for the year 2007. Educational level was expressed in three categories: primary, secondary and higher education. Employment status was organised into three categories: employed (full or part time), unemployed and inactive (retired, housework and/or caregiver or another reason for economic inactivity). The variable for chronic illness or disability was collected as a dichotomous value. Marital status was expressed in five categories: single, married, separated, widowed or divorced.
Prevalence and determinants of unmet dental care needs A descriptive analysis was performed using measures of absolute and relative frequency (categorical variables), and central tendency and dispersion (continuous variables). For the comparison of ratios between periods and population subgroups, the χ2 test was used with p
The impact of the economic crisis on unmet dental care needs in Spain Silvia Calzón Fernández,1 Alberto Fernández Ajuria,2 José Jesús Martín,3 Matthew Joseph Murphy2 1
GS Córdoba Sur. Servicio Andaluz de Salud, Córdoba, Spain 2 Área de Salud Pública. Escuela Andaluza de Salud Pública, Granada, Spain 3 Facultad de Ciencias Económicas y Empresariales, University of Granada, Granada, Spain Correspondence to Dr José Jesús Martín, Facultad de Ciencias Económicas y Empresariales, University of Granada, Campus Cartuja s/n, Granada 18011, Spain; [email protected] Received 4 June 2014 Revised 29 January 2015 Accepted 2 March 2015
ABSTRACT Objectives To analyse the impact that the economic crisis and the evolution of socioeconomic inequality before (2007) and during (2011) the current crisis have had on unmet dental care needs in Spain. Methods The Living Conditions Surveys from the years 2007 and 2011 were used, including 44 138 adults aged under 65 years. A descriptive and stratified analysis was carried out along with the calculation of the concentration index and a multivariate logistic regression jointly and separately by gender. The dependent variable was unmet dental care needs and the independent variables were income, employment status, gender, age, education and chronic disease. A dummy variable was created for the year of survey completion as a proxy measure for the economic crisis. The SPSS V.20 software was used. Results During the period under analysis, the unmet needs for dental services increased (from 6.2% to 7.2%) along with the concentration index (from −0.1412 to −0.189). The main correlations with unmet needs were: unemployment (OR=1.46), lower income (OR=2.44 for the income quintile) and the year 2011 with respect to 2007 (OR 1.13). For women, the OR is greater according to income level (2.44 compared with 1.77 in men) and the year 2011 (1.21 compared with 1.06), while for men unemployment had a greater effect (OR=1.52 compared with 1.46). Conclusions There has been an increase in unmet dental care needs as well as in the social gradient for service access. The most vulnerable groups are those with less purchasing power and the unemployed. The economic crisis has also increased this unmet need.
INTRODUCTION
To cite: Calzón Fernández S, Fernández Ajuria A, Martín JJ, et al. J Epidemiol Community Health Published Online First: [please include Day Month Year] doi:10.1136/jech2014-204493
Oral health is considered a fundamental component of general health,1 with extensive evidence backing the association between bad oral health and a greater risk of mortality.2 The burden of oral disease is particularly high in disadvantaged and impoverished population groups, in developing as well as developed countries.3 The WHO describes these differences as social inequalities, and considers them to be unjust and avoidable.4 These inequalities have been observed in self-perceived oral health5 as well as through dental examinations carried out by dentists.6 These differences are observed in Spain between regions and between social groups.7 Although there is no consensus on the theory that would explain the exact origin of these inequalities, it has been suggested that patterns of dental care use constitute one of the mechanisms through which they may occur.8 Thus, those who
find it difficult to access care also have more prevalent and severe diseases.9 Social inequalities also appear in the access to dental visits in Europe, including in Spain.10 The behavioural model, proposed by Andersen,11 considers that the accessibility of health services depends on individual factors, the health system and the social context. Therefore, regarding the access to dental services we must consider, in addition to the socioeconomic level, the influence of other factors such as chronic disease,12 marital status, gender, age, education and employment status.13 The Spanish healthcare system provides basic coverage for dental care ( preventive and restorative) with public financing for children. However, unlike other health services, publicly financed dental care for adults is limited to care for acute pathologies.14 All other dental procedures are paid for by individuals, leading to significant private spending on oral health, which amounts to 97% of total dental care costs. With the exception of 4.8% of the population, which belongs to special social security plans for public employees, there are no publicly discounted plans for the rest of the population for other dental services.15 Since 2007, many countries have experienced the consequences of the economic crisis which, in the case of Spain, was accompanied by an increase in unemployment from 8.26% in 2007 to 25.03% in 2012.16 It has been suggested that the crisis could have affected the accessibility of health services through the loss of disposable household income.17 In Spain, the access to medical visits, which are publicly financed, has not decreased significantly.18 However, unmet dental care needs increased in the period between 2007 and 2011.19 Certain evidence also exists regarding the impact of the crisis on the decrease of preventive dental visits and the perception of the population that this is the principal reason for not seeing a dentist.20 21 The objectives of this study are to estimate the effects of the crisis on unmet dental care needs in Spain and to analyse the evolution of socioeconomic inequalities on these unmet needs before (2007) and during (2011) the current crisis.
METHODS Sources and variables As a source of information, the Living Conditions Surveys (ECV) from years 2007 and 2011 were used. They were administered throughout Spain by the National Statistical Institute under European Union (EU) oversight in coordination with Eurostat.22 The survey includes a sample of 16 000
Calzón Fernández S, et al. J Epidemiol Community Health 2015;0:1–6. doi:10.1136/jech-2014-204493
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Research report households in Spain. Residents of the autonomous cities of Ceuta and Melilla were excluded, as were individuals over the age of 65 and those surveys lacking data for the dependent variable (244 people, 0.66% of the sample). The data from the two transversal surveys (2007 and 2011) were combined resulting in the inclusion of 43 894 individuals in the study. A dummy variable was created for each year studied (1 for 2007 and 0 for 2011) as a proxy measure for the economic crisis. The prevalence of unmet dental care needs represents the outcome variable, a binary value defined by ‘yes’ or ‘no’ responses to whether individuals had experienced an “unmet need for dental examination or treatment during the last 12 months”. A ‘yes’ response indicated that there had been at least one occasion when the person needed a dental examination or treatment but did not receive it. Additionally, a variable related to the reason for not seeking care was included. The independent variables used were those that were commonly linked to the accessibility of dental services in previous studies: age (as continuous), gender, education level, marital status, the presence of chronic disease, employment status and income level (stratified in quintiles).10–13 Individual disposable income was calculated as household income (net income after income taxes and social security payments) divided by the number of consumption units according to the modified equivalence scale developed by the Organization for Economic Cooperation and Development (OECD). This scale, first proposed by Hagenaars et al,23 assigns a value of 1 to the household head, 0.5 to each additional adult member and 0.3 to each child. The values were changed to constant values for the year 2007. Educational level was expressed in three categories: primary, secondary and higher education. Employment status was organised into three categories: employed (full or part time), unemployed and inactive (retired, housework and/or caregiver or another reason for economic inactivity). The variable for chronic illness or disability was collected as a dichotomous value. Marital status was expressed in five categories: single, married, separated, widowed or divorced.
Prevalence and determinants of unmet dental care needs A descriptive analysis was performed using measures of absolute and relative frequency (categorical variables), and central tendency and dispersion (continuous variables). For the comparison of ratios between periods and population subgroups, the χ2 test was used with p
