Characteristics of dental care-seeking behavior and related sociodemographic factors in a middle-aged and elderly population in northeast China

The current study shows that the frequency of dentist visits is low in both middle-aged
and elderly populations in northeast China. The frequencies of middle-aged (82.3 %)
and elderly (80.3 %) residents of northeast China who did not visit dentist in the
past year were much higher than in comparable populations in south China (20.9–76.0 %)
25], 26] and in other developed countries (28.6–49.7 %) 23], 32], 33]. The high burden of oral disease and limited oral health care resources in China
are preventing the dental care needs of elderly individuals from being adequately
met 34], particularly in the central region of northeast China. Although northeast China,
which bridges the Northeast Economic Zone and the Greater Bohai Economic Zone, is
considered one of the key political, economic, and cultural centers of the nation,
the data presented here indicate that both oral health status and oral health awareness
in this region are low.

The perceived need for dentist visits in middle-aged populations was higher than in
elderly populations, and higher in urban areas than in rural areas. Furthermore, the
frequency of regular oral health checkup and periodontal treatment was higher in urban
areas than in the rural areas. However, usage of oral health care service was generally
low in both middle-aged and elderly populations in northeast China, and the rate of
dental care visits was low. While 60–70 % of the subjects chose the option that “there
is a need for dental care visit,” less than 20 % had visited a dentist during the
past year. Less than 10 % of these chose periodontal treatment, while most of underwent
tooth extraction or received fillings or inlays. These results reflect a substantial
discrepancy between the needs and demands of oral health care service in middle-aged
and elderly people in northeast China.

With regard to the reasons for dental care visits, due to a lack of basic oral health
knowledge, we found that individuals had a generally high assessment of their oral
health status compared to the mean level reported in previous studies 29], 30]. Approximately half of middle-aged and elderly people thought that there was no problem
with their teeth, and there was therefore no need to visit a dentist. Moreover, less
than 7 % of these individuals actively followed regular oral health checkup and took
preventive measures, while more than 80 % of them visited dentists only when they
had acute or chronic toothache. Furthermore, compared with residents of urban areas,
more middle-aged people in rural areas reported a perceived absence of severe oral
diseases or a lack of time as reasons not to visit dentists. Indeed, most middle-aged
people in rural areas typically choose passive measures (self-medication, tolerance,
etc.) because they consider their oral diseases to be not severe. In contrast, although
the number of middle-aged people in urban areas who followed regular oral health checkup
was similarly limited, these individuals reported visiting dentists in a relatively
timely manner upon the onset of toothache symptoms. Reasons for these results, which
are similar to those of previous studies 35]–37], include differences in income level between rural and urban areas, and imbalances
in the distribution of oral health care resources 38].

Consistent with the lack of coverage of rural areas by the traditional reimbursement
system in China, and the fact that the new social health insurance system was in its
early stages in rural areas during the study period, the majority of participants
living in rural areas obtained dental care at their own expense. Whereas health insurance
covered a certain proportion of dental care visits in urban areas, there were limits
to such coverage and, which is likely why most participants living in urban areas
also paid for their own dental care. Economic status is an important constraint on
dental care-seeking behavior: 30–40 % of middle-aged and elderly participants could
likely not afford dental care, even when it was definitely required. Accordingly,
as they did not seek dental care services, the need for dental care is not reflected
by demand, which compromises the use of the existing, limited oral health care resources
34], 39].

With regard to choices of dental care clinics, there was a significant difference
between rural and urban areas in both the middle-aged and elderly groups. The results
of this study show that most people who live in rural areas went to private clinics
for their dental care. Our recent study 40] found a total of 1518 private clinics in central northeast China, accounting for
74.88 % of oral health resources. Most of these clinics are inexpensive, convenient,
have no time limit for treatment, and are distributed in communities and villages
and, as such, are emerging as the preferred choice for dental care in middle-aged
and elderly individuals. These features are of great importance for people of limited
financial means living in rural areas. However, the technical strength of such clinics
is relatively weak; for example, only 33.2 % of their staff are registered as dentists,
and only 42.5 % have a college degree 40], indicating a need for improved management and continuing education in these clinics
26]. The results of the present study also show that fewer people went to provincial
comprehensive hospitals and dental specialized hospitals above the county level, particularly
in rural areas. The relatively high expense could be an important factor restricting
the participants from seeking dental care at such hospitals. In addition, these hospitals
are generally located in city centers, and their service duration is limited, making
it inconvenient for people who seek dental care service. The advantages of these hospitals
include their advanced dental specialists with solid training and sophisticated treatment
techniques. We suggest that such oral health resources should be better developed
and utilized. For instance, these hospitals can allocate specialists and transfer
technologies to community clinics, which will help bridge the gap between the needs
and demands of dental care to improve oral health in northeast China.

Consistent with the findings of Lundegren et al. 12], the results of this study show that education levels are positively associated with
tooth brushing frequency. Participants with higher educational levels reported brushing
their teeth more often. Moreover, consistent with the data of Chaves et al. 41], the frequency of high income individuals who had never visited dentists was significantly
lower than in lower income individuals. After educational level and income had been
included in the logistic regression equation, however, there was no significant influence
on the frequency of dental care visits. These data indicate that although education
level and income influence the frequency of dental care visits, they cannot be considered
as determinative factors of such visits. In contrast, education levels in central
China are significantly correlated with oral health-related quality of life 28]. In addition to geographic disparities with other parts of the country, including
differences in region and lifestyle, northeast China has, since the 1930s, been a
prominent economic mega-region in China. In the years since the reformation and opening
up and the accompanying changes in the economic system, the development of this region
has gradually lagged behind the economically developed coastal regions. The restrictions
that the lack of economic development in northeast China have placed upon lifestyle
and culture in this region 42] have attenuated the overall impact of education level and income on dental care-seeking
behavior.

Consistent with findings from previous studies 25], 32], 36], 37], the results presented here show that rural residence is a significant impediment
to dental care-seeking behavior in middle-aged and elderly people. This phenomenon
has a variety of explanations. First, as observed in this study, middle-aged and elderly
people living in urban areas report greater access to oral health information than
those living in rural areas. Greater access to oral health knowledge not only increases
an individual’s awareness of oral health care, but can also improve the perception
of a person’s need for dental care 24]. Second, health insurance coverage is higher in urban areas compared to rural areas.
In rural areas, most of the middle-aged and the elderly participants obtained dental
care at their own expense, suggesting that the low coverage of dental health insurance
directly affects dental care-seeking behavior in this population. Because most rural
residents have lower incomes than urban residents, they may not be able to afford
such visits, which hampers the intent to seek dental care services. Finally, the availability
of health services could also affect dental care-seeking behavior 37], 43]. In parallel with the rapid development of urban economies, the demand for oral health
care is increasing among urban residents, and disparities in the allocation of oral
health resources between urban and rural areas are increasing. Our previous study
44] showed that urban areas in central northeast China have eight times as many dentists
as rural areas, and that the vast majority of oral health institutions and dental
manpower services were located in cities. As a consequence, rural oral health services
cannot meet the oral health needs of the majority of rural residents, which in turn
limits active dental care-seeking behavior among middle-aged and elderly people in
rural areas.

There are several limitations of the present study. First, information bias may be
present, as all the data collected were self-reported by the participants, with no
objective measures of oral health status provided by medical or experimental examination.
Second, stratified random sampling was used to obtain the sample in the present study,
thus members of the same family may have been included. Members from the same family
are likely to share similar health behaviors, which could also introduce bias. Third,
the degree of the variability in the urban areas may not be comparable with that in
the rural areas; however, no data were available regarding these differences, which
could bias the results. Finally, other sociodemographic factors, including smoking,
weekly low alcohol consumption, body mass index??25 mg/kg², and fear of dental care, have been recently suggested as possible determinants of
dental care-seeking behavior 10], 32]. Unfortunately, these data were not collected in the current study. We will address
these limitations in future studies.