Equity inthe use of dental services provided by the Brazilian Unified Health System (SUS) among the elderly: a population-based study

Abstract

The scope of this study is to establish the profile of elderly users of dental services provided by the Brazilian Unified Health System(SUS) and associated factors from the standpoint of equity. It involves an analytical cross-sectional study with hierarchical modeling conducted on the basis of a complex probabilistic sample of groups of the elderly (65-74 years of age) living in a densely populated Brazilian city. Independent variables were included relating to: socio-demographic characteristics, access to information on health, behaviors/health-care system and health outcomes. Descriptive, bivariate and multiple hierarchical analysis was performed. Of the 480 elderly persons included, 138 (31.2%) used dental services from the SUS. Use of these services was greater as per capita income and level of schooling decreased. It was lower among those who had not conducted exams of their own mouths (oral self-examinations) and higher among those individuals who used dental services for non-routine procedures. In addition, people whose relationship had been affected by oral health issues and a negative perception of their appearance used the SUS more frequently. The conclusion drawn is that the use of dental services of the SUS was most prevalent among the elderly living in precarious conditions.

Elderly; Use of services; Oral health

Resumo

Propõe-se caracterizar os idosos usuários de serviços odontológicos ofertados pelo Sistema Único de Saúde, considerando o princípio da equidade. Trata-se de um estudo transversal analítico com modelagem hierarquizada, conduzido a partir de uma amostra probabilística, complexa, por conglomerados de idosos (65-74 anos) residentes em um município brasileiro de grande porte populacional. Foram incluídas variáveis independentes referentes a: características sociodemográficas, acesso a informações em saúde, comportamentos/sistema de atenção à saúde e desfechos em saúde. Realizou-se análises descritivas, bivariadas e múltiplas hierarquizadas. Dos 480 idosos incluídos, 138 (31,2%) utilizaram serviços odontológicos provenientes do SUS. O uso desses serviços foi maior à medida que diminuíam a renda per capita e a escolaridade dos idosos, menor entre os que não haviam realizado o autoexame da boca e maior entre os que usavam os serviços odontológicos para procedimentos que não fossem rotina. Além disso, verificou-se que utilizaram mais o SUS pessoas que tiveram o relacionamento afetado pela saúde bucal e uma autopercepção negativa da sua aparência. Conclui-se que o uso dos serviços odontológicos no SUS foi predominante entre os idosos que vivem sob condições de vulnerabilidade.

Idosos; Uso de serviços; Saúde bucal

Introduction

The social inequalities still prevailing in Brazil are steeped in the nation’s history, with a fragmented and unequal social protection system. At the end of the 1980s, social movements brought on the creation of the country’s Unified Health System (SUS). The SUS’s doctrine-based principles and challenges to be overcome are as follows: equity, universality and full coverage. As the system celebrates its 27^th anniversary, investments in infrastructure and organization in terms of the supply of services, with priority on primary care, have brought on improvements in the public’s access to health-care assistance¹. Encouragement of social participation and the supply of activities for promotion and prevention have worked together to raise the population’s consciousness as to their right to health-care². In this context, in order to guarantee access to public health services, there is the need to overcome the problems brought on by the aging of the population, epidemiological accumulation and transition, and also a need for changes in the health-care model³. The increase in Brazil’s elderly population, arising from social, demographic and economic transformations, as well as changes in habits⁴, have combined to generate a rise in the demand for health-care services⁵. Consideration should further be given to the different realities and health needs of the elderly population^6,7, including the oral health of this age bracket.

The existence of oral problems in elderly people may compromise aspects relating to their communication, chewing ability and self-image⁸, as well as their quality of life (QoL)^9,10. Elderly Brazilians, in particular, have been the victims of a dental assistance model that excludes and mutilates them^11,12, generating a high prevalence of edentulism^13,14. Contrary to what happens with other types of medical services, most elderly people in Brazil have not sought out the SUS when it comes to oral health¹⁵. According to data obtained from population-based inquiries conducted in the country, it was found that in 2002/2003¹³, a mere 5.83% of the elderly had used dental services, while in 2010, the ratio rose to 14.7%¹⁴.

This scenario reveals the ineffectiveness of the SUS and public oral health policies with respect to the principle of universality, namely guaranteed universal access to and use of dental services. Moreover, the causes of the rise in the proportion of elderly people who have never used dental services cannot be identified, since the research adopted a cross-sectional approach. It is further noted that the use of dental services is predominantly private and that economic inequities can also be impacted in this reduction of access in recent years^13,14. The concept of “use” of health services is understood as all direct (appointments, hospitalization) or indirect (preventive and diagnostic exams) contact with health services¹⁶. The concept of “access,” on the other hand, refers to the need for health services and actually getting them, which can bring about improved health outcomes^16,17. When it comes down to it, the use of health services does not necessarily express improvements in access to such services.

For decades, access to dental services in Brazil was characterized by the orientation towards school-aged children¹⁸, subsequently by private practice and services assured to city workers with full benefits under the nation’s consolidated work laws (CLT), which include their work and social security booklets (CTPS) being signed by their employers. There was an assistance void in terms of access to dental services for Brazilians not fitting into these categories¹¹. Expansion in the access to public/governmental dental care occurred as from the year 2000 by means of oral health teams being included in the family health strategy¹⁹, in order to guarantee such access, overcome social inequalities and meet repressed demand, including the elderly. It should be pointed out that the use of such services, the result of improvement in guaranteeing access, have been appraised in both the international^20-22 and Brazilian^12,23-24 context. Studies^23-26 conducted prior to the 2010 survey analyzed the use of dental services in Brazil and evidenced a rise in the proportion of people using public/governmental services in recent years²⁷, though this rise was not evidenced in the last two epidemiological surveys conducted at a national level^13,14. Among the theoretical grounds used to appraise the determinants related to the use of services, the theoretical model proposed by Andersen & Davison in 1997²⁸, adopted in previous studies^23,24, stands out.

The theoretical model proposed by Andersen & Davidson²⁸ was previously translated into Brazilian Portuguese and described in another work¹², and it is the one most employed in analyzing determinants of use. In this model, it is understood that the characteristics of the context, the oral health system and the personal characteristics of distinct populations influence oral health behaviors²⁸. After all, such characteristics restrict or predispose people in terms of using dental services²⁹. Variables related to the context have been associated with greater or lesser use of services among the elderly, especially those in lower income brackets, which suggest inequities^12,24,30. Previous studies have further investigated the association between the use of these services and socio-demographic aspects; objective health conditions (race, income bracket, educational level)^24,31-33; and subjective health conditions, such as self-perception of health^12,23,26. On the other hand, no epidemiological studies were encountered that identified factors associated with the use of dental services offered by the SUS to the elderly population.

Respect for the SUS’s principles, such as universal and even-handed access to services and health promotion, protection and recovery, constitute the system’s guiding proposals¹. The principle of equity, dealt with in this article, recognizes that individuals are different from each other and thus merit different treatments that eliminate or reduce inequalities. That is, unequal treatment is fair when it benefits the neediest individual³⁴. Hence, analyzing the profile for use of health services is important, as it allows us to characterize the user population, identify their health conditions and explain their reasons for seeking out services, which are fundamental elements for planning and organizing health-care activities³⁴. By considering the various dimensions that interfere in the use of services²⁴, this study aims to evaluate whether one of the principles of the SUS, equity, has been achieved within the scope of providing dental services to the elderly.

Methodology

This study involves an analytical cross-section conducted among the elderly population (i.e. people in the 65-74 age bracket) of a densely populated Brazilian city [Montes Claros, the leading city in the North of Minas Gerais (MG) and the state’s third most populous city]. The appraisal criteria used were the oral health conditions proposed by the World Health Organizations (WHO) in 1997³⁵ and adopted in Brazil for its oral health policy in 2002/2003¹³. The study’s hierarchical modeling was carried out based on a complex probabilistic sample of groups of the elderly in two stages (census and age brackets) representative of the population. The sample calculation estimated the occurrence of events or diseases in 50%of the population, a sampling error of 5.5%, level of confidence of 95%, deff (design effect) equal to 2.0, and non-response rate of 20%, to offset possible losses. It is estimated that the sample consisted of 740 elderly persons.

The data was gathered at households belonging to the sectors and age brackets chosen, conducted by 24 dental surgeons trained and calibrated (Kappa inter/intra-examiners and interclass correlation coefficient) to perform the interviews and intra-oral exams. All the interviews and exams were carried out in a broad setting, under natural light, employing previously sterilized clinical oral mirrors and Community Periodontal Index (CPI) probes. The examiners who participated in gathering data showed a concordance of ≥ 0.60, as per the scale proposed by Fleiss³⁶, as modified by Cicchetti et al.³⁷ (ICC ≥ 0.61 and Kappa ≥ 0.61).The data was recorded on a hand computer software program, employing the Health Data Gathering Program developed for this research work.

Participating in the study were only elderly persons who did not have cognitive problems, reported having used dental services and answered the question relating to the place where the service was used. The elderly chosen underwent cognitive appraisals employing the version validated in Brazil of the Mini Mental State Examination (MEEM)³⁸. Different cut-off points were adopted for analysis of the MEEM, according to the educational levels of the elderly person, 21 for illiterate elderly people, 22 in the low level of schooling group (just 1st to 5th grades), 23 in the middle level (6 to 11 years of schooling) and 24 in the higher educational level (12 or more years of studies)³⁹. Elderly persons with point scores on the MEEM below that defined as the cut-off point were identified as elderly people with compromised cognitive abilities and were not considered in our investigation. At the end of the employment of such inclusion and exclusion criteria, the study population was reduced.

The dependent variable was the use of the SUS’s services, which was constructed based on the following question: Where did you use dental services?(public services, private services provided by independent ‘liberal’ professionals, private services through health coverage plans and arrangements, philanthropic services or other types of services?). The variable involves consulting dental services on the part of the interviewee throughout his or her entire life, and not just in the past few months or years, as has been gauged in certain works^26,40. There upon, the variable was transformed into a dichotomy: “SUS” (public services) and “other services” (private liberal services, private services through health coverage plans and arrangements, philanthropic services or other types of services).

The independent variables were grouped together in four blocks according to the theoretical model drawn up by Andersen & Davidson²⁸: demographic and socio-economic (age, sex, ethnicity or self-declared race, marital status, years of education, per capita income); access to oral health information (information about how to avoid oral health problems; about oral hygiene and mouth cancer); oral health behaviors/health-care systems (conducting auto-exam of mouth; frequency of daily cleaning of the oral cavity; reason for use, time frame of use of dental services, evaluation of services); and health outcomes, with the latter being divided into objective health conditions (edentulism, use of dental prostheses and need for same) and subjective ones (self-perception of the need for treatment, oral health, chewing, appearance, relationship affected by oral health, sensitivity to pain in teeth and gums in the past six months and discomfort in the head and neck). The gathering of data as regards access to oral health information was carried out by means of the following set of questions: Have you received information as to how to avoid oral problems? Have you received guidelines regarding oral hygiene in the dental services you have consulted over the course of your life? Have you received guidelines as to how to avoid oral (mouth) cancer in the dental services you have consulted over the course of your life? The questions that generated the remaining variables related to behaviors/health-care system were as follows: Have you ever conducted an exam of your own mouth? How many times per day did you brush your teeth in the past week? Why did you go to the dentist? How long has it been since you last went to the dentist? How would you evaluate the service you received? The questions that gave rise to the subjective variables regarding health outcomes were as follows: Do you consider that you need dental treatment every year? How would you rank your oral health? How would you rank your chewing? How would you rank the appearance of your teeth and gums? In what manner does your oral health affect your relationship with other people? How much pain have your teeth and gums caused you in the past 6 months?

The PASW Statistics 18.0 computer software program was employed to analyze the statistics. Correction for the design effect (deff) was carried out, in that the study was based on a complex sample per conglomerates in two stages. The descriptive analysis included absolute frequency (n), relative frequency (%) and the relative frequency with correction for the design effect (%*), the standard error and the deff for categorical variables. For the discrete variables, age and per capita income, the average and standard variation was included. There upon, bivariate analyses were conducted based on the Chi-square test, adjusted through the correction for the design effect. Only the variables that showed a level of significance (p-value) equal to or lower than 0.20 were included in the multiple hierarchical analyses. Hierarchical logistic regressions were carried out for estimation of the multiple models, inserting each one of the four blocks of variables according to the distal and proximal factors of the theoretical model used and modified by the linking of the primary and exogenous determinants in a single block. The final model presents the adjusted values of the variables that remain associated with the level of p ≤ 0.05, with intervals of 95% confidence in each one of the steps of the hierarchical analysis.

The ethical principles of this study have been upheld in accordance with Brazilian National Health Council’s Resolution No. 196/96, as approved by the Research Ethics Committee of the Montes Claros State University (CEP/Unimontes). All the participants in the study signed the document of consent of their own free and informed will.

Results

Out of the 736 elderly persons evaluated, 480 have been included in this study. This is because 123 had cognitive problems and, among the remainder, 12 had never used dental services.The prevalence of the use of dental services provided by the SUS came to 31.2%. The average age of the sample was 68.6 (± 3.05), with average schooling of 4.3 years (± 4.22). The descriptive analysis revealed a population where most people were in the following categories: female, low income and low schooling, and in most cases were using dental services for more than one year (Table 1).

Table 1
Descriptive analysis of the type of dental service used, demographic and socioeconomic characteristics, oral health-care system, access to health information, behaviors and health outcomes among the elderly in Montes Claros/MG. 2009 (n = 480).

• ε Standard error. Deff = Design effect. ^* With correction for design effect. ^** Variation in n.

In the bivariate analyses, the use of SUS services was associated (p ≤ 0.20) with variables relating to socio-demographic characteristics, access to oral health information, behaviors/oral health-care system and health outcomes, by means of objective and subjective conditions (Table 2). This association was considered in selecting the variables to comprise the hierarchical logistic model.

Table 2
Bivariate analysis of the factors associated with the use of dental services provided by the SUS among elderly people in Montes Claros/MG. 2009.

In the hierarchical multiple analysis (p ≤ 0.05), it was identified that the use of SUS dental services increased as income and educational levels decreased, and also that the elderly persons who used the dental services for other than routine/maintenance procedures did so because of bleeding, cavities and pain, and further that their relationships were affected by their oral problems. Moreover, it was found that such use was lower among those who did not conduct exams of their own mouths and that they considered the service average, poor or bad (Table 3).

Table 3
Hierarchical multiple logistic regression analysis of the factors associated with the use of dental services provided by the SUS among elderly people in Montes Claros/MG. 2009.

• Ref.: benchmark category. ^* p ≤ 0,05.

Table 4 shows the final model, as adjusted, and the respective R².

Table 4
Comparison between the final model and the adjusted model of the hierarchical multiple logistic regression analysis of the factors associated with the use of dental services provided by the SUS among elderly people in Montes Claros/MG. 2009.

• Ref.: benchmark category. ^* p ≤ 0,05.

Discussion

Three health-care systems coexist in Brazil: one that is public and universal (SUS); the second one, which is supplementary, based on insurance and health coverage plans (to be signed onto either voluntarily by employees and/or covered by employers); and the third, which involves direct payment by individuals when they use such services. This study revealed that the elderly used health coverage plans less (7.0%) than the overall proportion of Brazilians who had health coverage plans (17.9% in 2008). Furthermore, the use of private dental services by the elderly (60.9%) was higher than the prevalence encountered among the Brazilian population in general (51.6%)⁴¹. The prevalence among elderly persons who used public services in this work was similar to that encountered among Brazilian elderly persons¹⁴ in the national survey, but higher than other previous studies also conducted among the elderly in Brazil, which studied convenience samples^12,42, and lower than among the elderly in Europe, who attain rates of 80% in terms of using public dental services⁴³.

For the process of working with oral health in the public service, the directives adopted by the Brazilian Ministry of Health are intended to orient professionals undertaking scheduled activities for promoting health, disease prevention and health-care, with special focus on controlling chronic diseases and helping the most vulnerable portion of the nation’s populace⁴¹. The oral health teams that work on basic health-care are to adopt family and individual risk classification methods that guide the use of public dental services, especially for the neediest segments. These criteria would include families chosen based on analysis of their social risk factor, in order to carry out surveys of dental needs and to define such priority groups as pregnant and nursing mothers, patients with special needs, people suffering from hypertension, and the elderly, among others.

This study has revealed that the use of the SUS’s dental services was greater among the elderly who live in precarious conditions, which suggests that efforts to follow the equity principle have been successful. Use increased as income and educational levels decreased.

Such association between lower income levels and greater usage rates of public dental services has been identified previously^15,40,42. Higher household income can contribute to the possibility of access to private services^44,45, although low income is a factor that influences access inequity. It should be pointed out that access to private services can be an effective alternative when one considers certain barriers to accessing public services, such as the length of the waiting time for access to certain public services, with this alternative being hampered by the low income of the individuals involved. Another study⁴⁶, which analyzed the inequalities in the use of health services, noted that the characteristics which lead to unequal usage are not related to health needs as such, but rather to income, geographic location and the presence of a private health coverage plan among people who are better off.

It was identified that the use of the SUS’s dental services was greater among elderly people with less schooling. Brazil’s elderly population already suffers with the hurdles in accessing health services, resulting from their low educational levels, a fact previously identified in studies conducted both in our country^23,45 as well as in Northern European nations (Denmark, Sweden, Germany and the United Kingdom)⁴³. People with higher educational levels can have greater access to information regarding the importance of the regular use of dental services⁴⁴, which encourages the seeking out of services, either public or private. Despite the low level of schooling of the elderly age brackets, it is noted that older people with less education posted greater chances of using the SUS’s dental services, which should be recognized. The services should contribute to the principle of equity and bestow learning opportunities on the clinical environment, seeking to assure everyone with access to the required resources, so that dental care is effectively a human right⁴⁷.

Another important factor to be considered in the SUS health activities is the right to information, which impacts the behavior and the adoption of a healthy style of living and preventive habits. It was found that the use of dental services provided by the SUS was less frequent among those that had not performed exams of their own mouths, suggesting that encouraging self-exam practices seems to happen more often with those who use the SUS. The importance of health education as a tool that leads to healthy habits and behaviors has already been established in the literature^18,48, adding to the fact that educational orientation is more frequent in the public service milieu^49,50. Examining your own mouth is associated with the use of the service, in that perception of the need for professional assistance based on the presence of alterations in the oral cavity generates the demand for assistance⁵⁰, which can lead people to seek out the service.

The reason for using the dental services noted at the SUS in this study has been more related to seeking out treatment for bleeding, cavities and pain than to routinely using them for preservation of oral health. Such a finding indicates that the existing demand for oral health care interferes with the motivation for the use of the dental services and evidences that control of oral diseases in the elderly age brackets has not yet been achieved. Nevertheless, when we analyze the nation-wide reality¹⁴, we note that the use of such services for routine checkups has been more positive and in greater proportion than compared to the country. A previous study²⁴ analyzed the use of routine services among dentulous and edentulous elderly people and perceived inequities in terms of several factors, among them geographical barriers, income disparities and aspects related to the regularity of access over the course of time. Still speaking of time, this revealed a more unfavorable picture, since there was lower usage of the dental services in the past year in comparison with the national reality in 2010¹⁴.

Just as in other investigations, the precarious state of dentition evidences the sad reality for this age bracket in Brazil^13,14. In this investigation, it was noted that there was a predominance of edentulous elderly persons (57.7%), high usage (79.4%) and need for prostheses (68.8%). It should be pointed out that in Brazil most specialized dental services, such as the preparation of ready-made dental prostheses, are offered as a public service by the Specialized Dental Centers (CEO). In some cases, there is a lack of accessible centers or even the lack of financial resources to seek out private assistance. A study that analyzed the use of dental services by the elderly in European countries defined the state of dentition and the need for treatment as being the major determinants of use⁴³.

Health outcomes, that is, issues related to the normative^32-34 and subjective³⁰ conditions of oral health, were associated with the use of dental services in previous studies. In this study, our hierarchical analysis did not reveal that normative outcomes were associated with the use of the SUS’s dental services, insofar as the elderly were concerned, but rather evidence the importance of subjective factors in the differentiation of the type of service sought out by the elderly. The subjective conditions were investigated in studies that appraised self-perception of oral health^12,51, yet they have been neglected in analyses of health services among the elderly and the population in general^52-54. Nonetheless, associations were encountered in this investigation between the type of dental service used and subjective conditions.

The importance of the data relating to self-perception is due to the possibility of verifying when there is a need for making a behavioral change⁵⁵ or even seeking out the service to resolve a perceived nuisance. Elderly people who self-perceive their appearance in a negative manner tend to use the SUS more than other services, which gives the public system a greater possibility of being a door of entry that is more accessible and more readily facilitated to oral health-care for such population.

Elderly people whose relationships bear the impact of oral problems used the SUS more than other types of services. No other work appraising this issue has been encountered, though in the epidemiological survey of oral health conducted in 2003¹³ it was perceived that there was lower usage of services in the past year for elderly people reporting relationship impact, suggesting access problems. It is important to point out that the subjective variables are closely related to the physical, psychological and contextual state of the individual⁵⁶ and, for this reason, change can come about during the course of a day or week. Picking up on the subjectivity linked to well-being or the consequences of getting sick is always a difficult task, since it involves sentiments and values implicit in judgment⁵⁶. Taking into consideration that the design of the study adopted is the cross-sectional type, there is a limitation in the range of interpretation of the results presented herein.

It should be pointed out that the use of the SUS’s dental services and the variables investigated involve a dynamic process and reflect the evolution of a system that is constantly perfecting and modifying itself over the course of time. Since our study is a cross-sectional one, it is not possible to measure the time variations or establish cause and effect relations. Moreover, other variables relating to the use and quality of health-care provided should be considered in subsequent studies. In spite of this, this study has managed to identify that the most unfavorable conditions related to poverty, education, lack of information, impact on personal relations and those related to the disease also entail greater use of the SUS, even though the other services (private, philanthropic and health coverage plans) still represent most dental care provided in Brazil.

The reasons that explain such inequalities are historical and complex and the changes required to face up to them should start with the government, chiefly at the local level, which has the function of putting into practice the existing public policies, especially those having a bearing on health determinants. Hence, it is hoped that this study will contribute to increasing knowledge regarding the factors related to equity in the use of dental services provided to the elderly by the SUS.

Acknowledgments

We would like to thank the logistic support provided by Montes Claros State University (Unimontes) and Northern Minas United Colleges (FUNORTE), the financing provided by the Minas State Research Support Foundation (FAPEMIG)and the collaboration of the persons participating in the process of questioning the elderly persons surveyed. Andréa Maria Eleutério de Barros Lima Martins has a scholarship financed by the Brazilian National Council for Scientific & Technological Development (CNPq). Desirée Sant´Ana Haikal and Barbara Paloma Almeida Alecrim have FAPEMIG scholarships, and Efigênia Ferreira e Ferreira has a CNPq productivity scholarship.

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Publication Dates

• Publication in this collection
  Nov 2016

History

• Received
  25 July 2015
• Reviewed
  11 Jan 2016
• Accepted
  13 Jan 2016