
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)11771-9
10.1016/j.heliyon.2024.e35740
e35740
Research Article
Awareness and attitude towards dental coverage right affecting the dental service utilization among selected thais in Bangkok
Luksamijarulkul N. nicha.luk@mahidol.ac.th
a⁎
Tantipoj C. Chanita.tat@mahidol.edu
b
Amornsuradech S. a
Suepakdee N. gnatthawan@gmail.com
c
Boonsajjaritthikul P. pimwalanboon@gmail.com
c
Tuptim O. osafkaiser@yahoo.com
c
a Department of Community Dentistry, Faculty of Dentistry, Mahidol University, Ratchathewi, Bangkok, 10400, Thailand
b Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Ratchathewi, Bangkok, 10400, Thailand
c Mahidol International Dental School, Faculty of Dentistry, Mahidol University, Ratchathewi, Bangkok, 10400, Thailand
⁎ Corresponding author. Department of Community Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, 10400, Thailand. nicha.luk@mahidol.ac.th
03 8 2024
30 8 2024
03 8 2024
10 16 e3574025 12 2023
26 7 2024
2 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Oral health problems are one of the most prevalent public health issues in Thailand. However, the rate of dental service utilization is relatively low despite having three major healthcare coverages provided for Thai citizens. Objectives: This study aims to investigate whether awareness about dental coverage affects the rate of dental care utilization and the attitude towards dental coverage compared across coverage types. Methods: A cross-sectional analytical study based on Bangkok, Thailand using a newly developed questionnaire to assess socio-demographic information, dental healthcare utilization, dental coverage, and attitude towards dental coverage. Convenience sampling was used. Population studied was Thai citizens of working age (above 15 years old). Paper-based questionnaire forms were handed out in public venues. Data was analyzed with chi-square analysis to assess whether the sociodemographic characteristics and awareness of dental coverage correlates with dental care service utilization. Logistic regression was used for multivariate analysis to determine which variables had more influence upon dental care utilization.

Results

A total of 315 participants were included for data analysis. Chi-square analysis showed that gender, age, occupation, education, income, and awareness of dental coverage and reported type of dental coverage were all significantly correlated to dental healthcare service utilization (p-value <0.05). Multivariate analysis revealed that gender, age, career, and income still affect utilization when put into a logistic regression model, while awareness was no longer significant in predicting utilization rate.

Conclusion

In conclusion, sociodemographic factors that significantly affect dental care service utilization included age, gender, occupation, education and income. When weighted with other socioeconomic determinants of dental care utilization, awareness of dental coverage schemes did not have a significant prediction value.

Keywords

Dental service utilization
Awareness
Attitude
Dental coverage
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pmc1 Introduction

Oral healthcare is one of the primary contributions to having a good quality of life in the aspects of physical, psychological, and social well-being of a person. However, oral health problems are one of the most prevalent public health issues in Thailand. According to the 2017 Thailand National Health Survey, more than 40 % of its population across all age groups have oral health problems that remain untreated [1].

Due to the importance of dental healthcare utilization, Thai government increased accessibility to basic health services for their citizens through the use of three major coverage schemes including the Universal Coverage Scheme (UCS), the Social Security Scheme (SSS) and the Civil Servant Medical Benefit Scheme (CSMBS). All citizens with Thai national identification cards are eligible for the UCS. Citizens belonging to the workforce are eligible for the SSS. And lastly, CSMBS serves to protect civil servants and their immediate family members: spouse, parents, and children.

Despite this universal dental healthcare coverage, only 9.6 % of Thailand's population has paid a visit to the dentist in the span of 1 year [1], which was already an improvement from 2015 (with 8.1 %) [2]. This number is still far from adequate compared to developed countries such as the United States where the rate of dental visits is 65.7 % in the past year [3]. Even though multiple studies have shown that availability of dental coverage tends to increase the use of regular dental services, there is a clear contradiction between the availability of dental coverage and the rate of dental service utilization within the Thai population [4].

A number of studies investigated the reasons why people are not using healthcare coverage to cover their dental service costs, which includes long waiting time, poor quality of services, and extra uncovered costs. Yet, very limited studies in Thailand have explored the relationship between the awareness and attitude toward healthcare coverage in accordance with the rate of utilization of dental services in the general population.

Many studies show a positive correlation between the level of awareness of healthcare coverage and utilization of dental services under healthcare coverage [[5], [6]]. Maniyar and Umashankar indicated that all of the insured group aware of their coverage and have 4 times more dental service utilization than non-insured ones [6]. Similarly, So and Schwarz determined that covered subjects had higher utilization of dental service than both covered but unaware and uncovered subjects, who both shows similar trend of dental service usage [5].

Sukyou and Bhanthumnavin conduct a study on how knowledge and attitude towards Universal Health Coverage influence its utilization among taxi drivers in Bangkok, assuming that taxi drivers have full knowledge of their rights [7]. Compared with the studies from Maniyar and Umashankar, both studies indicate that the participants had positive attitudes toward their coverage due to the alleviation of financial burden [6]. However, the trend of the utilization rate for both studies are different. The investigation among taxi drivers with UHC in Bangkok indicated that taxi drivers have a decreasing rate of utilization despite their full awareness of dental rights due to the lack of understanding of their rights [7][. Many studies indicate that not only knowledge, attitude and awareness of dental coverage also affects the utilization rate of dental care but also other systemic factors such as poor quality of services, extra uncovered costs and long waiting time [3,[8], [9],10,7]. The research indicates that there are many factors that affect the rate of utilization of dental services in Thailand.

This study aims to investigate whether awareness about dental coverage affects the rate of dental care utilization and the attitude towards dental coverage compared across coverage types.

2 Method

2.1 Study design

This was a cross-sectional analytical study conducted from October to December 2019. The participants were Thai citizens (holding Thai Identification Card) of working age (above 15 years old). This study was approved by the Ethics Committee of Human Research, Faculty of Dentistry, Mahidol University, Bangkok, Thailand (COE MU-DT/PY-IRB Code:2019/055.1309.)

The data was collected using a paper-based, self-administered, anonymous questionnaire, along with informed consent. The sample population was selected by convenience sampling due to ease of reaching out to volunteers. The 360 questionnaires were distributed directly by the researchers around different areas in Bangkok. The venues for questionnaire distribution were as following: Private clinics, in front of a Mall in Bangkok, at a public hospital and at the faculty of Dentistry, Mahidol University and Rajavithi. The reason for choosing such settings for questionnaire distribution was to obtain a wide variety of population, from healthcare settings and at a general public setting.

The questionnaire used was a newly developed questionnaire formulated to inquire about the participant's socio-economic status, their dental care utilization, awareness of dental coverage, and their attitude towards dental coverage. The questionnaire content was reviewed for its validity by three experts in the field consisting of one biostatistician, one community dentistry specialist, and one dentist working in Governmental hospital. This was to determine the validity of each question through the use of Index of Conjugation (only IOC ≥0.5 were included, while others were revised before inclusion). The pilot study was conducted prior to the approval from the Ethics Board and consisted of 15 participants. The purpose of the pilot was to detect problematic wordings in the questionnaire that may cause misunderstandings.

The reviewed questionnaire was made out of 3 parts. The first part asked the participants about their socioeconomic status (including, age, sex, occupation, education, and income) and their frequency of dental care utilization. This was used to determine socioeconomic factors that may influence utilization of dental care service. The second part asked about their awareness of their existing dental coverage with a dichotomous question and the dental coverage they had between 4 options: SSS, UCS, CSMBS, or others (where participants must indicate their coverage if it is not listed in the former 3 options). The third part asked about their attitude towards dental coverage with 4 statements about dental coverage where participants must rate their agreement on a 5-point Likert scale (1 - strongly disagree to 5 - strongly agree) and an open-ended question was included for participants to write down their opinions on the benefits of dental coverage. All parts of the questionnaire are listed in detail in Table 1, Table 2.Table 1 Characteristics of participants crossed with dental service utilization.

Table 1Variable	Total
N (%)	Utilization	P-value	
	No
N (%)	Yes
N (%)		
Age (years)				0.02	
15–22	26 (8.3)	15 (17.4)	11 (4.8)		
23–35	105 (33.3)	29 (33.7)	76 (33.2)		
36–60	151 (47.9)	33 (38.4)	118 (51.5)		
>60	33 (10.5)	9 (10.5)	24 (10.5)		
Gender				0.005	
Male	145 (46.3)	50 (59.5)	95 (41.5)		
Female	168 (53.7)	34 (40.5)	134 (58.5)		
Career				0.153	
Self-employed	121 (38.8)	38 (45.2)	83 (36.4)		
Unemployed	42 (13.5)	14 (16.7)	28 (12.3)		
Private company employee	101 (32.4)	18 (21.4)	83 (36.4)		
Government employee	25 (8.0)	8 (9.5)	17 (7.5)		
Retired	23 (7.4)	6 (7.1)	17 (7.5)		
Education				0.002	
Junior high or lower	37 (11.8)	17 (19.8)	20 (8.7)		
High school or equivalent	65 (20.6)	23 (26.7)	42 (18.3)		
Undergraduate or higher	213 (67.6)	46 (53.5)	167 (72.9)		
Income (Baht/month)				<0.001	
<15,0000	97 (31.3)	41 (48.8)	56 (24.8)		
15,001–30,000	110 (35.5)	28 (33.3)	82 (36.3)		
>30,000	103 (33.2)	15 (17.9)	88 (38.9)		
Awareness about dental coverage				0.01	
No	111 (35.2)	40 (46.5)	71 (31.0)		
Yes	204 (64.8)	46 (53.5)	158 (69.0)		
Types of coverage				0.001	
No	103 (32.7)	37 (43.0)	66 (28.8)		
Yes	212 (67.3)	49 (57.0)	163 (71.2)		
SSS	129 (41.0)	24 (27.9)	105 (45.9)		
UCS	33 (10.5)	16 (18.6)	17 (7.4)		
CSMBS	41 (13.0)	7 (8.1)	34 (14.9)		
Other coverages	9 (2.9)	2 (2.3)	7 (3.1)		

Table 2 Attitude towards dental coverage according to the 4 statements about dental coverage, subdivided into favorable (scores 4–5) and unfavorable (scores 1–3).

Table 2Attitude	Valid feedback	No visit in a year	Visit once a year	P-value	
Lower financial burden	309 (97.5)	85	224	<0.001	
Favorable	226	62	204		
Unfavorable	43	23	20		
Improves treatment accessibility	310 (97.8)	85	225	0.004	
Favorable	263	64	199		
Unfavorable	47	21	26		
Motivates visits before symptoms	309 (97.5)	85	224	<0.001	
Favorable	256	58	198		
Unfavorable	53	27	26		
Decrease social inequality	308 (97.2)	85	223	<0.001	
Favorable	231	48	183		
Unfavorable	77	37	40		

Statistical analysis was done in two steps, first by conducting a univariate analysis of all independent factors to determine its correlation with utilization rate through the use of chi-square analysis. The significantly correlating factors were then further analyzed by multivariate analysis. The demographic data, dental coverage awareness, and attitude towards dental coverage were treated as independent factors, the frequencies and percentage of the answers are following Table 1, Table 2

For demographic information, age was put into groupings based on working years, 15–22 years old (may still be in education), 23–35 years old (newly entering workforce), 36–60 years old (working age), >60 years old (retired). Careers were grouped as follows (refer to Table 1); as the type of dental coverage can be determined based on it. Education was grouped into 3 levels of educational certification an individual would usually obtain. Income was grouped into 3 of the following based on minimum monthly wage required by the Thai government (300bht per day). Frequency for each characteristic divided into utilization and non-utilization of dental care services are shown in Table 1.

To analyze the attitude based on the Likert scale from all 4 statements, the answers were grouped into favorable outcomes, for scores 4–5, and unfavorable outcomes, for scores 1–3 (following Table 2). The data was then analyzed using chi-square. All the data analysis was conducted using PASW statistics for windows version 18.0 (SPSS Inc., Chicago, IL, USA).

The sociodemographic statuses of this study varied. The number of female participants (n = 53.7 %) were slightly higher than that of the male participants (n = 46.3 %). The majority of participants belong to the group of 36–60 years of age (45.3 %). As for occupation, most of the participants conduct their own personal business (37.9 %), followed by employees (%), students (%), civil servants (%), and retirees (%). Most participants had education at the level of undergraduate or above, with 213 participants (67.6 %) and have the highest percentage of utilization rate among all other groups of education (72.9 %). Monthly income was categorized into three groups, with most participants belonging to 15,000–30,000 baht per month group at 110 (35.5 %). This is followed by those who earn more than 30,000 baht per month, at 103 (33.3 %), and lastly less than 15,000 baht per month at 97 participants (31.3 %). As for the status of awareness of dental coverage, there were 204 (64.8 %) of participants who were aware of their existing dental coverage while 111 (35.2 %) participants were not. Participants were asked further about the type of coverage they had. There were 103 (32.7 %) of the participants who stated that they do not have any coverage at all while 212 (67.3 %) of the participants stated that they have healthcare coverage. Within those who state that they have healthcare coverage, the participants were further divided into 4 subcategories of the types of coverage that they had including the Social Security Scheme (SSS), the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and others which had the number of participants of 129 (41 %), 33 (10.5 %), 41(13.0 %) and 9 (2.9 %), respectively.

Of the total of 315 participants included for data analysis, 229 (72.7 %) participants had used dental healthcare services the past 12 months while 86 (27.3 %) of the participants did not. The utilization of dental healthcare services is indicated per each variable as shown in Table 1. Chi-square analysis was used to detect significant correlation between each variable to the utilization of dental healthcare services. Analysis showed that age, gender, occupation, education, income, and awareness of dental coverage and reported type of dental coverage were all significantly correlated to dental healthcare service utilization (p-value <0.05). The degree of significance is indicated in Table 1.

Attitude towards oral healthcare schemes is collected under 4 categories which indicates whether the healthcare schemes ‘lowers financial burden’, ‘improves treatment accessibility’, ‘motivates visits before symptoms’ and ‘decreases social inequality’ by dividing subjects further into 2 groups: ‘favorable’ or ‘unfavorable’ toward each category. Chi-square analysis was used to analyze significant correlation between attitude and utilization of dental healthcare services. Univariate analysis shows that all attitudes significantly correlate to the utilization of dental service, detailed in Table 2. When analyzed multivariate, however, only the attitude that suggests ‘healthcare coverage motivates visits before symptoms’ is significantly correlated to the utilization of dental service as shown in Table 3.Table 3 Multivariate analysis (n = 299) showing Adjusted odds ratio (AOR), 95 % Confidence Interval, and P-value for independent variables that significantly affect dental service utilization.

Table 3Variable	Adjusted odds ratio	95%CI	P-value	
Gender	
Male	Reference	Reference	Reference	
Female	2.29	1.27–4.12	0.006	
Age	
15–22	Reference	Reference	Reference	
23–35	3.21	0.93–11.06	0.065	
36–60	6.05	1.76–20.81	0.004	
>60	2.73	0.57–13.14	0.209	
Career	
Self-employed	Reference	Reference	Reference	
Unemployed	0.19	0.06–0.62	0.006	
Private company employee	0.53	0.15–1.80	0.308	
Government employee	0.19	0.05–0.79	0.022	
Retired	0.46	0.08–2.54	0.37	
Att3. Dental coverage motivates visits before symptoms	
Unfavorable (1,2,3)	Reference	Reference	Reference	
Favorable (4,5)	4.37	2.15–8.90	<0.001	
Income (Baht/month)	
<15,0000	Reference	Reference	Reference	
15,001–30,000	2.40	1.12–5.14	0.025	
>30,000	4.50	1.93–10.45	<0.001	

Independent variables were analyzed further to determine its value in predicting utilization rate in multivariate analysis. Every variable with significant p-value (p < 0.05) was entered into a multivariate logistic regression to eliminate confounding factors. Stepwise regression method revealed that gender, age, career, and income were significant, as stated in Table 3 while awareness and awareness type were no longer significant in predicting utilization rate.

Results showed that females, when compared to males, were more likely to utilize dental care service by 2.29 times The age group that was most likely to utilize dental care service when compared to age group 15–22 years old group was the 36–60 years old group, followed by 23–35 years old group. For career, each career was compared to the self-employed group. The unemployed group and the private company employee group showed a significant difference in the likelihood of utilization when compared to the self-employed group. The unemployed was 4.15 times more likely to utilize dental care service whereas the private company employee group was 2.37 times more likely. For income, the reference group was income <15,000THB per month. The income >30,000THB per month group were 4.50 times more likely to utilize dental care service with significance.

In terms of attitude towards dental coverage, those in favor with the statement that ‘dental coverage motivates visits before symptoms’ were more likely to visit the dentist than those with unfavorable opinion by 4.37 times.

3 Discussion

Results of this study showed that sociodemographic status contributes significantly to the rate of dental service utilization. Such sociodemographic status includes gender, age, education, income and career. Female participants were more likely to utilize dental care services than male participants according to the results, corresponding with many studies reported in Indonesia [11], Hongkong [5] and Thailand [4]. This may be due to the fact that females are more conscious about their esthetics and health and some may not be in full-time employment due to family reasons, and thus more motivated to receive dental care [5,12].

Working age (between 36 and 60 years old) appears to have the highest utilization rate which is in line with the study conducted by Jaichuen (2016), indicating that more than half of the working-age subjects utilized their healthcare coverage for dental treatment. However, CSMBS has the highest rate of utilization among the working-age group in the study mentioned, unlike our study where SSS has the highest rate [13].

Education, professions, and financial status also significantly correlate to the rate of dental service utilization. Higher levels of education can indicate that the individual has a higher level of health literacy which corresponds to the study conducted among Iranians and Thais where utilization level is related to the level of education [4,9]. Moreover, the result shows that the unemployed group had the higher rate of dental service utilization than private company employees who have the health coverage benefit provided by the SSS annually. This contradicts with Jaicheun who states that enterprise employees and government employees have the highest rate of dental service utilization while business owners, household business owners and private employees have the lowest [13].

In addition, the result shows that the higher one's income, the more likely for one to utilize dental care where individuals with income higher than 30,000 baht per month were 4 times more likely to utilize dental care service. Dental treatments are well known for its high cost and can lead to the lower rate of dental care utilization among less fortunate individuals even when necessary. This is in line with various studies which revealed that dental care utilization was more concentrated among socioeconomically advantaged participants [[9], [11], [12]]. Furthermore, the Canadian Dental Association (2007) showed that financial factors were particularly important determinants of the decision to receive any dental care. The result of this paper showed that as the income of households increases, the frequency of dental visits also increases [10].

The attitude that is significantly correlated to the utilization of dental service among the participants is the one that suggests that healthcare coverage motivates them to seek dental care before any dental symptoms arise. This indicates that healthcare coverage promotes a positive attitude toward preventive measures against oral diseases. Overall positive attitude towards oral healthcare also found in many studies [7] and results in higher frequency in dental check-ups [14,9,10]. However, a study conducted by Grytten (1996) also found no effect in dental care demand due to the subsidy scheme provided by the government [15].

It is worth mentioning that subjects who were aware of their healthcare coverage had a higher rate of dental service utilization compared to those who were unaware (77.45 % and 63.96 %, respectively). The results of this study corresponded to the results of a study conducted by So and Schwarz which indicates that the level of utilization is higher for those who are aware when compared with those who are unaware of their oral healthcare coverage [5]. Similarly, Maniyar and Umashankar indicated that the insured group are aware of their coverage and have 4 times more dental service utilization than non-insured ones [6]. It must be noted that the studies mentioned above did not analyze their results with multivariate analysis, so it may be difficult to extrapolate the degree of influence that awareness of coverage has upon the rate of utilization when compared to other variables. When our study weighed the influence of dental coverage awareness with other sociodemographic factors on utilization of dental care, it resulted with the insignificance of dental coverage awareness when compared to factors like age, gender, income, occupation, and education.

3.1 Limitation

A limitation of this study is the low number of participants, which may make it hard for the results of this study to be used to generalize to the whole Thai population. Furthermore, convenient sampling was used in only certain locations in Bangkok, which may skew the results, rendering it applicable to only certain groups of individuals. Some of the venues that we handed out questionnaires in were heavily healthcare centered locations such as hospital waiting areas and its surrounding. The individuals in these areas may already have higher rates of healthcare service utilization as well as dental care utilization.

Due to our inclusion criteria, there were participants that were not of working age and thus some parameters may not apply such as income (in terms of income for their career). When analyzing the data, such participants that answered that their career were being students would be included into the unemployed group. Since unemployment usually refers to the lack of income, this makes those in the unemployed group not truly unemployed as it includes groups such as housewives and students, which may depend on others for their financial needs, which makes dental care accessible, even more than those who have an official job.

Issues also arise from the structure and content of the questionnaire. There may be misunderstandings when a participant was asked whether they knew they had dental coverage or not, and what type of the coverage they had. Participants who were unaware that they had dental coverage were aware of their existing health coverage, which are essentially the same schemes that cover dental care services, and were able to answer later which dental coverage they had since they have the same name as the health coverage. Furthermore, we did not correlate the use of the coverage for receiving dental care service, as we only wanted to know whether the awareness of coverage was enough to motivate utilization of dental care in general.

4 Conclusion

In conclusion, sociodemographic factors that significantly affect dental care service utilization included age, gender, occupation, education and income. When weighted with other socioeconomic determinants of dental care utilization, awareness of dental coverage schemes did not have a significant prediction value. However, when on its own, awareness of dental coverage did seem to help indicate better understanding of the importance of regular dental visits. Similar to multiple studies on the determinants of dental care utilization, this study demonstrated that age, gender, occupation, education, and income were major contributions to regular dental care service utilization.

Policy Recommendations form the result of multivariate analysis, an individual's income was suggested to play a role in dental service utilization. The Universal Health Coverage scheme establishment not only aims to make dental care more accessible to all, but it also helps to lessen the financial burden for those who needs the care as well. Due to this purpose of the oral healthcare coverages, it is recommended that there should be more promotions and education about the use of oral healthcare coverage to low-income communities to reach unmet health needs due to lacking finances.

Data availability

Data will be made available on request.

Statement of contribution

Despite having three major healthcare coverages provided for Thai citizens, the rate of dental service utilization is relatively low. This study aims to investigate whether awareness about dental coverage affects the rate of dental care utilization and the attitude towards dental coverage compared across coverage types.

CRediT authorship contribution statement

N. Luksamijarulkul: Writing – review & editing, Supervision, Project administration, Methodology, Data curation, Conceptualization. C. Tantipoj: Formal analysis. S. Amornsuradech: Project administration, Methodology, Data curation. N. Suepakdee: Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. P. Boonsajjaritthikul: Writing – original draft, Project administration, Methodology, Formal analysis, Data curation. O. Tuptim: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following is the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e35740.
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