key: cord-0057496-qgx37fwk
authors: Hajek, André; Kretzler, Benedikt; König, Hans-Helmut
title: Factors Associated with Dental Service Use Based on the Andersen Model: A Systematic Review
date: 2021-03-03
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph18052491
sha: ab753ed4e85dae51843e58191b15d02fd9744d84
doc_id: 57496
cord_uid: qgx37fwk

Background: A systematic review synthesizing studies examining the determinants of dental service use drawing on the (extended) Andersen model is lacking. Hence, our purpose was to fill this knowledge gap; Methods: Three established electronic databases (PubMed, PsycInfo, as well as CINAHL) were searched. Observational studies focusing on the determinants of dental service use drawing on the Andersen model were included; Results: In sum, 41 studies have been included (ten studies investigating children/adolescents and 31 studies investigating adults). Among children, particularly higher age (predisposing characteristic), higher income (enabling resource) and more oral health problems (need factor) were associated with increased dental service use. Among adults, findings are, in general, less consistent. However, it should be noted that one half of the studies found an association between increased education (predisposing characteristic) and increased dental service. In general, study quality was rather high. However, it should be noted that most studies did not report how they dealt with missing data; Conclusions: Our systematic review revealed that all components (i.e., predisposing characteristics, enabling resources and need factors) of the Andersen model tend to be associated with dental service use among children, whereas the findings are more mixed among adults. In conclusion, beyond need factors, dental service use also tend to be driven by other factors. This may indicate over—or, more likely—underuse of dental services and could enrich the inequality discussion in dental services research.

Besides hospitalization and outpatient physician visits, dental visits are an important component of health care use. An increased dental service use (all types of dental services) reflects an increased economic burden. Moreover, it has been shown that frequent use of dental services is associated with negative emotions [1] and potential overtreatment [2] . However, postponing dental visits can also have deleterious oral health [3] and well-being effects [4, 5] . Therefore, knowledge about the factors associated with dental service use is important. Ultimately, this knowledge may be beneficial in managing dental service use and may help to avoid under-, over-or misuse of dental services.

Drawing on the well-known Andersen model [6] , various studies have examined the determinants of hospitalization or doctor visits [7, 8] . It is an important "behavioral model of health service use". Commonly, it differentiates between predisposing characteristics like sex or age, enabling resources like perceived access to health care use or disposable income, and need factors such as chronic diseases or self-rated health.

In further detail, individual predisposing characteristics cover social factors like education or social ties or "biological factors" like sex or age. Additionally, contextual predisposing factors cover, for example, cultural norms.

Enabling resources cover financial and organizational factors which could affect use of health services. Individual financing factors cover income and wealth (e.g., to pay for health services or out-of-pocket payments). Organizational factors include, among other things, waiting time for health care, transportation or travel time. Furthermore, contextual factors cover, e.g., hospital and physician density.

It can be differentiated between individual perceived need (like subjective health) and evaluated need (like illnesses diagnosed by a physician). Contextual need factors include environmental need characteristics like traffic and population health indices like indicators of disability.

Psychosocial factors like loneliness or personality-related factors are included in the extended Andersen model [8] . Various studies have shown that particularly need factors are associated with general health care use [9] .

To date, several studies [10] [11] [12] exist analyzing the factors associated with dental service use based on the Andersen model [6] mainly showing that predisposing characteristics, enabling resources (depending on the healthcare system) and need factors (such as oral health-related quality of life [13, 14] ) can determine dental service use.

Since it is often the aim of health care systems to provide equitable access to dental services, decreasing the influence of predisposing and particularly enabling resources is a key objective. To date, a systematic review is lacking synthesizing the existing evidence on the determinants of dental service use drawing on the Andersen model. Therefore, the purpose of the current systematic review is to address this gap in knowledge. In sum, this knowledge may assist in managing dental service use. In turn, this knowledge may help to increase oral health related quality of life [15] . Additionally, this systematic review may identify potential gaps in knowledge and may therefore guide and inspire future research in this area.

The methods of this review are in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [16] . It should be noted that our work was registered to the International Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42020193094). Additionally, a systematic review protocol has been published [12] .

In September 2020, a systematic literature search (PubMed, PsycINFO, CINAHL) was conducted. The search query for PubMed is described in Table 1 . Two reviewers (AH and BK) independently evaluated studies for inclusion. First, a title/abstract screening was conducted and second, a full-text screening was performed. Additionally, a manual hand search was conducted based on the references of the identified articles and also using forwards citation tracking.

If disagreements occurred, discussions were used to resolve them. This procedure was also applied if disagreements occurred in data extraction and evaluating the study quality.

For this systematic review, inclusion criteria were as follows: (1) observational studies examining the determinants of dental service use, (2) studies explicitly drawing on the Andersen model, (3) measurement of important variables with appropriate tools (e.g., using adequate tools to quantify dental service use), (4) studies in German or English language, published in a peer-reviewed journal. Studies were excluded when: (1) studies did not examine the determinants of dental service use, (2) studies did not use the Andersen model as theoretical foundation, (3) studies solely using disease-specific samples (such as individuals with cognitive disorders), (4) studies other than observational, (5) inappropriate measurement of key variables (e.g., unclear period for dental service use), (6) studies not published in English or German language or not published in a peer-reviewed scientific journal. There were no restrictions regarding location, demographic factors or time. A pretest was conducted prior to final eligibility criteria (sample of 100 titles/abstracts). However, the eligibility criteria did not change. The asterisk (*) is a truncation symbol. The number sign (#) refers to the search order.

One reviewer (BK) conducted the data extraction. The data extraction was crosschecked by the second reviewer (AH). If clarification was required, the study authors were contacted. The data extraction covered study design, explanatory variables (drawing on the components of the Andersen model), assessment of dental service use, characteristics of the sample, statistical approach and main findings.

To date, no consensus exists on a tool to assess the quality of health care use (HCU) studies [17] . Hence, in this current work we used a HCU tool originally developed by Stuhldreher et al. [18] and refined by Hohls et al. [19] . Additional details are provided by Hajek et al. [20] . It was also used in previous research (e.g., [17, 19] ). The quality assessment was performed by two reviewers (AH, BK).

The process of study selection is shown in Figure 1 (flow chart [21] ). In sum, n = 41 studies were included in our final synthesis (ten studies investigating children/adolescents [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] and 31 studies investigating adults ). We will present an overview of included studies by age group (children/adolescents; adults) in the next two sections. 

An overview of the studies and key findings among children/adolescents is shown in Table 2 . Results of adjusted regressions are presented in Table 2 . Studies were published between the years 2007 and 2020. Data came from South America (n = 4 studies, with: Brazil, n = 3; Peru, n = 1), North America (n = 3 studies, with: United States, n = 2; Canada, n = 1), and Asia (n = 3, with: China, n = 2; Saudi Arabia, n = 1). Nine out of the ten studies had a cross-sectional design, and one study had a longitudinal design [30] .

The period of dental service use ranged from six months [23, 29] to ever visiting a dentist in one's lifetime (in Saudi Arabia [22] and Brazil [24, 25] ). While all studies examined predisposing characteristics, nine out of the ten studies examined enabling resources [22] [23] [24] [25] [26] [27] [28] [29] [30] , eight out of the ten studies examined need factors [22, [24] [25] [26] [27] [28] 30, 31] and one study examined psychosocial factors [30] . The studies included covered all age groups in childhood/adolescence.

The sample size ranged from n = 350 individuals [24] to n = 71,614 individuals [23] , all age groups in childhood and adolescence were covered and the proportion of female children/adolescents ranged from 41% to 58%. Most studies used data from large survey studies. More details are shown in Table 2 . was positively and caregiver's educational level (higher: OR: 1.6, 95% CI: 1.5-1.8) was also positively related to dental services use. The area of residence and the caregiver's language were no significant predictors. Overweight was associated with decreased odds of dental attendance (OR: 0.7, 95% CI: 0.6-0.9). Income during the first wave (ß = 0.1, p < 0.001) and social involvement during the second wave (ß = 0.1, p < 0.001) were linked to increased chances of dental attendance.

A better self-rated health (e.g. good: ß = -0.5, p < 0.01) and disability (ß = 0.2, p < 0.01) during the first wave were associated with decreased chances of dental attendance. Overall health status was not significant. 

An overview of the studies and key findings among adults is shown in Table 3 . These studies were published between the years 1981 and 2020. Data came from Europe (n = 4 studies; Germany, n = 2; Sweden, n = 1; Finland, n = 1), South America (n = 6 studies, all studies were from Brazil), North America (n = 13 studies; United States, n = 12; Canada, n = 1), Asia (n = 6 studies; China, n = 2; South Korea, n = 1; Thailand, n = 1; Israel, n = 1; Sri Lanka, n = 1), Africa (n = 2 studies; Burkina Faso, n = 1; Sudan, n = 1). Three [32, 39, 48] out of the 31 studies had a longitudinal design, whereas the other 28 studies had a cross-sectional design [33] [34] [35] [36] [37] [38] [40] [41] [42] [43] [44] [45] [46] [47] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] .

The period of dental service use ranged from one year [33] [34] [35] [36] [37] [40] [41] [42] 44, 48, 50, 55, [57] [58] [59] [60] [61] to ever visiting a dentist in one's lifetime (in Brazil [53] ). All studies investigated predisposing characteristics, 30 out of the 31 studies examined enabling resources (except for [38] ), and 29 studies examined need factors (except for [35, 47] ). Across the studies, the sample size ranged from 210 individuals [38] to n = 60,202 individuals [42] , the average age ranged from 28 [54] to 78 years [59] , and the proportion of women ranged from 0% [57] to 72% [45] -with most studies having a proportion of women from 40% to 70%. While several studies used data from large survey studies, a few studies used rather specific samples (e.g., employees of public sector institutions in Kandy, Sri Lanka [38] or University employees in the United States [54] ). Further details are shown in Table 3 .

The key findings of our review are displayed in Table 4 (children) and Table 5 (adults) (for further details, please see Tables S1 and S2). The displayed determinants stratified by the component of the Andersen model (i.e., predisposing characteristics; enabling resources; need factors; psychosocial factors) displayed in Tables 4 and 5 were selected since they were investigated in at least half of the studies. However, it should be noted that none of the need factors met this criterion among adults (i.e., investigated Table 5 ). More precisely, none of the need factors was examined among adults in at least half of the studies. Therefore, we displayed the need factor which was examined most frequently in Table 5 (in ten studies out of 29 studies). Having a regular source of dental care was related to higher chances of having had a dental visit (OR: 4.8, 95% CI: 2.5-9.4). Acculturation, education, income, household size and dental insurance status were not significant.

Self-reported symptoms were associated with decreased odds of dental attendance (OR: 0.9, 95% CI: 0.8-0.9). Untreated decay, gum bleeding on probing and subjective need remained insignificant. One's beliefs (b = -0.1, ß < 0.05), one's income (b = 0.1, ß < 0.05) and one's information (b = -0.0, ß < 0.05) were significantly associated with dental attendance.

The number of teeth (b = -0.0, ß < 0.01), one's perceived need (b = -0.3, ß < 0.01) and wearing a denture (b = 0.2, ß < 0.05) were associated with increased or decreased odds of dental attendance.

Lee (2020) Regarding logistic regression, sex (ß = 1.0, p < 0.01) was associated with an increased likelihood of having made a dental visit.

Having a dentist as health counselor was associated with dental attendance (ß = 1.5, p < 0.01). Being a regular user and toothbrushing remained insignificant.

Need for fillings (ß = 0.9, p < 0.05), the number of filled (ß = 0.1, p < 0.01) teeth were associated with different odds of dental attendance. The number of decayed teeth was not significant.

McKernan (2018) A good oral health condition was associated with increased odds of dental visits (OR: 3.9, 95% CI: 1.9-7.9). Need of treatment and oral health problems were not.

Silva (2013) Perceived need for care was related to decreased odds of dental attendance (OR: 0.6, 95% CI: 0.5-0.7). Self-rated oral health and wearing removable dentures were not. Ordinal logistic regression found out that higher age was associated with a lower number of dental visits (OR: 0.8, p < 0.01).

Dental hygiene practices (OR: 1.5, p < 0.001), higher education (OR: 1.2, p < 0.01) and the presence of a usual source of care (OR: 45.9, p < 0.001) were related to dental visits.

Perceived need for care (OR: 0.7, p < 0.05), the number of caries (OR: 0.9, p < 0.05) and the number of filled teeth (OR: 1.5, p < 0.001) was linked to dental attendance. Need factors 29

Oral health problems 10 6 0 4

Children/adolescents. In sum, n = 10 studies examined predisposing characteristics [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . Four [23, 25, 27, 31] out of the six studies which examined age found a positive association with dental service use, whereas two studies did not identify such a link [29, 30] . While two studies [22, 26] found a link between being female and increased dental service use, five studies did not find a significant association between gender and dental service use [23, [28] [29] [30] [31] . Other predisposing characteristics were only examined in a few studies.

Adults. In sum, n = 31 studies examined predisposing characteristics . With regard to age, five studies [35, 42, 43, 47, 59] showed a positive association between age and dental service use, whereas two studies showed a negative association [39, 50] . Moreover, 14 studies did not identify a significant association between these factors [33, 34, 36, 37, 40, 44, 46, 49, 54, 55, 57, 58, 60, 62] . With regard to gender, while eleven studies found an association between being female and increased dental service use [32, 33, 35, 38, 41, 43, 47, 51, 54, 58, 61] , four studies found the reverse association [42, [48] [49] [50] and seven studies did not find a significant association [34, 36, 37, 40, 44, 46, 55] . With regard to education, eight studies found a positive association between education and dental service use [33, 34, 39, 44, 47, 49, 53, 56] , whereas four studies found the reverse association [36, 37, 41, 42] and three studies did not find a significant link [46, 54, 55] . Other predisposing characteristics were only examined in a few studies. However, it should be noted that most of the studies did not find a significant link between marital status and dental service use [34, 36, 37, 40, 44, 49, 54, 55] . Moreover, there was mixed evidence with regard to the association between ethnicity and dental service use.

Children/adolescents. In sum, n = 9 studies examined enabling resources [22] [23] [24] [25] [26] [27] [28] [29] [30] . Higher family income was associated with increased dental service use in four studies [23, 27, 29, 30] , whereas one study did not identify a significant link between these factors [22] . Other enabling resources were only examined in a few studies.

Adults. In sum, n = 30 studies examined enabling resources. While eight studies found a positive association between income/wealth and dental service use [31, 34, 39, 45, 47, 57, 60, 62] , three studies found a negative association [42, 52, 53] and six studies did not identify such a significant association [36, 40, 43, 46, 50, 54] . Other enabling resources were only examined in a few studies. However, it should be noted that most of the studies found a positive association between social support and dental service use [35, 55, 57, 60] and between usual source of care (i.e., having a dentist an individual usually goes to for dental care) and dental service use [36, 37, 59, 60] .

Children/adolescents. In sum, n = 8 studies examined need factors [22, [24] [25] [26] [27] [28] 30, 31] . Oral health problems were consistently associated with increased dental service use in all respective studies [24, 25, 27, 28] . Other need factors were only examined in a few studies.

Adults. In sum, n = 29 studies examined need factors. Oral health problems were associated with increased dental service use in six studies [36] [37] [38] 44, 52, 60] , whereas four studies did not identify a significant association [37, 49, 50, 55] . Other need factors were only examined in a few studies. However, it should be noted that there was mixed evidence with regard to the association between several other need factors (e.g., missing teeth, general health status, health problems, oral pain, decayed teeth or need of treatment) and dental service use.

Children/adolescents. In sum, only one study explicitly examined the role of psychosocial factors in dental service use [30] . Vingilis et al. [30] showed that psychological distress was not significantly associated with at least one dental visit during the last two years (yes/no). Personality characteristics were not examined.

Adults. No studies exist examining the role of psychosocial factors in dental service use among adults. Personality characteristics were not investigated.

The quality assessment of included studies is shown in Table 6 . In total, 80% to 100% of the criteria were achieved by the studies. Unclear handling of missing data (50% fulfilled), performance of sensitivity analyses (86% fulfilled) and reporting COI/funding (81%) were the categories with the most unmet criteria. 

The aim of this systematic review was to provide an overview of observational studies examining the determinants of dental service use based on the Andersen model. Among children, particularly higher age (predisposing characteristic), higher income (enabling resource) and more oral health problems (need factor) were associated with increased dental service use. Among adults, findings are, in general, less consistent. However, it should be noted that one half of the studies found an association between increased education (predisposing characteristic) and increased dental service.

The determinants of dental service use (stratified by children and adults) will be shortly discussed in the next paragraphs.

It appears plausible that age (predisposing characteric) is positively associated with increased dental service use since the perceived need for dental service use may increase in later childhood. However, the link between age and dental service use should be further investigated since it can be affected by unobserved confounders. Furthermore, enabling resources such as income may be important for access to dental services in certain countries (e.g., United States). For example, there is a poor access to oral health services in Peru [23] . On a different level, similar challenges exist in the United States [29] . Furthermore, need factors such as oral health problems are important for dental service use. This appears very plausible and indicates that such a need for help entails visits to dentists. Thus, they can have checked their symptoms immediately by dentists. Since only one study examined a psychosocial factor, we refrained from discussing these preliminary results to avoid overinterpreting the data.

There was mainly mixed evidence with regard to the link between several predisposing characteristics (e.g., gender, age, marital status or ethnicity) and dental service use. In contrast, there is some evidence suggesting a link between higher education and increased dental service use. This may be explained by the fact that higher education is associated with higher health literacy [64] which in turn is associated with health promoting behavior [65, 66] . There was also mixed and inconclusive evidence with regard to the link between enabling resources and dental service use-even when we only compare the association between income and dental service solely within one country such as the United States [34, 37, 39, 40, 45, 54, 57] . However, it should be noted that social support was associated with increased dental service use. A possible explanation is that relatives or friends may urge the individuals to visit a dentist in case of need. Another explanation is that family members of friends may ease the access to dental services (e.g., transport)-a factor which may become particularly important in late life. Thus, the living situation (e.g., living alone or living with family members) may be of importance and should be further investigated. Unexpectedly, need factors such as oral health, missing teeth, general health status, health problems, oral pain, decayed teeth or need of treatment were not consistently associated with dental service use. One possible explanation is that other factors such as dental anxiety or dental fear [58] may particularly drive dental service use in adulthood. Other studies (not based on the Andersen model) already demonstrated the importance of dental anxiety for dental service use [67] .

The fact that determinants of dental service use seem to differ between children and adults may be partly explained by the fact that data from countries such as Brazil, Peru or the United States [23, 29, 30] were used in the studies investigating children. Enabling resources such as income may be of particular importance for dental service use in these countries where there is a poor access to dental services. More generally, it should be emphasized that some degree of the inconsistency in the results may be attributed to the fact that health care systems vary in the countries (e.g., publicly funded healthcare system vs. private healthcare systems).

Regarding comparability of studies, dental service use was often quantified as dental service use (last six months to ever visiting a dentist) and was based on self-reports. This may introduce some recall bias since recall periods up to twelve months have been recommended in previous research [68] .

Our systematic review also revealed that most studies were cross-sectional. Only a few longitudinal studies exist. Nevertheless, longitudinal studies are required to gain further insights into the factors leading to dental service use and to deliver consistent estimates [69] . Moreover, studies from very different regions of the world (with different access to dental services (e.g., between emerging and industrialized countries) and different regulations for copayments) were included in our review.

In total, the study quality between the studies only varied slightly. Furthermore, the quality of the studies was relatively high-which may be partly explained by the fact that about one half of the studies have been published since 2017. Some have in common that they did not conducted robustness checks (sensitivity analyses). Robustness checks, however, are required to show the validity and credibility of the results. These checks are also recommended by current guidelines [70] . Furthermore, approximately one half of the studies did not clarify the way missing data were treated. However, this can have various consequences (in terms of biased estimates or marked loss of statistical power [71] ). Techniques like full-information maximum likelihood [72] can lead to more reliable results and therefore could be applied in upcoming studies.

This systematic review identified several gaps in knowledge. First, longitudinal studies are required to clarify the determinants of dental service use. Second, studies based on nationally representative samples are needed. Third, psychosocial and personality-related factors should be further examined. Fourth, studies from African countries are required. Fifth, the determinants of preventive dental service use should be further explored. Sixth, the large majority of studies focused on patient-related characteristics. Thus, future studies are required drawing attention to the characteristics related to the dentist and the dentist office. Seventh, dental service use in times of the COVID-19 pandemic should be further explored [73] .

Some strengths and limitations regarding our current systematic review are worth noting. Our current work is the first systematic review regarding the determinants of dental service use drawing on the Andersen model. We conducted a quality assessment. Additionally, two reviewers performed important procedures (study selection, extracting the data and evaluation of study quality). While the restriction to include only peerreviewed article may assure a high quality of the studies included, this restriction may be accompanied by the exclusion of some existing research (e.g., grey literature). Moreover, due to the language restrictions (i.e., published in English or German language), some studies may not be determined. Moreover, a meta-analysis was not performed due to study heterogeneity. Furthermore, future research is required to specifically focus on gender differences in dental service use.

Our systematic review revealed that all components (i.e., predisposing characteristics such as age, enabling resources such as income and need factors such as oral health problems) of the Andersen model tend to be associated with dental service use among children, whereas the findings are more mixed among adults. In conclusion, beyond need factors, dental service use also tend to be driven by other factors. This may indicate overor, more likely-underuse of dental services and could enrich the inequality discussion in dental services research.

Supplementary Materials: The following are available online at https://www.mdpi.com/1660-460 1/18/5/2491/s1, Table S1 : Key findings (children/adolescents)-extended, Table S2 : Key findings (adults)-extended. 

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Funding: This research received no external funding.

Data Availability Statement: Not applicable.

The authors declare no conflict of interest.

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