Inequalities in access and utilization of dental services: a cross-sectional study in an area covered by the Family Health Strategy Desigualdades no acesso e utilização de serviços odontológicos: estudo transversal em uma área atendida pela Estratégia Saúde da Família

This cross-sectional study aimed to investigate the presence of inequalities in the access and use of dental services for people living in the coverage area of the Family Health Strategy (FHS) in Ponta Grossa, Paraná State, Brazil, and to assess individual determinants related to them. The sample consisted of 747 individuals who answered a pre-tested questionnaire. Data analysis was performed by chi-square test and Poisson regression analysis, obtaining explanatory models for recent use and, by limiting the analysis to those who sought dental care, for effective access. Results showed that 41% of the sample had recent dental visits. The lowest visit rates were observed among preschoolers and elderly people. The subjects who most identified the FHS as a regular source of dental care were children. Besides age, better socioeconomic conditions and the presence of a regular source of dental care were positively associated to recent dental visits. We identified inequalities in use and access to dental care, reinforcing the need to promote incentives to improve access for underserved populations. Health Services Accessibility; Oral Health; Health Inequalities Introduction Oral diseases mostly affect disadvantaged people 1, who are less likely to receive dental care and more likely to have unmet needs than those in better social conditions 2,3,4. Inequalities in access to dental services have been identified in several countries, regardless of the nature, scope and efficiency of their health systems 3,5,6,7,8. The social gradient of oral health can also be observed when the deprived people are subject to health services not specifically prepared to deal with their actual needs 4. In Brazil, the most comprehensive information on access to dental services is provided by the health supplements of the National Household Sample Survey (PNAD) carried out in 1998 9, 2003 10 and 2008 11. The results of the PNAD 1998 showed that 18.7% of the Brazilian people had never consulted a dentist, and that this proportion was eight times higher for the lower-income group (39% versus 5%). Larger socioeconomic differentials were found among very young and old subjects 2,9. Subsequent information (PNAD 2003: 15.9%; PNAD 2008: 11.7%) recorded a declining trend for this group. Notwithstanding, inequalities in the access to dental services persisted, or even grew, as the proportion of those who have never consulted a dentist, among individuals with lower and higher incomes were, respectively, 31% and 3% in 2003 and 28.7% and 2% in 2008 10,11. Information related to the three PNAD ARTIGO ARTICLE ACCESS AND UTILIZATION OF DENTAL SERVICES S273 Cad. Saúde Pública, Rio de Janeiro, 27 Sup 2:S272-S283, 2011 surveys also revealed that the number of people who had recently visited a dentist (less than one year ago) were higher for the better income group (67.2% versus 28.5% in 2008) 10,11. Measuring access to health services is fundamental to instruct health policies. It allows forecasting the effective use of health services; it contributes to the promotion of social justice, and it contributes to improve the effectiveness and efficiency of health services 12. The concept of access to health services is complex and allows integrating the perception of health needs with the demand and effective use of services 13. This implies that people use health services at “proportional and appropriate” rates to their existing need for care 14. Andersen and Davidson 12 defined access as the actual use of health services and everything that facilitates or impedes their use. The concept is thus multidimensional, and encompasses both individual aspects and characteristics related to the organization of health services. “Potential access” to health services was defined as the resources that enable the use and increase the likelihood that it will take place; and the “realized access” represents the actual use of the services, which is influenced by other issues in addition to enabling factors, and reflect the perceived need of individuals and their societal determinants 12. Therefore, the use of health services is influenced by individual factors, by characteristics of the health system, the social context, and the past experience with using services 12,14. The possibility of inclusion, since the year 2000, of oral health services in the Family Health Strategy (FHS), added to the current programmatic guidance proposed by the recent National Oral Health Policy, aims to shift the traditional model of public dental services delivery, which had always been centered on emergency care or targeted to priority groups (school aged children), by extending the possibilities of access to oral health care to the entire population. Theoretically, this new organization should increase access and promote the regular use of dental services for the low-income population living in the FHS coverage areas, minimizing the unmet demand 15. In the last years, the provision and use of dental services in the FHS have been evaluated by some studies, which tried to assess its potential as an inclusive policy. At the aggregate level, Baldani et al. 16 identified redistributive trends in the allocation of financial resources and provision of public dental services among the municipalities of the Paraná State (Southern Brazil), which were positively associated with the presence of dental teams in the FHS. However, Souza & Roncalli 17 had observed, for some large municipalities of the Rio Grande do Norte State (Northeastern Brazil), that only those with better socioeconomic status had really experienced an increase in quality after the introduction of oral health services in the FHS. At the individual level, the few studies conducted so far have pointed to the persistence of inequalities in the access and use of dental services in the FHS, highlighting an unfavorable condition for populations with poor social conditions 18,19. Health care systems aim to maintain and improve health outcomes. This goal can only be achieved when instructed by adequate knowledge on how people use health services and what factors are associated with their use 8. The aim of this study is to investigate the presence of inequalities in the access and use of dental services for people (all ages) living in the coverage area of the FHS in Ponta Grossa, a city in the Paraná State. This study also aimed to assess individual determinants related to the access and use of dental services.