Assessment of Oral Health Care-Related Expenditure among People of Kerala: A Cross-Sectional Study.

Background: Oral health is an effective unit of general health. Dental caries and periodontal diseases are considered to be the major diseases present in modern times. Over the decades, the idea of maintaining effective oral health and interest in oral health prevention measures has diminished; thus increasing the cost of health care. Aims and
Objectives: This study aims to estimate the household expenditure on oral health care among people residing in Kerala, India. Materials and
Methods: Five hundred participants were surveyed who were residents of Kerala. A self-administered questionnaire that was tested and validated was used to assess the cost of oral health care. Data collected were analyzed using software for IBM SPSS version 23 for Windows (New York, USA).
Results: Of 500 people, 37% are men and 63% are women. 100% of people reported using a toothbrush as an oral hygiene aid. 65% of households reported changing toothbrush for 3 months or more, while 35% of families changed for 1 month or less. Significant statistically weak correlation was observed when education, employment, and income were compared to the annual expenditure on dental care. Furthermore, there has been a moderately strong correlation observed between the socio-economic status of families and the annual cost of dental care.
Conclusion: People should be aware of preventive oral hygiene aids, and appropriate policies should be formulated which will ultimately result in decreased expenditure on a curative aspect of the dental disease. Copyright:

INTRODUCTION

Oral health is a mirror of general health. Oral health problems not only cause catastrophic effects on public health budgets but also bring great financial burden and out-of-pocket (OOP) expenditure for those suffering.[123] Over decades, health in India has gained less attention, and particularly, oral health is the least. Majority of oral health problems result due to unhealthy environments and behaviors. Health is given less importance, with oral health coming in end. Lack of attention toward these dental diseases expresses itself in the form of a financial burden on the family, which is mainly dealt with OOP expenditure.[45] Hence, it is essential to know general expenditure on oral hygiene maintenance and sudden catastrophic expenditure related to oral disease particularly in Kerala state where no such studies had been conducted before. Hence, this present household study was undertaken to estimate oral healthcare-related expenditure among people residing in Kerala.

METHODOLOGY

This household cross-sectional questionnaire study included a total of 500 households. Only individuals who managed the household expenditure, i.e., head of family were interviewed. Inclusion criteria for survey participants were individuals who manage the household expenditure, i.e., family head/wife/mother and those who provided consent to participate. A self-designed 23-item structured questionnaire was specially designed in both Malayalam and English and pretested to suitably adapt to gather relevant information according to the objectives of the study. Data collected were categorized and tabulated into Microsoft 2013 excel sheet and were subjected to statistical analysis using IBM SPSS software versions 23 for windows (New York, USA), and frequency and mean, and percentage were calculated for expenditure on oral hygiene measures and dental treatment. The correlation was assessed using Pearson's correlation between education, occupation, income, socioeconomic status, and expenditure on dental care.

RESULTS

Out of 500 participants surveyed, 37% were male and 63% were female the majority (100%) reported to be using the toothbrush as an oral hygiene aid. Majority (65%) of the families reported changing of toothbrush at 3 months or more duration; however, 35% of the families admitted their toothbrush lasting for 1 month only. About 99% reported of using toothpaste/toothpowder and only 0.3% denied of using any kind of dentifrice. Tongue cleaning was practiced by 85% of individuals while 15% reported of not having the habit of tongue cleaning. The use of medicated mouthwash by the family was reported by 35%, while 65% family heads reported of not using any medicated mouthwash regularly. The use of toothpick or floss was not a regular practice. Only 12% out of 500 individuals reported of use of toothpick or floss as oral hygiene aids. The majority of the individuals reported visiting dentist only in need of any treatment, and only 18% reported having the habit of regular visits to the dentist. On asking about whether they or their family had encountered any dental problems in the last 1 year, 39% reported problem of pain, 51% reported of encountering bleeding gums, while 10% reported of suffering from halitosis. Self-medication was the treatment of choice in case of majority 60% for any dental problem, while 35% visited dentist and 5% reported of visiting to the physician. This study mainly focused on economic evaluation of expenditure on oral hygiene measures and dental care. On an average, each family spent about 51–450 international normalized ratio (INR) yearly on the purchase of toothbrushes. The annual expenditure on wooden toothpick ranged from 10 INR monthly to 120 INR yearly. Toothpaste and toothpowder being the majority type of dentifrices as a preventive oral hygiene measure for dental disease coasted on average 1200 INR annually. The habit of tongue cleaning, mouthwash, and toothpick/floss costed around 88 INR,260 INR, and 75 INR respectively for each family. Interviewed people spent around 2500 INR for the dental problem encountered last year as shown in Table 1, but when asked for the budget they kept for sudden dental emergency, only 1% of them reported of having a budget for the same with an average of 1000 INR as an emergency budget. On assessing the relationship between annual expenditure on dental care with education, occupation, income, and socioeconomic status of the families, a statistically significant weak correlation was observed when education, occupation, and income were compared with annual expenditure on dental care (r = 0.209, 0.217, and 0.360, respectively). While a moderately strong correlation was observed between the socioeconomic status of families and annual expenditure on dental care (r = 0.439) as shown in Table 2.

Table 1

Expenditure of participants on dental care

Question	Duration	Expenditure (INR), mean±SD
How much do you spend on toothbrush for you and your family per year?	Per month	51.67±37.68
	Per year	450.08±120.01
If you use wooden twig, then how much do you spend on it per year?	Per month	10±12.27
	Per year	120.08±21.67
How much do you spend on tooth paste/toothpowder for you and your family?	Per month	101.87±51.39
	Per year	1200.55±411.27
How much do you spend on tongue cleaner?	Per month	10.69±8.26
	Per year	88.10±108.89
How much do you spend on mouthwash for you and your family member?	Per month	32.42±22.76
	Per year	240.46±136.82
How much do you spend on toothpick/floss?	Per month	8.93±31.82
	Per year	88.26±42.61
How much did you spend on the treatment of dental problem for you and your family since the last 1 year?	Per year	2500.28±4868.01
How much budget do you keep for sudden dental emergency expenditure?	Per year	1000.32±459.32
Can you recall average annual expenditure on dental care (oral hygiene aids+dental treatment) for the last 1 year?	Per year	4120.16±5140.31

SD: Standard deviation, INR: Indian rupees

Table 2

Socioeconomic status of participants and expenditure on dental care

Expenditure on dental care	Education	Occupation	Income	Socioeconomic status
r	0.209	0.217	0.360	0.439
P	<0.001*	<0.001*	<0.001*	<0.001*

Highly statistically significant. r: Pearson’s correlation coefficient. *: P<0.05

DISCUSSION

Oral diseases such as periodontal diseases and dental caries are multifactorial; despite great improvements in the global oral health status, gingival and periodontal diseases still remain the major public oral health problems. Healthcare expenditure in developing and low-income nations relies primarily on OOP expenditure.[123456] OOP expenditure on oral care is any direct spending by households, including payment done on preventive measures for oral diseases and treatment of already existing oral health problems.[567891011] Analysis of expenditure of households on oral care has shown varying results. The analysis of expenditures, in general, has been a subject of supreme interest and discussion in recent times globally. Due to negligence for oral health, households in Kerala city were not able to allocate budget for emergency dental care. People gave less importance to regular checkup which adds to their negligence and restrict their oral healthcare mindset for the purchase on toothbrush and toothpaste and visiting the dentist only for dental pain. Our study found a positive correlation between income and expenditure, i.e., with the increase in income range, the expenditure on the dental health care increased; similar finding were reported by Barros and Bertoldi.[9] Thereby indicating that cost of dental care can act as a significant barrier to oral health. Findings of our study reports that most of the people show lack of preparedness toward sudden dental emergencies in terms of budget for sudden dental problems results in undue burden on family budget which is compensated by means of coping strategies such as saving, selling assets, and borrowing which ultimately affects household welfare in long term. Similar findings were reported by a survey conducted by Quintussi et al.[7] Our study revealed a weak positive correlation when education, occupation, and income were compared with annual expenditure on dental care and a moderately strong positive correlation when socioeconomic status of families was compared with annual expenditure on dental care, hence increase socioeconomic status with increased educational level increase awareness and concern toward oral health which is seen in the form of increased expenditure on dental health care.[678910] The findings of our study are consistent with the finding of a survey conducted by Bhushan et al.[10] The study highlights the OOP expenditure on oral health care of families residing in Kerala. To reduce OOP expenditure, there should be countrywide dental insurance coverage scheme that would focus on preventive measure. By implementation of such scheme, there will be integration of private and government sector, which will help in listing out probable barrier in utilization of oral healthcare services.

CONCLUSION

Thus, our research concludes that people should be made more aware of preventive oral hygiene aids that will ultimately lead to lower costs for dental treatment. Newer governmental policies should be formulated with special attention to tackle the rising burden of oral disease and increasing awareness regarding various preventive measures and oral hygiene aids, which will help in proper utilization and equity of oral hygiene practices among masses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.