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Journal of Public Health Advance Access published online on June 27, 2008
Journal of Public Health, doi:10.1093/pubmed/fdn047
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© The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Neighbourhood deprivation and dental service use: a cross-sectional analysis of older people in England


I. A. Lang, Trainee Specialist in Public Health and Honorary Research Fellow1,2
S. J. Gibbs, Consultant in Public Health2
N. Steel, Clinical Senior Lecturer3
D. Melzer, Professor of Epidemiology and Public Health1,2

1 Epidemiology and Public Health Group, Peninsula Medical School, Exeter EX2 5DW, UK
2 Public Health Directorate, Devon Primary Care Trust, Exeter EX1 1PQ, UK
3 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK


Address correspondence to Iain A. Lang, E-mail: iain.lang{at}pms.ac.uk

Background Appropriate dental care is an important part of maintaining good oral health. We examined the relationship between socioeconomic status, neighbourhood deprivation levels and older people's dental service use.

Methods We used logistic regression analysis to assess the relationship between self-reported dental service use and neighbourhood deprivation, adjusting for individual socioeconomic and health factors, in individuals aged 65+ in the 2005 Health Survey for England (n = 4240).

Results Among dentulous respondents, 69.9% reported attending for regular check-ups, 6.2% occasional check-ups, 18.4% only saw a dentist when in trouble and 5.6% never went to a dentist. In our adjusted model age, sex, region, education level, occupational social class, self-reported health and smoking status, but not degree of urbanization, were associated with use of dental services. Following adjustment for these other factors those living in the most deprived 20% of neighbourhoods, compared with those in the least deprived, had a relative risk ratio of 2.25 (95% confidence interval 1.59–3.17) of using dental services only when symptomatic, rather than going for regular or occasional check-ups. When alternative outcomes of reporting having recently seen a doctor or been a hospital inpatient were assessed these deprivation-related patterns in service use were not evident.

Conclusion Levels of neighbourhood deprivation are associated with the use of dental services by older people. Action is needed to ensure older people in deprived communities access appropriate and comprehensive dental services.

Keywords: dentistry, oral health, older people, health services, socioeconomic status


   Background
TOP
 Background
Methods
 Results
 Discussion
 Conclusion
 References
 
Oral health is an important public health issue that influences general health and quality of life1 and presents possibilities for effective intervention to prevent health problems developing.2 Oral-health-related quality of life varies with socioeconomic status1,3 and is associated with educational level,4,5 income4 and area deprivation,6–9 with the worst oral health found in those living in deprived households in deprived neighbourhoods.10 In older people, poor oral health often co-exists with other systemic diseases11 and affects nutrient intakes and nutritional status.12

An important part of maintaining good oral health is the use of appropriate dental services.1 Oral-health-related quality of life in adults is higher in those who regularly attend for dental check-ups than in those who attend only when symptomatic,13 and there are fewer discrepancies between self-reported oral and general health among those with good access to dental services.14 Availability of appropriate and comprehensive dental treatment is necessary to address clinical need and improve access to and use of comprehensive treatment in middle-aged and older adults.15,16 An additional reason why this is important is that oral cancers can be relatively easily detected at early stages17 and routine dental check-ups may be used for opportunistic screening for mucosal lesions,18,19 which are associated with earlier diagnosis of oral and oropharyngeal squamous cancer.20 The need to provide more and better oral health care for an ageing population was highlighted in a recent report by the World Health Organization.21

Like oral health, use of dental services tends to vary with socioeconomic status22 and equity of uptake of dental services is important if opportunistic screening for oral cancer in dental surgeries is to be effective and avoid the ‘inverse screening law’.23 There have been no recent nationally representative studies assessing patterns of use of dental services in England in relation to deprivation. Our aim in this paper was to assess whether self-reported use of dental services in community-dwelling older people in England varied in relation to the neighbourhood in which they lived as well as in relation to their own socioeconomic status.


   Methods
TOP
 Background
 Methods
Results
 Discussion
 Conclusion
 References
 
Subjects
Data for this study came from the Health Survey for England (HSE) 2005. The HSE is a national representative survey of individuals aged two and over who live in households in England. A new sample is drawn annually and respondents are interviewed about several core topics, including demographic and socio-economic indicators, general health and psychosocial indicators and use of health services. In 2005 the focus of the HSE was the health of people aged 65 or over and older people were oversampled.24 A total of 4240 adults aged 65 or over participated in the 2005 HSE and were asked about their use of dental services. (Data on this topic were not gathered for children and younger adults). Data from the HSE are available from the UK Economic and Social Data Service (www.esds.ac.uk).

Measures of neighbourhood deprivation
The Index of Multiple Deprivation (IMD) 2004 is based on distinct dimensions of deprivation measured separately at the small-area level. Seven components of deprivation are covered: income; employment; health and disability; education, skills and training; barriers to housing and services; living environment; and crime. Details of the theoretical and practical implementation of the IMD measure, including discussion of its reliability and validity, have been published.25

Using information from the 2001 Census, the UK Office for National Statistics calculated IMD scores at the super output area (SOA) level. SOAs, developed for use in small- area statistics and reporting, contain a minimum of 1000 individuals and a mean of ~1500. There are 34 378 SOAs in England.26 Because it is potentially disclosive, IMD information in the HSE is only available divided by quintiles and data on the seven separate dimensions are unavailable. In this study IMD divided by quintiles was used to represent the level of socioeconomic deprivation of the neighbourhoods in which respondents lived.

Measures of individual socioeconomic status
Information on education and social class came from individual and household responses and were independent of the IMD data. Education was assessed according to the age the respondent reported having completed full-time schooling, as asked in the HSE questionnaire, and was categorized as having left school at age ‘14 or younger’ and then by age in years up to ‘19 or over’. The occupational class of the household reference person (head of household) was categorized as: professional, managerial-technical, skilled non-manual, skilled manual, semi-skilled manual and unskilled/other.

Outcome variables
In relation to oral health and use of dental services, respondents were first asked whether they still had some of their own teeth or had lost them all. Those who had some of their own teeth were asked, ‘in general, do you go to the dentist for a regular check-up or only when you are having trouble with your teeth?’ Possible answers were ‘regular check-up’, ‘occasional check-up’, ‘only when having trouble’ and ‘never go to the dentist’. We recoded responses into two categories, asymptomatic visiting (regular or occasional check-ups) and symptomatic visiting (only when having trouble or never attending).

Statistical analysis
We used logistic regression to estimate the effects of neighbourhood deprivation level, with and without adjustment for individual socio-economic status, on use of dental services. Calibration weighting to reduce non-response bias was used24 and analyses were conducted using Stata SE Version 9.2 (StataCorp PL, College Station, TX). In addition to the individual- and household-level socioeconomic factors described above, we adjusted for the following factors known to be related to oral health and neighbourhood deprivation: age; sex; geographical region (English Strategic Health Authority); degree of urbanization (urban, town and fringe, village and rural); self-rated health (very good, good, fair, bad/very bad); smoking (regular smoker; former regular smoker; never a regular smoker).


   Results
TOP
 Background
 Methods
 Results
Discussion
 Conclusion
 References
 
Of the 4240 respondents, 1294 (30.5%) were edentulous and were not included in our analysis of dental service use. In models adjusted for age and sex, compared with those living in the least deprived 20% of neighbourhoods those living in the most deprived 20% of neighbourhoods had a relative risk ratio (RRR) of having lost all their teeth of 3.95 [95% confidence interval (CI) 3.14–4.97]. Levels of dental service use in relation to the characteristics of respondents are shown in Table 1. Higher levels of dental service use were evident in those who were younger, in women, in those who lived in town or village rather than urban settings, in those who were better educated, in those of higher social class and in those who had never been regular smokers. In relation to region, the highest levels of use were in the East Midlands and South East Coast Health Authorities and the lowest level was in London.


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  		Table 1 Characteristics of respondents to the Health Survey for England 2005 aged 65+ in relation to dental health service use

 
Figure 1 shows the relationship between neighbourhood deprivation and symptomatic dental visiting, adjusted for age and sex. As level of neighbourhood deprivation rises so does the likelihood of symptomatic dental use (RRR for trend = 1.37, P for trend < 0.001). Compared with those living in the least deprived 20% of neighbourhoods, those living in the most deprived 20% of neighbourhoods had an RRR of only using dental services when symptomatic of 3.12 (95% CI 2.32–4.21).


Figure 1
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  		Fig. 1 Relative risk ratios of symptomatic dental service use in participants of the Health Survey for England 2005 aged 65+ in relation to neighbourhood deprivation by quintiles, adjusted for age and sex, showing 95% confidence intervals.

 
Table 2 shows the pattern of association between neighbourhood deprivation and use of dental services following adjustment for individual socioeconomic, demographic and health-related behaviours. In our adjusted model age, sex, region, education level, occupational social class, self-reported health and smoking status were all associated with the use of dental services but degree of urbanization was not. As level of neighbourhood deprivation rose so did the RRR of symptomatic dental service use (RRR for trend = 1.27, P < 0.001). In these adjusted models, compared with those living in the least deprived 20% of neighbourhoods, those living in the most deprived 20% of neighbourhoods had an RRR of using dental services only when symptomatic of 2.25 (95% CI 1.59–3.17).


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  		Table 2 Relative risk ratios of dental health service use in respondents to the Health Survey for England 2005 aged 65+ , adjusted model

 
For comparison we considered two other outcomes related to health service use: whether the respondent reported having been a hospital inpatient in the 12 months preceding the survey, and whether the respondent reported having spoken to a doctor, aside from as part of a hospital visit, in the 2 weeks preceding the survey. Using the same models as above, we found no statistically significant association between neighbourhood deprivation and service use. For having been an inpatient, the RRR for trend in relation to neighbourhood deprivation was 1.01 (P = 0.863) and the RRR of the most deprived 20% compared with the least was 1.02 (95% CI 0.73–1.43). For having spoken to a doctor, the RRR for trend was 0.98 (P = 0.586) and the RRR of the most deprived 20% compared with the least was 0.91 (95% 0.69–1.19).

We repeated our models including income as well as education and social class. Household income in the Health Survey for England was assessed using a show-card on which banded incomes were presented. Equivalized household incomes were calculated by adjusting household income according to the number of adults and dependent children living there. Because there was a high level (24.2%) of item non-response on the income question, we did not include this variable in our main analysis. When we reran our analysis including equivalized household income in older people divided by quintiles we found a statistically significant relationship between income and likelihood of using dental services but the relationship between neighbourhood deprivation and dental service use was largely unchanged. For example, after this adjustment the RRR for not attending regular check-ups for the most deprived 20% compared with the least deprived was 2.01 (95% CI 1.32–3.05).

We also looked at the effects of mental health on dental service use. In older people, neighbourhood deprivation is associated with depression27 and psychosocial status,28 and older people experiencing psychological distress are less likely to access preventive care, including dental care.29 We used two measures of mental health, the 10-item Geriatric Depression Scale (GDS-10)30 and the 12-item General Health Questionnaire (GHQ-12),31 which screen for non-psychotic psychiatric disorders. Scores on the GDS-10 were available for 2521 (87.0%) of the participants in our analyses; scores on the GHQ-12 were available for 2618 (90.2%) participants and because of this item non-response we did not include them in our full model. In our adjusted models we found respondents with a higher score on the GDS-10 were more likely to use dental services only symptomatically. There was no association between GHQ-12 score and dental service use. Neither measure altered the overall association between neighbourhood deprivation and dental service use: for example, in a model containing an expanded term for GDS-10 the RRR associated with living in the most deprived 20% of neighbourhoods had an RRR of using dental services only when symptomatic of 2.19 (95% CI 1.49–3.21). There were no statistically significant interactions between these mental health measures and deprivation. (Full results available from authors.)


   Discussion
TOP
 Background
 Methods
 Results
 Discussion
Conclusion
 References
 
Main findings
These results show older adults who live in deprived neighbourhoods are less likely to report using dental services and that this difference is independent of their individual socioeconomic circumstances. In relation to only using dental services when symptomatic, rather than going for regular or occasional check-ups, there was a marked difference between those who live in the most deprived 20% of neighbourhoods and those in the least deprived 20%.

What is known already
Our results are in line with studies that have found variations in use of dental services in relation to area deprivation in adults in North America22,32,33 and Australia34 and in children in regions of England.35,36 Differences such as those we observed in use of dental versus other health care services have been noted before: for example, Bangladeshi adults in a deprived area of London were found to attend general medical practices but not general dental practices.37 No recent nationally representative studies assessing the relationship between deprivation and dental service use in England have been conducted.

What this study adds
This is the first study to use nationally representative survey data on older adults to assess the effects of individual and neighbourhood deprivation on dental service use. The data used here pre-date the April 2006 reforms of the NHS dental system in England and can provide a benchmark as to whether these reforms are effective in improving uptake of dental services. There is a paucity of data about older people's dental service use that enables us to compare characteristics of those who do and who do not use services. The most recent decennial Adult Dental Health Survey was conducted in 1998 so the data are now 10 years out of date, and that survey contained information on only small numbers of older people.

We suggest three reasons why older people in deprived neighbourhoods are less likely to use dental services, relating to physical access, costs and shared attitudes to oral health. First, deprived communities are more likely to suffer from a shortage of dentists38 and face geographical or physical challenges that make dental services difficult or impossible to access. Our results show neighbourhood deprivation affects access to dental but not medical services, although the comparison is not straightforward because GP and hospital visiting are usually needs led rather than related to preventive health care. Determinants of oral health are similar to determinants of general health39 and linking dental surgeries to primary medical care services, which are more likely to be located in deprived neighbourhoods, might be an effective way of improving equity of access to dental services. In relation to access, action at the neighbourhood level may be easier to implement than initiatives focused on individual behaviour change. Comparison of dental service use with use of other forms of preventive health care services, such as screening, might be informative.

Second, while fee-for-service causes access problems for the less well-off,40 capitation systems may make deprived neighbourhoods unattractive settings for dentists. The Audit Commission has recommended ways of funding dental services to improve equity of access.41 NHS dental services are means tested so straightforward lack of material resources should, in principle, not limit service use and it is likely that social norms and attitudes are important in explaining attendance behaviour. Nonetheless, it is unclear why dental service use should differ from other forms of health service use—as indicated by our sensitivity analyses—in terms of access by people from different socioeconomic backgrounds.

Third, older adults living in deprived neighbourhoods may be less aware of the benefits and importance of good dental health care. Older people in deprived neighbourhoods tend to have lower levels of education, poorer cognitive function42 and poorer physical function.43 Neighbourhood attitudes, including the ways that people in deprived neighbourhoods collectively respond to disadvantage, shape individual behaviours and may lead to norms that have a detrimental effect on the health behaviours of residents of deprived neighbourhoods.44,45 Increased efforts to promote understanding of the benefits of good oral health, and encourage use of dental services, may be needed in deprived neighbourhoods.

Limitations of this study
Our study uses an objective measure of neighbourhood deprivation, the IMD, calculated based on national census data and intended to capture a broad range of factors relating to neighbourhood deprivation. SOAs do not represent natural or community-defined neighbourhoods but were constructed using census and other official sources of data with the express purpose of maximizing internal social homogeneity.26 Although these summary scores of the overall level of deprivation in neighbourhoods are important, information on specific locales would provide additional information.

In England, there is no central register of dental patients, so obtaining self-reports of dental service use from a population-representative study represents the best way of obtaining an overview of dental service usage. At the time this survey was conducted there were known to be acute access problems to NHS dental services in some parts of England. Efforts to improve access were subsequently made and it may be that the cross-sectional data used here represent a period effect. Nonetheless, longitudinal studies have found that low probability of visiting a dentist is stable over time23—those reporting not visiting a dentist regularly are likely to have had this pattern of dental service use for some time.

No data were available on the use of dental services by edentulous participants, who were not asked the relevant questions. It is important that more research is conducted into the dental service use of this group in order to improve knowledge about the benefits or harms associated with opportunistic screening for oral cancers.


   Conclusion
TOP
 Background
 Methods
 Results
 Discussion
 Conclusion
References
 
Neighbourhood deprivation and use of dental services are strongly associated in community-dwelling older people in England. This relationship is present even when individual socioeconomic differences are taken into account. Although the reasons for this association are uncertain and require further exploration, it is clear that older people in deprived neighbourhoods underutilize dental services compared with those in more affluent areas. Action is necessary to ensure those in deprived neighbourhoods, who are at greatest risk of suffering poor oral health, can access and do use these important healthcare services.


   References
TOP
 Background
 Methods
 Results
 Discussion
 Conclusion
 References
 

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