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ACCESS AND UTILIZATION OF ROUTINE DENTAL SERVICES AMONG DIFFERENT SOCIO-ECONOMIC GROUPS IN ENUGU STATE, SOUTH EAST NIGERIA

DR. UGURU NKOLIKA P

REG NO: PG/MSc/08/53600

DEPARTMENT OF HEALTH ADMINISTRATION AND MANAGEMENT

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

UNIVERSITY OF NIGERIA ENUGU CAMPUS

JANUARY 2014

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CERTIFICATION

This is to certify that this research work titled: Access to and Utilization of Routine Dental

Services among different socio-economic groups in Enugu State, Southeast Nigeria was

conducted by Uguru Nkolika P. with registration number PG/08/Msc/53600 and presented to

the department of Health Administration and Management, faculty of health sciences and

technology University of Nigeria, Enugu campus in partial fulfilment of the requirement for the

award of Msc in Health Economics, Management and Policy.

………………………….. ……………………………………………. Prof. Uzochukwu BSC Date (Supervisor)

…………………………………. …………………………………………… Uguru Nkolika P Date

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DEDICATION

This work is dedicated to almighty God who made it all possible.

To my husband Dr. Chibuzo Uguru for all the support and encouragement throughout the

course of this study.

To my family and friends. May God bless you all.

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Acknowledgements

I am grateful to my supervisor Prof BSC Uzochukwu whose guidance enabled me to undertake

and finish this study. I am thankful to Prof. Obinna Onwujekwe, the Head of the Department

for his encouragement through the course of this study. I acknowledge World Health

Organization (AFRO), for the financial support to conduct this study.

To my statistician and all those who supported me in every way to see this project successfully

completed; God bless you all.

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ACRONYMS

LGA---------------- Local government area

OOP----------------- Out of pocket

PCA----------------- Principal component analysis

SES----------------- Socio-economic status

WHO--------------- World health organization

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Table of contents

Title page ………………………………………………………………….. 1

Certification ………………………………………………………………. 2

Dedication…………………………………………………………………… 3

Acknowledgement………………………………………………………….4

Acronyms…………………………………………………………………… 5

Table of content ………………………………………………………. 6

List of tables and figures………………………………………………. 7

Abstract ………………………………………………………………….. 8

CHAPTER ONE: Introduction ………………………………………. 10

CHATER TWO: Literature review………………………………….. 16

CHAPTER THREE: Research Method……………………………. 27

CHAPTER FOUR: Result……………………………………………… 35

CHAPTER FIVE: Discussion………………………………………….. 62

Conclusion: ………………………………………………………………. 66

CHAPTER SIX: References………………………………………….. 68

Consent Form ……………………………………………………………. 73

Annex A: Questionnaire …………………………………………. 74

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LIST OF TABLES and FIGURES

Table 1…………………………………………………………………..36

Table 2……………………………………………………………………38

Table 3…………………………………………………………………… 40

Table 4…………………………………………………………………… 42

Table 5…………………………………………………………………… 44

Table 6…………………………………………………………………… 46

Table 7…………………………………………………………………… 48

Table 8…………………………………………………………………… 50

Table 9…………………………………………………………………… 51

Table 10…………………………………………………………………. 53

Table 11……………………………………………………………………55

Table 12……………………………………………………………………57

Table 13……………………………………………………………………59

Table 14…………………………………………………………………….61

Fig 1 …………………………………………………………………………26

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Abstract

Oral health is integral and essential to general health. Good dental health has been thought to

be a privilege of the affluent communities in Africa due to the limited provision of accessible

and equitable oral health care. In high income countries studies have been done on the

accessibility and utilization of dental services among different socio economic status (SES)

groups. However there is limited research looking into this area of interest in Southeast

Nigeria. This research therefore sets out to generate evidence to fill this gap in knowledge.

The objective of this study was to examine the socio-economic status differences in access

and utilization of routine dental services in Enugu. The study was a quantitative Cross-

sectional hospital-based and community-based descriptive study conducted in Enugu

metropolis. An interviewer administered questionnaire was used to obtain responses from 385

household respondents and 295 patients from 2 dental clinics.

Majority of the respondents (61%) have had a dental experience before. Health seeking

pattern following a dental experience was visit to a dental clinic (62.9%), home treatment

(21.5%) and traditional healer (5.6%). Majority of the respondents in the richer quintile, go to

dental facility more than the poorer quintile who patronize the patent medicine dealer more

(p<0.05). The predominant reason for seeking care was for toothache (72%) followed by

difficulty in eating (52%) and to a lesser extent routine checkup (4%). Most of the patients

stated high treatment cost as a barrier to visiting the dental health facility (56.2%) followed by

staff attitude (51%) and distance to the facility (31.2%). A greater percentage of the

respondents paid out of pocket (97%) with their own money (78%) and very few had any

form of health insurance (0.8%), exemptions (0.4%) or subsidizations (0.85%) in treatment

cost.

There is no significant difference in access and utilization of dental services among different

socioeconomic groups because most people are ignorant of the reason for the regular dental

checkups due to a high emphasis on curative rather than preventive approach to health.

Majority of respondents irrespective of socioeconomic class seek care only when symptoms of

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disease are present. The major barrier to access is cost and most importantly utilization of the

available services is hampered by the attitude of the health workers, cost of seeking care in a

dental clinic and individual variations in perceived need of care.

It is recommended that a comprehensive health insurance package which covers oral diseases

should be put in place so as to help reduce the cost of dental treatment and the oral health

policy should be implemented to fast track the integration of preventive dental care into the primary

health program so as to improve oral health awareness.

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CHAPTER 1

INTRODUCTION

1.0 Background to the study

Oral health describes the well-being of the oral cavity, including the dentition and it’s

supporting structures and tissues. It is the absence of disease and the optimal functioning of

the mouth and its tissues, in a manner which preserves the highest level of self-esteem.1.

Oral diseases affect all human beings irrespective of location, country, nationality, race or

color. In addition, the financial impact on the individual and community is very high. Thus a

critical component of total health and recent research links oral disease to heart and lung

disease, diabetes; pre-mature, low-birth weight babies; and a number of other systemic

diseases.2

In the African Region there is a disproportionate level of oral diseases with grave and often

fatal consequences. Some of these diseases seem to be growing in prevalence as a result of

the massive social disruption on the continent.3 Although many oral diseases are not always

life-threatening, they are important public health problems because of their high prevalence,

and impact on individuals and society in terms of pain, discomfort, social and functional

limitations and also their effect on the quality of life.3

Oral diseases have gained prominence in Africa and amongst the most prominent are dental

caries (tooth decay), periodontal or gum diseases, oral cancers and the oral manifestation of

HIV/AIDS4. They are considered major public health problem worldwide though it seems to

have a very low priority in the African Region, where extreme poverty is predominant, and the

limited resources available to the health sector are most often directed towards life-

threatening conditions such as HIV/AIDS, tuberculosis and malaria.4, 5

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In sub-Saharan Africa, about 80% of the population is considered to be living below poverty

level, 6 and poverty is considered to be the most important determinant of health and ill-

health6. The presence of widespread poverty and underdevelopment in Africa means that

communities are increasingly exposed to all of the major environmental determinants of oral

disease.6 Although communicable and chronic diseases are major threats to health, the

incidence of oral diseases such as caries, periodontal conditions, oral cancers, oral

manifestations of HIV/AIDS and dental trauma are also on the increase.2 This is because

previous approaches to oral health in Africa have more often than not been modeled after the

high income countries and have failed to recognize the epidemiological priorities of the African

region or identify reliable and appropriate strategies to address them.6

The previous efforts to combat oral diseases have often consisted of providing unplanned and

sporadic curative oral health services, which in most cases are poorly distributed and only

reach the affluent or urban communities.6 consequently, the epidemiological transition in

relation to oral health due to increased urbanization is quite evident in the growing incidence

of these oral diseases.3, 7

In combating oral diseases, it is important to have an oral health plan, yet, only 14 out of 46

countries in Africa, have an oral health plan and this has inherently affected planning and

delivery of appropriate oral health care to the people.3 Some studies have postulated that

most of these problems are caused by lack of national oral health policies and plans,

inappropriately trained dentists, services that benefit only the affluent and urban communities;

lack of equipment and materials, supplies, and proper maintenance.3

In many African countries, the availability and accessibility of dental health services are

seriously constrained, and the provision of essential oral care is limited.7 Studies have been

undertaken in industrialized countries to assess the level and the pattern of utilization of dental

health services, 8, 9 unfortunately, this has been a neglected field of research in Africa11. The

few existing reports from Africa show very low utilization of dental services, and visits to a

dental care facility are mostly undertaken for symptomatic reasons.10,11,12,13 A survey

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conducted in a peri-urban settlement of South Africa found that 37.0% of adults had consulted

a dentist or medical practitioner, usually for tooth extractions.11 A study in the Ivory Coast

reported that only 11.4% of the city-dwellers in Abidjan had visited a dentist because of dental

problems.12 In Tanzania, the principal factors associated with the utilization of dental services

were distance to treatment facility and previous dental symptoms14. Concomitantly, self-

medication with herbal medicines or modern drugs seems to be a common practice in many

African countries.15, 16

At the World Health assembly and regional committee held in 1980 a call was made for the

integration of oral health programs into primary health care. This was re-emphasized in 2004

at the Federation Dentaire Internationale (FDI-International Dental Federation) Nairobi

conference.7 A consensus agreement was reached by the participants to support policies

enabling all people to have access to essential oral health care that includes, pain relief, oral

disease control and promotion of oral health along with the integration of oral health care in

primary health care programmes in an environment that is free from the transmission of

infectious disease.7

Notwithstanding, the results of the FDI Nairobi conference, access to oral care in Nigeria is still

very low as shown by a study where about only 9.0% of households had used dental services

within one year.13 In as much as variables such as “zone of residence” and “household

educational and social class ranking” affected use of oral care services,13 it may also be

influenced by a myriad of factors in which a lack of perception of the importance of oral health

and an ignorance of existing services is contributory.18 In a recent study it was noted that the

low dentist per capita ratio,19 which is also postulated in the FDI report as 1: 150,000 as

against a ratio of about 1:20,000 in most western countries.20 as well as the problem of

limited health insurance in the country has contributed to the poor access to dental care in

Nigeria.19 This needs to be addressed seriously for there to be a positive change.

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Some other studies have also shown that apart from the above factors, access and utilization

of dental services depend to a large extent on the level of awareness, socio economic and

socio demographic status and gender of the patient.21 Other studies carried out in Nigeria

about utilization patterns have shown that regular visits to the dental clinic is not a well

established tradition in developing countries which is evident in the utilization pattern of

14.1% shown in a study conducted on Nigerian students.22 Similarly, Akaji et al found that

utilization of dental services by secondary school students was also low at 14.9% and the

standard measure of appropriate utilization of dental care services of once a year was not

met.23 Other Nigerian studies observed that adult utilization of dental services though higher

than the previous ones at 26% was still low compared to western standards. 20,21

However, even with all these facts, policy makers have still not used any innovative approach

to improve access to and utilization of dental care.

1.1 Statement of the problem

Good dental health has often been thought to be a privilege of and has more often been a

preserve of the affluent communities6 in Africa. This notion probably is due to the fact that

the availability and accessibility of oral health services and provision of essential, affordable

and quality oral care is limited4. Many studies have been undertaken in the high income

countries to assess the level and pattern of utilization of dental services as well as their

accessibility to the populace among different socio economic status (SES) groups.24 However,

there is limited research looking into this area of interest in Southeast Nigeria. This research

therefore sets out to fill this gap in knowledge.

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1.2 General objective

To examine the socio-economic status differences in access to and utilization of routine dental

services in Enugu state

1.3 Specific objectives:

The objectives of this study were to:

1. Determine the level of access to and utilization of routine dental services in Enugu

State;

2. Examine if there are barriers to access to and utilization of routine dental services and

what these barriers are;

3. Determine if there are socio-economic status differences in access to and utilization of

routine dental services and

4. Inform policy changes towards ensuring equitable access to and utilization of routine

dental services based on research findings from objectives1-3.

1.4 Research Questions

1. Are access to and utilization of dental services low in Enugu State?

2. Are there any barriers to accessing dental services in Enugu State?

3. Is access to dental treatment different among different SES groups?

4. How are the available services utilized among different SES groups?

5. How can the findings be communicated to policy makers in order to improve oral health

care in the State?

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1.5 Definition of terms Routine dental services offered in dental clinics

The routine services offered in a dental clinic are Preventive, Restorative, Oral surgery and

prosthodontic care.

Preventive care: Periodontics - scaling and polishing, treatment of uncomplicated

Periodontal disease including root planning and management of acute infections or lesions of

the gum.

Restorative care: This comprises amalgam and composite resin fillings and stainless steel

crowns on primary teeth; Endodontics - Treatment of root canals and removal of tooth nerves

Oral Surgery: tooth removal and minor surgical procedures such as tissue biopsy and

drainage of minor oral infections.

Prosthodontics: creation of new dentures, crowns and bridges; repair and/or relining or

reseating of existing dentures and bridges.25

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CHAPTER 2 LITERATURE REVIEW

2.1 ORAL DISEASE

Oral diseases, such as dental caries, periodontal disease, tooth loss, oral mucosal lesions,

oropharyngeal cancers, oral manifestations of HIV/AIDS, necrotizing ulcerative stomatitis

(noma), and orodental trauma, are serious public-health problems, with considerable impact

on individuals and communities in terms of pain and suffering, impairment of function and

reduced quality of life.24 For example Noma, a debilitating orofacial gangrene, is an important

contributor to the disease burden in certain low- and middle-income countries, particularly in

Africa and Asia; the key risk factors are poverty, severe malnutrition, unsafe drinking water,

deplorable sanitary practices and infectious diseases like measles, malaria, and HIV/AIDS.26

The WHO policy for global oral health programme has emphasized that oral health is integral

and essential to general health, such that oral health can be seen as a determinant factor for

quality life.27 National oral health programs that include health promotion measures at

individual, professional and community levels, would go a long way in preventing oral

diseases. A greater emphasis however is being put on developing global policies based on

common risk factors and approaches which can be integrated with other programs in public

health.24

Treatment of oral disease is very costly and the fourth most expensive disease to treat in high-

income countries,28 and in low income countries the cost of treating dental caries alone

exceeds the total health care budget for children.28 In the high income countries, the burden

of oral disease is tackled through the establishment of advanced oral-health services which

primarily offer curative services to patients.28 In most cases the dental healthcare systems are

based on, demand for care, provided by private dental practitioners. However, most high

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income countries have effective organized public oral-health systems which include preventive

and curative measures.26 On the other hand in most low- and middle income countries,

investment in preventive oral health care is low and resources are primarily allocated to

emergency oral care and pain relief. 26.

2.2 BURDEN OF ORAL DISEASES

Historically dental caries and periodontal diseases are considered the most important

contributors to the global oral health burden.29 However, the severity and distribution of dental

caries vary in different parts of the world, and within the same countries or regions. In most

industrialized countries, dental caries are considered major health problem affecting about 60-

90% of school age children and a large majority of adults while lower levels were observed in

developing countries.29 In the last few decades though, major changes have occurred globally

in the patterns of oral disease with oral health improving dramatically in the industrialized

world, while a general decline is being experienced in the African region.29 This decline can be

largely attributed to increasing consumption of sugars and inadequate exposure to fluorides.26

On the other hand the reduction in caries incidence observed in industrialized countries was

as a result of numerous public health measures including effective use of fluorides, together

with changing living conditions, lifestyles and improved self-care practices.29

Unfortunately, oral health care has low priority in many African countries and most resources

devoted to health are channeled towards the control of communicable (infectious) diseases.6 It

is especially worthwhile to note, that in Africa the most rapid increase in prevalence and

severity of dental caries are occurring in the urbanized, higher socio-economic groups. 29 Such

trends reflect economic and cultural inclination in the region with the change of traditional

lifestyles i.e. from traditional starchy foods to a greater consumption of refined sugars.25 In

addition, the growing consumption of tobacco in many developing countries, has increased the

risk of periodontal disease, tooth loss and oral-cavity cancer.26 Moreover, periodontal disease

and tooth loss are linked to chronic diseases such as diabetes mellitus and the growing

incidence of diabetes in several countries may have a negative impact on oral health.256

Another disease which might have a negative effect on oral health is HIV infection. This occurs

18

because people with HIV infection have specific oral diseases which reduce the quality of life

of infected persons as a result of the difficulty they have in eating due to pain, dry mouth and

difficulty in chewing, swallowing and tasting food.26

Oral diseases and chronic diseases have common risk factors, and just like chronic diseases,

they have become increasingly prevalent in many of the poorest countries in the world,

inflicting a double disease burden on these countries which already have infectious diseases to

contend with.5,28 As is the case for major chronic diseases, oral diseases are linked to bad

dietary habits and oral hygiene behaviors, particularly widespread use of tobacco, excessive

consumption of alcohol, sugar and socio-environmental factors. 29

The presence of widespread poverty and underdevelopment in Africa exposes communities to

all of the major environmental determinants of oral disease. 30 The profile of oral disease is not

homogenous across Africa, with health indicators varying among countries and across groups

within countries.30 The most pressing oral health problems among African communities include

dental caries, periodontal diseases, trauma to teeth and jaws, oral cancer, cancrum oris and

oral manifestation of HIV/AIDs.29

These diseases have the greatest morbidity and mortality of all oral conditions in the region.

Taken together they have significant negative impact on the quality of life for millions of

people.30 Other problems include congenital abnormalities, dental fluorosis (particularly in the

Rift Valley area of East Africa), harmful practices (like removal of *four primary cuspids or

burning of gums before the teeth come out in order to prevent diarrhea which they claim is

associated with teething)30,331,32 , benign tumors and total tooth loss (edentulism).32 Of

particular concern is the fact that 90% of the caries in African countries remain untreated29

which alludes to the fact that oral health in Africa is in bad shape characterized by lack of

access to simple yet appropriate oral care.30

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2.3 ACCESS AND UTILIZATION OF DENTAL SERVICES

Access to health care services is a general concept summarizing a set of more specific

dimensions, such as availability, which refers to location of health services, affordability, which

is the ability of consumers to pay for health care services, and acceptability which is related to

individuals perceptions of the nature of health services and the way and level to which

organization of healthcare meets clients expectation. 33, 34 These different dimensions of access

influence an individual’s health care seeking process. Access to healthcare can thus be seen as

the empowerment of an individual to use health care based on the interaction between health

care systems and individuals, households and communities. It also reflects the individual’s

capacity to benefit from services given the circumstances and experiences the individual has

had in relation to the health care system.35, 36, 37

This then brought about the idea that exploring the compatibility between the health care

system and individuals was the bane of the access concept, showing that access is not a

passive concept but a communicative interaction between the individuals and the health

system.35 A strong health system should thus make provision for effective delivery of proper

treatment services. However in many developing countries, access to proper health services

remains a major problem. This is due mainly to the cost of health services, lopsided

distribution of health facilities in favor of the urban areas and gross underfunding of the health

sector resulting in lack of subsidies and exemptions to the poor35

Differences in access between individuals, may cause variations in the use of health services,

although these variations in use may occur in people with equal access because the individuals

often times make different choices when it comes to using health services.36 A person’s use of

health services usually depends in part to their socio demographic characteristics like marital

status, gender, educational level, occupation, income etc., their health beliefs and attitudes,

knowledge of the service being offered and the individuals perceived health need.38

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2.4 BARRIERS TO ACCESS AND UTILIZATION

The burden of oral diseases is often seen to be unevenly spread between upper and lower

socio-economic groups and access to care seems to depend not only on the ability to pay for

care but also on availability of dentists i.e. a low dentist population ratio, indiscriminate

distribution of available dentists and distance of dental clinic to the community.37 However

globally the most obvious factor which has been found to inhibit access to care is the inability

to pay for care.29, 2930 Nonetheless, some studies have shown that poor access to dental care is

a consequence of shortage of dentists because dentists practicing in those areas are not

enough.36,8 In addition, many people who live in areas with adequate supply of dentists and

with the ability to pay do not get services because they are homebound or institutionalized

and cannot access the facilities where dental services are provided. 37

In the industrialized economy, a hitch in the accessibility of dental care is that prevailing

reimbursement levels for dental care under public programmes are often too low to attract

dentists to offer care under these programmes most often because there is a parallel private

market for dental care supported by private insurance plans which attract higher fee levels.39 40

The providers in the public sector are prevented from extra billing or topping up payments by

charging additional amounts to patients thus these services remain inaccessible, despite the

general availability of providers and the affordability of services under public programmes.30

In contrast accessibility of dental services in most African countries is affected by lack of

National oral health policies and plans or poorly formulated policies.41 In countries where this

is not the case, oral health care is not given a priority and therefore whatever policies that

might be in place are not considered since most of the policy makers are unaware of the

severity of the disease.3,41 In addition provision of appropriate equipment and materials

together with poor maintenance of already existing infrastructure has further compounded the

problem. Thus the absence of well trained dentists or a lack of dental auxiliary staff will

contribute in making these services inequitably distributed.3 All this will inevitably affect the

planning and delivery of good and equitable oral health care services to the people.3

21

The shortage of the oral health workforce in many African countries signifies a major obstacle

for the provision of oral health care to all people. A rough estimate of the dentist population

ratio is approximately 1:50,000 as against a ratio of about 1:2000 in most high income

countries.41,41,43 This is grossly inadequate for a country like Nigeria for example, with a

population of over 140 million people.41 In many nations, attempts to improve the situation by

increasing the dental workforce through training more dentists have failed to improve equity of

oral health services.41 A common scenario is that newly trained dentists tend to cluster in the

urban areas, thus leaving a shortage of care in poorer rural regions. This phenomenon which

is termed the “inverse care law” means that communities with the greatest need have the

least access to resources and services.29 Another issue common to many countries around the

world, including those in Africa is the migration of trained health professionals from Africa to

more lucrative markets overseas. This “brain drain” further exacerbates the shortage of health

workers in the African setting. 44

Catastrophic Spending

Health expenditures are said to be catastrophic when they risk sending a household into, or

further into, poverty. When people have to pay fees or co-payments for health care, the

amount can be so high in relation to income that it results in “financial catastrophe” for the

individual or the household. Such high expenditure means that households reduce their basic

expenditures over a certain period of time such as food and clothing, or are unable to pay for

their children's education in order to cope with the medical bills of one or more of their

members. Catastrophic expenditure is usually measured by setting a reference or standard.

Several thresholds of between 5-20% have been proposed by different researchers in various

settings.5745 However, WHO has proposed that health expenditure be viewed as catastrophic

whenever it is greater than or equal to 40% of a household's non-subsistence income, i.e.

income available after basic needs have been met. 46 Every year, approximately 44 million

households, or more than 150 million individuals, throughout the world face catastrophic

expenditure, and about 25 million households or more than 100 million individuals are pushed

into poverty by the need to pay for services.

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2.5 ORAL HEALTH CARE IN NIGERIA

Similar to the general health services, oral health care in Nigeria has been organized through a

public/private mixture of providers based on an out-of-pocket payment system. 47 In Nigeria

Public health expenditure accounts for about 20-30% of all expenditures made on health with

about 70–80% of all expenditures being private.47 Of all the various private health

expenditures, out of pocket payment pattern is dominant which accounts for about 90% of all

household expenditures.48 This heavy reliance on this method of paying for health services has

created a situation where there is no pooling of risks to pay for health services and an absence

of risk sharing has ultimately transferred the burden of payment for health services on the

poor.49,49 With dental treatment being ranked as the fourth most expensive disease to treat

globally,28 the burden of this disease especially in a situation where the method of paying for

healthcare is out of pocket would be enormous.6

A major reason for delay in care seeking or failure to register occurrence of symptoms as

evidence of illness by households is the cost of care seeking.50 The anticipated expenditure on

health is usually enormous and includes the direct cost of care and the opportunity costs

associated with absence from work, especially where majority of the population are informally

employed and household production depends on day-to-day labor intensive effort.48, Thus

poorer populations might have illness episodes but rather than reporting it, might say that

they are not ill, overlook symptoms or may seek cheaper care from patent medicine dealers

and shopkeepers. 51 This consequence of out of pocket payment for health care is considered

a major impediment to access to and use of services by households who need health care.50

The absence of financial protection has been described as “a recently diagnosed disease of

health systems 52,53 with our health system ranking as the fourth worst in the world.54

Improvements in the health system in Nigeria would depend on improvements in the health

care financing structure of the country in ways that relieve households of the financial burden

of health care.

23

The national health insurance system was formally instituted and operationalized in 2005, but

covers only preventive and basic dental care while not covering any specialized dental

treatment.46 Thus realizing the limited impact of existing strategies, the World Health

Organization Regional Office for Africa (WHO/AFRO) developed a regional oral health strategy

to assist African countries and their partners in identifying priorities and planning preventive-

oriented programmes, particularly at the district level.40 The long-term objective is to provide

equitable and universal access to cost-effective quality oral healthcare and thereby

significantly reduce the incidence of oral diseases in Africa.5 In addition Nigeria has recently

revised its National Oral Health Policy which is aimed at improving the oral health status of

Nigerians through the establishment of a comprehensive oral health care system that is fully

integrated into primary health care while also addressing the curative and rehabilitative

aspects of oral health care.41

The Nigerian oral health policy was developed because it was observed that oral health was

not a priority in the Nigerian healthcare delivery system due to a lack of awareness of

individuals and policy makers about the prevalence and severity of oral diseases.41 This was

based on an erroneous misconception that oral diseases are not life threatening or severely

debilitating.41 and a complete absence of a financing framework for oral healthcare delivery

together with the underrated potential of saving costs in health budgets through oral health

promotion.41 The new oral health strategy which was revised to cover the years 2009 to 2013

hopes to counteract these basic problems by introducing programmes that are based on the

primary oral health care approach while not ignoring curative care.41 This approach would

consist of encouraging research on oral health issues, building a baseline database of oral

diseases in the country, improve awareness of the populace through health promotion

activities. Here emphasis is made on preventive care, in order to reduce prevalence and

incidence of oral diseases and also in the training and empowering of dental personnel. It will

also accentuate support for the widespread use of fluoride in low fluoride regions and also

make sure there is equitable access to oral health by every citizen through the National health

insurance schemes and many other funding Non- governmental organizations.41

24

The new oral health policy formulated and launched in 2012; though not yet implemented in

the Enugu state is geared towards putting oral health on the forefront and improving oral

health status of Nigerians.

25

2.6 Conceptual Framework The Andersen model of healthcare utilization framework was used for this study. It is

a conceptual model aimed at demonstrating the factors that lead to the use of health services.

According to the model, usage of health services (including inpatient care, physician visits,

dental care etc.) is determined by three dynamics: predisposing factors, enabling factors, and

need factors.55 (fig 1)

1) Predisposing factors: these are socio-cultural characteristics of individuals that exist prior to

their illness, Health beliefs and demographic characteristics of individuals.

● Socio-cultural structures include: education, occupation, ethnicity, social networks, social

interactions, and culture

● Health Beliefs include: attitudes, values, and knowledge that people have concerning and

towards the health care system. For instance, an individual who believes health services are an

effective treatment for an ailment is more likely to seek care

● Demographic characteristics are: age and gender

2) Enabling Factors: This looks at the logistical aspects of obtaining care. Examples of enabling

factors could be personal/family support, community factors and genetic and psychological

characteristics.

●Personal/family support where income, health insurance, regular source of care, and the

ability to access health services all come into play.

●Community support includes the availability of health personnel and facilities as well as

patient waiting time at health facilities.

3) Need factors: this is the most immediate cause of health service use. It represents both

perceived and actual or evaluated need for health care services.

● Perceived: this is how people view their own general health and functional state, as well as

how they experience symptoms of illness, pain, and worries about their health and whether or

not they judge their problems to be of sufficient importance and magnitude to seek

professional help.55

● Actual/Evaluated: This represents professional judgment about people's health status and

their need for medical care.55

26

27

CHAPTER 3 METHODOLOGY

3.1 STUDY AREA

This study took place in the urban area of Enugu State which is one of the 36 states of the

Federal Republic of Nigeria; and has Enugu as its administrative capital territory. Enugu State

is divided into 17 Local Government Areas (LGAs); of these, four LGAs, comprising Enugu

North, Enugu South, Enugu East and Nsukka largely make up what is regarded as the urban

areas while the remaining thirteen constitute the rural areas.

Geographically, Enugu State lies in the South-East of Nigeria, and shares borders with Abia

and Imo States to the South, Ebonyi State to the East, Benue State to the Northeast, Kogi

State to the Northwest and Anambra State to the West. It has a population of 3,257,298

million with urban population of about 1,032297, distributed among the four LGAs as follows,

279,089, 244,852, 198,723 and 309,633 respectively.54

The Ibos are the predominant ethnic group found in the state, although immigrants from other

parts of the country also reside in the state.54 The urban population is made up of mainly civil

servants, traders, artisans and students/pupils of the various educational institutions in the

state.54

In Enugu metropolis there are 3 public dental facilities, one mission dental clinic and 16 private

clinics.56 The public dental facilities are located at the University of Nigeria Teaching Hospital

28

Ituku -Ozalla, Federal School of Dental Technology Trans Ekulu and the Enugu State

Government Dental center.56 The study was a community and hospital based study. It was

conducted in four sites; Two dental clinics (one in a public institution; Federal Dental Clinic

Trans -Ekulu in Enugu East LGA and a mission institution; Baptist Dental Centre in Enugu

North LGA; While the other in households in the New Haven area in Enugu North LGA and

Abakpa Nike in Enugu East LGA.

3.2 Study design

This study was a quantitative cross-sectional hospital-based and community-based descriptive

study. Two different questionnaires were used; one health facility interview and the other

household. The household questionnaire was used to elicit dental health care seeking pattern,

access and utilization of routine dental services and barriers to access and utilization among

different socio-economic groups. While the hospital based study was meant to highlight the

accessibility and utilization of dental clinics among the different socio-economic status groups.

Study Population

This comprised randomly selected household residents of New Haven and Abakpa in Enugu

metropolis and all dental patients attending the dental clinics selected. (Patient exit interview)

3.5 Sample size determination

Sample size calculation for both community and hospital groups were calculated using the

formula for one group where the overall population size is greater than 10,000.57

3.5.1 Sample size for community survey

A prevalence of 9% obtained from the literature was used to estimate the sample size for the

community survey. 13

n = z2 pq

29

d2

Where: n = the desired sample size when population is greater than 10,000

z = the standard normal deviate, usually set at 1.96 which corresponds to 95%

Confidence level.

P = prevalence of household access to dental treatment services

q= 1-p

d= error (usually set at 0.05)

z = 1.96

p = 9% (0.09)

q = 1- 0.09 = 0.91

d = 0.05

n= (1.96)2 (0.09) (0.91) = 125

(0.05)2

However the sample size was too small and in order to get sufficient data to run the analysis

and get good results the error margin was reduced so as to increase the sample size. The

error margin was reduced to 0.03 at a power of 80%

n = (1.96)2 (0.09) (0.91) = 350

(0.03)2

In order to control for non-responders a 10% refusal rate was calculated in the household

survey to bring the estimated sample size to 385, however a total sample size of 407 was

used.

3.5.2 Sample size for health facility survey

A prevalence of 26% was used to calculate the sample size for the patient exit interview.20

n = z2 pq

30

d2

z = 1.96

p = 26% (0.26)

q = 1- 0.26 = 0.74

d = 0.05

n = (1.96)2 (0.26) (0.74) = 295

(0.05)2

Where P is the prevalence of dental clinic utilization patterns

In order to control for non-responders a 10% refusal rate was calculated and the sample size

for the hospital based survey became 325. However the total sample size used for the study

was 329 for the health facility based survey.

3.6 Sampling method:

A multistage sampling method was used: The study was an urban based study.

3.6.1 Selection of LGA’s

Two LGAs were randomly selected from the 5 LGAs regarded as urban areas in Enugu State.

From those two LGAs, two clinics were purposively selected, one a public enterprise and the

other a private (not for profit) enterprise, because of the large patient turn out in these places.

3.6.2 Selection of clients in Health facility survey

A list of daily patient turnover was obtained from the medical records of the respective dental

clinic. This provided a baseline of how many patients to interview within the data collection

period of one month. The list of patients registered daily acted as a sample frame from which

the sample size was obtained.

All the patients that attended the dental clinic during the period of data collection were

interviewed using a convenience sampling method until the stipulated sample size was

31

attained. The patients were interviewed as they were about to leave the clinic after being

attended to by the dentist or other dental auxiliary staff. Only patients who had accessed one

form of dental service or the other were interviewed. The patients were interviewed to elicit

accessibility of the dental services and also on their pattern of utilization of the existing

services this was done in order to bring out any barriers to access and utilization.

3.6.3 Selection of households for community survey.

Two LGAs were randomly selected. Each LGA had a sample frame of 20 wards from which 2

wards per LGA were selected by simple random sampling. From Enugu North, New Haven East

and West were selected and they comprised a total of 40 streets. Enugu East where Abakpa 1

and 2 were selected comprised a total of 31 streets. A list of all the streets were compiled by

trained fieldworkers. 20 streets were selected by simple random sampling per LGA (10 in each

ward) using the balloting technique. In selecting the households, the list of households were

collected from the sample frame which is the list of houses enumerated by trained field

workers. From this list, 10 households per street were selected by simple random sampling

using the balloting technique for inclusion in the study.

3.6.4 Selection of household respondents

One respondent per household was interviewed i.e. the primary care giver (who is usually the

mother) was interviewed or an adult representative who could give information about dental

healthcare seeking in that household.

3.7 Data collection procedure

Two different instruments were used for data collection

1. Questionnaire for patient exit interview

2. Questionnaire for household survey.

A structured interview using an interviewer administered technique was used. Close ended

questionnaire format with a few open ended questions was used for both questionnaires. The

32

questionnaire was administered by the interviewer to the sample population to elicit socio

demographic characteristics, access and utilization of dental services by respondents and SES

of respondents.

Households were enumerated by field workers trained by the researcher and questionnaires

administered to the primary care giver (wife/mother) or any adult member of the household

(who could answer the questions correctly) who had adequate knowledge about dental

experience of members of the selected households. Prior to the data collection the instruments

were pre-tested on 10 respondents and modifications were made to the instrument. A pre-test

was done in order to validate the instruments.

For the exit interviews, a pre-test was also conducted on 10 patients selected from another

clinic before actual data collection in order to validate the instruments. The instruments were

modified after the pre-test. During actual data collection, the pre-tested exit questionnaires

were administered to all patients seen at the dental clinic, and in case of pediatric (child)

patients the adults who accompanied them to the dental clinic were interviewed.

All data was collected by field workers who were trained by the researcher for 7 days on both

instruments.

3.8 Data Analysis Quantitative Data All data collected were validated by the researcher and entered into a data base created for

the study. EPI INFO, STATA and SPSS statistical software were used for analysis. A regression

analysis was done in order to determine the effects of the variables; predisposing, enabling

and need factors on utilization. A catastrophic analysis was done also to determine if the cost

of dental treatment was catastrophic to the respondents.

33

Catastrophic spending

Catastrophic is usually measured by setting a reference or standard. Several thresholds have

been proposed by different researchers in various settings. WHO used a threshold of 40% of

“capacity to pay” which was defined as income after subsistence needs are met. In practice

this amounts to income minus food expenditure58,59. Other thresholds of between 5-20% have

also been used 60 For this study the scenario that was explored for determining the incidence

of catastrophic health expenditure was: whether monthly expenditure on treatment as a share

of monthly non food expenditure was greater than 40%, Because of the difficulty in obtaining

reliable information of household income, the national minimum wage was used to calculate

the incidence of catastrophe.50

SES Index: SES index was used to categorize households and hospital respondents into SES quintiles:

least poor, averagely poor, poor, very poor and most poor. Principal components analysis

(PCA) was used to generate the SES index.58 The input to the PCA was information on

ownership of key assets such as a motorcar, a motorcycle, a radio, a refrigerator, a television

set, a gas cooker, iron, generator and a bicycle together with the per capita cost of food. The

SES index was disaggregated into quintiles with Q1 as the most poor and Q5 as least poor.

Chi-square was used to determine the SES differences of the key dependent variables e.g.

Knowledge of dental problems, and where to receive treatment, payment options and

payment coping mechanisms. All tests of significance were carried out at a p value ≤0.05

Ethical Clearance

All respondents gave informed consent before proceeding with the interviews. The

respondents were given an opportunity to ask questions and be fully informed before signing

the consent form. Consequently, the interviewee’s consent to participate in the study was

demonstrated by signing the Consent Form. In addition to the consent form, ethical clearance

for the Study was given by the Ethical Committee of University of Nigeria Teaching Hospital

Enugu.

*National minimum wage=18,000 Naira

34

CHAPTER 4

RESULTS 4.1 HOUSEHOLD SURVEY

Socio-demographic characteristics of respondents

This shows the characteristics of the respondents. Most of the respondents (56.8%) were the

household heads, mostly married men with a mean age of 31years. About 98.3% of the

respondents had attended school and 53% attained the secondary level (53%) while 23.2%

had attained a tertiary education level. The major source of income was government work

(29.7%) followed by artisans (18.7%) who are self-employed professionals (14%), with the

least source of income being farming (6%). About 2.2% of the respondents were unemployed

during the study period. The average number of people in households studied were 5.

A socio-economic status group distribution shows an even distribution of all participants into

quintile groups. (Table1)

35

Table 1. Socio-demographic characteristics of respondents

Variables Combined

n=407(%)

No of people in Household: Mean (SD) 5 (2.29)

Sex of respondent

Male

Female

231 (56.8)

176 (43.2)

Age last birthday: Mean (SD) 31 (11.3)

Marital status

Married

Single

Widowed

188 (46.2)

208 (51.1)

11 (2.7)

Educational status

Attended school

Did not attend School

400 (98.3)

7 (1.7)

Level of education

Primary

Secondary

Tertiary

Teacher training college

Nursing

37 (9.3)

212 (53.0)

105 (26.2)

16 (4.0)

30(7.5)

Major source of income in household

Artisan

Farmer

Government worker

Self- employed professional

Private sector

Business

Transporter

Un employed

76 (18.7)

24 (6.0)

121 (29.7)

57 (14.0)

43 (10.6)

40 (9.8)

37 (9.0)

9 (2.2)

SES Distribution of respondents

Q1(most poor)

Q2 (very poor)

Q3 ( poor)

Q4 (averagely poor)

Q5 (least poor)

82 (20.1)

81 (19.9)

82 (20.1)

81(19.9)

81 (19.9)

36

Knowledge of dental problems and where to receive treatment

Majority of the respondents representing 398 out of the 407 respondents (98.7%)have very

good knowledge of dental problems and 396 (97.5%) of them know that treatment for dental

problems are available. A greater percentage 301 (75.8%) of respondents know that dental

treatment can be accessed in a dental health facility, followed by 191 (48%) say dental care is

received in a hospital. Traditional healer (24.5%), patent medicine dealer (20.7%), home

treatment (4.0%) and pharmacy (16.1%) are the other places where respondents state that

dental treatment can be received. A minority (0.5%) have no knowledge of where dental care

can be accessed. (Table 2)

37

Table 2: Knowledge of dental problems and where to receive treatment

Variables ( n=407)

n (%)

Knowledge of dental problems 398 (97.8) Knowledge of availability of treatment for dental problems

396 (97.5)

*Knowledge of where to obtain dental care Dental health facility Traditional healer Home treatment Hospital Pharmacy Patent medicine dealer Don’t know

301 (75.8) 97 (24.5) 16 (4.0) 191 (48.1) 64 (16.1) 82 (20.7) 2 (0.5)

*Multiple responses

38

Dental experience and dental care seeking behavior

Results shows that about 251 (61%) of the respondents out of the 407 interviewed have had

a dental experience before. Majority received treatment in a dental clinic for toothache

(52.6%), followed by those who visited when they had other dental problems (33.1%). Those

who went for routine 6 monthly or yearly visits were in the minority at 1.9 and 2.4%

respectively. This was lower than those who didn’t go to the dental clinic at all. When asked

specifically when their last dental visit occurred, majority (76.1%) said it was within the last

one year while about 4% didn’t visit at all.

Dental care seeking: The most common place where respondents sought care was the

dental clinic (62.9%), this is followed by home treatment (21.5%) pharmacy and patent

medicine dealer (8.8) dental clinic went to a dental clinic followed by home treatment, and a

small percentage visited a traditional healer (5.6%). The predominant reason for seeking care

was for toothache followed by difficulty in eating and to a lesser extent mouth odour and

routine checkup. The seriousness of the dental problem (34.7%) and the experience of the

staff in the clinic18.3%) greatly influenced where people said they would receive care.

39

Table 3: Dental experience and dental care seeking behavior

Dental experience (n=407) n (%)

Respondents that have experienced dental problems 251 (61%) Frequency to dental clinic Never attended 6 monthly: Once every year: To clean my teeth: Toothache Only when I have dental problems

14 (5.6) 5(1.9) 6 (2.4) 11 (4.4) 132 (52.6) 83 (33.1)

Last dental visit (mths) No visit 0 to 12 13 to 24 25 to 36 Above 36

10 (4.0) 191 (76.1) 24 (9.5) 10 (4.0) 16 (6.4)

Dental care seeking (N=251) *n (%) Respondents sought dental care from: Dental clinic Traditional healer Home treatment Hospital (non dental) Pharmacy Patent medicine dealer Others

158 (62.9) 14 (5.6) 54 (21.5) 33 (13.1) 22 (8.8) 22 (8.8) 6 (2.3)

Reason for using facility Cheap treatment cost: Recommended: Experienced staff: Close to house: Seriousness of problem Only place I know

43 (10.6) 58 (14.3) 75 (18.3) 23 (5.7) 140 (34.7) 68 (16.7)

Reason for seeking care Difficulty in eating Toothache Shaking teeth Swollen mouth Ineffective drugs Mouth odour Headache Routine checkup

148 (52.1) 204 (72.1) 19 (6.7) 66 (23.3) 24 (8.5) 4 (1.4) 39 (13.7) 16 (6.6)

*Multiple responses

40

Barriers to Accessing dental health services

Majority of respondents (84.5%) said the dental clinic was open at convenient hours and

waited an average of 15 minutes before treatment. Though staff attitude was bad, the service

at the clinic as well as the environment was fair and majority were satisfied with infection

control practices (80.5%). Most of the patients stated high treatment cost as a barrier to

visiting the dental health facility (56.2%) followed by staff attitude (51%) and distance to the

facility (31.2%) (Table 4).

41

Table 4: Barriers to Accessing dental health services

Variable( N=251) Waiting time before treatment(mins) Mean (std)

15 (2.652)

Clinic hours: n (%) Are convenient Are not convenient

212 (84.5) 39 (15.5)

Staff number: Are appropriate Not enough staff Don’t know

202 (80.5) 44 (17.5) 5 (2.0)

Services at clinic Very acceptable Acceptable Unacceptable Very poor

101 (40.2) 110 (43.8) 39(15.5) 1 (0.5)

Staff attitude Excellent: Good: Bad: Very bad:

39 (15.5) 81 (32.3) 128 (51.0) 3 (1.2)

Clinic environment Very neat: Fairly neat: Dirty: Very dirty:

61 (24.3) 144 (57.4) 39 (15.5) 7 (2.8)

Infection control practices Satisfied Not satisfied

202 (80.5) 49 (19.5)

Reasons not to go to dental facility Distance of facility High treatment cost Electricity problem Poor quality treatment others

80 (31.8) 141 (56.2) 1 (0.4) 15 (6.0) 14 (5.6)

42

Payment options and payment coping mechanisms

A greater percentage of the respondents paid out of pocket (94.4%) without any form of

reimbursement while about 7 respondents (2.8%) said they were reimbursed after paying out

of pocket. A minority paid through installments (0.8%), insurance (0.8%) and in kind (0.8%).

When asked about how they coped with paying for treatment, majority of the respondents

(78%), said they paid with their own money, some respondents said someone else paid their

bill (17.9%), three of the respondents (1.2%) borrowed money and very few had benefited

from exemptions (0.4%) or subsidizations (0.8%) in treatment cost. (Table 5).

43

Table 5: Payment options and payment coping mechanisms

Variable N =251 n (%) Payment options OOP with reimbursement OOP without reimbursement Insurance Installment In kind Others

7 (2.8) 237 (94.4) 2 (0.8) 1 (0.4) 2 (0.8) 2 (0.8)

Payment coping Own money Borrowed money Someone else paid Exemption Subsidized Others

197 (78.5) 3 (1.2) 45 (17.9) 1 (0.4) 2 (0.8) 3 (1.2)

44

Relationship between utilization of dental clinic and independent factors Regression analysis shows educational level affects utilization of dental clinic positively

(P<0.05) perceived severity of the problem, experience of dental staff, ineffective drugs and

serious pain were positively associated with utilization of dental clinic. Cost of treatment and

mouth odour were also associated with utilization of dental clinic though negatively (P<0.05)

(Table 6).

45

Table 6: Linear regression analysis showing relationship between utilization of dental clinic and independent factors

Independent variables

Coefficient (Standardized).

Std. error p-value

Sex -0.004 .057 0.945

Marital status 0.045 .041 0.432

Religion -0.049 .127 0.333

Attended school 0.101 .192 0.049

Occupation 0.072 .013 0.152

Length of time lived in town

0.072 .002 0.185

Knowledge of dental disease

0.026 .166 0.590

Cost of treatment -0.155 .072 0.003

Perceived seriousness of problem

0.276 .059 0.000

Recommended by friend

0.016 .066 0.769

Experienced staff 0.273 .064 0.000

Close to house -0.005 .091 0.917

Not eating well 0.096 .055 0.082

Serious pain 0.213 .066 0.000

Mobile teeth -0.036 .103 0.494

Swollen mouth -0.029 .061 0.584

Drugs ineffective 0.143 .093 0.006

Bad breath -0.126 .206 0.012

46

Knowledge of availability of dental treatment and health seeking pattern among

different SES groups

There was no significant difference in knowledge of dental problems and knowledge of

availability of dental treatment among all the SES groups (P=0.28 and 0.84 respectively).

Analysis of responses to the question where do you seek dental treatment?, Majority of the

respondents in the richer quintile (23.8%), go to dental facility more than the poorer quintile

(at a p value of less than 0.05) who patronize the patent medicine dealer more (29.3%). The

richer quintile (Q4) patronize traditional healers more than the other quintile groups followed

by very poor quintile (Q2). However the poorest quintile (Q1) patronize traditional healers the

least. (P<0.05)(Table 7)

47

Table 7: Knowledge of availability of dental treatment and health seeking pattern among different SES groups

Variable N=251 X² (P value) Q1 n (%) Q2 n (%) Q3 n (%) Q4 n (%) Q5 n (%)

Knowledge of dental problems

78 (19.5)

77 (19.3)

81 (20.4)

81 (20.4)

81 (20.4)

9.75 (0.28)

Knowledge of availability of treatment for dental problems

78 (19.7)

78 (19.7)

79 (19.9)

81 (20.5)

80 (20.2)

4.23 (0.84)

Dental Health seeking: Dental health facility Traditional healer: Home treatment: Hospital: Pharmacy: Patent medicine dealer

45 (14.9) 9(9.3) 4 (25.0) 41 (21.5) 11 (17.2) 24 (29.3)

52 (17.2) 22(22.7) 4 (25.0) 47 (24.6) 19 (29.7) 18 (22.0)

67 (22.2) 17 (17.5) 0 (0) 28 (14.6) 7 (10.9) 16 (19.5)

66 (21.9) 30 (30.9) 5 (31.2) 37 (19.4) 15 (23.4) 12 (14.6)

72 (23.8) 20 (19.6) 3 (18.8) 38 (19.9) 12 (18.8) 12 (14.6)

40.3 (0.01) 18.4 (0.01) 5.00 (0.28) 10.1 (0.38) 8.18 (0.85) 6.63 (0.16)

48

Payment and coping methods among different SES groups There was no significant difference in out of pocket payment for treatment among all the SES

groups. However there were more cases of out of pocket payment with reimbursement for the

higher socio economic group while there was really no health insurance for any of the SES

groups apart from Q5 which showed some form of health insurance available. Though Q5 had

obtained some form of subsidization of treatment costs compared to the other groups there

was no significant difference among the groups (Table 8).

49

Table 8: Payment and coping methods among different SES groups

Variable N= 251 Q1 Q2

Q3

Q4

Q5

Chi-square (P value)

Payment methods n (%) n (%) n (%) n (%) n (%) Out of pocket with reimbursement

0 (0) 2 (0) 3 (42.8) 2 (28.6) 2 (28.6) 5.46 (0.24)

Out of pocket without reimbursement

42(20.5) 38(18.5) 39(19.0) 45(22.0) 41(20.0) 3.41 (0.49)

health Insurance 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) 8.79 (0.06) Installment 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 4.38 (0.35) In-kind others

1 (50) 0 (0)

0 (0) 0 (0)

0 (0) 1 (100)

1 (50) 0 (0)

0 (0) 0 (0)

2.74 (0.60) 4.16 (0.38)

Coping method Own money

41 (20.8)

36 (18.3)

39 (19.8)

41 (20.8)

40 (20.3)

2.48 (0.64)

Borrowed money 0 (0) 0 (0) 1 (33.3) 2 (66.7) 0 (0) 5.17 (0.27) Someone else paid 11 (24.4) 12(26.7) 8 (17.8) 9 (20.0) 5 (11.1) 3.45 (0.48) Exemption 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 4.03 (0.41) Subsidized payment others

0 (0) 0 (0)

0 (0) 1 (33.3)

0 (0) 1 (33.3)

0 (0) 1 (33.3)

1 (100) 0 (0)

8.75 (0.06) 1.97 (0.74)

50

At a threshold of >40% none of the SES quintiles incurred catastrophic spending. Table 9: Catastrophic spending by SES

Quintiles Incidence of

Catastrophe (%)

Q1(most poor)

Q2 (very poor)

Q3 (poor)

Q4 (average)

Q5 (least poor)

5.9

7.7

25.9

13.9

26.8

51

4.2 RESULTS FOR HEALTH FACILITY INTERVIEW Socio-demographic characteristics of exit patients

The average number of people per household was 5 with more female [200(61%)] than male

[129 (39%)] respondents. Majority of the respondents were married [178(54%)]. About a 147

(45.5%) of the respondents had secondary education, 140 (43.3%) had tertiary education.

And the minority had primary education (8.3%) and vocational training (2.9%). The major

source of household income among the respondents is Government worker (35%), followed

by artisan (18%) and business (13%). Self- employment (8%) and farming (4%) featured to a

lesser extent. The other sources of household income were private sector employment (12%)

and pension funds (10%) (Table 10)

52

Table 10: Socio-demographic characteristics of exit patients. Variables

(N= 329) No of people in Household: mean (std) 5 ( 0.128) Age last birthday: mean (std) 36 (0.867) n (%) Sex of respondent Male female

129 (39) 200 (61)

Marital status Married Single Divorced Widowed

178 (54) 135 (41) 2 (1) 11 (4)

Educational status Attended school Not attend. school

323 (98) 6 (2)

Level of education Primary Secondary Tertiary vocational

27 (8.3) 147 (45.5) 140 (43.3) 9 (2.9)

Major source of income in household Farmer Artisan Government worker Private sector Business Self employed pensioner

13 (4)` 62 (18) 114 (35) 40 (12) 42 (13) 26 (8) 32 (10)

SES Distribution of respondents Q1(most poor) Q2 (very poor) Q3 ( poor) Q4 (averagely poor) Q5 (least poor)

66 (20.1) 66 (20.1) 66 (20.1) 66 (20.1) 65 (19.8)

53

Patients’ perception on state of Dental clinic and rate of utilization of Dental

services

Patients (97%) stated that most dental clinics had convenient clinic opening hour’s. Majority of

the respondents (86%) said the clinics had appropriate number of staff and offered very

acceptable dental services (77.5%).

A large proportion of the patients knew that cleaning of teeth (73%), filling of teeth (64%)

and extraction of teeth (86%) were the services offered at the dental clinic. A lesser

proportion knew that fixing of crowns/dentures (22%) and root canal treatment (13%) were

also offered at the dental clinic. Most of them visited the dental clinic only when they had a

tooth ache (72%) or an obvious cavity in one or more teeth (36%). Patients to a lesser extent

went to the dental clinic for a routine checkup (4%) or cleaning (3%). (Table 11)

54

Table 11: Patients perception on state of Dental clinic and rate of utilization of Dental services Variables Total N=329

Open facility at last visit: n (%) Yes: No:

319 (97) 10 (3)

Attended to immediately 133 (41) Appropriate staff number 282 (86) Services at clinic: n (%) Very acceptable Acceptable Unacceptable

255 (77.5) 69 (21) 5 (1.5)

Convenient clinic hours: Mean(std) 90 (0.009) Knowledge of Services offered at facility: Cleaning of teeth: Filling of teeth: Extraction of teeth: Crowns/dentures Root canal treatment:

N=329 n* 240 (73) 210 (64) 282 (86) 72 (22) 42 (13)

Reason for attending Clinic Toothache: Routine checkup: Mouth odour: Cleaning: Swollen mouth: Bleeding gum: Shaking teeth Hole in tooth

N=329 n* 232 (72) 13(4) 6 (2) 11 (3) 22 (7) 16 (5) 13 (4) 116 (36)

*n= Multiple responses

55

Treatment received and cost of dental visit

A greater percentage of the patients had their teeth extracted (64%) when compared to those

who had their teeth filled (13.4%), cleaned (15.2%) or engaged in any other dental procedure

(7%). The average cost of treatment is 3,696.20 Naira (Table 12)

56

Table 12: Treatment received and cost of dental visit

Variables N=329 Treatment received at clinic: n (%) Extraction of teeth Filling of teeth Cleaning of teeth Others

212 (64.4) 44 (13.4) 50 (15.2) 23 (7.0)

Cost of visiting dental clinic: Mean (SD)* Treatment cost: Transport cost Total cost

3407.10 (4851.0) 245.27 (346.6) 3696.2 (5007.4)

*150Naira =1USD. All costs in Naira.

57

Utilization of Dental services by different SES groups

Toothache was a major reason for attendance at the dental clinic across all the SES groups

(P<0.05)

A greater percentage of Q1 (33.3%) and Q2 (33.3%) attended the clinic for swollen mouth

(P<0.05) when compared to the other SES groups. The higher SES groups Q4 and Q 5 went to

the dental clinic for routine checkup more than the other SES groups (35.7% and 28.6%

respectively) (Table 13)

58

Table 13: utilization of Dental services by different SES groups Variable N=329

Q1 n (%)

Q2 n (%)

Q3 n (%)

Q4 n (%) Q5 n (%)

X2 (P value)

Reason for attending Clinic Toothache: Routine checkup: Mouth odour: Cleaning: Swollen mouth: Bleeding gum: Shaking teeth Hole in tooth

54(22.9) 3(21.4) 0(0) 5(13.2) 8(33.3) 4(25.0) 5(38.5) 17(14.7)

45(19.1) 2(14.3) 0(0) 9(23.7) 8(33.3) 5(31.2) 0(0) 27(23.3)

49(20.8) 0(0) 3(50) 5(13.2) 1(4.2) 3(18.8) 1(7.7) 27(23.3)

39(16.5) 5(35.7) 2(33.3) 11(28.9) 4(16.7) 4(25.0) 5(38.5) 20(17.2)

49(20.8) 4(28.6) 1(16.7) 8(21.1) 3(12.5) 0(0) 2(15.4) 25(21.6)

9.96 (0.04) 5.59 (0.23) 0.72 (0.39) 2.33 (0.13) 3.96 (0.04) 2.21 (0.14) 8.53 (0.74) 5.31 (0.25)

59

Payment options and payment coping methods among different SES groups Out of pocket payment without reimbursement was the major form of payment across all SES

groups. Those in the poorer quintiles tended to borrow money or have someone else pay for

their treatment as compared to the richer SES. There was no significant difference in

exemption and subsidization of treatment costs across all SES groups. The fact that the

respondents in all the SES groups paid with their own money was statistically significant and

someone else paying for treatment was seen more in the poorer SES groups (P<0.05)

(Table 14)

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Table 14: showing preferred payment options and payment coping methods among different SES groups Variable N=329 (X²) P

value Payment options Q1 n(%)

Q2 n(%)

Q3 n(%)

Q4 n(%)

Q5 n(%)

Out of pocket with reimbursement

0 (0) 0 (0) 1 (20) 1 (20) 3 (60) 6.19(0.18)

Out of pocket without reimbursement

63 (20.1)

64 (20.4)

62 (19.8)

65 (20.8)

59 (18.8)

4.97 (0.2)

Insurance 2 (66.7) 0 (0) 0(0) 0 (0) 1 (33.3) 5.38 (0.25) Installment 1 (12.5) 2(25) 4 (50) 0 (0) 1 (12.5) 5.86 (0.2) In-kind 1 (50) 0(0) 1 (50) 0 (0) 0 (0) 3.00 (0.55) Payment coping method

Own money 46 (17.8)

53 (20.5)

56 (21.7)

50 (19.4)

53 (20.5)

5.53 (0.01)

Borrowed money 3 (42.9) 2 (28.6) 1 (14.3)

1 (14.3) 0 (0) 3.76. (0.43)

Someone else paid 15(28.8) 12 (23.1)

9 (17.3)

10 (19.2)

6 (11.5) 10.47 (0.001)

Exemption 1 (33.3) 2 (66.7)) 0 (0) 0 (0) 0 (0) 5.35 (0.25) Subsidized payment 1 (16.7) 1 (16.7) 0 (0) 1 (16.7) 3 (50) 4.16 (0.38)

61

CHAPTER 5

DISCUSSION

Access to dental services

The results show that majority of the household respondents (61%) had knowledge about

dental problems and also knew where they could receive treatment. Access to dental care

from our study is high, where a large percentage of the households studied had used dental

services within one year. This could however be explained by the fact that most of the

respondents in this study were well educated female urban dwellers who had an established

knowledge about dental diseases, and these factors according to previous studies can greatly

affect access and utilization of dental services.21 However it is worthy to note that this result

could also be brought about by low awareness of the preventive aspects of dental care and

with the increased prevalence of dental caries among the urbanized higher SES groups in

Africa 29 most of the respondents might have developed a dental problem which necessitated

a visit to a dental facility. This finding can also allude to the curative rather than preventive

culture of our society. Another factor that can account for increased utilization of dental

services is the increase in prevalence of diseases like HIV/AIDS which have a negative effect

on oral health and increase rate of hospital visitations due to difficulty in eating due to pain,

dry mouth, dysphagia etc.26 Thus our result is contrasting with a previous study which shows

access and utilization of dental services as being very low within Nigeria. 20, 21

Dental care seeking and utilization

From the results it was observed that majority of the respondents sought treatment in a dental

clinic (62.9%), which can be attributed to their level of education, belief that the staff in the

dental clinics were more experienced, perceived health needs or seriousness of condition, a

good percentage also visited other non-dental hospitals (13.1%) and practiced self-

medication at home (21.5%). This finding is common practice in most low income

countries.15,16 In addition it was noticed that majority of the respondents only seek dental

care when they have a dental problem such as toothache or normal masticatory functions are

62

impaired, and as such hardly ever go to the clinic for the twice yearly checkup advised by

dental surgeons. This advice is given because most dental conditions are of slow onset and it

is believed that within regular 6 monthly checkups any condition will be spotted and treated

before it progresses in severity. This can be attributed to the fact that the oral health

promotion programmes in the country are inadequate to sensitize the populace for the need to

have regular dental checkups, and the inability to integrate the oral health care delivery into all

relevant health programmes, and flag off the oral health component of primary health care

delivery services in the country.46 This health seeking pattern is corroborated by previous

studies which observed that visits to a dental care facility in most developing countries are

undertaken for mostly symptomatic reasons. 10, 11, 12, 13

Barriers to access and utilization of dental care

In examining the factors that constitute barriers to accessing dental care, our study shows that

attitude of staff in the facilities, the clinic environment and high treatment cost and to a lesser

extent distance to the health facility all affected access. In this light the results have

highlighted the fact that so many different factors come into play in accessing oral health

services and one factor alone might not be enough to constitute a barrier. This is because

access to healthcare services is a general concept summarizing a set of more specific

dimensions, such as availability which refers to location of health services, affordability, which

is the ability of consumers to pay for health care services, and acceptability which is related to

individuals perceptions of the nature of health services, and the way and level to which

organization of healthcare meets clients expectation. 35, 36

It was also observed that most of the respondents (78.5%) paid for dental treatment with

their own money and there was little or no form of healthcare financing mechanism to

alleviate the burden of the cost of treatment. This alludes to the lack of a good health system

in the country with little or no financial risk protection for oral health. 46 This emphasizes the

shortfall of the National health insurance scheme (NHIS), which though as it relates to oral

health; is supposed to cover only preventive and routine dental care does not do this.46 This

also alludes to a previous study which observed that gross underfunding of the health sector

63

resulting in lack of exemptions and subsidies for the poor which inadvertently increases the

cost the consumers have to bear can constitute a major barrier to access an36.

Access to health care can be explored through the option of availability of care and knowledge

about this availability. From our study, most of the respondents (97.8%) claimed to have

knowledge about dental problems and where they can be treated (97.5%). But it was

observed that the richer SES group tended to go to the dental clinics more than the poorer

group who patronized the patent medicine dealers (PMD) for toothache. This finding could be

caused by a myriad of factors. For example, the cost of treatment which in non dental clinic

settings, would take the form of purchase of drugs, would be cheaper in the PMD’s than the

dental clinics and also most PMD’s are located in residential areas making it more convenient

for the respondents to access care in them without necessarily spending on transport. This can

be corroborated by a study which observed that differences in access between individuals,

may cause variations in the use of health services38 although these variations in use may occur

in people with equal access because the individuals often times make different choices when it

comes to using health services.

In examining the factors that have a significant association with accessing and utilizing dental

care, our study shows that the educational status of the respondents, belief that there are

more experienced staff in a facility, cost of treatment, immense pain and perceived

seriousness of an illness is associated with utilization patterns. In this light the results have

highlighted the fact that so many different factors come into play in accessing oral health

services and one factor alone might not be enough to constitute a barrier or an incentive to

access dental care. This finding is corroborated by another study which observed that a

person’s use of health services usually depends in part to their socio demographic

characteristics like marital status, gender, educational level, occupation, income, their health

beliefs and attitudes, knowledge of the service being offered and the individuals perceived

health need. 38

64

Access and utilization of dental services among different socio-economic groups

The findings that the richer SES seemed to patronize traditional healers more than the poorer

SES; goes to buttress the fact that an individual’s beliefs irrespective of the SES group affects

the way a service is accessed or utilized. This also points to the fact that self medication with

herbal medicines or modern drugs seems to be common practice in most African countries.34

Even though majority of the respondents claim to know about dental problems and where

treatment can be obtained does not mean that they will go to the right place. However the

fact that they know about where they can obtain treatment means that in a way they have

access to dental service but are just not utilizing the service.

Out of pocket payment (OOP) is the major form of payment in Nigeria for health services, and

our results (94.4%) point to that fact and no socio-economic class is exempted from this as it

cuts across the socio-economic divide. The few people in the study who claimed to have their

payment for treatment reimbursed would most likely be Federal Government workers (formal

sector); who are the only people to as of now benefit from the country’s National Health

Insurance Scheme (NHIS). Majority of those in the poorer SES group who could not afford to

pay for treatment coped with the bills by having someone else pay for them. This will further

reduce access and utilization of dental services and also account for the fact that most people

go to the dentist only when they are in pain or feel there is a problem. Since the health

insurance scheme in the country has not yet been fully integrated into the dental sector, the

respondents are still paying OOP and in cases where they can’t afford the treatment they

either borrow or get someone else to pay for them; possibly a relation.

Majority of the respondents know the services being offered at the dental clinic; and that

cleaning, filling and extraction of teeth (73%, 64%, 86% respectively) are the major treatment

services being offered. Despite this knowledge, a large percentage of the respondents only

visit the dental clinic when they have a tooth ache (72%) or hole in the tooth (36%). Only

very few visit the dentist for regular checkups or cleaning. This can be demonstrated by the

fact that majority of the patients that went to the dental clinic had their teeth extracted

(64.4%). This could be because they were ignorant of existing services which can contribute

65

to poor utilization. However the cost of treatment and an individual’s perceived treatment need

can also contribute to poor utilization. Most patients only learn about the existence of

restorative and preventive dental treatment after they have visited a clinic to extract one or

more teeth. This is corroborated by observations from other studies that patients only visit the

dental clinic for symptomatic reasons10,11,12,13 The need for integration of preventive dental

services into routine primary health services cannot be overemphasized and the need for

awareness not only of oral diseases or where to receive treatment, but there is also a need to

raise awareness on also the preventive as well as the restorative aspect of dentistry, i.e. ‘what

to do if you have already developed a hole in the teeth to prevent numerous extractions’

Hence there is no significant difference in utilization of dental services among different

socioeconomic groups in this study.

Limitations of the study:

The study was carried out in an urban setting and this might account for the seemingly high

access and utilization rate bearing in mind that most good dental services are found mainly in

urban areas. Thus results can only be extrapolated to urban settings.

Further studies will need to be done to compare rural with urban findings.

Conclusion:

This study shows that access to dental services is high as evidenced by the high knowledge

generally of dental problems and availability of dental services. However most of the

respondents sought treatment in numerous other places apart from the dental clinic perhaps

due to the ignorance of services being rendered in those facilities and the tendency to take the

cheaper option of care. The major barrier to access is cost and most importantly utilization of

the available services is hampered by the attitude of the health workers, cost of seeking care

in a dental clinic and individual variations in perceived need of care.

There is no difference in access and utilization of dental services among different

socioeconomic groups because ignorance for the reasons for regular dental checkups is

common among all SES groups. Likewise there is a high emphasis on curative rather than

66

preventive approach to healthcare, and majority of respondents regardless of their

socioeconomic class seek care only when symptoms of disease are present.

Recommendations

• It is expedient that the oral health policy which has been recently revised should be

implemented to fast track the integration of preventive dental care into the primary

health programme, and improve awareness while emphasizing the need for preventive

dentistry.

• It is recommended that a comprehensive health insurance package which covers oral

diseases should be put in place so as to help reduce the cost of dental treatment.

• Training of healthcare staff in interpersonal communication should also be pursued

because staff attitude has been observed to be a barrier also to access and utilization.

• Researchers should collaborate with policy makers in the form of feedback workshops

or policy briefs so that research evidence would play a greater role in informing the

planning of subsequent oral health policies

67

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Certificate of consent for study on Access and Utilization of routine Dental treatment services in Enugu State. Interviewer: I would like to ask you about how you access and use dental services in this city. We shall not give you any money for participating in this study; however whatever information you give us will help to improve dental treatment services in Enugu state and make it easier for people to use it thereby increasing the oral health status of the people of Enugu State. Respondent: I was called to participate in this study about access and utilization of dental treatment services in Enugu State. I have read the consent form/information on the consent form has been read to me. I had opportunity to ask questions and the questions that were asked of me, I answered to the best of my ability. I volunteered on my own to be a part of the study. I also know that I can withdraw from this study at anytime and this withdrawal will not affect me or my household. Print Name of Respondent Date and signature of Respondent ------------------------------- ----------------------------------------------- If illiterate Print Name of independent illiterate witness (If possible this person should be selected by the Participant and have no connection to the research team) Print Name of Researcher/Interviewer Date and Signature of Researcher/Interviewer ---------------------------------------------- ----------------------------------------

73

74

ACCESS AND UTILIZATION OF DENTAL SERVICES IN ENUGU STATE HOUSEHOLD QUESTIONNAIRE Instructions for enumerator: please fill this next section at the beginning of the interview Questionnaire code: ------- district code ---------- S/no --------- Date of interview ----------------------------- Interview start time -------------------- Respondent’s home address------------------------------ Good day Sir/madam my name is ----------------------- I am a trained fieldworker from the Health Policy Research group College of Medicine University of Nigeria Enugu Campus. We are conducting a study to find out how people access and utilize dental healthcare services. We would like to find out your knowledge about dental problems and where you seek for treatment and also how you use the services available to you. We would like to assure you that your identity will be kept confidential during the research process and your participation is voluntary and you do not have to answer any question you do not want to, however it will be useful for our study so as to find ways to improve on the oral health of your household and community. If you have any questions you may ask them now or later. Thank you. (enumerator obtain consent ) I would now like to ask you a few questions about yourself and your household. Section A Demographic information

1. How many people live in your household including yourself [ ]

2. How many adults live in this household (greater than 18 yrs)? [ ]

3. How many children live in this household less than 5 yrs [ ], 5- 17yrs [ ]

4. Sex of respondent : Male =1, Female = 0 [ ]

5. Age of respondent (at last birthday) [ ]

6. What is your current marital status [ ] ; Single =1, Married =2, Divorced =3, Widow

=4, Separated = 5

7. What is your religion: Christianity=1, Islam=2, traditional religion=3 [ ]

Other = 4 specify …………………………………………..

8. Have you ever attended school? [__] 0=no, 1=yes, (if no go to question 11)

9. What was your highest completed education level? 1=yes, 0=no

75

9a.Primary [ ] 9b.junior secondary [ ] 9c.Senior secondary [ ] 9d.University [ ] 9e.Teachers training college [ ] 9f. Other [ ] Specify ------------

10. What was the number of years you spent schooling? [ ] years

11. What occupation is the major source of income in this household? [ ](please record the number corresponding to only one option in the box)

1. Unemployed 2. Farmer 3. Artisan/Petty trading 4. Government worker 5. employed in private sector 6. Big business 7. Self-employed professional 8. Other Specify ----------------------

12. I would like to know how long you have lived in this town. [ ]years

SECTION B: ACCESSIBILITY AND UTILIZATION OF DENTAL SERVICES ACROSS DIFFERENT SOCIO-ECONOMIC GROUPS: Knowledge about dental problems (Enter 1=yes or 0=no, 2= don’t know. except where indicated otherwise)

13. Do you or any member of your household have any knowledge about dental problems [ ]

14. Do you know if treatment for dental problems are available [ ] (if no go to question 16)

15. Where do you know think these services can be obtained? (multiple answers allowed)

a. Dental health facility [ ] b. Traditional healer [ ] c. Home treatment [ ] d. Hospital [ ] e. Pharmacy [ ] f. Patent medicine dealer [ ] g. other [ ] specify ……………………………

16. Have you or any of your household members’ ever experienced dental problems? [ ] (if no go to question 46)

17. If yes please when was your last dental experience or that of any member of your household [ ] (months)

18. Where did you or any member of your household go to receive dental care? (multiple answers allowed)

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a. Dental health facility [ ] b. Traditional healer [ ] c. Home treatment [ ] d. Hospital [ ] e. Pharmacy [ ] f. Patent medicine dealer [ ] g. Other [ ] specify ……………………………

19. What influenced your choice of where to receive care? (multiple answers allowed) a. Cost of treatment is cheap [ ] b. The problem was very serious [ ] c. It was recommended by a friend [ ] d. They have very experienced staff [ ] e. It is close to my house [ ] f. other [ ] specify ----------------------- 20. Why did you decide to receive dental care? (multiple answers allowed) a. I couldn’t eat well [ ] b. I was in serious pain [ ] c. My teeth were shaking [ ] d. My mouth was swollen [ ] e. The drugs I took did not stop the pain [ ] f. My mouth was smelling [ ] g. Other [ ] specify --------------------------------------- 21. Do you have any dental health facility where you go to for treatment? [ ] (if no go to question 39) 22. What were your reasons for going to that particular facility (multiple answers allowed) a. It was recommended by a friend [ ] b. I was referred there by my doctor [ ] c. It is close to my house [ ] d. Doctor is always available [ ] e. I can get there easily [ ] f. Availability of drugs [ ] g. Don’t know [ ] h. Other [ ] specify ---------------------------------------

77

23. How often do you go to the dental health facility? a. Regular 6 monthly checkup [ ] b. Once a year [ ] c. Only when I have toothache [ ] d. To clean my teeth [ ] e. Whenever I have any dental problem [ ] f. I have not gone to any [ ] g. Other [ ] specify ------------------------ 24. When last did you go to the dental health facility? [ ] months, [ ] yrs 25. What dental problem took you to the dental health facility (multiple answers allowed)

a. Toothache [ ] b. Routine checkup [ ] c. Bad breathe [ ] d. Came for cleaning [ ] e. Swollen mouth [ ] f. Bleeding gum [ ] g. Shaking teeth [ ] h. Hole in tooth [ ] i. Others [ ] specify ------------------------

26. The last time you went to the dental health facility was it open? [ ] 27. How long did you wait before you were attended to? [ ] minutes 28. Are the opening and closing times convenient for you? [ ] 29. Do they offer emergency services? [ ]

30. Do you think there was enough staff to attend to people’s need [ ] 31. How do you assess the dental services that are rendered in the facility? [ ] ( please note only one answer is allowed. Record number of correct answer in box) 1. Very acceptable 2. Acceptable 3. Unacceptable 4. Very poor

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32. How would you assess the attitude of the staff to the patients? [ ] (enumerator please note only one answer is allowed. Record number of correct answer in box) 1. Excellent 2. Good 3. Bad 4. Very bad 33. How was the clinic environment? [ ] (enumerator please note only one answer is allowed. Record number of correct answer in box) 1. Very neat 2. Fairly neat 3. Dirty 4. Very dirty 34. Were you satisfied with the facility’s infection control practices like sterilization?[] 35. Do you think the staff there were qualified enough to treat you? [ ] 36. Were you satisfied with the quality of treatment you receive there? [ ] 37. If you have another dental problem will you still go to the same dental clinic? [ ] (if yes go to question 39) 38. What are the things that will stop you from going there for treatment again? (let the patient answer freely)

a. The clinic is far from where I live [ ] b. The staff are not well mannered [ ] c. The cost of treatment here is high [ ] d. They never have light [ ] e. Others [ ] specify ------------------------------------

39. How much did you pay for the following: (in Naira) a. Registration/card [ ] c. Drugs [ ] d. X-ray [ ] e. Treatment received [ ] specify type of treatment ------------------ f. Others [ ] specify --------------------- g. Did not pay [ ] h. Total treatment cost [ ]

40. How far is this treatment facility/dental facility from your house (please list options if no answer is given)

a. 5km [ ] b. 5-10km [ ] c. greater than 10km [ ] d. Don’t know [ ]

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41. How did you get to this clinic/ treatment facility? 1=yes, 0=no a. I Walked [ ] b. Public transport [ ] c. Own transport [ ] d. Bike (okada) [ ] e. Other [ ]

42. How much did it cost you to get to and from the clinic? [ ] 43. Total cost (add Q39h and Q42)-------------------------------------

PAYMENT OPTIONS and PAYMENT COPING MECHANISM (enumerator please answer1=yes and 0=No, unless asked otherwise)

44. How did you pay for treatment? (enumerator may read options for respondent) a. Out of pocket with reimbursement [ ] b. Out of pocket without reimbursement [ ] c Insurance [ ] d Installment [ ] e. In kind [ ] f. others[ ] specify …………………………….

45. How did you cope with the payment. (Respondent can either answer yes or no to each option and multiple answers are allowed)

a. Own money [ ] b. Borrowed money [ ] c. Someone else paid [ ]

d. Was exempted from payment [ ] e. Payment was subsidized [ ]

f. Others [ ] (specify) -------------------------

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SECTION C: TO DETERMINE SOCIO-ECONOMIC STATUS OF RESPONDENT Household consumption Expenditures on food items 46a. Please we would want to know about your household food consumption in the last One week (interviewer to read list and record the corresponding amount) Items What

quantity How much Weekly

consumption of food items (cost)(Naira)

Rice

Beans

Garri

Yam

Cassava

Fish

Meat

Vegetables

Others

Total

46b. If the food items consumed in the last one week were produced by the household, how much would it be worth in the market if you were to sell them. Item Quantity Amount Total (

Qty×Amt)

Rice Beans Garri Yam Cassava Fish Meat Vegetables Others (name) Total 46c. Total food cost: interviewer to add 46a + 46b [ ] Naira

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Expenditures on non-food items 46d. How often does your household spend money on the following items and how much do they spend. Item Period codes

Weekly = 1, monthly = 2, quarterly = 3, bi-annually = 4, Annually = 5

Amount Spent Annual expenditure (interviewer to add up)

a. Clothing b. Rent c. Cooking fuel d. Healthcare e. Educational expenses

f. Other expenses (describe

g. TOTAL

SECTION D: Household characteristics and asset holding (Throughout this section 1= Yes 0 = No, 2= refuses to answer)) (Interviewer to read list, multiple answers allowed)

47. Does your household own any functional household item? a. Motorcycle [ ]

b. Motor car [ ] c. Bicycle [ ]

d. Radio [ ] e. Television [ ] f. Gas cooker [ ] g. Kerosene stove [ ] h. Iron [ ] i. Kerosene lamp [ ] j. Refrigerator [ ] k. Generator [ ]

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47. How many rooms are there in total in this house? [ ]

48. How many are used for sleeping? [ ]

49. What is your main source of drinking water? a. Private pipe [ ] b. Public pipe [ ] c. Well [ ] d. Water tanker supplies [ ] e. Rainwater [ ] f. sachet water [ ] g. Other (describe) [ ] 50. What kind of toilet facility do you have in your household? (1=yes, 0=no) a. Pit [ ] b. water system (flush toilet) [ ] c. Bush [ ] d. Others [ ] (describe) --------------------------------

51. Does your household share these toilet facilities with other households [ ]

0 = No 1 = Yes 2= refuses to answer 52. Is the place where you live? a. owned by you [ ] b. rented [ ] c. company owned [ ] d. Other [ ] -----------------------------------------

53. What material is the wall of your house made of? a. Mud [ ] b. Wood [ ] c. Concrete blocks [ ] d. Corrugated zinc [ ] e. Brick [ ] f. Don’t know [ ] g. Other [ ] (please specify)--------------------------------

THANK YOU. Enumerator to record time that interview ended ……………..

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INSTRUMENTS FOR ACCESS AND UTILIZATION OF DENTAL SERVICES IN ENUGU EXIT POLL QUESTIONNAIRE Instructions for enumerator: please fill this next section at the beginning of the interview Code: -------------------- Facility code ---------- S/no --------- Date of interview --------------------------------- Interview start time -------------------- Good day Sir/Madam My name is --------- ------------------------------ I am a trained fieldworker from the Health Policy Research group College of Medicine University of Nigeria Enugu Campus. We are conducting a study on the access and utilization of dental healthcare services in Enugu State. We would like to assure you that your identity will be kept confidential during the research process and your participation is voluntary and so you do not have to answer any question you do not want to. However it will be useful for our study if you do, so as to find ways to improve on the oral health of the citizens of Enugu State. If you have any questions you may ask them now or later. Thank you. (enumerator obtain consent ) I would like to ask you a few questions about yourself and your household. Section 1 Demographic information

1. How many people live in your household including yourself [ ]

2. How many adults (18 yrs and above)? [ ]

3. How many children live in your household less than 5 yrs [ ], 5- 17yrs [ ]

(no= 1, yes =2)

4. Sex of respondent : Male =1, Female = 0 [ ]

5. Age of respondent (at last birthday) [ ]

6. Marital status [ ] ; Single =0, Married =1, Divorced =2, Widow =3, Separated = 4

7. Religion: Christianity=0, Islam=1, traditional religion=2 [ ]

Other = 3 specify ………………………………………….. 8. Have you ever attended school? [ ] (0=no, 1=yes)

9. What was your highest completed education level? (1=yes, 0=no)

9a.Primary [ ] 9b.junior secondary [ ] 9c.Senior secondary [ ] 9d.University [ ] 9e.Teachers training college [ ] 9f. Other [ ] Specify ------------

10. What was the number of years you spent schooling? [ ] years

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11. What occupation is your household’s major source of income? please record the

number corresponding to only one option in the box) [ ]

1. Unemployed 2. Farmer 3. Artisan/Petty trading 4. Government worker 5. Employed in private sector 6. Big business 7. Self-employed professional 8. Other Specify ------------------------- 12. I would like to know how long you have lived in this town. [ ] year SECTION B: ACCESSIBILITY AND UTILIZATION OF ROUTINE DENTAL SERVICES ACROSS DIFFERENT SOCIO-ECONOMIC GROUPS Knowledge about dental problems (Enter 1=yes or 0=no, 2= don’t know. except where indicated otherwise)

Please I would like to ask you a few questions about how and where you seek dental treatment and also how you access these services

13. In your opinion is this clinic well located as to encourage easy access? [ ] 14. Is this where you normally come for dental treatment? 1=yes, no=0 [ ] 15. When you got to the dental clinic was the clinic open [ ] 16. Did you get attended to immediately [ ] (if yes go to question 18) 17. If no how long did you wait before you were attended to [ ] minutes 18. Are the clinic working hours convenient for you [ ] 19. Are they open after normal working hours [ ] 21. Do they offer emergency services [ ] 22. Do you think there are enough staff to attend to people’s needs [ ] 23. Do you know which types of services are being offered in this facility? (Ask respondent to mention them. Multiple answers are allowed) a. Cleaning of teeth [ ] b. Filling of teeth [ ] c. Extraction (removal) of teeth [ ] d. Crowns/dentures (artificial teeth) [ ] e. Root canal treatment (filling roots of teeth) [ ] f. Others [ ] please specify -----------------------------------

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24. What made you come to the dental clinic today (multiple answers allowed) a. I had toothache [ ] b. Routine checkup [ ] c. Bad breathe (my mouth is smelling) [ ] d. Came for washing and cleaning of teeth [ ] e. My mouth was swollen mouth [ ] f. Bleeding gum [ ] g. Shaking teeth [ ] h. Hole in tooth [ ] i. Others [ ] specify ------------------------ 25. When did the problem start? a. Yesterday [ ] b. A few days ago [ ] c. Last week [ ] d. 2 weeks ago [ ] e. A month ago [ ] f. Others [ ] specify ------------------ 26. Did they handle all your dental health needs or were you referred elsewhere for some treatments? [ ] 27. What are your reasons for attending this particular clinic? 1=yes, no=0 a. Recommended by a friend [ ] b. I was referred there by my doctor [ ] c. It is close to my house [ ] d. Doctor is always available [ ] e. I can get there easily [ ] f. Availability of drugs [ ] g. Don’t know [ ] h. Other [ ] please specify -------------------------------------------------------- 28. How often do you visit the dental clinic ? a. Regular 6 monthly checkup [ ] b. Only when I have toothache [ ] c. To clean my teeth [ ] d. Other [ ] please specify ---------------------------------------------------- 29. How would you assess the dental services that are rendered in this facility? [ ] (enumerator please note only one answer is allowed. Record number of correct answer in box) 1. Very acceptable

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2. Acceptable 3. Unacceptable 4. Very unacceptable 30. How long did you have to wait before being attended to [ ] minutes 31. How would you assess the attitude of the staff to the patients? [ ] (enumerator please note only one answer is allowed. Record number of correct answer in box) 1. Excellent 2. Good 3. Bad 4. Very bad 32. Did the doctor inform you about your treatment options and involve you in the treatment planning? [ ] 1= yes; 0 = no 33. How is the clinic environment? [ ] (enumerator please note only one answer is allowed. Record number of correct answer in box) 1. Very neat 2. Fairly neat 3. Dirty 4. Very dirty 33. Are you satisfied with the facility’s infection control practices like sterilization? [ ] 1=yes, 0=no 34. Do you think the staff here are qualified enough to treat you? [ ] 35. Are you satisfied with the quality of treatment you receive here? [ ] 36. If you have another dental problem will you come to this dental clinic? [ ] If yes go to no 38 37. What are the things that will stop you from coming here for treatment again? [ ] (let the patient answer freely) a. The place is far from where I live [ ] b. The staff are rude [ ] c. The cost of treatment here is high [ ] d. There is never electricity [ ] e. Dirty environment [ ] f. Other [ ] please specify ------------------------------------------------ 38. Would you recommend this dental clinic to anybody [ ] 39. How much do/did you pay for the following? a. Registration/card [ ] Naira b. Consultation [ ] Naira c. Drugs [ ] Naira d. X-ray [ ] Naira

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e. Treatment received [ ] specify type of treatment ------------------ f. Other [ ] specify --------------------- g. Total cost [ ] 40. How did you get to this clinic? a. I walked [ ] b. Public transport [ ] c. Own transport [ ] d. Motorbike (okada) [ ] e. Other [ ] please specify ------------------------------------------------ 41. How much did it cost you to get to and from the clinic? [ ] Naira 42. How far is this facility from your house (please list options if no answer is given)

a. 5km [ ] b. 5-10km [ ] c. greater than 10km [ ] d. Don’t know [ ]

43. Total cost (add Q38g and 40e) -------------------------------------(Naira)

PAYMENT OPTIONS and PAYMENT COPING MECHANISM (Please answer 0=no, 1=yes and 2=don’t know. Unless otherwise specified)

44. How did you pay for treatment? a. Out of pocket with reimbursement [ ] b. Out of pocket without reimbursement [ ] c. Insurance [ ] d. Installment [ ] e. In kind [ ] f. Other [ ] specify ……………………………. 45. How did you cope with the payment? (Respondent can either answer yes or no to each option and multiple answers are allowed) a. own money [ ] b. Borrowed money [ ] c. someone else paid [ ] d. was exempted from payment [ ] e. payment was subsidized [ ] f. other [ ] (specify) -------------------------

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SECTION C: TO DETERMINE SOCIO-ECONOMIC STATUS OF RESPONDENT (Please answer 0=no, 1=yes and 2=don’t know. Unless otherwise specified)

Household characteristics and asset holding (Interviewer to read list) 46. Does your household own any functional household item?

a. Motorcycle [ ] b. Motor car [ ] c. Bicycle [ ] d. Radio [ ] e. Television [ ] f. Gas cooker [ ] g. Kerosene stove [ ] h. Iron [ ] i. Kerosene lamp [ ] j. Refrigerator [ ]

47. How many people live in your household including yourself? [ ]

48. How many rooms are there in total in your house? [ ]

49. How many are used for sleeping? [ ]

50. What is your main source of drinking water?

a. Private pipe [ ]

b. Public pipe [ ]

c. Well [ ]

d. Water tanker supplies [ ]

e. Rainwater [ ]

f. Other (describe) [ ]

51. What kind of toilet facility do you have in your household? a. Pit [ ] b. water system (flush toilet) [ ] c. Bush [ ] e. Other [ ] (describe) --------------------------------

52. Does the patient share these toilet facilities with other households [ ]

53. Is the place where you live?

a = owned by you [ ] b = rented [ ] c = company owned [ ]

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54. What material is the wall of your house made of? h. Mud [ ] i. Wood [ ] j. Concrete blocks [ ] k. Corrugated zinc [ ] l. Brick [ ] m. Don’t know [ ]

n. Other [ ] (please specify)--------------------------------

THANK YOU. Enumerator to record time that interview ended ……………..