|Year : 2018 | Volume
| Issue : 1 | Page : 1-6
Knowledge and attitude towards dental insurance and utilization of dental services among insured and uninsured patients: A cross-sectional study
Radhika Maniyar, GK Umashankar
Department of Public Health Dentistry, M R Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||2-Feb-2018|
Department of Public Health Dentistry, M R Ambedkar Dental College and Hospital, # 1/36, Cline Road, Cooke Town, Bengaluru - 560 005, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: To assess the awareness and attitude towards dental insurance, and trends in utilization of dental services among insured and uninsured patients visiting a dental hospital in Bengaluru city.
Materials and Methods: A cross-sectional study was conducted among 200 patients visiting Dental College in Bengaluru; of which, 100 patients were insured under Employees' State Insurance Scheme and 100 were uninsured. A face-to-face interview was carried out to collect information on sociodemographic data, knowledge, and attitude toward dental insurance and utilization of dental services among insured and uninsured groups. Collected data were analyzed using descriptive statistics and Chi-square test.
Results: Among the insured group, only 29% had the knowledge about the total dental services covered in their insurance plan. Among the uninsured, only 4% were aware of the dental insurance integrated with health insurance plan. Dental treatment was perceived costly by 30% among insured and 81% among uninsured group. Among insured, 84% reported that dental insurance has benefitted them by reducing the financial burden and making the treatment easily available. Among uninsured, 74% believed that dental insurance can be beneficial to them. Statistical significant difference was obtained when overall attitudes among insured and uninsured groups were compared (P < 0.05). About 70.6% among insured and 49.3% among uninsured utilized dental services in the past 6–12 months.
Conclusion: Knowledge regarding dental insurance was poor in both groups, while the insured group showed a more positive attitude toward benefits of dental insurance. Utilization of dental services was seen more among insured group.
Keywords: Dental insurance, dental services, knowledge, utilization
|How to cite this article:|
Maniyar R, Umashankar G K. Knowledge and attitude towards dental insurance and utilization of dental services among insured and uninsured patients: A cross-sectional study. J Oral Res Rev 2018;10:1-6
|How to cite this URL:|
Maniyar R, Umashankar G K. Knowledge and attitude towards dental insurance and utilization of dental services among insured and uninsured patients: A cross-sectional study. J Oral Res Rev [serial online] 2018 [cited 2018 Aug 18];10:1-6. Available from: http://www.jorr.org/text.asp?2018/10/1/1/224543
| Introduction|| |
The economic growth of a country depends on the empowerment of people, which is highly reliant on the freedom they enjoy from poverty, hunger, malnutrition, and freedom to work which ultimately leads to healthy and productive life. Thus, health care becomes a fundamental necessity for human well-being. Oral health is central to a person's overall health, rightly called as the gateway of the body.
Oral diseases restrict activities in school, at work, and at home causing millions of school and work hours to be lost each year worldwide. Moreover, the psychosocial impact of these diseases often significantly diminishes the quality of life. Despite great achievements in the oral health of populations globally, problems still remain in many communities around the world - particularly among underprivileged groups, especially in developing countries. India being the second most populous country in the world accounts for 21% of the world's global burden of disease. Although impressive advance has occurred in addressing communicable diseases, noncommunicable diseases are still emerging which are responsible for two-thirds of the total morbidity burden. Dental diseases are one of the most common noncommunicable diseases, and dental treatment is considered to be the fourth most expensive treatment.
The escalating cost of dental treatment has been an important barrier in the utilization of these services in developing countries, especially like India, where two-thirds of the population resides in rural areas. People visit dentists only for curative services. While India has the fastest growing population, an ambitious growth aspiration, it has always had a disproportionately smaller health budget. Good health is supposed to be a national goal in itself, but unfortunately, India spends only 1.3% of its gross domestic product on healthcare sector. The government spending on dental care is barely minimal or nonexistent in India. Consequently, people are forced to go to private providers, resulting in substantial out-of-pocket expenditures. Thus, fee-for-service is still the major type of payment mechanism. The poor lack the resources to pay for it; they are far more likely to avoid going to care resulting in the further progression of dental diseases.
India serves as a home for around 47 crore workers which come from the unorganized as well the organized sector of the industry. To ensure the health protection of these working class individuals, health financing through social health insurance through mixed financing mechanisms – a combination of payroll contributions to include the middle class and formal sector workers and funds from general revenues of the government – pooled into a single fund that becomes available for healthcare financing in the country have been stressed on which led to introduction of schemes such as Employees' State Insurance (ESI) and Central Government Health Scheme (CGHS). These schemes include expenses covered for dental treatment as well.
Unlike most western countries, specific dental insurance plans are not common in India. Dental insurance is still in its nascent stage. It is usually integrated with general health insurance schemes.
However, if dental insurance is made available, people would be more than ready for seeking preventive and prophylactic care, thus reducing the burden of oral disease and future expenses. It will also make dental treatment more affordable, proving to be a boon for one and all.
Since there is a paucity of data on dental services being covered under social health insurance in the Indian scenario, an attempt is made here to assess the awareness, attitude toward dental insurance, and trends in utilization of dental services among insured and uninsured patients visiting a dental hospital in Bengaluru city.
| Materials and Methods|| |
A cross-sectional study was conducted among 200 patients in the age group of 20–60 years visiting dental college and hospital in Bengaluru. The study population consisted of two groups: insured and uninsured. Insured group comprised of patients insured under ESI Scheme since the hospital is empanelled with Employee's State Insurance Corporation (ESIC). The other group comprised of uninsured patients visiting the outpatient department of the hospital. The sample size was calculated based on the number of ESI patients visiting the hospital in 1 month, with a confidence interval of 95% and precision level of 5%. Both groups consisted of 100 individuals each respectively. Ethical clearance was obtained from the Institutional Review Board of the college. A written informed consent was obtained from the individuals who were willing to participate in the study.
A structured questionnaire was developed to assess the awareness, attitude toward dental insurance, and utilization of dental services. It was both in English and translated into the local language to ensure comprehension by all the patients. It was self-administered to the patients. Content validity was done using Aiken's V index which was 0.85, and Cronbach's alpha was 0.74 indicating good reliability.
The questionnaire consisted of two parts:
- Part 1: Consisted of sociodemographic details which included age, gender, and socioeconomic status
- Part 2: Consisted of multiple choice questions assessing their awareness, attitude toward dental insurance, and utilization of dental services.
The statistical analysis was performed using SPSS version 16.0 (IBM Corp). Descriptive statistics were performed to assess the awareness, attitude toward dental insurance, and utilization of dental services. The influence of dental insurance on utilization of dental services between the two groups was compared using a Chi-square test.
| Results|| |
The study participants comprised of insured group which included 100 patients insured in the social security scheme, i.e., ESI Scheme visiting the service clinic of the hospital and the uninsured group which included 100 patients visiting the outpatient department of the hospital. The sociodemographic details are presented in [Table 1]. Regarding the gender, almost equitable distribution was seen among both groups. The age of the participants ranged from 20 to 60 years with the majority of the participants belonging to the age group of 30–39 in the insured group and 30–49 years in the uninsured group. The majority of the participants belonged to the upper middle class followed by lower middle and lower class among the insured group, whereas the majority of them belonged to upper middle class followed by lower middle class among the uninsured group.
|Table 1: Distribution of demographic characteristics of the study participants|
Click here to view
The responses of the participants regarding awareness about dental insurance plans are depicted in [Table 2]. All of the participants among the insured group were aware about the social health insurance schemes such as ESI Scheme and CGHS. Apart from this, only 20% of them were aware of the general health insurance plan, whereas only 5% of them were aware of the dental insurance integrated with health insurance followed by 2% who were aware of the reimbursement plans like the ones offered by the corporate companies. Among the uninsured group, 34% of them were aware of the general health insurance plans, whereas only 4% and 5% of them were aware of the dental insurance integrated with health insurance plans and reimbursement plans, respectively.
|Table 2: Responses of study participants regarding awareness about dental insurance plans|
Click here to view
Dental treatment was perceived costly by almost more than two-thirds (81%) of the participants among the uninsured group, whereas only one-third (30%) of the participants among the insured group felt the same.
The responses of participants regarding attitude toward dental insurance are depicted in [Table 3]. More than three-fourths (84%) of the participants among the insured group reported that dental insurance has benefitted them. Among them, the majority of the participants (26%) reported that it has reduced financial burden, 11% reported that it has made the treatment easily available, 5% believed that it has helped people in seeking treatment at initial stages, 2% believed that it has reduced the inequality between rich and poor while 39% of the participants agreed that it has helped in multiple ways as mentioned above.
|Table 3: Distribution of the responses regarding questions related to the attitudes of participants toward dental insurance|
Click here to view
In response to the same question, almost three-fourths of the participants (74%) agreed that dental insurance could be beneficial to them. Among them, majority of the participants (27%) agreed that it could help in multiple ways, followed by 22% who believed that dental insurance would reduce the financial burden, 16% of them believed that it could make treatment easily available while 8% agreed that it could reduce the inequality between rich and poor and 1% agreed that it would help seeking the treatment at initial stages.
In response to the question whether government should introduce a dental insurance plan in India, almost three-fourths of the participants among both groups (I = 76%; UNINS = 75%) responded positively.
Regarding question on the dental insurance premium, almost more than three-fourths (84%) of the participants among the insured group and equivalent to three-fourth (75%) among the uninsured group agreed that it should be kept low so as to make the treatment affordable.
Almost more than three-fourth of the participants (83%) among the insured while about two-thirds of the participants (67%) among the uninsured group agreed that government should subsidize the insurance premium for the ones who cannot afford.
In response to the question, whether there should be tie-up with corporate hospitals for the treatment of poor patients, nearly more than three-fourths (78%) of the participants among the insured group responded positively whereas only 39% of the participants among the uninsured group agreed upon it.
[Figure 1] represents the dental services utilized in the last dental visit. It was seen that about half of the participants among the insured group (50%) had undergone endodontic treatment followed by 11% utilizing multiple dental services while only 5% had undergone tooth extractions and only 2% had visited for diagnostic purpose. While among the uninsured group, more than one-fourth of the participants (30%) had undergone endodontic treatment followed by 22% who had undergone tooth extractions. About 11% among the insured whereas 16% among the uninsured group had utilized multiple services.
|Figure 1: Utilization of dental services among insured and uninsured groups|
Click here to view
[Table 4] shows that the association between the insurance coverage and utilization of dental services was highly significant (P ≤ 0.001) suggesting that utilization of dental services was more by the insured individuals as compared to uninsured individuals.
|Table 4: Association between insurance coverage and utilization of dental services among study participants|
Click here to view
| Discussion|| |
The majority of the studies based on the insurance coverage and its impact on utilization of oral health-care services have been conducted in developed countries like the USA and Canada. Such studies are rare in developing countries. This is the first study of its kind in India, assessing the awareness, attitude, and utilization of dental services among insured and uninsured individuals. Socioeconomic development and health of the community are related to each other in such a way that it is impossible to achieve one without other, i.e., one cannot be achieved in isolation. No doubt, the economic development in India is gaining momentum over the last few decades, yet its health system is at crossroads today. Moreover, dental health is still a neglected area.
The present study revealed that the participants had poor awareness although favorable attitude toward dental insurance. Furthermore, it was observed that individuals with insurance coverage utilized more of dental services when compared to the uninsured ones.
The financial cost of dental treatment has always been a hindrance to the use of oral health services worldwide.,,, The dental treatment was perceived to be more expensive by the uninsured ones as compared to the insured ones. The insured participants in this study were covered under the social insurance scheme, i.e., ESI Scheme which is financed mainly by contributions from employers and employees and government. Hence, the insured ones feel that the burden of the cost of treatment is being reduced. The State Government's share of expenditure on the provision of medical care is to the extent of 12.5%. The maximum sharable amount is subject to the ceiling prescribed by the ESIC from time to time.
Social insurance is the key feature of the Bismarckian system of health care. In India, 90% of families earn their livelihood from the unorganized sector. They neither have any form of insurance or security nor do they have representative organizations that might help them by fighting for these benefits. The poor are particularly vulnerable to the lack of health security measures. They spend a greater percentage of their budget on health-related expenditures.
According to the results of the present study, only 20% among insured and 34% among uninsured had knowledge regarding the general health insurance plan. This is in line with the study done by Sodani in Rajasthan, who concluded that only 15% of the studied population was aware of health insurance. The results of the present study are in contrast with the study done by Mathiyazhagan and Reshmi et al. who reported that the studied population had reasonable knowledge about health insurance., Very few participants had knowledge regarding dental insurance integrated with health insurance plans. This is because unlike most western countries, specific dental insurance plans are not common in India. In India, oral health is normally integrated with the general health insurance schemes. Since the medical treatment expenses are so catastrophic making the individual or a family go indebted or impoverished, oral care becomes a neglected part in such circumstances.
More than three-fourths of the insured participants have reported that the insurance coverage was beneficial to them as it has reduced the burden of cost borne by the individual alone. Furthermore, it has made the treatment easily accessible. The three-fourths of the participants among the uninsured group have shown a positive attitude toward the benefits of the dental insurance plan such as reducing the financial burden, encouraging individuals to take treatment at the early stage, making services available for all thus reducing the inequality. Hence, the participants of both groups would like the government to introduce and implement such plans in India. This in line with the study done by Ananda and Abhishek, where 52% of the population feels that there is a need for a dental insurance plan. It also states that the lower the premium, the larger would be the number of people willing to take the insurance cover which is in concordance with our study.
The present study revealed that the frequency of a dental visit within the past 12 months was 4 times more of the insured individuals as compared to the uninsured ones. This is in accordance with the studies ,, that show that the individuals with insurance coverage tend to use more of dental services. It also shows that insurance status made no difference regarding the type of dental treatment received except for tooth extractions, which were more frequently reported by the uninsured individuals. This finding is in accordance with several studies done in Iran , and Australia., In general, fewer tooth extractions among those insured may reflect their better options for treatment, availability, and accessibility of dental services. This is also influenced by the level of education, income, attitude, and beliefs of an individual which should be taken into consideration in further studies, as it may overestimate the true effect of insurance on the use of dental services.
| Conclusion|| |
The present study results revealed that individuals have poor awareness regarding the dental benefits covered in their health insurance plans although they showed a positive attitude toward implementation of dental insurance plan in India. It also showed the positive relationship between insurance and demand for dental care. In developing countries like India, health insurance schemes should therefore include obligatory regular dental checkups to emphasize prevention-oriented dental care. Dental insurance can also bring about oral health care awareness percolating at the grass-root levels. It would serve as a good motivation to the people to regularly visit the dentist and this in turn serves as an effective preventive measure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rao MG, Choudhury M. Health care financing reforms in India. National Institute of Public finance and policy working paper. 2012:2012-100.
Bailoor DN, Shrivastava K, Handa H, Raghuvanshi V. Can dental insurance transform essential dental care in india? Assessing the role of oral physicians: A cross-sectional study and review. Int J Innov Res Dev 2014;7:303-7.
Parkash H, Shah N. National Oral Health Care Programme: Implementation Strategies. Directorate General of Health Services. New Delhi: Ministry of Health and Family Welfare, Govterment of India; 2000.
Mahajan A, Bedi R, Mahajan P. Dental indemnity in India-a missing link. Dentistry 2014;4:253.
Garla BK, Satish G, Divya KT. Dental insurance: A systematic review. J Int Soc Prev Community Dent 2014;4 Suppl 2:S73-7.
NDevadasan KE, Van Damme WI, Criel B. Community Health Insurance in India. Economic and Political Weekly. 2004;10:3179.
Toor RS, Jindal R. Dental insurance! Are we ready? Indian J Dent Res 2011;22:144-7.
] [Full text]
Raju HG. Oral health insurance in India. Annals and Essences of Dentistry 20101;2:208-10.
Locker D, Maggirias J, Quiñonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Public Health Dent 2011;71:327-34.
Widström E, Eaton KA. Oral healthcare systems in the extended European union. Oral Health Prev Dent 2004;2:155-94.
Birch S, Anderson R. Financing and delivering oral health care: What can we learn from other countries? J Can Dent Assoc 2005;71:243, 243a-d.
Chapin R. Dental benefits improve access to oral care. Dent Clin North Am 2009;53:505-9.
Standard Note on ESI. Available form: www.esic.nic.in/Publications/StandardNote310712. [Last accessed on 2016 Aug 02].
Sathish Chandra MR, Veena V. Social security measures in India: Perspectives. Ann Community Health 2014;2:48-53.
Sodani PR. Potential of the health insurance market for the informal sector: A pilot study. J Health Manag 2001;3:283-308.
Mathiyazhagan K. Willingness to pay for rural health insurance through community participation in India. Int J Health Plann Manage 1998;13:47-67.
Reshmi B, NAIR NS, Sabu KM, Unnikrishnan B. Awareness, attitude and their correlates towards health insurance in an urban south Indian population. Management in Health 2012;4:16.
Ananda S, Abhishek N. Developing a viable dental insurance plan: An explorative study for Indian market. Madras Univ J Bus Finance 2014;2:1-14.
Bayat F. Impact of Dental Insurance on Adults' Oral Health Care in Tehran, Iran. Doctoral Dissertation, University of Helsinki; 2010.
Bhatti T, Rana Z, Grootendorst P. Dental insurance, income and the use of dental care in Canada. J Can Dent Assoc 2007;73:57.
Bayat F, Murtomaa H, Vehkalahti MM, Tala H. Does dental insurance make a difference in type of service received by Iranian dentate adults? Eur J Dent 2011;5:68-76.
Brennan DS, Luzzi L, Roberts-Thomson KF. Dental service patterns among private and public adult patients in Australia. BMC Health Serv Res 2008;8:1.
Brennan DS, Spencer AJ, Szuster FS. Insurance status and provision of dental services in Australian private general practice. Community Dent Oral Epidemiol 1997;25:423-8.
[Table 1], [Table 2], [Table 3], [Table 4]