- Top of page
- Material and methods
- Conflicts of interest
The purpose of this study was to describe differences across countries with respect to the reasons for dental non-attendance by Europeans currently 50 yr of age and older. The analyses were based on retrospective life-history data from the Survey of Health, Ageing, and Retirement in Europe and included information on various reasons why respondents from 13 European countries had never had regular dental visits in their lifetime. A series of logistic regression models was estimated to identify reasons for dental non-attendance across different welfare-state regimes. The highest proportion of respondents without any regular dental attendance throughout their lifetime was found for the Southern welfare-state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare-state regimes. Factors such as patients’ perception that regular dental treatment is ‘not necessary’ or ‘not usual’ appear to be the predominant reason for non-attendance in all welfare-state regimes. The health system-level factor ‘no place to receive this type of care close to home’ and the perception of regular dental treatment as ‘not necessary’ were more often referred to within the Southern, Eastern, and Bismarckian welfare-state regimes than in Scandinavia. This could be relevant information for health-care decision makers in order to prioritize interventions towards increasing rates of regular dental attendance.
Regular dental attendance has a positive impact on oral health [1-6]. However, access to oral health care and regular dental attendance have been shown to vary considerably within and between populations [7-13]. Understanding why people do not seek regular dental care is an essential requirement for developing effective health-policy interventions to optimize the oral health of the population.
In the spirit of the conceptual framework established by Andersen in 1968 , need, predisposing, enabling, and system-level factors are important determinants of health-care use. Thereby, need comprises both perceived need and objective need for health-care services. Predisposing factors include immutable characteristics, such as age and sex, as well as potentially mutable characteristics, such as health beliefs. For example, previous evidence suggests that attitudes and perceptions about oral health and health care influence dental-attendance patterns [15-19]. Enabling factors relate to individual characteristics that may support or constrain the individual's use of health care. Specifically, such parameters include individuals' income [20-23], as well as access to and extent of dental insurance [24-29]. System-level factors relate to the way that care delivery is organized in a population. One such important determinant is the geographical distribution of health-care providers, indicating regional availability of dental services [30-32].
Previous evidence has described the role of individuals' need perception, lack of access to dental services, costs of dental treatment, life experiences (such as unemployment), and dental anxiety as determinants for not seeking regular dental attendance [9, 33-35]. So far, however, only little is known about the relative importance of various reasons for dental non-attendance across different countries and associated welfare-state regimes. A recent study suggests that Scandinavian welfare states, with more redistributive and universal welfare policies, have better population oral health than other welfare-state regimes . One potential pathway linking welfare-state regimes and population oral health is dental-care provision. In general, distinction between different welfare-state regimes provides the advantage of considering the broader institutional and political determinants of dental-care provision rather than considering only specific health-system characteristics, such as health insurance coverage. Should a lower level of non-attendance be observed in Scandinavia than in the other welfare-state regimes, health-care decision makers may then be interested in learning more about the underlying reasons for non-attendance most frequently reported by those other welfare states.
The purpose of the present study was to describe variations across various European countries and welfare-state regimes with respect to the reasons why individuals did not attend a dentist regularly throughout their lifetime and – by application of the Andersen  model of health-services use – to provide a framework enabling health-care decision makers to provide more effective programs for improving regular dental attendance within different welfare state regimes.
Material and methods
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- Material and methods
- Conflicts of interest
The present study is based on data from waves 2 and 3 of the Survey of Health, Ageing, and Retirement in Europe (SHARE). SHARE wave 3 (also called SHARELIFE) contains detailed retrospective life-history data of respondents, currently ≥50 yr of age, from 13 European countries (Denmark, Sweden, Austria, France, Germany, Switzerland, Belgium, the Netherlands, Spain, Italy, Greece, the Czech Republic, and Poland). These data were collected in 2008/2009. SHARE wave 2 was conducted in 2006/2007 and contains detailed information about health, socio-economic conditions, and family backgrounds of the elderly populations in several European countries. Data for SHARE waves 2 and 3 were collected using computer-assisted personal interviews and self-completed paper-and-pencil questionnaires. Subjects eligible to participate in SHARE were all household members ≥50 yr of age. More details about the methodology of SHARE and SHARELIFE are available in the literature [37, 38] and on the SHARE website (www.share-project.org).
SHARELIFE provides retrospective information on the reasons why individuals did not attend a dentist regularly throughout their lifetime. In total, 26,525 study participants, currently 50+ yr of age, responded to the question ‘Have you ever gone to a dentist regularly for check-ups or dental care?’ Respondents who answered ‘no’ (n = 8,551) were also asked the question ‘What are the reasons [you have never gone/weren't going] to a dentist regularly for check-ups or dental care?’ Respondents replied according to the following answer categories (multiple answers possible), which can be classified as perceived need [N], predisposing factors [P], enabling factors [E], and system level factors [S], according to Andersen's  conceptual framework:
- Not affordable [E]
- Not covered by health insurance [E]
- Did not have health insurance [E]
- Time constraints [E]
- Not enough information about this type of care [P]
- Not usual to get this type of care [P]
- No place to receive this type of care close to home [S]
- Not considered to be necessary [N] and
- Other reasons.
For each of the categories [N], [P], [E], and [S], a binary measure was constructed that indicates whether or not respondents chose an answer from the respective category. A further binary measure was constructed for the answer category ‘other reasons’ because the latter cannot be directly classified according to Andersen's  framework. The aforementioned binary measures were used as dependent variables within multivariate logistic regression models in order to detect variations in the reasons for dental non-attendance, according to different welfare-state regimes. For this purpose, all regression models include controls for different welfare-state regimes as dummy variables. Consistent with recent health-policy research [36, 39-43], and for the purpose of this study, we aggregated countries into groups with similar social welfare characteristics. We distinguished between the following welfare-state regimes: Scandinavian (Denmark and Sweden), Bismarckian (Austria, Belgium, France, Germany, the Netherlands, and Switzerland), Southern (Greece, Italy, and Spain), and Eastern (Czech Republic and Poland). Note that the Scandinavian welfare-state regime was used as the omitted reference category in regression analysis. In order to adjust for demographic influences, all models also included control variables for respondents’ age and sex. Socio-economic status was controlled for by the following two variables:
- Equivalized household income: 1st (lower), 2nd (middle), and 3rd (upper) tertiles within each country's distribution of current net monthly equivalized income according to the square-root approach, as applied by the Organisation for Economic Co-operation and Development ; note that observations for which income exceeded one million Euros were excluded from the study sample as statistical outliers; and
- Educational attainment – three categories according to the International Standard Classification of Education (ISCED): (pre-)primary (ISCED scores 0 and 1), secondary (ISCED scores 2 and 3), and postsecondary and tertiary (ISCED scores 4–6). See  for a detailed description of ISCED.
All data analyses were carried out using the software package stata/se 12.0 (Stata, College Station, TX, USA). The level of statistical significance was set at 5%.
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- Material and methods
- Conflicts of interest
Table 1 shows descriptive statistics for samples comprising respondents who attended a dentist regularly throughout their lifetime and respondents who did not attend a dentist regularly throughout their lifetime. In comparison with the sample of attenders, there was a significantly higher percentage of men among non-attenders. According to income tertiles and ISCED scores, non-attenders ranked significantly more often at the lower end of the socio-economic scale compared with attenders.
Table 1. Percentage of respondents reporting regular dental attendance (attenders) and percentage of respondents not reporting regular dental attendance (non-attenders) throughout their lifetime, stratified by sex, household income, and educational attainment
| ||Attenders (n = 17974)||Non-attenders (n = 8551)|
|Women||51.6 (0.4)||45.5 (0.6)|
|Men||48.4 (0.4)||54.5 (0.5)a|
|Lower income tertile||29.8 (0.4)||39.6 (0.6)a|
|Middle income tertile||34.4 (0.4)||31.1 (0.6)|
|Upper income tertile||35.9 (0.4)||29.4 (0.6)|
|ISCED scores 0–1||21.5 (0.3)||50.5 (0.6)a|
|ISCED scores 2–3||51.2 (0.4)||38.4 (0.5)|
|ISCED scores 4–6||27.4 (0.3)||11.1 (0.4)|
Table 2 presents population percentages of dental non-attendance and the associated reasons by respondents’ country of residence. Non-attendance ranged from more than half of respondents in Greece, Spain, and Italy to fewer than one in 10 respondents in Denmark and Sweden. ‘Not necessary’ as a reason for non-attendance ranged from about two thirds of respondents in Germany, Italy, Spain, and Poland to almost a quarter of respondents in Austria. ‘Limited information’ ranged from one third of respondents in Greece to three in 100 respondents in Denmark. The number of respondents citing ‘Unusual’ as a reason for non-attendance ranged from more than four in 10 in Austria, Belgium, and Greece to 13 in 100 in Sweden. ‘Not affordable’ as a reason for non-attendance ranged from more than a quarter of respondents in Switzerland and Spain to fewer than four in 100 respondents in the Czech Republic. ‘Limited coverage’ was reported most often in Spain (eight in 100 respondents). ‘Not insured’ was only rarely named as a reason for non-attendance. ‘Time constraints’ as a reason for non-attendance ranged from 10 in 100 respondents in Austria to fewer than one in 100 respondents in Switzerland and the Netherlands. ‘No provider nearby’ as a reason for non-attendance ranged from 18 in 100 respondents (Greece) to one in 100 respondents (Switzerland and Sweden). Respondents citing ‘Other’ as a reason for non-attendance ranged from almost one quarter (Sweden) to four in 100 (Italy).
Table 3 shows the percentages of dental non-attendance grouped by welfare-state regimes and associated reasons categorized according to Andersen's framework (see the Material and methods). Non-attendance ranged from more than one in two respondents in the Southern welfare-state regime to fewer than one in 10 respondents in the Scandinavian regime. For more than three in 10 respondents, perceived need was the reason most often given for non-attendance in all welfare-state regimes. The Eastern regime had the most respondents reporting this factor (six in 10). Predisposing factors were reported by almost three in 10 respondents from Scandinavia but by only 11 in 100 respondents from the Eastern regime. Respondents naming enabling factors as reason for non-attendance ranged from almost one in five in the Scandinavian regime to about eight in 100 in the Eastern regime. The health system-level factor (‘non-availability of a nearby provider’) was reported by almost 13 in 100 respondents from the Eastern regime but by only one in 100 respondents from the Scandinavian regime. ‘Other’ was most often named by respondents associated with the Scandinavian regime.
Table 3. Percentage of respondents reporting dental non-attendance and the percentage of respondents who reported self-perceived need, predisposing, enabling, health system, and other factors as reasons for non-attendance, throughout their lifetime, stratified by welfare-state regime
|Regime||Non-attenders ||Need ||Predisposing||Enabling||System level||Other|
|Scandinavian (n = 3986)||7.2 (0.4)||33.8 (2.8)||27.9 (2.7)||18.1 (2.3)||1.4 (0.7)||16.0 (2.2)|
|Bismarckian (n = 11329)||24.8 (0.4)||48.5 (0.9)||25.5 (0.8)||9.2 (0.6)||3.8 (0.4)||12.2 (0.6)|
|Southern (n = 7454)||56.0 (0.6)||53.6 (0.8)||17.8 (0.6)||13.2 (0.5)||9.1 (0.4)||9.2 (0.5)|
|Eastern (n = 3756)||34.0 (0.8)||59.8 (1.4)||11.2 (0.9)||8.5 (0.8)||12.5 (0.9)||12.5 (0.9)|
Table 4 shows ORs for the influence of welfare-state type, demographic, and socio-economic parameters, as well as educational attainment, on the frequency of reporting self-perceived need, predisposing, enabling, system-level, and other factors as reasons for dental non-attendance. These findings are also summarized graphically in Fig. 1. Relative to the Scandinavian regime, lack of perceived need was significantly more often named as a reason for non-attendance in all other welfare-state regimes. Men reported this reason significantly more often than women. Predisposing factors were reported significantly less often in the Southern and Eastern welfare-state regimes than in Scandinavia. Older respondents were significantly more likely than younger respondents to refer to this category. In addition, predisposing factors were more frequently reported within the highest category of educational attainment. Relative to the Scandinavian regime, enabling factors were reported significantly less often from the Bismarckian and Eastern regimes but were non-significantly different for the Southern welfare-state regime. Enabling factors were reported significantly more often by women and less often by those with higher socio-economic status and educational attainment. The health system-level factor was reported significantly more often by respondents from the Bismarckian, Southern, and Eastern welfare-state regimens in comparison with the Scandinavian regime. In contrast, ‘Other’ was reported significantly less often by respondents from the Bismarckian, Southern, and Eastern welfare-state regimes in comparison with the Scandinavian regime. Such reasons were also reported significantly less often with increasing age.
Table 4. Odds ratios for the influence of welfare-state type, demographic, and socio-economic parameters, as well as educational attainment, on the frequency of reporting self-perceived need, predisposing, enabling, system level, and other factors as reasons for dental non-attendance throughout a respondents' lifetime
|Welfare state regime|
|Bismarckian||1.74a (1.30–2.32)||0.98 (0.71–1.34)||0.49a (0.33–0.71)||3.39a (1.06–10.81)||0.62a (0.42–0.92)|
|Southern||2.54a (1.90–3.40)||0.56a (0.40–0.77)||0.75 (0.52–1.08)||6.77a (2.14–21.41)||0.35a (0.23–0.52)|
|Eastern||2.95a (2.17–4.01)||0.36a (0.25–0.52)||0.44a (0.29–0.67)||11.88a (3.74–37.75)||0.55a (0.36–0.83)|
|Age (in years)||1.00 (1.00–1.01)||1.01a (1.00–1.02)||1.01 (1.00–1.01)||1.01 (1.00–1.02)||0.96a (0.95–0.97)|
|Women||0.83a (0.74–0.92)||1.03 (0.90–1.18)||1.24a (1.05–1.47)||1.10 (0.90–1.35)||1.03 (0.87–1.23)|
|Lower income tertile||Reference||Reference||Reference||Reference||Reference|
|Middle income tertile||1.07 (0.94–1.21)||0.99 (0.84–1.16)||0.78a (0.64–0.95)||0.99 (0.78–1.26)||1.06 (0.86–1.30)|
|Upper income tertile||1.12 (0.98–1.28)||0.90 (0.76–1.07)||0.79a (0.65–0.98)||0.82 (0.63–1.06)||0.95 (0.76–1.18)|
| (Pre-)Primary education (ISCED scores 0–1)||Reference||Reference||Reference||Reference||Reference|
|Secondary education (ISCED scores 2–3)||1.05 (0.93–1.18)||1.07 (0.92–1.26)||0.86 (0.71–1.05)||0.85 (0.67–1.09)||1.03 (0.84–1.25)|
|Postsecondary and tertiary education (ISCED scores 4–6)||0.89 (0.73–1.07)||1.58a (1.26–1.98)||0.69a (0.50–0.96)||1.07 (0.74–1.55)||1.00 (0.74–1.34)|
- Top of page
- Material and methods
- Conflicts of interest
Based on life-history information from persons currently 50+ yr of age and living in 13 different European countries, the present study identified considerable differences among countries, as well as differences between various welfare-state regimes, with respect to the reporting frequency of reasons for never having attended a dentist regularly. The highest percentage of respondents without any regular dental attendance throughout their lifetimes was found for the Southern welfare-state regime, followed by the Eastern regime, the Bismarckian regime, and the Scandinavian regime.
The health system-level factor ‘no place to receive this type of care close to home’ and the perception of regular dental treatment as being ‘not necessary’ were more often referred to within the Southern, Eastern, and Bismarckian welfare-state regimes than in countries comprising the Scandinavian regime. Predisposing factors were more frequently cited as a cause of dental non-attendance in the Scandinavian welfare-state regime than in the Southern and Eastern welfare regimes, whilst enabling factors were named more often in the Scandinavian welfare-state regime than in the Bismarckian and Eastern welfare-state regimes. In comparison with the other welfare-state regimes, a higher proportion of Scandinavian respondents attributed their dental non-attendance to ‘other reasons’.
The present study also provides evidence of demographic and socio-economic influences. Non-attendance proved to be generally more prevalent among men and in those at the lower end of the socio-economic scale. Among those without any regular dental attendance throughout their lifetime, lack of perceived need was more prevalent among men. Predisposing factors were more frequently referred to with increasing age and by those with higher educational attainment. Enabling factors were more frequently cited by women and by individuals at the lower end of the socio-economic scale.
The results of the present study suggest that perceived need and predisposing factors are generally a more frequent reason for dental non-attendance than enabling and health system-level factors. In all countries except Austria, Denmark, and Greece, the most frequently named reason for dental non-attendance was that it is ‘not considered to be necessary’. In Austria, Denmark, and Greece, the most frequently named reason for dental non-attendance was that it is ‘not usual to get this type of care’. ‘Not enough information about this type of care’ was a further – although less frequently reported – predisposing factor.
Previous evidence suggests that dental anxiety is also an important predictor for non-regular dental attendance . Although dental anxiety could not be examined directly in the present study, it can be considered as another predisposing factor. Given that some proportion within the response category ‘other reasons’ may be attributable to dental anxiety, this may further highlight the high relevance of predisposing factors for dental non-attendance.
The results of the present study emphasize that perceived need and predisposing factors are important reasons for dental non-attendance. Yet, health-care decision makers may be concerned about the extent to which such characteristics are actually mutable. For example, previous evidence suggests that – despite enormous efforts to reduce population levels of dental fear – these have not decreased significantly over the past decades . Although it is always possible to increase oral-health promotional activities and to provide more information about the advantages of regular dental attendance, this does not necessarily imply that all non-regularly-attending patients will adapt a more regular pattern of seeking treatment.
Obviously, any classification system which groups countries together has its limitations. The present paper distinguished between Scandinavian, Bismarckian, Southern, and Eastern welfare-state regimes. This framework was applied to provide a broader appreciation of the institutional and political determinants of dental-care provision by welfare-state status. However, a broad classification of country groups may not fully take into account each and every detail of all individual characteristics. Caution should thus be applied when transferring conclusions made for welfare-state regimes to individual countries. Given considerable differences among countries with respect to various reasons for non-attendance, optimizing attendance within populations ultimately needs to be guided by country-specific priority setting.
Further limitations of the present study should be mentioned. First, as with any life-history information which is based on a retrospective survey, our findings may be subject to the potential influences of recall bias. However, it has recently been shown that SHARE participants provide reliable information about earlier life years . Second, some may argue that differences in dental non-attendance may partly be the consequence of differences in oral health status. Indeed, one limitation of SHARE is that it currently does not provide information about the respondents' number of teeth or about complete edentulism. Note, however, that not controlling for oral-health status does not negate the results of the present study because it examined why people have never sought dental attendance regularly throughout their entire lifetime. Even a person who is fully edentate at age 50+ could have gone to the dentist regularly at some point earlier in life, for example, when their dentition was more complete. Third, implementation of country-specific parameter estimates for demographic and socio-economic influences was complicated by the limited number of observations within a subset of countries. Some caution should be applied when interpreting parameter estimates that aggregate across countries. Finally, our study could only compare a limited number of countries against each other. Future research will benefit from better availability of survey data that include more countries and greater variability of institutional settings with other economic, social, and cultural influences.
All in all, the present study is the first to compare the levels of, and reasons for, dental non-attendance across several European countries and associated welfare-state regimes. The highest percentage of respondents without any regular dental attendance throughout their lifetimes was found for the Southern welfare-state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare-state regimes. Factors such as patients’ perception that regular dental treatment is ‘not necessary’ or ‘not usual’ appear to be the predominant reasons for non-attendance in all welfare-state regimes. The health system-level factor ‘no place to receive this type of care close to home’ and the perception of regular dental treatment as ‘not necessary’ were more often referred to within the Southern, Eastern, and Bismarckian welfare-state regimes than in Scandinavia. This could be relevant information for health-care decision makers in order to provide comparative prioritization of interventions that increase the rates of regular dental attendance and to develop programs that best meet the needs of their populace.
- Top of page
- Material and methods
- Conflicts of interest
This investigation was supported by the National Institute of Dental and Craniofacial Research of the US National Institutes of Health (3R01DE021678-06S1). The present paper uses data from SHARELIFE release 1, as of 24 November 2010, and SHARE release 2.5.0, as of 24 May 2011. The SHARE data collection has been primarily funded by the European Commission through the 5th framework programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the 6th framework programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5-CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812), and through the 7th framework programme (SHARE-PREP, 211909 and SHARE-LEAP, 227822). Additional funding from the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01 and OGHA 04-064, IAG BSR06-11, R21 AG025169), as well as from various national sources, is gratefully acknowledged (see www.share-project.orgfor a full list of funding institutions).