Prevalence and socioeconomic factors associated with non-utilization of dental care in Lebanon: A nationwide cross-sectional survey
Abstract
Objectives
To assess the prevalence of non-utilization of dental care in Lebanon and associated socioeconomic factors and self-care behaviours.
Methods
A nationwide, quantitative, survey-based study was conducted by trained interviewers with Lebanese residents aged ≥18 years between July and September 2019. Univariate analyses were performed using Pearson Chi Square test or the Fisher's exact test followed by a binary logistic regression using the SPSS Version 25.
Results
Of the 1070 participants, 247 (23.1%) did not utilise any type of healthcare and 144/247 (58.3%) did not utilise dental care. The prevalence of non-utilization of dental care was estimated at 13.5%. Only 4.7% of the respondents consulted their dentist in the past year, among which 53% cited pain/emergencies as the reason for their consultation. Socioeconomic factors associated with the non-utilization of dental care were lack of social medical insurance (OR, 0.49 [95% CI, 0.31 to 0.79]) and long waiting time/patient time restriction (OR, 2.05 [95% CI, 1.26 to 3.35]). On the other hand, facilitators for utilization of dental care included ethical standards/personal qualities of the dentist (OR, 0.53 [95% CI, 0.32 to 0.88]) and convenient cost with respect to the individual's economic status (OR, 0.28 [95% CI, 0.18 to 0.43]).
Conclusion
This study suggests that dental care practices in Lebanon, including the non-utilization of dental care, are suboptimal. Measures such as reducing sugar and tobacco consumption, providing information on oral hygiene, and using fluoride products are inexpensive; however, implementing these measures may take substantial time and input by multiple stakeholders.
1 INTRODUCTION
Dental caries is the most prevalent chronic disease today.1 The WHO has estimated that, in 2019, 42.7% of deciduous teeth and 28.7% of permanent teeth had untreated caries worldwide. Cases of untreated caries are reported in all regions irrespective of the geographical location, country, or socioeconomic status of individuals, with minor differences in prevalence estimates.2-4 In 2019, prevalence rates for untreated caries of permanent teeth were 30.6%, 28.9%, 27.8%, and 29.3% in low income, lower-middle income, upper-middle income, and high-income groups, respectively.2 Since a large proportion of oral diseases, including dental caries, are preventable through the implementation of population-based public health measures, this phenomenon could be better addressed. The main risk factors for the development of caries are consumption of sugar in food and beverages, inadequate oral hygiene, and the under-use of fluoridated toothpaste or other fluoridation measures.2 These preventive measures are even more necessary since public and private spending on oral health care worldwide amounts to nearly 390 billion United States dollars (USD), unevenly distributed between regions and countries. The low coverage of oral health may be one of the reasons behind this inequality in expenditure, and, as such, a high proportion of individuals do not have adequate access to oral/dental health care and to adequate preventative measures.5
In Lebanon, the prevalence of untreated caries in children under 9 years old with deciduous teeth is 44% and that for individuals with permanent teeth is 35%.6 Although Lebanon does not have a shortage of dentists, these high rates are seemingly attributed to the chronic underfunding of dental care and the lack of adequate implementation of prevention programmes. It is important to note that the Lebanese National Social Security fund does not cover dental procedures. Hence, the dental care is solely based on the private sector and the finances of the individual.7 The WHO estimates that oral health expenses in Lebanon are 17 USD per person per year while they are 495 USD and 195 USD per person per year in the US and France, respectively.6, 8, 9 In 2019, Lebanon's economic losses, related to oral diseases, were estimated to be 183 million USD.6 The primary aim of the study was to examine the factors associated with non-utilization of healthcare. The secondary aim was to evaluate the socioeconomic factors and self-care behaviours associated with non-utilization of dental care.
2 MATERIALS AND METHODS
2.1 Study population
A nationwide cross-sectional survey was conducted among Lebanese residents aged ≥18 years between July and September 2019. Prior to its initiation, the study was approved and registered in France by the institutional review board of the French commission for data protection and individual liberty (Commission Nationale Informatique et Libertée [CNIL]) under No. 2224711.
A probability-based, random, stratified sample was used to recruit participants proportionally from eight Lebanese governorates regrouped, prior to the initiation of the study, into five categories according to the old administrative division (5 provinces) and to the geographical location: Beirut; Mount Lebanon; Bekaa (including Baalbek–Hermel); North Lebanon (including Akkar); South Lebanon (including Nabatiyeh). Since Lebanese citizens are registered on the electoral rolls according to their city/district of birth and not of their residence, those were not considered a suitable source to reflect the population size residing in each district. As such, another method for sample size stratification was used. Assuming that parents would place their children in a school within the same area as their residence, the number of students enrolled in the schools of each district was used to reflect the adult population of that district. Once the number of students in each district was determined, that number was used to calculate the proportion of students who went to the schools of one district relative to the others. The sample size to be interviewed in each district was then estimated using the proportions retrieved by the earlier calculations.
The main cities of each district were then chosen, and the first household in each was selected using a lottery. The lottery included the numbers 1 through 10, with 1 being the first house at the entry of the main city. The number of the first household to be approached was then randomly selected, that is, if the lottery yielded number 5, then the interviewer would count 5 houses from the first house at the entry of the city and interview the participant in the 5th house. From then on, the selection was based on residence at an interval of 10 houses, and the participant in the 11th house would be interviewed. In case there was no one present in the selected house or the residents refused to take part in the study, the following house was selected by an interval of 10. Only one adult of Lebanese nationality was interviewed per household. Prior to answering any questions, the participants were provided with a one-paragraph summary explaining the objectives of the study in Arabic. An informed consent form was administered with the questionnaire, and participants were allowed to withdraw their consent at any time during the interview.
2.2 Study variables and data collection
The variables assessed in the survey were selected based on findings from a previous qualitative study conducted by Daou et al.10 in which factors associated with seeking oral health treatment in Lebanon were identified. The survey was pretested on a sample of 100 Lebanese participants from two different districts. Data from the pilot were not included in the present analysis.
The survey included 41 questions covering multiple categories. The present analysis reports measures with the following four categories: (i) sociodemographic (age, sex [assigned at birth], marital status, education, employment, annual income, health and dental care coverage/reimbursements), (ii) non-utilization of medical care (participants were asked whether they felt the need to visit a healthcare professional within the last 12 months but refrained from seeking the needed care. If the answer was “yes”, then the participant was asked to specify which type of healthcare services were not utilized: general medicine, optometry, or dentistry. Participants could choose more than on type), (iii) facilitators and barriers for seeking dental care (participants were asked to select all the factors that they perceived as facilitators and barriers from predefined lists—Predefined list of facilitators included convenient cost with respect to economic status, presence of a clear treatment plan, confidence in the quality of treatment and in the abilities of the dentist, appropriate scheduling of appointments/no long waiting time, modernity of the clinic/equipment, cleanliness of the clinic/equipment, personal relations with the dentist, proximity of the clinic to the patient's residence, adequate follow-up by the dentist, ethical qualities/standards, personal and relational qualities of the dentist, and the friendliness of the dental team; predefined list of barriers included cost of treatment, lack of financial coverage, dislike/fear going to the dentist, long waiting times, patient time restriction, forgetfulness/lack of any reminder, don't feel the need because teeth are healthy, bad previous experience, long commute to get to the dental clinic, doubt the cleanliness of the clinic/instruments, lack of confidence in the treatment and the dentist) and (iv) self-care practices (timing of the last visit to the dental clinic, reason for the last dental consultation, perception of regular visits to the dentist, and measures taken in case of a toothache) (Table S1).
Data were collected by trained interviewers. Participants were interviewed face-to-face at their own residence, directly after signing the informed consent. The questions and answers (in case of multiple-choice questions) were read out loud to the respondent, and participants were given enough time to answer open-ended questions or seek any clarification/ask questions.
2.3 Statistical analysis
The predetermined sample size was 1067 participants calculated in order to detect an assumed prevalence of 50% for non-utilization of care with a 95% confidence interval and a 3% margin of error.
Means, standard deviation (SD), and range (minimum [min], maximum [max]) were reported for continuous variables; numbers and percentages were reported for categorical variables. The prevalence of non-utilization of dental care was calculated using the number of participants who did not utilise dental care divided by the total number of participants. Univariate analyses were performed using Pearson Chi Square test or the Fisher's exact test. These were then followed by a binary logistic regression including the variables having a p-value < .2 in the univariate analysis. The significance level corresponded to p ≤ .05. The statistical analysis was performed using the SPSS statistical software Version 25 (IBM Corporation, Armonk, NY, USA).
3 RESULTS
A total of 1150 individuals were approached to take part, of whom 1070 participated in the study (response rate = 93.0%). Over half of the participants were males (60.1%) with a mean age of 39.5 ± 15.0 years (range 18–88 years). The mean age of women was slightly younger (37.0 ± 13.8 years; range 18–82 years). A total of 247 participants (23.1%) did not utilise any type of healthcare, and 144/247 (58.3%) reported not utilizing dental care (Table 1). More than half of the participants (53%) reported emergency situations as the reason for their last dental visit, even though 63.3% stated that regular visits to the dentist were useful for prevention of oral disease, and only 4.8% of participants stated that they had consulted their dentist in the past year. In case of a toothache, 46.7% of participants stated that they would first self-medicate with analgesics and 32.8% would visit a dentist. Facilitators associated with dental care use were cost with respect to the individual's economic status, the existence of a precise treatment plan/confidence in the quality of treatment and in the dentist's professional abilities, and the absence of long waiting time for appointments. On the other hand, barriers associated with utilizing dental care were cost of treatment/lack of financial coverage, dislike or fear of the dentist, and long waiting time at the dentists' office/patient time constraints (Table 1).
| Total responses n (%) | |
|---|---|
| Last visit to the dentist | |
| Less than 6 months ago | 12 (1.1) |
| Between 6 months and 1 year ago | 39 (3.6) |
| One or more years ago | 970 (90.7) |
| I have never been to the dentist | 48 (4.5) |
| Reason of last consultation | |
| Emergency (pain and/or accident) | 567 (53.0) |
| Routine visit | 253 (23.6) |
| Treatment | 203 (19.0) |
| No response | 47 (4.4) |
| Regular visit to the dentist isa | |
| Useful for prevention | 677 (63.3) |
| Necessary for the early discovery of oral diseases | 299 (27.9) |
| Not necessary | 136 (12.7) |
| For the benefit of the dentist to attract customers | 31 (2.9) |
| In case of toothachea | |
| Take pain killers | 499 (46.7) |
| Visit the dentist | 351 (32.8) |
| Consult the dentist by phone | 247 (23.1) |
| Consult a pharmacist | 120 (11.2) |
| Increase the frequency of brushing teeth | 60 (5.6) |
| Put Arak, a Lebanese alcoholic beverage, on teeth | 5 (0.5) |
| Increase the frequency of using oral rinses | 4 (0.4) |
| Facilitating factors for visiting the dentista | |
| Convenient cost with respect to economic status | 326 (30.5) |
| Presence of a clear treatment plan/confidence in the quality of treatment and in the abilities of the dentist | 321 (30.0) |
| Appointments are scheduled appropriately and there is no long waiting time | 241 (22.5) |
| Modernity/cleanliness of the clinic and instruments | 223 (20.8) |
| Personal relations with the dentist | 221 (20.7) |
| Proximity of the clinic to the residence | 205 (19.2) |
| Dentist adequately following-up on his/her patients | 193 (18.0) |
| Ethical qualities and standards/personal and relational qualities of the dentist | 186 (17.4) |
| The friendliness of the dental team in encouraging and offering assistance | 12 (1.1) |
| Feeling pain that would lead to visiting a dentist | 5 (0.5) |
| Barriers to my visits to the dentista | |
| Cost of treatment/lack of financial coverage | 361 (33.7) |
| I don't like/I fear going to the dentist | 356 (33.3) |
| Long waiting times at the dentist/patient time restriction | 323 (30.2) |
| I forget/lack of any reminder | 114 (10.7) |
| I don't feel the need because my teeth are healthy | 65 (6.1) |
| Bad previous experience | 33 (3.1) |
| Long commute to get to the dental clinic | 29 (2.7) |
| Doubt the cleanliness of the clinic and instruments | 21 (2.0) |
| Lack of confidence in the treatment and the dentist | 11 (1.0) |
| Non-utilization of healthcare | |
| Yes | 247 (23.1) |
| No | 818 (76.4) |
| No response | 5 (0.5) |
| If yes, type of non-utilized healthcarea | |
| Dentistry | 144 (58.3) |
| Medicine | 118 (47.8) |
| Optometry | 28 (11.3) |
- a Multiple answers were possible.
The prevalence of non-utilization of dental care was estimated to be 13.5% (144/1070). Based on univariate analysis, the rate of participants foregoing dental care (n = 144) seemed to be associated with several sociodemographic factors including marital status, educational level, mean annual income, social security coverage, and coverage or reimbursement of dental care (Table 2). Over half of the participants who did not utilise dental care were married (51.4% vs. single, 36.1%, or widowed/divorced, 12.5%) and did not have a tertiary education (61.1% vs. 38.9% with tertiary education). In addition, most participants within this subgroup had a low mean annual family income (72.2%) and no dental care coverage or reimbursement (93.8%).
| Characteristics | Non-utilization of dental care n (%) | p-Value | |
|---|---|---|---|
| Yes (n = 144) | No (n = 818) | ||
| Age range (years) | .189 | ||
| 18 to 33 (n = 441) | 54 (12.2) | 387 (87.8) | |
| 34 to 45 (n = 252) | 43 (17.1) | 209 (82.9) | |
| 46 to 64 (n = 208) | 36 (17.3) | 172 (82.7) | |
| ≥ 65 (n = 61) | 11 (18) | 50 (82) | |
| Sex (assigned at birth) | .097 | ||
| Males (n = 576) | 77 (13.4) | 499 (86.6) | |
| Females (n = 386) | 67 (17.4) | 319 (82.6) | |
| Marital status | .027 | ||
| Single (n = 418) | 52 (12.4) | 366 (87.6) | |
| Married (n = 473) | 74 (15.6) | 399 (84.4) | |
| Widowed/divorced (n = 71) | 18 (25.4) | 53 (74.6) | |
| Educational level | .001 | ||
| Tertiary (n = 499) | 56 (11.2) | 443 (88.8) | |
| No tertiary (n = 458) | 88 (19.2) | 370 (80.8) | |
| Employment status | .282 | ||
| Public sector (n = 64) | 14 (21.9) | 50 (78.1) | |
| Private sector (n = 586) | 86 (14.7) | 500 (85.3) | |
| Do not work (n = 294) | 42 (14.3) | 253 (85.7) | |
| Mean annual family income | <.001 | ||
| Low (n = 474) | 104 (21.9) | 370 (78.1) | |
| Moderate (n = 321) | 29 (9.0) | 292 (91.0) | |
| High (n = 54) | 3 (5.6) | 51 (94.4) | |
| Social security coverage | <.001 | ||
| Yes (n = 676) | 80 (11.8) | 596 (88.2) | |
| No (n = 283) | 64 (22.6) | 219 (77.4) | |
| Coverage or reimbursement of dental care | .034 | ||
| Yes (n = 113) | 9 (8) | 104 (92) | |
| No (n = 847) | 135 (15.9) | 712 (84.1) | |
- Note: Percentages are based on the total number of participants corresponding to the specific variable. As such the percentages in each row mount up to 100%.
Other factors that were suggested to be associated with non-utilization of dental care included the high cost of dental care, cost with respect to the participant's financial status, and several human factors/personal preferences (Table 3). Human factors were forgetfulness, long waiting time at the dentists' office/time constraints from the participant's side, not feeling the necessity to visit the dentist, participant's personal relationship with the dentist and the importance of a dentist's ethical standards and personal qualities (Table 3).
| Variables | Non-utilization of dental care n (%) | p-Value | |
|---|---|---|---|
| Yes (n = 144) | No (n = 818) | ||
| High dental treatment cost | <.001 | ||
| Yes (n = 301) | 92 (30.6) | 209 (69.4) | |
| No (n = 623) | 50 (8) | 573 (92) | |
| Convenient cost with respect to economic status | <.001 | ||
| Yes (n = 277) | 81 (29.2) | 196 (70.8) | |
| No (n = 666) | 59 (8.9) | 607 (91.1) | |
| Dislike/Fear of visiting the dentist | .568 | ||
| Yes (n = 328) | 47 (14.3) | 281 (85.7) | |
| No (n = 596) | 95 (15.9) | 501 (84.1) | |
| Lack of confidence in the dentista | .389 | ||
| Yes (n = 11) | 3 (27.3) | 8 (72.7) | |
| No (n = 913) | 139 (15.2) | 774 (84.8) | |
| Bad previous experiencea | 1 | ||
| Yes (n = 31) | 4 (12.9) | 27 (87.1) | |
| No (n = 893) | 138 (15.5) | 755 (84.5) | |
| Friendly or supportive assisting teama | 1 | ||
| Yes (12) | 1 (8.3) | 11 (91.7) | |
| No (931) | 139 (14.9) | 792 (85.1) | |
| Personal relationship with the dentist | .004 | ||
| Yes (n = 205) | 17 (8.3) | 188 (91.7) | |
| No (n = 738) | 123 (16.7) | 615 (83.3) | |
| Forgetfulness | .001 | ||
| Yes (n = 102) | 4 (3.9) | 98 (96.1) | |
| No (n = 822) | 138 (16.8) | 684 (83.2) | |
| Long waiting times at the dentist/patient time restriction | .002 | ||
| Yes (n = 299) | 30 (10) | 269 (90) | |
| No (n = 625) | 112 (17.9) | 513 (82.1) | |
| Reminder by the dentist | .562 | ||
| Yes (n = 180) | 24 (13.3) | 156 (86.7) | |
| No (n = 763) | 116 (15.2) | 647 (84.8) | |
| Appointments scheduled appropriately with no long waiting time | .283 | ||
| Yes (225) | 28 (12.4) | 197 (87.6) | |
| No (n = 718) | 112 (15.6) | 606 (84.4) | |
| Long commute to get to the dental clinica | .286 | ||
| Yes (n = 27) | 6 (22.2) | 21 (77.8) | |
| No (n = 897) | 136 (15.2) | 761 (84.8) | |
| Proximity of the clinic to the residence | 1 | ||
| Yes (n = 187) | 28 (15) | 159 (85) | |
| No (n = 756) | 112 (14.8) | 644 (85.2) | |
| Not feeling the necessity because my teeth are healthy | .003 | ||
| Yes (n = 60) | 1 (1.7) | 59 (98.3) | |
| No (n = 864) | 141 (16.3) | 723 (83.7) | |
| Feeling paina | 1 | ||
| Yes (n = 5) | 0 (0) | 5 (100) | |
| No (n = 938) | 140 (14.9) | 798 (85.1) | |
| Doubt the cleanliness of the clinic and instrumentsa | 1 | ||
| Yes (n = 18) | 2 (11.1) | 16 (88.9) | |
| No (n = 906) | 140 (15.5) | 766 (84.5) | |
| Modernity/Cleanliness of the clinic and instruments | .438 | ||
| Yes (n = 205) | 34 (16.6) | 171 (83.4) | |
| No (n = 738) | 106 (14.4) | 632 (85.6) | |
| Presence of a clear treatment plan/ confidence in the quality of care | 1 | ||
| Yes (n = 285) | 28 (15) | 159 (85) | |
| No (n = 658) | 112 (14.8) | 644 (85.2) | |
| Personal, professional, and ethical qualities of the dentist | .024 | ||
| Yes (n = 171) | 35 (20.5) | 136 (79.5) | |
| No (n = 772) | 105 (13.6) | 667 (86.4) | |
- a Fisher exact.
The logistic regression model further confirmed that the barriers associated with dental care utilization in Lebanon were lack of social medical insurance coverage (OR, 0.49 [95% CI, 0.31 to 0.79]), not feeling the necessity to visit the dentist (OR, 8.82 [95% CI, 1.17 to 66.25]), long waiting time at the dentists' office/patient time constraints (OR, 2.05 [95% CI, 1.26 to 3.35]), and forgetfulness (OR, 5.15 [95% CI, 1.55 to 17.18]) (Table 4). On the other hand, facilitators to the utilization of dental care were the ethical standards or personal qualities of the dentist (OR, 0.53 [95% CI, 0.32 to 0.88]) and convenient cost with respect to economic status (OR, 0.28 [95% CI, 0.18 to 0.43]) (Table 4).
| Variables | B | df | OR [95% CI] | p-Value |
|---|---|---|---|---|
| Age | 0.013 | 1 | 1.013 [0.995 to 1.032] | .157 |
| Sex (female) | −0.370 | 1 | 0.691 [0.445 to 1.072] | .099 |
| Marital status | ||||
| Single | 2 | .910 | ||
| Married | 0.153 | 1 | 1.166 [0.543 to 2.502] | .694 |
| Widowed/Divorced | 0.067 | 1 | 1.069 [0.631 to 1.812] | .804 |
| Education level (high) | −0.005 | 1 | 0.995 [0.621 to 1.596] | .984 |
| Mean annual family income | ||||
| Low | 2 | .001 | ||
| Medium | 0.924 | 1 | 2.520 [0.728 to 8.719] | .144 |
| High | 0.026 | 1 | 1.026 [0.286 to 3.677] | .969 |
| Social security coverage | −0.709 | 1 | 0.492 [0.308 to 0.786] | .003 |
| Dental care coverage | 0.491 | 1 | 1.634 [0.719 to 3.713] | .241 |
| Dentist qualities and ethical norms/personal qualities | −0.633 | 1 | 0.531 [0.319 to 0.883] | .015 |
| Personal relationship with the dentist | 0.388 | 1 | 1.474 [0.804 to 2.704] | .210 |
| Convenient cost with respect to the economic status | −1.275 | 1 | 0.279 [0.181 to 0.430] | <.001 |
| Not feeling the necessity because my teeth are healthy | 2.176 | 1 | 8.815 [1.173 to 66.246] | .034 |
| Long waiting times at the dentist/patient time restriction | 0.718 | 1 | 2.050 [1.255 to 3.348] | .004 |
| Forgetfulness | 1.640 | 1 | 5.153 [1.545 to 17.184] | .008 |
| Constant | −6.304 | 1 | 0.002 | <.001 |
- Note: Logistic regression method: Enter method; Overall percentage 84.2%; Omnibus test p < .001; Hosmer and Lemeshow test p = .711; Nagelkerk R square = .268.
- Abbreviations: B, Beta; CI, confidence interval; df, degree of freedom; OR, odds ratio.
The overall associations between the factors that the participants considered as facilitators or barriers to dental care utilization and sociodemographic variables are presented in Tables S2 and S3, respectively. The personal relationship with the healthcare professional and the timely appointments were both associated with the participant's educational status and sex. Cost was also an important factor associated with non-utilization of dental care, especially for participants who do not have dental coverage, those with a low income, and those without a tertiary education. In addition, women were slightly more concerned by the cost of care than men and were more frequently afraid of dental visits. The long waiting time was associated with participant's educational status, annual income, employment sector, and marital status.
4 DISCUSSION
This nationwide cross-sectional study assessed the prevalence of non-utilization of dental care by adults in Lebanon and the factors associated with such non-utilization. Approximately a quarter of the population (23.1%) did not utilise at least one type of healthcare service, and of those, more than half did not utilise dental care (58.3%). These rates were similar to those reported by other studies conducted in Lebanon and abroad.11, 12 In Lebanon, Truppa et al.11 reported that 26.2% of interviewed participants stated that they had never sought healthcare or that their last visit to a healthcare facility was more than 1 year prior to the date of data collection. Similarly, Daabek et al.12 reported that 25.4% of the French population skipped any type of healthcare, and 58% of them abandoned dental care.
In the current study, the prevalence of non-utilization of dental care with respect to the whole study population was estimated at 13.5%, which was lower than that reported by Truppa et al.11 (21.1%). This difference may be attributed to the different study population. The latter study interviewed mainly females of childbearing potential residing within a 7 km radius from International Committee of the Red Cross (ICRC)-supported facilities in three governorates only (Bekaa, Akkar, and Nabatiyeh).11 Compared to European countries, the prevalence rate of 13.5% is higher than the average rate of 8% reported by Tchicaya and Lorentz13 based on data obtained from the European Union Statistics on Income and Living Conditions survey (2007). Data from 24 European countries were collected, and the prevalence of non-utilization of dental care among individuals aged ≥16 years ranged between 2.5% and 21.9%, with 11 of 24 countries having a prevalence higher than the average.13
In the current study, only 4.8% of participants stated that they had consulted a dentist in the past year. This rate is lower than that reported in several other studies conducted in different countries including Lebanon, Jordan, and Kingdom of Saudi Arabia (KSA).14-17 Sacy14 and Kasparian and Ammar15 reported that 15 to 30% of the Lebanese population consulted their dentist annually. An even higher rate of participants visiting their dentist within the last 12 months was observed in cross-sectional studies conducted in Jordan and KSA (range 47.4% to 56.7%).16-18 The very low rate observed in the current study is alarming and proposes a major hurdle for the healthcare system, especially that awareness is not the only problem. Indeed, more than 60% of participants acknowledged that regular dental visits are important for the prevention of oral diseases, and 27.9% believed that it is necessary for early detection of such diseases. However, 53% of the patients reported that the main reason for the last dental visit was pain rather than a routine check-up. Indeed, other studies have also shown that one of the main reasons for seeking dental care is pain relief.17, 18 This notion reinforces the importance of engaging the population in health promotion programmes to encourage the adoption of preventive rather than only curative measures for oral diseases.19
Socioeconomic factors associated with non-utilization of dental care in Lebanon were varied and were not entirely limited to financial concerns such as low average annual family income and/or lack of social insurance coverage. Cost was the most frequently reported factor, especially in the absence of specific insurance coverage. Indeed, those without social insurance coverage were twice as likely to refrain from utilizing dental care. This finding was expected, as oral health care is not included in primary care coverage in most countries including Lebanon.20 Given that access to health insurance is linked to the individual's financial status, the most socially vulnerable people are those with a low income and/or unemployed who do not benefit from such coverage, therefore limiting their access to care. It has been suggested that individuals who use dental care are those who need it the least, and individuals who are in socially fragile situations have little or no perception of the need for care.21, 22 As for the association between dental care utilization and the dentist's personal qualities/ethical standards, it has been suggested that a skilled dentist and a good relationship with them and their team is important to improve the use of oral care.23-25 Moreover, in the current study, 86% of the Lebanese population expressed a fear or dislike of dentists. To help reduce this dislike/fear, it is essential to train professionals to improve their personal skills as well as their management of patients and the quality of care they provide.26
This nationwide cross-sectional study had several limitations including the unusual method of identifying participants.27 As mentioned earlier, electoral rolls could not be used as they are not representative of the individuals residing in a specific district. In addition, data on primary residences could not be used since many Lebanese families have more than one primary residence. The unorthodox method of sampling based on registered students may have skewed the distribution of the population across the country. Another limitation may have been the nature of the study,28 where participants may be timid in one-on-one interviews and not truly admit the reasons behind the non-utilization of dental care, especially when related to financial problems. Participants may have been hesitant to acknowledge their lack of care as being caused by personal negligence. Finally, this study only assessed the dental care behaviour of adults and factors affecting children dental visits may be different than those of adults. For example, paediatrics may be less likely to be directly affected by the cost of treatment and more likely affected by the fear from the dentist. Unfortunately, in the absence of an institutional prevention framework specifically targeting paediatrics, dental care habits of children are solely affected by their parent's preconceptions and behaviour. Even with the presence of these limitations, the findings of this study add to the body of knowledge for better understanding the Lebanese sociodemographic, economic, and dentistry-related factors associated with non-utilization of dental care and its prevalence in this country.
The aim of the Global Strategy on Oral Health is to enable all people to have universal oral health insurance coverage by 2030.29 Given Lebanon's current economic and political situation, it is unlikely that such coverage will be offered to the entire population, by the planned date. If local decision-makers do not take proactive, tangible steps regarding this public health problem, the overall burden of diseases will be greater, creating a source of major healthcare inequality.30, 31 Organising a prevention programme on a nationwide basis, similar to “M'T Dents” in France, which encourages young people to adopt good habits, is essential.26, 32 However, the implementation of such programmes takes time. Therefore, it may be appropriate to begin by organising free consultations and check-ups in dental clinics, especially in rural areas. In addition, it may be necessary to encourage the population to use the services of primary care centres accredited by the Ministry of Public Health. These healthcare facilities may offer primary dental care, such as emergencies and treatment of caries, to allow access to adequate oral healthcare.10 The Lebanese Ministry of Public Health, along with all concerned parties, should strongly consider implementing a nationwide action plan including training healthcare professionals as well as the general public, to reduce the burden of oral diseases.
5 CONCLUSIONS
In conclusion, the findings from this study suggest that dental care practices in Lebanon, including non-utilization of dental care, are suboptimal. The findings may aid the Lebanese Government to help reduce the impact of oral diseases, in particular dental caries. Prevention strategies such as reducing sugar and tobacco consumption, providing information on oral hygiene, and using fluoride products are potentially inexpensive, although implementing these preventative measures will take substantial time and concerted efforts by multiple stakeholders.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
