Oral health access in Brazil: analysis of inequities and non-access from the service user's perspective, according to the National Primary Care Access and Quality Improvement Program, 2014 and 2018

This was a cross-sectional study of data from external evaluations of the National Primary Care Access and Quality Improvement Program (2014 and 2018), using hierarchical multivariate logistic regression. ‘Non-access’ was defined as the service user not being able to make an appointment with a dentist.

Results:

We analyzed data on 37.262 individuals (2014 sample) and on a further 117.570 individuals (2018 sample). Greater likelihood of non-access was found for those who live in municipalities with greater inequalities and with less oral health coverage, those whose travel time to the health center is more than 11 minutes, being female, being aged between 25 and 39 years and those whose income was up to 1 minimum wage.

Conclusion:

Non-access was associated with municipal factors such as greater inequality; organizational factors such as less oral health coverage and travel time to the health center; and individual factors such as sex, age and income.

Keywords:
Cross-Sectional Studies; Health Services Accessibility; Dental Health Services; Primary Health Care.

Variables		2^nd Cycle						3^rd Cycle
		Access/never tried to access			Unable to access			Access/never tried to access			Unable to access
		n	%		n	%		n	%		n	%
Level 1 - Municipal environmental variables
HDI-M^a	Low HDI-M	17,508	47.0		2,135	5.7		53,791	45.8		1,664	1.4
HDI-M^a	High HDI-M	14,998	40.3		2,621	7.0		59,031	50.2		3,053	2.6
Gini Index	Low Gini	17,981	48.3		2,354	6.3		59,518	50.6		1,926	1.6
Gini Index	High Gini	14,525	39.0		2,402	6.4		53,304	45.4		2,791	2.4
Oral health coverage	Low or medium coverage	12,184	32.8		2,410	6.5		50,998	43.4		3,086	2.6
Oral health coverage	High coverage	20,223	54.4		2,333	6.3		61,854	52.6		1,632	1.4
Level 2 - Service organization variables
Time taken to get to the health center	Up to 10 min.	19,992	53.8		2,695	7.2		67,684	58.2		2,450	2.1
	11 - 30 min.	10,189	27.4		1,694	4.6		37,013	31.9		1,905	1.6
	Over 30 min.	2,233	6.0		361	1.0		6,834	5.9		313	0.3
Type of service provision	Scheduled appointment	6,628	17.8		1,266	3.4		96,050	84.4		4,049	3.6
	Order of arrival	25,233	67.7		3,356	9.0		12,147	10.7		470	0.4
	Fitting in or other	645	1.7		134	0.4		984	0.9		44	0.0
Appointment made for the same day	Yes	16,036	43.5		1,755	4.8		46,677	41.2		1,155	1.0
Appointment made for the same day	No	16,149	43.8		2,924	7.9		62,170	54.8		3,404	3.0
Opening hours meet user needs	Yes	28,697	77.7		3,799	10.3		107,484	91.8		4,082	3.5
Opening hours meet user needs	No	3,539	9.6		913	2.4		4,911	4.2		613	0.5
Periods of the day in which the health service is open	1 to 2 periods	31,000	83.2		4,471	12.0		97,219	89.0		4,013	3.7
Periods of the day in which the health service is open	3 periods	1,506	4.0		285	0.8		7,715	7.0		335	0.3
How many days a week the health service is open	1 - 4 days	1,724	4.6		296	0.8		2,782	2.4		200	0.2
	5 days	29,529	79.3		4,258	11.4		101,881	88.8		4,042	3.5
	6 or 7 days	1,253	3.4		202	0.5		5,531	4.8		292	0.3
Level 3 - Individual variables
Sex	Male	5,881	15.8		633	1.7		24,936	21.2		729	0.6
Sex	Female	26,625	71.4		4,123	11.1		87,916	74.8		3,989	3.4
Age group (years)	≤24	5,193	13.9		841	2.3		14,250	12.1		632	0.5
	25-39	12,736	34.2		2,032	5.5		34,726	29.5		1,821	1.6
	40-59	10,278	27.6		1,455	3.9		38,581	32.8		1,633	1.4
	≥60	4,299	11.5		428	1.1		25,295	21.5		632	0.6
Race/skin color	White	11,168	30.5		1,629	4.4		36,484	31.4		1,230	1.1
Race/skin color	Non-white	20,801	56.8		3,051	8.3		74,899	64.5		3,445	3.0
Schooling	None or just able to read and write	3,179	8.5		330	0.9		12,049	10.3		278	0.2
	Elementary education	14,863	39.9		2,111	5.7		48,855	41.7		1,989	1.7
	High school education	12,086	32.5		1,971	5.3		41,545	35.4		2,037	1.7
	Higher education	2,344	6.3		339	0.9		10,248	8.7		407	0.3
Level 3 - Individual variables
Income (minimum wages: MWs)	No income	20,651	58.3		2,974	8.4		12,326	12.5		627	0.6
	Up to 1 MW	3,183	9.0		481	1.4		28,092	28.6		1,152	1.2
	1 - 3 MWs	6,717	19.0		1,034	2.9		42,936	43.7		1,781	1.8
	4 or more MWs	331	0.9		46	0.1		10,997	11.2		366	0.4
Bolsa Família Program beneficiary	Yes	12,241	32.9		1,767	4.7		34,409	30.2		1,804	1.6
No	20,236	54.4		2,988	8.0		74,988	65.7		2,839	2.5

Variables		β	p-value	OR^a	95%CI^b
Variables	Level 1 - Municipal environmental variables
HDI-M^c	Low HDI-M	-0.168	p<0.001	0.86	0.78;0.91
HDI-M^c	High HDI-M	1.00		1.00
Gini index	Low Gini	1.00		1.00
Gini index	High Gini	0.106	0.002	1.11	1.04;1.19
Oral health coverage	Low or medium coverage	0.362	p<0.001	1.44	1.33;1.55
Oral health coverage	High coverage	1.00		1.00
Level 2 - Service organization variables
Time taken to get to the health center	Up to 10 min.	1.00		1.00
	11 - 30 min.	0.153	p<0.001	1.17	1.09;1.25
	Over 30 min.	0.181		1.20	1.05;1.36
Type of service provision	Scheduled appointment	1.00		1.00
	Order of arrival	-0.120	p<0.001	0.89	0.82;0.96
	Fitting in or other	0.240	0.042	1.27	1.01;1.60
Appointment made for the same day	Yes	1.00		1.00
Appointment made for the same day	No	0.325	p<0.001	1.39	1.29;1.49
Opening hours meet needs	Yes	1.00		1.00
Opening hours meet needs	No	0.545	p<0.001	1.73	1.58;1.88
Periods of the day in which the health service is open	1 to 2 periods	-0.096	0.194	0.91	0.79;1.05
Periods of the day in which the health service is open	3 periods	1.00		1.00
How many days a week the health service is open	1 - 4 days	0.118	0.002	1.13	0.91;1.39
	5 days	-0.113		0.89	0.76;1.05
	6 or 7 days	1.00		1.00
Level 3 - Individual variables
Sex	Male	-0.227	p<0.001	0.80		0.72;0.88
Sex	Female	1.00		1.00
Age group (years)	≤24	1.00		1.00
	25-39	0.014	P<0.001	1.01	0.93;1.11
	40-59	-0.077		0.93	0.84;1.02
	≥60	-0.458		0.63	0.55;0.73
Schooling	None or just able to read and write	-0.149	0.062	0.86	0.72;1.03
	Elementary education	-0.011		0.99	0.87;1.13
	High school education	-0.043		1.04	0.92;1.19
	Higher education	1.00		1.00

Variables		β	p-value	OR^a	95%CI^b
Level 1 - Municipal environmental variables
HDI-M^c	Low HDI-M	-0.272	p<0.001	0.76	0.70;0.84
HDI-M^c	High HDI-M	1.00		1.00
Gini Index	Low Gini	1.00		1.00
Gini Index	High Gini	0.321	p<0.001	1.38	1.28;1.48
Oral health coverage	Low or medium coverage	0.602	p<0.001	1.83	1.67;1.99
Oral health coverage	High coverage	1.00		1.00
Level 2 - Service organization variables
Time taken to get to the health center	Up to 10 min.	1.00		1.00
	11 - 30 min.	0.250	p<0.001	1.29	1.19;1.38
	Over 30 min.	0.165		1.18	1.01;1.37
Type of service provision	Scheduled appointment	1.00		1.00
	Order of arrival	0.213	0.002	1.24	1.10;1.40
	Fitting in or other	-0.101		0.90	0.60;1.36
Appointment made for the same day	Yes	1.00		1.00
Appointment made for the same day	No	0.570	p<0.001	1.77	1.63;1.93
Opening hours meet needs	Yes	1.00		1.00
Opening hours meet needs	No	0.954	p<0.001	2.60	2.32;2.91
How many days a week the health service is open	1 - 4 days	0.250		1.28	1.02;1.62
	5 days	-0.221		0.80	0.69;0.93
	6 or 7 days	1.00		1.00
Level 3 - Individual variables
Sex	Male	-0.200	p<0.001	0.82	0.74;0.91
Sex	Female	1.00		1.00
Age group (years)	≤24	1.00		1.00
	25-39	0.159	p<0.001	1.17	1.05;1.31
	40-59	0.088		1.09	0.97;1.23
	≥60	-0.290		0.75	0.64;0.87
Race/skin color	White	1.00		1.00
Race/skin color	Non-white	0.283	p<0.001	1.33	1.22;1.44
Schooling	None or just able to read and write	-0.404	p<0.001	0.67	0.54;0.82
	Elementary education	-0.032		0.97	0.84;1.11
	High school education	0.066		1.07	0.94;1.22
	Higher education	1.00		1.00
Income (minimum wages: MWs)	No income	0.339		1.40	1.18;1.66
	Up to 1 MW	0.273	0.001	1.31	1.14;1.52
	1 - 3 MWs	0.195		1.22	1.07;1.38
	4 or more MWs	1.00		1.00
Bolsa Família Program beneficiary	Yes	0.263	p<0.001	1.30	1.19;1.42
Bolsa Família Program beneficiary	No	1.00		1.00

Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil SRTVN Quadra 701, Via W5 Norte, Lote D, Edifício P0700, CEP: 70719-040, +55 61 3315-3464, Fax: +55 61 3315-3464 - Brasília - DF - Brazil
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[1] Correspondence: Yuri Wanderley Cavalcanti - Universidade Federal da Paraíba, Departamento de Clínica e Odontologia Social, Programa de Pós-Graduação em Odontologia, Cidade Universitária, Campus I, Castelo Branco, João Pessoa, PB, Brazil. CEP: 58051-900 E-mail: yuri@ccs.ufpb.br