Oral diseases are the most prevalent noncommunicable diseases around the world and have substantial impact on health, societies, and economies [1]. The World Dental Federation (FDI) Vision 2030 report aims to improve oral health and diminish oral health inequalities over the next decade [2]. FDI identified access to dental care and universal dental coverage as key pillars and global health priorities [3]. Improved dental healthcare services promote better work output (in education and employment) and help to alleviate impoverishment. Early detection of oral diseases reduces the expenditure on their treatment. Both having a direct positive impact on the overall quality of life [4].
Increasing access to dental healthcare services and promoting prevention is also a priority in Saudi Arabia reflected by the National Transformation Program, designed to fulfil the Saudi Arabia Vison 2030 [5]. Dental services in Saudi Arabia are provided by the public and private sectors; all Saudi citizens have the right to free dental care in primary, secondary and tertiary government facilities [6]. Non-Saudi residents are guaranteed access to dental care by mandatory health insurance provided through their employers [7]. Yet, utilization of dental services is still relatively low [8]. Other countries that also have free access for specific groups or varying coverage across populations still demonstrate inequalities in dental utilization [8–10]. However, little is known about the socioeconomic inequalities in utilization of dental services in Saudi Arabia. Few studies have investigated the predictors of dental utilization in Saudi Arabia. Most of these studies were localized to limited regions and targeted specific populations [8]. Assessing the extent of inequalities in use of dental services and the factors associated with them will help to identify approaches to reduce these inequalities and ultimately improve oral health [9].
The Anderson model of health care has been used as a theoretical framework to explore dental utilization [10]. This model suggests that predisposing characteristics, enabling resources and need factors shape the utilization of dental services [11, 12]. Predisposing characteristics comprise demographic factors such as age and gender [13], and social factors (e.g., education, ethnicity, and health beliefs) [14]. Predisposing characteristics affect the likelihood of using dental services through the natural history of oral diseases, genetic factors, health beliefs and social or cultural influences [15]. Enabling resources facilitate the use of dental services; income or wealth determines a person’s ability to pay for services, while insurance and cost-sharing rules define the actual price of the service and the amount that a patient pays out of pocket [16]. Need factors can be perceived need or evaluated need. Perceived need is how an individual evaluates their own health status, while evaluated need is an objective measurement of an individual’s health status often assessed clinically by health professionals [16].
Previous studies that have used the Andersen model to assess socioeconomic disparities in the utilization of dental services have shown that enabling factors are key predictors [9, 15, 17]. These significant predictors included out of pocket payment and history of receiving welfare [15], health insurance coverage [9], wealth [17, 18], education and income [9, 17]. Only one study in Saudi Arabia, to our knowledge has used the Andersen model to investigate the utilization of dental services among children. The study found that parental education was a significant predictor of dental use among young children [19].
Studies have used a range of socioeconomic indicators at the individual, area-based or contextual levels including education, occupation, income and indices of deprivation and material assets (e.g., home ownership) either as single measures or composite indices [9, 18, 20]. Income and education have been the main indicators used in previous Saudi Arabian research to explore dental utilization. Choosing the most appropriate socioeconomic indicator depends on the relevance of those indicators to the outcome and context of the study [21]. Income data can be an insensitive measure due to high nonresponse rates compared to other socioeconomic status measures [22]. Income is also an age dependent, less stable measure that does not provide a full picture of socioeconomic status in Saudi Arabia because as it does not take into account other resources such as wealth, inheritance or insurance coverage [21–23]. Education affects health by non-economic pathways such as health-related knowledge, lifestyle, and behavior. Measures of education are easier to collect and are more stable than income [21, 23]. However, an increase in the education level does not consistently equate with an increase in socioeconomic status. The limitations of using education and income as socioeconomic indicators in Saudi Arabia suggest a need to use multiple measures of socioeconomic status that are relevant in the local context [23]. Relevant contextual socioeconomic indicators include employment status, household wealth and an area-based measure of socioeconomic class specific for Saudi Arabia [24].
Assessing the socioeconomic inequalities in utilization of dental services among adults in Saudi Arabia will provide an evidence basis for effective planning of dental services to increase utilization and ultimately improve oral health. The study aimed to use the Andersen model to identify socioeconomic inequalities in dental services utilization, along with other predictors of utilization, for the Saudi Arabian context to inform future planning of dental services.