Possible Barriers towards Seeking Dental Treatment for the Indian Elders: A Questionnaire Study

This is a study to determine the possible barriers towards seeking dental treatment for the Indian elders and get an insight into the attitude of the elders towards their dental health problem. A total of 100 geriatric patients seeking oral health care above the age of 60 years were enrolled for the study from the outpatient Department of Prosthodontics and Geriatric dentistry, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka. A questionnaire consisting of one key question and 12 questions categorized into 4 sections as a) attitude towards oral health, b) family dental history, c) family attitude and d) finance was given to each participant. Results obtained were put to statistical analysis. Pearson chi-square and Likelihood-ratio chi-square were carried out and it was observed that there is a strong association between the four barriers as p = 0.000 < 0.05. It was concluded that there is a low ‘felt need’ which calls for improving the awareness among elders and motivating them to use the services available for them so that they lead a socially and economically productive life. Also the family attitude towards the patient especially with regard to the presence or absence of spouse has been identified as a major barrier in our study.


Introduction
One of the most evident changing paradigms that we witness in a developing nation like India is the increasing population of the geriatric patients which can be phrased as the "the grey tsunami. " India currently ranks fourth among countries of the world in the absolute size of the aged population, viz. 77 million. In 1981, the elders in India accounted for 6.3% of the population and now it is 7.7% [1]. The Indian elders face plenty of cultural and social challenges. To add to their vows their health needs are often neglected by both, the family and self. Factors like age, education, economic status, marital status, perception on living, anxieties and worries, addictions, degree of idleness, type of health centre visited, and whether the person is on some kind of medication, exert a significant influence on both the perceived and actual health status of the elders [2,3].
Less than 20 per cent of the population seeking outpatient services and less than 45 per cent seeking indoor treatment avail services in public hospitals [4]. It turns out that there must be certain barriers that prevent seeking dental treatment by the elderly population. Understanding of these barriers would help in appropriate programme planning for this target population to improve their health and quality of life [5].
The main purpose of this study is: 1. To determine the possible barriers towards seeking dental treatment for the Indian elders.
2. To get an Insight into the attitude of the elders towards their dental health problem.

Methodology
The study was started after obtaining ethical clearance by the Institutional Review Board. An informed written consent was obtained from all the subjects before their participation in the study.
A total of 100 geriatric patients seeking oral health care were enrolled for the study including 50 males and 50 female participants. They were recruited directly from the outpatient Department of Prosthodontics and Geriatric dentistry, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka. A questionnaire was designed and modified after conducting a pilot study.
The study included participants above the age of 60 years with a sound state of mental health and could respond independently to the questionnaire.
A questionnaire was designed including 13 questions. The first being the key question and the remaining 12 questions were categorized into 4 sections as a) attitude towards oral health, b) family dental history, c) family attitude and d) finance.
A printed version of the questionnaire was given to the participants to be filled independently, without influence of any caregiver or dentist. For patients who couldn't read or write a translator was provided for the same. Completed questionnaires were coded, data were recorded in a standard performa and statistically analyzed using SPSS20 software. Frequencies were used to describe association between variables which were examined using chi square tests. Results were considered significant at p < 0.05. no missing or unanswered questions. The summary of responses was as follows: • Key Question: What do you think possibly prevents the elders from seeking dental treatment? • Results has been explained in

Discussion
According to Daly, problems with heath care services can be classified as 5 A's: Availability, Accessibility, Affordability, Acceptability, Accommodation [6].
In the present study the key barriers considered were: A) Accessibility: patients perceived need towards oral health, family attitude towards patients needs and patients dependence on the family towards obtaining treatment and B) Affordability: cost of treatment.
Almost half the study population considered it normal to lose teeth in their life span. As age advances, people tend to forgo dental health care as they feel they are "too old". Manifestations of various chronic and systemic diseases are accompanied by pain and suffering resulting in restricted mobility [7][8][9][10].
More than 90% of the study population said that the presence or absence of their spouse affected their need for oral health care. But when their dependence on family was considered it came up as a barrier. Thus signifying that this set of people treated their spouse and themselves as a single entity within the family setup. The health status variable is a measure of intensity of health problems faced by the elderly person which in turn would instrument the intensity of personal care offered by co resident children [11]. 50% of the participants claimed their forefathers had better oral health than them and this was due a better lifestyle.
Pensions are expected to achieve the goals of minimizing poverty in old age, smoothening intertemporal life consumption which has significant fluctuations and ensuring that retirees do not outlive their pension benefits/incomes. The three pillar structure talked about in literature facilitate in this process. The first pillar is made up of publicly funded schemes providing modest benefits, or social security schemes. The second pillar consists of occupational schemes sponsored by employers for the benefit of employees or private mandatory pension programmes. The third pillar consists of additional voluntary contributions to meet retirement needs. This three-pillar scheme of World Bank does not take in to account the most important pillar namely family support systems [12]. In India, most of the elders are not covered by a pension system, and have to rely on family based arrangements or their own earnings [13]. The demographic trend combined with decline in joint family system is creating an explosive situation for the elders in India since we do not have a generalized social security and significant portion of our work force is selfemployed. The increasing life expectancy combined with consumerist culture, even post retirement is exacerbating the issue [14].
Unlike most of the previously conducted studies, there is a positive correlation between economic status, utilization and frequency of dental visits [15,16]; a nominal 20% of the participants in the present study felt cost to be a hindrance in seeking dental treatment. This statistics indicates the changing trend indicating that the elders of this generation are financially secure to take care of their medical needs towards their later years. The current wealth is a reflection of past economic activities as well as savings behavior of the elders over the life cycle with a view to provide for the old age, among other things. In other words, current wealth is an alternative form of old-age insurance and therefore is likely to have two-way effects between wealth and current living arrangements [17,18].
Lastly, similar to the study conducted by Borreani and Wright, the results of our study identified cost on transportation as the biggest indirect cost inferred by this age group [19,20]. This was especially true for individuals who did not have a family support to bring them for their dental treatment.
Thus to conclude, there is a low 'felt need' which calls for improving their awareness and motivating them to use the services available for them so that they lead a socially and economically productive life [7].
Also the family attitude towards the patient especially with regard to the presence or absence of spouse has been identified as a major barrier in our study.
Finally, the various limitations of the study are small sample size and localization of the study to a particular area. Also the study did not include dental anxiety and fear and relationship with the dentist at previous dental visits as barriers towards seeking dental treatment. Hence future studies should dwell into these barriers, should be conducted at multicentre level and with a larger sample size.