Explanatory factors of utilization of dental health services over time by older adults in Israel* Varda Soskolne, School of Social Work, Bar-Ilan University Gail K. Auslander, School of Social Work, The Hebrew University of Jerusalem W. Aubrey Soskolne, Hadassah-Hebrew University Faculty of Dental Medicine SHARE-Israel1 *This study was supported by grant 76/2011 from the Israel National Institute for Health Policy Research

Background Good oral health has implications for quality of life and general health, especially among older persons: Important for retaining teeth and preventing dental and oral diseases. Evidence for an association between periodontal diseases and CHD, diabetes and other diseases. Dental care is not included in the basic services provided under the National Health Insurance Law in Israel; services are provided almost exclusively in private dental clinics. Thus, dental care services in Israel are regressive SHARE-Israel2

Background Utilization rates of dental services among the elderly are relatively low compared to other adult age groups, and compared to utilization of medical services. Beyond economic barriers, factors that explain the low utilization rate have not been examined comprehensively SHARE-Israel3

Objectives Examine rates of utilization of dental services and reasons for non-utilization in Israel Examine explanatory factors of utilization of dental services in Israel at the two different waves of SHARE Examine which Wave 1 variables predict utilization of dental services in Wave 2 NOTE: The overall goal of the study is to compare the explanatory factors of utilization of dental services in Israel to the European countries SHARE-Israel4

Study model The analysis is based on Andersens Behavioral Model and examines a combination of predisposing (background variables), enabling (e.g., income, mobility) and need factors (e.g., dentate state) SHARE-Israel5

Study Model - Andersen Predisposing factors Enabling factors Need (perceived ) Utilization Barriers Age, gender, marital status, population group, education Perceived economic state, dental insurance, contact w/GP, health status, depression, physical and cognitive status Ability to bite and chew SHARE-Israel6

METHOD Inclusion criteria Age 65 Responded in both Wave 1 and Wave 2 N = 777 persons Analysis – after imputation to correct for missing data in multi-variate analysis SHARE-Israel7

Description of the population (n=777) Age: mean years ± s.d; range73.1±6.3; Gender: Female52% Male48% Marital Status: Married71% Not married29% Language: Hebrew81% Arabic13% Russian 6% Education: Elementary or lower30% High school, no matric.31% High school, matric.39% SHARE-Israel8

FINDINGS Utilization of dental services (seen a dentist in last year) Wave 1 – 39% Wave 2 – 34% In comparison: 80% and 81% in Sweden 52% and 48% in Netherlands 20% and 19% in Spain SHARE-Israel9

FINDINGS Wave 1 Purpose of visit (among those who saw a dentist) – Only routine/prevention 27.5% – Only for treatment 46% – Routine/prevention & treatment 26% Dental Insurance – 4.8% Ability to bite and chew hard food – 68% BARRIERS to seeing a dentist – Too costly (total N =95) – 51% – Unavailable care (total N = 32) 34% SHARE-Israel10

Variables related to utilization of dental services (bi-variate) In both wave 1 & 2, Significant associations of almost all variables with utilization of dental services SHARE-Israel11

Logistic regression: utilization of dental services, W1 95% C.I.O.R.Variables a Predisposing characteristics:.929, *** Age Reference Population group: Non-immigrant Jews.191, *** Arabs.142, *** Immigrants FSU Enabling characteristics 1.086, *** Able to make ends meet Need.986, # Able to bite/chew : yes a Non-significant variables included in the analysis, but not shown here: Gender, education, ADL, cognitive state, self-rated health, chronic illness, depression SHARE-Israel # P=0.07, *p< 0.05, *** p<

Prediction of utilization of dental services in W2 95% C.I.O.R.W1 Variables a Predisposing characteristics:.912, *** Age Reference Population group: Non-immigrant Jews.088, *** Arabs.165, * Immigrants FSU Enabling characteristics.989, # Able to make ends meet 1.001, * Number of chronic illnesses Need.986, *** Able to bite/chew : yes a Non-significant variables included in the analysis, but not shown here: Gender, education, ADL, cognitive state, self-rated health, depression SHARE-Israel # p<0.10, *p< 0.05, *** p<

Summary Age and population group are the predisposing variables that correlate with and predict utilization Economic status is the major enabling factor of utilization Contrary to expectations, More chronic illnesses predicts utilization Possible explanation: Increased awareness of the association between periodontal diseases and general health increases referrals to dentists? Ability to bite and chew is associated to and predicts utilization Two facets of life-long good health behaviors? The Paradox of Dental Need? SHARE-Israel14

Limitations of the study Limited choice of variables suitable to represent factors of the Andersen model Evaluation of dental needs is particularly poor Potential biases: i.e., problems of missing data, under-representation of Russian-speaking immigrants Significance of the study First longitudinal cohort study of utilization of dental care services in Israel Expanded theoretical framework Large sample size SHARE-Israel15

CONCLUSIONS Utilization is very low compared to younger Israelis and to elders in most countries in Europe Utilization of dental services reflects inequality in Israeli society (economic status, population group) Underutilization by those who most need services Lack of treatment may lead to oral and general health morbidity and eventually to higher costs including hospitalization SHARE-Israel16

RECOMMENDATIONS Policy Inclusion of dental services in the basket of services Training and incentives for dentists in geriatric dentistry Practice Health practitioners should encourage Israelis to get proper care irrespective of age Further Research Additional and more valid variables that are related to utilization in next waves of SHARE Other cohort studies SHARE-Israel17

THANK YOU Varda Soskolne: Gail Auslander: Aubrey Soskolne: SHARE-Israel18