SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON ECONOMIC BURDEN OF DENTAL DISEASES OF PATIENTS ATTENDING THE DENTAL UNIT OF UNIVERSITY HOSPITAL, LEGON BY SELI YAWA DEH (10506908) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT FOR THE AWARD OF MASTERS IN PUBLIC HEALTH DEGREE JULY, 2015 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I declare that all information produced from this project is a result of my own research. Other works cited have been duly acknowledged by means of referencing. No part of this research has been presented elsewhere for another degree. Signature: ………………….. Signature: ………………… Seli Yawa Deh Dr. Genevieve Cecilia Aryeetey (Student) (Supervisor) Date: ……………………….. Date: ……………………… University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This dissertation is dedicated to my parents Dr. Kodjo Deh and Mrs. Josephine Deh and my friend Kwadwo Agyapong for the care and support given me throughout the course of this programme. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGMENT This dissertation was made possible through the valuable contribution by many individuals. First and foremost, I express my sincere gratitude to Dr. Genevieve Cecilia Aryeetey for your guidance and supervision throughout this project. My special thanks goes to Professor Moses Aikins, Dr. Justice Nonvignon, Dr. Reuben Esena and the staff of the Department of Health Policy, Planning and Management for your assistance. I would also like to thank my siblings and friends for their support and encouragement. Finally, I would like to thank Edward Asiedu who assisted me at the data collection stage of this project as well as the staff of the dental unit, University Hospital, Legon and the patients who participated in the study for their assistance and cooperation. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Introduction: Dental health is essential to the general well-being of an individual. The most common oral diseases are dental caries and periodontal diseases. Significant economic costs are incurred by dental patients however limited studies have been conducted on the economic burden dental diseases place on its patients. This study therefore aimed to, estimate the costs of dental diseases and determine the economic burden of dental diseases on patients. Methods: Cross-sectional design was used in this study. Data was collected from 185 patients attending the dental unit of University Hospital, Legon. Direct cost was estimated from medical and non-medical costs. Indirect cost was estimated by valuing productivity time lost to patients and intangible cost such as pain was described using the Likert scale. The socioeconomic differences in the cost of dental diseases were determined using the wealth quintiles of patients. Results: The estimated total cost of dental diseases was GHS 27,184.00 (US$ 6,614.11) with the direct cost constituting 94.5% and indirect cost constituting 5.5% of the total cost profile. The mean cost was GHS 146.94 (US$ 35.75). The richer socioeconomic group had the highest cost per quintile with a mean of GHS 191.89 (US$ 46.69). The intangible cost described was highest for pain (49.2%). Conclusion: The costs of dental diseases are enormous hence dental health services should be made affordable for patients. Oral health intervention programmes should focus more on preventive than curative care in order to prevent dental diseases with its associated health expenditure, productivity losses and intangible costs. Keywords: direct cost, indirect cost, intangible cost, socioeconomic status, dental diseases University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS DECLARATION............................................................................................................................ i DEDICATION............................................................................................................................... ii ACKNOWLEDGMENT ............................................................................................................. iii ABSTRACT .................................................................................................................................. iv TABLE OF CONTENTS ............................................................................................................. v LIST OF TABLES ....................................................................................................................... ix LIST OF FIGURES ...................................................................................................................... x LIST OF ABBREVIATIONS ..................................................................................................... xi DEFINITION OF TERMS......................................................................................................... xii CHAPTER ONE ........................................................................................................................... 1 1.0 INTRODUCTION ................................................................................................................. 1 1.1 Background ........................................................................................................................... 1 1.2 Statement of the problem ...................................................................................................... 3 1.3 Conceptual framework for the economic burden of dental diseases ................................... 4 1.4 Justification ........................................................................................................................... 7 1.5 Objectives .............................................................................................................................. 7 1.5.1 General Objectives ......................................................................................................... 7 1.5.2 Specific Objectives ........................................................................................................ 7 1.5.3 Research Questions......................................................................................................... 8 CHAPTER TWO .......................................................................................................................... 9 2.0 LITERATURE REVIEW ................................................................................................... 9 2.1 Oral and Dental Health: definition, prevalence and effects ............................................... 9 2.2 Health and Dental Diseases ................................................................................................... 9 2.3 Global Burden of Dental Disease ........................................................................................ 11 2.4 Cost of Illness ..................................................................................................................... 12 2.5 Direct Costs ......................................................................................................................... 13 2.5.1 Direct medical costs...................................................................................................... 13 University of Ghana http://ugspace.ug.edu.gh vi 2.5.2 Direct medical costs on governments ........................................................................... 14 2.5.3 Direct medical costs on individuals .............................................................................. 14 2.5.4 Non-medical Costs ....................................................................................................... 15 2.6 Indirect costs ....................................................................................................................... 16 2.7 Intangible costs .................................................................................................................... 17 2.8 Sensitivity Analysis ............................................................................................................. 18 2.9 Effect of cost on dental health services utilisation .............................................................. 19 2.10 Effect of Socio-economic Status on Dental Health ........................................................... 21 2.11 Conclusion ......................................................................................................................... 21 CHAPTER THREE .................................................................................................................... 23 3.0 METHODS......................................................................................................................... 23 3.1 Type of study ....................................................................................................................... 23 3.2 Study area ........................................................................................................................... 23 3.3 Study variables ................................................................................................................... 23 3.4 Study population .............................................................................................................. 24 3.5 Sample size ....................................................................................................................... 25 3.6 Sampling Method ............................................................................................................... 26 3.6.1. Sampling procedure .................................................................................................... 26 3.7 Data collection techniques ................................................................................................. 27 3.8 Quality control.................................................................................................................... 28 3.8.1 Pre-data collection stage ............................................................................................... 28 3.8.2 Pretesting of questionnaire ........................................................................................... 28 3.8.3 Data collection stage ..................................................................................................... 29 3.8.4 Data entry and processing ............................................................................................. 29 3.9 Data Analysis ..................................................................................................................... 29 3.9.1 Estimation of direct costs ............................................................................................. 29 3.9.2 Estimation of direct medical cost ................................................................................. 30 3.9.3 Estimation of direct non-medical cost .......................................................................... 30 3.10 Estimation of indirect cost................................................................................................. 31 3.10.1 Productivity losses ...................................................................................................... 32 University of Ghana http://ugspace.ug.edu.gh vii 3.11 Description of intangible cost ........................................................................................... 33 3.12 Sensitivity Analysis ........................................................................................................... 34 3.13 Estimation of socio-economic status ................................................................................. 34 3.14 Assumptions ...................................................................................................................... 34 3.15 Proposal and funding information ..................................................................................... 34 3.16 Study limitations ............................................................................................................... 34 3.17 Ethical considerations ...................................................................................................... 35 CHAPTER FOUR ....................................................................................................................... 37 4.0 RESULTS............................................................................................................................ 37 4.1 Background characteristics of respondents ......................................................................... 37 4.2 Dental condition of respondents .......................................................................................... 39 4.2.1 Previous dental treatment of respondents ..................................................................... 39 4.2.2 Current dental condition of respondents ....................................................................... 39 4.2.3 Dental condition and socioeconomic status (SES) ....................................................... 39 4.2.4 Duration of dental condition of respondents ................................................................ 40 4.2.5 Type of treatment received by respondents .................................................................. 40 4.2.6 Travel time spent by respondents ................................................................................. 43 4.2.7 Waiting and treatment time spent by respondents ........................................................ 43 4.2.8 Total productive days lost by respondents ................................................................... 43 4.3 Direct cost of dental diseases .............................................................................................. 44 4.3.1 Direct medical cost ....................................................................................................... 44 4.3.2 Direct non-medical cost ................................................................................................ 44 4.4 Indirect cost of dental diseases ............................................................................................ 45 4.5 Direct cost per dental condition .......................................................................................... 46 4.6 Total cost of dental diseases ................................................................................................ 46 4.7 Direct cost of dental healthcare by wealth quintile ............................................................. 47 4.8 Sensitivity analysis of the cost of dental diseases ............................................................... 48 4.9 Intangible cost of dental diseases ........................................................................................ 50 University of Ghana http://ugspace.ug.edu.gh viii CHAPTER FIVE ........................................................................................................................ 51 5.0 DISCUSSION ........................................................................................................................ 51 5.1 Direct cost of dental diseases .............................................................................................. 51 5.2 Indirect cost of dental diseases ............................................................................................ 53 5.3 Cost of dental disease and socio-economic status ............................................................... 54 5.4 Intangible costs of patients .................................................................................................. 54 5.5 Sensitivity analysis .............................................................................................................. 56 CHAPTER SIX ........................................................................................................................... 59 6.0 CONCLUSION AND RECOMMENDATIONS ................................................................ 59 6.1 Conclusion ........................................................................................................................... 59 6.2 Recommendations ............................................................................................................... 59 REFERENCES ............................................................................................................................ 60 APPENDICES ............................................................................................................................. 67 Appendix I Informed Consent Form ........................................................................................ 67 Appendix II Questionnaire ........................................................................................................ 70 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 1: Table of variables ........................................................................................................... 24 Table 2: Estimation of direct medical costs .................................................................................. 30 Table 3: Estimation of direct non- medical costs......................................................................... 31 Table 4: Estimation of indirect costs ............................................................................................ 32 Table 5: Description of intangible cost ......................................................................................... 33 Table 6: Background characteristics of respondents .................................................................... 38 Table 7: Dental conditions as reported by the respondents .......................................................... 41 Table 8: Dental condition by wealth quintile ................................................................................ 42 Table 9: Type of treatment by wealth quintile .............................................................................. 42 Table 10: Mode of payment for treatment received by respondents ............................................ 42 Table 11: Travel time, waiting and treatment time spent by respondents .................................... 43 Table 12: Total days lost to respondents....................................................................................... 44 Table 13: Total cost of dental diseases ........................................................................................ 45 Table 14: Direct medical cost per reported dental condition ........................................................ 46 Table 15: Direct cost of dental healthcare by wealth quintile ...................................................... 48 Table 16: Sensitivity analysis of total cost of dental diseases ...................................................... 49 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1: Conceptual framework for the economic burden of oral diseases ................................. 6 Figure 2: Total cost of dental diseases .......................................................................................... 47 Figure 3: Patients intangible cost .................................................................................................. 50 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS CDC Center for Disease Control and Prevention COI Cost of Illness DALY Disability Adjusted Life Year GBD Global Burden of Disease HCA Human Capital Approach NHIS National Health Insurance Scheme OECD Organisation for Economic Co-operation and Development WHO World Health Organisation WTP Willingness to Pay YLD Years Lived with Disability YLL Years of Life Lost University of Ghana http://ugspace.ug.edu.gh xii DEFINITION OF TERMS Oral Health The state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking and psychosocial wellbeing. Dental diseases Disease conditions that affect the teeth, gums, other tissues and parts of the mouth. Direct cost The value of health care resources that are consumed with respect to the prevention, diagnosis and treatment of disease or injury, as well as the provision of an intervention, including costs related to side effects or other current and future consequences. Indirect Cost Indirect costs represent the value of output lost due to illness or premature death. Intangible Cost Intangible costs are defined as sufferings and discomfort borne by a patient because of a disease. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Background Oral health is essential to the overall wellbeing of an individual. Poor oral health occurs from poor oral hygiene and other oral health related problems. Some oral diseases include oral infections, trauma, injuries, hereditary lesions and oral cancer among others. The commonest types of oral diseases are dental diseases. Dental diseases are disease conditions that affect the teeth and surrounding tissues. In this study, the terms “oral diseases” and “dental diseases” are used interchangeably. The most common dental disease conditions are dental caries and periodontal disease. Dental caries affects about 90% of the world’s population and periodontal diseases affects about 20% of the world’s population while the global burden of dental diseases increased by 21% in the last 20 years (Marcenes et al., 2013). Currently, it is estimated that about 3.9 billion people are affected by the disease worldwide. Dental diseases are common in both developed and developing countries. According to Patel (2012), the prevalence of dental caries is irregularly distributed in Europe and in the last 30 years, Western Europe observed marked improvements in the prevalence of dental caries while some improvements were also recorded in Eastern Europe however, the prevalence of dental caries in Eastern and Central European children is still significant. In developing countries, prevalence of the disease is still increasing despite many interventions taken to reduce the incidence of the disease. For instance, India and Pakistan have prevalence rates of 50% and 55% respectively (Datta & Datta, 2013; Dawani et al., 2012). Some North African countries like Egypt and Tunisia have prevalence rates of about 70% (Hamila, 2013) and University of Ghana http://ugspace.ug.edu.gh 2 43% respectively (Maatouk et al., 2006). There are few studies on the overall burden of the disease in Africa but the World Health Organisation (WHO) attributes the greatest burden due to dental diseases to Eastern, Central and sub-Saharan Africa (Marcenes et al., 2013). This is evident in studies conducted in Kenya and Nigeria which reported about 49% and 60% prevalence of dental disease respectively (Bashiru & Omotunde, 2014). Dental caries prevalence of 55% was also reported among Ghanaian school children (Addo-Yobo et al., 1991) and Korle- Bu Teaching Hospital in Ghana recorded an increase of 75% in dental infections from 2010 to 2011. Dental diseases are associated with some economic cost. These include direct costs which includes cost of treatment, indirect cost which comprises lost wages due to dental diseases and intangible costs such as pain and reduced quality of life (Cunningham, 2000). Patients incur costs when they access dental healthcare. For instance, individual households in Kenya finance oral health care mainly from out-of-pocket payments (Kaimenyi, 2004). There are other non-monetary impact of dental diseases on society through reducing productivity and participation in the workforce. In Canada, over 40 million hours were lost due to dental problems and treatment with subsequent productivity losses of over $1 billion in 2009 (Hayes et al., 2013). The Australian economy also made about $2 billion per annum in productivity losses as a result of dental diseases (Richardson & Richardson, 2011). Despite these economic costs incurred by patients who have dental diseases very few studies have been conducted on the economic burden that dental diseases place on its patients hence the need to conduct cost of illness studies (COI) in this area to estimate such costs associated with the dental diseases. University of Ghana http://ugspace.ug.edu.gh 3 1.2 Statement of the problem Dental diseases are a major public health concern globally. The costs of treating dental conditions can be enormous and the World Health Organisation (WHO) identifies oral diseases to be among the most expensive diseases to treat (Hayes et al., 2013). In industrialised countries, dental treatment accounts for between 5% and 10% of total health care expenditures of the health sector of the countries (WHO, 2013). Countries within the European Union spent €54 billion on dental healthcare in 2004 (Patel, 2012) and in the United States, dental healthcare expenditure continues to rise. For instance, total dental expenditure for children aged 5-17 years amounted to $20 billion in 2009 (Centers for Disease Control and Prevention, 2014). The situation is different in the developing world. There are unmet population needs for oral health care in countries like Tanzania where the government’s oral healthcare budget was inadequate to meet the increasing oral health needs of the population (Astrøm & Kida, 2007). In 2014, the University Hospital recorded more than 7,800 dental cases (GHS, 2015). Basic dental treatments are covered by the National Health Insurance (NHIS) and other private insurance providers but dental patients are compelled to make out-of- pocket payments when more advanced dental treatments which are not covered by the NHIS are required. Indeed the treatment of dental diseases places significant economic costs on individuals and the society yet the economic impact of dental interventions has received limited attention in Ghana. This study seeks to identify the types of dental treatments received by patients who attend the dental unit at the University Hospital, Legon which provides a wide range of dental services and has a patient population with diverse background from the university community and University of Ghana http://ugspace.ug.edu.gh 4 surrounding areas, as well as also to estimate the costs and determine the economic burden of dental diseases on these patients. 1.3 Conceptual framework for the economic burden of dental diseases Economic burden of a disease is the total cost of a disease or an illness that is borne by an individual who suffers from the disease or businesses or societies who are responsible for payment of healthcare for employees or citizens. This study focuses on the economic burden of dental diseases on the individual. The costs associated with dental diseases include direct costs, indirect costs and intangible costs. According to a working paper on cost estimation published in 2009 by the Institute of Quality and Efficiency in Healthcare, direct costs refer to the resource consumption in the provision of health care interventions. Patients incur these costs in the form of medical and non-medical costs. The medical costs cater for the payments made for dental consultation, diagnostics, treatment and medication. Some costs are covered by the National Health Insurance Scheme (NHIS) and other private health insurance providers while out-of-pocket payments are made for dental services that are not covered by insurance. The non-medical costs include travelling costs, cost of food and other miscellaneous expenses made because of the disease. Indirect costs denote the production losses due to incapacity for work (in the case of illness); occupational disability (in the case of long-term illness or disability) or premature death. They are incurred by the patients who attend the hospital for treatment. This results in productivity losses to the patient due to lost work hours and lost earnings. Intangible costs are defined as the pain and suffering associated with a disease. Dental diseases such as dental caries, periodontal disease, and dentoalveolar abscess cause the individual to University of Ghana http://ugspace.ug.edu.gh 5 experience excruciating pain and suffering. Also, patients may have poorly arranged or missing teeth or poorly formed facial bones or fractured teeth in trauma cases. These dental conditions may affect the patient’s self-esteem which may result in reduced social interaction. The sum of these costs constitutes the economic burden of dental diseases. University of Ghana http://ugspace.ug.edu.gh 6 Figure 1: Conceptual framework for the economic burden of oral diseases Oral diseases and conditions  Caries,  Periodontitis  Dentoalveolar abscess  Dental anomalies Intangible cost  Pain  Difficulty with speaking  Difficulty with eating Indirect cost  Lost work hours  Lost wages Non- medical  Travel Cost  Cost of Food  Miscellaneous Medical cost  Cost of Consultation  Cost Treatment  Cost of Medication Direct cost Utilisation of oral health care services Economic burden of dental diseases University of Ghana http://ugspace.ug.edu.gh 7 1.4 Justification There is limited evidence on the economic burden of oral diseases on individuals and governments in Africa and Ghana in particular. As a result the country is unable to strategically organise and plan national and community oral health intervention programmes that can effectively address the oral health needs of communities in order to reduce the costs associated with dental diseases. This study was carried out to show the effect of dental diseases on patients who attend University Hospital, Legon, and to identify the costs of treatment associated with dental diseases. This is to contribute to knowledge in this area and may influence stakeholders to take more preventive than curative measures towards dental conditions in order to reduce economic costs associated with dental diseases in Ghana. 1.5 Objectives 1.5.1 General Objectives The general objective of this study is to determine the economic burden of dental diseases on patients attending the dental unit of University Hospital, Legon. 1.5.2 Specific Objectives The specific objectives of this study are 1. To estimate the direct cost of dental diseases. 2. To estimate the indirect cost of dental diseases. 3. To describe the intangible cost of dental diseases. University of Ghana http://ugspace.ug.edu.gh 8 4. To determine the socioeconomic differences in the cost of dental diseases. 1.5.3 Research Questions The research questions for this study are as follows. 1. What are the direct costs associated with dental diseases? 2. What are the indirect costs associated with dental diseases? 3. What are intangible costs associated with dental diseases? 4. What are the socioeconomic differences in the cost of dental diseases? University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Oral and Dental Health: definition, prevalence and effects Oral health is defined as a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking and psychosocial wellbeing (WHO, 2012). It means being free of chronic oral- facial pain conditions, oral and pharyngeal (throat) cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues, collectively known as the craniofacial complex (National Institute of Dental and Craniofacial Research, 2014). Dental health is concerned with the state of health of teeth, gums, tongue and other tissues within the oral cavity. Dental health is a subset of oral health however these two terms are used interchangeably in this study. Good dental health is achieved by practicing good oral hygiene which includes regular tooth brushing and making regular dental visits. The health of the mouth can be an indicator of an individual’s general health. Conditions such as anaemia, diabetes, human immunodeficiency virus (HIV) infections and some eating disorders like bulimia, show their first signs and symptoms in the mouth (Chapple, 2000). 2.2 Health and Dental Diseases Oral health is known to be significantly linked to the general health of an individual. This is because the mouth is one of the entry points of bacteria and other disease causing agents to the body. Dental diseases share a common risk with the four leading chronic University of Ghana http://ugspace.ug.edu.gh 10 diseases namely cardiovascular diseases, cancer, chronic respiratory diseases and diabetes (WHO, 2008). The two most common oral diseases are dental caries and periodontal disease. Some studies conducted in East Africa reported 37.5 % prevalence of dental caries (Gathecha et al., 2012) while those conducted in West Africa reported caries prevalence of about 49% (Faye et al., 2008). Periodontal disease affects the gums, bone and other supporting tissues of the teeth. Globally, about 5% - 20% of the adult population suffer from the disease and it is estimated that about 50% of the European population suffer from periodontal disease (Patel, 2012). Similar findings of 47% prevalence of periodontal disease was reported among the United States adult population (Dye et al., 2012). Higher prevalence of periodontal disease was found in studies conducted in Africa. Most countries reported an average of 80% prevalence of periodontal disease (Godson & Mumghamba, 2009). The Korle-Bu Teaching Hospital in Ghana ranked periodontal disease as 3rd in the top ten causes of out-patient attendance at the dental clinic (Korle-bu Hospital, 2012). Saini, Saini, & Saini (2010) reported that periodontal disease may be linked to cardiovascular disease, stroke, bacterial pneumonia, preterm births and low-birth weight babies. Dhadse et al, (2010) also found that people with periodontal disease are nearly three times as likely to suffer from heart disease. According to Li et al. (2000), poor oral health was more common in patients with cerebral infarction and dental and oral conditions are significantly associated with the diagnosis of a cerebral vascular accident. Also, Shanthi et al. (2012) found that periodontal disease may be a potential risk factor for preterm and low birth weight babies University of Ghana http://ugspace.ug.edu.gh 11 while Ettaro et al. (2004) observed a link between diabetes and periodontal diseases which imposes a large economic burden of $100 billion per year in the United States. 2.3 Global Burden of Dental Disease The Global Burden of Disease (GBD) Report (2010) estimates that 3.9 billion people worldwide suffer from dental problems and most do not get adequate treatment. In spite of significant achievements in oral health of populations globally, problems still remain in many communities especially among under-privileged groups in developed and developing countries (WHO, 2015). The burden of diseases is measured using the disability-adjusted life-years (DALYs) metric. This is the sum of years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs). This provides a single standardized measure by which the effects of all fatal and non-fatal diseases and injuries is compared (Marcenes et al., 2013). Since death as a direct result of oral diseases is rare, DALYs due to oral conditions are usually estimated based on YLDs. Marcenes et al. (2010) found that oral conditions accounted for 15 million DALYs globally. The largest increases in DALYs were observed in Eastern (51.7%) and Central Sub-Saharan Africa (50.5%) and Oceania (47.4%). Dental health care imposes financial burden on patients. In 2010, an estimated $108 billion was spent on dental services in the United States. Pryor et al. (2009) found about 7% of respondents incurred an average debt of $1,108 that resulted from dental health expenditure. Most of these dental out-of-pocket expenses constituted more than 27% of overall health care out-of-pocket expenditure. In some cases, it exceeded the average amount of prescription out-of-pocket costs compelling 7% percent of respondents University of Ghana http://ugspace.ug.edu.gh 12 delaying dental care because of cost (Pryor, Prottas, Lottero, Rukavina, & Knudson, 2009). Similar studies in Australia revealed that dental health expenditure accounted for 10% of total health expenditure in 2004 (Thompson, Cooney, Lawrence, Ravaghi, & Quiñonez, 2014). 2.4 Cost of Illness Cost of illness study is a type of economic study common in the medical literature, particularly in specialist clinical journals. The aim of a cost of illness study is to identify and measure all the costs associated with of a particular disease. There are significant costs associated with dental diseases and this remains a major public health issue for countries worldwide due to the effect it has on the individuals in particular and the society in general. The economic valuations of diseases are classified into three main categories namely direct costs, indirect costs and intangible costs (Institute for Quality and Efficiency in Health Care (IQWiG), 2012). The COI studies can be conducted from a number of perspectives. Each perspective contains different cost items. These different cost items may lead to varying outcome for the same illness. The societal perspective measure costs to a society, health care system, third-party payers, business sectors, the government, and the participants and their families. The provider perspective measure cost to the facility or health provider and the patient perspective measure costs to the patient alone. Each perspective provides useful information about the costs to the particular group however cost of illness studies do not indicate where resources should be allocated in the short term and this is a limitation of the cost of illness studies. University of Ghana http://ugspace.ug.edu.gh 13 2.5 Direct Costs Economic costs are either determined from either the perspective of the patient, provider or the society. The growing cost of dental health care has gained attention globally. Dental diseases can have varying effects on the consumption possibilities of individuals. Dental health care services employ both preventive and curative measures in treating dental health conditions. These have been identified as the direct cost of dental services which can be direct medical cost and direct non-medical cost. The cost of dental diseases generally results in increased expenditures on health goods and services. In some cases, individuals have to pay catastrophic proportions of their available income when they access such services (Xu et al., 2003). In order for the individual to adjust to the current change in both income and expenditure, he may reduce his consumption of non-health goods and liquidate his savings or assets. In some high-income countries, the expenditure for dental health care often exceeds that of other diseases such as cancer and heart disease (Patel, 2012) and it is estimated that the global cost of treating these diseases will exceed US$ 30 trillion thereby forcing many people into poverty (Patel, 2012). 2.5.1 Direct medical costs Direct medical costs which are incurred in the prevention or treatment of dental diseases is an important component of the cost of dental diseases. These expenses include dentists’ consultation, medication, dental insurance premiums and other forms of therapy related to dental health care. Costs of treatment are catered for either by insurance coverage or directly by the individuals who make out-of-pocket payment. This may result in enormous burden on the household income and on the national economy. University of Ghana http://ugspace.ug.edu.gh 14 2.5.2 Direct medical costs on governments The cost of dental health care accounted for 5% of total health expenditure and 16% of private health expenditure across the Organisation of Economic Co-operation and Development (OECD) countries in 2009 and the current European Union countries spent close to €79 billion on dental health care, and if the trends continue, this figure could be as high as €93 billion in 2020 (Patel, 2012). In the United States, spending for dental services increased to $110.9 billion in 2012. Out-of-pocket spending for dental services also increased by 3.0% in 2012 (Centers for Medicare & Medicaid Services, 2012). Australians spent approximately $7690 million on dental care annually, accounting for about 7% of total health expenditure with private funding accounting for 85% of the expenditure. In addition to dental care provided in the dental sector, it is estimated that general medical practitioner care for dental problems costs approximately $245–$350 million per year and the cost of treating dental problems in hospital is approximately $100 million (Harford & Chrisopoulos, 2012). 2.5.3 Direct medical costs on individuals Dental treatment can be expensive. Given these high costs of payments for simple dental conditions, health shocks are likely to increase the tendency for such households to incur catastrophic health payments. Xu et al. (2003) found that 19% of households who access general health borrowed money or sold personal items to pay and 16% were unable to afford the medications prescribed. With limited insurance coverage, out-of-pocket spending is a common phenomenon in many low and middle income countries particularly Sub –Saharan Africa and some parts of Asia and South America. Some reports from Thailand indicated that the poor were more likely to pay for health services University of Ghana http://ugspace.ug.edu.gh 15 from their own household income (Pannarunothai & Mills, 1997), while Kaimenyi (2004) found that households in Kenya finance oral health care mainly from out-of-pocket payment. Many people living in developing countries are poor live. These out-of-pocket- payments may result health ‘shocks’ which increases the tendency for such households to become poor (Xu et al., 2003). 2.5.4 Non-medical Costs Sherman et al. (2001) defines non-medical costs simply as expenditures that are a result of an illness but are not involved in the direct purchasing of medical services. These may include expenditures such as travel, lodging and home services. Distance to a dental facility is a major non-medical cost incurred by patients especially if they have to travel a long distance to seek dental care. This will result in increases in non-medical costs associated with seeking dental treatment In the United States, there are an estimated 154,000 dental practices (Fargo Wells Bank, 2011) and 92% of Europeans living in countries like Sweden and Netherlands have easy access to a dental clinic thereby saving on travel costs when seeking dental care (European Dental Competent Autorities and Regulators, 2010). On the contrary, people living in remote areas in most developing countries have to travel long distances to access dental healthcare as most dental clinics are located in the urban areas. This results in increases in non-medical costs associated with seeking dental treatment. Curtis et al. (2007) concluded in his study that perception of the impact of travel costs are major drivers restricting access to dental services for people living in remote locations. University of Ghana http://ugspace.ug.edu.gh 16 Foster et al., (2013) proposed three approaches to estimating direct costs. These are top- down, bottom-up, and econometric approach. The top-down approach uses known total cost expenditures and apportions these costs to broad severity and categories. The bottom-up approach requires the estimation of costs associated with a treatment or service and utilisation. This approach is used in this study since the study is conducted from the patient’s perspective. The costs are then estimated by multiplying unit costs and the number of units used. The econometric approach estimates the difference in costs in a cohort of individuals with and without a disease, but it is seldom used. 2.6 Indirect costs Indirect costs are the costs of resources for which no payments are made, but for which there is an opportunity cost or foregone benefit. Production losses due to illness influence the wealth of society. Indirect costs are often substantial compared to direct costs (Roijen et al., 1995). Indirect costs associated with treatment of dental disease include lost productivity or lost earnings resulting from time spent away from the workplace or school in order to access dental health services and lost days due to illness attributable to poor oral health. In Canada, the number of hours per worker either missed or in reduced activity is 3.5hrs. This translates into 40 million lost work hours resulting in productivity losses of over $1 billion (Roijen et al., 1995). Indirect cost is estimated using several methods. The two most common methods are the human capital approach (HCA) and the willingness-to-pay (WTP) approach. The HCA views an individual as producing a stream of output over a period of time, and measures costs indirectly associated with illness which is lost output or earnings due to morbidity University of Ghana http://ugspace.ug.edu.gh 17 and premature mortality. The WTP approach proposes that the value of health can be deduced from the amount of money an individual would be willing to pay to reduce the probability of an illness. A ‘‘linked’’ human capital and WTP approach embodies characteristics of both methods. An additional approach to estimating indirect costs is the friction cost method, which is similar to the HCA, but measures only the production losses incurred during the time it takes to replace a sick worker (Roijen et al., 1995). WTP is a variable indicator that depends on the economic and social stratum in which the survey which is a limitation to this method. 2.7 Intangible costs Intangible costs capture the psychological dimensions of illness including pain, anxiety, discomfort and suffering. They are difficult to measure and are not usually included in cost of illness (COI) studies. Intangible cost is often measured by the Contingent Valuation Method (CVM). This method is used to estimate cost on the basis of the individual’s willingness to pay to avoid the risk of damage to health. Pain, discomfort, sleepless nights, limitation in eating function leading to poor nutrition and time off school or work as a result of dental problems are common effects of dental diseases (Watt, 2005). In a study conducted in England, 47.5% of children experienced toothache and this was the primary reason for seeking dental care (Shepherd, Nadanovsky, & Sheiham, 1999). In the United States, the cost of chronic pain due to different diseases is estimated to be about $80 billion per year, with as much as 40% associated with orofacial pain and 90% of pre-adolescents reported an impact related to oral health. Prevalence of dental pain was found to be about 33% among Brazilian teenagers, of whom 9% reported distressing, excruciating pain. In Thailand, 74% of 35–44-year olds had daily University of Ghana http://ugspace.ug.edu.gh 18 performances affected by their oral state and 46% reported their emotional stability was affected (Sheiham, 2005). Adequate dentition is necessary to improve a person’s quality of life. However, there is a greater tendency to become edentate as one advances in life. Despite the improvement in oral health care services, edentulism still remains a public health concern in the world. Edentulism is irreversible and is described as the “final marker of disease burden for oral health”. The prevalence of edentulism amongst adults over 60 years of age was 25% and 21.7% in the United States and Canada respectively (Emami et al., 2013). Edentulism reduces masticating efficiency and affects food taste, food preferences, and food consumption patterns with suboptimal intakes of various nutrients which prevents edentate individuals from meeting current dietary recommendations (Lee et al., 2004) therefore edentulism affects the quality of life of an individual and comes as a cost to sufferers. 2.8 Sensitivity Analysis Sensitivity analysis is a way of determining how certain values of an independent variable will affect an outcome variable when some assumptions are made. The assumptions used in this studies was that al the respondents earned the current minimum wage. The challenge of this assumption is that some respondents may earn above or below the minimum wage. This technique which is used within specific limits depends on a number of independent variables. This is used to test the robustness of the results obtained by repeating the comparison between the independent variable and the outcome variable while changing the assumptions used. Sensitivity analysis aids in determining robustness of the conclusions of an economic evaluation. This is because there are uncertainties about elements of a given economic evaluation. Sensitivity analysis University of Ghana http://ugspace.ug.edu.gh 19 involves the use of several methods. One way sensitivity analysis determines the effect of variations in one independent variable on the outcome variable while keeping other variables constant at their baseline value. Two way sensitivity analysis involves varying two independent variables at the same time to determine the effect it will have on the outcome variable (Briggs, 1999). This test is performed because most elements in an economic valuation vary simultaneously. The third method is probabilistic sensitivity analysis. This method involves Monte Carlo simulations. It determines the extent to which the value of an outcome variable is impacted by a range of independent variables which are varied simultaneously with specified distributions. These simulations may result in a more practical outcome (Briggs, 1999). 2.9 Effect of cost on dental health services utilisation The utilisation of dental services is essential to promoting and maintaining optimum health and well-being. Utilisation is the actual attendance by the members of the public at health care facilities to receive care. Utilisation, which measures the number of visits per year or the number of people with at least one visit during the previous year, serves as an important tool for oral health policy and decision-making (Poudyal et al., 2010). Patients who attend dental clinics regularly are more likely to have dental diseases diagnosed in their early stages which results in the provision of more accurate and timely dental treatments. Lack of regular utilisation of dental health services may result in delayed diagnosis which leads to untreated dental diseases and sometimes death. Gender, age, education level, income level, geographic location, health insurance status and other factors are tied to household economic conditions and their ability to utilise dental health services (Wall, Vujicic, & Nasseh, 2012). University of Ghana http://ugspace.ug.edu.gh 20 The affordability of dental care is a major issue of concern to policy makers in several countries. According to Locker, Matear & Lawrence ( 2002), 26% of adults agreed that dental care is costly. Also, 35% of them mentioned that they could not afford the preventive and restorative treatments they required. They also noted that 30% of Canadian adults were unable to afford dental care in the past, with about 13% of them reporting a competing need, having to sacrifice other spending like buying food to pay for dental care. Again, 30% reported avoiding or delaying dental visits and 32% were unable to afford the recommended treatment. Some studies have highlighted the effect of high dental health expenditure on the well- being of individuals. Thompson et al. (2014) reported that more than a third of Canadians require dental treatment and those who have financial difficulties are more likely to have unmet dental care need. According to Chrisopoulos, Beckwith, & Harford (2011), the cost of dental care may be a barrier to Australians making regular dental visits and complying with recommended dental treatments. They observed that the percentage of adults who delayed dental visits due to cost increased from about 27% in 1994 to about 34% in 2008. In India, the cost of dental treatment was a barrier for 6.9% of the people who participated in a study (Devaraj & Eswar, 2012). Another study conducted in South West Nigeria also ranked the cost of treatment as the second major barrier to dental health care utilisation (Ajayi & Arigbede, 2012). This finding was similar to that of Kemuto (2010) who also found that 28% of patients who participated in a study at the University of Nairobi Dental Hospital cited the high cost of dental treatment as the reason for delaying dental health utilisation. University of Ghana http://ugspace.ug.edu.gh 21 2.10 Effect of Socio-economic Status on Dental Health Socioeconomic status (SES) provides a way of looking at how individuals or families fit into society using economic and social measures that have been shown to impact individuals' health and well-being. Socioeconomic status and health are closely related, and SES can often have profound effects on a person's health due to differences in ability to access health care as well as dietary and other lifestyle choices that are associated with both finances and education (Borskey, 2014). It is generally expected that people with low SES experience greater levels of oral disease compared to those within the higher SES. According to O’Reilly & Boyd-Boland (2006) profound disparities exist across socio- economic groups in Australia and the incidence of caries and periodontal disease increased as socio-economic status decreased. Again, socioeconomically disadvantaged groups rate their oral health poorer than more advantaged groups and report more tooth loss and more problems with their teeth, mouth or dentures. Celeste et al. (2011) in their study of trends in socioeconomic disparities in the utilisation of dental care in Brazil and Sweden concluded that a higher proportion of people of higher socioeconomic status visit the dentist more frequently than those in lower socioeconomic status due to relevant and persistent disparities in the utilisation of dental care in both countries. 2.11 Conclusion In conclusion, it can be seen that the consequences of dental diseases places economic burden on individuals and affects the quality of life of dental patients. From the review, I found that limited studies exist on the burden of dental diseases (prevention and University of Ghana http://ugspace.ug.edu.gh 22 treatment) on individuals and government as a whole in many developing countries. The studies cited in this review were mainly from developed countries. This cost of illness study conducted from the patients’ perspective therefore becomes relevant as it will not only bridge the knowledge gap in this field but also provide useful information for individuals and policy makers in the health sector on the burden of dental diseases in Ghana. University of Ghana http://ugspace.ug.edu.gh 23 CHAPTER THREE 3.0 METHODS 3.1 Type of study This study is a cross sectional cost –of –illness study from the perspective of the patient in a university hospital from May to July 2015. 3.2 Study area The study was conducted in University Hospital, Legon, one of the public hospitals in the Greater Accra region of Ghana. It is located at Legon in the Ayawaso West Wuogon district and Accra Metro Sub-District. The Ayawaso West Wuogon district is located in the Accra Metropolitan Area of the Greater Accra region of Ghana. It serves the University of Ghana community and the surrounding areas. It was built in 1957 to cater for the health needs of the university community. It is a 130 bed capacity hospital. It has four main departments namely Pediatrics Unit, Obstetrics and Gynaecology Unit, Medical Unit and Surgical Unit. University Hospital, Legon also has several clinics including the dental clinic which has 2 dental surgery units. The dental clinic has 6 dentists, 6 dental surgeon assistants and 2 non-medical staff. It attends to approximately 30-35 clients a day who present with various types of dental diseases. 3.3 Study variables The variables analysed in this study are direct cost, indirect cost and intangible cost of dental diseases. University of Ghana http://ugspace.ug.edu.gh 24 Table 1: Table of variables Cost type Cost variables Cost description Direct cost Medical 1. Cost of consultation 2. Cost of diagnostics 3. Cost of treatment 4. Cost of medication Non-medical 1. Travel Costs 2. Cost of Food 3. Miscellaneous expenses Indirect cost Productivity losses 1. Work hours lost 2. Lost wages Intangible cost Intangible Cost 1. Pain 2. Difficulty with eating 3. Difficulty with speaking 4. Difficulty with smiling 5. Avoiding the company of others 3.4 Study population Data collection was undertaken from 11th May, 2015 to 22nd May, 2015. The study population was made up of patients with dental diseases who attend the dental unit of the University Hospital, Legon. In 2014, 7,884 patients attended the dental unit. Currently, the unit attends to an estimated average of 30 patients daily. For the given period of the study which was 10 days, the population of the study was estimated to be 300 patients. University of Ghana http://ugspace.ug.edu.gh 25 3.5 Sample size The sample size (n) was calculated using the Cochrane Formula (Israel, 2013) . n = z2 p q d2 where z = 1.96, p = 0.5, (prevalence of 50% is assumed since the prevalence of dental diseases in Ghana is not known), q = (1-p) = (1-0.5) = 0.5. Therefore, q = 0.5, d (precision) = 5% (0.05). therefore, n = (1.96)2(0.5)(0.5) (0.05)2 n = 384 This formula only takes into consideration the precision and not the size of the population therefore the sample size of 384 was obtained regardless of the size of the population. The dental clinic at the University Hospital, Legon, attends to about 30 patients a day. It was estimated that about 300 patients will attend the unit during the period of the study. The finite population correction factor was used to adjust for the finite population (N). The sample size was calculated to be n = n0 1 + (n0 -1) N Where n=sample size, n0 = 384, N=population=300 n= 384 1+ (384-1) University of Ghana http://ugspace.ug.edu.gh 26 300 n= 384 (1+1.2767) n= 168.6 Adjusting for 10% non-response rate, = 168.6 x 10 100 = 16.9 approximately 17 Sample size n = Adjusted sample size +10% non-response rate =168.6+17= 185 Therefore, the sample size determined for this study was 185. 3.6 Sampling Method Non probability purposive sampling method was used in this study. 3.6.1. Sampling procedure The average number of patients who visited the dental clinic of the University Hospital, Legon, was estimated to be 30 patients per day. The number of patients expected to visit the dental clinic over the data collection period of 10 days was estimated to be 300 patients. The patients were recruited to participate in the study after they were registered by the receptionist at the unit. These patients were selected from the attendance book and those who satisfied the inclusion criteria and consented to participate in the study were interviewed. This procedure was repeated every day until the desired sample size of 185 was achieved. University of Ghana http://ugspace.ug.edu.gh 27 Inclusion Criteria Patients who were 18 years and above and who received dental treatment within the study period were included in the study. Exclusion criteria Patients who are less than 18years and patients who did not have dental treatment during the period of study were excluded from the study. Patients who received only consultation and patients who were reviewed were also excluded from the study. 3.7 Data collection techniques Data was collected by the Principal Investigator and one research assistant each recruiting approximately 10 study participants daily. This resulted in the recruitment of approximately 20 study participants in a day. The questionnaires were administered at the out-patient department of the dental clinic of the University Hospital every weekday between 8am and 2pm. Data was collected by interviewer administered structured questionnaires. It consisted of open and closed ended questions on the respondents’ demographic information, employment status, insurance status and household assets. The questionnaire also contained questions on type of dental illness, direct medical cost (costs of consultation, diagnostics, treatment and medication), non-medical cost (travel costs, food costs and miscellaneous expenses) indirect cost (productivity days lost, travelling time, and waiting time) and intangible cost (pain, difficulty with speech, difficulty with eating, difficulty with smiling and avoiding the company of others). University of Ghana http://ugspace.ug.edu.gh 28 3.8 Quality control In order to ensure that complete and accurate data was obtained, some measures were instituted during the pre-data collection stage, the data collection stage and the data entry and processing stage. 3.8.1 Pre-data collection stage Training of research assistants An individual with requisite background in dental health care and who could speak two of the common local dialects (Twi and Ga) spoken in the study area was recruited to serve as research assistant for the study. The assistant was trained for two days. The assistant was trained in the explanation and administration of the questionnaire and ethical issues such as the need to obtain informed consent before interviewing the study participants to ensure that he recruits and relates with the participants in the appropriate manner. 3.8.2 Pretesting of questionnaire The questionnaire was pretested on patients who attended the dental unit of the Ridge Hospital, Accra. This was performed by the Principal Investigator and the trained research assistant. The questionnaire was pretested to identify ambiguity and other difficulties that the participants may encounter in responding to the questions and the questionnaire was revised and restructured accordingly. The pretesting was also done to assess the research assistant’s administration of the questionnaires in order to prevent interviewer bias. University of Ghana http://ugspace.ug.edu.gh 29 3.8.3 Data collection stage The Principal Investigator ensured that the assistant adhered to the research guidelines. The questionnaires were given special codes which was indicative of the day on which a set of questionnaires were administered. Meetings were held at the end of every day to examine the completed questionnaires and discuss the challenges encountered in order to improve the method of collecting data. Also, measures were instituted to ensure that a study participant was not interviewed twice. 3.8.4 Data entry and processing Data entry controls were put in place to serve as checks in order to prevent wrong entries and other errors. Completed questionnaires were coded and double entered into Epi Info 7. Data were entered on the day it was collected by the Principal Investigator. Data were cross checked for errors, cleaned and exported to Microsoft Excel 2007 and STATA Version 12 for analysis. 3.9 Data Analysis The costs estimated in this study were costs incurred by the patients who attended the dental clinic of the University Hospital during the study period. 3.9.1 Estimation of direct costs Direct costs were estimated as costs incurred by the study participant in direct relation to the dental disease. This was obtained by estimating both the medical and non-medical costs incurred by the study participant. University of Ghana http://ugspace.ug.edu.gh 30 3.9.2 Estimation of direct medical cost Total medical costs were estimated by adding all the costs incurred by the consumption of medical goods and services by the study participant. These included the cost of consultation, cost of treatment, cost of diagnostic tests and cost of medication. The estimation approaches are shown in Table 2. Table 2: Estimation of direct medical costs Type of Costs Costs Estimation approach Consultation This is the summation of the costs of consultation and registration of the patients during the study period. Diagnostics This is the summation of the cost of diagnostic tests requested for the patients during the study period. Treatment This is the summation of the costs of the treatments like extractions and fillings received by the patients during the study period. Medication This is the summation of the medications prescribed for the patients during the study period. Total medical cost This is the summation of the total costs of consultation, diagnostics, treatment and medication for received by the patients during the study period. 3.9.3 Estimation of direct non-medical cost Direct non-medical cost was estimated by summing up the travelling cost, food cost and other miscellaneous expenses. The estimation approaches are shown in Table 3. University of Ghana http://ugspace.ug.edu.gh 31 Table 3: Estimation of direct non- medical costs Type of cost Estimation approach Travel This is the summation of all travel costs like taxi fares and bus fares incurred by the patient when travelling to the dental unit and from the dental unit to their homes during the study period. Food This is the summation of all costs incurred by the patients on food items purchased due to their dental disease during the study period. Miscellaneous This is the summation of all costs incurred by the patients on other items such as telephone calls or other pain reliving agents purchased because of their dental diseases. Total direct non-medical cost This is the summation of all travel costs, all food costs and all miscellaneous expenses incurred by the patients due to their dental diseases. 3.10 Estimation of indirect cost Total indirect cost was estimated by using the human capital approach (HCA) which measures output losses by lost earnings (Addo, Nonvignon, & Aikins, 2013). Productivity losses were estimated by calculating the total work hours lost and total lost earnings using the minimum daily wage in Ghana at the time of the study. University of Ghana http://ugspace.ug.edu.gh 32 3.10.1 Productivity losses Table 4: Estimation of indirect costs Category Estimation Approach Total travel time This is the summation of the hours spent travelling to the hospital and hours spent travelling from the hospital to the house. Valued travel time This was estimated by multiplying the total travel time spent by patients who are employed by the hourly rate of the daily minimum wage. Total waiting and treatment time This is the summation of the hours spent on waiting and treatment at the hospital. Valued waiting and treatment This was estimated by multiplying the total hours spent on waiting and treatment at the hospital by employed patients by the hourly rate of the daily minimum wage. Productivity days lost This is the summation of the total number of days lost by patients who are employed. Valued productivity days lost This was estimated by multiplying the total number of days lost by patients who are employed by the daily minimum wage. School days lost This is the summation of the number of days lost by patients who are students. Total indirect cost This is the summation of valued travel time, valued waiting and treatment time and valued productivity days lost by the patients. University of Ghana http://ugspace.ug.edu.gh 33 3.11 Description of intangible cost Intangible costs in this study were not estimated but described using the likert scale. Five likert items were used. They were “strongly disagree”, “disagree”, “neutral”, “agree” and “strongly agree”. “Strongly disagree” and “disagree” were collapsed into “disagree”. “Strongly agree” and “agree” were collapsed into “agree”. The five likert items assessed the patients’ ratings for pain, difficulty with chewing, difficulty with speaking, difficulty with smiling and avoiding the company of others due to dental disease. These are shown in Table 5. The responses were presented graphically using MS Excel 2007. Table 5: Description of intangible cost Category Description Pain Percentage of patients who agreed that they experienced pain Difficulty with chewing Percentage of patients who agreed that they experienced difficulty with chewing Difficulty with speech Percentage of patients who agreed that they experienced difficulty with speech Difficulty with smiling Percentage of patients who agreed that they experienced difficulty with smiling Avoiding the company of others Percentage of patients who agreed that they avoided the company of others due to their dental disease The responses were scored and the percentages of the responses were used in the description of the effect of dental diseases on the items being assessed. The results were presented graphically using Microsoft Excel 2007. University of Ghana http://ugspace.ug.edu.gh 34 3.12 Sensitivity Analysis Sensitivity Analysis was performed to assess the robustness of the cost estimates. This was done by varying the cost of medication and the minimum wage by 5%, 10% and 25%. 3.13 Estimation of socio-economic status Socio-economic status of the respondents was estimated by using the Principal Component Analysis to generate wealth quintiles in STATA Version 12 from asset ownership of study participants by grouping them into richest, richer, middle, poorer and poorest groups. 3.14 Assumptions The assumption that was made in this study is that the national daily minimum wage for the country is reflective of the average income earned per day by the respondent. 3.15 Proposal and funding information This research was self-financed. 3.16 Study limitations The limitations of this study are as follows. 1. The intangible costs were not valued in monetary terms but were described as no real market exists for such costs (Xie et al., 2008). 2. The accuracy of the number of days or hours lost by the patients as a result of dental diseases was based on the recall of the patient which may not be accurate. University of Ghana http://ugspace.ug.edu.gh 35 3.17 Ethical considerations The following were observed during the study. Ethical clearance Ethical clearance for the study was obtained from Ethical Review Committee of the Research and Development Division of the Ghana Health Service. Permission from study site Permission was obtained from the Head of the dental unit of University Hospital, Legon and School of Public Health, University of Ghana, Legon before the research is conducted. Description of subjects involved in the study The study population was made up of patients attending the dental unit of University Hospital, Legon who received dental treatment during the period of the study in May 2015. Informed consent The participants were allowed to give their informed consent by either signing or thumb- printing the consent form after the information required for their consent was read and duly explained to them before they were recruited to participate in the study. No patient was forced or coerced to take part in the study. The patients were made to know that participation was voluntary. The participants were also informed that they had the right to refuse or withdraw from the study at anytime without it affecting their ability to access dental health care at the facility in the future. A written consent was sought from study participants before data was collected from them. University of Ghana http://ugspace.ug.edu.gh 36 Privacy/Confidentiality/Anonymity The study was conducted in a manner that ensured the privacy of the respondents. All patients who gave consent were assured of anonymity. Data was also reported in a manner that prevented the use of the patient’s names which ensured confidentiality of information that was collected from participants. Potential Risks and Benefits The study population and other stakeholders in dental health care benefitted from this study. In the study population, the estimation showed the burden of dental disease on patients who attended University Hospital, Legon, and it identified the costs involved in treating such diseases and the loss of productivity due to the disease so that stakeholders will be informed to take more preventive than curative measures towards managing dental conditions in Ghana. There were no risks associated with study. Data storage and usage The questionnaires were coded and kept under lock and key in a cupboard, and the key was kept by the Principal Investigator. Data collected was coded and entered within 24 hours of collection, and was saved under a password known to only to the principal investigator. The soft copy of data was stored on a CD-ROM and external hard drive as well. The data collected will be kept by the Principal Investigator for 3-4 years to allow for publication of the research after which questionnaires will be destroyed. Conflict of interest I declare no competing interest. University of Ghana http://ugspace.ug.edu.gh 37 CHAPTER FOUR 4.0 RESULTS 4.1 Background characteristics of respondents A total of 185 questionnaires were administered to patients attending the dental unit of the University Hospital, Legon with 100% response rate. The highest age of the respondents was 90 years (1) and the lowest age of respondents was 18 years (1) with the mean age being 29 years. There were 82 male respondents and 103 female respondents. This constituted 44.3% and 55.7 % respectively of the total respondents. Majority (143) which represented 80% of the respondents had tertiary education while the rest had SSS/SHS/Vocational education (9.7%), middle school/JSS/JHS education (10) and 9 respondents had primary or no education. About 80% (147) of the respondents are single while 18.4% (34) are married and 2.2% (4) are either separated or divorced. The employment status of the respondents showed 36.2% (67) employed and 9.7% (18) unemployed with 54.1% (100) being students. More than half (53.5%) of the respondents were insured with the National Health Insurance Scheme (NHIS) and the rest were either insured with a private health insurance (10.3%) or uninsured (36.2%). The study population was evenly distributed among the wealth quintiles with 20% being poorest and 20 % being poorer. The middle richer and richest wealth quintiles were constituted by 21%, 19% and 20 % of the respondents respectively. The background characteristics of the respondents are shown in Table 6. University of Ghana http://ugspace.ug.edu.gh 38 Table 6: Background characteristics of respondents Characteristics Number (%) Sex: Male 82 (44.3) Female 103 (55.7) Age: <20 11 (5.9) 20-29 118 (63.8) 30-39 21 (11.4) 40-49 14 (7.6) 50-59 10 (5.4) 60+ 11 (5.9) Marital Status: Married 34 (18.4) Separated/Divorced 4 (2.2) Single 147 (79.5) Educational Status: No education /Primary 9 (4.9) Middle school/JSS/JHS 10 (5.4) SSS/SHS/Vocational 18 (9.7) Tertiary 148 (80.0) Employment Status: Employed 67 (36.2) Students 100 (54.1) Unemployed 18 (9.7) Insurance: Insured (NHIS) 99 (53.5) Insured (Private)**** 19 (10.3) Uninsured 67 (36.2) *JSS/JHS means Junior Secondary School/Junior High School **SSS/SHS means Senior Secondary School/Senior High School ***NHIS means National Health Insurance Scheme ****Private means other private insurance schemes (First fidelity, Profiler and Premium Mutual Health) University of Ghana http://ugspace.ug.edu.gh 39 4.2 Dental condition of respondents 4.2.1 Previous dental treatment of respondents A greater number of the respondents 69.2% (128) had a previous dental condition for which they have received treatment however 30.8% (57) of respondents reported of never having a dental condition for which they have received treatment. 4.2.2 Current dental condition of respondents Toothache was the highest reported dental condition accounting for 54.6% (101) of dental conditions reported by the respondents at the dental clinic. This was followed by gum disease which was reported by 27.0% (50) of the respondents. Swollen jaw (dento- alveolar abscess) was reported by 8 respondents. Broken tooth, mouth sores and other dental conditions including tooth sensitivity, pericoronitis and impacted lower third molar was also reported by 23 respondents. The current dental conditions of respondents are shown in table 7. 4.2.3 Dental condition and socioeconomic status (SES) Toothache was the most reported dental condition across all the socioeconomic groups. The highest percentage of 11.9% (22) was reported by the richest group followed by the poorest group who reported a percentage of 11.4% (21). The lowest percentage of 10.3% (19) was reported by both the poorer and the richer groups. Again, the richest group had the highest percentage of 6.5% (12) of those who reported with gum disease. This was followed 5.9% (11) who belonged to the poorest group. The rest of the dental conditions reported by the different socioeconomic groups are shown in Table 8. University of Ghana http://ugspace.ug.edu.gh 40 4.2.4 Duration of dental condition of respondents The respondents had their dental conditions for different durations before seeking dental treatment with 39.5% (75) having their dental condition for less than a week. The dental conditions which lasted for less than a month and less than a year were reported by 25.4% (47) and 35.1% (65) of the respondents respectively. 4.2.5 Type of treatment received by respondents The respondents received different kinds of treatment at the dental unit with 43.8% (81) of the respondents receiving medication followed by 21.6% (40) who had their teeth extracted. About 8% (15) received a restorative treatment (filling) while 21.1% (40) and 2.2% (4) of the respondents received preventive treatment in the form of scaling and polishing of their teeth (cleaning) and dentures respectively. Other treatments received by the respondents included root canal treatment and excision of Epulis among others. There were small differences in the type of treatment received by respondents in the different socioeconomic groups and these are shown in Table 9. About 50% (95) of the respondents paid cash for treatment received while 20.5% (38) and 28.1% (52) paid with the National Health Insurance Scheme (NHIS) and other forms of private health insurance respectively. The mode of payment for treatment received by the respondents is shown in Table 10. University of Ghana http://ugspace.ug.edu.gh 41 Table 7: Dental conditions as reported by the respondents Current dental condition: N (%) Bad Breath 3 (1.6) Broken Tooth 15 (8.1) Gum Disease 50 (27.0) Mouth sores 5 (2.7) Swollen Jaw 8 (4.3) Toothache 101 (54.6) Other* 3 (1.6) Duration of condition: