University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON ENABLERS AND BARRIERS TO THE UTILIZATION OF DENTAL SERVICES AMONG PATIENTS AT HAWA MEMORIAL SAVIOUR HOSPITAL, EAST AKIM MUNICIPAL ITY-EASTERN REGION-GHANA BY SAMUEL ADUSEI (ID: 10273251) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE DECEMBER 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Samuel Adusei, confirm that this dissertation presented towards the award of Masters in Public Health degree is my original work and has not been presented for any examination in any other institution. Where references have been used, these have been cited accordingly. …………………............ ………………………… Samuel Adusei Date (Student) …………………………. ………………………… Dr. Genevieve Cecilia Aryeetey Date (Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to the Adusei and Baafi family ii University of Ghana http://ugspace.ug.edu.gh AKNOWLEDGEMENT Thanks to the Almighty God for a successful completion of this research work. My utmost appreciation goes to my supervisor Dr. Genevieve Cecilia Aryeetey for her insightful contributions, encouragement and constructive criticisms towards this dissertation. I express my profound gratitude to the management of Hawa Memorial Saviour Hospital for their assistance. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: The importance of oral health in relation to general well-being of an individual cannot be over emphasized. One of the significantly greatest public health problems of recent times is oral health diseases with its attendant increasing prevalence globally, and in Sub Saharan Africa. Objective: The objective of this study was to assess barriers and enablers to dental service utilization at Hawa Memorial Saviour Hospital, Osiem, East Akim Municipality; Eastern Region- Ghana. Methods: The study was an analytical cross-sectional study conducted at the Hawa Memorial Saviour Hospital over a 23 day period between August and September, 2018. Systematic random sampling was used to select 113 study participants and a structured questionnaire was used to collect data from these study participants. Study participants were non critically ill patients aged 18 years and above accessing dental services in the facility. Data was analyzed using STATA 15.0. Mean age and mean income were computed with their respective standard deviations. Proportion of adequate utilization was computed with a 95% confidence interval. Simple logistic regression was performed to determine factors associated with utilization of dental services. Crude and adjusted Odds ratios were reported with 95% confidence intervals and statistical significance test set at p< 0.05. Results: The mean age of respondents was 50.9 years ± 18.3 SD. Females were in the majority 68.1% (77/113). Most of the respondents were married making up 41.6% (47/113). Sixty two percent of the respondents were employed (71/113). Christians were the majority 92.0% (104/113). The mean income was GH¢765.0 ± 422.4SD. Twenty seven percent (31/113) of respondents adequately utilized dental services with a minimum of 2 visits per year. Majority of respondents utilized dental services due to chronic dental conditions 71.7% (81/113). About 78.8% (89/113) of iv University of Ghana http://ugspace.ug.edu.gh respondents cited cost as a reason for inadequately utilizing dental services. Prior knowledge on existence of dental facility (aOR=9.94, 95% CI 2.11 – 46.64, p< 0.01) and amount paid out-of- pocket for dental services (aOR= 0.97, 95% CI 0.95 – 0.98, p< 0.0001) were significant predictors of dental services utilization. Conclusions: The study found that, proportion of dental service utilization at Hawa Memorial Saviour Hospital was low. It also found out that cost was a major barrier to dental service utilization and awareness of the existence of the facility was an enabler for adequate utilization. Recommendations: There is a need for awareness creation by management and staff to the general public on the existence of dental services at the Hawa Hospital. The management of Hawa Memorial Saviour Hospital should take steps on having a policy that considers holistic dental care as part of primary health care covered by the National Health Insurance or other private insurance to reduce out of pocket financing of dental services by their clients. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii AKNOWLEDGEMENT ........................................................................................................... iii ABSTRACT ............................................................................................................................. iv TABLE OF CONTENTS .......................................................................................................... vi LIST OF TABLES ......................................................................................................................x LIST OF FIGURES .................................................................................................................. xi LIST OF ABBREVIATIONS................................................................................................... xii DEFINITION OF SIGNIFICANT TERMS ............................................................................. xiii CHAPTER ONE .........................................................................................................................1 1.0 Introduction ...........................................................................................................................1 1.1 Background to the study ....................................................................................................1 1.2 Statement of the Problem ...................................................................................................4 1.3 Justification .......................................................................................................................6 1.4 Objectives of the Study ......................................................................................................6 1.4.1 General Objective ......................................................................................................6 1.4.2 Specific objectives ......................................................................................................6 1.5 Research Questions ............................................................................................................7 1.6 Conceptual framework .......................................................................................................7 1.6.1 Summary of framework ............................................................................................7 CHAPTER TWO ...................................................................................................................... 10 2.0 Literature Review ................................................................................................................ 10 2.1 Introduction ..................................................................................................................... 10 2.2 Behavorial model ............................................................................................................. 10 2.3 Utilization of dental services ............................................................................................ 11 2.4 Quality of care ................................................................................................................. 12 2.5 Proportion of patients that access dental services ............................................................. 13 2.6 Factors Influencing Utilization of Dental Services ........................................................... 14 2.6.1 Predisposing factors ................................................................................................ 14 vi University of Ghana http://ugspace.ug.edu.gh 2.6.2 Enabling factors (Enablers / Barriers) ................................................................... 18 2.6.3 Need factors ............................................................................................................. 24 Cultural ................................................................................................................................. 24 2.7 Summary of the literature review ..................................................................................... 26 CHAPTER THREE ................................................................................................................... 28 3.0 Methodology ....................................................................................................................... 28 3.1 Introduction ..................................................................................................................... 28 3.2 Design ............................................................................................................................. 28 3.3 Study area ........................................................................................................................ 28 3.4 Study population .............................................................................................................. 30 3.5 Inclusion criteria .............................................................................................................. 30 3.6 Exclusion criteria ............................................................................................................. 30 3.7 Variables ......................................................................................................................... 30 3.8 Sample Size Determination .............................................................................................. 33 3.9 Sampling ......................................................................................................................... 34 3.10 Data Collections Tool .................................................................................................... 34 3.11 Quality Control .............................................................................................................. 35 3.12 Training of interviewers ................................................................................................. 36 3.13 Pretesting of the Instruments .......................................................................................... 36 3.14 Data processing.............................................................................................................. 36 3.15 Data analysis .................................................................................................................. 37 3.16 Ethical Considerations ................................................................................................... 38 3.16.1 Ethical clearance.................................................................................................... 38 3.16.2 Participant’s consent ............................................................................................. 38 3.16.3 Voluntary consent .................................................................................................. 38 3.16.4 Privacy and confidentiality ................................................................................... 38 3.17 Reward .......................................................................................................................... 38 3.18 Potential risks/benefits ................................................................................................... 39 3.19 Compensation ................................................................................................................ 39 3.20 Protocol amendments ..................................................................................................... 39 3.21 Conflict of interest ......................................................................................................... 39 vii University of Ghana http://ugspace.ug.edu.gh 3.22 Funding information ...................................................................................................... 39 CHAPTER FOUR ..................................................................................................................... 40 4.0 RESULTS .......................................................................................................................... 40 4.1 Socio-demographic characteristics of respondents ....................................................... 40 4.2 Dental Service Utilization ................................................................................................ 42 4.3 Conditions presented at dental facility .............................................................................. 42 4.4 Type of treatment ............................................................................................................. 43 4.5 Enablers of utilization of dental services ...................................................................... 44 4.6 Barriers to utilization of dental services ........................................................................... 45 4.7 Associations between the independent variables and utilization of dental services............ 46 4.7.1 Socio-demographic factors associated with dental service utilization ......................... 46 4.7.2 Association between conditions presented and utilization of dental services ........ 49 4.7.3 Association between type of treatment and dental service utilization ................... 51 4.7.4 Accessibility factors associated with dental service utilization .............................. 52 4.7.5 Affordability factors associated with dental service utilization ............................. 53 4.7.6 Environmental factors associated with dental service utilization .......................... 54 4.7.7 Need factors associated with dental service utilization .......................................... 56 4.7.8 Knowledge factors associated with dental service utilization ................................ 57 4.8 Association between significant variables from bivariate analysis and dental service utilization. ............................................................................................................................. 57 4.9 Summary of findings ....................................................................................................... 59 CHAPTER FIVE ...................................................................................................................... 62 DISCUSSION .......................................................................................................................... 62 5.0 Introduction ......................................................................................................................... 62 5.1 Utilization of dental services .......................................................................................... 62 5.2 Socio-demographic factors associated utilization of dental services ............................ 63 5.3 Accessibility factors associated with utilization of dental services ............................... 67 5.4 Affordability factors associated with utilization of dental services .............................. 68 5.5 Environmental factors associated with utilization of dental services .......................... 69 5.6 Need factors associated with Utilization of Dental Services ......................................... 69 5.6.1 Knowledge factors associated with utilization of dental services .......................... 70 viii University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX ......................................................................................................................... 72 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............................................... 72 6.0. Introduction ........................................................................................................................ 72 6.1. Summary of the study ..................................................................................................... 72 6.2. Conclusions of the Study ................................................................................................ 73 6.2.1. Proportion of patients utilizing dental services ..................................................... 73 6.2.2. Socio-demographic characteristics (Predisposing factors) ................................... 73 6.2.3. Barriers to dental service utilization ...................................................................... 74 6.3. Contributions to Knowledge ........................................................................................... 74 6.3.1. Contributions to policy, practice and management of healthcare institutions..... 75 6.3.2. Contributions to research methodology ................................................................ 75 6.4. Recommendations of the study ....................................................................................... 76 6.5. Limitations to the study................................................................................................... 76 6.6. Future research ............................................................................................................... 77 REFERENCES ......................................................................................................................... 78 APPENDICES .......................................................................................................................... 86 APPENDIX A: Consent Form Participant .............................................................................. 86 APPENDIX B: Questionnaire ................................................................................................ 89 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES 2.6.3.1 Knowledge of dental services ........................................................................................ 25 Table 3.1: Study variables ......................................................................................................... 31 Table 4.1: Socio-demographic characteristics of respondents (n = 113) ..................................... 41 Table 4.2: Socio-demographic factors associated with dental service utilization ........................ 48 Table 4.3: Association between conditions presented and utilization of dental services ............. 50 Table 4.4: Association between type of treatment and dental service utilization ........................ 51 Table 4.5 Accessibility factors associated with dental service utilization ................................... 52 Table 4.6 Affordability factors associated with dental service utilization ................................... 53 Table 4.7 Environmental factors associated with dental service utilization ................................ 55 Table 4.8 Need factors associated with Dental Service Utilization ............................................. 56 Table 4.9 Knowledge factors associated with dental service utilization...................................... 57 Table 4.10 Results for multiple logistic regression with significant variables from bivariate analysis ..................................................................................................................................... 59 x University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual framework .................................................................................................9 Figure 4.1 Proportion of adequate utilization of dental services among respondents .................. 42 Figure 4.2: Various dental conditions presented to the dental clinic ........................................... 43 Figure 4.3: Types of treatments received at the dental clinic ...................................................... 44 Figure 4.4: Patient perspective of enablers of dental service utilisation ...................................... 45 Figure 4.5: Patient perspective of barriers to dental service utilisation ....................................... 46 xi University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CHAG Christian Health Association of Ghana CHPS Community-Based Health Planning and Services DHIMS District Health Information and Management System DMFT Decayed, Missing and Filled Teeth FDI Federation Dentaire International GHS Ghana Health Service HIV Human Immunodeficiency Virus HMSH Hawa Memorial Saviour Hospital OPD Outpatient Department RHMT Regional Health Management Team WHO World Health Organization xii University of Ghana http://ugspace.ug.edu.gh DEFINITION OF SIGNIFICANT TERMS Operational definitions of key terms used have been explained below. Accessibility Capability of being reached, being within reach or being available when needed. Dentistry A branch of medicine that consists of the study, diagnosis, prevention and treatment of diseases, disorders and conditions of the oral cavity, commonly in the dentition but also the oral mucosa. Periodontal disease An inflammatory disease that affects the soft and hard structures that support the teeth. Oropharyngeal Region in the oral cavity and back of the throat. Pathology Significant component of the causal study of disease and a major field in modern medicine and diagnosis. Apical abscess Localized collection of pus associated with a tooth. Misconception Deceptive thought or understanding deviating from standard norm and practices. Ludwig’s angina A serious potentially life-threatening cellulitis or connective tissue infection of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated may obstruct the airways, necessitating tracheostomy. xiii University of Ghana http://ugspace.ug.edu.gh Education The process of acquiring knowledge, skills, values and beliefs resulting in facilitation of learning .In this case, it is the effective use of the dental care services. Quality Measure of degree of standard and excellence attributed to a service rendered or received. Socio-demographic factors Age, ethnicity, sex, marital status, family size, etc. Utilization To put to use, especially to make profitable or effective use of something. xiv University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 Introduction 1.1 Background to the study The importance of oral health in relation to general well-being of an individual cannot be over emphasized. The prevalence of the disease is on the increase in both low and high income countries (Murray et al, 2014, Colakoglu et al, 2015). Oral diseases affect about 60 -90% of schoolchildren and nearly 100% of adults (WHO 2012). The increasing use of sugars and insufficient exposures to fluorides has significantly resulted to the ever-rising prevalence of dental caries in many developing nations, which previously recorded low prevalence and incidence rates (Kassebaum et al., 2015). The prevalence of dental disease is still surging despite interventions taken to reduce the incidence in developing countries. For example, North African countries like Egypt and Tunisia have prevalence rates of about 70% (Hamila, 2013) and 43% respectively (Maatouk et al., 2006). There are few studies on the overall burden of oral health disease in Africa but the World Health Organization (WHO) attributes the greatest burden due to oral 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 et al., 2014). Dental disease prevalence of 50% - 68% was also reported among Ghanaian residents (GDA, 2017). Korle Bu Teaching Hospital in Ghana recorded an increase of 75% in dental infections from 2010 to 2011. 1 University of Ghana http://ugspace.ug.edu.gh The effect of dental diseases on an individual is worth noting (World Oral Health Report 2012). Early recognition and treatment and intensifying utilization of dental services will help limit morbidities and mortalities associated with delayed presentation of dental ailments (Lee et al, 2015). Cognitive restructuring on prioritization of health and dental health awareness amongst other factors have been postulated to be solutions to the menace. The ideal however, is routine dental visit where early recognition of these conditions are made and then managed accordingly to prevent complications (Kanyi, 2010) Routine dental consultation is estimated to be every 6 months for children, teenagers and the elderly or each year for healthy adults (World Oral Health Report 2012). According to Bagramian et al (2009), regular visits to the dentist have an inverse relationship with the presence of dental ailments (e.g.: caries, teeth restoration, dental extraction needs or gum pathology). Therefore, the more dental service visit or dental service utilization, the lesser the prevalence of dental ailments. Despite the increase in oral diseases in developing countries, dental service utilization remains low (Kikwilu et al, 2008; Nasir et al, 2009). This has accounted for the late presentation of dental cases with its associated complications (Bahadori et al, 2013). Utilization of health services in dentistry refers to the number of individuals who visit a dental facility for service (Nasir et al 2009). The most common measure of utilization is the number of dental visits per person per year. According to Ajayi and Arigbede (2012), there are many factors reported to directly and indirectly influence a person’s utilization of oral health services. These include ill health related factors, service related factors, socio-demographic factors and attitudinal factors. Al-Hussyeen (2010), also indicated some factors thought to encourage dental service utilization such as quality of dental care, convenient appointments, modern and up-to-date dental 2 University of Ghana http://ugspace.ug.edu.gh clinic, good client-dentist relationship, etc. These factors are considered enablers to service utilization Studies conducted in industrialized and middle-income developing countries show that low socio- economic status groups have lower utilization rates of oral health service (Nagarjuna et al 2016). These individuals have many financial, material and social disadvantages, all of which may adversely affect oral health (Watt, 2012). Furthermore, according to Petersen and Kwan ( 2011), low socio-economic individuals often have fewer resources available to secure nutritious foods, adequate health care and other elements necessary for maintaining a satisfactory level of health and quality of life. Under these circumstances, prevention of oral diseases and oral health maintenance often become a lower priority. These hindrances to service utilization are considered barriers. Some of the setbacks to dental service utilization according to a research conducted by Slack-Smith et al (2010) were fear, cost lack of awareness and poor doctor-patient relationship. Conversely, Bommireddy (2016) reported health care provider factors, which were considered enablers (facilitators) to service utilization. They included friendliness of staff, patient centered appointments, good communication skills and welcoming health team. Affordable cost effective dental services, shorter distance travelled to access services and well-equipped dental facilities were reported as factors that also encouraged service utilization (Nagarjuna et al, 2016). With increasing prevalence of dental diseases in developing countries and poor dental service utilization, the study seeks to assess the barriers and enablers to utilization of dental service at Hawa Memorial Saviour hospital at Osiem; a rural area in the East Akim Municipality, Eastern Region of Ghana. 3 University of Ghana http://ugspace.ug.edu.gh 1.2 Statement of the Problem According to WHO (2012), about 60-90% of school-aged children and nearly 100% of adults in both developed and developing countries are affected by oral illness. Again, developing countries are now becoming more affected because of increasing consumption of sugars and exposure to fluorides (Kassebaum et al, 2015). Some of the commonly experienced dental conditions in the sub-region include dental caries, dental abscess, periodontal disease and gingivitis (Siddiqui et al., 2013). The neglect of oral health has resulted in increased indisposition, cerebral complications and impairments which often lead to treatment procedures that are complex, tasking and associated with considerable financial, logistic and requirements with additional health risks. Some of the complications associated with delayed presentation of dental diseases include; periodontitis, apical abscess, Ludwig’s angina, aspiration pneumonitis, endocarditis, meningitis, and death among others (Nyvad, 2008). These can be averted by timely, preventive and curative dental care. According to WHO report (2012), routine dental visit is expected to be at least every six months (i.e. twice in a year or more). This is considered adequate utilization. Despite availability of dental services in Ghana, the majority of the population underutilize the service (less than 0.3% of OPD cases) contributing to the gradual increasing prevalence of dental diseases (DHIMS 2 dental service utilization data set accessed 26th October 2017). Analyses of the District Health Information Management System 2 data also showed a decline in persons with dental ailments who visited various facilities in the country from about 100,000 in 2012 to about 73,000 in 2016, 4 University of Ghana http://ugspace.ug.edu.gh justifying underutilization of dental services available (DHIMS 2 dental service utilization data set accessed 26th October 2017). Some enablers and barriers to utilization identified in literature include, among others, cost, fear and anxiety from dental procedures, complications from previous procedures, lack of knowledge on available dental facilities and services and ignorance (Darwish et al, 2015; Kikwilu et al, 2008). In the East Akim Municipality of Ghana where this study was carried out, despite the availability of numerous dental clinics, utilization of dental service in the district is low (DHIMS 2 dental service utilization data set accessed 26th October 2017). Example, Hawa Memorial Saviour Hospital (HMSH), recorded dental caries as the highest dental condition in 2016 and according to the facility’s annual report, only 32 clients visited the dental clinic in the first half of 2016 and 49 clients in the first half of 2017 (Half year report 2017,HMSH ,accessed 11th June 2018). In addition, from the annual reports of Hawa Memorial Saviour Hospital, 2015 to 2017, 94 dental attendances were recorded for the year 2015 and only 21.3% met the WHO criteria of adequate utilization (thus 2 or more visits). This reduced to 12.9% (out of 132 total dental OPD attendance) in 2016 and 9.5% in 2017 (Annual report, 2017) It therefore appears utilization of dental services in the facility is low despite the service availability. Why is this so? What are some of the barriers that limit utilization of dental services and what are some of the factors that enhance utilization of dental services in this facility? These are the issues that this study seeks to address. 5 University of Ghana http://ugspace.ug.edu.gh 1.3 Justification Hawa Memorial Saviour hospital, a prototype situated at Osiem, a rural area in the East Akim Municipality, has been experiencing fall in OPD attendance for dental care, with relatively fewer patients as against previous attendances. Attendances were 53 at January 2017, dropped to 31 in February, rose to 58 in March and then fell to 35 in April (Annual report, 2017). This periodic rise and fall in OPD attendance is a cause of concern There is thus the need to assess factors influencing dental service utilization in the facility. What may be considered a barrier in one facility, may be an enabler in another facility. Due to these contextual variations in the factors that influence utilization, it has become necessary to conduct this research to determine the barriers and enablers to use of dental services at this facility. This findings from the study will inform facility managers and other relevant stakeholders in their decision making to improve on dental service delivery. 1.4 Objectives of the Study 1.4.1 General Objective To assess barriers and enablers to utilization of dental services at Hawa Memorial Saviour Hospital, Osiem, East Akim Municipality-Eastern Region of Ghana. 1.4.2 Specific objectives The following specific objectives will be pursued: 1. To determine the proportion of patients who adequately utilize dental services at Hawa Memorial Saviour Hospital. 6 University of Ghana http://ugspace.ug.edu.gh 2. To assess predisposing (socio-demographic) factors associated with utilization of dental services. 3. To assess barriers to utilization of dental services at Hawa Memorial Saviour Hospital. 4. To assess enablers to utilization of dental services at Hawa Memorial Saviour Hospital. 1.5 Research Questions The following questions will help find answers to respond to the objectives of the study: 1. What is the proportion of patients who adequately access dental services at Hawa Memorial Saviour Hospital (HMSH)? 2. What are the predisposing (socio-demographic) factors associated with utilization of dental services at Hawa Memorial Saviour Hospital? 3. What are the barriers to the use of dental services at Hawa Memorial Saviour Hospital? 4. What are the enablers to the use of dental services at Hawa Memorial Saviour Hospital? 1.6 Conceptual framework 1.6.1 Summary of framework The behavioral model of health service utilization proposed by Anderson and Newman (Babitsch et al, 2012) has been adopted for this study. It classifies predictors of service utilization into three determinants. Predisposing factors: they increase the chance of using services (age, gender, education, occupation, marital status, income level, religion). 7 University of Ghana http://ugspace.ug.edu.gh Enabling factors: that may facilitate or prevent service use (income, place of residence, cost of service, and quality of service). From his model, the enabling factors could be facilitators and/or barriers to service utilization. Need factors: they represent the immediate cause of health service use (self-perceived health status, chronic or acute illness) In this study, the enabling factors included the following; affordability (whether services rendered is affordable), accessibility (measure of the distance covered to access dental care), availability, staff attitude, perception of quality of care, environment (whether the environment is attractive, noisy and conducive for care), and post op complication (whether client has suffered any post op complication such as bleeding, swelling or unbearable pain in the facility, that could prevent subsequent visits). The need factors include factors such as, whether client had enough knowledge of dental services, cultural beliefs or misconceptions that may hinder one’s willingness to access services,. All these influence clients’ perceived need to seek health care. 8 University of Ghana http://ugspace.ug.edu.gh Enabling factors Predisposing factors (Socio-demographic Affordability factors) Utilization of Accessibility Age Dental Services Availability Education Gender Marital status Staff attitude Occupation Income Level Environment Religion Need Factors Post-op complication Self- reported illness Acute illness Perception related to Chronic illness quality of care Knowledge Satisfaction with  Awareness of services service existence  Benefits of dental Environment service  Number of expected visits/year  Cultural practices and Misconceptions Figure 1: Conceptual framework Dental practioner 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 Literature Review 2.1 Introduction This chapter reviews various studies done related to variables under investigation in the conceptual framework as well as some theoretical framework on health service utilization. It focuses on the factors affecting utilization of dental services, which are categorized as predisposing factors, enabling factors and need factors of dental services according to the adopted Anderson’s model of health belief. It also outlines some statistics on dental service utilization as well as proportion of patients who utilize dental services. 2.2 Behavorial model The behavior model of health services utilization has been the main emphasis of significant theoretical and research attention. There are four major types of utilization models. Namely, models of patient decision making, consigned in sociological philosophy and research; the health belief model, in psychological concept; economic models of the plea for medical care; and the behavioral model of health services utilization that has directed much health services study on access to and heath care service utilization (Aday et al, 2014). Since this research also seeks to identify the very dynamics, enablers or inhibitors to service utilization, the behavioral model has been chosen. It classifies predictors of service utilization into three determinants. Predisposing factors: they increase the chance of using services (age, gender, education, occupation, marital status, income level, religion). Enabling factors: that may facilitate or prevent service use (income, place of residence, cost of service, and quality of service). From his model, the enabling factors could be 10 University of Ghana http://ugspace.ug.edu.gh facilitators and/or barriers to service utilization. Need factors: they represent the immediate cause of health service use (self-perceived health status, chronic or acute illness), (Babitsch et al, 2012) 2.3 Utilization of dental services Dental service utilization explains the attendance of individuals to dental health facilities in pursuance of care (Nasir et al., 2009). That is, the commonest estimate of service utilization is the number of dental visits per person per year. Routine dental consultation is estimated to be every 6 months for children, teenagers and the elderly or each year for healthy adults (WHO 2012). One of the surest ways of early recognition and prompt treatment of dental ailment to prevent complication is through utilization of its services. However, this information appears to just be in the known but not fully practiced, as the statistics for utilization is still on the decrease. In India, about 25,000 dentists graduate annually from the over 289 existing dental institutions (Ambika et al, 2015). Despite the large working class, majority of the Indian population suffer from poor access to fundamental dental care. There is an appreciable disparity with regards to the ratio of dentists to population in both rural and urban communities; with 1:10,000 in urban and 1:150,000 in rural setting. Notwithstanding the equity gap in access, patients self-finance dental services rendered to them in both private and public facilities (Ambika et al, 2015). According to a national study in US, only 41-50% of the populace utilize dental service, even though experts recommend regular visitation (Nasseh et al, 2015), supporting the aforementioned argument of dental service underutilization. 11 University of Ghana http://ugspace.ug.edu.gh 2.4 Quality of care Quality of care is measured by the extent of good health outcomes caused by service delivery on individual and populations. These are consistent with recent professional knowledge (Griffin et al, 2010). Useful qualitative indicators, coupling other approaches such as qualitative analysis of specific activities, could monitor quality of health care. Indicators of quality of care can be categorized into structural, process and outcome indicators (Herndon et al, 2015). ‘Structure’ refers to the setting within which care happens. This involves material and human resources and organizational structure. Facilities, equipment and financing, constitutes material resources. Qualification of personnel constitutes human resources. Methods of peer review, reimbursement, medical staff, etc. makes up the organizational structure. ‘Process’ refers to the systematic activities in rendering and obtaining care. It involves diagnosis making, treatment and establishing good patient interaction. ‘Outcome’ denotes the effect obtained from rendering care to an individual or population. One of the major factors that determine patient satisfaction with care given is the improvement in patient’s knowledge, and behavior change modification that is encompassed in outcome of care. Quality care should be easily accessible, acceptable, good and ethically adhered to (Johara et al, 2009). It should be imbibed with the activities of caring, competence, confidence, compassion and knowledge based skills (Baâdoudi et al, 2016). It should be noted that, an effective and efficiently delivered health care should be centered on quality. Good quality healthcare will promote utilization, whereas the otherwise will discourage service utilization. 12 University of Ghana http://ugspace.ug.edu.gh 2.5 Proportion of patients that access dental services United State population has seen major changes in its dental service utilization (Nasseh et al., 2015). Utilization of dental care was at its peak among children in the year 2013. Utilization among the working class stabilized from 2012 to 2013, after years of trend reduction. There was also significant reduction in service utilization in 2003 among working adults. This was partly due to only a small proportion of individuals having private visitation (Nasseh et al., 2015). There has also been an increase in service use among children over the past decade, more so among those from poor homes (Nasseh et al, 2014). The disparity in dental service utilization has been closed significantly between low and high income children groups, whiles that for adults has broadened (Nasseh et al, 2014). The American Dental Association’s Health Policy Institute (HPI) has played a pivotal role in dental service utilization studies (American Dental Association 2016). Currently, one of the biggest issues with oral health care in Africa is the wide gap between the availability of services offered for the wealthy and the lack of services for the poor, largely living in rural areas (WHO Regional Office for Africa, 2014). In 2014, only 7 out every 100 of 12 year olds in Burkina Faso had never been to a dentist, and this was also the case with 61% of 35-44 year olds living there ((Josefczyk, 2015). In Madagascar, 83% of 12 year olds had never received dental care (Josefczyk, 2015). Many countries in Africa, Asia and Latin-America have a shortage of oral health personnel and by and large the capacity of the systems is limited to pain relief or emergency care. In Africa, the dentist to population ratio is approximately 1:150000 against about 1:2000 in most industrialized countries. (https://www.who.int/oral_health/action/services/en/retrieved, May, 2019). 13 University of Ghana http://ugspace.ug.edu.gh 2.6 Factors Influencing Utilization of Dental Services This sub-section illustrates the conceptualized factors that influence utilization of dental service. They include predisposing factors, need factors and enabling factors. 2.6.1 Predisposing factors This sub-section presents literature related to the predisposing factors influencing utilization of dental services. Socio-demographic factors Inequalities in socio-demographic characteristic produce health disparities in the world, including oral health (WHO 2015). Due to contextual variations in socio-demographic factors, different studies have shown variable associations between the various demographic factors and utilization of dental services (Herkrath et al, 2018). According to research conducted by Gupta et al (2012), socio-demographic factors that were found to influence utilization among the rural population of Jaipur, India, included, education, occupation, socio-economic status/income level, and age. Those with high educational level, high occupation group, and high socio-economic status (income level) better patronized dental care as against those with low middle-income level, illiterate and low social class. This could be partly explained by the fact that, the former have enough information on benefits and complications from late dental presentation and are financially sound enough to access health care. These results are consistent with research done by Bhushan et al. (2012) in India. Age as a determinant of dental service utilization has also been given much study. Disparities in service use between the aged and young have been seen in previous studies (Dye et al, 2011). 14 University of Ghana http://ugspace.ug.edu.gh Nearly about 100% of the adult populations over the past 5 years have not used dental services as against 11% in those below 35years in a study conducted in India (Panchbhai 2012). High cost and lack of access were revealed as fundamental barriers for dental service underutilization among the elderly in a study conducted in Switzerland (Peterson et al, 2010). It was also found in other studies that, most of the elderly did not recognize the dying need for dental health care (Herkrath et al., 2018; Gupta et al., 2014). Adults are more likely to have the notion that disease and inabilities are inevitable. Studies conducted on all age ranges revealed that those who were old consented to the statement that “A person has to expect a good deal of illness and some aches and pains, especially when he is old” (Borreani et al, 2010). This pre- conceived statement of diseases being as a result of aging, provides the basis of elderly coping with diseases they ensue. However, it is a major barrier to early reporting of diseases for prompt care, to prevent complications (Abott et al., 2013) The Swiss Federal Statistical Office, Switzerland, estimated 67%of the 55-63 year group, visited dentist regularly as opposed to greater than 80%, visiting a primary health physician. Those 75 years and above had 40% of them no longer visiting a dentist with over 90% visiting a specialist or primary health care doctor (Nitsche, 2015). The plausible reason for the decline in service utilization was because, they often spent more time and money visiting the general practioner than the dentist (Nitsche, 2015). This is further evidenced by a Brazilian research conducted by Mullachery et al. (2008), which explained that dental care utilization and frequency of dental services utilization was seen more among the young than the old. 15 University of Ghana http://ugspace.ug.edu.gh Females are generally believed to have better health seeking behavior than males due to obvious reasons (Ferraro et al, 2010). They often share their problems; they do not internalize pain as against their counterparts who are more secretive. However, due to the effect of several other confounding factors believed to influence utilization of health services, sex as a determinant of health seeking behavior does not always show significant association with utilization (Barker et al., 2014). According to Poudyal et al., (2010), in Mangalore, there was no difference in dental service utilization between males and females. This finding was however different from that of Lukacs (2010), where females utilized dental services more. The patient’s educational level can significantly affect his or her level of health care utilization, in addition to recognizing the relevance of early dental care visit. Low level of education has been found to be the main contributing factor to dental service underutilization (Chou et al, 2011). Studies have argued that the absence of education can affect an individual’s level of understanding of information given and ability to make right decisions concerning their health (Figueira et al, 2008). The implication is that, those with low educational status may not recognize the need to access routine dental services. Conversely, those with high level of education have been found to enhance and reinforce health seeking behaviour (Dupas, 2011). Those with high educational status were found to better patronize dental service as compared with their counterpart with lower education level (Bhushan et al., 2012). This could possibly be explained by the fact that the former have enough knowledge and information first, about the existence of dental services and secondly the importance of regular dental visitation. 16 University of Ghana http://ugspace.ug.edu.gh Marital status could influence health care seeking behavior (Chaibva, 2008). It has been documented that unmarried clients have higher chance of underutilizing health care due to lack of spousal support (Chaibva, 2008). On the other hand, it has also been observed that married patients may be deficient in their ability to make own informed decisions regarding their health (Lindstrom, 2009). Thus, the power to make health decisions relies more often than not, solely on their spouse and other powerful family members (Okunseri et al, 2009). Meaning that, the effect of marital status on health seeking behaviour is contextual, with majority of the cases, experiencing positive association with utilization of health service. According to a research conducted by Kim (2016) in Korea, most participants utilizing dental services were married (around 70%), while 18% of them were single. Occupational status and Income level (both real and perceived) are important conjecturers of health service use (Vazuquez et al, 2015). According to a survey done in Australia, findings suggested that, manual workers were less likely to have dental visits in the past year than other occupational workers (Roncalli et al, 2014). The odds of utilizing dental services having had extraction at one’s last visiting among blue-collar workers were 2.5 times that of those in managerial or professional occupations (Singh et al., 2014). Poverty and race were found to be significant predictors of utilization according to a survey of black and white adults in Florida (Singh et al, 2014), in that, the lowest rates occurred more among the financially underprivileged African- Americans. The odds of service utilization among the non-poor African-American was same as that of the impoverished whites in this study (Cohen et al, 2011). The perceived ability to pay for dental care as well as income level were significant predictors of utilization. According to Vashisth et al, (2012) the odds ratio of service utilization 17 University of Ghana http://ugspace.ug.edu.gh among poor older adults was 0.55 times that of high income group. It is obvious from above that, income level and one’s occupational status are both significant contributors to service utilization. It is believed that religion plays an essential role in health and service utilization for that matter. Due to the current dispensation of increasing spirituality worldwide, majority of people prefer to associate their ailment to spiritual origin rather than coming to hospital to seek for care (Butani et al, 2008). They will often spend most of the time within the natural history of disease visiting their spiritual leaders and when they become unsuccessful, they come to the health care provider as their final resort to health, by which time it is often late. Despite this foundation truth, some others still patronize health care as early as the onset of disease. Due to contextual variations, research conducted by Poudyal et al. (2010), also showed differences in level of utilization of dental care among some religious groups in Mangalore. Hindus (59.9%) were in the majority, with 34.6% Muslims and the least being Christians (5.5%). Due to the low percentages of Christians and Muslims, the variable, religion, was sub-divided into Hindus (59.9%) and 40.1% non-Hindus, for easy statistical analysis with significant statistical results. 2.6.2 Enabling factors (Enablers / Barriers) This sub-section presents literature related to the Enabling factors influencing utilization of dental services. This section looks at the factors that will encourage service utilization and those that will hinder service utilization. It will look at factors such as staff attitude, environment, affordability, 18 University of Ghana http://ugspace.ug.edu.gh availability and accessibility of dental services. These factors are thought to have significant influence on service utilization. Generally speaking, attitude of providers personnel, skills of service provider, quality of the service provided, cost of services provided and even location of dental clinic significantly determine client’s satisfaction with services provided and hence, its influence on service utilization (Prakash, 2010). A study conducted in Saudi Arabia to examine factors that influence dental service utilization indicated quality of dental care as one of the most significant positive determinants (Quadri et al., 2018)This was consistent with the multivariate analysis results; which documented quality of dental care as having a significant relationship with service utilization (Al-Husssyen, 2010). This finding also explained why they were very satisfied with services rendered. The services met the suggested quality of care indicators. In the above studies, the presence of friendly staff, patient centered appointments, good recommendations from friends who have utilized the services, were major contributing health care provider factors. Agarwal and Murinson, (2012) also reported that, good patient doctor relationship, welcoming health team and good communication skills were promoters of health service utilization. On the other hand, Ha and Longnecker, (2010) reported that, inhibitory health care provider and facility factors to dental service utilization were, inconvenient appointments, poor communication skills and staff unfriendliness. Again, in these above research, patients were more likely to visit clinics with dental specialist than those with general dental physicians. This however, revealed that, health care provider skills play an important role in determining one’s choice of dental visit. Again, in the same research 19 University of Ghana http://ugspace.ug.edu.gh conducted, fear of experiencing post-operative complications following a dental procedure was a barrier to dental service utilization. Implying that, a dental practitioner with fewer post-operative complications is more likely to attract patients than a counterpart whose clients frequently experience post op complications (Al-Hussyeen, 2010). Environment A study in five sub-Saharan African countries of Ghana, Nigeria, Kenya, Zambia and Uganda showed that there has been little action by government to make the deployment patterns in favor of rural areas (Adebayo et al, 2014). These studies indicated that most relatively well-equipped hospitals and health units were also found in urban environments. The quality of services provided in the rural areas was far lower compared with the urban facilities (Adebayo et al, 2014). This disparity in health service has necessitated a move by the sub-region and Ghana for that matter to initiate attainable and realistic health policies that seek to breach this equity gap. Results from some studies revealed that the location and design of the dental clinic could be a basis for attracting clients to further patronize the dental facilities they visited (Wall et al, 2012). Well- equipped dental facilities with appropriate dental chairs and equipment made service provision holistic in meeting the clients need hence encouraged them to patronize dental services timely as scheduled by their dentist (Manski et al, 2012). 20 University of Ghana http://ugspace.ug.edu.gh Affordability of dental services One’s ability to access health care also depends significantly on his or her ability to pay for the service (Muirhead et al, 2009). In Ghana like most other countries, dental care is relatively more expensive than general health services. Just a few dental procedures such as tooth extraction, scaling and polishing among other few other procedures are partially covered by the National Health Insurance Scheme. These partially covered services must be complemented by co- payments sometimes. It is obvious that, health financing dental service delivery; an important component of the health system is given little attention, as most patients would have to pay for majority of the services received. This health system disparity could partly account for the relatively lower service utilization in dental care than other health service delivery (Ramraj et al, 2013). Dental indemnity coverage and patronizing dental services has been a major area of concern and deliberation (Locker et al, 2011). The geriatrics with private insurance visits their dentist more frequently than their counterparts. According to a research conducted in US, the equity gap between dental need and service utilization has been found to be because of individual self- financing of service. E.g. out-of-pocket payment. The study again indicated, insuring dental patients, relief them off their health financing challenge, but does not do away with the price gap (Wall et al., 2012). 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). 21 University of Ghana http://ugspace.ug.edu.gh In 2014, the University of Ghana 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. A study in Ghana by Maxwell, 2010 states that at the beginning of the year 2000, the share of households out of pocket (OOP) payment to total health expenditure in Ghana was considerably higher than the regional average for Sub-Saharan Africa (50 percent versus 39 percent respectively in 2006) according to WHO (2010). Healthy life is worthy of living but as has already been noted, financial barrier is a major obstacle to health care delivery and accessibility. It is in confirmation of this that Ministry of Health (MOH) in its earlier report, under the policy framework of the national health insurance scheme states: “The implementation of the “cash and carry” system compounded the utilization problem by creating a financial barrier to health care access especially for the poor. It is estimated that out of the 18% of the population who require health care at any given time, only 20% of them are able to access it”. In the quest for attaining middle income levels by the year 2020, as enshrined in Ghana Poverty Reduction Strategy document (GPRS, 2003), these health outcomes are not only disturbing but unacceptable for middle income status. A number of good health financing policies have already been tried in our health delivery systems in Ghana, ranging from „free health care‟, ‟token fees‟ to the „cash and carry‟ systems but have all either failed or proven to be unsustainable with dire consequences on the people, especially the core poor in society (Paul, 2011). Governmental organizations globally, are more interested in dealing with the outrageous pricing of general hospital services rather than price challenge with dental care (Survashe et al, 2018). 22 University of Ghana http://ugspace.ug.edu.gh Higher cost of dental services as a barrier to dental service utilization was reported by the patients in study to determine barriers to dental service utilization. (Nagarjuna et al, 2016) Availability and accessibility of dental service The patients also reported the distance from home as a barrier to dental service utilization (Jain et al., 2013). In rural and hard to reach areas where health care is far away from most homes, clients often report geographic inaccessibility as a major obstacle to health care. They would have to travel a very long distance before accessing health care. This however often discourages them, making them resort to alternative medical care, which is often closer to them. Inequity in access to dental services, exemplifies the nature of dental service utilization with its attendant poor oral health related quality of life among the disadvantaged and socially marginalized dental category (Carreon et al, 2011). Dentistry is categorized into the field of cure and that of prevention. The former is technically involving and more expensive than prevention. This brings before the patient, a very different perception of dentistry, more importantly regarding the cost involved in treatment. E.g. cost involved in root canal treatment and dental rehabilitation. This cost element indeed captures financial accessibility as a very important determinant for health service utilization (Locker et al, 2011) Additionally, the above issues of availability and accessibility of dental services, cannot be treated in isolation from the political and economic structural context of the community. It has to be treated in unison not forgetting the fundamental components of health living. It is therefore clear that both 23 University of Ghana http://ugspace.ug.edu.gh availability and accessibility of dental services in a community significantly affects service utilization (Gavett, 2015). 2.6.3 Need factors This sub-section presents literature related to the need factors influencing utilization of dental services. Cultural Beliefs Some researchers argue that the cultural context of any given program cannot be underestimated, as culture and beliefs have been found to be major determinants of service utilization (Butani, 2008). Some studies have postulated that reasons for underutilization of services, objections to referrals as well as indecisions with regards to the need to seek urgent health care, are based on cultural beliefs (Henderson et al, 2008). Up until recently, when health education has been intensified, majority of people did not recognize dental ailment as a condition to bring to hospital for care. They often will use herbal preparations for cure, and when complications such as dental abscess and cerebral abscess set in, they would then rush in to the hospital (Kochlar et al, 2014). All these could be better appreciated, when health is studied under one’s socio-cultural context. According to Butani et al (2008), many cultural groups lack strong preventive orientation in relation to oral health. Many cultures have little understanding of gum disease. Brushing teeth is purposely for removing left over food from oral cavity, but the concept of plaque and removal is not well appreciated. The use of modern methods of oral hygiene such as dental floss, mouth rinse, and tongue cleaners is often viewed with doubt. Oral pain is treated using culturally accepted means passed down 24 University of Ghana http://ugspace.ug.edu.gh through progenies (Vani et al, 2010). For Example, some African-American families use cotton balls soaked in aspirin solution, alcohol or salt water as a home remedy for pain and swelling (Chandra et al, 2009). 2.6.3.1 Knowledge of dental services Awareness and benefits of dental services Being better informed of the existence of dental care services, the need to patronize its services and attendant benefits play an essential role in determining service utilization (Kwan et al, 2010). Those who fall in this category often patronize dental service as compared with those who have little or no knowledge of the existence of dental services and even if they do, still have little or no knowledge of its availability in their catchment area as well as the benefits associated with regular dental visitations (Herkrath et al., 2018). The result of a study to determine barriers to dental services utilization indicated that, respondents in the higher education group showed higher dental visits than the lower education group. This was so because, education may be correlated with high health awareness, which in turn stimulates preventive behaviour such as regular visits for a checkup (Nagarjuna et al, 2016). A similar assertion in another study claimed that, recognizing the benefits of routine dental visits often precipitated the need to regularly visit a dentist (Survashe et al, 2018). When to access and number of dental visits Knowledge of when to access dental care and the recommended number of dental visits is a good precedence for service utilization. Knowing when to visit a dentist and how often to do that, will improve dental health, as it is less likely for people to present late with complications from dental ailments (Mashoto et al, 2009). Routine dental consultation is estimated to be every 6 months for 25 University of Ghana http://ugspace.ug.edu.gh children, teenagers and the elderly or each year for healthy adults. According to Nagarajappa et al., (2015), regular visits to the dentist have an inverse relationship with the presence of dental ailments (E.g. caries, teeth restoration, dental extraction needs or gum pathology). Therefore, the more dental service visit or dental service utilization, the lesser the prevalence of dental ailments. Source of information Health education programme should be a better avenue for intensifying dental health awareness (Amin et al, 2008). During these programmes, members should be educated by public health officers and health practioners on where, when and why to access dental care. They should be aware of the complications associated with late presentation of dental diseases, so as to deter them from seeking alternative health care, but rather report to the dentist when symptoms of dental ailment is earlier recognized (Okemwa et al, 2010; Paul,2011). Lack of adequate knowledge of the existence and availability of dental services has been cited as contributors to the poor utilization of dental services (Seli, 2017; Onyejaka et al,2016). 2.7 Summary of the literature review Its obvious from the above literature review that, dental service under-utilization which has resulted in the increased prevalence of dental diseases, has significantly contributed to the global burden of oral diseases. Unlike most of the reviewed research that only sought to investigate factors that influence utilization of dental services, this one seeks to further categorise them into enablers and barriers.This will better provide the organizational board, with relevant information on the major hinderances to dental service utilization and then make informed descion towards improving dental care in the municipality, country and sub-region as a whole. 26 University of Ghana http://ugspace.ug.edu.gh In addtion, as against other studies that narrowed in on age groups, this study increased the age gap to include lots of views from the wide respondents. Thus, their views on enablers and barriers to dental service utilization. 27 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 Methodology 3.1 Introduction This chapter presents the methods that was applied to collect data for analysis in the study. It is divided into eight sections. 3.2 Design The study was primarily a descriptive cross-sectional study. It adopted a quantitative approach in data collection and analysis. It quantified observations at a point in time, where both exposure (independent variables) and outcome (utilization of dental services) were measured at the same time. Systematic random sampling was used to select study participants and a semi-structured questionnaire to collect data from these study participants. The study participants were non critically ill patients aged 18 years and above accessing dental services in the facility. The theory for the study was an adapted Anderson and Newman model of health belief centered on health service utilization. 3.3 Study area The study was conducted at Hawa Memorial Saviour Hospital (HMSH) at Osiem in the East Akim Municipality of Eastern region. It is a mission Hospital established by the Saviour Church of Ghana, with headquarters at Osiem in the Eastern Region. 28 University of Ghana http://ugspace.ug.edu.gh The municipality is one of the twenty-one (21) districts of the Eastern Region of Ghana. The capital is Kibi. In the 2010 Population and Housing census, the total population was 167,896 constituting 49.7 percent males and 51.3 percent females and 40% of the population is rural (GSS, 2010). Majority of the population are in the youthful age according to the 2017 Eastern regional population breakdown. The major group is Akyems and minor tribes are Ewes, Frafras, Dagartis, Krobos, Akuapem and Ashantis etc. The main economic activities in the municipality are farming, petty trading, small- scale industries and currently small scale mining. The road network in the municipality is good. The old Kumasi-Accra road passes through the municipal capital whiles the new road passes through Apedwa, and Asafo. All the other sub- municipalities have tarred roads with major towns linked with tarred roads. The feeder roads are also well maintained. For health infrastructure, there are two public hospitals, one CHAG hospital (Hawa Memorial Saviour Hospital), one private, four health centers, two reproductive and Child health centers, two clinics, two private maternity clinics and sixteen functioning CHPS compounds (35 demarcated CHPS sites). Majority are Christians, followed by Muslims and the other religion. Some pertinent cultural practices that are used in mitigating oral diseases involve mainly herbal medications, over the counter drugs, among others. Services rendered at HMSH include internal medicine, pediatrics, general surgery, obstetrics and gynecology, specialist services such as eye, dental, ENT and orthopedics The facility was established in February 2008. Its dental facility started in the year 2014 with a staff capacity of four (4) with one dental surgeon, dental surgery assistant and two staff nurses. The dental facility has a dwindling outpatient (OPD) attendance. The total dental OPD attendance 29 University of Ghana http://ugspace.ug.edu.gh in 2015 was 94, 132 in 2016 and down to 63 in 2017. The slight surge in 2016 immediately followed a dental community outreach programme conducted by the hospital facility. Commonly seen cases include dental caries, apical abscess, periodontal diseases, tooth extraction for caries, scaling and polishing and occasionally tooth replacement. 3.4 Study population The target population consisted stable and cooperative (thus non critically ill patients) patients aged 18 years and above accessing dental services at the Hawa Memorial Saviour Hospital. This population was targeted since they can give detailed information on their experiences with dental services offered for their respective visits in the dental facility. 3.5 Inclusion criteria Patients aged 18years and above accessing dental services in the facility. 3.6 Exclusion criteria Patients aged 18 years and above who are critically ill and accessing dental services in the facility (cannot cooperate with data collection). 3.7 Variables The outcome variable for this study was utilization of dental services while the independent variables were predisposing, enabling and need factors. Details of these variables are shown in the table below. 30 University of Ghana http://ugspace.ug.edu.gh Table 3.1: Study variables Variables Description Measurement Dependent Utilization of dental Annual number of dental visits As stated by respondent service per person How many times in the past year have you visited the hospital for dental services) Independent Predisposing factors (Socio-demographic factors) Age Age at last birthday As stated by respondent Sex Either male or female As stated by respondent Level of education Primary, Secondary, Tertiary, As stated by respondent or No formal education Marital status Married , Divorce, Co- As stated by respondent habiting, Single Occupation Kind of job or client’s As stated by respondent profession Religion Christian, Islamic, Traditional, As stated by respondent Others specify Income level Monthly income As stated by respondent obtained/Amount of salary or wages earned from job Enabling factors(Enablers/ Barriers) Affordability Is service covered by NHIS or As stated by respondent Out-of-pocket? If so, is it expensive? Accessibility Distance of facility from home. As stated by respondent Is it near (walking distance), far or very far? 31 University of Ghana http://ugspace.ug.edu.gh Variables Description Measurement Availability Adequacy of dental services. As stated by respondent I.e. required number of dental personnel, dental chair, etc. Attitude of health Friendly ,humaneness, good As stated by respondent personnel communication and inter- personal skills Post op complications Any previous complications As stated by respondent from dental procedure or heard of any dental post- operative complications in the facility Environment Cleanliness of the surrounding. As stated by respondent Is the environment quite or noisy? Design of the facility attractive enough? Perception of quality of Are you satisfied with quality As stated by respondent care of care offered you? (Thus was service rendered effective in managing your dental ailment?) Need factors Knowledge of Dental Service Source of information Friend, relatives, internet. As stated by respondent Others specify When to access Examining client’s knowledge As stated by respondent of when to access dental services. What health conditions will necessitate dental visit? 32 University of Ghana http://ugspace.ug.edu.gh Variables Description Measurement Time of 1st visit When was client’s 1st visit to As stated by respondent dentist Number of dental visits As stated by respondent Benefits of dental services As stated by respondent Awareness Awareness on the existence of As stated by respondent available dental facilities, need to access services Cultural practices and If there exist any belief that As stated by respondent Misconceptions hinders access to dental services Self- reported illness W h ether client willingly report As stated by respondent his or her illness to the facility Acute illness Whether illness had a short As stated by respondent history Chronic illness Whether illness had a long As stated by respondent history or it is a condition previously seen for which review is sought 3.8 Sample Size Determination In order to obtain an appropriate sample size for the study, the formula for estimating a single proportion with absolute precision was used to calculate sample size. The formula is denoted as follows: 𝑍2𝑝(1 − 𝑝) n = 𝑚𝑜𝑒2 33 University of Ghana http://ugspace.ug.edu.gh Where: n: required sample size z: standard normal deviate of a 95% confidence level, P=31.9% (Andra Pradesh research on dental service utilization), moe= absolute precision of 9 %( 0.09) Calculated as follows: 1.962 × 0.319(1 − 0.319) n = (0.09)2 n= 103 Therefore, the sample size of 103 was used accordingly. Adjustment for a 10% rate of non- responses of 10.3 yielded a final sample size of 113.3 ~ 113 3.9 Sampling The study adopted a systematic random sampling approach. The estimated daily attendance at the facility was 8. Five (5) interviews were conducted a day over a 23 day period between August- September, 2018. With the estimated daily attendance around 8, the sampling interval was calculated by dividing 8 by 5 to obtain 1.6 which is approximately 2. After which a random number was selected between 1 and 2 i.e. the sampling interval as the starting point. For this research the starting point was the number 1. Then every 2nd person was selected until the total sample size of 113 was obtained. 3.10 Data Collections Tool A structured questionnaire was used to collect the data in this study. The questionnaire composed of both closed ended and open ended questions. Questionnaires were used for data collection because they offer considerable advantages in the administration: questionnaires present an even 34 University of Ghana http://ugspace.ug.edu.gh stimulus potentially to large numbers of people simultaneously and provide the investigation with an easy accumulation of data. They give respondents freedom to express their views or opinion (Barberi et al, 2008). The questionnaires were divided into three sections. The first section asked questions relating to client factors or predisposing factors (socio-demographic characteristics) influencing the utilization of dental services at Hawa Memorial Saviour Hospital. Section 2 inquired about enabling factors influencing the utilization of dental services at Hawa Memorial Saviour Hospital. Section 3 asked questions relating to need factors influencing the utilization of dental services. Two trained research assistants administered the questionnaires. Each questionnaire was administered within 20-30 minutes. Utilization was measured as a binary variable where two or more visits will be considered adequate and less than two considered inadequate. The questionnaire was developed by the researcher based on the objectives and conceptual framework. 3.11 Quality Control Sansoni et al. (2010) defines quality control as the technique involved in administering the same instrument twice to the same group of subjects. The questionnaire was administered to ten (10) respondents selected for the pilot study within an interval of one week. The final questionnaire was evaluated for validity as well as internal consistency. Cronbach’s alpha was used to check for internal consistency. Pearson Product Moment Correlation Coefficient (r) of 0.6 was calculated for each questionnaire. Scores obtained from the pretest was correlated to get the coefficient of reliability. 35 University of Ghana http://ugspace.ug.edu.gh Two research assistants were recruited and trained to assist in the data collection. Training touched on issues of confidentiality, professionalism among others. Written protocols and reference guides were given to the research assistants to use during the data collection period. Supervision was key in ensuring that the data was collected as required. The collected data was saved on a Google drive (cloud storage) with adequate password to ensure data security and data loss. 3.12 Training of interviewers The principal investigator organized a training session for all interviewers and accompanied them to the field for the pretesting of the data collection tools. The observations and lessons learnt during the pretesting were used to retrain the interviewers. 3.13 Pretesting of the Instruments The study instrument (questionnaire) was pre-tested on patients (with similar characteristics) who were randomly selected other than those to be interviewed for the main study. After the pre-testing, the questionnaire was modified where needed. 3.14 Data processing Regular verification and validation of data was done with all inconsistencies checked and resolved between the researcher, research assistants and the data entry clerk. All data collected was cleaned, entered into a computer and processed using STATA Version 15 Software. 36 University of Ghana http://ugspace.ug.edu.gh 3.15 Data analysis Pre-coded data was entered into Microsoft excel spreadsheet and was imported into STATA version 15.0 for statistical analysis. In descriptive analysis, mean age and mean income were computed with their respective standard deviations. Percentages and frequencies were computed for socio demographic variables; sex, marital status, educational level, and religion. Proportion of respondents who adequately utilized dental services (2 or more times per year) was also recorded with the 95% confidence interval. Furthermore, a preliminary Chi square test of association between independent variables and the outcome variable was done. However if at least one variable within a particular category shows statistically significant association with the outcome variable then it is followed with a simple logistic regression to determine both the association and strength of association with the outcome variable (Utilization of Dental Services). For example, the category dental treatment had all its variables not been statistically significant from the Chi Square test of association with dental service utilization. Hence a simple logistic regression was not followed. Hence Chi Square test of association was done for the categories, conditions and type of treatment received. Variables that showed statistically significant associations in the simple logistic regression included educational level, religion, time of travel to facility (in minutes), prior knowledge on existence of dental facility, amount paid out-of-pocket for dental services and personal decision to visit dental facility. These significant variables were fitted into a final multiple logistic regression to determine factors associated with utilization of dental services at the Hawa Memorial Savior Hospital. Crude and adjusted Odds ratios were reported with their 95% confidence intervals with statistical significance set at p< 0.05. 37 University of Ghana http://ugspace.ug.edu.gh 3.16 Ethical Considerations 3.16.1 Ethical clearance Ethical clearance for this study was obtained from the Ghana Health Service Ethics Review Committee as a way of ensuring that the study conformed to the full requirement of research using human subjects. The data collection commenced after receipt of ethical clearance. A letter of introduction seeking approval to use the facility for the study was sent from the School of Public Health, College of Health Sciences - UG, to the District Director of Health Services - East Akim and the management of Hawa Memorial Saviour Hospital. 3.16.2 Participant’s consent A participant’s consent form was developed to either be signed or thumb printed by participants (see appendix C). Written informed consent was obtained from the individuals in the communities who agreed to be part of the study, especially for those who had to thumb print the consent form. 3.16.3 Voluntary consent Participation in the study was voluntary and participants were free to opt out any time during the study, without any penalty in opting out. 3.16.4 Privacy and confidentiality All data obtained with the hard copy of the questionnaire would be destroyed after a period of one year. The soft copies would be deleted from the personal computer and external drive after five years of the study. 3.17 Reward There was no reward of any kind for the participants involved in the study. 38 University of Ghana http://ugspace.ug.edu.gh 3.18 Potential risks/benefits The study did not pose any harm to the participants, but rather, the results of the study would help strengthen dental health care provision in the country. The respondents' involvement in this study was through the questionnaires and therefore, were not exposed to any form of risks. 3.19 Compensation There were neither financial benefits nor other materialistic benefits to participants. 3.20 Protocol amendments In the event of any changes to the title or study location in the course of the study, this was communicated to the ethics review committee accordingly. 3.21 Conflict of interest There was no conflict of interest whatsoever related to the study. The study was solely for academic purposes and responses to the questionnaires would be used as such. 3.22 Funding information The total cost of the funding for the entire research was borne by the researcher. 39 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.1 Socio-demographic characteristics of respondents The results in Table 4.1 below shows the socio-demographic characteristics of respondents. All questionnaires were completed. The mean age of respondents was 50.9 years ± 18.3 SD. Females were in the majority 68.1% (77/113). Most of the respondents were married making up 41.6% (47/113). Sixty two percent of the respondents were employed (71/113). Majority of the respondents had some form of formal education 88.5% (100/113). Christians were in the majority 92.0% (104/113). The mean income was GH¢765.0 ± 422.4SD. 40 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Socio-demographic characteristics of respondents (n = 113) Variables Frequency Percent (%) Mean Age (M ± SD) 50.9years ± 18.3SD Sex Male 36 31.9 Female 77 68.1 Marital Status never married 20 17.7 Married 47 41.6 Living together 5 4.4 Divorced 15 13.3 Widowed 26 23.0 Employment status Unemployed 30 26.6 Self employed 46 40.7 Public sector 20 17.7 Private sector 5 4.4 Student 12 10.6 Educational Level No education 13 11.5 Primary 22 19.5 Junior high school 41 36.3 Senior high school 11 9.7 Tertiary 26 23.0 Religion Christian 104 92.0 Muslim 8 7.1 Traditionalist 1 0.9 Others 0 0.0 Mean Income (M ± SD) GH¢765.0 ± 422.4SD 41 University of Ghana http://ugspace.ug.edu.gh 4.2 Dental Service Utilization Twenty seven percent (31/113) of respondents adequately utilized dental services with a minimum of 2 visits (p = 27.4%, 95% CI = 19.5 – 36.6%). (See Figure 4.1) 27.4% Inadequate utilization (≤ 1 Dental visits) Adequate utilization (≥ 2 Dental Visits) 72.6% Figure 4.1 Proportion of adequate utilization of dental services among respondents 4.3 Conditions presented at dental facility Majority of respondents 85.8% (97/113) cited toothache as a condition that brought them to the facility, 80.5% (91/113) also cited gum disease as a condition and 24.8% (28/113) also cited mouth sore as a condition that brought them to the facility. This was a multiple response question (See Figure 4.2) 42 University of Ghana http://ugspace.ug.edu.gh 100 90 85.8% 80 80.5% 70 60 58.4% 50 46.9% 40 41.6% 30 20 24.8% 16.8% 10 2.7% 0 Bad breath Broken teeth Gum disease Toothache Painful swelling Missing teeth Mouth sore Painless swelling Figure 4.2: Various dental conditions presented to the dental clinic 4.4 Type of treatment Majority of respondents 84.1% (100/113) indicated medication as the type of treatment they received at the dental facility and 13.3% (15/113) also indicated dentures. (See Figure 4.3) 43 University of Ghana http://ugspace.ug.edu.gh 100 90 88.5% 80 84.1% 70 60 63.7% 50 47.8% 40 30 20 10 13.3% 0 Cleaning Dentures Extraction Filling Medication Figure 4.3: Types of treatments received at the dental clinic 4.5 Enablers of utilization of dental services Majority of respondents utilized dental services due to chronic dental conditions 71.7% (81/113) and 48.7% (55/113) did so during routine check-ups. (See Figure 4.4) 44 University of Ghana http://ugspace.ug.edu.gh Chronic dental condition 71.7% Friendly staff attitude 69.0% Awareness of importance of dental hygiene 64.6% Clean hospital environment 57.5% Knowledge and capability of staff 54.9% Routine dental check up 48.7% 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 Figure 4.4: Patient perspective of enablers of dental service utilisation 4.6 Barriers to utilization of dental services Majority of respondents 78.8% (89/113) cited cost as a reason for inadequately utilizing dental services, 55.8% (63/113) also cited the distance as a barrier and 24.8% (28/113) also indicated an unfriendly hospital environment as a reason for not adequately utilizing dental services. (See Figure 4.5) 45 University of Ghana http://ugspace.ug.edu.gh Cost 78.8% Distance to facility 55.8% Fear 54.9% Poor attitude of staff 46.0% Shyness 38.1% Unfriendly hospital environment 24.8% Others 12.4% 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Figure 4.5: Patient perspective of barriers to dental service utilisation 4.7 Associations between the independent variables and utilization of dental services 4.7.1 Socio-demographic factors associated with dental service utilization The results of the simple logistic regression conducted to determine associations between each socio-demographic characteristic and utilization of dental services is shown below in Table 4.2. The socio-demographic characteristics that showed significant association with utilization of dental services included; educational level and religion. 46 University of Ghana http://ugspace.ug.edu.gh Respondents who had obtained tertiary level education had significantly 5.56 times the odds of utilizing dental services as compared to respondents who had no level of education (cOR = 5.56; 95% CI = 1.08 – 28.63). Also, respondents who were Muslims had significantly 5.27 times the odds of utilizing dental services as compared to respondents who were Christians (cOR = 5.27; 95% CI = 1.17 – 23.61). 47 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Socio-demographic factors associated with dental service utilization Variables Utilization Of Dental Services cOR (95% CI) p-values Adequate utilization Inadequate (≥ 2 dental utilization visits/yr) (≤ 1 dental visit/yr) (n = 31) (n = 82) Mean Age 51.2 ± 18.9 50.9 ± 18.2 1.00 (0.97 – 1.02) 0.936 Sex Male(Ref) 9(25.0) 27(75.0) 1.00 Female 55(71.4) 22(28.6) 1.20 (0.49 – 2.96) 0.692 Marital Status Never Married(Ref) 6(30.0) 14(70.0) 1.00 Married 12(25.5) 35(74.5) 0.80 (0.25 – 2.55) 0.706 Living Together 2(40.0) 3(60.0) 1.56 (0.20 – 11.83) 0.669 Divorced 4(26.7) 11(73.3) 0.85 (0.19 – 3.77) 0.829 Widowed 7(26.9) 19(73.1) 0.86 (0.24 – 3.12) 0.818 Employment Status Unemployed(Ref) 8(26.7) 22(73.3) 1.00 Self Employed 13(28.3) 33(71.7) 1.08 (0.39 – 3.04) 0.879 Public Sector 5(25.0) 15(75.0) 0.92 (0.25 – 3.35) 0.895 Private Sector 0(0.0) 5(100.0) 1 Student 5(41.7) 7(58.3) 1.96 (0.48 – 7.99) 0.346 Educational Level No Education(Ref) 6(37.5) 10(62.5) 1.00 Primary 5(21.7) 18(78.3) 0.46 (0.11 – 1.91) 0.287 Junior High School 8(18.2) 36(81.8) 0.37 (0.10 – 1.32) 0.125 Senior High School 2(11.8) 15(88.2) 0.22 (0.04 – 1.33) 0.099 Tertiary 10(76.9) 3(23.1) 5.56 (1.08 – 28.63) 0.040 Religion Christian(Ref) 25(24.0) 79(76.0) 1.00 Muslim 5(62.5) 3(37.5) 5.27 ( 1.17 – 23.61) 0.030 Traditionalist 1(100.0) 0(0.0) 1 Mean Income 807.2 ± 465.7 750.8 ± 410.4 1.00 (0.99 – 1.002) 0.623 48 University of Ghana http://ugspace.ug.edu.gh 4.7.2 Association between conditions presented and utilization of dental services The results from a Chi Square test of association is shown below in Table 4.3. Most conditional factors did not show any significant association with utilization of dental facilities. These factors that showed no significant association with utilization of dental facilities included; bad breath, broken teeth, toothache, painful swelling, missing teeth, mouth sore and painless swelling. However, gum disease showed significant association with utilization of dental services (p = 0.045). 49 University of Ghana http://ugspace.ug.edu.gh Table 4.3: Association between conditions presented and utilization of dental services Variables Utilization p-value Adequate Inadequate utilization(≥ 2 utilization(≤ 1 dental visits/yr) dental visit/yr) Bad breath +0.721 Bad breath 3(5.7) 50(94.3) No bad breath 5(8.3) 55(91.7) Broken teeth +1.000 Broken teeth 5(7.6) 61(92.4) No broken teeth 3(6.4) 44(93.6) Gum disease +0.045 Gum disease 4(4.4) 87(95.6) No gum disease 4(18.2) 18(81.8) Toothache +0.598 Toothache 8(8.3) 89(91.7) No toothache 0(0.0) 16(100.0) Painful swelling +0.717 Painful swelling 4(8.5) 43(91.5) No Painful swelling 4(6.1) 62(93.9) Missing teeth +1.000 Missing teeth 1(5.3) 18(94.7) No missing teeth 7(7.5) 87(92.5) Mouth sore +0.407 Mouth sore 3(10.7) 25(89.3) No mouth sore 5(5.9) 80(94.1) Painless swelling +1.000 Painless swelling 0(0.0) 3(100.0) No painless swelling 8(7.3) 102(92.7) *statistically significant (p<0.05) + Fisher’s exact 50 University of Ghana http://ugspace.ug.edu.gh 4.7.3 Association between type of treatment and dental service utilization The results from a Chi Square test of association is shown below in Table 4.4. The type of treatment received did not show any statistical significance with utilization of dental services. Table 4.4: Association between type of treatment and dental service utilization Variables Utilization p-value Adequate utilization Inadequate utilization (≥ 2 dental Visits) (≤ 1 dental Visit/yr) Cleaning +0.709 Cleaning 6(8.3) 66(91.7) No cleaning 2(4.9) 39(95.1) Dentures +0.287 Dentures 2(13.3) 13(86.7) No dentures 6(6.1) 92(93.9) Extraction +1.000 Extraction 7(7.4) 88(92.6) No extraction 1(5.6) 17(94.4) Filling +1.000 Filling 4(7.4) 50(92.6) No filling 4(6.8) 55(93.2) Medication +0.593 Medication 8(8.0) 92(92.0) No medication 0(0.0) 13(100.0) Enablers and Barriers of dental service utilization For this study, enablers and barriers were addressed using accessibility, affordability, environmental, need and knowledge factors. They could be enablers or barriers depending on whether they enhanced utilization or not. 51 University of Ghana http://ugspace.ug.edu.gh 4.7.4 Accessibility factors associated with dental service utilization As shown in Table 4.5, a minute increase in time spent to arrive at the facility significantly reduces the odds of utilizing dental services by 61% (cOR = 0.39; 95% CI = 0.18 – 0.87). Respondents who knew about the existence of dental facilities had significantly 9.38 times the odds of utilizing dental services two or more times compared to those who did not know about the existence of dental facilities (cOR = 9.38; 95% CI = 3.67 – 23.97). (See Table 4.5) Table 4.5 Accessibility factors associated with dental service utilization Variables Utilization Of Dental Services cOR (95% CI) p-value Adequate Inadequate utilization utilization (n = 31) (n = 82) Distance of facility from home Not Far(Ref) 3(23.1) 10(76.9) 1.00 Far 26(27.1) 70(69.7) 1.24 (0.32 – 4.86) 0.759 Very Far 2(50.0) 2(50.0) 3.33 (0.32 – 34.83) 0.315 Time Of Travel To Facility (In Minutes) 1.09 ± 0.67 1.36 ± 0.46 0.39 (0.18 – 0.87) 0.021 Means Of Transport Walk(Ref) 12(29.3) 29(70.7) 1.00 Public Transport 18(25.7) 52(74.3) 0.84 (0.35 – 1.98) 0.684 Private Transport 1(50.0) 1(50.0) 2.42 (0.14 – 41.87) 0.544 Prior Knowledge On Existence Of Dental Facility No prior knowledge(Ref) 10(13.0) 67(87.0) 1.00 Have prior knowledge 21(58.3) 15(41.7) 9.38 (3.67 – 23.97) 0.000 52 University of Ghana http://ugspace.ug.edu.gh 4.7.5 Affordability factors associated with dental service utilization Table 4.6 shows the associations between each affordability factor and utilization of dental facilities. A GH¢1 increase in the amount paid out of pocket for dental services significantly reduces the odds of utilization of dental services by 3% (cOR = 0.97; 95% CI = 0.95 – 0.98). Furthermore, a simple t-test conducted to test significant difference in amount paid out of pocket by those on NHIS and privately insured revealed no significant difference in amount paid out of pocket. Those on NHIS paid an average of 211.42 Ghana Cedis out-of-pocket and those who were privately insured paid an average of 264.15 Ghana Cedis out-of-pocket. (Mean difference= -52.7, 95% CI= -144.91 39.469, p>0.05). (See Table 4.6) Table 4.6 Affordability factors associated with dental service utilization Variables Utilization Of Dental Services cOR (95% CI) p-value Adequate Inadequate utilization utilization (n = 31) (n = 82) Ability to pay for dental services Able to pay for dental services (ref) 9(34.6) 17(65.4) 1.00 Not able to pay for dental 0.352 services 22(25.3) 65(74.7) 0.64 (0.25 – 1.64) Mode of payment for dental services NHIS(ref) 4(57.1) 3(42.9) 1.00 Private Insurance 27(25.5) 79(74.5) 0.26 (0.05 – 1.22) 0.087 Amount paid out-of-pocket for dental services 122.3 ± 17.9 246.6 ± 113.9 0.97 (0.95 – 0.98) 0.000 Amount paid for health insurance 20.0 ± 5.9 18.5 ± 6.9 1.04 (0.97 – 1.11) 0.309 53 University of Ghana http://ugspace.ug.edu.gh 4.7.6 Environmental factors associated with dental service utilization The environmental factors did not show any statistically significant association with utilization of dental services as shown below in Table 4.7. 54 University of Ghana http://ugspace.ug.edu.gh Table 4.7 Environmental factors associated with dental service utilization Utilization Of Dental Variables Services cOR (95% CI) p-value Adequate Inadequate utilization utilization S (n = 31) (n = 82) Cleanliness of clinic Clean(ref) 5(27.8) 13(72.2) 1.00 Not clean 26(27.4) 69(72.6) 0.98 (0.32 – 3.01) 0.972 Noisiness of clinic Noisy (ref) 25(27.5) 66(72.5) 1.00 Not noisy 6(27.3) 16(72.7) 0.99 (0.35 – 2.82) 0.985 Attractiveness of clinic Attractive (ref) 7(33.3) 14(66.7) 1.00 Not attractive 24(26.1) 68(73.9) 0.71 (0.25 – 1.96) 0.503 Communication skills of staff Good communication skills(ref) 30(27.8) 78(72.2) 1.00 Bad communication skills 1(20.0) 4(80.0) 0.65 (0.07 – 6.05) 0.705 Doctorial skills Good doctorial skills (ref) 30(27.3) 80(72.7) 1.00 Bad skills 1(33.3) 2(66.7) 1.33 (0.12 – 15.25) 0.817 Explanation of procedures Procedures explained(ref) 27(27.0) 73(73.0) 1.00 Procedures not explained 4(30.8) 9(69.2) 1.20 (0.34 – 4.23) 0.775 Perception of quality of care good(ref) 28(28.0) 72(72.0) 1.00 Poor 0(0.0) 2(100.0) 1 Fair 3(27.3) 8(72.7) 0.96 (0.24 – 3.89) 0.959 Post-op problems after dental procedure Post op -complication(ref) 4(20.0) 16(80.0) 1.00 No post- op complication 27(29.0) 66(71.0) 1.64 (0.50 – 5.34) 0.415 Recommend dental facility Likely to recommend 31(29.0) 76(71.0) 1 Not likely to recommend 0(0.0) 6(100.0) 1 55 University of Ghana http://ugspace.ug.edu.gh 4.7.7 Need factors associated with dental service utilization The odds of adequate dental service utilization was reduced by 58% among respondents who did not visit dental services by themselves compared to those who indicated that they visited the dental facilities by themselves (cOR = 0.42; 95% CI = 0.18 – 0.99) (See Table 4.8). Table 4.8 Need factors associated with Dental Service Utilization Variables Utilization Of Dental Services cOR (95% CI) p-value Adequate Inadequate utilization utilization (n = 31) (n = 82) Personal decision to visit dental facility Personally decided(ref) 14(40.0) 21(60.0) 1.00 Did not decide personally 61(78.2) 17(21.8) 0.42 (0.18 – 0.99) 0.048 If no, who informed decision Relatives(Ref) 3(30.0) 7(70.0) 1.00 Friends 7(25.0) 21(75.0) 0.78 (0.16 – 3.85) 0.758 Others 21(28.0) 54(72.0) 0.91 (0.21 – 3.84) 0.895 Duration of dental condition Less Than 3 Weeks(Ref) 4(36.4) 7(63.6) 1.00 More Than 3 Weeks 27(26.5) 75(73.5) 0.63 (0.17 – 2.32) 0.488 Fear of pain during dental treatment Fear of pain(ref) 16(23.5) 52(76.5) 1.00 No fear of pain 15(33.3) 30(66.7) 1.63 (0.70 – 3.74) 0.255 Fear of bleeding during dental treatment Fear of bleeding(ref) 16(27.1) 43(72.9) 1.00 No fear of bleeding 15(27.8) 39(72.2) 1.03 (0.45 – 2.36) 0.937 Cultural means to manage dental condition Use cultural mean(ref) 12(27.3) 32(72.7) 1.00 Do not use cultural means 19(27.5) 50(72.5) 1.01 (0.43 – 2.37) 0.976 56 University of Ghana http://ugspace.ug.edu.gh 4.7.8 Knowledge factors associated with dental service utilization Table 4.9 shows the associations between each knowledge factor and utilization of dental facilities. However, all these factors did not show any significant association with the utilization of dental services. Table 4.9 Knowledge factors associated with dental service utilization Utilization Of Dental Variables Services cOR (95% CI) p-value Adequate Inadequate utilization utilization (n = 31) (n = 82) Knowledge on expected number of visits Every 6 Months(Ref) 14(25.5) 41(74.5) 1.00 Annually 3(30.0) 7(70.0) 1.26 (0.29 – 5.52) 0.764 Once In A Lifetime 4(33.3) 8(66.7) 1.46 (0.38 – 5.61) 0.578 Others 10(27.8) 26(72.2) 1.13 (0.44 – 2.91) 0.806 Visit to other dental facilities within the past year Visited(ref) 8(20.5) 31(79.5) 1.00 Did not visit 23(31.1) 51(68.9) 1.75 (0.69 – 4.39) 0.234 4.8 Association between significant variables from bivariate analysis and dental service utilization. After adjusting for all variables in the simple logistic regression with p < 0.05, Table 4.10 shows the adjusted odds ratio of all the variables adjusted for in the multiple logistic regression. (See Table 4.10) Respondents who had obtained tertiary level education had significantly 5.56 times the odds of utilizing dental services as compared to respondents who had no level of education (cOR = 5.56; 57 University of Ghana http://ugspace.ug.edu.gh 95% CI = 1.08 – 28.63). However, after adjusting for other variables this association was found not to be significant (aOR = 0.94; 95% CI = 0.09 – 9.16). Also, respondents who were Muslims had significantly 5.27 times the odds of utilizing dental services as compared to respondents who were Christians (cOR = 5.27; 95% CI = 1.17 – 23.61). This association was found not to be significant after adjusting for other variables (aOR = 2.41; 95% CI = 0.21 – 27.15). A minute increase in time spent to arrive at the facility significantly reduces the odds of utilizing dental services by 61% (cOR = 0.39; 95% CI = 0.18 – 0.87). This association was not significant after adjusting for other variables (aOR = 0.78; 95% CI = 0.24 – 2.58) Respondents who knew about the existence of dental facilities had significantly 9.38 times the odds of utilizing dental services two or more times compared to those who did not know about the existence of dental facilities (cOR = 9.38; 95% CI = 3.67 – 23.97). However, this association was statistically significant after adjusting for other variables (aOR = 9.94; 95% CI = 2.11 – 46.64). A GH¢1 increase in the amount paid out of pocket for dental services significantly reduces the odds of utilization of dental services by 3% (cOR = 0.97; 95% CI = 0.95 – 0.98). This association was still significant after adjusting for other variables (aOR = 0.97; 95% CI = 0.95 – 0.98). The odds of adequate dental service utilization was reduced by 58% among respondents who did not visit dental services by themselves compared to those who indicated that they visited the dental facilities by themselves (cOR = 0.42; 95% CI = 0.18 – 0.99). This association was found not to be significant after adjusting for other variables (aOR = 0.81; 95% CI = 0.16 – 4.00). 58 University of Ghana http://ugspace.ug.edu.gh Table 4.10 Results for multiple logistic regression with significant variables from bivariate analysis Variables cOR (95% CI ) p-value aOR (95% CI ) p-value Educational Level No Education (Ref) 1.00 Primary 0.46 (0.11 – 1.91) 0.287 0.11 (0.01 – 1.04) 0.054 Junior High School 0.37 (0.10 – 1.32) 0.125 0.21 (0.02 – 1.97) 0.171 Senior High School 0.22 (0.04 – 1.33) 0.099 0.09 (0.005 – 1.47) 0.090 Tertiary 5.56 (1.08 – 28.63) 0.040 0.94 (0.09 – 9.16) 0.959 Religion Christian(Ref) 1.00 Muslim 5.27 ( 1.17 – 23.61) 0.030 2.41 (0.21 – 27.15) 0.477 Traditionalist 1 1 Time of travel to facility (in minutes) 0.39 (0.18 – 0.87) 0.021 0.78 (0.24 – 2.58) 0.685 Prior knowledge on existence of dental facility Did not have prior knowledge (Ref) 1.00 Had prior knowledge 9.38 (3.67 – 23.97) 0.000 9.94 (2.11 – 46.64) 0.004 Amount paid out-of-pocket for dental services 0.97 (0.95 – 0.98) 0.000 0.97 (0.95 – 0.98) 0.000 Personal decision to visit dental facility Decided personally(ref) 1.00 Did not decide personally 0.42 (0.18 – 0.99) 0.048 0.81 (0.16 – 4.00) 0.796 4.9 Summary of findings Twenty seven percent (31/113) of respondents adequately utilized dental services with a minimum of 2 visits (p = 27.4%, 95% CI = 19.5 – 36.6%). Majority of respondents utilized dental services due to chronic dental conditions 71.7% (81/113). Majority of respondents 78.8% (89/113) cited cost as a reason for inadequately utilizing dental services, 59 University of Ghana http://ugspace.ug.edu.gh The socio-demographic characteristics that showed significant association with utilization of dental services include; educational level and religion. Respondents who had obtained tertiary level education had significantly 5.56 times the odds of utilizing dental services as compared to respondents who had no level of education (cOR = 5.56; 95% CI = 1.08 – 28.63). However, after adjusting for Religion, Time of travel to facility (in minutes) , Prior knowledge on existence of dental facility, Amount paid out-of-pocket for dental services, Personal decision to visit dental facility, this association was found not to be significant (aOR = 0.94; 95% CI = 0.09 – 9.16). Also, respondents who were Muslims had significantly 5.27 times the odds of utilizing dental services as compared to respondents who were Christians (cOR = 5.27; 95% CI = 1.17 – 23.61). This association was found not to be significant after adjusting for Educational Level, Time of travel to facility (in minutes) , Prior knowledge on existence of dental facility, Amount paid out- of-pocket for dental services, Personal decision to visit dental facility (aOR = 2.41; 95% CI = 0.21 – 27.15). The environmental factors did not show any significant association with utilization of dental services. Need factor ( individual’s personal decision to visit dental facility):The odds of adequate dental service utilization was reduced by 58% among respondents who did not visit dental services by themselves compared to those who indicated that they visited the dental facilities by themselves (cOR = 0.42; 95% CI = 0.18 – 0.99). This association was found not to be significant after adjusting for Educational Level, Religion, Time of travel to facility (in minutes) , Prior knowledge on existence of dental facility, Amount paid out-of-pocket for dental services, (aOR = 0.81; 95% CI = 0.16 – 4.00). 60 University of Ghana http://ugspace.ug.edu.gh Knowledge factors did not show any significant association with the utilization of dental services. Accessibility factor associated with Utilization of Dental Services was time spent travelling to the dental facility. A minute increase in time spent to arrive at the facility significantly reduces the odds of utilizing dental services by 61% (cOR = 0.39; 95% CI = 0.18 – 0.87). This association was not significant after adjusting for Educational Level, Religion, Prior knowledge on existence of dental facility, Amount paid out-of-pocket for dental services, Personal decision to visit dental facility (aOR = 0.78; 95% CI = 0.24 – 2.58) Respondents who knew about the existence of dental facilities had significantly 9.38 times the odds of utilizing dental services two or more times compared to those who did not know about the existence of dental facilities (cOR = 9.38; 95% CI = 3.67 – 23.97). However, this association proved to be significant after adjusting for Educational Level, Religion, Time of travel to facility (in minutes), Amount paid out-of-pocket for dental services, Personal decision to visit dental facility (aOR = 9.94; 95% CI = 2.11 – 46.64). A GH¢1 increase in the amount paid out of pocket for dental services significantly reduces the odds of utilization of dental services by 3% (cOR = 0.97; 95% CI = 0.95 – 0.98). This association was still significant after adjusting for Educational Level, Religion, Time of travel to facility (in minutes) , Prior knowledge on existence of dental facility, and Personal decision to visit dental facility (aOR = 0.97; 95% CI = 0.95 – 0.98). 61 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.0 Introduction This chapter presents the discussion of the findings of the empirical study and compares these findings with existing literature. There are 5 sections under this chapter. Section one presents on Utilization of dental services. Socio-demographic factors associated with utilization of dental services have been discussed in section two. Section three focuses on Accessibility factors associated with utilization of dental services. Discussion of Environmental factors associated with utilization of dental services have been reported in section four and Need factors associated with utilization of dental services including Knowledge factors have been discussed in section five. 5.1 Utilization of dental services In this study, twenty seven percent of respondents adequately utilized dental services with a minimum of 2 visits in a year. This proportion of respondents who utilize dental services is quite low indicating poor utilization at the Hawa Hospital. A higher percentage has been recorded in a national study in US, thus, 41-50% of the populace utilize dental service. In the US, the proportion was even described as low because experts recommend regular visitation (Nasseh et al, 2015). In Madagascar, 83% of 12 year olds had never received dental care (Josefczyk, 2015). Many countries in Africa, Asia and Latin-America have a shortage of oral health personnel and by and large the capacity of the systems is limited to pain relief or emergency care. In Africa, the dentist to population ratio is approximately 1:150000 against about 1:2000 in most industrialized countries. (https://www.who.int/oral_health/action/services/en/retrieved, May, 2019). A plausible 62 University of Ghana http://ugspace.ug.edu.gh reason for low dental service utilization in Africa and Ghana for that matter, as dentist to population ration is relatively lower. A research conducted by Vignesh and Priyadarshni in India revealed that, 31.58% of the investigated patients considered gum bleeding a normal phenomenon, therefore did not recognize the need to report such condition to the dentist (Vignesh et al, 2012). Such a phenomenon may be a plausible reason for low utilization of dental services at the Hawa Hospital in the East Akim Municipality of Ghana. In India, about 25,000 dentists graduate annually from the over 289 existing dental institutions (Ambika et al, 2015). Despite the large working class, majority of the Indian population suffer from poor access to fundamental dental care. There is an appreciable disparity with regards to the ratio of dentists to population in both rural and urban communities; with 1:10,000 in urban and 1:150,000 in rural setting. Notwithstanding the equity gap in access, patients self-finance dental services rendered to them in both private and public facilities (Ambika et al, 2015). The equity gap with relatively lower rural ratio can also be a plausible reason for the relatively lower service utilization in the rural area, where Hawa is situated. 5.2 Socio-demographic factors associated utilization of dental services In this study, results of the simple logistic regression conducted to determine associations between each socio-demographic characteristic and utilization of dental services showed significant association between utilization of dental services and some socio-demographic factors. These were educational level and religion. 63 University of Ghana http://ugspace.ug.edu.gh Respondents who had obtained tertiary level education had significantly 5.56 times the odds of utilizing dental services as compared to respondents who had no level of education. Similar findings have been documented in other studies, in that, high educational level have been observed to promote positive health seeking behavior (Herkrath et al, 2018). According to Bhushan et al. (2012), those with high educational status were found to better patronize dental service as compared with their counterpart with lower educational level. This could possibly be explained by the fact that the former have enough knowledge and information first, about the existence of dental services and secondly the importance of regular dental visitation. However this finding was not evident in the current study. Partly because it was limited to one facility with limited sample size which in turn affects the ability to obtain reliable results for all variables investigated. Other studies have also documented that low educational status reduces utilization of dental services. Low educational status has been identified as a major contributing factor to dental service under-utilization (Chou et al, 2011). The argument put across by these researchers suggests that, the absence of education can affect an individual’s level of understanding of information given and ability to make right decisions concerning their health (Chou et al, 2011). Perhaps patients with low educational status may not recognize the need to access routine dental care. However, after adjusting for other variables, this association was found not to be significant. This could have resulted from sample size being too small or that educational level has no association with utilization of dental in the presence of the variables adjusted for. Also, Muslims had significantly five times higher odds of utilizing dental services as compared to respondents who were Christians. This finding on the association between utilization of dental services and religion ought to be discussed in context since religions differ across various study settings. Due to contextual variations, research conducted by Poudyal et al. (2010), also showed 64 University of Ghana http://ugspace.ug.edu.gh differences in level of utilization of dental care among some religious groups in Mangalore. Hindus (59.9%) were the majority, with 34.6% Muslims and the least being Christians (5.5%). Due to the low percentages of Christians and Muslims, the variable, religion, was sub-divided into Hindus (59.9%) and 40.1% non-Hindus, for easy statistical analysis with significant statistical results. In the Ghanaian context, Christians are the majority and Muslims form the second larger group. In this study, respondents were either Muslim or Christians. All other socio-demographic characteristics, age, sex, marital status, employment status, and income, did not show any significant association with utilization of dental services at the facility. Meanwhile different studies have shown varying associations between the various demographic factors and utilization of dental services (Herkrath et al, 2018). According to research conducted by Gupta et al (2014), socio-demographic factors that were found to influence utilization among the rural population of Jaipur, India, were occupation, socio-economic status/income level, and age. High occupation and socio-economic status groups (income level) better patronized dental care as against those with low middle-income level, and low social class (Bhushan et al. 2012). Age as a determinant of dental service utilization has also been given much study. Disparities in service use between the aged and young have been observed in previous studies (Dye et al, 2011). Nearly 100% of the adult populations over the past 5 years had not used dental services as against 11% in those below 35years in an Indian study (Panchbhai, 2012). It was also found in other studies that, most of the elderly did not recognize the dying need for dental health care (Peterson et al, 2010). 65 University of Ghana http://ugspace.ug.edu.gh This is further evidenced by a Brazilian research conducted by Mullachery et al. (2008), which explained that dental care utilization and frequency of dental services utilization was seen more among the young than the old. The difference in this observation between the two aged groups was statistically significant. Females are generally believed to have better health seeking behaviour than males due to obvious reasons. They often share their problems; they do not internalize pain as against their counterparts who are more secretive. However, due to the effect of several other confounding factors believed to influence utilization of health services, sex as a determinant of health seeking behaviour does not always show significant association with utilization (Barker et al., 2014). This could have accounted for the lack of significant association between sex and utilization in this study. The sample size could also be a contributing factor. Perhaps if an inter-facility study was done to get more numbers for the sample size, such socio demographic characteristics may show associations with utilization of dental services. In a research conducted by Poudyal et al. (2010), in Mangalore, there was no significant difference between the dental visit history among males and females. This finding was however different from that of Lukacs (2010) and Manski et al, (2012) where females utilized dental services more. Marital status, although insignificant in this study, could influence health care seeking behaviour (Chaibva, 2008). It has been documented that unmarried clients have higher chance of underutilizing health care due to lack of spousal support (Chaibva, 2008). In other literature, it has also been observed that married patients may be deficient in their ability to make own informed decisions regarding their health (Lindstrom, 2009). 66 University of Ghana http://ugspace.ug.edu.gh Thus the power to make health decisions relies more often than not, solely on their spouse and other powerful family members (Okunseri et al, 2009). Meaning that, the effect of marital status on health seeking behaviour is contextual, with some of the cases, experiencing positive association with utilization of health service whiles others show negative association or no associations at all. 5.3 Accessibility factors associated with utilization of dental services In this study, a minute increase in time spent to arrive at the facility significantly reduces the odds of utilizing dental services. This finding suggests the effect of long distance from home to facility on utilization and it is consistent with a report that, distance from home is a barrier to dental service utilization (Jain et al., 2013). In rural and hard to reach areas where health care is far away from most homes, clients often report geographic inaccessibility as a major obstacle to health care. They would have to travel a very long distance before accessing health care. This however often discourages them, making them resort to alternative medical care, which is often closer to them. However this was not significant after adjusting for other variables. Thus the association turned out to be insignificant. Respondents, in this study, who were aware of the existence of dental services at the facility had significantly nearly ten times the odds of utilizing dental services (two or more times in a year) compared to those who did not know about the existence of dental services in the facility. This association proved to be significant after adjusting for other variables. The implication of this finding is that, there should be awareness creation on the availability of dental services. It is only natural for individuals not to patronize a service they unaware of. This is however consistent with research findings of Gavett, 2015 in US. 67 University of Ghana http://ugspace.ug.edu.gh 5.4 Affordability factors associated with utilization of dental services A GH¢1 increase in the amount paid out of pocket for dental services significantly reduces the odds of utilization of dental services by 3%. This association was still significant after adjusting for other variables. Also, amount paid for insurance (whether private or NHIS) did not significantly predict utilization. Further analysis (t-test), revealed that there was no significant difference in the amount paid out of pocket by respondents who were on NHIS and those who were privately insured. This finding suggests that perhaps many of the services rendered at the dental facility were not covered by insurance or perhaps what is covered by NHIS did not differ from services covered by Private insurance. Hence cost, in general for the patronage of dental services at the Hawa Hospital, is a significant barrier to utilization. Majority of respondents in this study cited cost as the commonest reason for inadequately utilizing dental services. High cost and lack of access were revealed as fundamental barriers to dental service utilization among the elderly (Peterson et al, 2010). The cost element indeed captures financial accessibility as a very important determinant for health service utilization (Ramraj et al, 2013). The issue of dental service polarization, describing dentistry as a quality service associated with higher cost, also worsened disparities in the distribution of dental care. This cost often serves as a barrier to service utilization, especially among the geriatric group (Locker et al, 2011) Additionally, the above issues of cost cannot be discussed in isolation from the political and economic structural context of the community. It has to be treated in unison not forgetting the fundamental components of healthy living (Gavett, 2015). 68 University of Ghana http://ugspace.ug.edu.gh 5.5 Environmental factors associated with utilization of dental services The association between environmental factors and dental service utilization was not significant in the current study. This finding does not agree with other studies (Adebayo et al, 2014). Results from some studies revealed that the location and design of the dental clinic could be a basis for attracting clients to further patronize the dental facilities they visited (Guay, 2004). Well- equipped dental facilities with appropriate dental chairs and equipment made service provision holistic in meeting the clients need hence encouraged them to patronize dental services timely as scheduled by their dentist. These studies further indicated that the urban communities tend to have more furnished equipment and clinics than those in the rural areas. The provision of services, in terms of quality, in the urban facilities were very high comparatively, to that of the rural areas (Adebayo et al, 2014). This, no show of association could mean that participant’s decision to utilize dental services did not bother on the hospital environment of Hawa Hospital. On the other hand, there could be an association between environment and utilization which could have been detected if the sample size used was relatively larger. 5.6 Need factors associated with Utilization of Dental Services With regards to the needs factors (Personal decision to visit dental facility, Duration of dental condition, fear of pain during dental treatment, fear of bleeding during dental treatment, and cultural means to manage dental condition) measured in this study, none of them showed significant association with dental services utilization in the multivariate analysis. 69 University of Ghana http://ugspace.ug.edu.gh However, Personal decision to visit dental facility was significant in the bivariate analysis. The odds of adequate dental service utilization was reduced by 58% among respondents who did not visit dental services by their own decision compared to those who indicated that they visited the dental facilities by their own volition. These findings of lack of statistically significant association differs from literature that have stated associations between such factors and dental utilization. Although the variable ‘Cultural means to manage dental condition’ did not show statistically significant association with utilization, Some researchers argue that any programme must take into consideration socio-cultural context of the population as cultural practices and traditional beliefs could be a negative factor contributing to services utilization (Butani, 2008). Some individuals often use herbal preparations for cure, and when complications such as dental abscess and cerebral abscess set in, they would then rush in to the hospital. All these could be better appreciated, when health is studied under one’s socio-cultural context. According to Butani et al (2008), many cultural groups lack strong preventive orientation in relation to oral health. Perhaps at the Hawa Hospital patients simply did visit dental unit for other reasons rather than the use of cultural means to manage their dental challenges. Thus most of the dental patients did not resort to cultural means in managing their dental conditions. 5.6.1 Knowledge factors associated with utilization of dental services Knowledge factors (Knowledge of expected number of visits, visit to other dental facilities within the past year) did not show any significant association with the utilization of dental services. However, literature from other studies have documented that people with adequate knowledge often patronize dental service as compared to those who have little or no knowledge of the 70 University of Ghana http://ugspace.ug.edu.gh existence of dental services and even if they do, still have little or no knowledge of its availability in their catchment area as well as the benefits associated with regular dental visitations (Herkrath et al., 2018). A similar assertion was made in another study (Survashe et al, 2018). They stated that recognizing the benefits of routine dental visits often precipitated the need to regularly visit a dentist (Survashe et al, 2018). 71 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 6.0. Introduction This chapter presents the summary based on the general objective, conclusions based on the specific objectives, contribution to knowledge and recommendations arising out of the findings, limitation to the entire study and suggestions for future research. There are 5 sections under this chapter. Section one presents the summary of the study. Section two presents the conclusions of the study. Section three presents the contribution of the study to knowledge. Section four presents the recommendations of the study. Limitations to the study are presented in section five. Section six presents the future research. 6.1. Summary of the study This section presents the summary of findings in the study based on the general objective. The general objective of the study was to assess barriers and enablers to utilization of dental services at Hawa Memorial Saviour Hospital, Osiem, East Akim Municipality-Eastern Region of Ghana. A quantitative research method was applied where 113 patients who were attending dental unit in the hospital responded to a structured questionnaire. Generally, the findings of the study showed that dental service utilisation (2 or more per year) was low, revealing also that, amount paid out of pocket was associated with significant reduction in utilization. Cost was stated as the commonest reason for not utilizing dental services at the hospital by respondents. Prior knowledge of existence of the dental facility at the Hawa hospital significantly predicted utilization. 72 University of Ghana http://ugspace.ug.edu.gh 6.2. Conclusions of the Study This section presents the conclusions of the study based on the specific objectives, which were: to determine the proportion of patients who adequately utilize dental services; to determine enabling factors influencing utilisation of dental services among; to determine barriers to the utilization of dental services at the Hawa Memorial Saviour Hospital. The following discussed conclusions have been set around these objectives accordingly. 6.2.1. Proportion of patients utilizing dental services The study found and concludes that, proportion of dental service utilization is lowat Hawa Memorial Saviour Hospital. This finding agrees with that of Vignesh et al, (2012) and Ambika et al, (2015), but differs from that Nasseh et al, (2015) which concluded higher dental service utilization. 6.2.2. Socio-demographic characteristics (Predisposing factors) The study concluding on the basis of the Predisposing factors (socio-demographic characteristics) showed that age, level of education, , marital status, occupation, , religion, and income were not significantly associated with dental service utilisation. These findings differ from earlier studies that have shown associations (Chou et al, 2011; Poudyal et al, 2010). Studies have shown varying associations between the various demographic factors and utilization of dental service (Herkrath et al, 2018; Bhushan et al. 2012). 73 University of Ghana http://ugspace.ug.edu.gh 6.2.2. Enabling factors The study found and concludes that, factors on Availability, Staff attitude, and Environment did not significantly predict dental services utilization. This conclusion has some similarities with earlier findings (Kanyi et al, 2010; Kikwilu et al, 2008). The study also found and concludes that factors that touched on Affordability, Accessibility significantly predicted dental services utilization. Respondents who had prior knowledge of the existence of dental facilities had significantly higher odds of utilizing dental services two or more times compared to those who did not know about the existence of dental facilities. Awareness of the existence is an enabler of adequate utilization. 6.2.3. Barriers to dental service utilization This study also concludes that, increase in cost is a fundamental barrier to dental service utilization. A GH¢1 increase in the amount paid out of pocket for dental services, significantly reduces the odds of utilization of dental services. Others studies also documented cost as barriers (Jain et al, 2013; Bommireddy et al, 2016) 6.3. Contributions to Knowledge This section presents the study contribution to knowledge in respect of policy, practice and management of healthcare institutions and research methodology. 74 University of Ghana http://ugspace.ug.edu.gh 6.3.1. Contributions to policy, practice and management of healthcare institutions The study makes a significant contribution to policy, practice and management of healthcare institutions, especially the private not for profit health facilities in Ghana and elsewhere. It would be recalled that World Health Organisation (2010), has put in place different policies that are focused on oral health care and its utilization in the world. However, it should be noted that the implementation of such policies are usually affected by some context specific factors, including those found in this study. Even as health policy makers in Ghana are making strategic efforts to ensure improved health, there are equally some challenges that private healthcare institutions, especially the not-for-profit ones face. 6.3.2. Contributions to research methodology The study makes some contribution to methodology since there are some strengths therein. This study is the first on dental service utilization conducted in the Hawa Memorial Saviour Hospital. The study used a facility-based cross-sectional design to collect empirical data for analysis. The target population consisted of Patients aged 18years and above assessing dental services at Hawa Memorial Saviour Hospital. The administered questionnaire enabled the successful collection of data on potential confounders, which were accounted for in the analysis. The application of the quantitative method enabled the researcher to quantify the results of the study. This would not have been possible if the qualitative method had been applied. Bryan (2012) reported that larger sample sizes make conclusions from quantitative research more generalizable. Statistical methods applied in the analysis make them reliable (Rahman, 2017). The findings in this study can be compared with other quantitative findings because of the systematic, standardized nature of quantitative outcomes. 75 University of Ghana http://ugspace.ug.edu.gh 6.4. Recommendations of the study This section presents the recommendations of the study for consideration by policy makers, healthcare practitioners and management teams of healthcare institutions. That is to show that the study makes some recommendations based on the findings for consideration by health policy makers, management of healthcare institutions and other stakeholders in the healthcare environment. 1. The management and staff at the Hawa Memorial Saviour Hospital should create awarenessof existence dental services at the Hawa Hospital by way of community outreach and screening programmes. 2. Health professionals at the Hawa Memorial Saviour Hospital must educate their customers on the need to utilize dental services more regularly. 3. The management of Hawa Memorial Saviour Hospital should take steps on having a policy that considers holistic dental care as part of primary health care covered by the National Health Insurance or other private insurance. 6.5. Limitations to the study This section presents the study’s limitations. Thus, the study encountered some limitations, which have to be brought to the fore so as to enable future researchers to see how they could address them. Associations found in this study could not be deemed to be causal since the study was cross- sectional. The number of dental care visits was measured by self-reporting.It is well documented that self-reporting is liable to response bias (Van de Mortel, 2008). Due to a small sample size, some variables that would have shown associations may not have shown associations with dental 76 University of Ghana http://ugspace.ug.edu.gh service utilisation. Conducting this study at the HMSH has limited the conclusions to just the facility. Such incidences are therefore, considered to be limitations to this study. 6.6. Future research This section presents the areas of research that future studies could look at. That is, based on the limitations to the study, the following areas are suggested for future researchers to consider in their endeavours. Further research could be done in the East Akim Municipal using many facilities with a large sample size. These studies could be done comparing estimates of dental services utilization in both public health and private facilities. 77 University of Ghana http://ugspace.ug.edu.gh REFERENCES Aday, L. A., Andersen R. M. (2014). Health Care Utilization and Behavior, Models of. 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Integrating the common risk factor approach into a social determinants framework. Community Dent Oral Epidemiol. 40(4):289–296. WINNIE W. KANYI, (2010). Factors influencing utilization of dental conservation methods in adults in Gatanga division Thika district, Kenya. WHO, (2012). WHO | Oral health. Retrieved from http://www.who.int/mediacentre/factsheets/fs318/en/. World Health Organization. (2015). Health in all policies: training manual. Geneva. World Health Organization World Oral Health Report. (2012). Retrieved from https://www.fdiworlddental.org/events/world- oral-health-forum/2012-world-oral-health- forum/ 85 University of Ghana http://ugspace.ug.edu.gh APPENDICES SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA APPENDIX A: Consent Form Participant My name is Samuel Adusei. I am a graduate student from the School of Public Health, College of Health Sciences, University of Ghana, undertaking a research on ‘Enablers and Barriers to utilization of dental services at Hawa Memorial Saviour Hospital, East Akim Municipality, Eastern region, Ghana. Purpose of the study The study seeks to find out the various factors that serve as barriers and enablers to the use of dental services in the chosen facility. Participants are required to share their experiences by responding to questions. Potential Risks / Benefits Be assured that the research come at no risk and no cost except the precious time that you will use to fill the questionnaire. Privacy / confidentiality Personal information that will make you identifiable will not be included in the questionnaire. The questionnaires that clients will respond to will be anonymous (will not bear names of participants) so you will not be identified. Be assured that your privacy and confidentiality will be respected. Data storage You are assured that the information gathered will be kept by the principal investigator and used to assess the facility and any amendment needed to be instituted to help provide better health care. 86 University of Ghana http://ugspace.ug.edu.gh The data will be stored on devices such as compact disks (CDs) and memory sticks for reference purposes. The data would be discarded after a period of five years. Voluntary Agreement Voluntary withdrawal and compensation You are free to be part of the study and decide to leave at any point you want. No one will be upset if you decide not to partake in the study. You can choose a place of convenience to answer the questions. Dissemination of results Results released will be disseminated to all parties involved in a professional manner without exposing certain confidential messages without the consent of the participant. Participant’s Consent The above document describing the benefits, risks and procedures for the research titled ‘Enablers and Barriers to Utilization of Dental Services at Hawa Memorial Saviour Hospital, Osiem- E/R’ has been explained to me. I have read or have had someone read all of the above, asked questions, received answers regarding participation in this study, and am willing to give my consent to participate in this study as a participant. Date Name and Signature/Thumbprint of patient Statement by Person taking consent I certify that the nature and purpose in this research have been duly explained to the above individual. Date Name and Signature of Person Who Obtained Consent Contacts for Additional Information 87 University of Ghana http://ugspace.ug.edu.gh If you have any further clarification, contact: Address Hawa Memorial Saviour Hospital, Box 1. East Akim, Osiem. Telephone Number: 0245164424. Email Address: Samuelamponsem1@gmail.com In case of any concern, you can contact the Ethics Administrator, Ms. Hannah Frimpong, GHS/ERC on 024-599-7061. 88 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: Questionnaire TOPIC: ENABLERS AND BARRIERS TO UTILIZATION OF DENTAL SERVICES AT HAWA MEMORIAL SAVIOUR HOSPITAL, EAST AKIM, EASTERN REGION OF GHANA. Introduction This research is meant for academic purposes. The aim of the study is to determine the Enablers and Barriers to utilization of dental services among patients assessing dental services in Hawa Memorial Saviour Hospital. You are kindly requested to provide answers to these questions as honestly and precisely as possible. Responses to these questions will be treated as confidential. Section Predisposing factors (socio-demographic) A Question Response 1 Age of respondent… (As at last birthday) 2 Sex 1. Male 2. Female 3 Marital status 1. Never married 2. Married 3. Living together 4. Divorced/ separated 5. Widowed 4 What is your employment status? 1. Unemployed 2. Self employed 3. Public Sector 4. Private Sector (formal) 5. Student/Apprentice 5 What is your current level of education? 1. No education 89 University of Ghana http://ugspace.ug.edu.gh 2. Primary 3. Middle school/JSS/JHS 4. SSS/SHS/Vocational 5. Tertiary 6 What is your religious affiliation? 1. Christian 2. Muslim 3. Traditionalist 4. Other specify 7 What is your monthly income in GH₵? GH ₵……………………. Section Enabling factors B Accessibility Question Response 8 How far is the facility from home? (in kilometres) ………………………..km 9 How far is the facility from home? (in minutes/hours) ……………min/………….hours 10 What means of transport do you use when accessing the dental facility? 1. Walk 2. Public transport 3. Private transport 11 Were you aware of the existence of this dental clinic? 1. Yes 2. No 90 University of Ghana http://ugspace.ug.edu.gh 12 What was your source of information on dental care? 1. Friends and Relatives 2. During a visit to health institution 3. Media 4. Others Affordability 13 Are you able to pay for dental services? 1. Yes 2. No 3. Sometimes 14 By what means do you pay for services? 1. NHIS 2. Private Insurance 3. Out of pocket 4. Insurance and out-of-pocket 15 How much do you pay out-of-pocket for dental services GH₵…………………….. 16 What type of services do you pay for out-of pocket? 1. Consultation 2. Diagnosis 3. Surgery 4. Review 5. Post-op 6. Others 17 How much do you pay for health insurance (Private or NHIS?) GH₵…………………… Environment/ Provider factors 18 Is the dental clinic envi ronment clean? 1. Yes 2. No 19 Is the environment nois y? 1. Yes 2. No 91 University of Ghana http://ugspace.ug.edu.gh 20 Is the place attractive fo r dental visitation? 1. Yes 2. No 21 Were the staff friendly, humane and with good communication skills? 1. Yes 2. No 22 In your opinion, did the doctor possess requisite skills to treat you? 1. Yes 2. No 23 Did the doctor or nurse explain your procedure or condition to you? 1. Yes 2. No 24 What is your perception of quality of care rendered to you in the clinic? 1. Good 2. Poor 3. Fair 25 Have you suffered any post-op complication following dental procedure in this facility? 1. Yes 2. No 26 If yes, what post-op complication was it? 1. Bleeding 2. Pain 3. Swelling 4. Infection 5. Other 27 Are you likely to recommend the dental facility to anyone? 1. Yes 2. No Section Need factors C 92 University of Ghana http://ugspace.ug.edu.gh 28 Did you decide to visit the dental facility by yourself? 1. Yes 2. No 29a If no, who then informed your decision to visit the dental clinic? 1. Relatives 2. Friends 3. Others 29b If yes, what condition brought you to the facility? 1. Bad breath 2. Broken teeth 3. Gum disease 4. Toothache 5. Painful swelling 6. Missing teeth 7. Mouth sore 8. Painless swelling 29c For how long have you had this condition? 1. less than 3 weeks 2. more than 3 weeks 30 What type of treatment did you receive 1. Cleaning 2. Dentures 3. Extraction 4. Filling 5. Medication 31 Do you have any fear of pain during dental treatment? 1. Yes 2. No 32 Do you have any fear of bleeding from the gum in the process of receiving treatment? 1. Yes 2. No 93 University of Ghana http://ugspace.ug.edu.gh 33 Do you use any other cultural means other than orthodox to manage your dental conditions? 1. Yes 2. No 33a If yes, indicate what cultural means a. Concoctions or herbal preparations b. Don’t do anything c. Others Section Utilization of dental services D 34 What is the number of dental visits expected of an individual in a year? 1. Every 6 months 2. Annually 3. Once in your life time 4. Others 35 What are some of the benefits of routine dental care? Can choose more than one answer 1. Improves oral hygiene 2. Reduces dental caries 3. Prevents dental complications 4. Time wasting 36 Have you ever visited this facility for dental services in the past year? 1. Yes 2. No 37 How many times have you visited this dental clinic in the past year? 38 Have you ever visited other facilities for dental services in the past year or two? 1. Yes 2. No 94 University of Ghana http://ugspace.ug.edu.gh 39 What factors will positively influence (enablers) you to visit a dental facility? 1. Pre-existing/chronic dental condition 2. Clean hospital environment 3. Friendly staff attitude 4. Knowledge and capability of staff 5. Aware of importance of dental hygiene 6. Routine dental check up 40 What factors will positively influence (enablers) you to visit a dental facility? 1. Pre-existing/chronic dental condition 2. Clean hospital environment 3. Friendly staff attitude 4. Knowledge and capability of staff 5. Aware of importance of dental hygiene 6. Routine dental check-up 7. Others 41 What factors will positively influence (enablers) you to visit a dental facility? 1. Pre-existing/chronic dental condition 2. Clean hospital environment 3. Friendly staff attitude 4. Knowledge and capability of staff 5. Aware of importance of dental hygiene 6. Routine dental check-up 7. Others 42 What factors will negatively influence (barriers) you not to visit a dental facility? 1. Fear 2. Cost 3. Shyness 4. Distance to facility 5. Poor attitude of staff 6. Unfriendly hospital environment 7. Others 95 University of Ghana http://ugspace.ug.edu.gh 43 What factors will negatively influence (barriers) you not to visit a dental facility? 1. Fear 2. Cost 3. Shyness 4. Distance to facility 5. Poor attitude of staff 6. Unfriendly hospital environment 7. Others 44 What factors will negatively influence (barriers) you not to visit a dental facility? 1. Fear 2. Cost 3. Shyness 4. Distance to facility 5. Poor attitude of staff 6. Unfriendly hospital environment 7. Others 96 University of Ghana http://ugspace.ug.edu.gh 45 Do you or any household member own any of the following assets? 1 Yes, 2 is No 1. Electricity 1 2 2. Wall clock 1 2 3. Radio 1 2 4. Car 1 2 5. Television 1 2 6. Mobile phone 1 2 7. Land line telephone 1 2 8. Refrigerator 1 2 9. Freezer 1 2 10. Generator/invertor 1 2 11. Washing machine 1 2 12. Computer/tablet 1 2 13. Photo camera 1 2 14. Video deck/dvd/vcd 1 2 15. Sewing machine 1 2 16. Bed 1 2 17. Table 1 2 18. Cabinet/cupboard 1 2 19. Internet access 1 2 20. Motor cycle 1 2 97