Community Dent Oral Epidemiol 2012; 40: 297305 All rights reserved

2012 John Wiley & Sons A/S

Demand for and utilization of dental services according to household income in the adult population in Norway
Grytten J, Holst D, Skau I. Demand for and utilization of dental services according to household income in the adult population in Norway. Community Dent Oral Epidemiol 2012; 40: 297305. 2012 The John Wiley & Sons A S Abstract Objectives: The aim of this study was to describe the effect of income on demand and utilization of dental services according to household income in the adult population. Methods: The data were collected using a questionnaire, which was sent to a random sample of Norwegians aged 20 years or older living at home, 1861 persons in total. Demand was measured according to whether the person had been to the dentist during the last year. Utilization was measured as expenditure for dental treatment for those who had been to the dentist during the last year. The independent variables were the respondents household income, age, gender, education, dental status and the mean fee for a dental consultation in the municipality. In the rst stage, we carried out a logistic regression analysis of the log odds of having demanded dental services during the last year. In the second stage, we carried out a multiple regression analysis of expenditure for dental treatment for those who had been to the dentist during the last year. Results: Altogether, 80% of the respondents had been to the dentist during the last year. Demand during the last year varied most according to dental status. There was little difference between men and women. The results of the logistic regression showed that the probability of having been to the dentist was 0.82 for those with a household income of 25 000 and 0.85 for those with a household income of 100 000. Mean expenditure for dental treatment was 355. There was no statistically signicant relationship between household income and expenditure for dental treatment. Conclusions: Differences in demand for dental services according to household income are small, and there are no differences in utilization according to income. The ndings are interesting, because in a population in which people have to pay almost all the costs for dental treatment themselves, one would expect the income differences in demand and utilization to be greater.

Jostein Grytten, Dorthe Holst and Irene Skau

Department of Community Dentistry, University of Oslo, Oslo, Norway

Key words: demand; dental services; household income; inequalities; utilization Jostein Grytten, Department of Community Dentistry, University of Oslo, Post Box 1052, Blindern, 0316 Oslo, Norway Tel.: +47 22 84 03 87 Fax: +47 22 84 03 03 e-mail: josteing@odont.uio.no Submitted 18 October 2010; accepted 4 December 2011

A fundamental research question relating to dental services and health services is whether services should be subsidized. The arguments put forward in favour of public health insurance in the health care market, including the dental care market, have been discussed by Evans and Williamson (1). Basically, public health insurance has four objectives. These are: (i) reduction in nancial risks
doi: 10.1111/j.1600-0528.2011.00659.x

resulting from the possibility of illness and need for services; (ii) improvements in oral health resulting from increased level of utilization; (iii) increased efciency of dental care delivery and (iv) reduction in inequalities in access to dental care. The present study focuses on the latter issue: inequalities in access to dental services among adults in Norway. Subsidized dental care is

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justiable if there are inequalities in access to the services according to peoples income (1, 2). The international studies provide inconclusive results (3). Most studies were carried out in the USA in the early or mid-1960s. A common nding was that number of dental visits increased as income rose (47). Also, the elasticity for dental visits with respect to income was >1, implying that dental care is a luxury good (2, 5). However, it has been argued that limited condence should be placed on the results from these studies (810). The results are unreliable mainly because of specication errors and underidentied demand curves (for a review see 911). In addition, the studies were carried out so long ago that the results cannot necessarily be generalized to dental services today. Most of the later studies have been performed within insured American populations. Not surprisingly, these studies found a low elasticity (below 0.10) for demand with respect to family income (1214). There are few studies from the last 2 to 3 decades in which accessibility to dental care in noninsured populations has been examined. However, the studies that have been carried out show mixed results. Some show either no effect (15) or only a small effect of income on accessibility (6, 1624), while some show a fairly large effect (2530). In the present study, the effect of income on demand and utilization of dental services in the adult population was examined. The results are of particular relevance with respect to whether dental care should be subsidized by the state or not. A high income elasticity can be used as an argument for more public nancing of dental services (1, 2). This is particularly the case if dental care can be classied as a luxury good, as indicated by some of the studies from the USA between the 1960s and 1970s. This research question is particularly relevant, because in Norway, there is neither public nancing nor private insurance arrangements for dental treatment for adults. Adults pay virtually all the cost of dental treatment themselves. This is very different from the situation in neighbouring countries. For example, in Sweden, and now also in Finland, there are extensive public insurance arrangements for dental treatment. Our null hypothesis is that the income elasticity in Norway is zero. The alternative hypothesis is that the income elasticity is different from zero and positive. We focus on factors related to the demand side of the dental care market and not the supply side. This is appropriate, because the supply side has

been widely investigated in several other studies of the dental care market in Norway, in particular research questions related to supplier-induced demand (3133).

Material and methods

Data
The data were collected using a postal questionnaire developed in the autumn of 2008, which was sent by TNS Gallup to a sample of Norwegians aged 20 years or older living at home, 1861 persons in total. The sample is representative of the adult Norwegian population, with the exception of people who live in institutions (such as nursing homes and hospitals). This latter group is not represented in the sample. The sample fraction is 0.05%. The sample was obtained in the following way. The adult Norwegian population was rst stratied according to age, gender and place of residence. Within each stratum, a proportional and random sample of persons was drawn to select enough respondents, in this case 1861 persons (for further details see TNS Gallups web site: (http:// www.tns-gallup.no). This was not the type of sample for which it was appropriate to give a drop-out rate. When people in the population did not want to be in the sample, TNS Gallup selected more persons at random until the sample contained the required number of people (n = 1861). Much work was carried out to make the sample as representative of the adult population as possible. So the representativeness of the sample was extremely good (Table 1). The distribution of the sample according to gender, age and place of residence was about the same as the distribution in the population (Table 1). To improve the representativeness of the sample even further, it was weighted. The distribution of the population according to gender, age and place of residence was used to construct the sampling weights.

Variables
We distinguished between demand and utilization of dental services. Demand is a patient-initiated process, where an individual identies a dental care need and seeks dental care to meet that need (34). We assume that whether one goes to the dentist or not, and which dentist one actually goes to (demand), is a decision that consumers make

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Household income and utilization in Norway Table 1. Description of the sample and representativeness in relation to the population per cent 20 years and oldera Gender Women Men Age 2029 years 3039 years 4049 years 5059 years 6069 years 7079 years 80 years Place of residence (region) Eastern Norway Southern Norway Western Norway Trndelag Northern Norway Size of the municipality <2000 inhabitants 20005000 inhabitants 500010 000 inhabitants 10 00030 000 inhabitants 30 000 inhabitants
a

Sample (n = 1861) 51.2 48.8 16.0 20.3 20.4 18.3 15.0 7.2 2.8 50.1 5.5 25.1 9.1 10.3 2.8 9.4 12.5 28.9 46.4

50.6 49.4 16.7 19.1 19.3 17.0 13.6 8.1 6.2 50.6 5.6 25.5 8.7 9.6 2.5 9.6 12.8 28.8 46.4

Sources: Statistics Norway population statistics and Norwegian Social Science Data Services municipalities database. Data as per 1 January 2009.

themselves. Utilization is a process in which a patient uses dental services in a way that is determined by decisions arrived at jointly by herself himself and the dentist. In practice, this is a decision that the patient usually delegates to the dentist. The dentist is the patients agent. As a measure of demand, we used whether a person had been to the dentist during the last year. Utilization was measured as expenditure for dental treatment for those who had been to the dentist during the last year (35). Our distinction between demand and utilization is based on the way Stoddart and Barer (34) made this distinction in their studies of medical services in 1981. In 1985, Yule and Parkin (10) argued that this distinction would also be appropriate for dental services. In the following years, demand and utilization were distinguished in studies of the Norwegian and Finnish market for dental services (6, 24). This distinction is primarily important in empirical studies. Classical demand variables, such as household income, gender, age and dental status, have strong effects on demand but weak effects on utilization (for example, see references 6, 36). The distinction between demand

and utilization was not taken into account in the rst studies of consumption of dental services between the 1960s and 1970s. The dependent variable in these studies was most often number of dental visits per year, which is a measure of both demand and utilization. Several researchers have also criticized these studies for specication errors and biased results, which resulted in an incorrect estimation of the effects of household income on consumption of dental services (911). TNS Gallup collected the following background information about each respondent: gender, age, level of education, household income and dental status. The respondents were classied according to whether they had no remaining teeth left (reference category), 19 teeth, 1019 teeth and 20 teeth or more left. Previous studies have shown that self-reports of number of teeth and expenditure for dental services are reliable (3740). Variable denitions and descriptive statistics are presented in Table 2. The nonitem response rate for the independent variables is reported in Table 2, last column. The nonresponse rate for number of remaining teeth and household income is slightly lower than for the other variables. Fees for dental care are not the same everywhere in Norway. Therefore, we included an additional variable in the analyses to control for differences in fees in different market areas (municipalities). This variable measures the mean fee for a dental consultation in each municipality. Information was collected from each dental practice and aggregated to the level of the municipality. There are 430 municipalities in Norway. Data were collected by the Institute of Community Dentistry, University of Oslo in December 2006 (for further details about sampling procedures and the representativeness of the data, see references 33 and 41).

Analyses
The data were analysed according to a two-part model. Existing research shows that this method of analysis gives reliable and unbiased results (42, 43). In the rst part of the model, logistic regression was used to study demand for dental services. This is an appropriate analysis for dichotomous dependent variables (44). The outcome measure in a logistic regression analysis is the log odds. The odds is a fraction where the numerator is dened as the probability of having been to the dentist, and the denominator is dened as not having been to the dentist. In the second part of the model, multiple regression analysis was used in the

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Grytten et al. Table 2. Variable denitions and descriptive statistics Variables Demand Expenditure Household income Low household income Middle household income High household income Male Age 2029 Age 3044 Age 4559 Age 60 Compulsory school Secondary school University college No teeth 19 teeth 1019 teeth 20 teeth Consultation fee Denition 1 if demanded dental services during the last year, 0 otherwise Expenditure for dental services during the last year for those who have visited the dentist, in Respondents household income during the last year, in 1000 1 if respondents household income during the last year was 25 000 1 if respondents household income during the last year was in the range 25 001 125 000 (=reference category) 1 if respondents household income during the last year was >125 000 1 if man 1 if respondent between 20 and 29 years 1 if respondent between 30 and 44 years 1 if respondent between 45 and 59 years 1 if respondent 60 years and older (=reference category) 1 if respondent has compulsory school education (=reference category) 1 if responendent has upper secondary school education 1 if respondent has university college education 1 if respondent has no remaining teeth (=reference category) 1 if respondent has 19 remaining teeth 1 if respondent has 1019 remaining teeth 1 if respondent has 20 remaining teeth Mean dental fee for a consultation within the municipality, in Mean (SD) 0.80 355 (925) 92 (124) 0.13 Number of respondents 1861 1447 1720 1720

0.09 0.49 0.16 0.31 0.28 0.18 0.09 0.04 0.51 0.02 0.03 0.05 0.90 68 (7)

1720 1861 1859 1859 1859 1859 1847 1847 1847 1772 1772 1772 1772 1861

analysis of expenditure for those who had been to the dentist during the last year. In both analyses, we used the log of household income and the log of expenditure for dental treatment. The regression coefcients then represent the elasticity of household income with respect to demand for and utilization of dental services (45). To simplify the results from the logistic regression analyses, we calculated the predicted probabilities for having been to the dentist for different income groups. This was done by recalculating the log odds into probabilities (44). We carried out additional analyses where we tested for nonlinear effects of household income. We were particularly interested in testing whether the effect of household income was different for those who belonged to the lower or upper tail of the income distribution compared with those who belonged to the middle-income distribution. If those in the lowest income group demanded less dental care than those in the middle-income groups, this can be interpreted as a poverty effect. We dened the poverty group as those

with a household income of 25 000. The reference group was those who had a household income within the range 25 001 to 125 000. Those with an income above 125 000 belonged to the upper tail of the income distribution. Age, gender, education, dental status and the mean fee for a consultation were included as control variables. All models were estimated using multilevel analyses to take into account the clustering of respondents within municipalities. The results reported in Tables 4 and 5 are from analyses performed on the sample where weights were used. To test the robustness of our ndings, we report, in the text only, the size and the level of statistical signicance of the regression coefcient for household income from the analyses where the weight variable was not used. The data were analysed using the computer program Statistical Analysis Software (SAS Institute Inc., Cary, North Carolina). The logistic regression analyses were carried out using the procedure proc glimmix, while proc mixed was used for the multiple regression analyses.

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Results
Demand and utilization according to background characteristics
Table 3 shows the proportion of the adult population that had been to the dentist during the last 12 months according to the background characteristics of the respondents. While there was little difference between women and men, the table shows that the proportion who had been to the dentist was smallest for the youngest adults. There was little difference in visits during the last year according to education. For the lowest income group, 72% had been to the dentist during the last year, compared with 86% for the highest income group. Dental status was the factor that created the largest variation in the proportion that had been to the dentist during the last 2 years. For edentulous people, 46% had been to the dentist during the last year. For people with 1019 of their own teeth, 88% had been to the dentist during the last year. Eighty per cent of the adult population had visited the dentist during the last year (Table 2). On average, the adult population had expenditure for dental treatment of 355 for the last year. There

was little difference according to gender, but large differences according to age (Table 3). Adults 60 years and older had three times higher expenditure than those who were young. On average, those with lower education had higher expenditure than those with higher education. Expenditure varied more with education than with income. With regard to dental status, those with fewer than 20 remaining teeth, but who were not edentulous, had 23 times higher expenditure than those with 20 remaining teeth or more.

Income elasticities for dental services

In the logistic regression analysis, in which we studied the relationship between the log of household income and the log odds for having demanded dental care during the last year, the regression coefcient was 0.17 and statistically signicant at the conventional level (P 0.05) (Table 4). Owing to the log transformation of household income, this regression coefcient can be interpreted as the elasticity of household income with respect to demand for dental services. This result is based on the analyses where the weight variable was used. The corresponding coefcient where the weight variable was not used was 0.22

Table 3. Proportion of respondents who have demanded dental services during the last year and their mean expenditure for dental services in , according to background characteristics of the respondents Proportion who have demanded dental services during the last year 83.2 77.0 66.8 76.4 86.6 0.86 74.0 79.8 82.0 71.5 83.8 81.8 76.5 86.1 85.6 45.7 71.1 87.8 81.0 Mean expenditure for dental services during the last year () 346 363 168 240 429 485 706 331 300 320 428 340 350 298 289 325 843 1046 287

n Gender Women Men Age 2029 years 3044 years 4559 years 60 years Education Compulsory school Upper secondary school University high school Total household income 25 000 25 00150 000 50 00175 000 75 001100 000 100 001125 000 >125 000 Dental status No remaining teeth 19 remaining teeth 1019 remaining teeth 20 remaining teeth 985 876 214 511 555 579 178 736 933 212 382 386 363 226 151 34 52 102 1584

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Grytten et al. Table 4. Regression coefcients for demand for dental services. Logistic regression with random effects and sample weights. Multilevel analyses Household income continuous variable Condence interval for the odds ratio 1.011.39 0.520.88 0.130.34 0.220.52 0.461.13 0.481.26 0.721.28 1.1611.04 1.6112.28 2.6115.02 0.243.73 Household income dummy variables Condence interval for the odds ratio 0.441.05 0.882.43 0.510.87 0.140.35 0.220.52 0.461.13 0.481.27 0.721.26 1.2011.39 1.6312.50 2.6215.13 0.243.69

Independent variables Household income (log) Low household income High household income Male Age 2029 Age 3044 Age 4559 Compulsory school Upper secondary school 19 teeth 1019 teeth 20 teeth Consultation fee (log) Concordant value n *P 0.05. Reference Reference Reference Reference group group group group

Logit coefcient (standard errors) 0.17 (0.08)* )0.39 )1.54 )1.08 )0.33 )0.25 )0.04 1.28 1.49 1.83 )0.05 67.4 1652 (0.13)* (0.24)* (0.22)* (0.23) (0.25) (0.14) (0.57)* (0.51)* (0.44)* (0.70)

Odds ratio 1.18 0.68 0.21 0.34 0.72 0.78 0.96 3.58 4.44 6.25 0.95

Logit coefcient (standard errors) )0.39 0.38 )0.40 )1.51 )1.07 )0.32 )0.24 )0.04 1.30 1.50 1.83 )0.06 67.3 1652 (0.22) (0.25) (0.13)* (0.23)* (0.21)* (0.23) (0.24) (0.34) (0.57)* (0.51)* (0.44)* (0.70)

Odds ratio 0.67 1.46 0.66 0.22 0.34 0.72 0.78 0.95 3.69 4.51 6.29 0.93

age: 60. education: university college. dental status: no remaining teeth present. household income: 25 001- 125 000.

(P 0.01). Based on the results where the weight variable was used, we calculated the predicted probabilities for having been to the dentist for the different income groups. Given a household income of 25 000, the probability for having been to the dentist was 0.82. Given a household income of 100 000, the probability increased to 0.85. As the income groups we have chosen in this example are close to the outer limits of the income distribution, they almost represent the maximum difference in demand according to household income. We did not nd a poverty effect of household income. The logit coefcient for those with a middle household income was not statistically signicant different from those with a low household income. Further, the logit coefcient for those with a high household income was not statistically signicantly different from those with a middle household income. The other results shown in Table 4 generally support the descriptive results shown in Table 3. Women go the dentist more often than men, younger people less often than older people and those who have their own teeth go more often than those who are edentulous. Table 5 shows the effect of the explanatory variables on expenditure for dental treatment for

those who had been to the dentist during the last year. Again, the results shown in Table 5 generally support the descriptive results shown in Table 3. An important nding is that the income elasticity is low and not statistically signicant at the conventional level (P 0.05). This was the case both for the analyses where the weight variable was used and not used. The regression coefcient for those with a middle household income was not statistically signicantly different from those with a low household income, that is, there was no poverty effect. Further, the regression coefcient for those with a high household income was not statistically signicantly different from those with a middle household income. Older people have higher expenditure than younger people, and edentulous people have higher expenditure than people who have their own teeth.

Discussion
The results show that a large proportion of the adult population has been to the dentist during the last twelve months. This is in accordance with studies from Norway and from the other Nordic countries. Household income has a small, but

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Household income and utilization in Norway Table 5. Regression coefcients for expenditure for dental services. Ordinary least square regression with random effects and sample weights. Multilevel analyses Household income continuous variable Independent variables Household income (log) Low household income High household income Male Age 2029 Age 3044 Age 4559 Compulsory school Upper secondary school 19 teeth 1019 teeth 20 teeth Consultation fee (log) R2 n *P 0.05. Reference Reference Reference Reference group group group group Regression coefcient (standard errors) 0.005 (0.04) 0.10 )0.40 )0.19 0.03 0.26 )0.03 )0.43 )0.33 )0.82 0.32 0.06 1242 (0.06) (0.10)* (0.08)* (0.08) (0.11)* (0.06) (0.36) (0.33) (0.31)* (0.31) Household income dummy variables Regression coefcient (standard errors) )0.06 )0.03 0.09 )0.39 )0.19 0.03 0.26 )0.03 )0.41 )0.32 )0.82 0.31 0.06 1242 (0.11) (0.09) (0.05) (0.10)* (0.07)* (0.07) (0.10)* (0.06) (0.36) (0.33) (0.31)* (0.31)

age: 60. education: university college. dental status: no remaining teeth present. household income: 25 001- 125 000.

statistically signicant effect on demand, but not on utilization. This is in line with much of the international literature from the last 10 to 20 years, which shows that the income elasticity for dental services is low (1214, 1624). When elasticities are low, this means that consumers demand for dental services is not inuenced very much by changes in household income. In microeconomic terminology, this means that dental services can be regarded as essential goods, that is, if income is reduced, the reduction in demand and utilization is proportionately less. In Norway, a substantial increase in the income level of the population is expected in the future, because of high revenue from the production of oil and gas (46). Our results indicate that the growth in the demand for dental services and utilization of dental services will be substantially lower than could be expected in relation to the increase in the income of the population in the future. In other words, dental services will be given less priority than other goods and services. It is interesting that we nd such low-income elasticities in a population in which there is no public or private insurance for dental services. There can be three reasons for this. First, income differences in the Norwegian population are relatively small, which is reected in the correspondingly small differences in demand for dental services according to income group (47). Second,

more than three quarters of the population goes regularly to the dentist at least once a year (48). This is a result of the fact that there has been an adequate supply of dentists since the 1980s. With regular dental visits, dental disease can be detected at an early stage and treated before the damage has become extensive. This also means that the costs for treatment will not be too great. This is supported by the result that 80% of those who have been to the dentist during the last year in our sample had expenses under 375. This is a manageable amount, even for those who are in the lowest income group. Third, free dental care in childhood has probably contributed to better oral health in adulthood. In Norway, well over 90% of children and young people under 19 years of age receive regular appointments with a public dentist or a dental hygienist (49). All their dental treatment is free, and they receive information and guidance about how to prevent dental disease. This means that positive dental behaviour can be established early in life, which helps to ensure good dental health in adult life. Two per cent of the adult population in Norway is edentulous (Table 2). This may be due to a poverty effect that originated decades ago. The majority of edentulous people in Norway are 70 years or older. They had their teeth extracted at a time in the 1950s and 1960s when there was

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poor access to dental services. At that time tooth extractions and dentures were often the only type of treatment that low-income people could afford. High income people were more likely to afford types of treatments where their teeth were not extracted, such as llings, crowns and bridges. Our present analyses on the set of cross-sectional data from 2008 cannot identify these differences in dental health that occurred decades ago. However, our data show that there is no poverty effect with respect to utilization of dental services today, even for those who are elderly and or edentulous (Table 5). Seen in isolation, our ndings provide little support for a comprehensive public insurance arrangement for dental treatment. The low-income elasticities that we have found in this study indicate that there are small differences in access to dental services according to income. Therefore, the redistribution effects of a public insurance arrangement would probably also be small. However, a limitation of our study is that the sample is relatively small. Small groups of patients with extensive treatment needs are not necessarily represented in our sample. These are groups that must be taken into account in a discussion of the role of public insurance in the funding of dental services. The effects of the other variables are as expected and in line with ndings from similar studies from Norway (50, 51). Men attend the dentist less often than women. Young people attend less often than older people. Young people go regularly to the dentist, but they go every other year rather than every year. This reects differences in preferences and needs. Older people have more restorations and therefore have greater needs for repair than younger people. As expected, people who are edentulous only attend the dentist when they need new prostheses, but have higher expenditure when they do attend. People in this group may require more costly procedures than people who have all their teeth. The explained variances in the multiple regression analyses are small (Table 5). This is most likely due to measurement errors in the expenditure variable and or the omission of variables that measure dental care needs at the clinical level (for example, the occurrence of caries and periodontal diseases). The R2 is not a measure of the models goodness-of-t. Therefore, a low R2 value does not imply that the regression coefcients are biased (52). In conclusion, we found that differences in demand for dental services according to income are small, and there are no differences in utilization

according to patients income. The study was carried out in a population for which there is no public or private insurance arrangement for dental treatment. Nearly all dental treatment has to be paid for by the patient. The ndings can probably be explained by the fact that income differences in the population are relatively small and that a large proportion of the population goes regularly to the dentist, so that dental diseases can be detected at an early stage and teeth can be repaired before the damage has become very extensive and costly to treat.

Acknowledgments
The authors wish to thank Linda Grytten for translating the manuscript to English. TNS Gallup had the necessary permission from the Norwegian Data Inspectorate to perform the study.

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