SCIENTIFIC ARTICLE

Australian Dental Journal 2007;52:(3):205-209

Demographic, health and lifestyle factors associated with dental service attendance by young adults
LM Slack-Smith,* CR Mills, MK Bulsara MJ OGrady

Abstract Background: The aim of this study was to describe the demographic and health and lifestyle factors associated with dental service attendance in the previous 12 months by young Australian adults (1824 years). Methods: Population-based data from the 2001 Australian National Health Survey were analysed. Proportions and single associations between variables of interest and dental service attendance were calculated. A logistic regression analysis using significant single association variables was then conducted. Results: Overall, 41 per cent of young adults in this study had visited a dental professional in the previous 12 months. Females, those in cities, those with private insurance, those who spoke languages other than English, those in the highest socioeconomic group and those with healthy behaviours were subgroups most likely to have visited a dental professional. With logistic regression, factors found to be associated with dental services attendance were being female, having private health insurance and low alcohol consumption. Conclusions: In this study, the proportion of young adults who had visited a dental professional in the previous 12 months was only 41 per cent. It is therefore suggested that oral health policy and promotion activities be encouraged for this group, paying attention to young adults in groups with low attendance.
Key words: Dental services, young adult, epidemiology, oral health. Abbreviations and acronyms: ABS = Australian Bureau of Statistics; NHS = National Health Survey. (Accepted for publication 16 November 2006.)

*School of Dentistry and School of Population Health, The University of Western Australia, Perth. School of Population Health, The University of Western Australia, Perth. School of Dentistry, The University of Western Australia, Perth.
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INTRODUCTION Young adulthood is a transition period from adolescence to adulthood when independence is sought, new relationships are formed, and patterns of behaviour are established for the future.1 Oral health is important during young adulthood due to its influence on appearance and self-esteem. The oral health behaviours and attitudes of young adults are also important to their future health as good oral health in young adulthood is likely to translate to fewer dental health and general health problems later in life. For example, evidence suggests that periodontitis may be a risk factor for coronary heart disease2 and preterm low birthweight.3,4 In Australia, dental attendance and access to services for young adults has been described as less than optimal, with research showing that this group is less likely to visit a dental professional than other age groups.5-8 It has also been reported that the high percentage of adolescents using dental services tends to decrease sharply in young adulthood as young adults leave the public dental care system (school dental services) and take responsibility for their own oral health.8 Young adults are more likely to attend dental services when they have a problem, rather than for a check-up.9 Qualitative research supports the observation that young adults are unlikely to visit the dentist for a check-up, even when care is available for no cost, for reasons such as lack of relevance, previous negative experiences and adoption of the negative views of others.10 Another qualitative study indicated that young people believe they have little control over their oral health.11 Most oral health problems are preventable, yet the burden of oral disease such as dental caries and periodontal diseases remains problematic especially in industrialized countries.12,13 In Australian adults, dental caries and gum diseases are among the most prevalent illnesses.8 Assuming that the use of professional dental services has a positive impact on oral health,14 then epidemiological research about the use of dental services by young adults would provide valuable information that can be used to inform health policy, guide the allocation of resources and assist oral health promotion efforts.
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Table 1. Description of study variables, percentage of young adults attending a dental professional in the previous 12 months and single associations between explanatory variables and dental service use
Variable* Description Level Sample n Demographic factors Gender Completion of high school Language spoken at home Socio-economic disadvantage Gender of the respondent Whether or not the respondent completed high school Main language spoken by the respondent in their home Index of socio-economic disadvantage. Respondents classed as highest were the most disadvantaged, respondents classed as lowest were the least disadvantaged Whether or not the respondent lived in a capital city Whether or not the respondent was covered by private health insurance Whether or not the respondent had a government concession card (entitles the person to discounted services, e.g., public transport, medical services etc) Self assessment of health Whether or not the respondent currently smoked Perceptions of physical activity undertaken for recreation, sport, health or fitness Alcohol risk level as derived from intake over a 7-day period Female Male# No# Yes Other English# Highest Middle Lowest# 865 759 540 1084 237 1387 611 301 710 53 47 33 67 15 85 38 18 44 45 37 35 44 46 40 38 38 46 <0.01 <0.01 0.01 <0.01 % % Using dental service (previous 12 months) p-value

Living in a major city Private health insurance

No Yes# Insured Not insured# Yes No#

486 1138 558 1039 505 1119

30 70 35 65 31 69

38 43 51 36 37 43

0.03 <0.01

Government concession card

0.08

Health and lifestyle factors General health Smoking status Level of physical activity Positive Negative# Non smoker# Smoker High to moderate Low to sedentary# None to low Medium to high# 1431 193 1069 555 633 991 1435 189 88 12 66 34 39 61 88 12 41 41 44 37 42 41 42 33 0.59 <0.01 0.23

Alcohol consumption

<0.01

*Further details regarding variables available from the National Health Survey 2001 guide.22 #Denotes reference group used for comparison in the univariate analysis.

When considering access to dental care, Andersens behavioural model for the use of health services is useful as this model highlights the contribution and importance of different factors at both the individual and community level (i.e., predisposing, enabling and need related). This model was developed to assist in interpreting national health survey data from the United States.15 In the literature, factors found to be associated with dental service attendance in adults and older adults include age (this factor varied by gender in our previous aged paper), gender, ethnicity, education, socio-economic level, exercise, marital status, health status, health beliefs, dental insurance, smoking status and dental anxiety.16-19 In Denmark, dental service use by 2034 year olds was found to be associated with age, gender, exercise habits, cost, dental anxiety and perceived condition of teeth.14 In South Australian adults aged 2024 years, utilization was found to be associated with gender and cost, as well as having private health insurance and a government concession card.5 In American adolescents, a lack of annual dental visits was found to be associated with gender, ethnicity,
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age, perception of health, insurance, family income and parent education.20 The direction of these factors was clear in some instances, e.g., those with private insurance were more likely to attend but other factors such as age, gender, ethnicity and socio-economic status require more careful interpretation. The main objective of any health care system is to maintain and improve health outcomes.21 This can only be achieved if adequate knowledge exists about how people use health services and what factors are associated with this use. The objective of this study therefore was to describe and identify the demographic and health and lifestyle factors associated with dental service attendance in the previous 12 months by young Australian adults (1824 years) using high quality population-based data from the 2001 National Health Survey (NHS).22 MATERIALS AND METHODS This study used population-based data from the 2001 NHS22 which was made available as an Australian
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Bureau of Statistics (ABS) Confidentialised Unit Record File (CD Rom). The NHS was a population-based survey to obtain national benchmark and trend information about a range of health-related issues. In all, 26 863 people responded to the survey, an approximate response rate of 90 per cent.22 These data provided a range of demographic and health-related variables with which dental service attendance could be compared. The outcome of interest in this study was whether study participants had visited a dental professional in the previous 12 months. Overall, there were 1628 respondents aged 1824 years in the data set. Of the 1628 respondents, 4 did not know if or when they had last seen a dental professional and were therefore excluded from the study, leaving a sample size of 1624. Small numbers of responses were missing for two variables, socio-economic disadvantage (2 of 1624 respondents) and private health insurance (27 of 1624 respondents). The analyses were conducted using SAS for Windows (Version 9.1). The ABS provided a weight for each record which when applied allowed for extrapolation to the 2001 Australian population.22 To protect against bias, provide a more accurate value of the test statistic and to allow for the effects of stratification, normalized survey weights were used.22,23 The use of normalized survey weights allows for the sample to approximate the 2001 Australian population but retains the original survey standard errors24 and ensures that confidence intervals are not falsely narrowed. To describe service use, the proportion of young adults attending a dental professional in the previous 12 months was calculated (overall and for each variable). To select variables for inclusion in the logistic regression analysis, single associations between explanatory variables and dental service use were calculated using a Wald chi-square statistic. The demographic, health and lifestyle variables investigated (Table 1) were guided by the literature and were dependent on availability within the data set. Smoking status, level of physical activity and alcohol consumption were included due to their impact on the overall health of a person. Individual variables found to be significant in the univariate analysis were modelled together in a logistic regression analysis. This method of analysis was chosen as it allowed researchers to look at the comparative impact of an independent variable on the dependent variable (i.e., dental service use) with all other independent variables being controlled for. All main effects were modelled together and then removed via a backward selection strategy with a significance level to stay in the model of p=0.05. The sample size for the multivariable analysis was reduced to 1595 as complete variable information was not available for 29 respondents. Ethics approval for this study was obtained from the Human Research Ethics Committee of The University of Western Australia.
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RESULTS The demographic and health and lifestyle details of those in the sample are shown in Table 1. Overall, 41 per cent of those investigated had visited a dental professional in the previous 12 months. Those aged 2024 years were less likely to have attended a dental professional in the previous year (40 per cent) than the younger group age 1819 years (43 per cent) but this difference was not significant so the two groups were pooled for the remaining analysis. To select variables for inclusion in the logistic regression analysis, single associations between explanatory variables and dental service use were calculated and are shown in Table 1. Overall, young adult females were more likely than males to have visited a dental professional in the previous 12 months. In terms of education, those who had completed high school were more likely than those who had not completed high school to have visited a dental professional. Significant differences in dental attendance by language spoken at home were also found as young adults who mainly spoke English were less likely than those who spoke other languages to have recently visited a dental professional. Young adults in the lowest socio-economic disadvantage category (i.e., the most advantaged) were more likely than young adults of highest disadvantage and middle disadvantage to have used dental services in the previous 12 months. Young adults living in a major city and young adults with private health insurance were more likely to have visited a dental professional than those living in other geographic areas or without private health insurance. When health and lifestyle variables were analysed it was found that young adults who smoked and young adults who consumed alcohol at levels of medium to high risk were less likely to have visited a dental professional than young adults who were non-smokers or young adults who consumed alcohol at levels relating to low risk. Variables found to be individually associated with dental service use in the previous 12 months were then analysed via a logistic regression analysis (i.e., gender, completion of high school, language spoken at home, level of socio-economic disadvantage, living in a major city, private health insurance, smoking status and

Table 2. Factors found to be associated with dental service attendance in young adults in the previous 12 months using a logistic regression analysis
Variable* Private health insurance Gender Odds ratio 95% CI p-value 1.6-2.4 1.2-1.7 1.0-1.9 <0.01 <0.01 0.04 Insured 1.9 Not insured# Females 1.4 Males# Alcohol None to low risk; 1.4 consumption Medium to high risk#

*None of the variables were found to be inter-correlated, VIF=1.0, tolerance=0.99. #Denotes reference group in the regression analysis.
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alcohol consumption). When modelled together it was found that private health insurance, gender and alcohol consumption were significant predictors of recent dental service attendance in young adults. Young adults who had private health insurance, young female adults and young adults who consumed none to low levels of alcohol were more likely to have recently visited a dental professional (Table 2). DISCUSSION Considering the low proportion of young adults who had recently visited a dental professional as found in this study, it is suggested that oral health promotion activities and dental visits be encouraged for this group. We found that 41 per cent of young people in Australia (aged 1824 years) visited a dental professional in the previous 12 months compared to 45.5 per cent of South Australians (aged 2024 years).5 Other Australian studies have found dental service use to be between 45 per cent (2024 years) and 55 per cent (18 years).5,9 A United States study found the proportion of young adults having a recent dental visit decreased with age.20 We found a similar trend but it was not statistically significant. Our study found several factors relating to the individual (i.e., gender, private health insurance and alcohol consumption) were important in explaining dental service use in young Australian adults as we would expect from Andersons behavioural model.15 These findings are in agreement with the current literature. Our observation that young females and those with private health insurance were more likely to have attended agrees with the literature.5,20,21,25 Having private health insurance may affect ability to pay. The finding that young adults who consumed alcohol at levels of medium to high risk were less likely to have visited a dental professional is possibly related to a lack of concern with their health which is of concern as numerous oral health problems are associated with excessive alcohol use. As a result, it is suggested that young adults who do not have private health insurance, who are male, or who consume alcohol at medium to high levels of risk be considered as important target groups when health professionals define oral health priorities and health promotion campaigns. It would be very useful to know whether infrequent dental attendance is associated with negative health behaviour in general this helps us understand the causal pathway for dental attendance. CONCLUSION The main strength of this study was the use of population-based survey data, which had a high response rate and large sample size.22 A limitation of this study is that the self-reported data on service utilization could not be validated and that the wording of the survey dental attendance questions did not distinguish between dental visits for preventive care, the treatment of pain or other reasons.
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Findings from this study should be used to inform health policy, guide the allocation of resources and target oral health promotion efforts so as to ensure good oral health outcomes for young adults. It is suggested that further oral health research occur for this age group, especially in terms of how dental visits influence short- and long-term oral health outcomes as this knowledge would be useful to dental professionals and would contribute to understanding in the area of health service use. ACKNOWLEDGEMENTS The authors would like to thank Dr Anne Read for valuable comments on the manuscript and Ms Helen Baros for assistance with the literature search. The Australian Bureau of Statistics supplied the data but they are not responsible for the analysis. The Department of Health (WA) provided support for this project. REFERENCES
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17. Slack-Smith LM, Hyndman J. The relationship between demographic and health-related factors on dental service attendance by older Australians. Br Dent J 2004;197:193-199. 18. Dixon GS, Thomson WM, Kruger E. The West Coast Study. I: Self-reported dental health and the use of dental services. N Z Dent J 1999;95:38-43. 19. Wilson AA, Branch LG. Factors affecting dental utilization of elders aged 75 years or older. J Dent Educ 1986;50:673-677. 20. Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with use of preventive dental and health services among US adolescents. J Adolesc Health 2001;29:395-405. 21. Skaret E, Raadal M, Kvale G, Berg E. Gender-based differences in factors related to non-utilization of dental care in young Norwegians. A longitudinal study. Eur J Oral Sci 2003;111:377382. 22. Australian Bureau of Statistics. National Health Survey 2001: Users Guide. Canberra: Australian Bureau of Statistics, 2003. 23. Lehtonen R, Pahkinen E. Practical methods for design and analysis of complex surveys. Chichester, England: John Wiley & Sons, 1996.

24. Taylor R, Page A, Morrell S, Carter G, Harrison J. Socioeconomic differentials in mental disorders and suicide attempts in Australia. Br J Psychiatry 2004;185:486-493. 25. Ekanayake L, Ando Y, Miyazaki H. Patterns and factors affecting dental utilisation among adolescents in Sri Lanka. Int Dent J 2001;51:353-358.

Address for correspondence/reprints: Dr Linda Slack-Smith School of Dentistry (M512) The University of Western Australia 35 Stirling Highway Crawley, Western Australia 6009 Email: lindas@cyllene.uwa.edu.au

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