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Oral health, Needs and demand, Socioeconomic status, Adults, IntroductionOral health is one of the key elements of overall health [ 1, ]. Oral diseases are known as one of important public health issues due to their adverse effect on general health and quality of life, and high cost of treatment [ 1, ]. Oral health need assessment considered as a key element of oral health care planning [ 2, ]. The advantages of community health need assessment can be summarized as measuring the burden of diseases, determining differences in patterns of need in populations, identifying patient&,rsquo s priorities, realistic estimate of needed health care interventions, and cost-effective allocation of limited resources [ 2, ]. Bradshaw [ 3, ] has described three types of need, which can be applied in the health context normative need is determined by clinician and professional staffs, perceived (felt) need is refection of self-assessment of health need, and expressed need is a perceived need that has led to receipt of services. Although the most commonly used method of assessing need for dental care is solely based on clinical criteria, reliance on merely clinical indicators suffers from several limitations including deficiency in objectivity and reliability, neglect of health behaviors and patient compliance, disregard of patient&,rsquo s attitude and consumer rights, and neglect of quality of life concept [ 2, , 4, ]. Gift et al. [ 5, ] presented a model showing subjective perception of oral health was affected by demographic, enabling and predisposing factors. Financial capabilities such as income, insurance and level of education are considered as enabling factors. It should be taken into account that enabling factors do not predict demanding services since the key determinative factor for receiving services is perception of the need [ 6, ].The role of socioeconomic factors as important determinants of oral health in different communities has increasingly been noticed. According to the World Health Organization (WHO) report, inequality in oral health care is a major research priority in the 21st century [ 7, ]. The issue was clearly evidenced by studies conducted in developed countries so that socioeconomic inequalities have been observed in subjective oral health [ 8, - 9, ]. However, due to the lack of sufficient research in developing countries, more investigations in these areas are needed. Besides, few studies regarding subjective oral health and socioeconomic inequalities in adults have conducted in Iran. In Ghorbani et al.&,rsquo s study [ 10, ] in Tehran, despite the significant association of number of self-reported non-replaced extracted teeth and lower level of education and wealth index, there was no similar association of perceived oral health with socioeconomic levels. During the last three decades, Iran Ministry of Health and Education has tried to provide basic dental services by prioritizing deprived groups in underserved areas like rural and suburban regions. Little is known about the impact of this strategy on the extent of subjective oral health inequality. In literature review, we could not find any recently published study in this regard performed outside of Iran&,rsquo s capital. To clarify the issue, the aim of this study was to measure perceived unmet oral health need (PUOHN) across different socioeconomic indicators in Mashhad and Kerman, two of the largest cities in east of Iran.Materials and MethodDesign and study populationThe aim of this cross-sectional study was to assess inequalities in PUOHN in adult population (18 and over) of Mashhad and Kerman cities by telephone interview. All the phone numbers were obtained from Telecommunication Company. Phone numbers were categorized into 35 urban regions (28 regions in Mashhad, 7 regions in Kerman). 34 percent of regions were located in suburban areas (Mashhad 10, Kerman 2). To reach a representative sample, estimated sample size was distributed proportionally among urban regions based on stratified random sampling. At first, according to population of the two cities, the sample size was distributed (Mashhad 1100, Kerman 375). In the next step, exact required sample size of each urban region was calculated based on proportion of the number of telephone lines in each urban region to the entire city phone lines. To compensate for non-respondent or busy phone lines, five-fold numbers of determined sample size, random phone numbers were obtained by Excel &,ldquo RAND BETWEEN&,rdquo function. Kerman University of Medical Science granted ethical approval for the study [number IR.kmu.REC.1394. 549]. Correspondingly, informed consent was obtained from the participants at the beginning of the interview.InterviewWe performed a systematic review on questionnaires on PUOHN. The result implied that comprehensive questionnaires were not available [ 11, ]. Therefore, a structured questionnaire was designed. Firstly, the developed questionnaire was revised based on qualitative validation process. In the next step, content validity index and content validity ratio were assessed. Except for two deleted items, all of the questions gained the acceptable scores. Reliability was assessed by test-retest method and use of Cronbach&,rsquo s alpha. The results of reliability assessment were acceptable too. The development and validation process of the questionnaire has also been reported [ 12, ]. The telephone interview was conducted by three trained interviewers. Before performing the main part of the project and during the pilot study, the interview process was reviewed and some corrections were made in the questionnaire. Each interview lasted about seven minutes. Non-respondent or in-use lines were withdrew from the call list after two attempts. Phone calls were made in the morning and evening of workdays from June to October 2016.Study variablesOutcomeThe outcome, PUOHN was evaluated by the following question &,ldquo during the past year, do you think your dental needs were met? Yes, no&,rdquo Independent variablesPredisposing variables potentially associated with PUO-HN included gender, age and educational level (illiterate, elementary school, middle school, high school or diploma, associate degree, bachelor&,rsquo s degree and over). Enabling variables were job (employee, self-employed, worker, housewife, student, unemployed), insurance coverage, dental insurance, type of insurance (private or public insurance), residential location (urban or sub urban area according to the phone number region), household size, and family socioeconomic indictors such as the use of personal car or public transport, monthly family income (Iranian Rial), house area (m2), and house ownership (own, rent).Statistical analysisStatistical analysis was performed using SPSS software (version 20). Bivariate analyses were conducted to determine significant predisposing and enabling variables associated with PUOHN. Then, significant predictor variables were fitted in logistic regression model. ResultsTo reach 1475 interview, 7291 phone calls were made. Of all 2854 answered calls, 630 were commercial lines, 1475 individuals participated in the study and 749 were not willing to participate (response rate of 63%). Characteristics of the studied population are presented in Table 1,. VariablesMean or (%)PUOHN (Perceived Unmet Oral Health Need)(%)p value (chi-square#,)Gender 0.97Male30.250.1 Female69.850.2 Age 0.22818-3029.447.5 31-4541.753.5 46-6018.450.4 &,gt 6010.546.2 Education level 0.012Illiterate3.742 Elementary school1250.9 Middle school10.460 High school or diploma38.154.1 Associates degree7.751 Bachelor&,rsquo s degree and over28.144.4 Job &,lt 0.001Employee17.640.3 Worker1.575 Self-employed22.256.2 Student4.328.1 House wife52.951.6 Unemployed1.575 Insurance 0.079Yes89.149.4 No10.957 Dental insurance &,lt 0.001Yes33.738.1 No47.853.3 Unknown18.543.5 Residential area 0.897Urban75.450.3 Sub urban24.650.7 House ownership 0.001Owned62.753.8 Rental36.165.5 Other1.281.1 Transportation &,lt 0.001Personal car56.951.9 Public transport39.663.3 Other3.570.4 Type of insurance 0.113Public (governmental)78.351.9 Private(supplemental)18.544 Unknown3.247.2 Income (Rial)16900000900000-150000000*,0.022#,Family members3.81-11*,0.029#,House area(square meter)11720-1000*,0.007 #,*For continuous variables, range (minimum maximum) is presented. #association of continuous variables with binary PUOHN was tested by using logistic regression. |