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Bastani et al. Cost Eff Resour Alloc (2021) 19:54 https://doi.org/10.1186/s12962-021-00309-0

R E S E A R C H

What makes inequality in the area of dental and oral health in developing countries? A scoping review Peivand Bastani1*† , Mohammadtaghi Mohammadpour2†, Gholamhossein Mehraliain3, Sajad Delavari1 and Sisira Edirippulige4

Abstract Background: Equity in health is an important consideration for policy makers particularly in low and middle income developing country. The area of oral and dental health is not an exception. This study is conducted to explore the main determinants that make inequality in oral and dental health area in developing countries.

Methods: This was a scoping review applying the framework enhanced by Levac et al. Four databases of Scopus, PubMed, WOS and ProQuest were systematically searched applying to related keywords up to 27.11.2020. There restriction was placed in the English language but not on the study design. All the related studies conducted in the low or middle income developing countries were included. A qualitative thematic analysis was applied for data analy- sis and a thematic map was presented.

Results: Among 436 articles after excluding duplications, 73 articles were included that the number of publications from Brazil was greater than other developing countries (33.33%). Thematic analysis of the evidence has led to 11 determinants that may result in inequality in oral and dental health services in developing countries including per- sonal characteristics, health status, health needs and health behaviours, social, economic, cultural and environmental factors, as well as insurance, policies and practices and provided related factors.

Conclusion: The policymakers in the low and middle income developing countries should be both aware of the role of inequality determinants and also try to shift the resources to the policies and practises that can improve the condi- tion of population access to oral and dental services the same as comprehensive insurance packages, national surveil- lance system and fair distribution of dentistry facilities. It is also important to improve the population’s health literacy and health behaviour through social media and other suitable mechanisms according to the countries’ local contexts.

Keywords: Inequality, Oral health, Dental health, Developing countries

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom- mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Open Access

Cost Effectiveness and Resource Allocation

*Correspondence: [email protected] †Peivand Bastani and Mohammadtaghi Mohammadpour have equal participations as co-first authors 1 Health Human Resources Research Centre, School of Health Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran Full list of author information is available at the end of the article

Background The populations’ oral and dental health is among the public health concerns globally. Evidence shows that the distribution and severity of the diseases related to oral and dental health can vary around the world [1]. While some evidence emphasizes that the prevalence of dental caries is decreased among both developing and devel- oped countries [2], other studies show the high preva- lence of dental diseases among those populations with

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low socioeconomic status [3]. Such these contradictions can simply indicate that the issue of oral and dental health needs to be considered yet.

On the other hand, other evidence, indicates that the treatments applied for oral and dental diseases are con- sidered as the 4th expenditures even among industrial and developed countries [4]. Because of the intensive costs and due to the relationship among the frequency of these diseases and the social, behavioural and envi- ronmental factors [1], it seems that this issue needs more consideration among low and middle income developing countries. In this regard, the previous studies have shown the inequalities in the area of oral and dental health. Such an inequality can be either due to the unfair provision of the services or each of the inappropriate access or utili- zation of the services by the population [5]. According to the evidences almost 4.6% of healthcare expenditures globally is allocated to the dental caries and the related treatments. Such an expenditure is varied from one country to the others and in many regions is funded by out of pocket payments at the time of patients’ needs [6] that can intensify the inequality and access to the dental services.

Equity as one of the main aims for the healthcare poli- cymakers is directly pointed to any potential differences in the population’s health including either their financing, access to the services or the health level of the commu- nity [7]. According to the evidences, different determi- nants can lead to inequality in oral and dental diseases. Among them the social, cultural, ethnical, psychologi- cal and behavioral factors can be considered [8]. In this regard evidence shows that socio-determinants of health (SDH) the same as education, income, environmental condition, the community’s working life as well of the other factors the same as adequate oral health profes- sionals can play an important role in decreasing dispari- ties and as a results, promoting the health equity [9].

At the same time, the present knowledge indicates that the population’s income along with the cost of den- tistry services are among other important determinants that can affect the affordability of the services and con- sequently intensify the inequality [10]. So, a clear iden- tification of these determinants should be mentioned comprehensively to shed the light for policymakers for better allocation of the resources and equitable provision of oral and dental health services particularly in develop- ing countries.

According to what was said, although the indications of inequality in dental services has been reported in many communities, the challenge is much more highlighted among low- and middle-income countries. Accord- ing to the evidences, many inconsistency and knowl- edge gaps are obvious in the area of oral policies among

these countries [11, 12] that make the national, local and regional policy makers pay more attention to this area. In another words, to the best of our knowledge, although many contents are considered a single or mul- tiple cause of inequality in the area of oral and dental health, a scoping review in the context of low and middle income developing countries is not presented. Moreover, as the issue of inequality in health is related to the con- text and setting, the determinant factors may differ from the developed or in transition countries to the developing or under developed ones. Considering all the above, this scoping study is conducted to explore the main determi- nants that make inequality in oral and dental health area among developing countries. This approach can make an opportunity to consider the whole related scope, and explore all the determinants stated in the related litera- ture to pave the way for health policymakers in develop- ing countries in order to plan based on the evidence and applied to the context.

Methods The present scoping review was conducted in Novem- ber 2020. This kind of reviews, is generally applied to define and clarify the determinants and key concepts of a research scope and map the evidences and conceptual boundaries of the topic [13]. Different frameworks are proposed to conduct a scoping review. First of all, was suggested by Arksey and O’Malley with a five obligatory and an optional consequential steps [13]. This framework has renewed by Levac, Colquhoun and O’Brien [14]. According to Levac et  al. all the six steps of the Arksey and O’Malley’s framework was enhanced. In this study the later framework is applied because of more explicit details, clarity and rigor through the review process [15].

Clarifying and linking the purpose and research question At the first step of the scoping review the purpose of the study was confirmed as “determination of the main and sub factor affecting inequality in oral and dental health services among developing countries”. According to this purpose the following research question was defined: “What are the main determinants of inequality in access to oral and dental health services”.

Balancing feasibility with breadth and comprehensiveness of the scoping process At the second step, the area and scope of seeking the evidences were identified. In this regard, four main data- bases including PubMed, ISI Web of Science, Scopus and ProQuest were systematically searched. Related keywords were chosen and they were combined applying logical operators OR/AND in order to increase the sensitivity of

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the search. The main keywords were “dental health”, “oral health”, “socioeconomic”, “healthcare disparities”, “utili- zation” and “inequality”. Although the aim of the scop- ing review was to explore the determinants of inequality in oral and dental health among developing countries, “developing country” was not applied as the main key word because many of the studies directly pointed to the name of the developing country not the general term. The search strategy was conducted up to 27 Nov 2020 considering two limitations for time and language. The time limitation was considered from 1 Jan 2000 to 27 Nov 2020 and the language limitations was defined for those articles which has published in a full text format in Eng- lish. The syntax search is presented in Table  1 according to each of the aforementioned databases. Also, at the end of the process of systematic search, a google search was implemented for retrieving the related pre-prints and unpublished or grey literature in this area.

Using an iterative team approach to selecting studies and extracting data Applying the aforementioned search strategy (Table  1), all the four databases were systematically searched. 6521 cases were reached following this strategy. After reviewing the titles, 4535 cases were remained and after screening and omitting the duplications, a total of 436 articles were included. These articles were screened first by their abstracts and the relevant abstracts were com- pletely reviewed by their full texts. In this step, the eli- gibility of the articles was defined so that, those articles with no English full-texts and those articles with no full- texts format the same as conference proceedings were excluded. Furthermore, those articles in any formats of editorials, commentaries and letters were excluded and were not eligible to analyse because they do not contain

any data-driven results. Another screening stage in this step was selecting those studies according to the list of the developing countries based on the World Economic Situation Prospects released by the United Nations 2020 (https:// www. un. org/ devel opment/ desa/ dpad/ wp- conte nt/ uploa ds/ sites/ 45/ WESP2 020_ Annex. pdf ).

In this regard, all the original or review articles with any qualitative or quantitative design derived from any of the developing countries based on the aforementioned list which indicate the aim of the present scoping review were included. Meanwhile, none of the records identified through other sources were eligible for including data analysis step.

For managing the pre-stated process, Endnote X7.1, by Thomson Reuters was applied. Figure  1 shows the PRISMA flowchart.

Incorporating a numerical summary and qualitative thematic analysis In order to extract the data from the included articles, a data extraction form was prepared including the first authors’ name, the year and place of publication, the study aim and design and the main results (Additional file  1: Table  S1). Microsoft Excel software version 2013 was applied to extract the data. This step is carefully done by one of the researchers (MM) and the extracted results were described according to the frequency of pub- lications via Fig.  2. For evidence synthesis a qualitative thematic analysis was conducted. For this propose, after extracting the effective factors of oral and dental health inequality from each article as the final code, the new concepts were made by categorizing the codes, the topic charting process was applied via a table to determine which codes belonged to each category.

Table 1 The search strategy of the scoping review

Databases Key words combination

PubMed ((("Dental Health Surveys"[Mesh]) OR ( "Oral Health"[Mesh] OR "Dental Health Services"[Mesh] )) AND ((((("Socioeconomic Factors"[Mesh]) OR "Hierarchy, Social"[Mesh]) OR ( "Healthcare Disparities"[Mesh] OR "Health Status Disparities"[Mesh] )) OR "Social Determi- nants of Health"[Mesh]) OR "Social Class"[Mesh])) AND (((("dental services"[Title/Abstract]) OR ("dental visits"[Title/Abstract])) OR (utilization[Title/Abstract])) OR ("use of services"[Title/Abstract]))

SCOPUS TITLE-ABS-KEY("oral health") OR TITLE-ABS-KEY("Dental Health Surveys") OR TITLE-ABS-KEY("Dental Health") OR TITLE-ABS-KEY("dental care") AND TITLE-ABS-KEY("Socioeconomic Factors") OR TITLE-ABS-KEY("Social Hierarchy") OR TITLE-ABS-KEY(Inequalities) OR TITLE- ABS-KEY("Social Disparities") OR TITLE-ABS-KEY("Social Gradient") OR TITLE-ABS-KEY("Health Status") OR TITLE-ABS-KEY("socioeconomic disadvantage") OR TITLE-ABS-KEY("socioeconomic inequalities") OR TITLE-ABS-KEY("Social Determinants") AND TITLE-ABS-KEY("dental services") OR TITLE-ABS-KEY("dental visits") OR TITLE-ABS-KEY("utilization") OR TITLE-ABS-KEY(access) OR TITLE-ABS-KEY("use of services")

WOS TOPIC: (“Dental Health Surveys” OR “Oral Health Disparities” OR “Dental Health” OR “Oral Health” OR "dental care") (“Socioeconomic Factors” OR “Social Hierarchy” OR “Inequalities” OR “Social Disparities” OR “Social Gradient*” OR “Health Status*” OR “socio-

economic disadvantage” OR “socioeconomic inequalities” OR “Social Determinants” OR “Socio Economic Status”) TOPIC: (“dental services)

ProQuest (MESH.EXACT("Dental Care") OR MJMESH.EXACT("Dental Health Surveys") OR MJMESH.EXACT("Dental Health Services") OR MJMESH. EXACT("Oral Health")) AND (MJMESH.EXACT("Socioeconomic Factors") OR MESH.EXACT("Social Class") OR MJMESH.EXACT("Social Determinants of Health"))

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Identifying the implications of the study findings for policy, practice or research A qualitative thematic analysis was conducted to achieve the main and the sub determinants of the inequality in the scope of oral and dental health services as well as the implications for policy makers and oral and den- tal health providers. For a qualitative thematic analysis [16], first we have familiarized with the data through a continuous process of reviewing the extracted data and comparing it with the included articles, then, the cod- ing process was started and the initial codes were made

and ladled through an open coding process based on the research question. Continuing the coding process, the initial codes were refined to reach to the final codes. All the final codes that indicate on any sort of inequality in utilizing the oral and dental services in the mentioned countries were analysed thematically. In a way that, after finalizing the codes, the final emerged codes were catego- rized and classified to make the sub-themes and then the main themes with more synthesis in a higher conceptual- ity level. These sub-themes and main themes, then were reviewed and finalized and finally the appropriate labels

Sc re en

in g

In cl ud

ed El ig ib ili ty

noitacifitnedI

Study extract from four above database (6521)

Abstract meaning inclusion criteria

(n =146)

Full text study for analysis (n = 73)

Records iden�fied through PROQUEST

database (n =1146)

Records iden�fied through WOS

database (n =1227)

Records iden�fied through SCOPUS

database (n =2798)

Records iden�fied through PUBMED

database (n =1321)

Duplicate remove: (1550)

Record delete a�er studying �tle:

(4535)

Record screened by reviewing �tles and duplicates: 436

Records iden�fied through other

database (n =29)

Fig. 1 The PRISMA flowchart of the scoping review

Page 5 of 12Bastani et al. Cost Eff Resour Alloc (2021) 19:54

were chosen and the suitable definition and demonstra- tion of the main and sub themes were presented in a table (Table 2). The qualitative software MAX QDA version 10 was used to analyse the data.

Adopting consultation as a required component of scoping study methodology In order to achieve an appropriate schematic and under- standable map for the policymakers, a thematic map was presented. A mini expert panel was conducted including the research team with sufficient reflexivity in the quali- tative studies and thematic analysis and three representa- tives of national oral and dental health policymaking to finalize the thematic map.

Results Results showed that 6521 cases were reached following the present strategy. After reviewing the titles, 4535 cases were remained and after screening and omitting the duplications, a total of 436 articles were included. Among 436 articles after excluding duplications, 73 articles were included and extracted.

Descriptive analysis of the included studies showed that most of these articles (33.33%) were published about Brazilian setting. China and Iran have the second and the third proportion of the articles respectively. Figure  2 compares the distribution of the included articles accord- ing to the place of publication.

Other results demonstrated that most of the arti- cles (87%) had a cross-sectional design while the policy

analysis (1%), ecological studies (1%) and the studies with the case–control design (1%) were among the least meth- odological approaches. (Fig. 3).

Other descriptive results of the study are shown in Fig. 4. According to Fig. 4, there was a rising in the atten- tion to the topic from 2004 to 2018 and most of the arti- cles have been published in 2018.

Thematic analysis of the evidences has led to 11 deter- minants that may result in inequality in oral and dental health services in developing countries including per- sonal characteristics, health status, health needs and health behaviours, social, economic, cultural and envi- ronmental factors, as well as insurance, policies and prac- tices and provided related factors (Table 2).

As Table  2 shows, the aforementioned determinants can affect the equality or inequality of oral and dental health services in three levels.

The first level is the micro-individual level. It is the most related area to the populations attributes and include: personal characteristics of the population, health status of the population and the population’s health needs and health behaviours. In another words, accord- ing to the included and analysed literature, some per- sonal characteristics the same as age [18, 19], gender [23] and race [20, 21] can directly and indirectly affect the access to oral and dental health services. These charac- teristics along with the populations’ physical [17], dental [22, 25–27] and psychological [29–31] health status can determine the health needs and the health behaviours consequently.

33.33%

13.89%

9.72%

5.56% 4.17%4.17%4.17%4.17%4.17%

2.78%2.78%2.78% 1.39%1.39%1.39%1.39%1.39%1.39%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Fig. 2 The included articles distribution according to the publication place

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Table 2 The main determinants of inequality to oral and dental health access among developing countries

Main themes Sub-themes Final codes References

Micro Individual level Personal characteristics Age [4, 17–19]

Sex [20]

Skin colour [20, 21]

Higher self-esteem [22]

Gender/child gender [23]

Health status Periodontal status [24]

Severity of dental caries [25]

Self-rated oral health [22, 26, 27]

Systemic disease history [17]

Decayed teeth [28]

Psychological health status [29–31]

Health needs Dental treatment needs [28, 32]

Perceived dental treatment needs [4, 20, 33, 34]

Perceived oral health care need [35]

Evaluated need characteristics (oral clinical status) [23]

Health behaviours Oral health beliefs [22]

Regular brushing [22, 27]

Oral hygiene practice [4]

Children’s dental behaviours [36]

Oral health education for parents and children [36]

Oral health knowledge [36]

Macro level Social determinants Rural–urban disparity [25]

Unemployment [25, 37, 38]

Employment statu

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