The oral health service utilization prevalence in the past 12 months was 9.5% among 3-year-old children, 12.1% among 4-year-old children, and 17.5% among 5-year-old children. Compared with the Third National Oral Health Survey, among 5-year-old children, the prevalence of utilization of dental care increased slightly, but there is still a gap between utilization in China and the level of dental health care utilization in developed countries. In our study, we aimed to explain the patterns of dental service utilization among 3- to 5-year-old children in China with Andersen’s behavioural model. We find that education, knowledge, attitude, dental pain, evaluated dental health, and dmft scores are associated with oral health utilization, while annual per capita income and rural-urban location can also affect the use of dental service.
Behalf of the biological imperatives among the predisposing characteristics, demographic factors suggested the possibility of needing health services. In the current study, we considered the effects of age and sex and found that age but not gender had a significant effect on dental care utilization. Oral health service utilization during the past 12 months showed a rising trend with age. This finding could possibly be explained by the cumulative effect of increasing oral problems as children grow [24]. The teeth of older children are exposed to environmental conditions for a longer period of time, which increases the likelihood of dental disease [24,25]. According to the Fourth National Oral Epidemiology Report [3], the prevalence of dental caries in deciduous teeth increases with age between 3 and 5 years of age. Another explanation is that older children are able to more clearly convey their pain or discomfort to parents and dentists and can better cooperate during dental procedures [20].
For preschool children, parental characteristics play an important role in the utilization of health services. Educational level influences one’s lifestyle and is associated with acquiring dental knowledge [11,14]; in this manner, educational level influences health behaviours and preventive treatment [17,24,25]. In this study, nearly half of the parents had no more than a junior high school education; regarding reasons for not visiting dentists, approximately 70% of parents believed that their children did not have any dental diseases. This unrealistic optimism may stem from the absence of health knowledge. Oral pain is often mistakenly regarded as the only symptom of perceived disease [26]. Prior studies have also mentioned that in China, traditional Chinese medicine considers the oral cavity to be part of the entire body; therefore, the first treatment modality for dental disease is sometimes home remedies rather than professional treatment [7].
Regarding the enabling variables, both personal and community characteristics were attributed to the availability of health service resources. Our results confirmed that family income demonstrated a positive relationship with dental health service utilization. The susceptibility to caries and dental pain is socio-economically and geographically unequal [27]. Children who are disadvantaged by poverty have an increased burden of disease but attend few dental visits [28]. Regarding medical insurance, the reimbursement prevalence for oral diseases is notably low in China [29], and the public must pay out of pocket for clinical treatment. The low-income population is focused on meeting basic needs and is less likely to seek dental care [30]. Furthermore, a prior study confirmed that poverty associated with education leads to reduced knowledge and a poor attitude regarding oral health [31]. Thus, financial barriers have a negative effect on dental care; similar results have been reported in prior studies [32-35].
The influence of community can be explained by spatial accessibility. The results of this study showed that children who lived in urban areas were more likely to receive dental services than those who lived in rural areas. This phenomenon may have occurred because health system-related economic resources are not dispersed homogeneously throughout the country [14]. A shortage in the dental workforce, particularly paediatric dentists, is a common social issue in low-income areas [36]. The density of pediatric dentists at county (city) level is significantly related to the utilization of oral health care at county (city) level [37]. A similar finding was reported in America, where utilization of dental care showed a negative trend as urbanization decreased [38].
According to Andersen’s behavioural model, dental care need was regarded as the prime determinant of the use of health services. Perceived illness or the probability of its occurrence was a main reason for seeking dental services. Traditionally, three measures can be used to evaluate need: need perceived by an individual, need perceived by parents and need perceived by a clinical evaluation. Dental pain is often associated with oral ulcers, tooth eruptions and dental caries, all of which have a crucial impact on the psychological and physical well-being of children; decay in the primary molars has been cited as the principal predictor of such pain [39]. Results from the multiple regression analysis in the present study showed that pain was the strongest factor associated with oral health service utilization. For preschool children, Caries severity impacted the quality of life [40]. Ferreira-Junior et al found that the prevalence of dental pain was higher among those living in cities with lower human development index and with a higher percentage of their population with an incomplete primary education [41]. According to prior studies, dental pain, which can lead to difficulty in eating and consequently result in malnutrition and underweight, has become the most important reason for dental treatment [25,42].
In accordance with previous studies [35], our study showed that parents’ perception of their children’s dental health was an important predictor of a child’s use of oral health care services. Parents who evaluated their child’s dental status as “poor” took their child to the dentist more often than those who evaluated their child’s status as “good”. However, a study based on Brazilian school children showed that children who thought their oral health was “good/excellent” were more likely to seek dental services [17], and this study emphasized the association between socioeconomic inequalities and health outcomes. An explanation for these differing results might be parents’ beliefs about seeking curative or preventive services [43]. Thus, the utilization patterns of oral health services among preschool children in China are still disease-oriented, and effective methods for promoting preventive dental care need to be expanded. Parents who considered their child’s overall health to be poor were less likely to bring their child to an oral hospital; this is possibly because whole body health is more urgent than oral health, and thus oral health becomes a secondary concern.
In the present study, the dmft was associated with oral health service utilization. Another study confirms the results [44]. The prevalence of dental caries based on clinical examination was 63.1%, however, only 17.6% of children were reported to have utilized oral health services. This difference suggests that dental need did not translate into demand. A prior study indicated that potential demand is caused by both demanders and suppliers [45]. Due to parents’ lack of awareness or incorrect awareness of oral health, there is no effective demand for treatment of unrecognized diseases. Furthermore, disadvantages associated with medical institutions providing inappropriate services, such as high cost, difficult registration, and long waiting time, among others, are also important factors that affect patients’ visits. A study has shown that oral hygiene service utilization increases slightly, when a child is diagnosed with an oral problem [46]. To achieve the goal of continuously and effectively transforming objective need into subjective demand, the countermeasures that are adopted must be aimed at changing behaviour on both the supply and demand sides. For example, oral examinations may be carried out in school or in the community, and when a child is found to have dental caries, timely treatment may be given.
When calculating the survey weights, data of the 3-5-year-old age group in the Sixth Population Census of China were not available, so we selected the data from 1-4-year-old age group as a substitute, which may have affected the accuracy of the results. In addition, per capita household income was obtained by filling in missing values. Although accurate data were utilized to the greatest extent possible, this data substitution may have resulted in deviations to some extent. Our study was a cross-sectional study; hence, the limitations of this study design could be reflected in our results. First, the children in the sample were all from kindergartens, and children not attending kindergartens in remote areas were not included, resulting in selection bias. Second, because the studied factors occurred in the past, recall bias was unavoidable. Third, the questionnaire was completed by the parents, and its accuracy was subject to the parents’ understanding of their children. Fourth, our study is of cross-sectional design, which excludes any inference about causality, A future longitudinal study is highly desirable to address these limitations.
Despite the above limitations, this study was still a comprehensive and systematic reflection of the current utilization of health services by preschool children in China. To improve the oral health of pre-schoolers in China, the study findings have some implications for policy adjustment to increase the utilization of oral health services. First, it is time for the government to pay attention to the inequality in the distribution of dental resources and take measures to solve this problem. Second, expansion of insurance coverage for dental treatments would be beneficial for children who are less able to afford oral health services. Third, strengthen the oral health education of parents and caregivers, and advocate routine dental visits.