Exploring the Socio-Demographic Profile of Non-Completion in Public Oral Healthcare Services: A Cross-Sectional Study in Melbourne, Victoria

Abstract

(1) Background: Completion of the full oral health course of care (CoC) is essential to prevent further deterioration of oral and overall health. Understanding these patterns, particularly in public oral healthcare services, is crucial for improving access to and the delivery of care. This study aims to identify the socio-demographic and clinical characteristics of adult patients who did not complete required dental treatments within a 12-month period at Monash Health Dental Services (MHDS), Melbourne, Victoria. (2) Methods: Data were collected on patients’ course of care (CoC), socio-demographic characteristics, and clinical information from the MHDS Titanium electronic database. This study represents a secondary data analysis from adult patients who attended MHDS between November 2022 and October 2023, excluding emergency dental care visits. Logistic regression analyzed the socio-demographic and clinical variables affecting CoC. (3) Results: Our findings identified several significant predictors of incomplete CoC; being a non-priority group, mental health clients, refugees, and identifying as Aboriginal or Torres Strait Islanders (OR = 1.41; 95% CI: 1.08–1.84). Conversely, speaking a language other than English increased the odds of completing treatment (OR = 0.85; 95% CI: 0.74–0.98). By age, patients in the 36-to-55- or the 56-to-75-year-old age groups were more likely to be in the incomplete group (OR = 1.65; 95% CI: 1.37–1.98; and OR = 1.43; 95% CI: 1.22–1.66, respectively). (4) Conclusions: This study identified predictors of discontinued care, emphasizing accessibility and equitable outcomes for users of public oral healthcare. The findings indicate that the predictors of course of care (CoC) completion differ from barriers to accessing care. This highlights key objectives in public health dentistry, focusing on improving accessibility and promoting equitable oral health outcomes for vulnerable populations.

1. Introduction

Regular dental visits play a crucial role in the early detection and treatment of oral conditions, as well as in promoting oral health and educating individuals on oral hygiene [1,2]. However, due to the inequalities present in the Australian health system, not all Australians are achieving the same degree of oral health [3]. Substantial oral health disparities continue to exist among different groups within the Australian population [4]. In 2022–2023, 52% of Australians visited a dentist [4]. Notably, approximately 20% of adults who were eligible for subsidized public oral healthcare accessed these services [5,6].

Understanding the utilization of public oral healthcare services is essential due to oral health’s impact on overall quality of life. Investigating oral healthcare utilization can shed light on under-represented population groups, often from socially disadvantaged backgrounds. These groups are a priority in Australia’s National Oral Health Plan [3]. Evidence shows that eligible individuals from socially disadvantaged backgrounds in Victoria experience poorer periodontal health, and higher rates of dental disease like caries and oral cancer [7,8,9]. Research indicates that these groups encounter elevated rates of oral health issues and face significant hurdles in accessing and completing dental care. Access to public oral healthcare in Australia is predominantly determined by the possession of a Commonwealth Health Care or Pensioner Benefit Card. These cards provide individuals with eligibility for subsidized oral healthcare services. However, the allocation of appointments is typically conducted on a “first-come first-served” basis.

However, the ability of a person to use oral healthcare services (i.e., access) extends beyond mere accessibility; adherence to treatment becomes equally, if not more, significant when involving patients eligible for public dental services, as universal access does not ensure adherence to treatment [10,11]. Extensive evidence highlights that the outcomes of dental treatment (such as tooth preservation, recurrent pain, and overall quality of life) are directly linked to the completion of the course of care (CoC) [10,12]. Additionally, studies demonstrate that individuals who do not finish their treatment courses often belong to the high-caries patient group [13,14]. Furthermore, incomplete and non-compliance with dental treatments pose financial burdens on patients, oral healthcare service providers, and society at large.

Therefore, it is important for oral health providers to identify the causes behind the discontinuation of dental treatment, ensuring that oral healthcare needs are treated, and any barriers are effectively addressed. The aim of this study was to investigate the socio-demographic characteristics of adult individuals who had not completed necessary dental treatments within a 12-month period at Monash Health Dental Services in Melbourne, Victoria. Investigating the socio-demographic characteristics and clinical information of patients was hypothesized to identify factors contributing to incomplete dental treatment.

The completion of full comprehensive oral care will prevent the deterioration of oral conditions and consequently general health. These profiles offer insights into the specific oral health services required and assess whether current services align with the needs of beneficiaries of public dental services in Victoria. Such an approach serves the public health interest of consumers while benefiting oral health providers. These data hold significance in guiding planners towards developing effective oral health education interventions to increase awareness among patients on the importance of completing CoCs. Further examination of incomplete CoC groups will highlight how to engage with these patients and overcome obstacles that interfere with patient compliance with oral healthcare treatments. This aligns with crucial objectives in public health dentistry, emphasizing accessibility and equitable oral health outcomes, particularly for the most vulnerable [15].

2. Materials and Methods

2.1. Study Setting

Monash Health Dental Services, located in Victoria’s capital city, stands as Victoria’s largest public health dental provider, catering specifically to priority population groups. This encompasses Aboriginal and Torres Strait Islander peoples, children, youth, homeless individuals or those at risk of homelessness, pregnant women, refugees, asylum seekers, and those seeking specialized healthcare including mental health services [3].

2.2. Study Design and Study Population

This study was an audit of dental records conducted as part of a quality assessment and improvement activity, using a cross-sectional study design to evaluate the current status of treatment adherence by adult clients (18 years or older), accessing Monash Health Dental Services over a 12-month period; between November 2022 and October 2023.

This research involved a secondary analysis of information sourced from the capabilities of an Electronic Health Record (EHR) system (i.e., the Titanium electronic database) that was not primarily designed for clinical research. The data used for this study encompassed clients for whom information, including their course of care category, was completely documented at the time of the data collection. Information was gathered from all clinics from MHDS (n = 7), capturing data from all clients within the specified data collection timeframe. Ethical approvals for this study were obtained from Monash Health Human Research Ethics Committee. The preparation of this manuscript adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) recommendations [16].

2.3. Independent Variables

The following socio-demographic characteristics were included in this analysis: age (‘18 to 34’; ‘35 to 54’; ‘55 to 74’; and ‘75 and older’), sex (Male/Female), Aboriginal/Torres Strait Islander status (Yes/No), country of birth (‘Australia’/‘Other’), asylum seeker (Yes/No), preferred language (‘English’, ‘Other than English, but not Dari’ and ‘Dari’), need for interpreter (Yes/No), and priority access to identified clients belonging to a priority access group (Yes/No).

Australia offers various types of concession and healthcare cards, each with distinct eligibility criteria and benefits. These cards grant card holders access to public healthcare services and allow for more affordable medications (‘Pensioner Card’/‘Health Card’, or ‘Non-card Holder’).

Data on the location of clinics used within MHDS were recorded as ‘Thomas St.’ and ‘Other’, which included the six dental clinics: ‘Berwick’; ‘Kingston’; ‘Cranbourne’; David St’; ‘Pakenham’; and ‘Springvale’. Distance to the dental clinic was classified as ‘Close’ if they lived in the same or contiguous postcodes; and ‘Not close’.

Type of course of care was recorded according to the Australian Dental Association service item code and descriptor [17]: (‘Endodontics’, ‘Exodontia/Surgery’, ‘Restorative’, ‘Dentures’, ‘Periodontics’, ‘Prevention’, ‘Radiography’, ‘Dental examinations’, and ‘Others’).

2.4. Outcomes

For the purposes of this study, the outcome of interest was the course of care (CoC). The course of care was classified as ‘No compliance’ (‘Closed CoC with the reason that treatment was not completed’), and ‘Compliance’ (‘Closed CoC with the reason that treatment was completed’ or ‘Open CoC without future appointment’). Open courses of care with a future appointment, indicating that the client was still under care, were excluded from this analysis. Emergency CoCs were also excluded from this analysis.

2.5. Analysis

This analysis first presents descriptive details regarding the sample’s demographic and clinical characteristics. To determine differences between groups on dependent variables, ANOVAs (continuous measures, e.g., age) and Chi-square tests (categorical measures, e.g., sex) were used. To explore how socio-demographic and clinical variables related to the probability of having incomplete dental treatment, a stepwise logistic regression analysis (LRA) was conducted. This analysis aimed to explore the likelihood of an adult patient being in the incomplete CoC group, using socio-demographic (e.g., age sex, type of health card, etc.) and clinical predictors (e.g., type of CoC, etc.). The final model comprised predictor variables with a p-value below 0.05. The stepwise selection method using forward selection was employed to develop the final model, where cases with missing values were excluded using casewise deletion. IBM-SPSS Statistics (Version 29.0) facilitated data manipulation, checking for assumptions under multivariate methods, and overall analysis.

3. Results

During the specified period, excluding those who received emergency care only, a total of 6742 adults received treatment at the dental clinics of Monash Health. Of them, 1094 adult patients were excluded due to having ongoing CoC with scheduled future appointments. Of the remaining 5648 adults, 41.3% (n = 2333) were participants who had not completed the dental treatment required with no future appointment. On average, the sample was 30.3 years of age (SD 27.5). Approximately one-quarter (22.7%) of the participants were aged 76 years or older, with seventy-seven individuals being over 90 years of age. Overall, there were more females (56.1%) than males (43.9%).

About one-third (35.0%) of clients were born in Australia. Another 21.1% nominated Afghanistan as their country of birth. The remaining clients nominated another 104 countries of birth, but none reached more than 2.8% of the total cases. Of all public dental service adults included in this study, only 2.6% (n = 145) reported having Indigenous heritage. According to language spoken at home, 66.8% reported English as the language spoken at home. Public dental clients nominated 68 different languages, including English. The most frequently reported language other than English (66.8%) was Dari (12.6%) (see

Table 1. Bivariate associations between predisposing, enabling, need, and clinical variables and non-compliance with course of care in oral healthcare †.

Variable	N (%)	Compliance %	Non-Compliance %
Sex
Male	2470 (43.9)	58.6	41.4
Female *	3152 (56.1)	59.0	41.0
Age group ***
18 to 34	1044 (18.5)	41.4	58.6
35 to 54	1358 (24.0)	51.5	48.5
55 to 74	1966 (34.8)	66.7	33.3
75 and older	1280 (22.7)	68.1	31.9
Language spoken at home
English	3771 (66.8)	60.7	39.3
Other than English and Dari	1165 (20.6)	59.0	41.0
Dari	712 (12.6)	47.6	52.4
Card type ***
Pensioner Card	1443 (25.5)	50.2	49.8
Healthcare Card	3715 (65.8)	64.2	35.8
Non-card Holder	490 (8.7)	42.0	58.0
Course of Care ***
Examination	1242 (26.1)	45.9	54.1
Preventive	1243 (22.0)	49.5	50.5
Radiograph	699 (12.4)	51.9	48.1
Restorative	372 (6.6)	64.5	35.5
Endodontics	46 (0.8)	60.9	39.1
Periodontics	31 (0.5)	54.8	45.2
Dentures	1473 (25.9)	82.7	17.3
Exodontia	170 (3.0)	61.2	38.8
Other	372 (6.6)	43.5	56.5
Refugee status (Yes) ***	868 (15.4)	37.3	62.7
Mental health patient (Yes) **	351 (6.2)	51.6	48.4
Aboriginality (Yes) ***	145 (2.6)	34.5	65.5
Non-priority group (Yes) ***	3874 (68.7)	65.6	34.4

† Chi-square test * p < 0.05; ** p < 0.01; *** p < 0.001.

). Of those who reported speaking a language other than English at home, only 16.7% (n = 942) indicated the need for an interpreter. Eight-hundred-sixty-eight clients reported refugee status (15.4%). Of the total sample, 65.8% held a pensioner concession card, and 25.5% held a healthcare card. Another 8.7% were non-card holders.

The largest distribution of clients was seen in the Thomas Street clinic (51.1%), with 91.6% of clients living close to the clinics. Overall, the largest proportion of oral healthcare services provided were prosthetic appliances (33.5%), followed by oral examinations, consultation referrals, etc. (18.8%), and X-rays (13.5%). Another 11.3% received preventive treatments (e.g., dietary analysis, oral hygiene instruction, tobacco counselling, fissure sealants, etc.), and 6.0% received restorative treatments.

Table 1 presents the results of the bivariate analysis. This analysis suggests that age, language spoken at home, type of health card, course of care, and belonging to a priority group play a significant role in compliance with CoC.

However, to better explore the probability of incomplete required dental treatment at Monash Health Dental Services in the last 12 months, a logistic regression analysis was performed using 12 predictors, including 5 predisposing variables (age, sex, distance to CHC, country of birth, and type of health card), 5 enabling and needs variables (priority access, refugee status, language spoken at home, aboriginality, and need for interpreter) and 2 clinical variables (type of course of care, clinic). The final model included seven statistically significant variables significantly associated with the probability of not completing dental treatment [χ²(9) = 716.69; p < 0.001]. After controlling for all the variables present in the model, those who spoke English at home were more likely to be in the group with incomplete dental treatment (OR = 1.18; 95% CI: 1.02–1.35), compared to clients who spoke languages other than English at home. By type of CoC, those in the ‘Dentures’ group were less likely to have incomplete treatments compared to the other CoC groups (OR = 0.28; 95% CI: 0.24–0.33) (

Table 2. Regression coefficient, odds ratios, and 95% confidence interval for odds ratios for the factors predicting non-compliance with course of care in oral healthcare (n = 5648).

	β Coefficient	Odds Ratio	95% Confidence Interval
Age group
18 to 34		Reference
35 to 54	−0.81	0.92	0.78–1.09
55 to 74	−0.42	0.66	0.55–0.78
75 and older	−0.31	0.73	0.61–0.90
Language spoken at home
English (1 = Yes)	0.16	1.17	1.02–1.35
Refugee status (1 = Yes)	0.73	2.08	1.73–2.50
Aboriginality (1 = Yes)	0.86	2.37	1.64–3.41
Mental health client (1 = Yes)	0.36	1.43	1.13–1.80
Clinic (1 = Thomas St)	−0.32	0.73	0.65–0.82
Type of course of care (1 = Dentures)	−1.27	0.28	0.24–0.33
Constant	0.025

The variance in dental visits accounted for using the full model was 16.0% (η² = 0.160).

).

Refugees were more likely to be in the incomplete group (OR = 2.08; 95% CI: 1.73–2.50) compared to non-refugees. Aboriginality increased the odds of being in the non-completion group (OR = 2.37; 95% CI: 1.64–3.41). When compared to clients 18 to 34 years of age, those in the 55-to-75-year-old or in the 75 and older age groups were less likely to be in the incomplete group (OR = 0.66; 95% CI: 0.55–0.78; and OR = 0.73; 95% CI: 0.61–0.90, respectively). However, those in the 35-to-54-year-old group showed no difference from the 18–35-year age group in terms of being in the non-compliance group. By dental clinic, those who attended the Thomas St clinic were less likely to be in the non-completion group (OR = 0.73; 95% CI: 0.65–0.82). Additionally, mental health clients were more likely to be in the non-completion group (OR = 1.43; 95% CI: 1.13–1.80). The variance for the ability to predict a non-completion case, using the full model, was 16.0% (Nagelkerke r² = 0.160) (Table 2). In the final multivariate model, there were no differences associated with the non-completion of required treatment by sex, card type, need for interpreter, proximity to the CHCs, country of birth, or belonging to any other priority group.

4. Discussion

This cross-sectional study identified several factors associated with incomplete dental treatment, which highlights the complex interplay of socio-demographic factors and clinical circumstances (i.e., type of course of care, location of clinic, etc.) influencing completion of dental CoC in public dental settings. Patients receiving ’Dentures’ were less likely to have incomplete treatment compared to other CoC groups. Furthermore, refugees and individuals identified as Aboriginal and Torres Strait Islander were more likely to have incomplete oral health treatments despite being given priority access and co-payment exemption. The location of treatment also played a role, with services provided at various sites associated with varying chances of incomplete treatments. Further research needs to be conducted to identify contributing factors. Identifying the reasons behind non-compliance can provide insight into the complex interplay of factors influencing patient compliance/non-compliance behavior; for example, knowledge and attitudes about oral health treatments, socioeconomic status, cultural beliefs, and past patient experiences.

In the present study, certain demographic and clinical variables reported in the literature as associated with the use of services [18] did not show significant associations with the non-completion of oral health treatments; for example, sex. Research indicates that women often use dental services more frequently than men [19]; however, the present findings showed no statistically significant differences. Regarding an age effect, oral healthcare needs vary across age groups. For instance, older adults may have specific dental care requirements, and their use of health services may be influenced by other healthcare needs associated with ageing or may have medical conditions that make oral health treatments challenging. Despite this, we found that the oldest group (i.e., 76 years or more) had the same probability of completion as those in the youngest age groups (i.e., 18–34 years). However, those aged 35 to 75 years were more likely to be in the non-completion group.

Usually, the cost of treatment and financial constraints delay care and may hinder individuals from completing treatments, but this is a group of patients that receive care at a subsidized cost. Using types of health cards as a proxy for income, the present findings would indicate that income is not a factor in non-compliance oral health outcomes.

Refugee and ethnic minority populations generally face barriers such as language, cultural differences, systemic inequalities, and poor oral health literacy, which are shown to lead to lower oral healthcare service utilization, negative oral health beliefs, and negative oral health behaviors [20]. However, our findings indicate that this statement held true specifically for refugees, while there were no significant differences in completing the course of care (CoC) between other non-Australia-born and Australia-born patients in the multivariate analysis. Moreover, by employing the language spoken at home as a proxy of acculturation, the present findings imply a potential link between the cultural construct and oral health experiences. Given that cultural factors impact individuals within a cultural or ethnic group differently, the exploration of acculturation experiences becomes imperative for the delivery of culturally competent services and programs [21]. It was observed that patients who spoke a language other than English at home were less likely to complete dental treatment compared to patients who indicated English as their spoken language at home.

In summary, the present findings are of importance as they suggest that variables linked to access to oral healthcare and service utilization may not necessarily be associated with compliance. This insight underscores the need for additional efforts to understand factors influencing both service usage and adherence to treatment, prompting further exploration in the realm of healthcare dynamics. Further research needs to be conducted to identify the barriers these patients experience. Recognizing these factors are essential for crafting targeted public health initiatives, enhancing healthcare accessibility, and minimizing disparities in oral health outcomes, ensuring better completion rates of necessary dental treatments among diverse patient groups within public dental care settings. Tailored interventions or programs specifically designed to address the distinct requirements of diverse demographic groups play a pivotal role in fostering fair and inclusive utilization of oral health services [22]. Furthermore, this holds even more significance as research has demonstrated that disparities in oral health closely parallel those observed in general health [23] and continue across the entire lifespan [24].

While this information is useful, it only provides initial information. The findings reflect the socio-demographic and clinical characteristics of those who used Monash Health Dental Services, which represent an urban population. As such, this analysis permits only an approximation of the true profile. Further exploration of non-compliance groups, in particular, by geographic variations (those living in remote/rural regions), by health literacy, and for patients under 18 years, is needed. Additionally, users were healthcare card holders, and as such were at an economic or social disadvantage and may have worse non-completion rates than those who are able to access private dentistry [25].

In the same manner, information about structural barriers to care, such as a lack of transportation to reach oral healthcare services, was not available. Several factors may contribute to the non-completion of oral healthcare treatments [26]. Factors such as dental phobia or anxiety, or pain or discomfort from treatments, may lead individuals to avoid or delay completing dental treatments. Misunderstanding or lack of information regarding the severity of their dental issues and the importance of completing treatments; time constraints and practicalities of life; other health conditions; and a lack of trust in the dentist’s skills or communication were not explored in the present study. Some of these factors are more easily researched using different research methodologies (i.e., qualitative methods), and would have provided complementary information to understand non-compliance, as well as the general oral health experience.

Nonetheless, while our data may have limitations, Monash Health is the largest healthcare provider in the state of Victoria, and as such we believe that our study represents a substantial sample of users of dental public health services. The significance of this insight lies in its role in designing targeted health programs catering to specific user groups’ needs. By adopting targeted interventions, we can create a more inclusive and responsive healthcare environment, promoting better oral health outcomes for diverse populations. This information constitutes valuable contributions to healthcare delivery and for the formulation of policies [27].

Completion of the full oral health course of care (CoC) is essential to prevent further deterioration of oral and overall health. The findings from this study offer insights into predictors of discontinued CoCs among beneficiaries of public oral healthcare services, helping to identify non-compliance groups and informing strategies to address oral health priorities, diminish health inequalities in health and wellbeing, and enhance the coordination and targeting of services to align with local needs. By examining incomplete CoC groups, the research highlights the health needs of consumers and benefits oral health providers. The findings suggest that predictors of CoC completion differ from barriers to access, reinforcing key objectives in dental public health by emphasizing accessibility and promoting equitable oral health outcomes, particularly for vulnerable populations. Evidence suggests that integrating oral health into primary care services is a targeted approach which may begin to address oral health inequalities [28]. Such coordinated efforts may enhance service delivery, ensuring equitable oral health outcomes for those most in need.

Further exploration of non-compliance groups would provide additional information on how to reach and engage these groups and overcome the barriers they face in accessing oral healthcare. Inappropriate approaches could inadvertently exacerbate inequalities, following the principle of the “inverse care law”, where those in greatest need may not receive the necessary attention [23,29].