Prevalence of oral pain and barriers to use of emergency oral care facilities among adult Tanzanians

In Tanzania, most of the oral health care is rendered at government owned dental clinics, which are established within the hospitals in the regional and district capitals. Patients from rural areas have to travel to towns to seek dental services. Before 1994, the health care services, oral health included, were fully funded by the government. Thereafter, the policy on cost sharing in health was introduced, by which patients aged six years and above are required to pay for their health care. Along with this policy, patients age 60 years old and above and any younger patient who is confirmed to be poor that he/she is unable to pay for health care also receives service free of charge. Since documentation for age and personal/family income is not well developed in Tanzania, the exception criterion based on age or inability to pay presents a challenge to hospital administrators. A study which compared the attendance data one year before and after the introduction of cost sharing in health revealed an overall drop of 33% in attendances, indicating a negative effect on the utilization of oral health services in Tanzania [1].

Oral pain has been the major cause of attendances in all dental clinics in Tanzania [2]. A review of patient records at the School of Dentistry, Dar es Salaam indicated that the majority of patients who had attended the dental outpatient clinics during the month of March 2007 complaining of pain had delayed for two to three days before they reported for treatment. The negative impacts of orofacial pain on quality of life have been documented as substantial in several studies [3–6]. The major negative impacts of orofacial pain include physical and psychosocial disabilities to the persons afflicted [3–6], and to their associates [6].

Reducing the episodes and the duration of oral pain is one of the objectives of oral health care in Tanzania. To achieve this objective, oral health care planners and providers will, among other undertakings, require a better understanding of the barriers to prompt seeking of emergency oral care due to oral pain. Once the barriers to prompt seeking of emergency oral care have been identified and addressed, people would likely seek emergency oral care without delays and therefore reduce the duration of suffering from oral pain. This would in turn contribute to the improvement in the quality of life and the well being of Tanzanians, which has been identified as one of the broad outcome measures for reduced poverty and improved economic growth for Tanzania [7].

Literature on oral pain and the utilization of oral health care in Tanzania indicates that all the previous studies reported high proportions of patients who sought care due to oral pain. A report by van Palenstein and Nathoo shows that in 1989, 77% to 97% of all the dental attendances in Tanzania were due to oral pain [8]. In 1993, Mosha et al. [9] reported that on average, 82% of all the adults who had attended the oral health care facilities in Tanzania had sought emergency oral care at least once during their lifetime. In an interview of families who lived in a catchment area of a rural health centre which had rendered emergency oral care for two years, 40% of all families interviewed had one or more of their members who had used the service within the two years of its establishment [9, 10].

None of the publications quoted in the preceding paragraph reported on the prevalence of oral pain in the community or on the barriers to the use of the emergency oral care facilities. In their report, van Palenstein et al. [8] pointed out that the hospital data might be showing only a tip of the iceberg of all the people who suffered from oral pain in communities. The aim of this study was to determine the prevalence of oral pain and/or discomfort and the barriers to use of the emergency oral care facilities due to oral pain or discomfort among adult Tanzanians.

Respondents from rural areas were more likely to report lack of money for transportation to dental clinics as a reason for not seeking emergency care from the oral health care facilities than their counterparts from urban areas (OR = 2.12, CI = 1.34–3.36, P < 0.01). They were also more likely report dental clinics far from home (OR = 5.31, CI = 2.09–13.54, P < 0.001); self medication at home (OR = 3.65, CI = 2.25–5.94, P < 0.001); and being treated by traditional healer (OR = 5.31, CI = 2.25–12.49, P < 0.001) as reasons for not seeking emergency care from the oral health care facilities than their counterparts from urban areas. Moreover respondents from rural areas were less likely to report that they had no substantial reasons for not seeking emergency care from the oral health care facilities than urban residents (OR = 0.58, CI = 0.45–0.75, P < 0.001).

Women were more likely to report that they had no money for treatment than men (OR = 1.37, CI = 1.03–1.83, P < 0.05). Also women were less likely to report no substantial reason for not seeking emergency care from oral care facilities than men (OR = 0.68, CI = 0.54–0.85, P < 0.01). Older adults were more likely to report dental clinic far from home as a reason for not seeking emergency oral care than young adults (OR = 2.80, CI = 1.59–4.93, P < 0.001). They were also more likely to report lack of money for treatment (OR = 1.36, CI = 1.01–1.81, P < 0.05) and/or transport to clinic (OR = 1.51, CI = 1.04–2.20, P < 0.05) as reasons for not seeking emergency oral care than young adults. Also older adults were less likely to report that they had no substantial reason for not seeking emergency care than young adults (OR = 0.61, CI = 0.48–0.78, p < 0.001).

The interpretation of the data reported in this study should be done with the following methodological limitations in mind: First, probability sampling was not used to obtain study clusters. Secondly, only adults who were present at their homes during the study hours were interviewed. Although random sampling was used to obtain regions for inclusion into the study and the study hours adjusted to suit times when most of adults were expected to be present at their homes, one cannot say with certainty that the data is representative of adults in Tanzania. Nevertheless, the strategy of moving from one household to another and interviewing adults at their homes minimized the selection bias that would arise from calling respondents to one location in a street. Calling respondents to one location in a street would have included, in the study, only adults who were enthusiastic and ready to participate in joint street activities, while leaving out adults who were less receptive. This also controlled the selection bias that could have arisen from street leaders selecting the households of their interest. In addition, the fact that each administrative zone was represented took care of the possible variations between zones. Furthermore, the predetermined number of respondents in each sex and age-group ensured that both sexes and age-groups were fairly represented in the study. Given all these control measures, the authors were satisfied that the findings reported in the present study were reliable enough to be used for planning purposes.

The prevalence of oral pain reported in the current study (58.8%) was higher than those reported in Brazil, Nigeria, and Burkina Faso which were 39.9%, 34%, and 27.7% respectively [4, 13, 14]. The proportion of respondents (26.5%) who used the emergency oral health care facilities following an episode of oral pain in the present study is similar to that reported among adults in Burkina Faso (27.7%) [14]. In the present study, lack of money was the most frequently reported barrier to seeking emergency oral care. This finding is similar to that reported among rural villagers in Tanzania, adult population in Burkina Faso and among University students in Kenya [10, 14, 15]. Similar findings were also reported among underserved communities in USA [16–18]. These findings indicate that cost may be a major barrier for seeking oral care in many communities whose earnings just meet the bare minimum of life.

The finding that 58.8% of all respondents had experienced some episodes of oral pain or discomfort during the 12 months preceding the interview, indicate that oral health problems are common among adults in Tanzania. Since only 26.5% of those who experienced some episodes of oral pain or discomfort sought emergency oral care in oral health care facilities, it can be extrapolated that if all adult Tanzanians who experience oral pain or discomfort would seek emergency oral care in oral health care facilities, the current workload in these facilities would triple, and would necessitate an increase in the facilities and human resources to meet such demand.

About a third of respondents who had not sought emergency oral care despite having experienced oral pain or discomfort during the last 12 months leading to the study, gave no substantial reasons for not seeking such service. These might have had only mild discomfort that did not require emergency oral care. It might also mean that pain disappeared before they were able to seek treatment. Similar response could also have been elicited from adults who tolerated oral pain due to other competing needs that involved time and finances. It is on this account that it is worth noting that the questionnaire did not adequately capture the reasons why some respondents did not have 'substantial reasons' for not seeking emergency oral care. It is hereby recommended that future studies on reasons for not seeking emergency oral care should be undertaken to address this shortfall.

About a third of the respondents could not seek emergency oral care because of financial reasons. The Ministry of Health should make people aware of the provision for exemption for those who cannot pay for these services. This will allow more people who cannot afford the treatment fees to access emergency oral care. It is hoped that the current government's efforts aimed at reducing poverty and increasing the economic growth for all Tanzanians are likely to reduce the identified barriers for seeking emergency oral care. This is because higher economic status has been shown to correspond with high utilization of oral health services [14]. There is also a need to raise awareness among Tanzanians on the importance of prompt seeking of oral care to prevent adverse sequel of advanced oral diseases. This is particularly important because, as already mentioned, 1/3 of those who had had pain or discomfort reported to have no substantial reasons for not seeking emergency oral care. In addition, a study among the people in one region in Tanzania did reveal that not all people in Tanzania who report to have not utilized health services due to financial reasons are actually unable to pay for the service. Rather, they use the pretext of being poor as a convenient way of explaining away their negligence [19].

The findings that women were more likely to report that they had experienced oral pain than men is likely to be due to cultural traditions. In Tanzania, men tend to shy away from reporting pain because it is generally taken as 'normal' for a man to tolerate pain. This observation conforms to what has been reported in other countries [20–22]. This may also explain why more men than women did not seek emergency oral care on the assumption that pain would disappear spontaneously.

People who live in rural areas were disadvantaged in relation to accessing the emergency oral care from oral care facilities compared to those who live in urban areas. In the present study, respondents from rural areas were more likely than respondents from urban areas to give reasons such as distance from their home, lack of money for transportation to dental clinics; being treated by traditional healers; and using medicines at home for not seeking emergency oral care from oral care facilities. Since oral pain and discomfort were equally prevalent among rural and urban residents, there is a need for establishing oral health care services in rural health centres and dispensaries.

From the present study, we conclude that: a) the prevalence of oral pain or discomfort was equally high among rural and urban adult Tanzanians; b) only a quarter of those who had experienced episodes of oral pain or discomfort sought emergency oral care from the oral care facilities; and c) proportionately more rural residents reported more barriers to the use of oral care facilities than did urban residents. The Ministry of Health should consider establishing oral health care services in rural areas to improve accessibility of oral care facilities by rural residents. Because a third of the respondents did not give reasons for not seeking emergency oral care despite having experienced oral pain, further studies are needed to better understand the oral health care seeking behaviour among adult Tanzanians.