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Utilization of dental health care services in context of the HIV epidemic- a cross-sectional study of dental patients in the Sudan
© Nasir et al; licensee BioMed Central Ltd. 2009
Received: 27 January 2009
Accepted: 16 November 2009
Published: 16 November 2009
HIV infected patients should be expected in the Sudanese dental health care services with an increasing frequency. Dental care utilization in the context of the HIV epidemic is generally poorly understood. Focusing on Sudanese dental patients with reported unknown HIV status, this study assessed the extent to which Andersen's model in terms of predisposing (socio-demographics), enabling (knowledge, attitudes and perceived risk related to HIV) and need related factors (oral health status) predict dental care utilization. It was hypothesized that enabling factors would add to the explanation of dental care utilization beyond that of predisposing and need related factors.
Dental patients were recruited from Khartoum Dental Teaching Hospital (KDTH) and University of Science and Technology (UST) during March-July 2008. A total of 1262 patients (mean age 30.7, 56.5% females and 61% from KDTH) were examined clinically (DMFT) and participated in an interview.
A total of 53.9% confirmed having attended a dental clinic for treatment at least once in the past 2 years. Logistic regression analysis revealed that predisposing factors; travelling inside Sudan (OR = 0.5) were associated with lower odds and females were associated with higher odds (OR = 2.0) for dental service utilization. Enabling factors; higher knowledge of HIV transmission (OR = 0.6) and higher HIV related experience (OR = 0.7) were associated with lower odds, whereas positive attitudes towards infected people and high perceived risk of contagion (OR = 1.3) were associated with higher odds for dental care utilization. Among need related factors dental caries experience was strongly associated with dental care utilization (OR = 4.8).
Disparity in the history of dental care utilization goes beyond socio-demographic position and need for dental care. Public awareness of HIV infection control and confidence on the competence of dentists should be improved to minimize avoidance behaviour and help establish dental health care patterns in Sudan.
The number of dentists in the public sector in Sudan has increased from 244 to 512 in the period from 2003 to 2007 and the dentist population ratio in Khartoum state (1.7:100000) is the highest in the country . Dental care utilization of the public in light of the Human Immunodeficiency Virus (HIV) epidemic is so far poorly understood. With the exception of the Sudan the HIV epidemics in the Middle East and North Africa is comparatively small . This is particularly so in Sub-Saharan Africa where an estimated 22 million people were living with HIV and Acquired Immune Deficiency Syndrome (AIDS) towards the end of 2007 and where access to dental health care services is commonly very limited [3, 4]. In Sudan, the largest country on the Sub Saharan African continent, the prevalence of HIV and AIDS is still low. According to a population based study conducted in 2002, the sero-prevalence was estimated to be 1.6% [5, 6]. However, being bordered by nine countries, some having a high prevalence of HIV and AIDS and having experienced long term ethnical and political conflicts, Sudan is vulnerable for an increase in the prevalence of HIV infections . Thus, HIV infected patients should continue to be expected in the Sudanese dental health care services with an increasing frequency.
Oral lesions might be encountered at an early stage of HIV infection . Weinert et al.  identified 16 oral conditions that might occur in HIV infected patients, seven of which can be suppressed by drug therapy. Oral health professionals can contribute to early diagnosis, prevention and treatment of HIV and AIDS infection . Thus, it is recommended that HIV infected individuals should see a dentist regularly . A number of studies have indicated unwillingness on the part of dental professionals to treat persons with HIV and AIDS due to fear of loosing non-HIV infected patients [11, 12]. Since cross-infection might take place from patient to patient, from dentist to patient and vice versa, the advent of the HIV pandemic with increased awareness of cross infection among dental professionals and the public, has necessitated introduction of strict HIV protective procedures in dentistry [13, 14]. However, poor compliance with standard infection control procedures have been reported, for instance in the South African Demographic and Health Survey of 1988 as well as more recent studies [15–17].
Recent findings based on the 1998 Community Health Assessment Project (CHAP) and the Behavioural Risk Factor Surveillance System (BRFSS) revealed that socio-demographics in terms of race (whites more likely to visit the dentist), income (higher income most likely to visit the dentist), education (higher education more likely to visit the dentist) and marital status (married most likely to visit the dentist) are the most important determinants of dental visiting habits in the general US population [14, 18, 19]. Several other factors have been reported to be associated with use of dental care, such as gender, non-poverty status, having a positive attitude towards dental health- and dental health care, having pain and being dentate [14, 19, 20]. Little is known, with respect to the public's HIV related knowledge, attitudes and fear of contagion in the dental environment and how such perceptions impact dental attendance patterns. Humphris et al.  reported that one third of the UK regular dental attendees believed that there was at least a slight risk of contracting HIV infection at the dental clinic. Lancaster et al  reported common misunderstandings regarding the public's knowledge about HIV and AIDS. In a Nigerian study of public perceptions of cross-infection control in dentistry, more than half of the respondents investigated felt that they could contract an infection in the dental clinic and 43% identified HIV as a risk . Pistorius et al  examined dental patients in Germany and found that about 17% were generally afraid of contracting an infection at a dental office. Thomson et al  examined perceptions of cross infection in dentistry among Australians and found that 3.6% reported delayed or avoided dental visits due to perceived cross infection, the avoidance rate being highest in females and those who reported concern about cross infection control. A Mexican study revealed that only 21.2% of the study participants intended to continue treatment at a dental practice where patients with HIV were treated and 20% had similar intentions if the dentist was HIV positive . To date, there has been no study exploring dental care utilization in the context of public knowledge of HIV and AIDS and perceived risk of contagion in the Sudan.
Focusing on a sample of Sudanese dental patients with reported unknown HIV status, this study assessed the extent to which the components of Andersen's model in terms of predisposing factors (socio-demographics), enabling factors (knowledge, attitudes and perceived risk related to HIV and AIDS infection in dental practices) and need related factors (clinically and self perceived oral health status) predict dental care utilization in terms of their relative contribution. It was hypothesized that enabling factors in terms of HIV related knowledge, attitudes and fear of contagion would add to the explanation of dental care utilization independent of predisposing- and need related factors.
The present cross-sectional study was carried out from March to July 2008. Survey participants were recruited from dental clinics at two teaching hospitals in Khartoum state; Khartoum Dental Teaching Hospital (KDTH) and University of Science and Technology (UST). In both hospitals, all patients coming with dental complains are registered and then seen at the outpatients 'diagnostic' department for oral examination. All patients between 20 and 60 years of age with reported unknown HIV and AIDS status were invited to participate in the study. A total of 769 patients in KDTH (response rate 769/2650, 29.0%) and 491 patients in UST (response rate 491/950, 52%) consented to participate in a clinical examination, and an interview. Pre-test and post-test counselling was arranged before the conduction of the study. Reason for not participating was mainly due to time constraints on the part of patients and eagerness to receive the dental treatment. A sample size of 1200 patients was assumed to be satisfactory for a two-sided test assuming the proportion of dental care utilization in the previous 2 years to be 0.15 and 0.20 in patients with respectively low- and high education, a significance level of 5% and a power of 95%. Ethical permission was obtained from the Norwegian Regional Ethical Committee, Sudan National AIDS Programme (SNAP) and from the UST, and KDTH prior to conduction of the study.
One trained and calibrated dentist (EFN) conducted all clinical examinations in dental clinic settings equipped with an adjustable dental chair and artificial lightening. Examination was conducted using disposable gloves, sterilized dental mirrors, periodontal probes and dental explorers. Dental caries was recorded using the Decayed, Missing, Filled Teeth (DMFT) index, according to the guidelines by WHO  and recorded 0 or 1 (no caries experience, DMFT>0). Duplicate clinical caries registrations with 2 months interval were carried out among fourteen chair side dental assistants at UST. Intra examiner reliability in terms of Cohen's kappa for the DMFT components was 1.
A structured face-to-face interview including, questions on socio-demographic characteristics, oral health related behaviours, sources of HIV and AIDS related information, HIV related knowledge and attitudes was constructed in English and translated into Arabic by a dentist and then re-translated back to English by another dentist to check for consistency in the language. Two dentists (a male and a female) were assigned and trained for carrying out the interviews. Patients were interviewed in a confidential atmosphere while waiting for the clinical examination. The behavioural model proposed by Andersen was applied to identify variables to be considered relative to the use of dental health care services.
Percentage distribution (n) of dental patients' socio-demographic characteristics (predisposing factors) in UST and KDTH hospitals:
UST % (n)
KDTH % (n)
Total % (n)
52.4 (257) **
University and higher
Technical, office, skilled labour
Travelling inside Sudan
Travelling outside Sudan
Use of dental services was assessed by asking "During the past 2 years - have you attended a dental clinic in order to receive treatment? Responses were given as (1) yes and (2) no.
Data were analyzed using the Statistical Package for Social Sciences version 15.0 (SPSS Inc., Chicago, Illinois, USA). Bivariate analyses were conducted using cross-tabulations and Chi-square statistics. Determinants of use of dental care services were examined by multiple binary logistic regression analysis using the logistic model and 95% Confidence Interval (CI) whilst taking into account the hierarchical relationship between the various independent variables, as hypothesized by Anderson's model . After controlling for predisposing factors (socio-demographics) at step I, enabling factors and need related factors were entered in step II and step III, respectively. Initially, multiple logistic regression analyses were conducted with the variables at each step separately (including all variables that were statistically significantly associated with utilization of dental care in bivariate analysis). Variables to be included in the various steps of the final hierarchical model were selected if p < 0.05 after adjustment for all other "same step" variables.
Sample profile- predisposing factors by hospital of attendance
A total of 1262 dental patients participated in the study (mean age 30.7, Standard Deviation (SD) 8.5), 56.5% females and 61.0% from KDTH. Most of the participants (42.9%) resided in Omdurman city, followed by (31.4%) in Khartoum city, (16.2%) in Khartoum North city, and (9.5%) in other states. Table 1 gives the percentage distribution of participants' socio-demographic characteristics (predisposing factors) according to hospital of attendance. The patients attending UST were less frequently males (35.2% versus 48.6%), less frequently in the younger age group (47.6% and 58.3%), and had more frequently travelled outside Sudan (41.5% versus 26.9%) as compared to their KDTH counterparts.
Enabling- and need related factors by hospital of attendance
Frequency distribution of enabling- and need related factors by hospital of attendance
KDTH % (n)
Knowledge on transmission
Knowledge on risk groups
Previous experience with HIV/AIDS
Perceived personal risk as dental patients
Attitudes towards people with HIV-infection
Attitudes towards dental clinics
Need related factors
One or more
Perceived general health
Perceived teeth condition
Satisfaction with teeth condition
Predisposing-, enabling and need related factors associated with use of dental services during the past 2 years
Percentage distribution (n) of use of dental service by socio-demographic characteristics (predisposing factors).
Use of dental service % (n)
Hospital of examination
More than 30
Primary and secondary
University and higher
Technical, office, skilled labour
Travelling inside Sudan
Travelling outside Sudan
Percentage distribution of use of dental care by enabling- and need related factors.
Use of dental service % (n)
Knowledge on transmission
Knowledge on risk groups
Perceived risk of health workers
Perceived personal risk as dental patients
Attitudes towards HIV-infected persons
Attitudes towards dental clinics HCW/patients HIV-infected
Need related factors
One or more
Perceived general health
Satisfaction with oral condition
Use of dental care regressed upon predisposing, enabling and need related factors: Odds ratios (OR) and 95% Confidence Intervals (95% CI)
Step 1 Predisposing factors
Travelling outside Sudan
Travelling inside Sudan:
Nagelkerke's R 2 = 0.069
Step II Enabling factors
Knowledge HIV transmission:
Perceived personal risk:
Attitudes towards HIV
Nagelkerke's R 2 = 0.104
Step III Need related factors
Nagelkerke's R 2 = 0.168
This study is the first to confirm disparities in dental care utilization of Sudanese adult dental patients according to selected predisposing-, enabling- and need related factors. In accordance with the propositions of Andersen's behavioural model the present results confirmed the relationships between dental care utilization and socio-demographics (predisposing factors), HIV related knowledge, attitudes and perceived risk (enabling factors) and clinical (objective) - and subjective oral health indicators (need related factors). This suggests that use of dental health care services might be explained by variables organized into the three conceptual domains of predisposing, enabling and need-related factors among Sudanese adults attending university referral hospitals in Khartoum state. In addition, enabling factors, such as knowledge of HIV transmission, perceived personal risk of contagion, experience with HIV-infected people and attitudes towards HIV infected people contributed independently to the explained variance in dental care beyond that of predisposing- and need related factors. Nevertheless, the model explained only 18% and 16% of the variance in dental care utilization in KDTH and UST, indicating the importance of other influencing factors not accounted for in the present study, such as culture, dental cost, affordability and aspects of the Sudanese dental care system itself. Predisposing and need-related factors were the strongest predictors of dental care utilization in the total sample, as well as separately in the samples from UST and KDTH. Notably, it is not possible to assert that the present results demonstrate the crude impacts of the various factors considered since each could be biased by background confounding factors. Moreover, the study participants were patients attending two referral university hospitals for treatment, implicating that individuals who attended dental care for prophylactic- or other reasons, were excluded from the study group. This might have led to an overestimation of previous utilization rate since dental attendees that were excluded might also be low frequent users of dental care. They might also possess HIV-related attitudes and perceptions that are different from those of the respondents in the present study. Although this study provides valuable information by focusing on dental patients, it is unsure how close an approximation the present estimates are to the real situation of the general adult population in Khartoum state. Thus, studies based on random samples from the broader population could be recommended for future studies to provide answers to questions such as whether there are differences among dental attendees and non attendees regarding their perceptions of HIV-related issues and contagion in the dental environment.
About half of the investigated patients, and UST patients more frequently than KDTH patients, reported having received dental care at least once during the 2 years preceding the study. Evidently, the percentage of regular dental attendees varies across different populations. It has been reported to vary between 24% and 26% among adults in Tanzania and Nigeria, respectively [19, 29, 30]. In spite of the relatively high rate of dental attendance as identified by the present study, about 96% presented with untreated dental caries and half the sample was dissatisfied with their tooth condition (Table 2). Andersen's health behaviour model proposes that efficient access to health care services might be established when the level of health status improves relative to the amount of health care services received . The present results indicating high levels of untreated dental caries irrespective of dental attendance frequency might point towards an inefficient access to oral health care services in Sudan. The number of dentists in the public sector in Sudan, has increased from 244 to 512 in the period from 2003 to 2007, which meant the expansion of coverage as well as access to dental services . As shown in Table 4, higher rates of dental care utilization were found among patients having dental caries and perceiving a bad dental condition but also among those who were satisfied with their general health status, suggesting that the utilization pattern of health care services for medical and dental problems differ . Thus, the burden from a bad general health condition might compete with contemporaneous effects of oral health problems regarding dental care utilization. This reasoning was supported by the identification of an interaction effect of perceived health condition and dental caries, indicating that dental caries did not impact utilization rates among participants considering their health condition to be bad. If a bad general health condition has higher priority compared to oral health needs, members of the public that are in bad physical condition will not receive appropriate levels of dental care. This accords with previous results in terms of people reporting more unmet need for dental health care than for general health care services .
Having been travelling inside Sudan and being a female increased the odds of having received dental care during the 2 years preceding this study. To the extent that travelling reflects higher socio-economic position of the participants, the present results accord with numerous studies globally showing that use of dental care occurs more frequently in females and socio-economically advantaged- compared with males and socio-economically disadvantaged groups . The finding that females were the most frequent previous users of dental care is consistent with their reported propensity to possess more health related knowledge than men and also to be less likely to engage in health deteriorating behaviours. Unexpectedly, unemployed participants were more likely to use dental care than were their employed counterparts (Table 3). This result might reflect a "healthy worker effect" and also the fact that unemployed have more time to visit dental clinics than the employed part of the population. This finding is consistent with what has been reported in previous studies .
Although the majority of the participants were of higher education, most of them confirmed having received little HIV information, confirmed low levels of knowledge on transmission modes and risk groups, were un-experienced with HIV infected people and feared HIV contagion in the dental environment (Table 2). Whereas almost half of the study participants reported positive attitude towards HIV infected people, only a minority were in favour of ordinary dental clinics treating HIV infected patients. The relatively high level of fear of HIV infection observed among the study participants (75%) might reflect a certain scepticism about infectious control procedures taken by the dentist although being able to see infection control measures in action is not identical to either interpreting those measures or being aware their effectiveness. Studies from South Africa identified lack of protective eye wearing during dental procedures, not washing hands between patients, not disassembling an item prior disinfection/sterilization and not using sterile drill for each patient . Studies of Nigerian patients and patients from industrialized countries have revealed that dental patients expect adequate infection control procedures and are informed that such measures are beneficial to both dental staff and patients . On the other hand, large proportions of dental patients being totally ignorant to the sterilization methods utilized in dentistry have also been reported . In light of previous studies suggesting that fear of contracting HIV tend to decrease with increasing level of education , the present results suggest that social resources related to HIV and AIDS seem to be influenced by factors other than people's educational level.
Being knowledgeable about modes of HIV transmission and having frequently been exposed to HIV and AIDS infected people seems to have impacted negatively- or acted as barriers towards dental care utilization (Table 4). On the other hand, having positive attitudes towards HIV infected people facilitated dental attendance. This is consistent with recent findings among dental attendees in Nigeria where about 60% of the study participants were unwilling to attend a dental clinic if they knew that patients with HIV were treated there . Consistently, a German study of dental patients revealed that about 10% were in favour of separate waiting rooms for HIV infected patients . An unwillingness to attend dental care on the part of patients being knowledgeable about transmission modes and experienced regarding HIV related issues is consistent with the findings of previous studies. Robinson and Croucher  investigated asymptomatic patients with HIV and found that among those who had attended dental care previously, 51% stopped after testing positive for HIV and AIDS. Personal experience with HIV and AIDS acting as a barrier towards utilization of dental care might be attributed to the fact that the estimated prevalence of HIV and AIDS is still low in Sudan and with a general trend of keeping HIV infection in secret . Concern about HIV contagion in dental practice was associated with more frequent use of dental care in the multivariate analyses which seems at first counterintuitive but are consistent with findings among dental attendees in the United States . In contrast, studies from other industrialized countries have shown that concern about HIV contagion in dental practices increases the likelihood of dental avoidance behaviour . It is possible that among those who expressed increased concern about HIV contagion, anticipated impacts of not receiving dental care have outweighed any perceived risk of cross-infection. Considering the cross-sectional design of the present study, increased concern about HIV contagion in dental practice might be a consequence of frequent experience with dental care and with the application of improper cross-infection control procedures in the dental environments.
The present data have shown that the components of Andersen's behavioural model explained 18% and 16% of the variance in dental care utilization of UST and KDTH patients, respectively. Enabling factors contributed independently to the explained variance in dental care beyond that of predisposing- and need related factors. Being knowledgeable about modes of HIV transmission and having positive attitudes towards HIV infected people impacted negatively and positively on dental care utilization. This suggests that disparities in dental care utilization of dental patients goes beyond socio-demographic position and need for dental care. According to the present study, dental patients had received little HIV information, confirmed low levels of knowledge on transmission modes and feared HIV contagion in the dental environment, whereas only a minority were in favour of ordinary dental clinics treating HIV infected patients. Together the present findings point to an urgent need for dental professionals and the government to address these disparities by improving public awareness of successful HIV infection control and confidence placed on the competences of dentists in order to minimize avoidance behaviour and to help establish dental health care patterns in this region.
My acknowledgement goes to University of Bergen, administration and staff of KDTH and UST in Sudan, dental patients, and dentists who helped in data collection and made this work done. Financial support form the University of Bergen is highly appreciated.
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