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Factors Affecting Dental Utilization and Dental Expenses in the Economically Active Population: Based on the 2010∼2014 Korea Health Panel Data
J Dent Hyg Sci 2019;19:23-30
Published online March 31, 2019;  https://doi.org/10.17135/jdhs.2019.19.1.23
© 2019 Korean Society of Dental Hygiene Science.

Jin-Ha Lee , Eunsuk Ahn

Department of Dental Hygiene, Kyungbok University, Pocheon 11138, Korea
Correspondence to: Eunsuk Ahn, Department of Dental Hygiene, Kyungbok University, 154 Sinpyeong-ro, Sinbuk-myeon, Pocheon 11138, Korea Tel: +82-31-539-5339, Fax: +82-31-539-5339, E-mail: esann@naver.com
Received January 28, 2019; Revised February 14, 2019; Accepted February 25, 2019.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background:

The health of the economically active population contributes to increased corporate productivity by reducing the productivity loss caused by disease and increasing job efficiency, which in turn is a national benefit. Since the economically active population is a concept encompassing workers and a source of economic development for a country, that population’s health should be treated with importance not only from a personal standpoint but also at a national level.

Methods:

In this study, data of 11,007 adults aged 20 years and older who participate in economic activities were analyzed in the five-year Korea Health Panel Study from 2010 to 2014 including the number of dental visits and dental medical expenses.

Results:

Factors related to “gender,” “education level,” “age,” “duty category,” “income level,” “employment type,” “national health insurance,” and “chronic disease status” of the economically active population are affected in relation to the number of visits and dental medical expenses. The number of dental visits increased with higher education levels (p<0.001), and the number of visits to the dentist increased with older age (p<0.001). Dental medical expenses were 91,806 Korean won (KRW) more for “white-collar workers” than for “blue-collar workers” (p<0.03), and 127,674 KRW more for “regular workers” than for “atypical workers” (p<0.02).

Conclusion:

When it is necessary to improve policies to enhance the efficiency of the distribution of health and medical resources in the overall balance of the dental health sector, we should try to identify various factors of oral health disorder due to income inequality among the classes according to the country’s employment type in order to find ways to reduce the health gap among the social classes.

Keywords : Dental medical expenses, Dental visits, Economically active population, Employment type
Introduction

Health diminishes the loss of productivity that may be caused by absence due to a disease, while enhancing quality of life, thereby increasing overall professional efficiency1,2). This would contribute to boosting the productivity of enterprises and ultimately benefit the nation, and, thus, managing the health of the economically active population is a common goal among individuals, enterprises, and the government1,2). The “economically active population” refers to employed and unemployed individuals age 15 years or older3). It is a concept that encompasses all workers and is the root of a nation’s economic growth. Hence, the health of the economically active population is an important issue not only for individuals but also for a nation4).

Differences in employment conditions are key factors that increase the risk of disease in workers, as they affect health risk factors, such as physical, biological, and psychosocial environment, and behaviors beyond the differences in socioeconomic conditions5). There is a gap in health states among workers according to work status whereby non-regular workers have poorer perceived health than regular workers6), and multiple studies have also reported a gap in health states among workers according to type of occupation, whereby manual workers show a higher risk of disease and noncompliance with regular health check-ups than non-manual workers7).

Oral health is intimately related to general health, and oral diseases and tooth decay have an adverse impact on quality of life functionally, psychologically, and socially. Therefore, preventing and managing oral diseases should be approached from the perspective of potentially not only improving oral but also general health8,9). However, people tend to perceive dental treatments as less urgent than medical treatments, and oral diseases are often neglected due to high treatment costs10). As people age, the severity of oral diseases increases and treatment costs continuously multiply11). A prior study using the Medical Expenditure Panel Survey data reported that regular dental visits and dental treatment patterns differ according to race, type of health insurance, and income12), and multiple studies in Korea pinpointed to financial burden and lack of time as the key reasons why workers fail to seek early dental treatment after developing an oral disease13).

Although most workers are aware of the need for dental treatment, they cannot seek early treatment because they are not able to deviate from their workplace during work hours, and studies have reported that this varies according to job position14).

In South Korea, the rate of non-covered services among many dental treatments is high, and the relatively low health insurance coverage is a significant problem10). To increase the efficiency of health and medical resource allocation while ensuring equity in overall dental medicine, more studies on dental visits and dental costs, including non-covered service costs should be conducted15). Furthermore, there are also few studies investigating the differences in dental visits and dental costs among the economically active population according to job position. Thus, this study aims to provide foundational data to rectify current policies so as to lower health inequity according to job position and type of occupation among the economically active population by conducting a longitudinal survey of the factors that affect the number of dental visits and dental costs among the economically active population using the 2010∼2014 Korea Health Panel Survey (KHPS) data.

Materials and Methods

1. Participants and data

Data from the 2010∼2014 (five years) KHPS were analyzed. The KHPS collects data from 90% of the 2005 comprehensive population and household survey in order to ensure representativeness of the study population16). Because the survey is conducted using the same households every year, it is possible to observe the trends in people’s number of dental visits and medical costs over the years and to compute the total dental expenses including non-covered service costs16).

The number of dental visits and dental expenses was collected from the outpatient medical service data, and comprehensive data combining household member information, income of household members, and identification numbers for household members were used (HPID). On the basis of the HPID, there were 17,885 participants in 2010, 17,035 in 2011, 15,872 in 2012, 14,839 in 2013, and 13,973 in 2014. After excluding duplication we limited the age to 20 years or older according to our study purpose of examining the economically active population, resulting in a total of 11,007 individuals included in the analysis. Older adults aged 65 years or older were not excluded, as they are included among the employed and unemployed individuals aged 15 years or older according to the definition of economically active population in Statistics Korea data. However, data from only currently working old adults were included for the job position and type of occupation variables.

2. Study variables

The number of dental visits and dental expenses between 2010 and 2014 (five years) were set as the dependent variables. Gender, education level, age17), duty category, income level, employment type, national health insurance, and chronic disease status were set as independent variables, all of which were converted to categorical variables (Table 1).

Study Variable

Variable  Variable name  Description
Dependent variablesNumber of dental visits2010∼2014 (for 5 years) total number of dental visits
Dental medical expenses2010∼2014 (for 5 years) total dental medical expenses
Independent variablesGender1=man
2=woman
Education level1=less than elementary school graduation
2=less than high school graduation
3=more than a college graduate
Age group (y)a1=20∼44
2=45∼54
3=55∼65
4=over 65
Duty category1=white-collar worker
2=blue-collar worker
3=unemployed person
Income level1=income level(1)
2=income level(2)
3=income level(3)
4=income level(4)
5=income level(5)
Employment type1=regular worker
2=atypical worker
3=not applicable
National health insurance1=employment-based insurance
2=local health insurance
3=medical care, etc.
Chronic disease status1=chronic disease
2=non-chronic disease

aClassification according to the 2nd Korean Longitudinal Study of Aging Panel Survey in 200817).


3. Analysis

The differences in the number of dental visits and dental expenses according to participants’ general characteristics were compared with two independent-samples t-tests and a one-way ANOVA. The factors that affect the number of dental visits and dental costs were identified with linear regression analysis. Statistical significance was set at 0.05 for all statistical analyses, and STATA 11.0 (Stata Corp., College Station, TX, USA) software was used.

Results

1. Number of dental visits and dental costs according to general characteristics

The mean number of annual dental visits for five years was 4.5, and the mean dental expense was 458,151 Korean won (KRW). Regarding duty category, the number of dental visits was the lowest among blue-collar workers (3.59) and the highest among white-collar workers (4.77). Regarding employment type, the number of dental visits for regular workers was 3.98, and that for atypical workers was 4.11. Dental expenses were the lowest for blue-collar workers (382,095 KRW) and the highest for white-collar workers (499,304 KRW). Regarding employment type, dental expenses were the highest for regular workers (504,558 KRW) and the lowest for atypical workers (397,521 KRW) (Table 2).

The Number of Visits to the Dentist and the Expenditure on Dental Care according to the General Characteristics of the Study

   Variablen (%)Dental medical expenses (KRW)No. of dental visits


Mean±SEp-valueMean±SEp-value
Gender
 Man4,733 (43.01)441,895±18,4740.2324.51±0.120.861
 Woman6,271 (56.99)470,421±15,3514.53±0.10
Education level
 ≤Elementary school2,741 (24.91)505,632±26,9850.0014.94±0.16<0.001
 ≤High school4,794 (43.57)479,007±17,7394.84±0.12
 ≥University3,469 (31.52)391,813±18,6613.74±0.12
Age group (y)a
 20∼444,053 (36.83)307,448±13,567<0.0013.15±0.09<0.001
 45∼542,133 (19.38)513,062±29,0744.84±0.18
 55∼642,033 (18.48)666,316±36,6126.15±0.21
 ≥652,785 (25.31)483,457±23,6035.08±0.17
Duty category
 White-collar worker4,437 (40.32)499,304±20,3970.0024.77±0.12<0.001
 Blue-collar worker1,945 (17.68)382,095±25,5033.59±0.14
 Unemployed person4,622 (42.00)450,652±17,0994.68±0.12
Income level
 Income level(1)2,153 (19.57)442,671±25,503<0.0014.95±0.20<0.001
 Income level(2)2,224 (20.21)377,296±23,6773.89±0.15
 Income level(3)2,219 (20.17)370,558±22,7613.96±0.15
 Income level(4)2,242 (22.42)535,857±28,7904.99±0.18
 Income level(5)2,166 (19.68)565,863±30,4294.84±0.17
Employment type
 Regular worker831 (7.59)504,558±53,3260.0043.98±0.24<0.001
 Atypical worker3,151 (28.77)397,521±19,3214.11±0.13
 Not applicable6,971 (63.64)481,984±15,1884.78±0.10
National health insurance
 Employment-based insurance7,090 (64.48)491,928±15,180<0.0014.60±0.090.318
 Local health insurance3,278 (29.81)419,314±20,9744.38±0.15
 Medical care, etc.627 (5.70)275,248±37,3774.29±0.33
Chronic disease status
 Chronic disease7,309 (66.42)505,609±15,425<0.0015.10±0.10<0.001
 Non chronic disease3,695 (33.58)364,276±17,4443.38±0.11

Data were determined by t-test or ANOVA analysis.

KRW: Korean won, SE: standard error.

aClassification according to the 2nd Korean Longitudinal Study of Aging Panel Survey in 200817).


2. Factors that affect the number of dental visits and dental expenses

Table 3 shows the results of linear regression analysis with all study variables to identify the factors that affect the number of dental visits and dental expenses.

Factors Affecting the Number of Dental Visits and Dental Medical Spending in the Study

   VariableDental medical expenses (KRW)No. of dental visits


CoefficientSEp-valueCoefficientSEp-value
Gender
 ManRef.Ref.
 Woman56,90326,0700.030.160.170.354
Education level
 ≤Elementary schoolRef.Ref.
 ≤High school61,56135,1970.080.900.23<0.001
 ≥University67,52245,4970.130.800.290.006
Age group (y)a
 20∼44Ref.Ref.
 45∼54188,74135,549<0.0011.440.23<0.001
 55∼64330,35141,400<0.0012.540.27<0.001
 ≥65200,03746,420<0.0011.630.30<0.001
Duty category
 White-collar workerRef.Ref.
 Blue-collar worker−91,80641,2480.03−0.520.270.052
 Unemployed person−77,74635,4020.09−0.160.230.496
Income level
 Income level(1)Ref.Ref.
 Income level(2)−43,44541,6970.30−0.460.270.084
 Income level(3)−50,52542,4400.23−0.370.270.174
 Income level(4)97,01242,7150.020.490.280.077
 Income level(5)114,38944,9470.010.160.290.580
Employment type
 Regular workerRef.Ref.
 Atypical job−127,67452,2700.02–0.190.340.573
 Not applicable−23,75757,9770.680.150.370.685
National health insurance
 Employment-based insuranceRef.Ref.
 Local health insurance−85,89427,722<0.001−0.360.180.046
 Medical care, etc.−232,52855,459<0.001−0.930.360.009
Chronic disease status
 Chronic diseaseRef.Ref.
 Non-chronic disease−55,77028,5980.05−0.930.18<0.001
 Constant302,33295,7750.003.570.62<0.001

Data were determined by linear regression analysis.

KRW: Korean won, SE: standard error, Ref.: reference.

aClassification according to the 2nd Korean Longitudinal Study of Aging Panel Survey in 200817).


Education level, age, type of health insurance, and chronic disease status were found to affect the number of dental visits, while gender, age, duty category, income level, employment type, and type of health insurance were found to affect dental expenses.

The number of dental visits increased with an increase of both education level and age. Dental expenses were the highest among white-collar workers, 91,806 KRW higher than among blue-collar workers and 77,746 KRW higher than among the unemployed. Regarding employment type, dental expenses were 127,674 KRW higher among regular workers than among atypical workers.

Discussion

South Korea has seen a rise in the average national income with continuous economic growth, but the income inequity across social classes has been aggravated by a deepening gap according to socioeconomic conditions and employment type, as the atypical working population grew because of the implementation of policies promoting labor flexibility in response to the rising unemployment rate18). Such changes in the labor market have surfaced as serious social problems because they lead not only to wage differences between regular and atypical workers according to employment type and conditions, but also differences in welfare19). Thus, this study aimed to investigate the factors that induce socioeconomic gaps, such as type of occupation and employment, as well as identifying factors that affect the number of dental visits and dental expenses in the economically active population.

Women visited dental offices about 0.1 times more than men did and also spent 56,903 KRW more than men did. This seems to support previous findings that women are more interested in oral health than men are20) and that they tend to avoid health-related risks more than men do21). In terms of age, the number of dental visits in the 55∼64 years group was about 2.5 times higher and 1.6 times higher than that of the 20∼44 years group and 65 years or older group, respectively. Dental expenses were also 330,351 KRW higher in the 55∼64 years group than among the 20∼44 years group and 65 years or older group, respectively. These results are in line with previous study results that dental visits increase with advancing age22), and that dental utilization is higher among individuals age 50 years or older23). This may be because dental diseases are progressive diseases, and conditions that damage oral functions become chronic with advancing age, thereby increasing the need for treatment10). Dental visits and dental expenses increased as education level and income increased, where the number of dental visits is about 0.1 times higher and dental expenses are 114,389 KRW higher in the fifth income quintile than in the first quintile. The fourth income quintile group also takes about 0.4 more dental visits and spends 97,012 KRW more than the first quintile group. Yeo and Jeong24) reported that oral health knowledge and interest as well as number of dental visits increase as income and education level increase. These results seem to reflect the reality in which a person’s ability to pay for medical costs serves as an important factor in dental service utilization, as many dental treatments are non- covered services25,26). Regarding the type of health insurance, the number of dental visits was about 0.3 times and 0.9 times higher among those with employment-based insurance than among those with local health insurance and those receiving medical aid, respectively, and dental expenses were 85,894 KRW and 232,528 KRW higher, respectively. In particular, recipients of medical aid spent significantly less in dental expenses than the other two groups. According to a prior study, outpatient dental expenses rise with an increase of household living expenses, which is in line with a report that the narrow scope of dental coverage in Korea leads to high costs even for a single treatment and makes individuals’ financial conditions an important factor affecting their dental service utilization15).

Regarding duty categories, blue-collar workers visited dental offices about 0.5 times less and spent 91,806 KRW less on dental services than did white-collar workers. In terms of employment type, regular workers visited dental offices about 0.1 times more and spent 127,674 KRW more on dental services than did atypical workers. These results were similar to previous findings that risk for poor health is higher among atypical workers than among regular workers, and that prevalence of dental caries and periodontal disease and oral health behaviors, such as tooth brushing, are higher among manual laborers, including agricultural and fishery workers and simple laborers, than among non-manual laborers, including managers, professionals, and relevant workers19). Job position, which refers to type of employment, is one of the most widely used indices for determining socioeconomic position. It has been reported that atypical workers face higher psychological pressure and stress due to their unstable employment status than do regular workers27,28). Difficulty with adjusting to a new work environment due to short employment periods can hinder self-control, thereby easily inducing poor health behaviors, such as smoking, drinking, and excessive sugar intake, as opposed to promoting healthy behaviors27,28). Therefore, reducing employment anxiety by implementing policies that help workers maintain stable employment would be an effective measure both for stabilizing employment and reducing oral health inequity. Furthermore, occupation- related features, such as type of work and work environment, are highly associated with health. Previous studies reported that production workers are less educated than are office workers, that they often neglect to perform health behaviors due to lack of oral health knowledge, and that they fail to seek timely treatment because of the high treatment costs or lack of time available to seek treatment13).

Yoon et al.29) reported that the standardized mortality ratio for suicide as well as total mortality from suicide were higher among agricultural and fishery workers. These results suggest that intensive labor beyond financial reward and material hardship induce poor mental and physical health, which may worsen oral health as well.

All in all, gender, education level, age, duty category, income level, and employment type were found to affect the number of dental visits and dental expenses in the economically active population. This study is meaningful in that unlike previous studies, it conducted a longitudinal analysis to identify the factors that affect the number of dental visits and dental expenses from the perspective of duty category and employment type based on the 2010∼2014 KHPS data. However, one limitation of this study is that we could not consider dietary habits and oral health behaviors, such as tooth brushing and use of oral care products, which may affect dental service utilization, because these were not included in the KHPS. Another limitation is that we could not perform separate subgroup analyses for more specific employment types and type of occupation because many participants were excluded for not having received any dental service in the study period, as dental treatments are generally less urgent because they are not generally life-or-death situations and many dental treatments are not covered and thus are costly. Nevertheless, one strength of this study is that we observed the trends of longitudinal dental service utilization over a five-year period, as opposed to previous cross-sectional studies that were largely focused on specific years. Furthermore, this study is meaningful in that it included non-covered service costs, which have not been examined in previous data.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

This study was exempted from review by the Institutional Review Board at Hanyang University (IRB No. HYI-18-157-1).

ORCID

Jin-Ha Lee, https://orcid.org/0000-0002-3062-8216

Eunsuk Ahn, https://orcid.org/0000-0002-9404-4826

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