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Oral Healthcare Utilization Factors Shaping the
Perceived Oral Health Outcome Among Gond
Tribes of Chhattisgarh: A Cross-Sectional Study
Based on Andersen's Behavioral Model
Niharika Benjamin , Vishakha Rani , Bedkekar Sushma , Rohini Sharma , Aditya Purushottam Burile ,
Elashri Chatterjee
1. Department of Public Health Dentistry, Hitkarini Dental College and Hospital, Jabalpur, IND 2. Department of Public
Health Dentistry, Dr. B.R. Ambedkar Institute of Dental Sciences, Patna, IND 3. Department of Public Health Dentistry,
M.R. Ambedkar Dental College and Hospital, Bangalore, IND 4. Department of Medical Affairs, Sekhmet Technologies
Private Limited, Gurugram, IND 5. Department of Public Health, Lok Biradari Prakalp Hospital, Gadchiroli, IND 6.
Department of Periodontology, Hitkarini Dental College and Hospital, Jabalpur, IND
Corresponding author: Niharika Benjamin, niharika.benjamin0@gmail.com
Abstract
Introduction: The Gonds are a highly ancient and expansive tribal community, ranking among the largest in
the world. A review of the literature has suggested that they are more vulnerable to oral diseases and are less
inclined to utilize oral health services due to the comprehensive approach that considers the socioeconomic,
cultural, and structural factors affecting the Gond community's access to oral health services. Tribal health
requires action in the health sector. Utilization is an essential marker of the health status of any population
and is necessary to bridge the gap between tribes and the wider portion of the community. Hence, this study
was conducted among the Gond tribes of Chhattisgarh to evaluate the oral healthcare utilization factors
shaping the perceived oral health outcome using Andersen's behavior model.
Materials and methods: This cross-sectional study was carried out among 400 Gond tribes residing in
villages of Chhattisgarh. Data was collected through a standardized questionnaire, adapted from Andersen's
behavioral model of healthcare utilization during house-to-house survey. The questionnaire included
predisposing, enabling, perceived, and evaluated need factors. Oral health status for evaluated need was
assessed using the World Health Organization (WHO) Oral Health Assessment form (1997), and the
perceived oral health outcome was measured using Oral Health Impact Profile-14 (OHIP-14). Results were
computed using descriptive statistics, chi-square test, and one-way analysis of variance (ANOVA).
Multivariate analysis was done using binomial logistic regression.
Results: The dental visit in the past one year was only 14%. The findings of logistic regression revealed that
the perceived oral health outcome was significantly associated with age, occupation, and positive belief in
the efficacy of dentist, perceived need, and presence of dental caries.
Conclusion: The findings of the present study support Andersen's behavioral model and suggest that there is
an interrelationship of predisposing characters, predisposing health beliefs, and enabling need factors that
determine the likelihood of use of services, which in turn determines the good or bad oral health outcome.
Categories: Dentistry
Keywords: predisposing health belief, oral health quality of life, healthcare utilization, gond tribes, dental caries,
andersen’s behavioral model
Introduction
There has been a notable enhancement in healthcare facilities over the years. Amid the significant
advancements made globally, there remain those who reside in seclusion, preserving their ancestral
principles, practices, beliefs, and myths, and are commonly referred to as tribes. Worldwide, there are 350-
370 million indigenous people in over 90 countries [1]. In India, there are 705 tribal groups, accounting for
around 8.61% of the nation's total population. These groups consist of 104.28 million people and inhabit
almost 15% of the land area of the nation. Chhattisgarh is the homeland of nearly 33 tribal groups
constituting 31.8% of the total population [2]. Manendragarh-Chirmiri-Bharatpur (MCB) is one of the
districts in Chattisgarh that has 131 villages and major tribes inhabit these villages. The original inhabitants
of the Manendragarh (MCB) district were the Kols, Gonds, and Bhuinhars [3].
The Gonds are a highly ancient and exceptionally vast tribal community globally. The medical care of
disease has been closely linked to the shared beliefs, conventions, traditions, values, and behaviors related
to health and disease. Within the Gond community, a multitude of folktales exist, some of which pertain to
matters of health. The accumulation of medical knowledge and healthcare procedures among tribal
1 2 3 4 5
6
Open Access Original
Article DOI: 10.7759/cureus.55957
How to cite this article
Benjamin N, Rani V, Sushma B, et al. (March 11, 2024) Oral Healthcare Utilization Factors Shaping the Perceived Oral Health O utcome Among
Gond Tribes of Chhattisgarh: A Cross-Sectional Study Based on Andersen's Behavioral Model. Cureus 16(3): e55957. DOI 10.7759/cureus.55957
communities throughout history is referred to as 'traditional healthcare systems' or 'indigenous health
practices'. These systems encompass both herbal remedies and psychosomatic approaches to therapy. This
activity has consistently incorporated elements of mysticism, the paranormal, and magic, frequently
culminating in distinct magico-religious rituals. These convictions should not be disregarded as ordinary
superstitions but rather require thorough review due to their significant impact on diseases, managing
illnesses, and the utilization of healthcare facilities [4].
Studies related to the oral health status of tribes have reported dominance of untreated caries, high
prevalence of calculus, dental fluorosis, periodontal disease [5], high prevalence of tobacco use, and
associated high prevalence of leukoplakia that demands high treatment needs [5-7]. The tribes are more
vulnerable to diseases and are less likely to utilize health services due to socioeconomic, cultural, and
structural factors affecting the Gond community's access to oral health services. This is exacerbated by the
limited knowledge of the necessary precautions to safeguard their well-being, individual beliefs and
customs, their geographical remoteness from medical centers, the absence of dependable transport routes,
and financial limitations [5,7] . According to Mooney, access is primarily determined by the availability of
resources, whereas utilization is influenced by both the availability of resources and the level of demand.
The utilization of care among people can be influenced by many different variables that are unrelated to
healthcare itself but influence a person's desire for health services [8]. Andersen's model is widely
recognized as one of the most prominent frameworks for studying healthcare usage [9]. Throughout the
years, this model went through numerous adjustments and was selected considering its ability to determine
the most prognostic characteristics for dental utilization. These elements may be employed to guide targeted
efforts to improve care, and multiple variables may be modified and intervened upon [10].
The model claims that certain individuals exhibit a higher propensity to utilize medical services, which can
be attributed to specific settings: (i) Predisposing components, which generally consist of individual
demographic traits; (ii) enabling variables that pertain to the resources accessible to an individual for
acquiring services, such as income, dental insurance, and having a designated dental provider; and (iii) the
need component, which encompasses both the subjective perception and the evaluation of health status by
medical professionals [11]. The correlation among these three kinds of contextual elements ultimately
decides the probability of service utilization. In the late 1960s, Andersen proposed in the updated model that
health outcomes and satisfaction with care can be influenced by health practice and service utilization. The
approach offers a scientific comprehension of many health outcomes and the factors that influence them,
including the social, cultural, behavioral, and attitudinal determinants [9].
Utilization is a crucial measure of the well-being of many people. This information is required to connect
the culturally distinct and socially separated Gond tribes with the rest of the society. Understanding this is
needed for the overall improvement of their health status and oral health in particular. Moreover, there is no
information available regarding oral healthcare utilization among the tribal population. Hence, this study
was conducted among Gond tribes of Chhattisgarh to assess the oral healthcare utilization factors shaping
the perceived oral health outcome using Andersen's behavioral model.
Materials And Methods
The study population comprised of Gond tribes of Chhattisgarh residing in the villages of Manendragarh
(MCB) district and was carried out from April 2023 to June 2023. The study was approved by the Institutional
Ethical Committee, M.R. Ambedkar Dental College and Hospital (approval no.
MRADC&H/ECIRB/0827/2016-17), and written informed consent was obtained from the participants.
Eligibility criteria
Individuals who were native or permanent residents of Manendragarh (MCB) district of
Chhattisgarh between the ages 15 to 55 years and above, living in the area for more than 10 years, and could
comprehend the questionnaire were included. The migrants of other tribes and chronically ill patients with
limited movement who were absent on the examination day and not willing to cooperate or give consent to
the oral examination were excluded.
Data collection
Data was gathered through in-person interviews utilizing a questionnaire, which was subsequently followed
by a clinical examination.
The sample size for the study involving the Gond tribes of Chhattisgarh residing in the villages of
Manendragarh (MCB) district between April 2023 and June 2023 was determined using the desired
confidence level of 95% and an acceptable margin of error of 5%. The required sample size was calculated
based on the estimated prevalence rate of dental issues in the Gond population at about 30%. The calculated
sample size was approximately 305 individuals. Adjustments were likely made to account for potential non-
response or exclusion criteria, ensuring the final sample size sufficiently represented the target population
and provided statistically reliable results.
2024 Benjamin et al. Cureus 16(3): e55957. DOI 10.7759/cureus.55957 2 of 14
Questionnaire
A structured closed-ended questionnaire (proforma) in the tribal local language was developed to record the
data that consisted of seven sections based on the type of questions in each section. Section I consisted of
socio-demographic information, section II consisted of information on predisposing health beliefs, section
III consisted of information regarding the enabling resources, section IV consisted of information regarding
the perceived need for oral health, section V consisted of the usage of dental services, section VI
included perceived oral health outcome, and section VII included evaluated need through measurement of
oral health status.
Section I: Predisposing factors of utilization: The predictors of utilization were measured by taking into
account socio-demographic variables such as age, gender, education, marital status, occupation, and
socioeconomic background. The study included individuals who were 15 years of age or older. These
participants were categorized into five age groups: 15-24, 25-34, 35-44, 45-54, and 55 years and older.
Educational attainment was evaluated based on the greatest possible degree of qualification obtained, which
includes a degree or higher, education under the degree level, or no formal education. The occupation was
evaluated as either unemployed, lacking specialized skills, possessing a certain degree of skill, owning a shop
or being a farmer, or having a semi-professional or professional career. Following the recording of the
family's monthly earnings as per capita income and the overall number of household individuals, the
socioeconomic class was determined using a modified Prasad et al. classification of socioeconomic class
(2017). The study condensed the groups into three: upper class, middle class, and lower class [12].
Section II: Predisposing health belief: The questionnaire consisted of eighteen items assessing oral health
beliefs. Each item encompassed five groupings of responses. Reverse coding was applied to all the questions
with negative wording. According to previous research conducted by Chen and Tatsuoka, the 18 items
related to oral health beliefs were categorized into six factors. These factors include the perceived
seriousness of disease (rated on a scale of 4-20), the perceived importance of oral health (rated on a scale of
3-15), the betterment of preventive practices (rated on a scale of 2-10), the efficacy of dentists (rated on a
scale of 2-4), barriers (rated on a scale of 6-35), and motivation [13].
Oral health beliefs encompassing attitudes, perceptions, and understanding of oral health significantly
influence individuals' willingness to seek dental care, adhere to treatment plans, and engage in preventive
behaviors. Positive oral health beliefs often correlate with trust in the competence and effectiveness of
dentists, leading to regular dental visits and better treatment compliance. Conversely, negative oral health
beliefs may result in hesitancy to seek care, treatment delays, or dissatisfaction with dental services.
Section III: Enabling factors of utilization of dental services: Enabling factors were measured as oral health
education advice, awareness about dentists, availability of dental service, transport facilities, perceived
treatment expense, and dental anxiety.
Section IV: Perceived need for oral health: The perceived need was assessed by a three-point scale (Good;
Fair; Poor).
Section V: Use of dental services: The inquiries "Have you visited a dentist within the past 12 months?" were
used to evaluate the frequency of past dental visits and the individual's familiarity with dental
appointments (Yes; No). The purpose of dental visits was evaluated based on the question "In general, why
do you seek dental care?" (a routine appointment; an occasional appointment; solely when experiencing
dental issues).
Section VI: Perceived oral health outcome: The Oral Health Impact Profile-14 (OHIP-14) evaluates the
occurrence of issues related to the oral cavity or dentures across seven parameters: functional constraints,
pain, psychological discomfort, physical impairment, psychological impairment, social impairment, and
handicap. Participants are requested to evaluate each item during the past three months using a five-point
scale. The combined effect of responses to items 1-2, 3-5, and 7-8 represented the physical function; the sum
of items 5-6 and 9-10 represented the psychological function; and the sum of items 11-12 and 13-14
represented the social function.
Section VII: Objective need: The objective need was assessed by the professional using the World Health
Organization (WHO) proforma 1997. The variables such as community periodontal index (CPI) Index,
attachment loss, dentition status, prosthetic status, and treatment needs parameters were included.
Clinical Examination
The clinical examination was done at the participant’s home, and it was carried out under natural or
artificial lighting.
Training and calibration of the investigator: A single researcher performed the participant examinations.
2024 Benjamin et al. Cureus 16(3): e55957. DOI 10.7759/cureus.55957 3 of 14
The process of intra-examiner standardization involved the evaluation of 400 participants proceeded by
their revisiting one week later. This contributed to a diagnostic acceptance rate of 85% and the kappa
statistic of 0.82. The investigator was trained to record WHO 1997 oral health status proforma before the
commencement of the study. The instruments were autoclaved in a private dental clinic in that particular
area and carried in a sterile pouch to the site of examination. It took about five minutes for the clinical
examination and about 20 minutes for the questionnaire to be answered by the participants. The assistant
was trained to help the investigator while interviewing the participants.
Statistical analysis
The statistical analysis was performed using Statistical Package for the Social Sciences (IBM SPSS Statistics
for Windows, IBM Corp., Version 25, Armonk, USA). The data was computed employing the Mean ± SD, and
the quantitative factors were analyzed statistically using an analysis of variance (ANOVA). The categorical
factors were evaluated using the chi-square test. Binary logistic regression analysis was applied to appraise
the association between age, education, socioeconomic status, enabling factors, the perceived need for oral
health, decayed, missing, and filled teeth (DMFT), prosthetic need in the maxillary arch, past dental visits,
and perceived oral health outcomes. A P-value less than or equal to 0.05 was considered statistically
significant.
Results
The study was conducted on 400 Gond tribes inhabiting the confined villages of Chhattisgarh. The sample
consisted of 47.8% (n=191) males and 52.3% (n=209) females, belonging to 15-55 years of age with a mean
age of 34.84 ± 12.2. Predisposing factors consisted of age, gender, education, occupation, socioeconomic
status, and predisposing health beliefs. Most participants, a total of 182, had not attended school (45.5%),
309 were married (77.3%), and 131 were farmers or shop owners (32.8%). Few, around 26, had completed
higher education (6.5%).
There was no significant association found between the age group and reason to visit (P=0.168) with a
majority (99%) of subjects reporting that they visit the dentist only when there is a problem and belonged to
the 15-24 years age group, and only 1.4% of subjects who belonged to 25-34 years of age group reported that
they visit a dentist for regular checkup. There was no significant association found between gender and
reason to visit the dentist (P=0.209). Females (97.6%, n=204) reported the reason to visit the dentist as only
when there is a dental problem, and 95.8% (n=183) of males reported at checkups when there was a
problem. However, significant differences were noted between reason to visit and education, occupation,
and socioeconomic status (P<0.05) (Table 1).
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Age group
Reason to visit the dentist
P-value Regular visit Occasional visit When in problem
n % n % n %
15-24 0 0.0 1 1.0 95 99.0
0.168
25-34 2 1.4 2 1.4 141 97.2
35-44 0 0.0 4 4.2 91 95.8
45-54 0 0.0 2 6.7 28 93.3
55 and above 0 0.0 2 5.9 32 94.1
Gender
Male 2 1.0 6 3.1 183 95.8
0.209
Female 0 0.0 5 2.4 204 97.6
Education
No schooling 0 0.0 6 3.3 176 96.7
0.019Schooling below degree level 0 0.0 4 2.1 188 97.9
Degree or above 2 7.7 1 3.8 23 88.5
Marital status
Married 1 0.3 10 3.2 298 96.4
0.343
Unmarried 1 1.1 1 1.1 89 97.8
Occupation
Unemployed 0 0.0 5 3.5 137 96.5
0.036
Semi-skilled worker 0 0.0 0 0.0 73 100
Skilled worker 0 0.0 1 3.2 31 96.8
Shop owner and farmer 0 0.0 4 3.0 127 97
Professional 2 9.1 1 4.5 19 86.4
Socioeconomic status
Upper class 1 1.3 5 6.3 74 92.5
0.013Middle class 1 0.4 2 0.8 260 98.9
Lower class 0 0.0 4 7.0 53 93.0
TABLE 1: Association between predisposing socio-demographic characters and reason to visit
the dentist
n: Number of participants
No significant association was found between periodontal disease (P=0.842) or loss of attachment (P=0.860)
and dental visits in the past year. However, a highly significant association was observed between dental
caries and dental visits (P=0.006), with 17.8% (n=43) of caries patients visiting the dentist compared to 91.8%
(n=146) of those without caries. The prosthetic status of the maxillary arch showed no significant
association with dental visits (P=0.524), whereas the mandibular arch exhibited a highly significant
association (P=0.001), with all prosthetic patients visiting the dentist. Additionally, a significant association
was found between prosthetic need in both arches and dental visits (P<0.01), with 25% (n=18) and 25.8%
(n=23) of patients needing prosthetics in the maxillary and mandibular arches, respectively, upon visiting
the dentist in the past year (Table 2).
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Variables
Past dental visits
P-valueYes No
n % n %
CPI status
Absent 9 13.2 59 86.8
0.842
Present 47 14.2 285 85.8
Loss of attachment
Absent 23 14.4 137 85.6
0.860
Present 33 13.8 207 86.3
DMFT
Absent 13 8.2 146 91.8
0.006
Present 43 17.8 198 82.2
Prosthetic status in the maxillary arch
Absent 55 13.9 341 86.1
0.524
Present 1 25.0 3 75.0
Prosthetic status in the mandibular arch
Absent 54 13.6 344 86.4
0.001
Present 2 100 0 0.0
Prosthetic need in the maxillary arch
Absent 38 11.6 290 88.4
0.003
Present 18 25 54 75
Prosthetic need in the mandibular arch
Absent 33 10.6 278 89.4
0.001
Present 23 25.8 66 74.2
TABLE 2: Association between oral health status and dental visits in the past one year
n: Number of participants; CPI: Community periodontal index status; DMFT: Decayed, missing, filled teeth index
There was a high statistically significant association found between the barrier (P=0.001), total predisposing
health belief (P=0.021), and reason to visit the dentist. There was no significant association found between
the perceived seriousness of disease (P=0.144), perceived importance of oral health (P=0.058), benefits of
preventive practices (P=0.075), efficacy of dentist (P=0.829), and motivation (P=0.269) (Table 3).
Predisposing health belief
Reason to visit the dentist
P-valueRegular visit Occasional visit When in problem
Mean±SD Mean±SD Mean±SD
Perceived seriousness of disease 4.00±0.00 3.45±0.47 3.63±0.39 0.144
Perceived importance of oral health 4.00±0.00 3.48±0.40 3.68±0.33 0.058
Benefits of preventive practices 3.00±1.41 3.63±0.50 3.67±0.40 0.075
Efficacy of dentist 4.00±0.00 3.81±0.40 3.83±0.39 0.829
Barriers 4.00±0.00 2.9±0.40 3.00±0.37 0.001
Motivation 4.00±0.00 3.81±0.60 3.55±0.65 0.269
Total predisposing health beliefs 3.88±0.15 3.36±0.28 3.45±0.24 0.021
TABLE 3: Association between predisposing health belief and reason to visit the dentist
SD: Standard deviation
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There was a statistically significant association found between the age group and perceived oral health
outcome (P=0.022), with a maximum of 96.7% of subjects in the age group of 45-54 years perceived good
oral health outcome. The majority (17.9%, n=17) of subjects in the 35-44 years age group reported poor
perceived oral health outcomes (Table 4).
Age group
Perceived oral health outcome
P-valueGood Poor
n % n %
15-24 86 89.6 10 10.4
0.022
25-34 135 93.8 9 6.3
35-44 78 82.1 17 17.9
45-54 9 96.7 1 3.3
55 and above 28 82.4 6 17.6
Gender
Male 175 92.1 15 7.9
0.077
Female 181 86.6 28 13.4
Education
No schooling 167 91.8 15 8.2
0.038Schooling degree level 169 88.5 22 11.5
Degree or above 20 76.9 6 23.1
Marital status
Married 270 87.7 38 12.3
0.065
Unmarried 86 94.5 5 5.5
Occupation
Unemployed 131 92.3 11 7.7
0.001
Semi-skilled worker 59 80.8 14 19.2
Skilled worker 29 90.6 3 9.4
Shop owner and farmer 122 93.8 8 6.2
Professional 15 68.2 7 31.8
Socioeconomic status
Upper class 70 87.5 10 12.5
0.132Middle class 239 91.2 8.8 10
Lower class 47 82.5 10 10.8
TABLE 4: Association between predisposing socio-demographic characters and perceived oral
health outcome
n: Number of participants
Among the domains of predisposing health belief, only the efficacy of the dentist was found to have a
significant association (P=0.018) with perceived oral health outcomes. Whereas there was no significant
association found between the perceived seriousness of disease (P=0.927), perceived importance of oral
health (P=0.799), benefits of preventive practices (P=0.813), barriers (P=0.918), motivation (P=0.842), and
perceived oral health outcome (Table 5).
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Predisposing health belief
Perceived oral health outcome
P-valueGood Bad
Mean±SD Mean±SD
Perceived seriousness of disease 3.98±0.38 3.63±0.40 0.927
Perceived importance of oral health 3.16± 1.02 3.12 ±0.89 0.799
Benefits of preventive practices 3.67±0.42 3.66±0.41 0.813
Efficacy of dentist 3.83±0.37 3.69 ±0.51 0.018
Barriers 3.01±0.37 3.02±0.38 0.918
Motivation 3.54±0.64 3.69±0.74 0.151
Total predisposing health beliefs 3.45±0.25 3.45±0.23 0.842
TABLE 5: Association between predisposing health belief and perceived oral health outcome
SD: Standard deviation
There was a statistically significant association found between the enabling factor of oral health utilization
and perceived oral health outcome (P=0.036), with a maximum, i.e., 91.2% (n=208) of participants who
found that there are no resources and perceived good oral health outcome and the majority, i.e., 14.2%
(n=19) of participants reported poor resources and perceived poor oral health outcome (Table 6).
Enabling resources
Perceived oral health outcome
P-valueGood Poor
n % n %
No resources 208 91.2 20 8.8
0.036
Poor resources 115 85.5 19 14.2
Fair resources 33 89.2 4 10.8
Total 356 89.2 43 10.8
TABLE 6: Association between enabling factors and perceived oral health outcome
n: Number of participants
There was a high statistically significant association found between the perceived need for oral health and
perceived oral health outcome (P=0.000), with a maximum, i.e., 94.0% (n=79) of subjects who reported good
perceived oral health outcome also found their oral condition as good and the majority, i.e., 27.4% (n=17) of
subjects who reported poor perceived oral health outcome also found their oral condition as poor (Table 7).
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Perceived need for dental treatment
Perceived oral health outcome
P-valueGood Poor
n % n %
Good 79 94.0 5 6.0
0.001
Fair 232 91.7 21 8.3
Poor 45 72.6 17 27.4
Total 356 89.2 43 10.8
TABLE 7: Association between perceived need for oral health and perceived oral health outcome
n: Number of participants
There was no significant association between the loss of attachment and perceived oral health outcome
(P=0.345), with a maximum, i.e., 90.4% (n=217) of subjects who had a loss of attachment reported good
perceived oral health outcome and a maximum of 12.6% of subjects who did not have a loss of attachment
reported poor perceived oral health outcome (Table 8).
Oral health status
Perceived oral health outcome
P-valueGood Poor
n % n %
CPI status
Absent 60 88.2 8 11.8
0.773
Present 296 89.4 35 10.6
Loss of attachment
Absent 139 87.4 20 12.6
0.345
Present 217 90.4 23 9.6
DMFT
Absent 149 93.7 10 6.3
0.019
Present 207 86.3 33 13.8
Prosthetic status in the maxillary arch
Absent 353 89.4 42 10.6
0.357
Present 3 75.0 1 25.0
Prosthetic status in the mandibular arch
Absent 355 89.4 42 10.6
0.073
Present 1 50 1 50
Prosthetic need in the maxillary arch
Absent 340 89.9 38 10.1
0.048
Present 16 76.2 5 23.8
Prosthetic need in the mandibular arch
Absent 341 89.7 39 10.3
0.139
Present 15 78.9 4 21.1
TABLE 8: Association between oral health status and perceived oral health outcome
n: Number of participants; CPI: Community periodontal index status; DMFT: Decayed, missing, and filled teeth index
The findings of the multivariate analysis indicated that irrespective of the use of dental services many
predisposing socio-demographic characteristics, predisposing health beliefs, and perceived and evaluated
needs had their effect on perceived oral health outcomes. Their overall explanatory power was R2 = 0.365,
i.e., 36.5% of the deviance in dental visits in the past one year could explain these factors (Table 9).
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Variables P-value Odds ratio
95% Confidence interval
Upper bound Lower bound
Age (reference 55 and above) 0.022
15-24 years 0.993 0.99 0.16 5.89
25-34 years 0.218 0.35 0.06 1.84
35-44 years 0.689 1.37 0.28 6.55
45-54 years 0.049 2.8 0.08 0.99
Education (reference degree level or above) 0.319
No schooling 0.645 1.75 0.160 19.3
Schooling below degree 0.320 1.05 0.32 30.4
Occupation (reference professionals) 0.004
Unemployed 0.006 2.59 0.03 3.94
Semi-skilled worker 0.108 1.35 0.01 1.53
Skilled worker 0.017 2.4 0.00 0.57
Shop owner and farmer 0.004 1.4 0.03 0.34
Efficacy of dentist 0.007 2.8 0.114 0.715
Enabling resources (reference fair resources) 0.165
No resources 0.436 1.74 0.08 2.38
Poor resources 0.436 1.45 0.43 7.08
Perceived need (reference poor) 0.001
Good 0.002 1.20 0.03 0.45
Fair 0.001 2.05 0.91 0.54
DMFT 0.005 2.68 0.98 0.66
Past dental visits (reference no visit) 0.119 0.25 0.81 5.91
Prosthetic need (maxilla) 0.467 0.818 0.89 2.46
TABLE 9: Binary logistic regression analysis showing the association between age, education,
socioeconomic status, enabling factors, perceived need for oral health, DMFT, prosthetic need in
the maxillary arch, past dental visits, and perceived oral health outcome
DMFT: Decayed, missing, and filled teeth index
The study, conducted on a sample of 400 Gond tribes inhabiting confined villages in Chhattisgarh, provided
comprehensive insights into the demographic factors and health beliefs influencing dental visits and
perceived oral health outcomes within this population. Analysis revealed intriguing patterns in reasons for
dental visits, with significant variations observed across different demographic groups. For instance, while
the majority of participants sought dental care only when faced with a problem, significant disparities
emerged based on factors such as age, gender, education, occupation, and socioeconomic status. Notably,
individuals with higher education levels or belonging to certain occupational categories were more likely to
seek dental care regularly or occasionally, indicating a potential link between education, occupation, and
health-seeking behavior. Moreover, the study highlighted the significant impact of dental caries on dental
visits, underscoring the importance of preventive dental care and early intervention strategies.
Interestingly, while no significant associations were found between periodontal disease or loss of
attachment and dental visits, prosthetic status and need exhibited varying associations, suggesting potential
disparities in treatment utilization among individuals with different oral health conditions.
2024 Benjamin et al. Cureus 16(3): e55957. DOI 10.7759/cureus.55957 10 of 14
In addition to demographic factors, the study delved into the role of predisposing health beliefs in shaping
dental visits and perceived oral health outcomes. The findings revealed significant associations between
certain health beliefs, such as the efficacy of dentists and perceived barriers, and reasons for dental visits.
These insights shed light on the complex interplay between individual perceptions, attitudes, and
healthcare-seeking behaviors, emphasizing the importance of addressing both structural and attitudinal
barriers to improve access to dental services.
Furthermore, the study examined the association between demographic factors and perceived oral health
outcomes, revealing intriguing patterns in how age, education, occupation, and socioeconomic status
influence individuals' perceptions of their oral health. Notably, enabling factors such as access to resources
and perceived need for dental treatment emerged as significant predictors of perceived oral health
outcomes, highlighting the importance of addressing systemic barriers and promoting awareness to enhance
oral health outcomes among tribal communities.
Overall, the study's findings underscore the need for targeted interventions aimed at addressing disparities
in dental care utilization and improving oral health outcomes among marginalized populations such as the
Gond tribes in Chhattisgarh. By addressing both structural barriers and individual beliefs and perceptions,
policymakers and healthcare providers can work towards ensuring equitable access to dental services and
promoting better oral health outcomes for all members of the community.
Discussion
The results presented in this study provide evidence in favor of Andersen's behavioral model of service
utilization and health outcomes, particularly in perceived oral health. The study analyzes many social,
attitudinal, and behavioral aspects that have significance in comprehending the circumstances surrounding
the use of services for oral health within the particular tribal group. This study has incorporated the concept
of predisposing health beliefs as a component within Andersen's model. It proposes that the objective to
engage in a particular action arises from a combination of beliefs, including attitudes, norms, and perceived
behavioral regulation. These characteristics serve as predictors of intentions, which in turn are associated
with behavior. Individual attitudes and perceived norms are predicted by the demand for and availability of
resources, which in turn determine the intention and subsequent actual usage of services [14]. On the other
hand, an individual's health beliefs, attitudes, values, and knowledge regarding oral health and dental care
may serve as a pathway through which social structural elements impact the availability of resources, the
level of need, and the utilization of services [15]. Given the limited number of studies examining the usage of
dental services across tribal populations, most comparisons are made with the general population as a
whole.
The current study revealed that 86% of the participants had not sought dental care during the past year and
none were seeking dental care within the past month. Concerning reasons to visit the dentist, the present
study reported only when there is an oral health problem as the major (96.8%) reason to visit the dentist.
The number of subjects visiting the dentist decreased significantly in the older age. This can be partly
explained by the fact that as age increases people believe that dental problems are due to aging and ill health
and other systemic conditions seem more important than oral health [16]. In the present study, the number
of female participants was relatively greater as opposed to the number of males. This was congruent with
the findings of an earlier study [17], while it was contrary to a previous study done by Nagarjuna P et al. [18].
Over 50% of the sample population had not received any sort of formal schooling, as demonstrated in the
current study. This could be because the population is less aware of the importance of education and the
failure of implementation of government educational programs in this area. Also, the burden of the
financial crisis compels them to work to earn a livelihood rather than to spare time for education. The
finding suggests that as the level of education increased, the number of subjects visiting the hospital also
increased. Marriage significantly amplified the exponential growth of making decisions in prosthetic therapy
(a 2.228-fold rise), with unmarried individuals serving as the baseline comparison group [19]. In contrast, the
study done by McDonald did not show the impact of marital status on the utilization of dental care [20].
More past dental visits and more regular visits were seen with the higher occupation group. The reason for
this may be that occupation and socioeconomic status are interrelated, which enables them to seek private
dental treatments. Low perceived importance to oral health, unavailability of dentists nearby and lack of
transport facilities, belief in home remedy, and misperception towards dental treatment were found as
major barriers associated with low utilization of dental services [21,22].
Eliminating the barrier of expensive medical treatment can be achieved by the implementation of
complementary health camps, which have demonstrated efficacy in disease screening and delivery of
preventive treatment. It was seen that individuals with a fair and good perception of their oral health
reported more regular or occasional dental visits in the past one year. Afonso-Souza et al. also found that
people who rated their oral health as poor were substantially more inclined to disregard regular dental
examinations in comparison to those who rated their oral health as good [23].
The study revealed that a majority of the individuals had a pocket depth of 4-5 mm (42.8%) and calculus
(35.3%). The rise in periodontal disease among the participants could be attributed to inadequate oral
2024 Benjamin et al. Cureus 16(3): e55957. DOI 10.7759/cureus.55957 11 of 14
hygiene practices, tobacco use, limited understanding of the state of oral health, and presumably indigenous
brushing patterns. The results of the current study were consistent with a similar prior study [24]. In this
study, CPI did not have a significant association with past dental visits (P>0.05) and reason to visit (P>0.05).
The prevalence of dental caries was 80%, and the filled teeth were very low among Gond tribes, which
indicates the dominance of untreated caries. Access to food, the type of diet they consume, low
socioeconomic status, low level of education, lack of importance towards oral health, lacking enabling
resources, and barriers to access oral healthcare are some factors that result in high caries prevalence [25].
These findings indicate high treatment needs among the population and less utilization of oral health
services. A study undertaken by Doughan et al. among individuals from Lebanon found similar results to the
current study, indicating that the participants had a higher requirement for prostheses due to their dearth of
understanding regarding tooth replacement [26].
The present study disclosed that the perceived oral health outcome was significantly associated with past
dental visits, whereas there was an insignificant association found between perceived oral health
outcome and reason to visit. Among the predisposing factors, only age and occupation showed a significant
association with perceived oral health outcomes. Middle-aged adults had 2.8 times the odds of having good
perceived oral health outcomes as compared to the elderly. This finding is similar to the finding of previous
studies, which showed that as the age advances the perceived oral health outcome becomes poor [27]. The
participants who perceived higher efficacy of dentists had 2.8 times the odds of having good perceived oral
health outcomes. This was congruent with the finding of a study conducted by Broadbent et al., which
explains that people with a favorable belief in the efficacy of dentists have much better clinical conditions
and self-rated oral health [28]. The findings showed that individuals with fair perceived oral health had 2.1
times the odds of having a good perceived oral health outcome and individuals with good perceived oral
health had 1.2 times the odds of having a good perceived oral health outcome as compared to poor perceived
oral health. This finding was in line with the previous study conducted by Massod et al., where people with
poor self-reported health had 2.3 times higher odds of poor perceived oral health outcomes than the
participants with good self-reported health [29]. The results revealed that the individuals with more
untreated dental caries had 2.6 times the odds of having a good perceived oral health outcome. The study
conducted by Papaioannou et al. also showed similar findings [30].
The study has some limitations such as the data gathered in the current cross-sectional study were analyzed
according to the causal sequencing proposed in Andersen's model. However, it is important to note that this
grouping does not necessarily indicate a causal relationship. In order to delve deeper into intricate
processes, subsequent investigations must adopt an approach that is longitudinal. The perceived need for
therapy is known to impact the decision to seek treatment (utilization of healthcare services) and the other
way around. Incorporating the examination of such mutual interactions is necessary for future
investigations. Moreover, a limitation of OHIP-14, which is employed to evaluate perceived oral health
outcomes, concerns its potential failure to sufficiently account for variations in anticipations across
different geographical areas. Consequently, this could lead to inaccurate assessment of perceived oral health
outcomes either through downplaying or exaggerating its importance depending on the specific group being
studied. Ultimately, the conclusions on service utilization are likely specific to the belief system, culture, and
organizational framework of services accessible to the Gond tribes of Chhattisgarh. The cross-validation of
the findings should encompass samples from more tribal groupings and diverse states. Also, the challenges
of reducing long-standing oral health disparities, expanding access to oral health services at affordable
prices, and keeping up with the quality of the treatment are to be dealt with judiciously by government
officials and health policymakers to strengthen the Indian oral health system.
Conclusions
In summary, our study highlights insufficient utilization of oral healthcare services among participants,
indicating a lack of priority given to oral health. Positive beliefs and behaviors, such as recognizing the
importance of dentists and understanding the seriousness of oral diseases, are associated with higher service
utilization. Factors like proximity to dental services, affordable treatment costs, and reduced dental fear
contribute to more equitable utilization. Individuals who acknowledge their dental needs and perceive
dentists as effective are more likely to seek care. However, many participants underestimate their oral health
needs. To improve service utilization and oral health outcomes, addressing barriers to access and increasing
awareness are essential steps.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Niharika Benjamin, Vishakha Rani, Bedkekar Sushma, Rohini Sharma, Aditya
Purushottam Burile, Elashri Chatterjee
Acquisition, analysis, or interpretation of data: Niharika Benjamin, Vishakha Rani, Bedkekar Sushma,
2024 Benjamin et al. Cureus 16(3): e55957. DOI 10.7759/cureus.55957 12 of 14
Rohini Sharma, Aditya Purushottam Burile, Elashri Chatterjee
Drafting of the manuscript: Niharika Benjamin, Vishakha Rani, Bedkekar Sushma, Rohini Sharma, Aditya
Purushottam Burile, Elashri Chatterjee
Critical review of the manuscript for important intellectual content: Niharika Benjamin, Vishakha
Rani, Bedkekar Sushma, Rohini Sharma, Aditya Purushottam Burile, Elashri Chatterjee
Supervision: Niharika Benjamin
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. M.R. Ambedkar Dental
College and Hospital issued approval MRADC&H/ECIRB/0827/2016-17. Animal subjects: All authors have
confirmed that this study did not involve animal subjects or tissue. Conf licts of interest: In compliance
with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All
authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could
appear to have influenced the submitted work.
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