Introduction

Healthcare seeking behavior (HSB) is, any action or inaction, taken by individuals who believe that they have a health problem or believe that they are ill [1]. It comprises activities carried out to maintain good health, to prevent ill health, as well as any departure from a good state of health [2]. Different authors have used varied models to explain health-seeking behavior, however, the Health Belief Model, as well as Andersen's Health Behaviour Model have aptly described the series of steps people take towards accessing health care [3,4]. These models focus on an individual's belief about their health condition and the perceived consequence of the individual's action or inaction.

The factors that significantly affect health-seeking behavior during illness episodes and also, the utilization of the formal or informal oral healthcare facilities and self/home care remedies by individuals seeking oral health care, have been described in several studies [5–7]. These studies have shown that the decision to seek care through a particular process or from a particular provider is influenced by a variety of factors such as socioeconomic status (SES), sex, age, severity and type of illness, access to services and perceived quality of the service [6–8]. Besides, geographic location, family size, educational status, and cultural factors are influencers of oral health-seeking decisions in Nigeria [8–11]. The process of decision making for healthcare is complicated and might entail seeking the counsel of friends and family members, weighing potential risks and benefits, and forgoing other types of consumption that can be financed with resources used to purchase oral health care [11]. Thus, oral healthcare-seeking seems to be inextricably linked to the demand for oral healthcare services [12]. Thus the demand for oral healthcare services is often associated with an individual's choice about which service to access and when and where to access healthcare services [13].

Oral diseases as a key element of overall health has created huge public health concern mostly because of their significant impact on the quality of life of individuals, as well as the health system [14]. Dental caries and periodontal diseases are the most common oral diseases in the world and have been found to affect a large proportion of any population, making it a public health issue [15]. Dental caries is one of the most important contributors to the global oral health burden [16], and affects 60 to 90% of school children and almost 100% of adults worldwide [17]. It is estimated to affect 3.5 billion people globally and 2.3 billion people globally, suffer from caries of permanent teeth [18]. However, treating oral health conditions has been known to be expensive and despite this, not usually a part of universal health coverage [18]. The prevalence of oral diseases continues to increase in most of the low and middle-income countries with increasing urbanization and changes in living conditions [18].

In Nigeria, the prevalence of dental caries ranges from about 4 to 40% in adults [19,20], and the prevalence of untreated dental caries is 90% [21], affecting disadvantaged people [22], who are less likely to receive dental care or seek dental care in good oral healthcare facilities [17,23]. Studies in Enugu state Nigeria, have also recorded similar patterns with the prevalence of untreated dental caries cases at 97% [24]. The oral health utilization pattern for dental services in Enugu state show urban-rural disparity with 15.5% utilization in rural areas [24,25] and 65.4% in urban areas [26]. Another study conducted in Enugu state showed that uptake of regular scaling and polishing is low amongst the low socio-economic status groups and respondents living in rural areas [27]. This is as a result of poor oral health awareness, low financial power, political and health system challenges such as inadequate number and maldistribution of skilled human resources for oral health, inadequate dental facilities, and inadequate funding for oral health [19–22,25–27].

Studies investigating oral health-seeking behaviors have observed that inappropriate HSB has been linked to worse oral health outcomes, increased morbidity and mortality, and poorer oral health statistics [28,29]. These studies also show that not all community members, especially in rural areas or the poorer SES groups, receive information about oral health, or receive adequate oral health-promoting measures [28,29]. The decision to seek appropriate oral healthcare, therefore, lies on the respondent. Thus, to better understand the determinants of demand for dental caries treatment services, further insight into respondent's oral health-seeking behavior would be an added advantage.

This study thereby sought to identify the factors that affect an individual's decision to seek oral health care and to choose from among different providers. An understanding of oral health-seeking behavior will enable policymakers understand the drivers of demand for oral health services and inform the implementation of appropriate oral health strategies to improve access.

Materials and methods

Results

Table 1 below, showed that 42.1% of the respondents were male, while 57.9% were female. 51.9% of the respondents belonged to the 21 to 40 years age group, while a majority of the respondents (57.4%) had completed senior secondary school. Most of the respondents (31.8%) were petty traders, and 6.7% were subsistence farmers.

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Table 1. Socio-economic/demographic characteristics of respondents.

https://doi.org/10.1371/journal.pone.0246164.t001

Table 2 showed that the major dental problems experienced by respondents in the study such as pain (95.7%), hole in the tooth (91.3%) were similar across both geographic locations (p<0.05). Respondents’ in rural areas sought treatment in private dental clinics and used home remedies more than urban residents who visited the public dental facilities and patent medicine dealers (PMD) more (p<0.05). Majority of respondents across geographic location cleaned their teeth once a day.

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Table 2. Oral health seeking pattern and perception of need.

https://doi.org/10.1371/journal.pone.0246164.t002

Table 3 below shows a statistically significant relationship between, gender, type of occupation, dental symptoms and seeking dental treatment at a dental clinic (p<0.05). The male respondents were less likely to visit the dental clinic than the female respondents. In addition, self-employed professionals, government workers and petty traders were more likely to go to the dental clinic for dental treatment compared to the unemployed. Respondents that brush twice daily are 0.8 times more likely to visit a dental facility than those that don’t brush daily, but CI includes 1 so the variable was not significant to the model. Respondents without pain, were 0.2 times less likely to visit a dental clinic than those with pain and respondents in poorest SES group were less likely to go to the dental clinic than those in least poor SES group.

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Table 3. Multiple logistic regression analysis between socio-economic and demographic factors associated with seeking care in a dental facility.

https://doi.org/10.1371/journal.pone.0246164.t003

Table 4 below shows that majority of the respondents (61.9%) had tooth extractions as a type of treatment for dental caries and this is influenced by the geographic location of respondents (p<0.05). 23% of respondents had dental fillings done with a greater percentage being in rural areas (p<0.05).

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Table 4. Dental caries treatment received and determinants of the type of treatment received by respondents at a dental facility.

https://doi.org/10.1371/journal.pone.0246164.t004

Table 5 shows that the least poor SES group tend to seek dental treatment in the private facilities more than the poorest SES (26.7%). The poorest and very poor SES groups used home treatment and traditional healers more for dental treatment than the least poor SES.

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Table 5. Level of inequities in utilization of dental caries treatment services across socioeconomic status groups.

https://doi.org/10.1371/journal.pone.0246164.t005

Dental filling and extraction were the most used treatment options for dental caries treatment. The least poor (Q5) SES groups had tooth extractions done more than the other SES groups (p<0.05), while the poor (Q4) SES group had more dental fillings done. The concentration index shows very little income-related inequality. Cheaper treatment cost, the severity of dental problem and family recommendations, influenced where the poorest SES group sought treatment the most.

Discussion and conclusion

Our study showed that all respondents had one form of oral health problem or the other and a majority had dental caries necessitating treatment. This lends credence to observations from other studies where dental caries was found to carry a high global oral health burden [14,15,17]. Using the Andersen and Newman’s healthcare utilization model, we discussed our findings based on the three dynamics of healthcare utilization mainly predisposing, enabling and need factors. The major predisposing factors to oral health seeking observed in this study include: gender, occupation, oral health awareness: We observed a gender influence on oral health-seeking, where the females visited the dental facility for treatment more than the males. The regression analysis buttresses this fact showing that females are more likely to visit the dental facility more than males. Women are the natural caregivers and as such are likely to seek healthcare treatment for every member of the family. Their frequent attendance at health facilities, often lead to a higher oral health awareness level than the males, which support their oral health-seeking behaviour for dental caries treatment [26]. Self-employed professionals and government workers made more visits to the dental clinic when compared with the unemployed. This can be associated with their financial capability and possibly increased awareness about oral health diseases. The fact that most government workers or professionals are likely to be under health insurance, will increase the likelihood of them visiting a dental facility.

Our logistic regression analysis shows that the geographic location and socio-economic status group though not statistically significant, have a negative regression coefficient implying that any increase in socioeconomic status will possibly result in an increase in the demand for treatment in a dental facility. In addition, any movement towards the urban area will result in an increase in the demand for dental caries treatment in a dental facility. This is similar to findings that showed higher dental service usage for adolescents who moved to better SES [38,39].

The enabling factors that influenced where dental caries treatment was sought include cost of services, qualification of provider, income, social or community network. This study showed that respondents' choice of provider was influenced by recommendations from friend/family members, and cost of services which always stands out as the determining factor for health-seeking [37,39]. Thus, oral health-seeking and decision about what type of treatment to receive could be said to depend on the counsel and recommendations of family and friends and the cost of services. Tooth extraction seemed to be the most preferred treatment sought by study respondents from both public and private clinics.

Results show that the poorest SES, sought dental treatment in the public facilities more than the least poor SES. This is because the cost of dental caries treatment services was cheaper in public facilities. Cost and availability of service concerning SES also influenced where treatment was sought. This conforms with the practice in other countries like China, where the private facilities were patronized by adults from higher-income households [41]. The poorest SES were also found to use home treatment and seek traditional healers more than their least poor counterparts. From this finding we can deduce that the poorer SES will usually seek the treatment they can afford first in non-dental facilities and if the disease increases in severity or cannot be appropriately managed by cheaper unorthodox means, they will then seek more expensive orthodox treatment. It could also be a pointer to their level of oral health awareness. As stated in the findings, the major mode of payment for health services was out-of-pocket and none of the respondents from the rural area had health insurance. This is not surprising, however, as a small number of respondents in the urban center have health insurance. Households bear a greater portion of these costs and other indirect costs with little or no financial risk protection. To some households, this may be catastrophic [40,41]. This calls for a need to provide some sort of financial risk protection mechanisms such as dental health insurance as this will have a positive impact on oral health-seeking behaviour of households. The oral health care system needs to be strengthened to function more effectively and decrease overall consumer economic burden if universal health coverage is to be achieved.

Dental filling and extraction are the most utilized treatment options for dental caries treatment. The rural respondents seemed to do more dental fillings and tooth extractions than the urban dwellers, thus suggesting an association between type of treatment with geographic location. However, it is important to note that there is a constant disintegration of social and economic boundaries between urban and rural areas [42], and in the context of this study, a university campus is located on the boundary of this rural area and as such, both low income and middle-income group workers who work in the institution and or make a living from the presence of the institution tend to settle more in the rural study area surrounding the institution and commute to work, possibly, to reduce household expenditures. Thus, it is difficult to associate utilization of a dental facility purely by geographic location.

Amongst the SES groups, the least poor seemed to opt more for extraction than the other SES groups. However, this can be explained by the fact that most respondents visited the dental facility when they were in severe pain, necessitating extraction or more advanced dental treatment such as root canal. The treatment choice of the poorest SES groups was influenced more by the cheaper treatment option. The financial impact of dental caries treatment was felt by all SES groups since most payment was out of pocket. However, we can deduce that the poorest SES group felt the impact more because of their low-income bracket. This is a clear indication that the poor will suffer more economic, financial, and intangible burden of oral health disease than the rich.

Need factors, include: severity of illness necessitating care, perceived health status, level of pain from a tooth. The severity of dental pain, dental swellings and other dental symptoms were observed to increase visit to a dental facility. Our findings show that majority of the respondents only went to the dental clinic when there was severe pain. Usually, an individuals’ perception of health will determine if the individual seeks care. Our study shows that the severity of dental pain is a major influencer of oral health-seeking behaviour.

In conclusion, females, those who are self-employed & government workers were more likely to use a dental facility for dental caries treatment. Cost of services, qualification of provider, social or community network such as recommendation from friends and family are enablers of oral health-seeking and treatment of dental caries in a dental facility. Severity of dental pain or dental condition affecting functionality such as tooth mobility or aesthetics such as tooth discoloration, influence the need to seek oral health services in a dental facility. It's important to note that the introduction and use of dental health insurance may reduce cost constraints for oral health-seeking in dental facilities.

The clinical implication for primary health care is that most dental complications could be prevented if oral health promotion activities to increase awareness were increased. This will equally reduce the high demand for dental caries treatment which is expensive. It will also promote self-care and increase the utilization of primary health care for the production of better health at lower costs.

Supporting information