Fatores contextuais e individuais associados com a utilização dos serviços de saúde bucal por adultos no Brasil.

Abstract

The use of health services is determined by a complex interaction between several factors. Given the search for universality and integrality imposed by public policies of oral health, the evaluation of the use of oral health care and its determinants is relevant to support the planning and management of actions and services. Thus, this study aimed to evaluate the contextual and individual determinants and mechanisms of the dental services utilization in Brazil by adults. The study evaluated two outcomes, non-utilization and time interval since the last dental visit among those who had already been to the dentist, using secondary data from the National Health Survey 2013. In the first article, multilevel logistic regression analyzes were conducted to estimate the effects of contextual and individual variables on the outcomes in the State capitals. The hierarchical modeling was guided by the behavioral theoretical model of health services utilization proposed by Andersen. The second article used structural equation modeling with to identify the direct and indirect effects (paths) between the constructs, observed variables and the dental services utilization by adults in Brazil, according to the specified model also based on the behavioral model. Multigroup analyzes were performed to evaluate whether the models were equivalent (invariant) for rural and urban areas. Predisposing and enabling contextual characteristics were shown to be associated with the dental health services utilization. Sex, age, race/skin color, schooling, income, social network, health insurance, self-perception of oral health and number of missing teeth also influenced the outcomes. A greater proportion of individuals who had never been to the dentist was found among the residents in rural areas, as well as a contact longer ago with the service among those who had already been attended. The measurement model showed to be invariant, which did not occur with the structural models. The variables were related differently in urban and rural areas and also regarding the two evaluated outcomes. The study revealed possibilities for intervention to reduce inequalities in the dental services utilization, including the development of new strategies and the reinforcement of existing actions for the active inclusion of groups with less access to the services, including males, the elderly, blacks, browns and indigenous people, as well as individuals with low schooling and income and edentulous. Increased availability of services in rural areas with a change in the healthcare model and the organization of referral pathway can increase potential access and minimize oral health needs of rural populations. Inclusive actions for the elderly and male individuals living in these areas can also foster the reduction of barriers to services. The planning of actions should consider the mechanisms that determine the services utilization. In addition, the implementation of intersectoral actions can provide a more rational and effective use of available resources.