The case for affordable oral health care: the public voice
Gagandeep Kaur A * , Georgios Tsakos B , Tami Yap C , Tania King D , Manu Raj Mathur E F and Ankur Singh A GA
B
C
D
E
F
G
Abstract
Although we have scientific and policy discussions on the need for oral health care, rarely have populations been asked about their expectations regarding this important matter. Therefore, the public voice has been absent from these discussions. This study aims to quantify public support among working-age Australian adults regarding the essentiality of oral health care and assess whether oral health care affordability differs by sociodemographic characteristics.
Descriptive analysis of nationally representative data from Australia.
Using cross-sectional survey weights, we analysed data from wave 18 (2018) of the Household, Income and Labour Dynamics in Australia study. The analysis included 11,028 working-age Australians aged 20–54 years.
Almost all (96.4%) working-age Australian adults considered oral health care as essential; however, 6.5% do not get treatment due to lack of affordability. Higher proportions of specific disadvantaged groups, such as the unemployed, those with lower educational attainment, lower income, and participants with disability, reported not availing themselves of oral health care due to lack of affordability compared to less disadvantaged groups.
Overwhelmingly, working-age Australian adults considered oral health care to be essential. The vast majority reported getting oral health care when needed, indicating no major affordability concerns. However, the lack of affordable dental care was a barrier, particularly for the disadvantaged groups, preventing them from accessing oral health services. This highlights the need to provide equitable oral health care, ideally by implementing the principles of universal oral health coverage.
Keywords: affordability, Australian adults, dental care, disadvantaged groups, Household, Income and Labour Dynamics survey, HILDA, oral health care, universal health coverage, working-age Australians.
Introduction
Advocacy for improving population oral health has taken centre stage at a global level. Notably, a dedicated Lancet Commission on Oral Health1 has been established and the World Health Organization (WHO) has drawn attention to the neglect of oral health, highlighting that over 3.5 billion people suffer from oral disease globally.2 The WHO’s Draft Global Oral Health Action Plan (2023–2030)3 outlines two overarching global targets to improve oral health worldwide. The first objective is to achieve universal health coverage (UHC) for oral health, aiming to provide essential oral health care services to 80% of the global population by 2030. The second goal is to reduce the burden of oral diseases, with a target of a 10% relative decrease in the combined global prevalence of major oral diseases by 2030. The main components of UHC, as defined by WHO, include enhancing population coverage, extending the services covered and ensuring financial protection.2,3 However, even in high-income countries with UHC, oral health care typically remains separate from general health care,2 further hindering efforts to improve oral health through integrated care. Within this context, the affordability of appropriate oral health services according to need remains a key issue.
The Draft Global Oral Health Action Plan (2023–2030)3 also features a list of 100 proposed actions, including engaging with civil society to encourage active participation, particularly from marginalised populations. It emphasises prioritising oral health research with a focus on public health interests and advocates for conducting participatory research involving a diverse range of community members to identify oral health needs, which is crucial given that rarely have populations been asked about their expectations regarding the need for oral health care, meaning that the public voice is absent from the scientific discussions on oral health care and access to it. Acceptability is an important element of the right to health, which is informed by the Availability, Accessibility, Acceptability and Quality framework.4 So, even in the presence of effective, quality services, people need to be receptive to services in order to make use of them. Knowledge of public opinion is crucial for politicians and policymakers to understand the needs, perceptions and expectations of the public with regard to oral health care. Additionally, social participation in public health decision-making is critical for health equity.3
Aligning with the targets of WHO, a recent inquiry report published by the Senate Select Committee on Access and Provision of Dental Services in Australia5 also overwhelmingly supports improved access to oral health care for all Australians and the attainment of UHC for oral health in Australia. The Senate report also highlights the poor state of oral health in Australia with a particular emphasis on barriers to access and inequalities in oral health care. Oral health is shaped by a multitude of interconnected factors, including biological, social, economic, cultural and environmental determinants.6 Research conducted on socioeconomic inequalities in untreated dental caries has revealed significant inequalities based on income and education levels in Australia and other high-income countries.7 These inequalities are primarily attributed to modifiable risk factors, including inadequate access to fluoridated water, excessive sugar intake and unfavourable dental attendance.7 There is a significant cost barrier in Australia, where oral health care is predominantly privatised, resulting in high out-of-pocket expenses.8 Access to public dental care is primarily available to children (via the Child Dental Benefits Schedule) and adults with healthcare or pensioner concession cards. As a result, most working-age adults fully fund their dental treatments out-of-pocket. According to national data, adults aged 25–44 years are more likely to have experienced toothache in the past 12 months than any other age group (23%), and this age group also has the highest proportion of having one or more teeth with untreated decay (35.7%).9
Studies in Australia have found that, despite improvements in some oral health outcomes, socioeconomic inequalities in oral health care are on the rise.10 Socioeconomic barriers, such as the cost of oral health services, have been identified as contributory factors to oral health inequalities, but these studies are limited to children10 or specific disadvantaged population groups, such as Aboriginal and Torres Strait Islander peoples.11,12 Since policies are typically formulated by experts and informed by input from trained professionals, such as dentists, regarding the significance of access to oral health care, it becomes essential to delve into the perspectives of the general population on this matter. Despite existing studies on the inequalities in accessing oral health care in Australia, most are limited to certain population groups,13–15 and there is a lack of evidence regarding two factors: (1) the perception of the essential nature of oral health care and (2) not seeking care due to affordability issues as perceived by people, instead of experts, and how this may vary across socioeconomic status. Additionally, existing studies have not adequately examined disability as a metric for assessing social disadvantage. We also find that despite existing policies addressing oral health care for children and the ongoing discussions regarding policies for seniors, there is a notable absence of policy emphasis on the working-age group.5 These gaps highlight the need for further investigation and analysis in the Australian context. This study aims to address these gaps in knowledge by using nationally representative data from a well-established cohort study to report the proportion of the working-age Australian population that considers dental care ‘essential’, as well as the proportion of the Australian population not receiving essential dental care due to lack of affordability. Further, we examine sociodemographic differences in these outcomes.
Methods
Study population
Data from the Household, Income and Labour Dynamics in Australia (HILDA) study was used for our analysis. HILDA is a nationally representative cohort study of Australian households, which has collected demographic, economic and health information from Australians annually since 2001.16 Data from wave 18 (year 2018) were used to examine working-age Australian adults’ perceptions about oral health care. Based on the latest census data from the Australian Bureau of Statistics, the average retirement age (of all retirees) is 55.4 years, and 55% of Australians over 55 years of age are retired.17 As this analysis focussed on working-age adults, the analytical samples were restricted to those aged from 20 to 54 years, which allowed this study to examine the oral health access needs of individuals who are typically active in the workforce and less likely to receive subsidised public oral health care.
Outcomes
Two outcome variables were derived: (1) essentiality (i.e. perception of whether oral health care should be an essential service) and (2) affordability. To assess the perceived essentiality of oral health care, respondents were asked to indicate: ‘Whether you think each of these are things that are essential – things that no one in Australia should have to go without today – Dental treatment when needed’. Valid response options were ‘yes/no/refused/don’t know’. Individuals who responded ‘yes/no’ were included in this analysis.
To measure affordability, respondents were asked to indicate: ‘Whether you (and your family) have – Dental treatment when needed?’ And for those who responded ‘No’ – ‘is that because you cannot afford it?’. Responses to these two questions were combined to derive a categorical variable classifying people who have access to dental treatment when needed, those who do not have dental treatment due to unaffordability and those who do not have access to treatment due to other reasons.
Sociodemographic characteristics
It is known that people’s perception of oral health and its utilisation is affected by social and demographic factors.18,19 Therefore, for this analysis, age, sex, education, remoteness, disability status, country of birth, employment status and income were considered relevant sociodemographic variables. Age was restricted to 20–54 years and converted to a categorical variable for statistical analysis and collapsed into four categories: (1) 20–24 years, (2) 25–34 years, (3) 35–44 years and (4) 45–54 years. Education was categorised based on the highest education level achieved by the participant: (1) Bachelor’s degree or higher, (2) Year 12, or certificate, or diploma and (3) those with less than Year 12 level of education. The Australian Standard Geographical Classification for remoteness was used and included ‘major city’, ‘inner regional’, ‘outer regional’ and ‘remote’ (includes very remote). Country of birth was classified as Australia, English-speaking countries and non-English-speaking countries. Weekly disposable income (Australian dollars) was categorised into tertiles (tertile 1: $−765.1−$1521.8; tertile 2: $1522.6−$2385.4; tertile 3: $2388.0−$16,317.1).
Statistical analysis
Descriptive analysis was used to quantify the prevalence and 95% confidence intervals (CIs) for essentiality according to sociodemographic characteristics. To provide descriptive insights into socioeconomic inequalities univariate logistic regression models were used to assess the association between each descriptive (socioeconomic and sociodemographic) variables and perception of essentiality. Similarly, univariate logistic regression models were used to assess the association between each descriptive variable and getting dental treatment versus not getting treatment due to lack of affordability. Each model was adjusted for age and sex. Additionally, the age-adjusted models were analysed separately for males and females. STATA v17 software was used for analysis.20
Results
The total number of participants in the cross-sectional analysis was 11,028. The characteristics of this sample are presented in Table 1. About 77% (n = 8495) of participants were employed, 3.9% (n = 429) were unemployed and 14% (n = 1542) were not in the labour force. The majority of respondents were born in Australia (78.2%), and of those remaining, 6.5% were born in English-speaking countries and 10.2% were born in non-English-speaking countries. Most participants lived in major cities (68.2%). Regarding educational qualifications, 30.5% of participants had a Bachelor’s degree or higher level of education; 50.7% had a Year 12, or certificate, or diploma; and 13.7% had less than a Year 12 level of education. Overall, 19.6% of participants identified as having a disability.
| Variable | n | % | |
|---|---|---|---|
| Age (years) | |||
| 20–24 | 1567 | 14.2 | |
| 25–34 | 3632 | 32.9 | |
| 35–44 | 2692 | 24.4 | |
| 45–54 | 2817 | 25.5 | |
| Sex | |||
| Male | 5343 | 48.4 | |
| Female | 5685 | 51.6 | |
| Remoteness area | |||
| Major cities | 7523 | 68.2 | |
| Inner regional | 2290 | 20.8 | |
| Outer regional | 1061 | 9.6 | |
| Remote/very remote | 151 | 1.4 | |
| Highest education level | |||
| Bachelor’s or higher | 3367 | 30.5 | |
| Year 12, certificate, diploma | 5591 | 50.7 | |
| Less than year 12 | 1506 | 13.7 | |
| Missing | 564 | 5.1 | |
| Country of birthA | |||
| Australia | 8619 | 78.2 | |
| English-speaking countriesB | 719 | 6.5 | |
| Other countries | 1125 | 10.2 | |
| Missing | 565 | 5.1 | |
| DisabilityA | |||
| Yes | 2156 | 19.6 | |
| No | 8303 | 75.34 | |
| Missing | 569 | 5.2 | |
| Employment statusA | |||
| Employed | 8495 | 77.0 | |
| Unemployed | 429 | 3.9 | |
| Not in labour force | 1542 | 14.0 | |
| Missing | 562 | 5.1 | |
| Weekly disposable income | |||
| $−765.1−$1521.8 (tertile 1) | 3672 | 33.3 | |
| $1522.6−$2385.4 (tertile 2) | 3673 | 33.3 | |
| $2388.0−$16,317.1 (tertile 3) | 3683 | 33.4 | |
| Oral health care – essentiality | |||
| Yes | 10,634 | 96.4 | |
| No | 394 | 3.6 | |
| Oral health care – affordability | |||
| Have treatment when needed | 10,179 | 92.3 | |
| No treatment (due to affordability) | 714 | 6.5 | |
| No treatment (due to other reasons) | 135 | 1.2 | |
Almost all participants perceived that getting oral health care when needed is essential (96.4%). It was found that 92.3% were able to access treatment when needed, but 6.5% did not access treatment when needed due to unaffordability, and 1.2% did not access treatment when needed due to other reasons (Table 1). Table 2 presents age-adjusted odds ratios (ORs) of the regression models for association between each descriptive variable and perception of essentiality. The unadjusted models are presented in Supplementary Tables S1 and S2. As shown in Table 2, the 35–44-year age group were more likely to perceive dental treatment when needed as essential versus not essential compared to 45–54 year olds (OR: 1.87; 95% CI: 1.24–2.82). Compared to those residing in metro areas, those in remote or very remote areas were four times more likely to perceive dental treatment when needed as essential versus not essential (95% CI: 1.02–17.23). However remote/very remote participants were very small in number (n = 151). Compared to those born in Australia, people born in other English-speaking countries were less likely to perceive dental treatment as essential (OR: 0.54; 95% CI: 0.30–0.99), and those born in other (non-English) speaking countries were more likely to perceive dental treatment as essential (OR: 1.90; 95% CI: 1.13–3.20). There were no substantial differences in perception of essentiality across other sociodemographic characteristics (Table 2), but there were variations in affordability (Table 3). Participants residing in inner regional areas were most likely to not access oral health care due to lack of affordability (OR: 1.58; 95% CI: 1.24–2.01) compared to those living in major cities. Compared to individuals with a Bachelor’s degree or higher education, those with a Year 12, certificate or diploma level qualification were 2.67 times (95% CI: 1.8–3.97), and those with less than a Year 12 education were 3.96 times (95% CI: 2.64–5.93) more likely to not have treatment due to lack of affordability. Individuals with disability were three times more likely to not get treatment due to unaffordability than those without disability (OR: 3.08; 95% CI 2.46–3.85). Compared to those who were employed, unemployed individuals (OR: 3.05; 95% CI: 1.86–4.99) and those not in the labour force (OR: 2.54; 95% CI: 1.97–3.28) had higher odds of not having oral health treatment due to lack of affordability. Similarly, individuals in the lowest-income tertile had an over six times higher likelihood of not having treatment due to lack of affordability than the higher-income group (95% CI: 3.99–9.37). Compared to individuals born in Australia, individuals born in other English-speaking (OR: 0.61; 95% CI: 0.39–0.96) and non-English-speaking countries (OR: 0.97; 95% CI: 0.62–1.51) were less likely to not access treatment due to unaffordability.
| Variable | ORA,B (females) | 95% CI | ORA,B (males) | 95% CI | Total ORB,C | 95% CI | |
|---|---|---|---|---|---|---|---|
| Age (years) | |||||||
| 45–54 | – | – | – | – | Reference (Ref) | – | |
| 35–44 | – | – | – | – | 1.87 | 1.24–2.82 | |
| 25–34 | – | – | – | – | 0.98 | 0.67–1.43 | |
| 20–24 | – | – | – | – | 1.46 | 0.93–2.29 | |
| Sex | |||||||
| Male | – | – | – | – | Ref | – | |
| Female | – | – | – | – | 1.19 | 0.89–1.58 | |
| Remoteness area | |||||||
| Major cities | Ref | – | Ref | – | Ref | – | |
| Inner regional | 1.27 | 0.78–2.07 | 1.62 | 1.00–2.62 | 1.44 | 1.02–2.02 | |
| Outer regional | 0.78 | 0.45–1.35 | 0.76 | 0.45–1.28 | 0.77 | 0.53–1.12 | |
| Remote/very remote | 3.37 | 0.45–24.94 | 5.06 | 0.69–37.29 | 4.19 | 1.02–17.23 | |
| Highest education level | |||||||
| Bachelor’s or higher | Ref | – | Ref | – | Ref | – | |
| Year 12, certificate, diploma | 0.84 | 0.50–1.42 | 0.92 | 0.53–1.61 | 0.87 | 0.60–1.28 | |
| Less than year 12 | 0.71 | 0.37–1.37 | 0.75 | 0.38–1.46 | 0.72 | 0.45–1.14 | |
| Country of birth | |||||||
| Australia | Ref | – | Ref | – | Ref | – | |
| English-speaking countriesD | 0.49 | 0.22–1.10 | 0.59 | 0.25–1.42 | 0.54 | 0.30–0.99 | |
| Other countries | 1.60 | 0.78–3.28 | 2.27 | 1.07–4.80 | 1.90 | 1.13–3.20 | |
| Disability | |||||||
| No | Ref | – | Ref | – | Ref | – | |
| Yes | 1.44 | 0.91–2.30 | 1.04 | 0.66–1.64 | 1.22 | 0.88–1.68 | |
| Employment status | |||||||
| Employed | Ref | – | Ref | – | Ref | – | |
| Unemployed | 2.20 | 0.70–6.95 | 0.97 | 0.48–1.99 | 1.32 | 0.71–2.43 | |
| Not in labour force | 1.38 | 0.77–2.48 | 1.26 | 0.65–2.45 | 1.34 | 0.86–2.08 | |
| Weekly disposable income | |||||||
| $2388.0− $16,317.1 (tertile 3) | Ref | – | Ref | – | Ref | – | |
| $1522.6−$2385.4 (tertile 2) | 1.00 | 0.62–1.63 | 0.83 | 0.51–1.36 | 0.86 | 0.60–1.22 | |
| $−765.1−$1521.8 (tertile 1) | 0.95 | 0.58–1.56 | 0.79 | 0.47–1.30 | 0.91 | 0.64–1.28 | |
Note: ‘Ref’ or ‘reference’ is the reference category, which serves as the baseline for comparison against other categories to estimate odds ratios.
| Variable | ORA,B (females) | 95% CI | ORA,B (males) | 95% CI | Total ORB,C | 95% CI | |
|---|---|---|---|---|---|---|---|
| Age | |||||||
| 45–54 | – | – | – | – | Reference (Ref) | – | |
| 35–44 | – | – | – | – | 0.96 | 0.7–1.31 | |
| 25–34 | – | – | – | – | 1.18 | 0.89–1.57 | |
| 20–24 | – | – | – | – | 1.11 | 0.80–1.56 | |
| Sex | |||||||
| Male | – | – | – | – | Ref | – | |
| Female | – | – | – | – | 1.16 | 0.92–1.46 | |
| Remoteness area | |||||||
| Major cities | Ref | – | Ref | – | Ref | – | |
| Inner regional | 1.56 | 1.12–2.18 | 1.59 | 1.12–2.27 | 1.58 | 1.24–2.01 | |
| Outer regional | 1.24 | 0.82–1.87 | 1.00 | 0.62–1.62 | 1.14 | 0.83–1.55 | |
| Remote | 0.51 | 0.07–3.75 | 0.70 | 0.17–3.00 | 0.62 | 0.19–2.00 | |
| Highest education level | |||||||
| Bachelor’s or higher | Ref | – | Ref | – | Ref | – | |
| Year 12, certificate, diploma | 2.49 | 1.55–4.01 | 2.95 | 1.44–6.02 | 2.67 | 1.8–3.97 | |
| Less than year 12 | 4.12 | 2.55–6.66 | 3.85 | 1.87–7.92 | 3.96 | 2.64–5.93 | |
| Country of birth | |||||||
| Australia | Ref | – | Ref | – | Ref | – | |
| English-speaking countriesD | 0.40 | 0.22–0.71 | 0.89 | 0.47–1.68 | 0.61 | 0.39–0.96 | |
| Other countries | 1.03 | 0.57–1.86 | 0.88 | 0.44–1.77 | 0.97 | 0.62–1.51 | |
| Disability | |||||||
| No | Ref | – | Ref | – | Ref | – | |
| Yes | 3.12 | 2.29–4.24 | 3.08 | 2.22–4.26 | 3.08 | 2.46–3.85 | |
| Employment status | |||||||
| Employed | Ref | – | Ref | – | Ref | – | |
| Unemployed | 2.94 | 1.22–7.08 | 3.20 | 2.04–5.01 | 3.05 | 1.86–4.99 | |
| Not in labour force | 2.43 | 1.76–3.37 | 2.85 | 1.92–4.24 | 2.54 | 1.97–3.28 | |
| Weekly disposable income | |||||||
| $ 2388.0− $16,317.1 (tertile 3) | Ref | – | Ref | – | – | ||
| $ 1522.6− $2385.4 (tertile 2) | 1.75 | 0.97–3.15 | 2.91 | 1.57–5.40 | 2.20 | 1.43–3.39 | |
| $−765.1−$1521.8 (tertile 1) | 5.67 | 3.18–10.10 | 6.87 | 3.73–12.65 | 6.12 | 3.99–9.37 | |
Note: ‘Ref’ or ‘reference’ is the reference category, which serves as the baseline for comparison against other categories to estimate odds ratios.
Discussion
This study examined the perceptions and experiences of a nationally representative sample of working-age Australian adults regarding essentiality and affordability of oral health care. Our study found that an extremely high proportion of working-age Australian adults consider oral health care when needed as an essential service for all people. However, there are differences in accessing dental treatment when needed, and these differences are primarily related to affordability. This lack of affordability is more common in certain groups, including individuals with disability, those with lower education qualifications and those who are unemployed, reflecting the socioeconomic inequalities experienced by these groups. Additionally, compared to middle- and higher-income individuals, low-income individuals are more likely to not have treatment because of affordability issues. What is noteworthy is that individuals eligible for a means-tested health care card and, therefore, subsidised dental care, likely fall within the lower tertile. Unaffordability remains a barrier to accessing dental treatment when needed among this group of low-income individuals, as oral health care is not covered under Medicare. Even for the small proportion who are eligible for public dental care, this may suggest that dental subsidies do not sufficiently reduce dental costs among low-income earners and warrants further attention.
Although the inefficiency of health systems in providing access to ‘adequate’ oral health care has been researched,21 the public voice on oral health care is still absent from this discussion. Existing studies have focused on quantifying the unmet needs of oral health care at a population level in Australia,15,22,23 as well as in other countries;24–26 but, this study contributes novel findings about perception of essentiality of oral health care among working-age group in Australia using population-based data from a well-established national cohort study. Overwhelmingly, Australian working-aged adults consider oral health care as essential. In addition, this study confirms previous findings15,22,23 that affordability is a critical issue for unmet oral health needs in Australia, with key differences apparent according to employment status, educational attainment and disability status. The unaffordability of oral health care can be attributed to various factors. These include the high costs of services and out-of-pocket expenses, which arise from the privatised system and lack of healthcare policy coverage for individuals in the working-age group.8 Additionally, a lack of education and awareness regarding preventive oral health care also contributes to this issue.8
The estimate for lack of treatment due to unaffordability in this study (6.5%) differs from that of the National Study of Adult Oral Health (NSAOH 2017–18) (22.6%)27 and the Australian Bureau of Statistics – Patient Experiences in Australia survey (17.6%).28 It is noted that the sample for this study was restricted to working-age adults only, and there are differences in the way the survey questions are phrased, which could account for different interpretations by participants. For instance, the HILDA questionnaire uses the term ‘dental treatment when needed’ compared to ‘recommended treatment’ used in the NSAOH. The answers may reflect differences in individuals’ perceived need for treatment compared to practitioners’ recommendations. Existing literature documents a disconnect between perceived need for oral health care and clinically assessed objective need. Several studies have shown that individuals may underestimate or not perceive their need for dental treatment despite having significant oral health issues, and this may be influenced by their sociodemographic background.18,29,30 However, perceived need plays a vital role in health seeking behaviour as it is a major factor that drives individuals to actively seek dental services.29 The Australian Bureau of Statistics – Patient Experiences in Australia survey28 includes individuals who delayed seeing a dental health professional in addition to those who did not see one, whereas the HILDA questionnaire only pertains to individuals who did not get treatment. It is also important to acknowledge that what is considered essential treatment can differ among individuals and may not solely depend on disease severity. A binary variable expressing dental treatment being essential or not may not fully consider the complexity and number of treatment options available. Asking more specific questions about the type of treatment needed can provide a clearer understanding of what is perceived as essential treatment.
This study has shown that working-age individuals in Australia are receptive to oral health services but are unable to avail themselves because of affordability issues. In order to reduce inequalities in oral health care provision, it is important to formulate policies to reduce financial barriers to affordability of oral health services, including preventative care, primarily among populations experiencing social disadvantage. One of the ways to address the issue is by provision of affordable essential oral health services, which cover the most prevalent oral health problems and provide cost-effective interventions for oral health promotion, prevention, treatment and rehabilitation.31,32 Although achieving UHC poses challenges, striving for universal access to essential and quality oral health services can serve as a feasible step toward UHC. A key to implementation of essential oral health care is to make it universally available to everyone, irrespective of their socioeconomic status or other characteristics.32 Affordable access to oral health care can facilitate disease prevention and health promotion, but it is also critical that oral health services focus not only on treatment but also on prevention of oral diseases.32
Other solutions include those recommended by the Senate inquiry into the Provision of and Access to Oral Health Services in Australia.5 In addition to UHC, these solutions encompass universal access to preventative care for everyone, which may have a beneficial long-term impact on oral health.5 Other recommendations, like means-tested policies and the Senior Dental Benefits Schedule, are beneficial but limited, as they exclude most working-age adults.5 Although these policies may serve as initial steps, we recommend implementing an action plan towards providing universal access to oral health care for all Australians. Additionally, the social, economic, commercial and political determinants of oral health should not be ignored.33 Efforts should also focus on contextual factors, such as the high availability and consumption of a cariogenic diet, as well as factors that limit access to oral health resources, including community water fluoridation, availability of healthy and nutritious fruits and vegetables and tobacco cessation services.33 Quoting the first line of the book ‘The Health Gap’: ‘What good does it do to treat sick people and then send them back to what made them sick?’34
In conclusion, working-aged Australian adults overwhelmingly considered oral health care to be essential. Even though the vast majority were able to get dental treatment when needed, the disadvantaged groups could not afford such care. This inequality in access to dental treatment further perpetuates inequalities in experience of oral diseases, as those who cannot afford treatment are more likely to experience delays, leading to subsequent complications and financial burdens of more expensive treatments. This study helps bring the public voice into the debate regarding equitable access to oral health care coverage, as has been prominently outlined in the recent global discourse on strengthening oral health systems.35
Data availability
This study used unit record data from the Household, Income and Labour Dynamics in Australia Survey [HILDA] conducted by the Australian Government Department of Social Services (DSS). The findings and views reported in this study, however, are those of the authors and should not be attributed to the Australian Government, DSS, or any of DSS’ contractors or partners. DOI: http://dx.doi.org/10.26193/IYBXHM
Conflicts of interest
GT received an honorarium as an Associate Editor for the Community Dentistry and Oral Epidemiology journal and as the Chair of the Platform for Better Oral Health in Europe organisation.
Declaration of funding
TK is supported by a University of Melbourne Dame Kate Campbell fellowship and a Victorian Endowment for Science, Knowledge and Innovation (VESKI) fellowship. AS is funded by Australian Research Council DECRA award DE230101210.
Author contributions
AS, GT and TY contributed to conception and design of the study. AS and GK acquired data for the analysis. GK, GT and AS contributed to data analysis. AS, GK, GT, TK, TY and MM contributed to interpretation of data. GK drafted the manuscript. GK, AS, GT, TK, TY and MM revised the manuscript. All authors approved the final manuscript and revisions.
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