Original Research

Utilization of dental services by rural riverside populations covered by a Fluvial Family Health Team in Brazil

AUTHORS

name here
Diego Cordeiro
1 MSc, PhD Student *

name here
Fernando J Herkrath
2 PhD, Public Health Researcher ORCID logo

name here
Adrielly C Guedes
3 BDS, MSc Student

name here
Luiza Garnelo
4 PhD, Public Health Researcher

name here
Ana Paula CQ Herkrath
5 PhD, Adjunct Professor

CORRESPONDENCE

*Mr Diego Cordeiro

AFFILIATIONS

1, 5 School of Dentistry, Federal University of Amazonas, Av. Ayrão 1539, Praça 14 de Janeiro, Manaus, Amazonas 69025-050, Brazil; and Doctoral Program in Public Health in the Amazon, Manaus, Amazonas, Brazil

2 Doctoral Program in Public Health in the Amazon, Manaus, Amazonas, Brazil; Leônidas and Maria Deane Institute, Oswaldo Cruz Foundation, Rua Teresina 476, Adrianópolis, Manaus, Amazonas 69057-070, Brazil; and Superior School of Health Sciences, Amazonas State University, Av. Carvalho Leal 1777, Cachoeirinha, Manaus, Amazonas 69065-001, Brazil

3 Leônidas and Maria Deane Institute, Oswaldo Cruz Foundation, Rua Teresina 476, Adrianópolis, Manaus, Amazonas 69057-070, Brazil

4 Doctoral Program in Public Health in the Amazon, Manaus, Amazonas, Brazil; and Leônidas and Maria Deane Institute, Oswaldo Cruz Foundation, Rua Teresina 476, Adrianópolis, Manaus, Amazonas 69057-070, Brazil

PUBLISHED

16 January 2024 Volume 24 Issue 1

HISTORY

RECEIVED: 23 February 2023

REVISED: 29 August 2023

ACCEPTED: 23 September 2023

CITATION

Cordeiro D, Herkrath FJ, Guedes AC, Garnelo L, Herkrath AC.  Utilization of dental services by rural riverside populations covered by a Fluvial Family Health Team in Brazil. Rural and Remote Health 2024; 24: 8258. https://doi.org/10.22605/RRH8258

AUTHOR CONTRIBUTIONSgo to url

This work is licensed under a Creative Commons Attribution 4.0 International Licence


abstract:

Introduction:  Rural riverside populations of Brazil face several difficulties to access health services. The Brazilian National Primary Care Policy implemented the Fluvial Family Health Teams (FFHT), which is a specific primary care team arrangement for these territories. The aim of the study was to assess the use of dental services by adults living in rural riverside areas covered by a FFHT.
Methods:  A household-based cross-sectional survey was carried out with a rural riverside population of 38 localities on the left bank of the Rio Negro, Manaus, Amazonas, representative of the area covered by the FFHT. Stratified random sampling was calculated based on the number of adults and households in each riverside locality. An electronic questionnaire was used to obtain information on sociodemographic and oral health conditions, and the utilization of dental services. After descriptive analysis, logistic regression analyses were performed to estimate the odds ratios for the outcome ‘use of dental health services over the past 12 months’.
Results:  A total of 492 individuals, aged 18 years or more, from 38 rural riverside areas were assessed. The mean age of participants was 43.5 years (standard deviation 17.0), ranging from 18.0 to 90.7 years. Of these participants, 3.1% had never been to a dentist and 21.9% had been to a dentist more than 3 years ago. Among those who attended the dental service, 77.4% of appointments occurred in public health services. Dental pain over the previous 6 months (odds ratio (OR)=2.44; 95% confidence interval (CI) 1.51–3.96), higher education (OR=2.62; 95%CI 1.23–5.56), most recent appointment in public health services (OR=1.86; 95%CI 1.19–2.93), edentulism (OR=0.38; 95%CI 0.17–0.85) and dissatisfaction with oral health (OR=0.59; 95%CI 0.38–0.93) were associated with the dental services utilization.
Conclusion:  The study results revealed that approximately a quarter of the individuals did not use dental services over the previous 3 years or have never used them. Despite the increase in access provided by the FFHT, edentulous individuals, individuals dissatisfied with their oral health, and those with lower levels of education were less likely to use dental services, while individuals who experienced dental pain sought dental services more frequently. These findings suggest that the healthcare model offered to this population must be rearranged.

Keywords:

Brazil, dental health services, healthcare utilization, primary health care, rural health services.

full article:

Introduction

Access to dental healthcare services, whether for preventive or curative treatments, is hard for those who live in rural areas1-4. In Brazil5,6, as in other countries, people who live in rural areas use dental services less than those who live in urban areas7,8. The last Brazilian National Health Survey (2019) revealed that approximately 48% of the Brazilian adult and elderly population used dental services in the year prior to the survey, but this percentage dropped to 35.8% when only the rural population was considered7.

Although dental services should be equally offered by a universal health system, the use of dental services is unequal between different social groups, economic strata, and levels of education9,10. Socioeconomic status is a significant determinant for the use of health services11-13, and there is evidence that this is even stronger in rural areas8. Levels of education and income are socioeconomic factors that systematically determine the use of dental services. Lower levels of education and income are associated with lower use of dental services9, especially in the Brazilian population7,8,11,14.

Place of residence also explains inequalities in oral health conditions. Rurality has previously been associated with tooth loss in Brazilian adults and elderly15-17 and Chilean adults18, higher prevalence of dental caries in Colombian children19 and with the oral health-related quality of life in Brazilian adults6. Furthermore, Peruvian children who do not brush their teeth are more common in rural areas20. Rural populations travel greater distances to access health care than urban populations, have fewer dentists per individual, and have less water fluoridation21. In addition, these populations have lower availability of primary care services8, and more difficulty in accessing early interventions, and educational and preventive activities22,23. In summary, there are differences in health conditions, access to and quality of health care between rural and urban areas24,25.

Each Brazilian rural region has specific characteristics and singularities26,27. The rural riverside populations of the Amazon, in the North Region of the country, live along or close to riverbanks. Their lives are influenced by demographic dispersion, seasonality of rivers (floods and ebbs), and distances. Moreover, these populations face social vulnerability and difficulty in accessing goods and public services27-29. This region is also characterized by lower access to and use of health services30. The latest national surveys revealed that the percentage of dental appointments was lower in populations from the North Region when compared to the South, Southeast and Midwest regions of the country7,31.

The Fluvial Family Health Teams (FFHT) were implemented to increase the coverage and access to health services, including dental services, in these remote locations in Brazil. In the fluvial teams, the health professionals carry out their duties on a mobile fluvial health unit (vessel) and visit the locations intermittently on monthly trips. The community health workers are the only FFHT professionals who live in the rural riverside localities32,33.

Equity in the use of dental services remains a public health challenge34. Investigating the determinants of the use of dental services in remote populations allows identification of intervention opportunities to reduce inequalities in dental care. Given that there are few studies on the rural riverside populations in the Amazon and from other countries, the aim of this study was to assess the utilization of dental services as well as the associated factors in a rural riverside population residing in areas covered by the FFHT.

Methods

This household-based cross-sectional survey was conducted to describe the sociodemographic and health profile of the rural riverside populations who live along the Negro river, in the municipality of Manaus, Amazonas, Brazil.

The survey was carried out in 38 rural riverside localities on the left bank of the Rio Negro. The settlements are located in the territory covered by the FFHT and are organized into five areas: Apuaú, Mipindiaú, São Sebastião do Cueiras, Santa Maria, and Costa do Arara (Fig1)25.

Stratified random sampling was performed based on the number of individuals and households in each locality according to information from primary health care, totaling 2342 people in 765 households. The sample size calculation considered the representativeness of adults and elderly of both sexes, and the probability of finding individuals in each household. One adult and one elderly person of each sex from each household were randomly selected, when necessary. The calculation considered a prevalence of 50% of the outcome of interest and a precision of 0.05, in addition to 10% of possible losses or refusals. After this, it was adjusted for the finite population, resulting in 239 households and 509 adults aged 18 years or older. Those with cognitive impairment and who did not have a family member who could respond to the questionnaire were excluded from the sample.

The interviews were conducted using electronic questionnaires developed in the Research Electronic Data Capture (REDCap) v8.11 (REDCap; https://www.project-redcap.org), an open-source application to create and manage surveys and databases. A structured questionnaire with closed questions was administered directly to the participants by trained interviewers. After the interviewers’ theoretical training, two pilot studies were carried out in rural areas of the municipality not included in the main study. The survey included socioeconomic characterization, health conditions, and use of and access to health services.

The main study outcome, dental services utilization, was measured by a question about the most recent dental appointment, with five possible answers: during the past 12 months, more than 1 year to 2 years ago, more than 2 years to 3 years ago, more than 3 years ago, or had never been to the dentist.

The sociodemographic characteristics were gender, age, race/skin color, family income, level of education, recipient of a cash transfer program, and occupation (yes/no). The variables related to oral health were self-reported tooth loss, dental pain and satisfaction with oral health. Self-reported tooth loss was measured using two questions from the Brazilian National Health Survey (https://www.pns.icict.fiocruz.br/questionarios): ‘(1) As for your upper teeth, how many teeth have you lost?’ and ‘(2) As for your lower teeth, how many teeth have you lost?’ The number of missing teeth was the sum of the numerical answers to the two questions, ranging from 0 to 32. The number of missing teeth, dichotomous outcomes of total tooth loss (edentulism), severe tooth loss (up to eight natural teeth) and non-functional dentition (less than 20 natural teeth) were also described. These conditions are not mutually exclusive. The individuals were asked if they had experienced dental pain over the previous 6 months (yes/no). Satisfaction with oral health was assessed using a five-point Likert scale, ranging from ‘very satisfied’ to ‘very dissatisfied’.

The data collected were exported directly from REDCap to a Stata v15 database (https://www.stata.com). After the descriptive analysis, bivariate logistic regression analyses were performed between the independent variables and the outcome of dental services utilization over the past 12 months. Hierarchical multiple analysis analysis was then performed, according to the Andersen behavioral model of health services utilization35. Individual predisposing, enabling and need characteristics defined the three blocks of variables. Variables with p<0.10 at the time of entry into the model were retained in the subsequent models. The level of significance adopted for all analyses was 0.05.

table image Figure 1:  Areas of coverage and rural riverside localities on the left bank of the Negro river included in the study.

Ethics approval

The study was approved by the Human Research Ethics Committee of FMT/HVD under Certificate of Presentation for Ethical Consideration 57706316.9.0000.0005, and the research participants signed an informed consent.

Results

A total of 492 individuals, aged 18 years or more, from 38 rural riverside localities were assessed. The mean age of participants was 43.5 years (standard deviation 17.0), ranging from 18.0 to 90.7 years. Primary education was the highest level of education (58.7%) in the sample and 12.0% of individuals never attended school. Just over half of the population had a household income of less than one minimum wage (53.4%). The sociodemographic characteristics of the individuals are shown in Table 1.

  The most recent dental appointment within the previous 12 months was observed in 50.8% of the sample, and 3.1% of the participants reported never having been to a dentist. The most dental appointment was carried out in the public health service for 77.4% of participants, and the main reasons for the appointments were prevention (36.9%), dental pain (22.4%), and tooth extraction (20.6%). The mean number of missing teeth was 10.9, and 34.4% of the sample presented non-functional dentition, 19.8% had severe tooth loss and 10.4% of the population was edentulous. One quarter of the individuals reported being dissatisfied or very dissatisfied with their oral health. Table 2 shows the characteristics related to the use of dental services, and the self-reported and subjective clinical outcomes of oral health.

In the unadjusted bivariate analyses, higher education, having an occupation, using public services, and having had dental pain during the previous 6 months were associated with a greater use of dental services within the previous 12 months, while older age and edentulism were associated with a lower utilization of these services. In the adjusted analysis, high school education (OR=2.62; 95%CI 1.18–5.82), having had the most recent dental appointment in the public health service (OR=1.89; 95%CI 1.20–2.97), and dental pain over the previous 6 months (OR=2.44; 95%CI 1.51–3.95), were factors associated with greater use of dental services. Edentulism (OR=0.38; 95%CI 0.17–0.85) and dissatisfaction with oral health (OR=0.6; 95%CI 0.38–0.93) were associated with lower dental services utilization. The estimates obtained in the bivariate analyses are shown in Table 3 and the adjusted estimates in Table 4.

Table 1:  Sociodemographic characteristics of study participanttable image

Table 2:  Study population use of dental services and self-reported oral health conditionstable image

Table 3:  Bivariate analysis between the outcome ‘use of oral healthcare services over the past 12 months’ and independent variablestable image

Table 4:  Hierarchical multiple analysis between sociodemographic and oral health-related variables and the outcome ‘use of oral healthcare services over the past 12 months’table image

Discussion

The study findings showed that a quarter of the rural riverside population in the Amazon region had not used dental services over the previous 3 years, and revealed the relevant role of the public sector for accessing services by the study population. Furthermore, the use of dental services was associated with socioeconomic status and factors related to oral health. Individuals with a higher level of education, those who had had their last dental appointment in the public service, and those who reported dental pain during the previous 6 months were more likely to use the services, while edentulous individuals and those dissatisfied with their oral health reported using the service less frequently.

Approximately a quarter of the sample reported that they had used the service more than 3 years ago or had never been to a dentist. The use of dental services is less frequent in rural areas in various regions around the world1-3,9,36. Socioeconomic inequalities and caries experience were associated with service utilization in Mexico and Peru37,38. In Latin America, when compared to general health care, dental services utilization is lower for both mothers and children39, with maternal engagement increasing the chances of services utilization40. Data from several countries, such as Chile, Brazil, Peru, and Colombia, show a lower likelihood of dental services utilization in rural areas 12,18,38,41.

The national health survey carried out in Brazil in 2013 showed that the use of dental services was lower in rural areas8, although no difference in the adjusted analysis in the 2019 survey was observed7. The first survey showed that, among those who had used dental services, the time interval since the most recent dental appointment was greater among residents in rural areas than among residents in urban areas8. Poor accessibility, issues related to mobility or lack of transportation, limited availability of dental services, lack of professionals in rural areas, and not considering oral health as a priority when compared to other needs such as food insecurity, are all possible explanations for the lower use of dental services in rural areas9,42,43.

The Amazonian rurality, in turn, has singularities that can increase disparities between rural and urban areas. The geographic environment leads to economic and social impacts, and affects access to health services. For the rural riverside population, fluvial barriers make mobility hard due to the great distances between homes and healthcare centers, and the time for travelling has a huge variation according to the floods and ebbs27,30,44. Moreover, the lack of regular public transportation to the urban area and the poor financial resources of the population for transportation also hinder access45. The low availability of health services, the absence of permanent oral healthcare services in communities, and the burden of cost of transportation for riverside people to seek treatment in other locations have been pointed out as reasons why Amazonian riverside populations do not frequently use dental services, as shown by one of the few studies carried out in these populations46. The same difficulties were also mentioned in a Peruvian study that evaluated access to maternal care in a riverside population47. These barriers have negative effects on oral health, as the regular use of dental services is a protective measure against tooth loss in riverside populations in the Amazon48.

Need is strongly associated with the use of health services35. In the present study, the main reason reported for the most recent dental appointment was the need for dental treatment, whether due to pain, tooth extraction, or other reasons (61.5%). Residing in rural areas reduces the probability of seeking dental care to prevent oral diseases, and the use of dental services in rural areas is mainly for curative treatments1,2,46,49-51. In Peru, people living in rural areas have a higher number of caries with pulpal involvement, while in Ecuador and Mexico dental services utilization was associated with pain-related motivations37,52,53. As the rural population faces greater barriers to access dental care, it is assumed that they are less likely to have several dental attendances for preventive or conservative treatments37,54.

A study of a rural US population showed that adults in rural areas were 65% less likely to receive preventive dental procedures than their urban counterparts, and were more likely to receive restorative treatment and indication for tooth extraction2. For a rural population in India, a study reported that dental appointments were motivated by need, either for pain relief (31%) or extraction (54%), and not for preventive dental care55. Dental pain has been identified as the main reason for seeking dental care56-58 both in urban and rural areas55. In the present study, individuals who reported dental pain over the previous 6 months were more likely to use dental services, and more than 20% of the participants reported dental pain within the same period of time. Another study conducted in a similar Amazonian population showed that dental treatment focused on pain relief, particularly by tooth extractions46. The use of dental services is expected when a pain episode occurs59 and longer intervals between dental appointments are associated with a greater chance of seeking dental care due to pain49,57. In rural riverside areas of India, the low availability of dentists, geographic barriers, and lack of transportation hinder the use of services, even in cases of toothache60. Dental pain is mainly caused by dental caries, which is highly prevalent in riverside populations6,60. When dental pain is due to caries, tooth extraction tends to be more frequent because of the limited availability of services, financial limitations of the population, delay in searching for treatment, and the desire for a definitive solution for dental pain46.

The most recent dental appointments in the public health service were associated with the use of dental services. To improve access to and use of dental services in Brazil, an adapted model of primary care was implemented for the riverside populations. The presence, even if intermittent, of the fluvial health unit undoubtedly brings the services closer to the communities. The FFHT, which responds to the specificities of rural riverine localities, operates in areas of great territorial distances and can remain in transit for up to 20 days a month, providing health care to this population61. The fluvial mobile health units are also present in other countries with riverside populations, such as India, Ecuador, and Bangladesh. In general, presence of multidisciplinary health teams and the itinerant regime of the services are similar. However, the model in Bangladesh does not include a dentist in the teams. In this case, dental care is assumed by a dental technician60,62,63. In contrast, in countries such as Venezuela and Colombia, which also have riverside populations, there is no documented evidence in the literature of fluvial units promoting healthcare provision. In such scenarios, populations must journey to areas where these services are available, adhering to the conventional model of health care64, increasing inequities in the healthcare system.

In Brazil, since the implementation of fluvial health units, people who had once been excluded from traditional healthcare models have now been covered by health services, and access to health services has increased, ensuring care for populations in remote and difficult-to-access areas30,65. This finding emphasizes the importance of healthcare approaches directed to peculiar population groups, such as the rural riverside populations of the Amazon66 and other regions with similar populations. However, it is necessary to recognize that, although accessibility to primary health care has improved, the traditional biomedical model of care still prevails, and needs to be overcome30.

The use of dental services by the riverside population was more frequent among individuals with higher education. The association between the use of dental services and education corroborates the literature3,8,9,11,14,50. A higher level of education may be associated with better health literacy67, better understanding of the consequences of health behaviors68, including use of health services35, and higher income69, thus favoring healthier choices70. The school environment and level of education can also strengthen social ties, which have an impact on the use of dental services8. In rural areas of Ecuador, age and education presented a significant effect on self-perceived oral health53. In relation to income, studies on rural populations have found that financial limitations are a relevant aspect for the use of dental services7,8,16. However, in this study, this association was not observed. It can be assumed that, since this is a homogenous low-income population, it becomes difficult to discriminate the impact of income on the use of dental services.

Edentulous individuals and those who were dissatisfied with their oral health used dental services less frequently. A study carried out in a rural population in southern Brazil also showed that a greater number of missing teeth and worse self-perception of health were associated with lower use of dental services16. A recent systematic review revealed that individuals with a poorer self-perception of oral health, edentulous individuals, or individuals with severe tooth loss used dental services less frequently than those with a better perception of oral health and greater number of remaining teeth9. These findings are concerning because they highlight that those who are most in need of dental services do not use them or use them less frequently. It should also be noted that there is a lack of prosthetic rehabilitation for rural riverside populations, which precludes the comprehensiveness of the dental services and comprehensive care.

As this is a cross-sectional study, causal relationships cannot be assumed between the associated factors. Information bias may also have occurred once the data were self-reported. However, although not carrying out a oral clinical examination of the participants can be considered a limitation, the literature shows that self-perception of the number of remaining teeth is a valid measurement71.

The healthcare model offered by the FFHT is a good example of how the specificities of a population can guide the implementation of new strategies for the provision of health services. However, the study findings reinforce the importance of preventive actions to reduce oral diseases, such as dental caries, and the need to reorganize the health promotion model for rural riverside populations, considering the geographical environments, the way of life and the socioeconomic vulnerability. Health and intersectoral public policies that reduce health inequalities and improve access to care, as well as the oral health conditions, are necessary.

Conclusion

The population studied mostly accessed the public service for using dental services, but a quarter of participants had last used the service more than 3 years previously or had never used the service. The main reason for seeking the health services was dental pain and need for tooth extractions. Higher level of education was associated with a more frequent use of dental services. Individuals whose last appointment had been in the public service were more likely to use the service. The use of dental services was less frequent among the rural riverside adults, elderly edentulous and those dissatisfied with their oral health. Although the FFHT has provided an increase in access, the study findings suggest that dental services are centered on illness, reproducing the current hegemonic biomedical model. Therefore, they must be reoriented to meet the specific demands of the rural riverine population, focused on health promotion and prevention of oral diseases, as well as public policies capable of reducing inequities in dental services utilization and oral health conditions of this population.

Funding

The study was funded by the Amazonas State Research Support Foundation (call for projects PPSUS 01/2017), by the ILMD Fiocruz Amazônia PROEP-LABS (call for projects 001/2020 and 025/2022). This project was carried out during the term of the Postgraduate Development Program in the Legal Amazon (call for projects 013/2020), and Program Inova Amazônia Fiocruz (call for projects 004/2022). FJH is a FAPEAM Research Productivity Fellow.

Conflicts of interest

The authors declare no conflicts of interest.

references:

1 Lee W, Li C, Serag H, Tabrizi M, Kuo Y. Exploring the impact of ACA on rural‐urban disparity in oral health services among US noninstitutionalized adults. The Journal of Rural Health 2021; 37(1): 103-113. DOI link, PMid:32045057
2 Luo H, Wu Q, Bell RA, Wright W, Quandt SA, Basu R, et al. Rural‐urban differences in dental service utilization and dental service procedures received among US adults: results from the 2016 Medical Expenditure Panel Survey. The Journal of Rural Health 2021; 37(3): 655-666. DOI link, PMid:32697007
3 Piotrowska D, Pędziński B, Jankowska D, Huzarska D, Charkiewicz A, Szpak A. Socio-economic inequalities in the use of dental care in urban and rural areas in Poland. Annals of Agricultural and Environmental Medicine 2018; 25(3): 512-516. DOI link, PMid:30260181
4 Wen PC, Lee C, Chang YH, Ku LJ, Li CY. Demographic and rural-urban variations in dental service utilization in Taiwan. Rural and Remote Health 2017; 17(3): 4161. DOI link, PMid:28838246
5 Reda SF, Reda SM, Thomson WM, Schwendicke F. Inequality in utilization of dental services: a systematic review and meta-analysis. The American Journal of Public Health 2018; 108(2): e1-e7. DOI link, PMid:29267052
6 Maia C de VR, Mendes FM, Normando D. The impact of oral health on quality of life of urban and riverine populations of the Amazon: a multilevel analysis. PLoS ONE 2018; 13(11): e0208096. DOI link, PMid:30500840
7 Fagundes MLB, Bastos LF, do Amaral Júnior OL, Menegazzo GR, da Cunha AR, Stein C, et al. Socioeconomic inequalities in the use of dental services in Brazil: an analysis of the 2019 National Health Survey. Revista Brasileira de Epidemiologia 2021; 24(suppl2): e210004. DOI link, PMid:34910058
8 Herkrath FJ, Vettore MV, Werneck GL. Utilisation of dental services by Brazilian adults in rural and urban areas: a multi-group structural equation analysis using the Andersen behavioural model. BMC Public Health 2020; 20(1): 953. DOI link, PMid:32552777
9 Reda SM, Krois J, Reda SF, Thomson WM, Schwendicke F. The impact of demographic, health-related and social factors on dental services utilization: systematic review and meta-analysis. Journal of Dentistry 2018; 75: 1-6. DOI link, PMid:29673686
10 Northridge ME, Kumar A, Kaur R. Disparities in access to oral health care. Annual Review of Public Health 2020; 41(1): 513-535. DOI link, PMid:31900100
11 Galvão MHR, de Souza ACO, Morais HG de F, Roncalli AG. Inequalities in the profile of using dental services in Brazil. Ciência e Saúde Coletiva 2022; 27(6): 2437-2448. DOI link, PMid:35649030
12 Schroeder FMM, Mendoza-Sassi RA, Meucci RD. Oral health condition and the use of dental services among the older adults living in the rural area in the south of Brazil. Ciência e Saúde Coletiva 2020; 25(6): 2093-2102. DOI link, PMid:32520257
13 Qi X, Qu X, Wu B. Urban-rural disparities in dental services utilization among adults in China's megacities. Frontiers in Oral Health 2021; 2: 673296. DOI link, PMid:35048016
14 Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PLoS ONE 2018; 13(2): e0192771. DOI link, PMid:29420660
15 Santillo PMH, Gusmão ES, Moura C, Soares R de SC, Cimões R. Factors associated with tooth loss among adults in rural areas in the state of Pernambuco, Brazil. [In Portuguese]. Ciência e saúde coletiva 2014; 19(2): 581-590. DOI link, PMid:24863834
16 Cericato GO, Agostini BA, Costa F dos S, Thomson WM, Demarco FF. Rural-urban differences in oral health among older people in Southern Brazil. Brazilian Oral Research 2021; 35: e135. DOI link, PMid:34932664
17 Saliba NA, Moimaz SAS, Saliba O, Tiano AVP. Dental loss in a rural population and the goals established for the World Health Organization. [In Portuguese]. Ciência e saúde coletiva 2010; 15(S1): 1857-1864. DOI link, PMid:20640349
18 Quinteros ME, Cáceres DD, Soto A, Mariño RJ, Giacaman RA. Caries experience and use of dental services in rural and urban adults and older adults from central Chile. International Dental Journal 2014; 64(5): 260-268. DOI link, PMid:25125265
19 Cerón-Bastidas XA, Suárez-Molina A, Guauque-Olarte S. Differences in caries status and risk factors among privileged and unprivileged children in Colombia. Acta Stomatologica Croatica 2018; 52(4): 330-339. DOI link, PMid:30666064
20 Hernández-Vásquez A, Azañedo D. Tooth brushing and fluoride levels in toothpaste used by Peruvian children under 12 years old. [In Spanish]. Revista Peruana de Medicina Experimental y Salud Pública 2019; 36(4): 646-652. DOI link, PMid:31967256
21 Skillman SM, Doescher MP, Mouradian WE, Brunson DK. The challenge to delivering oral health services in rural America: oral health services in rural America. Journal of Public Health Dentistry 2010; 70: S49-S57. DOI link, PMid:20806475
22 DeAngelis S, Warren C. Establishing community partnerships: providing better oral health care to underserved children. Journal of Dental Hygiene 2001; 75(4): 310-315.
23 Schoo A, Lawn S, Carson D. Towards equity and sustainability of rural and remote health services access: supporting social capital and integrated organisational and professional development. BMC Health Services Research 2016; 16(1): 111. DOI link, PMid:27038803
24 Lutfiyya MN, McCullough JE, Haller IV, Waring SC, Bianco JA, Lipsky MS. Rurality as a root or fundamental social determinant of health. Disease-a-Month 2012; 58(11): 620-628. DOI link, PMid:23062678
25 Anderson TJ, Saman DM, Lipsky MS, Lutfiyya MN. A cross-sectional study on health differences between rural and non-rural U.S. counties using the County Health Rankings. BMC Health Services Research 2016; 15(1): 441. DOI link, PMid:26423746
26 Pessoa VM, Almeida MM, Carneiro FF. How to ensure the right to health for 'rural, forest and water' populations in Brazil? [In Portuguese]. Saúde Debate 2018; 42(S1): 302-314. DOI link
27 Garnelo L, Parente RCP, Puchiarelli MLR, Correia PC, Torres MV, Herkrath FJ. Barriers to access and organization of primary health care services for rural riverside populations in the Amazon. International Journal for Equity in Health 2020; 19(1): 54. DOI link, PMid:32731874
28 Gama ASM, Fernandes TG, Parente RCP, Secoli SR. A health survey in riverine communities in Amazonas State, Brazil. [In Portuguese]. Cadernos de Saúde Pública 2018; 34(2): e00002817. DOI link
29 Sousa A, Herkrath FJ, Wallace C, Farmer J, Bousquat A. Primary health care in the Amazon and its potential impact on health inequities: a scoping review. Rural and Remote Health 2022; 22(1): 6747. DOI link, PMid:34973683
30 Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Access and coverage of primary health care for rural and urban populations in the northern region of Brazil. Saúde Debate 2018; 42(S1): 81-99. DOI link
31 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Revista de Saúde Pública 2017; 51(S1). DOI link, PMid:28591351
32 Brazil. Ministério da Saúde. Ordinance No. 2.488, 21 October 2011. Brasília: Ministério da Saúde, 2011.
33 Brazil. Ministério da Saúde. Ordinance No. 2.436, 21 September 2017. Brasília: Ministério da Saúde, 2017.
34 Bawaskar HS, Bawaskar PH. Oral diseases: a global public health challenge. The Lancet 2020; 395(10219): 185-186. DOI link, PMid:31954454
35 Andersen RM, Davidson PL. Improving access to care in America: individual and contextual indicators. In: TH Rice, GF Kominski (Eds). Changing the US health care system: key issues in health services policy and management. 3rd ed. San Francisco, CA: Jossey-Bass, 2007; 3-31.
36 Mariño R, Glenister K, Bourke L, Morgan M, Atala‐Acevedo C, Simmons D. Patterns of use of oral health care services in Australian rural adults: the Crossroads‐II Dental sub‐study. Australian Dental Journal 2021; 66(4): 397-405. DOI link, PMid:34152019
37 Medina-Solís CE, García-Cortés JO, Robles-Minaya JL, Casanova-Rosado JF, Mariel-Cárdenas J, Ruiz-Rodríguez MDS, et al. Clinical and non-clinical variables associated with preventive and curative dental service utilisation: a cross-sectional study among adolescents and young adults in Central Mexico. BMJ Open 2019; 9(9): e027101. DOI link, PMid:31537556
38 Aravena‐Rivas Y, Carbajal‐Rodríguez G. Geographical and socioeconomic inequalities in dental attendance among children in Peru: findings from the Demographic and Family Health Survey 2017. Community Dentistry and Oral Epidemiology 2021; 49(1): 78-86. DOI link, PMid:33016467
39 Susarla SM, Trimble M, Sokal-Gutierrez K. Cross-sectional analysis of oral healthcare vs. general healthcare utilization in five low- and middle-income countries. Frontiers in Oral Health 2022; 3: 911110. DOI link, PMid:35815119
40 Medina-Solis CE, Maupomé G, Del Socorro Herrera M, Pérez-Núñez R, Ávila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. Journal of Public Health Dentistry 2008; 68(1): 39-45. DOI link, PMid:18179470
41 Guarnizo-Herreño CC, Watt RG, Garzón-Orjuela N, Suárez-Zúñiga E, Tsakos G. Health insurance and education: major contributors to oral health inequalities in Colombia. Journal of Epidemiology and Community Health 2019; 73(8): 737-744. DOI link, PMid:31097482
42 Barnett T, Hoang H, Stuart J, Crocombe L. Non-dental primary care providers' views on challenges in providing oral health services and strategies to improve oral health in Australian rural and remote communities: a qualitative study. BMJ Open 2015; 5(10): e009341. DOI link, PMid:26515687
43 Franco CM, Lima JG, Giovanella L. Primary healthcare in rural areas: access, organization, and health workforce in an integrative literature review. Cadernos de Saúde Pública 2021; 37(7): e00310520. DOI link, PMid:34259752
44 Fausto MCR, Giovanella L, Lima JG, Cabral LM da S, Seidl H. Primary health care sustainability in rural remote territories at the fluvial Amazon: organization, strategies, and challenges. Ciência e Saúde Coletiva 2022; 27(4): 1605-1618. DOI link, PMid:35475839
45 da Silva DCB, Garnelo L, Herkrath FJ. Barriers to access the pap smear test for cervical cancer screening in rural riverside populations covered by a fluvial primary healthcare team in the Amazon. International Journal of Environmental Research and Public Health 2022; 19(7): 4193. DOI link, PMid:35409875
46 Cohen-Carneiro F, Souza-Santos R, Pontes DG, Salino AV, Rebelo MAB. Provision and utilization of dental services in Amazonas State, Brazil: a case study in a riverine population in Coari Municipality. [In Portuguese]. Cadernos de Saúde Pública 2009; 25(8): 1827-1838. DOI link, PMid:19649424
47 Lazo-Gonzales AO, Sarmiento-Casavilca T, Espinosa-Henao OE, Ruelas-González MG, Alcalde-Rabanal JE. Looking at maternal health of Asháninka communities from the conceptual framework of the accessibility of care. International Journal for Equity in Health 2023; 22(1): 154. DOI link, PMid:37580769
48 de Souza VGL, Herkrath FJ, Garnelo L, Gomes AC, Lemos UM, Parente RCP, et al. Contextual and individual factors associated with self-reported tooth loss among adults and elderly residents in rural riverside areas: a cross-sectional household-based survey. PLoS ONE 2022; 17(11): e0277845. DOI link, PMid:36413557
49 Rambabu T, Koneru S. Reasons for use and nonuse of dental services among people visiting a dental hospital in urban India: a descriptive study. Journal of Education and Health Promotion 2018; 7: 99.
50 da Fonseca EP, Frias AC, Mialhe FL, Pereira AC, Meneghim M de C. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS ONE 2017; 12(8): e0183310. DOI link, PMid:28859102
51 Onwuka C, Onwuka CI, Iloghalu EI, Udealor PC, Ezugwu EC, Menuba IE, et al. Pregnant women utilization of dental services: still a challenge in low resource setting. BMC Oral Health 2021; 21(1): 384. DOI link, PMid:34353295
52 Cadenas De Llano-Pérula M, Ricse E, Fieuws S, Willems G, Orellana-Valvekens MF. Malocclusion, dental caries and oral health-related quality of life: a comparison between adolescent school children in urban and rural regions in Peru. International Journal of Environmental Research and Public Health 2020; 17(6): 2038. DOI link, PMid:32204433
53 Curtis D, Ortega F, Monar J, Bay Rc, Eckhart S, Thompson P. Assessing self-reported oral health status of three Andean indigenous communities in Ecuador. Journal of International Oral Health 2017; 9(5): 207. DOI link
54 Kadaluru U, Kempraj V, Muddaiah P. Utilization of oral health care services among adults attending community outreach programs. Indian Journal Dental Research 2012; 23(6): 841. DOI link, PMid:23649084
55 Bhat M, Do LG, Roberts‐Thomson K. Association between dental visiting and missing teeth: estimation using propensity score adjustment. Journal of Investigative and Clinical Dentistry 2018; 9(3): e12326. DOI link, PMid:29424486
56 Cohen LA, Bonito AJ, Eicheldinger C, Manski RJ, Macek MD, Edwards RR, et al. Behavioral and socioeconomic correlates of dental problem experience and patterns of health care-seeking. The Journal of the American Dental Association 2011; 142(2): 137-149. DOI link, PMid:21282679
57 Nazir M. Factors associated with dental pain related to last dental visit among adult patients. Dental and Medical Problems 2018; 55(1): 63-68. DOI link, PMid:30152637
58 Rauch A, Hahnel S, Schierz O. Pain, dental fear, and oral health-related quality of life-patients seeking care in an emergency dental service in Germany. The Journal of Contemporary Dental Practice 2019; 20(1): 3-7. DOI link, PMid:31058610
59 Duncan RP, Gilbert GH, Peek CW, Heft MW. The dynamics of toothache pain and dental services utilization: 24-month incidence. Journal of Public Health Dentistry 2003; 63(4): 227-234. DOI link, PMid:14682646
60 Shekhawat KS, Chauhan A, Ahmed F, Das D, Hazarika D, Sarma B, et al. Prevalence of dental caries, dental pain and oral hygiene practices among riverine islanders of Brahmaputra in north eastern state of Assam, India. The Online Journal of Health and Allied Sciences 2019; 18(2): 1-6.
61 Kadri MRE, dos Santos BS, Lima RT de S, Schweickardt JC, Martins FM. Floating Primary Health Center: a new approach to primary care in the Amazon, Brazil. [In Portuguese]. Interface (Botucatu) 2019; 23: e180613. DOI link
62 Rodas EB, Mora F, Tamariz F, Vicuna A, Merrell RC, Rodas E. River health: description of an integral healthcare program in a remote river basin of Ecuador. In: M Jordanova, F Lievens (Eds). Space Technology for E-health. New York: United Nations, 2007; 24-26.
63 Ahmed JU, Rahanaz M, Rubaiyat-i-Siddique. Friendship Floating Hospitals: healthcare for the riverine people of Bangladesh. Journal of Developing Societies 2019; 35(1): 175-194. DOI link
64 Vargas I, Vázquez ML, Mogollón-Pérez AS, Unger JP. Barriers of access to care in a managed competition model: lessons from Colombia. BMC Health Services Research 2010; 10(1): 297. DOI link, PMid:21034481
65 Lima RT de S, Fernandes TG, Martins Júnior PJA, Portela CS, dos Santos Junior JDO, Schweickardt JC. Health in sight: an analysis of primary health care in riverside and rural Amazon areas. Ciência e Saúde Coletiva 2021; 26(6): 2053-2064. DOI link, PMid:34231718
66 Pucciarelli MLR. Family health strategy in rural Amazonian riverside areas: case study on the organization of work in a basic fluvial health unit in Manaus. [In Portuguese]. Master's thesis. Manaus: Instituto Leônidas e Maria Deane, Fundação Oswaldo Cruz, 2018.
67 van der Heide I, Wang J, Droomers M, Spreeuwenberg P, Rademakers J, Uiters E. The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey. Journal of Health Communication 2013; 18(S1): 172-184. DOI link, PMid:24093354
68 Viinikainen J, Bryson A, Böckerman P, Kari JT, Lehtimäki T, Raitakari O, et al. Does better education mitigate risky health behavior? A mendelian randomization study. Economics & Human Biology 2022; 46: 101134. DOI link, PMid:35354116
69 Card D. The causal effect of education on earnings. In: O Ashenfelter, D Card (Eds). Handbook of Labor Economics. Elsevier, 1999; 1801-1863. DOI link
70 Watt RG, Sheiham A. Integrating the common risk factor approach into a social determinants framework. Community Dentistry and Oral Epidemiology 2012; 40(4): 289-296. DOI link, PMid:22429083
71 Pedro REL, Bós ÂJG, Padilha DMP. Validation of a telephone interview to assess oral health in the elderly. [In Portuguese]. Revista Brasileira De Ciências Do Envelhecimento Humano 2011; 8(2). DOI link