Journal Article

Inequalities in dental service utilization among adults in Bangladesh, Bhutan, and Nepal: a population-based cross-sectional study

Acharya, Kiran, Rahman, Md Mahfuzur, Ahmed, Anam, Nagata, Abir, Kubota, Yu, Nakagawa, Takatoshi, Gyeltshen, Tshewang, Rahman, Md Shafiur, Shahriar, Abu Saleh Muhammad

2025

Overview

Background Oral health is integral to overall well-being and Universal Health Coverage (UHC), yet disparities in dental service utilization (DSU) persist in low- and middle-income countries (LMICs). Socioeconomic status (SES) and educational inequalities exacerbate barriers to accessing essential dental services, limiting UHC progress. Therefore, this study assessed absolute and relative socioeconomic and education-based inequalities in DSU in Bangladesh, Bhutan, and Nepal and identified demographic and socioeconomic determinants. Methods Data from the most recent WHO STEPwise approach to surveillance (STEPS) surveys in Bangladesh (2017–18), Bhutan (2019), and Nepal (2019) were analyzed. Inequalities in DSU were assessed using the slope index of inequality (SII), relative index of inequality (RII), and relative concentration index (RCI). The determinants of DSU were assessed using mixed-effects binary logistic regression models. Results Ever DSU was highest in Bhutan (48.8%), followed by Bangladesh (29.1%) and Nepal (5.6%). Socioeconomic inequalities in DSU were significant in Bhutan, with higher utilization concentrated among the wealthiest groups (SII: 33.9, 95% confidence interval [CI]: 27.8–40.1 for ever DSU; RII: 2.11, 95% CI: 1.86–2.39), while education-based disparities favored individuals with higher education (RII: 1.85, 95% CI: 1.62–2.13). In Bangladesh, education-based inequalities in DSU were evident only in urban areas (SII: 17.3, 95% CI: 8.2–26.5; RII: 1.69, 95% CI: 1.38–2.06). In Nepal, DSU was uniformly low across all groups, with minimal or even reversed socioeconomic and educational disparities. Independent determinants of DSU, identified through adjusted mixed-effects logistic regression, included older age, higher education, and urban residence in Bangladesh; higher education and SES in Bhutan; and female sex in Nepal. Conclusions DSU was limited across Bangladesh, Bhutan, and Nepal, with the lowest rates observed in Nepal. Substantial socioeconomic and educational inequalities in DSU were evident in Bhutan and Bangladesh. These findings underscore the need for UHC-aligned, equity-focused reforms, including national oral health policies, targeted outreach to disadvantaged groups, and expanded access to preventive services.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adolescent / Adult / Adults / Analysis / At risk populations / Bangladesh / Bhutan / Biostatistics / Confidence intervals / Cross-Sectional Studies / Dental care / Dental caries / Dental Health Services - statistics & numerical data / Dental insurance / Dental service utilization / Dentists / Education / Education, Higher / Education-based inequality / Environmental Health / Epidemiology / Female / Health care access / Health policy / Healthcare Disparities - statistics & numerical data / Households / Humans / Improving social inequities in health in the Global South / Inequality / Low- and Middle-Income countries / Male / Medical care / Medicine / Medicine & Public Health / Medicine, Preventive / Middle Aged / National health insurance / Nepal / Oral hygiene / Patient Acceptance of Health Care - statistics & numerical data / Population studies / Preventive health services / Public Health / Regression analysis / Regression models / Rural areas / Sensitivity analysis / Sociodemographics / Socioeconomic Factors / Socioeconomic inequality / Socioeconomics / Statistical analysis / Surveys / Toothpaste / Universal health coverage / Urban areas / Utilization / Vaccine / Young Adult