Provision of Government-funded and Pro Bono Dental Care: Are There Gender Differences?

Dentists act as stewards in the provision of dental care to the community at large. As such, delivery of dental care to those with low socioeconomic status is, in part, dependent on dentists’ acceptance and adoption of government-funded dental programs and the provision of pro bono care.

In 2009, an estimated 7.6% of Canadian dentists had practices primarily treating publicly insured patients.¹ About 70% of practices included < 10% publicly insured patients.¹ In general, long-standing complaints from dentists about government-funded programs include low remuneration, high administrative burden, constrained clinical decision-making and low patient compliance.^1,2

Canadian dentists also provide pro bono care to those in need.^1,3 For 16.7%, this amounts to > $1000/month, for 72.8%, < $1000/month and 8.1% of dentists report no pro bono work.¹ As a policy instrument to improve access to care, facilitating dentists’ willingness to provide more pro bono care through tax incentives has been suggested, an idea supported by approximately 69% of Canadian dentists.¹

Although research has shed light on some of the factors that are associated with dentists’ participation in government-funded programs, almost nothing is known about what influences pro bono care.¹ At the same time, much like medicine, pharmacy and law, dentistry has experienced an influx of women in an otherwise historically male-dominated profession.^4,5 The shift toward more women in the dental workforce is a relatively recent phenomenon and, thus, there are few Canadian studies investigating what this may mean for the profession and dental care delivery.^6-8 What literature exists suggests that, when compared with male dentists, female dentists are more likely to be generalists than specialists, retire at an earlier age, spend more time interacting with patients and refer patients to specialists.⁶ Two recent Canadian studies demonstrated that female dentists work marginally fewer hours per week and are less likely to be practice owners.^7,8 These outcomes appear to be gendered, meaning they are, in part, predicted by such things as spousal/partner support for family responsibilities, including child care and household chores and spousal/partner career concessions.^7,8

Given that certain aspects of dentistry are associated with gender differences based on previous studies,^4-8 we aimed to determine whether there are factors associated with the provision of government-funded and pro bono dental care among Ontario dentists, and whether there are gender differences. Studying these phenomena can help us understand dentist practice patterns and what potential correlates affect these patterns.

Methods

Study Design and Data Collection

This study is a secondary data analysis of a cross-sectional survey of practising dentists in Ontario, which was completed in 2012. The participants were selected through random sampling of the 8398 registered dentists in Ontario found in the 2010 Royal College of Dental Surgeons of Ontario listing. The original objective of the survey was to analyze differences between male and female dentists on personal and professional issues through a 52-item questionnaire. A list of the questions from that survey relevant to this study can be found in Appendix 1, and further description of the study design, sampling and survey instrument is provided elsewhere.^7,8

In brief, an initial sample size of 941 dentists was determined based on a conservative measure of variation in response to questions (50/50 split), a 95% confidence interval and 3% sampling error. This sample size was tripled to 3000. The sampling frame was stratified by gender, with a random start systematic sample drawn from each stratum (1500 men, 1500 women). A single mail-out was completed. The survey was approved by the University of Toronto’s Office of Research Ethics (protocol reference #27977), as was this secondary analysis (protocol reference #35607).

Study Variables

The outcomes under study included the percentage of a dentist’s patients covered by government-funded dental programs and the amount of monthly pro bono work provided (in Canadian dollars). Both pieces of information were ascertained from specific questions in the survey (see Appendix 1) asking dentists to provide a numerical value in response. We treated dentists’ responses as continuous variables.

Potential correlates were selected from the survey, a priori, based on hypothesized relations with the outcomes, in addition to factors that are linked to the outcomes in the literature. We grouped these variables into 4 distinct categories: personal (e.g., age, gender, income), family (e.g., marital status, children), practice (e.g., location, ownership status, number of staff) and professional (e.g., year of graduation, location of initial dental training, hours worked per week).

Data Analysis

Data analysis was undertaken using SPSS, v. 21.0 (IBM Corporation, Armonk, New York, USA). All variables were compared between males and females using Student’s t test for continuous variables and χ² tests for categorical variables. A bivariate analysis was used to determine potentially significant factors affecting the reported percentage of government-funded patients and monthly amounts of pro bono care. Variables showing an association at p < 0.15 in the bivariate analysis were included in the multivariable regression. Multivariable linear regression was then used to determine the dominant predictors. Stratified analyses (male and female) undertaking the above process were also conducted to determine qualitatively whether there are gender differences in the potential correlates.

Results

The 867 survey respondents included 463 men, 401 women and 3 who did not report a gender. This represented a 28.9% response rate. Details of the sample population are provided in Table 1.

Government-funded patients

On average, Ontario dentists reported that 15.7% of their practice consisted of government-funded patients (Table 2). Male and female dentists reported similar percentages (15.4% and 16.0%, respectively, p > 0.05).

Bivariate analysis of the whole sample showed the following characteristics to be significantly associated with higher reported levels of government-funded patients: being a specialist, practice ownership, relationship status (married), equal caregiver status with spouse, household responsibilities, higher percentage of pediatric patients and planned retirement age (Table 3). Among male dentists only, the following characteristics were significantly associated with reported levels of government-funded patients: age (+0.2%), graduation year (−0.2%), being a specialist (+5.1%), number of staff (+0.3% with each increase in staff), practice ownership (−12.0%), relationship status (single +18.5%, married +2.5%, divorced +2.9%), caregiver status (spouse −5.7%, equal +0.04%, other +2.0%), percentage of pediatric patients (+0.2% for each 1% increase in pediatric patients treated) and planned retirement age (+0.4% for each 1-year increase in retirement year). For female dentists, it was: age (−0.2%), graduation year (+0.3%), practice ownership (−9.9%), responsibility for household chores (spouse −6.1%, equal −1.6%, paid −8.5%) and percentage of pediatric patients (+0.3% for each 1% increase in pediatric patients treated).

• dental profession, organizations, Public Health, Treatment

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Table 3: Bivariate analysis of factors associated with the relative percentage of government-funded patients within Ontario dental practices

Variable	All respondents (n = 864)			Male dentists (n = 463)			Female dentists (n = 401)
	β	SE	p	β	SE	p	β	SE	p
Note: SE = standard error.
Gender (reference: male)	0.71	1.49	0.63
Age (continuous)	0.04	0.07	0.60	0.23	0.09	0.02	−0.24	0.12	0.05
Internationally trained (reference: domestically trained)	0.02	1.89	0.99	−0.97	2.95	0.74	0.43	2.52	0.87
Graduation year (continuous)	0.00	0.07	1.00	−0.17	0.09	0.07	0.26	0.12	0.02
Specialist (reference: generalist)	4.25	2.19	0.05	5.09	2.78	0.07	3.14	3.56	0.38
Hours worked/week (continuous)	−0.03	0.08	0.73	−0.12	0.11	0.26	0.08	0.11	0.45
Number of staff (continuous)	−0.16	0.14	0.25	−0.26	−0.08	0.13	0.03	0.23	0.89
Practice owner (reference: associate)	−10.63	1.69	< 0.001	−11.95	2.60	< 0.01	−9.90	2.29	< 0.01
Academically affiliated (reference: no)	−2.20	3.18	0.49	−4.86	4.32	0.26	0.98	4.71	0.84
Population at practice location (reference: small 1000–29 999)
Large (≥100 000)	0.22	2.17	0.93	−0.99	2.83	0.86	1.78	3.41	0.87
Medium (30 000–99 999)	0.96	2.81	0.93	0.42	3.69	0.86	1.78	4.35	0.87
Relationship status (reference: single)
Non-married	9.70	4.57	0.01	18.50	7.31	0.02	4.19	5.88	0.16
Married	2.00	3.31	0.01	2.52	5.28	0.02	−4.72	4.29	0.16
Divorced	−0.33	4.49	0.01	2.85	6.62	0.02	−1.29	6.33	0.16
Annual income (reference: < $100K)
$100–$200K	0.64	2.68	0.27	−1.98	4.27	0.51	2.33	3.49	0.51
> $200K	−1.92	2.62	0.27	−3.86	4.07	0.51	−0.42