Examining the Effect of Income-Based Inequalities and Dental Service Provision on Dental Service Utilization among Older Australians: A Multiple Mediation Analysis

Introduction: Public service provision is one of the keys to reducing inequalities in the utilization of dental services. Given the increase in the aging population, there should be a focus on older adults' oral health. However, this is often overlooked. Objectives: This study investigates the effectiveness of public services in reducing income-related inequalities in dental service utilization among older South Australians. Methods: A multiple counterfactual mediation analysis using the ratio of mediator probability weighting approach was used to explore the proposed mediation mechanism using a South Australian population of older adults (>= 65 y). The exposure variable in the analysis was income, and the mediators were concession cards and the last dental sector (public or private). The outcome variable was the time of last dental visit. Results: Half of the older adults with high income (>=$40,000) owned a concession card, and 10% of those who attended public dental services belonged to this group. Interestingly, only 16.3% of the study participants had visited the public dental sector at their last dental appointment. Results showed a negligible indirect effect (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.85-1.05) and a significant direct effect (OR, 3.09; 95% CI, 2.24-4.87). By changing the potential outcome distributions to the counterfactual exposure distributions and taking the mediators' distribution as a counterfactual exposure distribution, the odds of dental visits occurring before the past 12 mo approximately tripled for low-income compared to high-income individuals. Conclusion: Income inequalities were associated with relatively delayed dental visits in older South Australians, and provision of public services could not improve this pattern. This might happen due to inequitable access to concession cards and public services. A review of policies is required, including addressing income inequalities and implementing short-term approaches to improve service utilization patterns in older South Australians. Knowledge Transfer Statement:The findings of this study can enable policymakers for informed decision-making about the provision of public dental services for older Australians. This study emphasizes the importance of reviewing the current public dental services and subsidies and implementing short-term approaches to reduce income inequalities for older Australians.