PSPC POR number: POR-014-23

CANADA DENTAL BENEFIT – EXPANDED BASELINE SURVEY

Executive Summary

HC POR – 23-01

Prepared for Health Canada

Supplier id: The Strategic Counsel

Contract number: CW2271909

Contract Value: $182,147.53

Award Date: 2023-06-06

Delivery Date: 2023-09-13

Registration number: POR 014-23

For more information on this report, please contact Health Canada at:

hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Canada Dental Benefit – Expanded Baseline Survey

Executive Summary

Prepared for: Health Canada

Supplier: The Strategic Counsel

September 2023

This public opinion research report presents the results of an online and telephone survey conducted by The Strategic Counsel on behalf of Health Canada. The research study was conducted with 2,250 Canadians with a household income of less than $90,000 between July 26 and August 23, 2023.

Cette publication est aussi disponible en français sous le titre: Prestation Dentaire Canadienne – Enquête De Référence Élargie

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB

200 Eglantine Driveway, Tunney's Pasture

Jeanne Mance Building, AL 1915C

Ottawa, Ontario K1A 0K9

Catalogue Number:

H14-442/2024E-PDF

International Standard Book Number (ISBN):

978-0-660-69526-6

Related Publication (Registration Number: POR-014-23)

Catalogue Number: H14-442/2024F-PDF (Final Report, French)

International Standard Book Number (ISBN): 978-0-660-69527-3

^©His Majesty the King in Right of Canada, as represented by the Minister of Health, 2023.

Executive Summary

A. Background

In the 2022 federal budget, the Government of Canada committed $5.3 billion over five years to provide dental care for Canadians who are unable to access proper dental care because of the cost. In December of 2022, an interim measure (the Canada Dental Benefit) was launched, providing tax-free payments for eligible Canadians with children under the age of 12 and household incomes of less than $90,000 annually.

In Budget 2023, the Government of Canada proposed to provide $13 billion over five years and $4.4 billion ongoing to Health Canada to implement the Canadian Dental Care Plan (CDCP). The CDCP will provide dental coverage for uninsured Canadians with an annual family income of less than $90,000, with no co-pays for those with family incomes under $70,000. The plan is set to launch by the end of 2023 and will be administered by Health Canada, with support from a third-party benefits administrator.

B. Research Objectives

1. Purpose

While the Canada Dental Benefit targeted eligible Canadians based on their household income with children under 12 years of age, the new CDCP is being introduced to a wider spectrum of eligible Canadians whose household incomes are less than $90,000 annually and who do not have access to an insurance plan that includes dental coverage. In replacing the interim CDB, the new Plan will continue to encompass dental care for children under age 12 but will be rolled out initially for seniors aged 65 and older, children and youth aged 12 to 17, and people with disabilities who meet the other eligibility criteria. People living in rural and remote communities as well as racialized communities will also be a key focus for the new plan.

Conducting a baseline survey is an important component in the lead-up to the launch of the plan. Based on a more complete understanding of the concerns, attitudes and behaviours of target audiences for the CDCP as they pertain to dental care coverage and oral health in general, the results will inform the development of related communication and marketing activities.

2. How the Research Will Be Used

The research findings from this study will be used as input in the development of messaging for the eventual long-term national dental care program, known as the Canadian Dental Care Plan. They will also be used to evaluate communications initiatives which have been deployed to date in order to improve future efforts. Additionally, the research findings will assist in identifying opportunities to raise awareness of the Plan as well as identify barriers and gaps in accessing and awareness of the Plan. With the research findings from this study, communications, advertising, and marketing materials will better reach and resonate with key target audiences, resulting in a higher uptake of the Plan.

3. Objectives and Key Research Questions

The primary objective of this research is to establish a baseline level of awareness and barriers to access among those eligible for the CDCP. More specifically, the research will be used to:

• Determine the level of awareness of the existing CDB, and the upcoming CDCP, among Canadians with a household income of less than $90,000;
• Identify the barriers to accessing the existing CDB, the future CDCP and dental care in general; and
• Identify opportunities to maximize uptake of the CDCP.

C. Methodology in Brief

A dual-methodology approach was undertaken to complete this research study, utilizing an online panel as well as telephone specifically targeting respondents in remote areas.

A 15-minute online survey was administered to 2,150 adult Canadians, aged 18 and older. Eligible respondents included those with a household income under $90,000 per year.

The total sample consisted of Canadians, aged 18+ with quotas set for six priority groups – families with children under the age of 12, families with children aged 12 to 17, seniors aged 65 and over, people with disabilities, people from racialized communities and those living remotely. A strict quota was also set on the sample (excluding the remote component) to ensure that approximately 70% of respondents did not have access to private dental insurance (another requirement to be eligible for the new Plan). The remainder (30%) comprised those who did have dental insurance. The sample was structured in this manner to allow for comparisons in the attitudes and behaviours between those with and without access to insurance coverage.

Regional quotas were also applied (again with the exception of remote completions), and monitoring was undertaken while the survey was in field in order to obtain broad representation from all regions of Canada. A disproportionate sampling plan was employed, including oversampling in Atlantic Canada and the Prairies to ensure sufficiently robust samples in these areas to be able to analyze the results within and between regions. A weighting scheme was applied in order to bring the final sample back into line with the distribution of the population in Canada, by region^[1]. Given the highly targeted audiences for this survey, only soft quotas were set for gender and age.

As noted above, a telephone methodology was employed to reach remote respondents (n=100). This approach was taken based on the assumption that a nationwide online panel would not yield sufficient completes to provide useful insights for this group. The length of telephone interviews varied between 20 and 30 minutes.

Given the reliance on a commercial online panel as the primary methodology, the study utilized a non-probability approach to sampling. As such, a margin of error cannot be applied to the final sample of n=2,250 and no inferences can be made to the broader target population. The fieldwork was conducted between July 26^th and August 23^rd, 2023.

D. Total Contract Value

The contract value was $182,147.53 including HST.

E. Key Findings

Affordable dental care is a significant concern for many Canadians, particularly for those without access to dental coverage, but also for those with children under 18 years of age, those in larger households and people from racialized communities.

• Among a select list of issues, the cost of living, affordability of dental care and housing affordability garnered the highest levels of concern (96%, 86%; 85%, respectively are 'somewhat/very concerned' about each of these three issues). By comparison, access to dental services is less of an issue, but is still concerning for 70% of respondents and more so for those without insurance (73%) compared to those with dental coverage (62%).
• Many believe there is a clear connection between oral health and overall well-being and see dental care as vitally important for themselves and their children. Nine in ten respondents (or more in the case of their children) view regular dental care as important. And, while just over half (56%) rate regular care for themselves as 'very important,' this increases to 66% when it comes to care for their children under age 12, and to 71% for those with children aged 12 to 17.
• Care for children tends to be prioritized over adult care – while 65% of respondents say they make appointments for themselves only when they feel it is necessary (higher among those without insurance (70%)), this drops to 51% who take the same approach with their children (although this is the case for a higher percentage of those without insurance (57%)).
• Over two thirds of those without insurance (69%) say they would schedule more regular dental appointments for themselves if they had a bit of extra money. This compares with 59% among those with dental coverage.
• Notably, those living in larger households of five or more members would be more inclined to schedule more regular visits to the dentist (79%), compared to those in smaller households of 2 to 4 people (68%) or just one person (61%).

Although many respondents rate their general oral health positively, a significant proportion do not follow generally recommended oral hygiene instructions or practices and have experienced issues such as bleeding gums and tooth pain. There is a clear correlation between insurance coverage, regular dental visits and overall good oral health/oral health habits.

• While most respondents rate the health of their teeth and gums as good to excellent (65%), the proportion who offer the highest rating of 'very good/excellent' varies considerably between those with dental insurance (39%) and those without (28%).
• Almost half of respondents (49%) say they brush their teeth twice a day – morning and evening. The balance of respondents tends to brush less often – either once a day (33%) or less frequently (8%). Relatively few (9%) brush their teeth three times daily or more often.
• Similar patterns are evident for children under age 12 with very few brushing their teeth more than twice a day. Again, access to dental insurance appears to positively affect brushing habits – a higher proportion of those with coverage report brushing twice daily – although there is no difference based on insurance coverage with respect to those brushing their teeth more frequently than this.
• Irrespective of one's insurance status most respondents rarely or never use an oral rinse (52%). While a modest proportion of respondents use a mouthwash or mouth rinse on a daily basis (19%), this habit is somewhat more common among those who frequent the dentist on a yearly basis or more often.
• Flossing is also undertaken infrequently, with just one third (34%) of all respondents (and just 15% of children under age 12) reporting they floss daily or more often. And, while there is some correlation between flossing and access to dental insurance, the practice of daily flossing is not the norm regardless of insurance status. There is, however, a slight uptick in daily flossing among those who visit a dental office more frequently – at least once every 12 months.
• About one third of all respondents have experienced bleeding gums (35%) and tooth pain (31%), while one quarter or slightly more have reported dry mouth (28%) or tooth decay (25%) in the last 12 months. With the exception of bleeding gums, these issues are more commonly reported by those without access to dental insurance.
• With respect to dental care, while one in four (24%) have had a filling within the last 12 months, those with dental coverage are more likely to report having had a filling compared to those without (31% vs. 20%). Of note, while the percentage of respondents reporting that their child under 12 years of age has had a filling is about the same (29%) as for adults, there is no difference based on insurance status. This finding provides further evidence that parents tend to prioritize their children's dental care needs over their own.

There is a stark difference based on access to insurance in the proportion of those saying they have a dentist or oral health professional who provides services to them/their family. Nine in ten of those with insurance have access to dental care. This drops by 26 points to just six in ten of those without insurance coverage. It is also lower among racialized communities and for persons with a disability.

• Those with insurance coverage are not only more likely to have visited the dentist within the last year, compared to those who do not have coverage (77% vs. 48%), but are also more likely to visit the dentist on a yearly basis or more often (80% vs. 49%).
• By contrast, about one in three of those without insurance visit the dentist only when required or when there is an emergency, compared to just one in ten of those with insurance.
• A higher proportion of respondents with insurance visit the dentist for preventive care and services (e.g., regular check-ups and cleaning, fillings, and dental sealants and fluoride treatments). By contrast, insurance status has little bearing on the reasons for parents taking their children under the age of 18 to the dentist, with about equal numbers citing regular check-ups and fillings. This finding, along with others, underpins a key insight from this research (and previous research on the Canada Dental Benefit^[2]) that parents do their best to obtain dental care for their children.
• Payment for dental services also varies based on one's insurance status – those without coverage are more likely to pay by credit card or in cash, while those with insurance are more likely to say their costs are partially or fully covered.

Cost is the primary barrier to accessing regular dental care both for adult respondents and for those with children. For those without dental insurance, cost becomes quite a significant barrier with almost two thirds (64%) citing this as an issue preventing them from obtaining dental services, a 22-point difference relative to those with insurance coverage (42%).

• Another two in five (38%) mention a lack of insurance coverage, an issue which is cited with much greater frequency among those without insurance (47%) relative to those with coverage (15%). Other impediments include the cost of getting to and from the dentist (22%) and anxiety or fear (17%).
• The degree to which various barriers are cited varies – for example, parents of children under 18 years of age are more inclined to face additional barriers related to the cost of travel, anxiety and fear, lengthy waitlists, a lack of time, and trouble finding care for their children.

Awareness of the CDCP is reasonably high (43%)^[3], with impressions being mainly driven by coverage in the news media. Strong levels of awareness are also accompanied by a general familiarity with key aspects and features of the Plan, particularly its focus on dental care for lower income families with children as well for seniors. Moreover, among those who have not already applied for the Canada Dental Benefit there is overwhelming support for the new program across all target audiences.

• Of those who had heard about the new program, nearly three in four (72%) recall hearing about the new program via the news and/or in the media, while information shared on social media appears to have had some penetration (18%), more so among racialized communities and those in the younger age cohort (18-34 years of age).
• Of those who had heard about the new program about one third (32%) were prompted to look for information. While modest proportions of respondents with dental coverage sought information about the program, results indicate that respondents without access to insurance were more likely to do so. This was also the case for other priority groups and key target audiences, including parents with children under 18 years of age and those with a disability.
• Notably, respondents 65 and older were generally less inclined to seek out information about the program, relative to the average. However, those who did were somewhat more likely to learn about the program's focus on dental coverage for their demographic – seniors. At the same time, respondents aged 65+ were also slightly more likely to say they hadn't learned much about the program after looking for information about it, suggesting that there may be some value in targeting this audience with additional focused communications.
• There is significant support for the program across the board (82% overall, and 58% who 'strongly support' the program) and it is particularly high among those who do not have access to dental insurance (84%), compared to those who do (76%). While lower levels of support were registered by respondents who identified as Indigenous, it is important to note that almost three quarters (72%) are supportive.
• The main motivators for applying to the program center on opportunities for eligible respondents to have their dental costs covered and for improved dental health for the entire family (themselves and their children). Other motivators are a factor of the ease of enrolment as well as reliable information about the Plan and what it offers. Additionally, the need for urgent dental care would incentivize many to apply.
• Among parents of children under 12 who do not have dental insurance, over one in ten (14%) indicate having already applied for the Canada Dental Benefit, and another 47% say they are planning to apply.

F. Conclusions and Recommendations

Results from this study underscore a clear need and desire for the CDCP. As noted above, affordable dental care is a major concern for many. Additionally, the new program is widely supported by those who would be eligible to apply based on a household income of less than $90,000 a year, and it would meet an evident gap in obtaining regular dental care for those who are currently uninsured. The program addresses a key impediment to regular dental care related to the cost of dental services and a lack of dental coverage.

Larger households, in particular, would be positively impacted – compared to smaller or single-person households they are among the most concerned about affordable dental care and about accessing the services of a dentist or oral health professional. They are also currently more likely to schedule appointments only when it's necessary and would be more inclined to schedule regular appointments for themselves if they had extra money to do so. This group is more likely to have looked for information about the program, suggesting that they are receptive to hearing more about it. More so than others in smaller households the health of their family is among the primary motivators for applying to the program. Moreover, for all families with children under 18 years of age, having more than one child requiring dental care is a motivator for about one in five.

With respect to increasing awareness of the CDCP and maximizing uptake, additional efforts may be required to enhance awareness of the program among younger eligible Canadians (including those without children), people from racialized communities, and those with a lower socio-economic status (especially those with an annual household income under $20,000). For lower income households, it will be important to understand and explain how the CDCP is or is not integrated with other dental coverage offered by provincial/territorial governments which also targets this demographic. Although those aged 65+ exhibit higher levels of awareness of the Plan and its focus on seniors, they are less likely to have looked for information about it and, among those who have are more likely to say they didn't learn much. Some in this group may also be covered by provincial/territorial programs that offer dental services to lower income seniors (e.g., the Ontario Seniors Dental Care Program (OSDCP)). Outreach to all these groups should consider multi-channel strategies which leverage earned, paid and owned media in addition to social media and word-of-mouth. Oral health professionals also play a key role in communications as their interactions with their patients on a regular basis permit reinforcement of key messaging around good oral health practices (see below).

From a communications perspective, there are opportunities to share important information about the program and reinforce a number of key messages with the various target audiences. These recommendations are based on what respondents appear to have focused on when looking for information about the program as well as what they said would encourage them to apply for the program, including:

• The eligibility or qualifying criteria for the CDCP;
• How the CDCP is integrated with other dental programs;
• Key features of the program relating to coverage (e.g., no co-pays for those with household incomes of less than $70,000); and
• The importance of regular dental care at all stages of life and, for families, the value of early preventive care for children.

At the same time, efforts should be made to ensure the application process is simple and straightforward and that information about the Plan is readily available in formats and on platforms which enhance perceptions of trust and reliability. For some, additional information which would direct them to dental clinics/offices or oral health professionals in their community who are taking part in the program would also be helpful, especially for those who currently do not have access to dental care – an issue more so for households with lower levels of income and education, racialized communities, persons with a disability, and those in rural communities. Strategies may need to be developed to address the specific challenges of those living in remote communities who have limited access to year-round dental care or must travel long distances to access dental services.

The launch of the CDCP also presents an opportunity to educate the broader population and specific target audiences on better oral health practices. The research underscores the correlation between more regular visits to the dentist and good oral health habits so one might expect to see improvements over time with uptake of the CDCP. Key messages include the following:

• The importance of brushing your teeth at least two times a day using a soft-bristle toothbrush and fluoride toothpaste – Men, persons with a disability, lower SES households, and those who have not visited a dentist or oral health professional are more likely to brush once a day or less often and they are key audiences for this message.
• Regular flossing plays a crucial role in overall dental hygiene, reduces the risk of tooth decay and gum disease and benefits your heart health – Key groups for this message are similar to those noted above and include men, persons with a disability, racialized communities, those between the ages of 18 and 44, lower SES households, and those who visit the dentist infrequently.
• Regular use of an oral rinse is recommended – While most rarely or never use mouthwash, this behaviour is more pronounced among those who see a dentist or oral health professional on an infrequent basis, and among people living in rural areas.
• The connection between cavities and gum disease and other serious health conditions – Although many appear to be aware of and/or appreciate this connection, it could be further emphasized among younger people (aged 18-34).

Communications plans and strategies supporting the launch of the CDCP and any related educational campaigns on good oral hygiene should keep in mind that it is mothers who generally tend to schedule dental appointments for children. The research also suggests that children's oral health practices closely emulate those of their parents. As such, there may also be opportunities to speak more directly to mothers about dental care for children given that women tend to follow recommended oral hygiene habits more closely than men.

Following the launch of the CDCP it is recommended that tracking be undertaken at semi-regular intervals to gauge awareness of the program and assess the target audience's experience (from enrollment through accessing dental services). Tracking over time should also assess the extent to which the program has had an impact on dental practices, including more frequent visits for preventive dental care purposes as well as improved oral hygiene habits.

Statement of Political Neutrality

I hereby certify as Senior Officer of The Strategic Counsel that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Government of Canada's Policy on Communications and Federal Identity and Directive on the Management of Communications. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, party standings with the electorate, or ratings of the performance of a political party or its leaders.

Signed:

Donna Nixon, Partner

1. The weighting scheme was developed to align the data regionally with Census 2021 data from Statistics Canada.
2. Canada dental benefit baseline survey: final report.
3. The question was asked on an unaided basis, asking respondents if they had heard about "the Government of Canada's new program on dental care" without providing the id of the program.