Table 3.

Oral and Dental services utilization determinants

Themes	Sub-themes	Final code	References
Financial considerations	Cost	Inadequate financial support for dental care	[15, 20]
		High cost of dental	[10, 15, 20–22, 24]
	Repayment methods	Nonpaid services and reimbursement by insurance systems	[15, 24]
		Inadequate insurance coverage	[10, 24]
	Socioeconomic factors	Patients’ socioeconomic status	[10, 20]
Patient-Provider Relationship	Perceptions and Attitudes	Negative perceptions and attitudes of healthcare providers	[10, 15, 21–24]
		Patients’ negative perceptions and attitudes toward providers	[20, 22]
	Communication	Psychological response	[10, 15, 21]
		Insufficient knowledge and experience of providers in establishing communication	[10, 15, 20, 21, 24]
		Challenges in patient-provider communication	[15]
	Behavior support	Poor providers’ attention to behavior management	[21, 24]
		Uncooperative patients	[15, 21, 24]
Accessibility and Availability of Services	Accessibility challenges	Inappropriate working hours of healthcare facilities	[15, 20, 22, 24]
		Long waiting time	[15, 20, 22, 24]
		Difficulty in scheduling appointments	[15, 20]
		Transportation challenges	[15, 20–22, 24]
		Insufficient accessibility to dental facilities	[15, 20, 22, 24]
	Workforce	Insufficient enthusiastic and skilled dentists	[10, 15, 21, 22, 24]
Patient Factors	Sociocultural factors	Ethnic and racial differences	[21]
		Families shape	[22]
	Caregiver Factors	Lack of health literacy and awareness among individuals, families, and caregivers	[20, 21, 23, 24]
		Family limitations in accompanying children	[15, 20, 24]
		Low parental demand for care	[21]
	Contextual factors	Underlying medical conditions	[21, 22]
		Dental anxiety	[15, 20–24]
		Failure to seek treatment for very young children	[15]
Quality of Care	Evidence-based service	Lack of evidence-based, comprehensive need assessment policies	[10, 20, 21]
		Inaccurate needs assessment (unmet needs and others)	[10, 15]
	Services provision	Inadequate service provision	[15, 20, 21, 23, 24]
		Provision of unnecessary care to patients	[15]
		Medical restrictions to use continuous general anesthesia	[15, 24]
	Managerial factors	Inadequate training for providers	[15, 22, 24]
		Lack of integration of oral health into primary care	[10, 20, 21, 23]
		Administrative limitations and referral system issues	[10, 20, 21]