Health Reports
Characteristics of cost-related avoidance of oral health services among people in Canada eligible for the Canadian Dental Care Plan

Abstract

Background

Cost and lack of dental insurance coverage are major obstacles to accessing dental care in Canada. This study estimates the prevalence and explores the characteristics of cost-related avoidance of oral health services among a nationally representative sample of people in Canada aged 12 years and older who may qualify for coverage under the Canadian Dental Care Plan (CDCP).

Data and methods

Data from the 2023 to 2024 Canadian Oral Health Survey were used to construct a population-based cohort of CDCP-eligible individuals based on income and insurance status. The responses from 11,189 CDCP-eligible individuals in Canada who answered questions about avoiding visits to an oral health professional or avoiding recommended dental care because of the cost were analyzed. Generalized linear models were used to examine the association between sociodemographic characteristics and the outcomes of cost-related avoidance of oral health services.

Results

During the period from November 2023 to March 2024—before the CDCP was available to help pay for care—47% of CDCP-eligible individuals avoided visits to an oral health professional and 38% avoided recommended dental care in the past year because of the cost. Young and middle-aged adults, uninsured individuals (compared with those with public insurance), and individuals with an adjusted family net income of less than $38,800 reported greater cost-related avoidance of oral health services. After adjustments, dental insurance status (odds ratio [OR]: 5.78; 95% confidence interval [CI]: 3.74 to 8.94) and self-reported mouth problems (OR: 4.80; 95% CI: 3.87 to 5.96) had the strongest association with cost-related avoidance of dental visits in the past year. The same was true for cost-related avoidance of recommended dental care (OR: 3.15; 95% CI: 2.07 to 4.78 and OR: 5.11; 95% CI: 4.17 to 6.27, respectively).

Interpretation

This study identified cost as a significant barrier to accessing oral health care for nearly half of CDCP-eligible individuals. The findings suggest that the use of oral health services by CDCP-eligible individuals in Canada is largely influenced by their income and ability to pay out of pocket for dental care expenses, rather than their need for treatment, leaving many vulnerable to unmet oral health care needs. Establishing baseline estimates of cost-related avoidance before the CDCP became available to help pay for care is essential for gauging the success of easing financial barriers and facilitating effective program monitoring.  

Keywords

Barriers to accessing dental care, cost-related avoidance, Canadian Dental Care Plan (CDCP), low-income population, dental care access disparities

Authors

Juliana Valeria Gondro and Janine Clarke are with the Centre for Health Data Integration and Direct Measures at Statistics Canada. Monica Emode, Dana Ivancevic, Kayla Ortlieb, and Julie Farmer are with the Oral Health Branch at Health Canada.

 

What is already known on this subject?

• Many people face financial barriers that limit their access to oral health care. In Canada, dental costs are covered through a mix of private insurance plans, government-subsidized programs, and out-of-pocket payments, leaving many individuals to pay for their dental care.
• The cost of oral health services remains a major barrier to seeking care in Canada, particularly among those most in need of care but least able to access it.
• In December 2023, the Government of Canada introduced the Canadian Dental Care Plan (CDCP) to help make oral health care more affordable for eligible residents with an annual adjusted family net income of less than $90,000. While the CDCP aims to assist those without insurance, individuals with coverage through a provincial, territorial, or federal government program may still qualify.

What does this study add?

• This study, based on the 2023 to 2024 Canadian Oral Health Survey, estimated the prevalence of cost-related avoidance of oral health services among individuals in Canada who may be eligible for the CDCP once it is fully implemented. Unlike previous research, this study analyzed the characteristics of CDCP-eligible individuals reporting cost barriers.
• This study introduced a novel method to establish a baseline of cost-related avoidance that can be used to inform program monitoring ahead of future changes in access to oral health care in Canada.
• The findings from this study confirmed existing evidence that individuals with poor oral health and no dental insurance are more likely to avoid oral health care because of the cost, reinforcing ongoing concerns about access barriers among those with the greatest needs.
• Further research is needed to explore how expanding coverage to eligible residents may affect cost-related barriers, access to oral health care, and any potential changes in the oral health status of Canadians.

Introduction

Many people living in Canada face cost barriers that make it difficult to access or receive oral health services. In Canada, dental care expenses are covered through out-of-pocket payments or a combination of private and public insurance plans, leaving many individuals to pay for their dental care.^Note 1, ^Note 2 In 2021, Canadian households collectively spent an estimated $7.43 billion on out-of-pocket oral health care costs, an average of $460.50 per household. These out-of-pocket expenses represented 43.8% of all oral health care spending in Canada.^Note 3 One result of these high out-of-pocket costs is that many people in Canada avoid visiting an oral health professional, or decline recommended dental care because of the cost, which is known as cost-related avoidance.^Note 4, ^Note 5, ^Note 6, ^Note 7 Cost-related avoidance of oral health services is associated with a higher risk of oral health diseases and disparities in health outcomes that extend beyond oral health.^Note 8, ^Note 9

In Canada, national health survey data have consistently found that about one in four individuals avoids going to an oral health professional because of the cost.^Note 10, ^Note 11, ^Note 12 Previous studies have examined cost-related avoidance among populations facing barriers to accessing oral health care (e.g., age, sex, income, and insurance coverage). However, these studies relied on earlier data, and recent evidence capturing the current experiences of vulnerable populations remains limited.^Note 7, ^Note 13, ^Note 14, ^Note 15 Using new data from the 2023 to 2024 Canadian Oral Health Survey (COHS), this study provides updated estimates and a more comprehensive understanding of the diverse oral health needs, experiences, and person-level factors that contribute to cost-related avoidance across all provinces in Canada. Understanding why some individuals avoid dental visits and others forgo recommended dental care helps identify where cost barriers arise in the care process (e.g., gaining access to care or following through with recommended care).

In December 2023, the Government of Canada launched the Canadian Dental Care Plan (CDCP) using a staggered approach to eligibility. CDCP aims to make the cost of oral health care more affordable for eligible Canadian residents with an adjusted family net income (AFNI) of less than $90,000 and is intended to help those without dental insurance. However, those with dental coverage through a provincial, territorial, or federal government social program may still qualify (see Appendix A).^Note 16 Obtaining baseline estimates of cost-related avoidance before the CDCP was available to help pay for care is important for assessing financial barriers to oral health care and supporting program monitoring.

This article builds on previous research and explores key dimensions of oral health access by (1) estimating the prevalence of cost-related avoidance among a nationally representative sample of people eligible for coverage under the CDCP, before it was launched, and (2) examining individual and sociodemographic characteristics related to the outcomes of cost-related avoidance of oral health services.

Data and methods

Data source

The 2023 to 2024 COHS is a national household survey administered by Statistics Canada that collected information on the oral health status and care needs of people living in Canada and their access to oral health services. Data were collected from adults aged 18 years and older living in the provinces from November 2023 to March 2024, before the CDCP was available to help pay for care. Where applicable, responding adults also provided information for all household members aged 17 years and younger. Of the 51,793 in-scope units, responses were obtained from 27,039 households, resulting in a response rate of 52.2%. This yielded 33,840 observations, including adult respondents and household members aged 17 years and younger.^Note 17 People living on reserves and other Indigenous settlements in the provinces, people living in the three territories, the institutionalized population, and members of the Canadian Forces living on a base were excluded from the survey.18 Additional details about survey coverage and methodology are described elsewhere.^Note 17, ^Note 18

Study sample

The study sample included respondents aged 12 years and older who may qualify for coverage under the CDCP once staggered enrolment is complete—referred to hereafter as “CDCP-eligible individuals” (n= 11,189)—and were identified among the 29,703 survey respondents aged 12 and older. Eligibility was determined based on income and insurance status. Individuals were considered eligible if they had an AFNI of less than $90,000 and indicated that they either did not have dental insurance or were covered by public insurance through a provincial, territorial, or federal government program (8% of the analytical sample). Those with an AFNI of $90,000 or more (n = 8,618), with private insurance (n = 15,320), or who did know if they had insurance or what type of insurance they had (n = 1,154) were excluded. These exclusion criteria were not mutually exclusive.

Main outcomes and measures

To gather details on cost-related avoidance, the responding adult was asked, “In the past 12 months, have [you / you or other household members] avoided going to an oral health professional for your dental care due to the cost of care?” and “In the past 12 months, have [you / you or other household members] avoided getting any dental care recommended by an oral health professional because of the cost of care?” Responses were available at the household level only. Approximately 67% of COHS respondents aged 12 years and older came from multi-person households, so person-level information on cost-avoidance outcomes was unavailable. To estimate cost-related avoidance at the person level, Statistics Canada developed a novel method to model and impute the two cost-avoidance concepts for respondents aged 12 years and older. Details on the creation of the person-level modelled variables can be found in Appendix B.

Covariates

Covariates were selected based on the Levesque conceptual framework and their relationship to the outcomes.^Note 19 This patient-centred model defines five system-level dimensions of access (approachability, acceptability, availability and accommodation, affordability and appropriateness) and five corresponding individual abilities (ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage). This study explores these dimensions to better understand where individuals face cost-related barriers when seeking oral health care (e.g., gaining access to care or following through with recommended care).^Note 19

Sociodemographic factors, such as age, gender, race, and Indigenous identity, were used to examine how cost-related barriers affect diverse populations (ability to seek). Place of residence, and recency of dental visits provided context for accessing services (ability to reach). Insurance status and income adjusted for household size were used as a proxy for an individual’s ability to access or generate resources to cover the cost of the oral health care they need (ability to pay). Finally, needs-based variables (mouth problems) were included to explore individuals’ recognition and assessment of their oral health care need. However, they are not attributed to a specific individual ability within the model, as these dimensions often overlap and interact, reflecting the complex and multifaceted nature of access to care.^Note 13, ^Note 20

Age was categorized into six groups: 12 to 17 years, 18 to 34 years, 35 to 49 years, 50 to 64 years, 65 to 79 years, and 80 and older. Gender was reported as a three-level variable. Given the small size of the non-binary population, data was aggregated to a two-category gender variable to protect the confidentiality of responses. Individuals in the category “non-binary persons” were distributed into the other two gender categories. The category “men+” includes men, boys and some non-binary respondents, while the category “women+” includes women, girls and some non-binary respondents. To allow for distinction between race and Indigenous identity, a population group variable was categorized into three groups: Indigenous population (First Nations, Métis, and Inuit), non-Indigenous and non-racialized population (White), and non-Indigenous and racialized population (including South Asian, Chinese, Black, Filipino, Latin American, Arab, Southeast Asian, West Asian, Korean, Japanese, and groups not included elsewhere).

Rural or urban status was defined by whether the respondent resided in a population centre or a rural area, and province was identified based on the respondent’s province of residence. Visits to an oral health professional were grouped into two categories: less than a year ago and one year ago or more. Dental insurance was categorized in two groups based on CDCP eligibility criteria: no insurance and public insurance only. The AFNI was adjusted for household size and grouped into four income levels, each representing one-quarter of the CDCP-eligible sample with family incomes less than $90,000 (first quartile, less than $12,300; second quartile, $12,300 to less than $24,700; third quartile, $24,700 to less than $38,800; fourth quartile, $38,800 to less than $90,000). Values were rounded to the nearest hundred to protect confidentiality. The adjusted AFNI was used in the analyses to better reflect the financial resources available to each household (see Appendix C).^Note 21

The mouth problems variable combines two self-reported indicators: “any persistent or ongoing mouth pain” and “avoided eating particular foods because of problems with the mouth,” with responses grouped as “often or sometimes” and “rarely or never.” Finally, disability status was based on a positive response to the question, “Do [you / you or other household members] identify as a person with a disability?”

Analysis

The prevalence of cost-related avoidance of oral health services was calculated using survey weights (person-level weights) to represent the CDCP-eligible Canadian population aged 12 years and older. Descriptive analyses explored the distribution of covariates, such as income, dental insurance, and other sociodemographic characteristics. To account for the complex survey design, variance estimation was performed using bootstrapping to estimate confidence intervals.

To explore the associations between cost-related avoidance of oral health services and covariates, a survey-weighted generalized linear model with quasi-binomial distribution was applied, adjusting for sociodemographic factors and other relevant variables. Univariate regression models were used to assess the crude association between each cost-related avoidance outcome and covariate. All variables were then included in the model to control for other factors and determine the effect of each variable on the specific outcome being analyzed. Of the 11,189 respondents considered to be eligible for the CDCP, 608 were excluded because of incomplete covariate information, leaving a final analytical sample of 10,581. Adjusted odds ratios (ORs) were obtained as the final output.

The significance level was set at p < 0.05. Analyses were performed using RStudio.

Ethics approval

Because this study used a publicly available dataset that excludes information that could identify individuals, it did not require approval from the Health Canada and Public Health Agency of Canada Research Ethics Board.

Results

Among the CDCP-eligible population aged 12 years and older, the mean age was 54 years, 53% were women, and 20% identified as a person with a disability. Non-Indigenous and non-racialized individuals accounted for 69% of the study population. The median adjusted AFNI, accounting for household composition, was $24,700, reflecting the typical household income level in the CDCP-eligible population. The majority of the study population (84%) lived in urban areas, and 8% reported having access to public insurance. Over half (52%) had visited a dental professional within the last year (Table 1).



In terms of cost-related avoidance, among the CDCP-eligible population, 47% avoided visits to an oral health professional and 38% avoided recommended dental care (Table 2). A slightly higher percentage of women reported avoiding visits (50%) and forgoing recommended dental care (41%), compared with men (44% and 35%, respectively). CDCP-eligible adults aged 35 to 49 (67%) were more likely to report avoiding visits to an oral health professional, followed by those aged 18 to 34 years (60%) and those aged 50 to 64 years (52%). Among older adults, those aged 65 to 79 years had higher rates of avoiding visits to an oral health professional (40%), compared with youth aged 12 to 17 years (24%) and seniors aged 80 years and older (24%). Similar trends by age groups were observed among those avoiding recommended dental care because of the cost.



Cost-related avoidance varied by geography. Overall, 49% of CDCP-eligible individuals living in urban areas avoided visits to an oral health professional, compared with 38% of those living in rural areas. Compared with other provinces, fewer CDCP-eligible individuals living in Quebec avoided visits to an oral health professional because of the cost (37%). Similar trends were observed for avoiding recommended dental care.

Finally, because of the cost, about half of CDCP-eligible individuals without insurance (50%) avoided visits to an oral health professional, and two in five (40%) avoided recommended dental care. Among those with public insurance, the rates were 20% and 22%, respectively.

Unadjusted and adjusted results of the generalized linear model are presented in Table 3 for individuals who avoided visits to an oral health professional in the past year because of the cost, and in Table 4 for those who avoided recommended dental care in the past year for the same reason. In the unadjusted model, lower odds of avoiding visits to an oral health professional were observed among the youngest (aged 12 to 17 years) and the oldest (aged 65 and older) age groups, and among those who reported visiting an oral health professional in the past year (Table 3). Lower odds were found among the same age groups for CDCP-eligible individuals who reported avoiding recommended dental care (Table 4). Conversely, individuals without insurance and those reporting mouth problems had higher odds of avoiding visits to an oral health professional and avoiding recommended dental care.

 

The full model revealed that, among all covariates, dental insurance status and self-reported mouth problems had the largest associations with cost-related avoidance of visits to an oral health professional and recommended dental care in the past year. Specifically, in the full model, CDCP-eligible individuals without insurance had nearly six times higher odds (OR: 5.78; 95% CI: 3.74 to 8.94) of avoiding visits to an oral health professional and more than three times higher odds (OR: 3.15; 95% CI: 2.07 to 4.78) of avoiding recommended dental care than those with public insurance.

Additionally, CDCP-eligible individuals who reported having mouth problems often or sometimes had almost five times higher odds of avoiding visits to an oral health professional (OR: 4.80; 95% CI: 3.87 to 5.96) and avoiding recommended dental care (OR: 5.11; 95% CI: 4.17 to 6.27) because of the cost than those who reported rarely or never having mouth problems.

Moreover, CDCP-eligible individuals with an adjusted AFNI of $12,300 to less than $24,700 (second quartile) (OR: 1.69; 95% CI: 1.30 to 2.20) and of $24,700 to less than $38,800 (third quartile) (OR: 1.42; 95% CI: 1.10 to 1.82) had greater odds of avoiding visits to an oral health professional because of the cost, compared with those with an adjusted AFNI of $38,800 to less than $90,000 (fourth quartile).

Discussion

This study found that, before the CDCP was available to help pay for care, cost-related avoidance of oral health services among a nationally representative sample of CDCP-eligible people in Canada aged 12 and older was high. Specifically, because of the cost, nearly half (47%) of the CDCP-eligible population avoided visits to an oral health professional and more than one-third (38%) avoided recommended dental care, suggesting that an individual’s ability to pay strongly determines their decision to seek preventive or necessary dental services.^Note 1 While these findings demonstrate that cost barriers are more prevalent among the CDCP-eligible population—occurring when individuals seek access to oral health care and while receiving it—they are consistent with a previous study using COHS data that found lower rates of cost-related avoidance of visits and treatment (24% and 21%, respectively) in the overall Canadian population.^Note 22

After adjusting for key sociodemographic factors, cost-related avoidance of oral health services was reported most often among young and middle-aged CDCP-eligible adults, those without insurance, and those with an AFNI of less than $38,800. These findings align with previous studies, demonstrating that cost-related avoidance of oral health services is a universal problem in Canada and elsewhere.^Note 8, ^Note 20, ^Note 23, ^Note 24, ^Note 25, ^Note 26, ^Note 27

Among the CDCP-eligible population, this study found that dental insurance and the presence of mouth problems had a strong association with cost-related avoidance of oral health services, after adjusting for key sociodemographic factors. These findings may reflect the characteristics of the study sample, which comprises individuals with lower incomes and poorer self-reported oral health compared with the general population.^Note 28 This pattern is consistent with the “inverse care law,”^Note 29 which highlights that individuals most in need of care, such as those with persistent oral health issues, are often least likely to receive it.^Note 13, ^Note 29, ^Note 30, ^Note 31

The association between mouth problems and cost-related avoidance of care may indicate significant unmet needs among CDCP-eligible individuals. While oral health issues like pain or discomfort often motivate people to seek care, financial constraints may prevent them from accessing the services they need, contributing to a cycle of avoidance and worsening oral health outcomes.^Note 1 Two-thirds of CDCP-eligible individuals who avoided visits to an oral health professional in the past year also reported the presence of mouth problems during the same period, suggesting that many individuals recognize their need for care but forgo dental visits because of barriers such as cost or lack of insurance.^Note 32 Because of the cross-sectional nature of this study, causality cannot be inferred, as the temporal relationship between mouth problems and cost-related avoidance cannot be confirmed.

This study also found that cost-related avoidance was lower among CDCP-eligible individuals with public insurance. Nevertheless, more than one in five (22%) avoided recommended dental care in the past year, and among those who visited an oral health professional during the same period, 22% still avoided recommended care because of the cost (data not shown). These findings suggest that while insurance may reduce financial barriers, it does not fully eliminate them.^Note 4, ^Note 14, ^Note 20 Public dental plans in Canada typically cover a narrow range of services and are available only to specific populations, leaving some necessary services or populations without coverage.^Note 2 Additionally, observed provincial differences among CDCP-eligible individuals who reported avoiding visits to an oral health professional or recommended care may be attributable to variations in the cost of living or cost of oral health across Canada—factors that influence the ability to reach care.^Note 2, ^Note 33 Overall, the findings underscore the key role insurance plays in reducing out-of-pocket expenses and lowering financial barriers to oral health care. However, gaps in dental coverage may still lead to delays in accessing necessary care or may be prohibitive for individuals with low income.^Note 5, ^Note 34, ^Note 35

The study findings suggest that while insurance plays a significant role in alleviating financial barriers to oral health care, income remains an important determinant of access. CDCP-eligible individuals with an adjusted AFNI of $38,800 to less than $90,000 were less likely to report avoiding visits to an oral health professional and avoiding recommended dental care because of the cost, suggesting that individuals in lower income brackets may experience more financial constraints that make it difficult to access care.^Note 4, ^Note 8, ^Note 20, ^Note 27 For example, when insurance does not cover the full cost of care, people must be willing to pay the remaining cost out of pocket.

Within lower-income groups, structural barriers beyond income may influence access to care. A limitation of the present study is the inability to explore non-financial barriers at the individual level (e.g., indirect costs associated with treatment such as lost time at work, transportation or childcare; fear and beliefs around receiving treatment; time constraints; and availability of oral health providers) that could further influence access.^Note 36 The appropriateness of recommended care also could not be assessed, as information on the type of recommended care respondents avoided (e.g., elective versus medically necessary dental procedures) was unavailable. In addition, data on individuals’ ability to participate in decision making were not collected. Future studies directly focused on the impact of shared decision making between patient and provider in addressing cost concerns would be beneficial.^Note 37

This study has several other limitations. The results are based on self-reported survey data, which may be subject to recall and social desirability bias. Additionally, responses for individuals aged 17 and younger in the household were provided by another household member, introducing the possibility of proxy response bias, as these responses may not fully reflect the actual behaviours or experiences of the younger individuals. This study is based on a survey that excludes people living in the territories, on reserves and other Indigenous settlements in the provinces, and in institutions, such as long-term care homes and correctional facilities. These exclusions may introduce bias, as these populations could face greater barriers to oral health services and higher rates of cost-related avoidance. As a result, the findings may underestimate the true extent of cost-related avoidance in these groups. The cost-related avoidance variables were originally collected at the household level, rather than at the individual level. While the modelled variables allowed estimation of individual-level responses, findings should be interpreted with caution, as these estimates may not perfectly align with individual cost-related avoidance behaviours or may indicate the presence of other unmeasured confounders.

Conclusion

A significant proportion of individuals eligible for CDCP reported cost-related avoidance of oral health services before the CDCP was available to help pay for care, highlighting the impact of income and limited ability to pay out of pocket on access to dental care. Most notably, insurance status and self-reported mouth problems, either in the form of having oral pain or avoiding certain foods, were strongly associated with avoiding visits to an oral health professional. These findings are particularly significant, as they highlight the vulnerability of those with unmet oral health needs and the impact of cost barriers on their capacity to obtain care in response to those needs.

Appendix

Appendix A
Applications for the Canadian Dental Care Plan

Applications for the Canadian Dental Care Plan opened in phases. Applications for eligible seniors (aged 65 and older), adults with a valid Disability Tax Credit Certificate, and children younger than 18 opened in 2024. All remaining eligible residents were able to apply starting in May 2025.

Appendix B
Derived variables for person-level cost-related avoidance

The COHS questionnaire included two household-level questions regarding the avoidance of dental care because of the cost: “In the past 12 months, have [you / you or other household members] avoided visiting an oral health professional for dental care due to the cost?” and “In the past 12 months, have [you / you or other household members] avoided receiving recommended dental care from an oral health professional because of the cost?” In previous surveys, such as the Canadian Community Health Survey (CCHS) and the Canadian Health Measures Survey, these questions were asked at the person level, making cross-survey comparisons challenging. To address this issue, Statistics Canada developed a methodology to model and impute these concepts at the person level for individuals aged 12 and older.
Data from the 2022 CCHS were used to develop and validate separate logistic models for each person-level avoidance concept, using common predictor variables from both surveys. These models were subsequently applied to the COHS data. For each respondent, two derived variables were generated: (1) the estimated probability of avoiding visits to an oral health professional for dental care because of the cost and (2) the estimated probability of avoiding recommended dental care from an oral health professional because of the cost.
To reconcile person-level derived variables with household-level information on cost-avoidance, additional adjustments were applied:

• Reference point estimates: Using estimated probabilities, person-level care-avoidance estimates were calculated for the COHS at the province-by-age group level. These served as reference points for further adjustments.
• Deterministic rules: Deterministic adjustments were applied where household-level responses allowed:
• Condition 1: Respondent lives alone and answered “No” to household-level care avoidance questions. Rule: Set person-level derived variables to 0.
• Condition 2: Respondent lives alone and answered “Yes” to household-level care avoidance questions. Rule: Set person-level derived variables to 1.
• Condition 3: Respondent lives in a multi-member household and answered “No” to household-level care avoidance questions. Rule: Set person-level derived variables to 0.
• Probabilistic adjustments: For respondents where deterministic rules could not be applied, modelled probabilities were adjusted to ensure that province-by-age group estimates matched those initially calculated while keeping adjusted values between 0 and 1.

Considerations when using derived variables: (1) It is important to acknowledge that there may be differences in the underlying data used to develop the derived variables. The model was validated by comparing estimates with data from the 2022 CCHS. It assumes relationships between predictors and each cost-related avoidance outcome from the 2022 CCHS remain valid for the COHS (conducted from late 2023 to early 2024). External factors, such as inflation, may impact these assumptions. (2) Although variance from modelling is unaccounted for, the predictions for each cost-related avoidance outcome assumes a fixed model output. That is, it is assumed that the prediction does not change unless the data used in the models change. Additional variance arises from adjustments made to derived variables. (3) The derived variables can be used with person-level weights and bootstrap weights to produce care avoidance estimates from the COHS. When generating these estimates, the derived variables should be treated as continuous variables. (4) While the model performs well at a macro level, reliability decreases with disaggregation involving multiple variables. To ensure accuracy, disaggregate derived variables by no more than two dimensions simultaneously (e.g., by age group and sex at the national level, or by province and another variable).

Appendix C
Adjustment of the adjusted family net income

The adjusted family net income was adjusted by household size and was calculated by dividing the AFNI by the square root of the number of the people in the household.