Unequal Smiles: Gendered Barriers to Oral Health Services in Resource-Constrained Settings

Abstract

Background: Oral health inequities remain a neglected public health concern in low- and middle-income countries, where access to dental services is shaped not only by resource constraints but also by gendered social relations. In Pakistan, limited public oral healthcare infrastructure intersects with entrenched gender norms, potentially producing unequal access to services, particularly for women.

Objective: This study explored gendered barriers to access and utilization of oral health services in resource-constrained settings of Khyber Pakhtunkhwa (KP), Pakistan.

Methods: An exploratory qualitative study was conducted in rural and peri-urban communities of Mardan and Peshawar districts, KP. Data were collected through six focus group discussions with community members (four with women and two with men; n = 42) and six in-depth interviews with public-sector dental providers and frontline health workers (n = 6). Participants were purposively selected to capture diversity in gender, age, and socio-economic background. All discussions and interviews were conducted in Pashto or Urdu, audio-recorded, transcribed verbatim, and analyzed thematically using an inductive–deductive approach informed by a gender analytical framework.

Results: The findings reveal that access to oral health services is deeply gendered and shaped by interlinked household, socio-cultural, economic, and health system factors. Women’s oral health needs were consistently deprioritized within households, normalized as non-urgent, and delayed until pain became severe. Limited decision-making autonomy, financial dependency, and mobility restrictions significantly constrained women’s ability to seek care, particularly in rural areas. Systemic deficiencies in public oral healthcare including inadequate staffing, equipment shortages, and poor service availability further exacerbated gender disparities. Low preventive awareness and normalization of oral disease contributed to delayed care-seeking among both genders, with disproportionately adverse consequences for women. These barriers were mostly pronounced at the intersection of gender, poverty, and rural residence.

Conclusion: Unequal access to oral health services in KP is not solely a function of service scarcity but is structurally produced through gendered power relations and institutional neglect of oral health. Addressing oral health inequities requires gender-responsive health system strengthening, integration of oral health into primary care, financial protection mechanisms, and community-based interventions that challenge restrictive gender norms.