Race, Ethnicity, Culture and Educational

ResearchVirginia J. Dodd, PhD, MPH

Educational Research Seminar Series 9/27/2013

Approach• Race and health• Culture and dental care• Ethnicity and dental care• Race and dental care• Oral health and vulnerable populations• Oral health disparities• Going to the dentist• Social value and oral health• Dental care and extrinsic motivators• Dental care and intrinsic motivators

Race and Health

1860 1880 1900 1920 1940 1960 1980 2000 2020 20400

1000

2000

3000

4000

5000

6000

7000

1

3329

578054755179

4696430139113770

341830432722

22922242198718171742

157214941345125912701052994

785701601485381344310255276223240276228224179243244247220214205162143113786170392271031213685326211111211111

N = 72,3311873 - 2013

Race and Oral Health

1900 1920 1940 1960 1980 2000 20200

50

100

150

200

250

104

196188

157

121122120123110

1029395

8388

43

7563

7161

4453

313624231914

71414111191065

167

17791012

51194432121

N = 24661921 - 2013

Culture and Dental Care• May 2013

– Understanding Muslim patients: cross-cultural dental hygiene care

• 1967The practice of dentistry in ancient Egypt

N=1322

N = 1322

Culture and Dental Care

1960 1970 1980 1990 2000 2010 20200

10

20

30

40

50

60

70

80

90

36

81

6966

80

73

68

57

6462

55

5054

45

54

45

39

51

2327

32

181916

18

95

1511

69

67875

85544

2111

Summary: Culture and Dental Care• Managing the socially deprived

patient.• Social and attitudinal correlates of

health care among Mexican Americans.

• Pain: anxiety and attitudes in Black, White and Puerto Rican patients.

• The dental patient's cultural response to the need for dental care.

Summary: Culture and Dental Care

• Predictors of multiple tooth loss among socioculturally diverse elderly subjects.

• Transcultural dental training: addressing the oral health care needs of people from culturally diverse backgrounds.

• Cross cultural adaptation of oral health-related quality of life measures.

• A psychosocial approach to dentistry for the underserved: incorporating theory into practice.

• Screening for oral health literacy in an urban dental clinic.

Summary: Culture and Dental Care

N = 1443

Ethnicity and Dental Care• 2013 = 35 publications

– Evaluation of an oral health promotion program at the time of birth on dental caries in 5-year-old children in Vorarlberg, Austria.

• 1966 = 1 publication– Survey of needs for dental care, 1965. II.

Dental needs according to age and sex of patients: Bureau of Economic Research and Statistics.

Ethnicity and Dental Care

1960 1970 1980 1990 2000 2010 20200

10

20

30

40

50

60

70

80

90

100

35

94

83

747576

87

63

74

54

74

585956

45

363841

31333434

24

13

21

12

4

17

1186

976843455

11

2321111

Summary: Ethnicity and Dental Care

• Burden of oral disease among older adults and implications for public health priorities.

• Edentulism trends among middle-aged and older adults in the United States: comparison of five racial/ethnic groups.

Summary: Ethnicity and Dental Care

• A tool for assessing cultural competence training in dental education

• Are survivors who report cancer-related financial problems more likely to forgo or delay medical care?

• Are there differences in dental care access, treatment, or treatment response by ethnicity?

Race and Dental Care

1960 1970 1980 1990 2000 2010 20200

20

40

60

80

100

120

140

1 1 1 3 1 2 513

6 8 5 72

6 6 4 61 4 4

9 9 1010121716

2517

5

25

36

242019

3440

3539

66

47

5648

545454

131

29

N = 985 1964 - 2013

Summary: Race and Dental Care• Early populations were Native

Americans.• Racial similarities and differences in

family dental care patterns.• Variations in use of dental care

facilities by low-income white and black urban populations.

Summary: Race and Dental Care• 1980s Hispanic populations• 1990s “poor and underserved”• 2000 Use of dental care by HIV-

infected medical patients• Rural-urban differences in Medicaid

use

Summary: Race and Dental Care• 2012: Edentulism trends among

adults. • 2013: Social support and dental

visits.– Geographic differences rural vs. urban

“going to the dentist”

N = 1671946-present

1940 1950 1960 1970 1980 1990 2000 2010 20200

2

4

6

8

10

12

14

1 1121 11111

3

12

12

11

7

5

3

6

1

45

9

2

5

7

1

55

1

6

9

5

3

7

3

1211

8

13

Topic Summary: “going to the dentist”

• Much of the research involved children.

• 1979: A two-wave interview study of frequency of dental visits and dental complaints.

• 1978: How are you going to keep dentists down on the farm once they’ve seen Chicago (or New York)?

Topic Summary: “going to the dentist”

• 1990: Assessment of a single item dental anxiety question.

• 1994: Today’s dental student is training for tomorrow’s elderly baby boomer.

• 1997: Dental health attitudes among dentate black and white adults.

Topic Summary: “going to the dentist”

• 2002: Informed consent: optimism or reality?

• 2004: Who is going to treat our edentulous adults?

• 2005: An exploratory study on cultural variations in oral health attitudes, behaviors, and values of first-year dental students.

Topic Summary: “going to the dentist”

• 2005: People with disabilities: how are we going to meet their needs?

• 2006: How did we get here? Where are we going? Hopes and gaps in access to oral health care.

• 2007: The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear.

Topic Summary: “going to the dentist”

• 2009: Access to care: what are we going to do about it?

• 2011: Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist.

Topic Summary: “going to the dentist”

• 2013: What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance.

• 2013: The oral health of vulnerable older adults and persons with disabilities.

Social Value and Oral Health

0 2 4 6 8 10 12 14 16 18 200

5

10

15

20

25

10

3

17

13 12

20

9 10 10 11

8

13

97

5 4

10

7

N = 2531967 - 2013

Topic Summary: Social Value and Oral Health

• Religious Leaders' Opinions and Guidance Towards Oral Health Maintenance and Promotion: A Qualitative Study.

• Clinical status in adolescents: is its impact on oral health-related quality of life influenced by psychological characteristics?

N = 2531967 - 2013

Topic Summary: Social Value and Oral Health

• Shaping the next generation of 'population oral healthers'.

• Access to oral health services for urban low-income Latino children: social ecological influences.

• How people on social assistance perceive, experience, and improve oral health.

N = 2

Dental Care and Extrinsic Motivators

• 1994– Obstacles to regular dental care related

to extrinsic and intrinsic motivation. (Finland)

• 2012– The impact of intrinsic and extrinsic

factors on the job satisfaction of dentists.

N = 6

Dental Care and Intrinsic Motivators

• 2012– Evaluating the effects of coaching to

improve motivational interviewing skills of dental hygiene students.

• 1992– Intrinsic motivation in dental care.

Oral Health and Vulnerable Populations

1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 20200

5

10

15

20

25

30

35

12

283030

26

2019

31

15

1112

8

213221111

Oral Health and Vulnerable Populations

• Disparities• Literacy rates • Role of the workforce• Demographic issues• Access barriers

N = 2791973 - 2013

Oral Health Disparities

1975 1980 1985 1990 1995 2000 2005 2010 20150

20

40

60

80

100

120

140

160

59

136

119

959590

445037

2436

202013

2232311111 N= 862 1977 - 2013

Topic Summary: Oral Health Disparities

• Increasing screening intentions for oral and pharyngeal cancer

• The oral health of vulnerable older adults and persons with disabilities

• Integrating oral and general health screening at senior centers for minority elders

• Distinct epidemiologic characteristics of oral tongue cancer patients.

Topic Summary: Oral Health Disparities

• Racial and ethnic disparities in utilization of dental services among children in Iowa: the Latino experience.

• Head and neck cancer disparity in underserved communities: probable causes and the ethics involved.

• Social inequality in oral health.

Topic Summary: Oral Health Disparities

• Racial/ethnic disparities in health and health care among U.S. adolescents.

• Using telehealth technologies to improve oral health for vulnerable and underserved populations.

• Distribution of caries in children: variations between and within populations.

• Social disparity and oral health.

Topic Summary: Oral Health Disparities

• Barriers impeding access to primary oral health care among farm worker families in Central Florida.

• Access to and utilization of oral health care by homeless children/families.

• Socioeconomic factors in adolescents' oral health: are they mediated by oral hygiene behaviors or preventive interventions?

Moving Forward

Moving Forward• The majority of the literature on

racial and ethnic groups offers epidemiologic data on health disparities.– Lacks depth

• Research offering findings on oral health beliefs and practices of specific racial, ethnic, and cultural groups is sparse.

Moving Forward• Use of theoretical or strong

conceptual frameworks is scarce.• Current information available

provides a limited picture of oral health related beliefs, thoughts, and behaviors for specific population groups.

• Differences in use contribute to oral health disparities– how do we remedy the issues? Why are there differences?

Moving Forward• How do we create dental consumers?• Access barriers (intensity) have not

been identified for all population groups.– Methods for reducing/removing the

barriers are absent from the literature.• Looking below the barriers– are there

other “undiscovered” reasons for differences in access patterns?

Moving Forward• Much of the literature employs

samples recruited from clinical populations.– Movement into the community will be

required to reach individuals who do not seek regular dental care.

• Oral health literacy – Related to treatment decisions… how?– Tailored materials- do they make a

difference? What degree of tailoring?

Moving Forward• Cultural competence

– Multi cultural office settings• Does inclusiveness make a difference?

• Treatment by front office staff– Staff trained in cultural competence vs.

untrained staff – is there a difference?• Dignity, judgment

– How can these perceptual barriers?

Moving Forward• Dentist/patient engagement during

appointment.• Does provider training in cultural

competence improve case acceptance and/or return visits?

• Extractions, tooth loss- what does this mean to different population groups?– Missing teeth: Scarlet letter of the poor?

Moving Forward• Do patients who receive care for

acute dental problems in an emergency department follow-up their referral for definitive care?– Why or why not?

• Do treatment decisions differ by level of OHL?

• Identify oral health beliefs, values, and practices of different population groups.

• What are the factors associated with missed dental appointments?

• What is the actual cost of ECC?– DALY…

• Social and intellectual development affected• Permanent teeth may be affected• Malocclusion, missing teeth– self-esteem• Early learning foundation poor– not much to

build on… prospects for college low… job prospects questionable… missing teeth can add to a lack of marketability.

– What is the cumulative cost of early and un or under-treated dental disease?

Moving Forward• It is time to apply some of the broad

concepts to determine how they work.

• Social, behavioral, environmental, biological aspects must be considered.

• Solutions will require an interdisciplinary approach.

Different Perspectives• Consideration of different

perspectives…..

• Coronary angioplasty is like going to the dentist(2000).

Any discussion or questions?

Thank you for your attention!