JADA Continuing Education
Dental visits among Hispanics in the United States, 1999
THOMAS P. WALL, M.A., M.B.A. and
L. JACKSON BROWN, D.D.S., Ph.D.
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ABSTRACT
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Background. This article describes dental visits among Hispanics and Hispanic subgroups in the United States.
Methods. This study is based on an analysis of data regarding dental visits among Hispanics two years of age and older from the National Health Interview Survey of 1999. The authors compared the 1999 data with a combined sample from 1978 through 1980.
Results. Although the level of dental visits for all Hispanic subgroups increased between the period of 1978 through 1980 and 1999, the level of dental visits was lowest among Mexican-Americans. For Mexican-Americans born outside the United States, the longer they had lived in the United States, the more likely they were to have visited a dentist.
Conclusions. Increases in the utilization of dental services among Hispanics provide some optimism for reductions in the level of untreated oral disease among Hispanics in the future. However, if increases in dental care utilization among Mexican-Americans fail to keep pace with those among other segments of the U.S. population, this population group risks falling further behind.
Practice implications. Hispanic patients will make up a greater percentage of all dental patients in the future. The impact of this growth will vary greatly by state.
In an article we published in 2003 that focused on recent trends in dental visits and dental insurance in the United States, a significant finding was that in 1999, Hispanics had the lowest level of dental visits of all racial and ethnic groups examined.1 We pointed out that further analysis of Hispanics was needed, considering that the growth rate of the Hispanic population has been much higher than has that of other segments of the U.S. population. According to recent estimates from the U.S. Census Bureau, Hispanics are now the nation’s largest minority.2
Increases in the utilization of dental services among Hispanics provide some optimism for reductions in the level of untreated oral disease among Hispanics in the future.
There were about 32.4 million Hispanics in the United States in 2000, composing 11.8 percent of the total resident U.S. population. Census projections indicate that by the year 2050, the number of Hispanics will rise to just more than 98 million, or 24.3 percent of the total population.3 Clearly, the pattern of dental visits among Hispanics will have an increasing impact on the overall level of dental visits in the United States.
An analysis of National Health Interview Survey, or NHIS, data collected from 1978 through 1980 found that Mexican-Americans, Cuban-Americans, and Puerto Ricans visited the dentist less frequently than did white non-Hispanics. Mexican-Americans had the lowest proportion of people who went to a dentist within a year compared with Puerto Ricans and Cuban Americans.4
This article examines dental visits among the various subgroups making up the Hispanic population in the United States. It also presents a breakdown of the Mexican population in terms of whether they were born in the United States. (This is relevant in terms of this population’s assimilation, or lack thereof, into U.S. society. Those born in the United States would be expected to be the most assimilated.) For those not born in the United States, we present dental visits by number of years in the United States.
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METHOD
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The NHIS is a multipurpose survey conducted annually by the National Center for Health Statistics, or NCHS, and the Centers for Disease Control and Prevention, or CDC, and is the principal source of information on the health of the civilian, noninstitutionalized household population of the United States. NHIS data are collected through personal household interviews. Most information about oral health in the NHIS is obtained for all people two years of age and older. Data are released on an annual basis.
The interviewed sample for 1999 consisted of 37,573 households, which yielded 97,059 people in 38,171 families.5,6 Some information was collected for everyone in the family. Additional information, about topics such as the dental visit and private dental insurance, was collected from two subsamples. The adult subsample consisted of one adult per household for a total of 30,801 people 18 years of age and older. The child subsample consisted of one child per household for a total of 12,910 children, who ranged in age from newborn to 17 years. The total household response rate in 1999 was 87.6 percent. The final response rate for the sample adult component was 69.6 percent. The final response rate for the sample child component was 78.2 percent.
Our analysis focuses on respondents who reported having had a dental visit within the past 12 months. We assumed that respondents with an unknown interval since last their dental visit had not had a dental visit in the preceding 12 months. We based the educational level for those younger than 18 years of age on the highest level completed by either parent.
The primary focus of this article is a current examination of dental visits among various segments of the Hispanic population in the United States. However, we also present trend data comparing all Hispanics with African-American and white Americans during a 10-year interval (1989 to 1999). When it came to presenting trend data for the individual subgroups of Hispanics, we found that the 1989 NHIS sample did not contain enough Hispanics to support such an analysis. However, we did find an earlier study that was able to generate sufficient numbers for analysis by combining three NHIS samples for the years 1978, 1979 and 1980.4 The earlier study provided a basis for this article’s analysis of trends among the various segments of the U.S. Hispanic population between the combined 1978–1980 period and 1999.
We used the SUDAAN statistical package (Version 8.0; Research Triangle Institute, Research Triangle Park, N.C.) to calculate standard errors and perform statistical tests, since it includes adjustments for the correlation introduced by the complex sample design used for the 1999 NHIS.
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RESULTS
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Whereas the percentage with a dental visit during the past year was lowest among blacks in 1989, Hispanics reported the lowest level of dental visits in 1999 (Figure 1
). An 11.7 percentage point increase in the level of dental visits from 1989 to 1999 among blacks combined with a 6.7 percentage point increase among whites reduced the difference between these two groups from 14.8 to 9.8 percentage points in 1999.
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Figure 1. Percentage of the U.S. population who had visited a dentist by race/ethnicity: 1989 versus 1999 National Health Interview Survey. Sources: Wall and Brown1 and National Center for Health Statistics.5,6
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However, the 5.5 percentage point increase in visits among Hispanics combined with the 6.7 percentage point increase among whites resulted in an increase in the difference between Hispanics and whites from 12.9 to 14.1 percentage points. The difference between blacks and Hispanics was 1.9 percentage points in favor of Hispanics in 1989 and 4.3 percentage points in favor of blacks in 1999.
Among Hispanics, the level of dental visits was close to 60 percent among all subgroups except Mexicans (Figure 2). The difference between the 54.2 percent among Mexicans born in the United States and the 34.9 percent among those born in Mexico was almost 20 percentage points. Differences in the level of visits between those born in the United States and those who were not were 10.6 percent for Puerto Ricans, 8.3 percent for Cubans, 7.6 percent for Dominicans and 8.9 percent for Central and South Americans (not shown in Figure 2).
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Figure 2. Percentage of the U.S. population who had visited a dentist, 1999 National Health Interview Survey. SE: Standard error. Source: National Center for Health Statistics.5,6
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Figure 3 shows changes in the percentage who had had a dental visit between the 1978–1980 period and 1999 among those aged four years and older for three Hispanic subgroups in the United States. Although all groups reported double-digit increases, the increase was smallest for Mexican-Americans (13.2 percentage points) and largest for Cubans (18.9 percentage points). The increase for Puerto Ricans was16.5 percentage points.
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Figure 3. Percentage of the Hispanic population in the United States who had visited a dentist among those 4 years old and older, National Health Interview Survey 1978–1980 and 1999. Sources: Trevino and Moss4 and National Center for Health Statistics.5,6
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Mexicans made up two-thirds of all U.S. Hispanics in 2000. Central and South Americans, Puerto Ricans, Cubans and other Hispanic people (6.4 percent) made up the other one-third7 (Figure 4 shows a breakdown of the U.S. Hispanic population in 2000). According to the 1999 NHIS, 60 percent of Mexicans, 57.3 percent of Puerto Ricans, 31.7 percent of Cubans, 36.4 percent of Dominicans and 27.4 percent of Central and South Americans living in the United States were born in the United States.
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Figure 4. Percentage of U.S. population reporting Hispanic ethnicity, 2000 census. Source: U.S. Census Bureau.7
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The major subgroups of Hispanics in the United States differ in several factors related to the demand for dental care, including age, education, income and percentage with private dental insurance7 (Table 1). We constructed logistic regression models to determine the respective influence of these variables on the likelihood of having visited a dentist. The odds ratios for these models are presented in Table 2.
The reference group for the models in Table 2
was the group with the lowest level of dental visits—Mexicans living in, but not born in, the United States. The first model with dummy variables for each of the remaining Hispanic groups shows that other Hispanics, including Mexican-Americans born in the United States, were two to three times more likely to visit a dentist than were members of the reference group. However, as we added other variables to the model, the advantage of the other groups over the reference group declined, and the difference between Mexicans born in the United States and those born in Mexico was reduced but remained statistically significant.
In the full model (6) (Table 2), those with dental insurance were almost twice as likely to visit a dentist as were those without dental insurance. Hispanics with some college education were 1.6 times as likely to visit a dentist as those without college education. Those in the highest income group were 1.7 times as likely to visit a dentist as were those in lower income groups. Compared with Hispanics 18 to 64 years old, Hispanic children aged between two and four years were one-half as likely to visit a dentist, children aged between five and 17 years were 1.8 times as likely to visit a dentist, and those aged 65 years and older were 1.5 times as likely to visit a dentist. Furthermore, among elderly Hispanics, those who were edentulous were much less likely to visit a dentist than those who were dentate. Female Hispanics were 1.5 times more likely to visit a dentist than were male Hispanics.
A model with Mexican-Americans born in the United States as the reference group and Mexicans not born in the United States omitted, and in which we controlled for all of the variables shown for model 6 (Table 2), showed that the other Hispanic groups were more likely to report having visited a dentist than were Mexican-Americans born in the United States. The odds ratio for Puerto Ricans was 1.4; for Cubans, 1.6; for Dominicans, 1.8; and for Central and South Americans, 1.4. Thus, even after we controlled for socioeconomic characteristics, dental insurance and age, Mexican-Americans visited dentists less than did other Hispanics.
Figure 5 (page 1016) is based on Mexicans living in, but not born in, the United States. Among this group, the percentage with a visit increased according to the number of years in the United States. Whereas 24.3 percent of those who had lived in the United States for less than five years reported a dental visit, 43.2 percent of those who had lived in the United States for 15 or more years reported having had a dental visit.
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Figure 5. Percentage of Mexican-Americans who had visited a dentist among Mexicans not born in the United States, by number of years in the United States. Source: National Center for Health Statistics.5,6
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Table 3 shows that the longer members of this group remained in the United States, the more likely they were to possess characteristics and resources positively related to the likelihood of utilizing dental care.7 The percentage with some college education increased from 11.6 percent for those who had lived in the United States for less than five years to 17.1 percent for those who had lived in the United States for 15 years or more. The percentage with annual incomes greater than $20,000 increased from 41.3 percent to 68.5 percent, and the percentage with private dental insurance increased from 3.1 percent to 21.1 percent.
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TABLE 3 SOCIAL AND ECONOMIC CHARACTERISTICS OF MEXICANS NOT BORN IN THE UNITED STATES, BY NUMBER OF YEARS IN THE UNITED STATES.*
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DISCUSSION
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Projections presented in the introduction to this article indicate that Hispanics will grow from just less than 11.8 percent of the population to 24.3 percent by the year 2050. This increase from 32.4 million to 98.2 million Hispanics accounts for approximately one-half of the total expected growth in the U.S. population from 275 million in 2000 to 404 million in 2050. However, as the percentage of Hispanics increases, the percentage of Hispanics who are born outside of the United States is expected to decrease from its 2001 level of 35.5 percent to 20.0 percent in 2050.8,9
Changes in the racial and ethnic makeup of the U.S. population between 2000 and 2050 are presented in Figure 6.3 The number of blacks in the population is projected to increase from 33.5 million in 2000 to 53.5 million in 2050. As a percentage of the total, blacks will represent 13.2 percent of the total population in 2050, up slightly from 12.2 percent in 2000. The population of whites, on the other hand, is projected to increase from 196.7 million to 213 million, but drop as a percentage of the population from 71.5 percent to 52.8 percent of the total. The population of Asians is projected to increase from 10.5 million to 35.8 million, or from 3.8 percent of the population to 8.9 percent. The American Indian/Alaska Native population is projected to grow from 2.1 million to 3.2 million, but remain steady in terms of percentage of the total population at 0.8 percent.
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Figure 6. U.S. population in 2000 as compared with the projected U.S. population in 2050. Source: U.S. Census Bureau.3
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A greater proportion of dental patients in the future will be Hispanic and Asian.10 The states that have the highest concentrations of these two population groups will be affected most.
As shown in Figure 7, the states with the highest percentage of Hispanic populations are located in the Southwest.11 California and Texas are home to half of the total number of Hispanics in the United States and 65.5 percent of all Mexican-Americans. Of the total number of Hispanics in New York, 52 percent are "other Hispanic or Latino" and 37 percent are Puerto Rican. Of the total number in New Jersey, 51 percent are "other Hispanic or Latino" and 33 percent are Puerto Rican. Of the total number in Florida, 37 percent are "other Hispanic or Latino" and 31 percent are Cuban.11
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CONCLUSION
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The fact that Hispanics as a group reported the lowest level of dental care utilization in 1999 was due primarily to low utilization among Mexicans in the United States. Because Mexicans make up two-thirds of all Hispanics in the United States, they have a dominant impact on overall dental visit estimates for Hispanics.
However, the trends presented in this article provide some reason for satisfaction. Firstly, the utilization of dental services by all Hispanic subgroups increased from 1978–1980 to 1999, and the percentages of Cubans, Puerto Ricans and Dominicans as well as Hispanics from South and Central America who had visited a dentist during the year preceding their NHIS interview appears to have reached, or were approaching, overall national levels.
Another source of optimism from this report is that the dental care utilization rate of Mexican-Americans who were not born in the United States converges towards the utilization rate of Mexican-Americans born in the United States as the time they have been in the United States increases. This is partly the result of this group’s acquiring more of the socioeconomic resources that enable them to avail themselves of dental care at higher levels the longer they live in the United States.
A more troubling finding of our study is that the dental care utilization rate for Mexican-Americans (both those born in the United States and those born elsewhere) remains below that of the overall national level, and below the utilization rate of other Hispanics in the United States. The lower utilization rate among Mexican-Americans compared with that among other Hispanics persists even after age, income, education, sex and dental insurance coverage are statistically controlled. The reasons for this difference are not explained by the analysis in this article and indicate that further research is needed into the causes of this finding.
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Mr. Wall is the manager, Statistical Research, Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "wallt{at}ada.org". Address reprint requests to Mr. Wall.
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Dr. Brown is associate executive director, Health Policy Resources Center, American Dental Association, Chicago.
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REFERENCES
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- Wall TP, Brown LJ. Recent trends in dental visits and private dental insurance, 1989 and 1999. JADA 2003;134:621–7.
- Cohn D. Hispanics are nation’s largest minority. Washington Post June 18, 2003. Available at "www.washingtonpost.com/wp-dyn/articles/A9464-2003Jun18.html?nav=hptop_tb". Accessed June 23, 2003.
- U.S. Census Bureau. Table 15: resident population by Hispanic origin status, 1980 to 2000, and projections, 2005 to 2050. In: U.S. Census Bureau. Statistical abstract of the United States 2001: The national data book. 121st ed. Washington: U.S. Department of Commerce, Economics and Statistical Administration, Census Bureau; 2001:17.
- Trevino FM, Moss AJ. Health indicators for Hispanic, black, and white Americans. Hyattsville, Md.: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics; 1984:1–88. DHHS publication (PHS) 84–1576.
- National Center for Health Statistics. Dataset documentation, National Health Interview Survey, 1999. Hyattsville, Md.: National Center for Health Statistics; 2002.
- National Center for Health Statistics. NHIS Survey description, National Health Interview Survey, 1999. Hyattsville, Md.: National Center for Health Statistics; 2002.
- U.S. Census Bureau. Table 41: social and economic characteristics of the Hispanic population—2000. In: U.S. Census Bureau. Statistical abstract of the United States 2001: The national data book. 121st ed. Washington: U.S. Department of Commerce, Economics and Statistical Administration, Census Bureau; 2001:43.
- Population Projections Program, Population Division, U.S. Census Bureau. Projections of the resident population by race, Hispanic origin, and nativity: middle series, 2001 to 2005. Available at: "www.census.gov/population/projections/nation/summary/np-t5-b.txt". Accessed June 13, 2003.
- Population Projections Program, Population Division, U.S. Census Bureau. Projections of the resident population by race, Hispanic origin, and nativity: middle series, 2050 to 2070. Available at: "www.census.gov/population/projections/nation/summary/np-t5-g.txt". Accessed June 13, 2003.
- Qui Y, Ni H. Utilization of dental care services by Asians and native Hawaiian or other Pacific Islanders: United States, 1997–2000. Hyattsville, Md.: National Center for Health Statistics; 2003. Advance Data from Vital and Health Statistics, no. 336.
- U.S. Census Bureau. Table 23: resident population by Hispanic origin status, 1980 to 2000, and projections, 2005 to 2050. In: U.S. Census Bureau. Statistical abstract of the United States 2001: The national data book. 121st ed. Washington: U.S. Department of Commerce, Economics and Statistical Administration, Census Bureau; 2001:25.
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ABSTRACT
METHOD
