BACKGROUND

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
An estimated 2.7 million Floridians (16.8 percent) are of Hispanic origin, which is the fourth highest in absolute numbers (after California, Texas and New York) and proportion (after New Mexico, California and Texas) in the United States.² Florida’s Hispanic population is more diverse than Hispanic populations in any other region of the United States, and it includes a large number of people of Cuban, Puerto Rican and Central or South American origin.²

Hispanic families experience substantial barriers to receiving dental care, including lack of insurance,⁵ underrepresentation of Hispanics in the U.S. dental work force⁶ and cultural and linguistic obstacles.¹ Consequently, Hispanic adults and children are less likely than their non-Hispanic counterparts to see a dentist within a given year,⁷ and they bear a disproportionate burden of oral disease. For example, the prevalence of untreated dental caries is higher among Hispanic children⁸ and adults⁹ than it is among non-Hispanics in the same age groups. Therefore, a critical need exists to improve access to dental homes for Hispanics.

The concept of a dental home—a place where accessible, comprehensive, continuous and coordinated care is provided in the community by culturally competent practitioners^10,11—is important in understanding and redressing oral health disparities. Some of the characteristics of a dental home, such as comprehensive care and culturally competent staff members, though important, may be difficult for patients to assess. Thus, for the purpose of this investigation—one of the first to address oral health care among Hispanics—we chose to limit the definition of a dental home to patients’ reports of having a regular dentist.

In addition to perceived social status, acculturation may be a significant factor in the establishment of a dental home.

Little is known about the effect of subjective social status on access to, or use of, dental services by Hispanics. Subjective social status has been characterized as a person’s belief about his or her place in a status order. Theoretically, the concept of subjective social status likely reflects not only people’s current socioeconomic circumstances, but it also incorporates an assessment of their educational and economic background, as well as their future prospects. Similar to the association that has been well-established for other measures of social class or social hierarchy, a person’s subjective assessment of his or her social status appears to be a powerful predictor of his or her health status.¹²

In addition to perceived social status, acculturation may be a significant factor in the establishment of a dental home, whereby cultural background is recognized, valued and respected by dental care providers. The purpose of this study was to explore whether adults’ perceived social status (a measure of acceptance into communities) and language spoken in their homes (a measure of acculturation) were independently associated with having a dental home among four Hispanic groups in Florida.

	SUBJECTS AND METHODS

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Instrument development. As part of a larger study on attitudes and barriers to participating in cancer screenings, we developed a telephone-based survey instrument to assess health attitudes and behaviors among Hispanic subgroups in Miami-Dade County, Fla. Questions addressed the influence of ethnicity on beliefs about health care, including oral health care, and assessed respondents’ perception of possible prejudice or preferential treatment of non-Hispanics. Each respondent also was asked whether he or she had any kind of insurance coverage that paid for routine dental care, including dental insurance, prepaid plans such as health maintenance organizations or government plans such as Medicaid. We pretested the questionnaire among a sample of telephone respondents and used it in an earlier study.¹³ Further details on the Spanish-language survey are provided elsewhere (B.A. Hastie, H.L.L., S.L.T., unpublished data, 2005).

We used a modified version of the MacArthur Scale of Subjective Social Status¹⁴ to assess respondents’ perceived social status. Using a similar methodology as that reported by Singh-Manoux and colleagues,¹² the interviewer asked each respondent to think of a ladder with 10 rungs as representing where people stand in the United States. At the top of the ladder (represented by the number 10) are the people who are the best off—those who have the most money, the most education and the most-respected jobs. At the bottom (represented by the number 1) are the people who are the worst off—those who have the least money, the least education and the least-respected jobs or no job.

The interviewer then asked them to place themselves on this ladder, at this time in their lives, relative to other people in the United States by selecting a number from 1 to 10. Similarly, they were asked to place themselves on a ladder that represented where people stand in their communities. At the top of the ladder (number 10) are people who have the highest standing in their communities, and at the bottom of the ladder (number 1) are people who have the lowest standing in their communities.

Sampling scheme and telephone survey. We chose Miami-Dade County as the geographic area because a large proportion of the state’s Hispanic population resides there. In 2000, approximately 57.3 percent of the almost 2.3 million residents in the county were Hispanic.² By selecting the entire sample of respondents from this county, we hoped to control for a wide variety of potential confounding regional effects (such as differences in the number and distribution of dental offices) in examining dental care issues among Hispanic subgroups.

Trained interviewers fluent in English and Spanish who were employed by the University of Florida Survey Research Center, Gainesville, conducted the interviews. The sample was selected by using a random-digit-dialing (RDD) strategy that maximized productivity not only in contacting Hispanic respondents in general, but in contacting respondents in nationality subgroups. An RDD sample is a set of telephone numbers that are made up, given knowledge of existing area codes and telephone exchanges. Because we had no guarantee that these randomly dialed numbers would have a residence on the other end of the line, the sampling was done within telephone working banks, which are defined by the area code, prefix (exchange) and the first two digits of the suffix. We chose each bank with the restriction that it needed to have only one residence in that group of telephone numbers.

According to 2000 U.S. census data, the largest Hispanic subgroups in Miami-Dade County were of Cuban (n = 650,601), Colombian (n = 84,260), Nicaraguan (n = 83,802) and Puerto Rican nationality (n = 80,327). We chose to focus on these four groups. We used data regarding country of birth from the 2000 U.S. census to identify census tracts in Miami-Dade County with relatively large numbers of people from these countries. Census tracts are small, relatively permanent statistical subdivisions of a county. Census tracts usually include between 2,500 and 8,000 people and, when first delineated, were designed to be homogeneous with respect to population characteristics, economic status and living conditions.

Because the Cuban community in Miami-Dade County is so large and dispersed, we attempted to combine census tracts into strata, one for each of the four groups, choosing those census tracts that had the largest number of households. Although telephone banks do not conform to census tracts, working banks can be geographically coded to correspond to census tracts, thereby providing some information about the characteristics of respondents that can be expected when people are called.

We determined nationality by classifying the respondents’ country of origin based on the following criteria. If the respondent was born in Cuba, Columbia, Nicaragua or Puerto Rico, we considered him or her to be of that nationality regardless of his or her ancestry. If the respondent was born in any other country, the interviewer asked him or her to identify his or her mother’s country of origin. If it was any of these four countries, we assigned that nationality to the respondent. If the respondent and his or her mother were born elsewhere, then the interviewer questioned him or her regarding the father’s place of birth. If he was not born in any of the four countries, the interview was terminated. Thus, the respondents or at least one of their parents were born in one of the above four countries.

Given our power analysis from previous surveys and the expected margins of error associated with key questions, we targeted 250 completed interviews in each of the four subgroups. We completed a total of 892 telephone interviews. Interviews were conducted in the respondent’s language of preference, which was Spanish primarily.

Analytic variables. Because we were interested in identifying differences among the major Hispanic groups in terms of having a regular dentist (that is, in assessing the presence of a dental home), our dichotomous dependent variable was whether or not the respondents had a regular dentist. The main predictor variables were primary language spoken at home and perceived social status. Demographic variables included in the analyses were nationality, age, sex, education, employment status, dental insurance status and median household income.

Because respondents to telephone surveys frequently are unwilling or unable to provide valid information regarding household income, we used an alternative strategy to characterize respondents’ incomes. We used the median household income for each respondent’s area of residence as the proxy for each person’s household income. The telephone number for each respondent was matched to the census tract, as defined by the U.S. Census Bureau. For analytic purposes, we split the household income variable at the median, resulting in an annual household income of less than $39,195 or greater than or equal to $39,195.

Data analysis. We performed bivariate analyses comparing selected characteristics between respondents, and we compared perceived social status by nationality, sex, education, employment status, primary language spoken at home, income level, having a dental home and dental insurance status. We also conducted bivariate analyses to examine the association between having a dental home and the two primary predictor variables—language spoken at home and perceived social status—as well as other potential demographic correlates. We used ² statistics for all categorical variables.

To examine the association between the primary predictor variables and the outcome while controlling for possible confounders, we then examined the likelihood of having a dental home by using multiple logistic regression modeling. Variables associated with having a dental home in the bivariate analysis (at P .10) were tested in multivariate models. We retained the predictor variables in the final logistic regression model if they were statistically significant correlates of the outcome at P .05 (based on Wald ² values).

	RESULTS

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Characteristics of respondents. We collected relatively complete data from 810 respondents. The sample was composed of 450 respondents of Cuban descent, 139 respondents of Nicaraguan descent, 132 respondents of Colombian descent and 89 respondents of Puerto Rican descent (Table 1). Cubans were the oldest nationality group, with 24.9 percent of the respondents aged 61 to 92 years. Nicaraguan respondents were the youngest nationality group, with 33.8 percent between 18 and 30 years old. At least 63.8 percent of the respondents in each nationality group were female.

Perceived social status. Table 2 (page 1577) shows respondents’ perceived social status according to selected demographic variables. Less than 25 percent of all respondents perceived their social status in the United States to be higher than that in their community. Only 17.8 percent of Cuban respondents perceived themselves to be at a higher social status in the United States than they were in their community. Community status ratings did not differ significantly by sex.

As shown in Table 3 (page 1578), slightly more than one-half of the respondents (58.5 percent) reported having a dental home. However, having a dental home tended to differ by nationality in the bivariate analysis (P = .07): 66.3 percent of Puerto Ricans, 60.4 percent of Cubans, 54.5 percent of Colombians and 51.1 percent of Nicaraguans reported having a dental home (Table 3). In the bivariate analysis, the proportion of subjects who reported having a dental home differed significantly by sex, educational attainment, employment status, primary language spoken at home, perceived social status and dental insurance status. We found no significant difference in the prevalence of having a dental home among age groups or by median household income level.

	DISCUSSION

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The key findings of this investigation were that respondents who perceived themselves to be at a higher social status in the United States were significantly more likely to have a dental home, and those who reported a higher community status were less likely to have a dental home. Those who spoke a language other than English most of the time at home were less likely than those who primarily spoke English at home to have a dental home. In addition, respondents with dental insurance were significantly more likely than those without dental insurance to have a dental home, as were women and people with post–high-school education.

Modified version of MacArthur Scale of Subjective Social Status. We used a modified version of the MacArthur Scale of Subjective Social Status¹⁴ to test for the influence of perceived social status in the community and in the United States on having a dental home. We found that those who rated their status in their community higher than that in the United States as a whole (that is, they placed themselves lower on the social status ladder relative to other people in the United States) were less likely to have a dental home than were those who perceived themselves to be at a higher relative standing in society in general.

Our results may help explain the findings of Singh-Manoux and colleagues,¹² who reported that the further down a person places himself or herself on the perceived social status ladder, the greater his or her ill health. Our findings also support other studies’ conclusions that low-income and minority Americans experience greater levels of oral disease, are less able to obtain dental care and are less likely to seek care than are higher-income and nonminority Americans.^15,16

After controlling for education, income, age and other variables, Manski and Magder¹⁵ found that Hispanics and blacks were less likely to visit a dentist than were whites. They contended that although traditional utilization determinants, such as income, education and insurance, are related clearly to dental care utilization, other systematic racial or ethnic differences, including language or cultural barriers, must be important because the traditional determinants do not explain completely the utilization patterns for all people. Because income is a measure of socioeconomic status, which is strongly associated with the use of dental services, and disparities in oral disease experience have been shown to increase with age, minority status and income gap,^17,18 we were not surprised to find that most respondents who perceived themselves to be on the lower rungs of the broader social status ladder (that is, rungs 4 and below on the U.S. social status scale) did not have a dental home.

Household language. We also found that respondents who primarily spoke Spanish at home were more likely than those who primarily spoke English to perceive their status in the community to be higher than that in the United States. This is important because speaking English in the home may be a measure of acculturation, and evidence suggests that acculturation is a predictor of greater use of health services by Hispanics.¹ The fact that more Puerto Ricans and Cubans than Colombians and Nicaraguans reported speaking primarily English at home could indicate greater acculturation of the former groups.

Consistent with the hypothesis that acculturation influences Hispanics’ use of health services,¹⁹ we found that respondents’ primary household language was a strong and significant correlate of having a dental home. Some support for this finding can be found in a study of Latino nationality groups.¹ Stewart and colleagues¹ found that, among a group of Mexican-Americans, Cuban-Americans and Puerto Ricans, ranking low on measures of acculturation was a predictor of fewer visits to the dentist compared with the number of visits for people ranking high on measures of acculturation. Moreover, less-developed English skills may present a challenge in establishing effective communication with those outside the home, further limiting acculturation and making these people less willing to be involved with institutions, such as the dental office, that represent the larger society.

Poor communication may be a deterrent to effective interaction between patients and health care providers. Having limited English skills may make it difficult for people to establish a dental home by inhibiting communication between the dentist and patient.²⁰ Although many studies have documented that people seek, and have a preference for, health care providers who share the same culture and ethnic background,² it is unlikely that patients’ preferences per se are the driving force for racial and ethnic disparities in health care use and outcomes; rather, the race and ethnicity of the clinician and patient can affect their ability to communicate and negotiate with one another.²⁰

Culturally competent health care. In a study that sought to determine what patients considered to be culturally competent health care, Tucker and colleagues²¹ conducted 20 focus group interviews with 135 patients who were recruited from community-based clinics in north central Florida that serve a disproportionately high percentage of Hispanic and black patients. The investigators found that the most common comments made by Hispanic men and women concerned the impact of language on their levels of trust in, and comfort with, their physicians. For example, some participants commented that they believed physicians should speak Spanish or that language presented a communications barrier. Others expressed concerns about the accuracy with which the translator conveyed their messages to the physician and feared that important information might have been missed.

Moore and colleagues²² found that physicians’ active listening to patients might be important both for the doctor-patient relationship, as well as for patients’ future treatment decisions. For example, listening intently to patients can provide dentists with more information, which may help them confirm with the patient that he or she understands his or her dental condition and the reasons for the recommended treatment plan. In addition, it is possible that patients view active listening as a sign that the dentist is interested in their welfare and, therefore, he or she may be more likely to provide high-quality care. Thus, the quality of communication between the dentist and patient may influence the patient’s decision about whether to follow through with the recommended treatment.

A culturally competent dental home would be a place in which a mechanism is established for communication that fosters ongoing care.¹¹ However, achieving diversity at all levels of the health care system may further influence the way in which patients of varied cultural and linguistic backgrounds are served.²³

Study limitations. A major limitation of this study was that respondents were not asked whether they had teeth. This information would have allowed us to exclude edentulous subjects from the analysis, because dentate status is a strong correlate of dental care utilization.²⁴ A second limitation arises from the inherent nature of telephone-based surveys. Although this survey method is cost-effective for obtaining population-based data, certain people are excluded easily or underrepresented, such as those who do not have a telephone in the household, those who are difficult to contact because of the hours they are at home and those who simply refuse to participate.²⁵ Finally, because we surveyed people who identified themselves as Colombian, Cuban, Nicaraguan or Puerto Rican, the sample is not representative of the entire U.S. or Floridian Hispanic population.

	CONCLUSIONS

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
This is one of a few studies that have identified factors that may influence Hispanics’ ability to establish a dental home. Compared with study participants who perceived that their social standing was equal in their community and in the United States in general, those who perceived themselves to be at a higher social status in the United States were significantly more likely to have a dental home, and those who reported a higher community status were less likely to have a dental home. Respondents who primarily spoke a language other than English at home were less likely than those who primarily spoke English to have a dental home.

These findings suggest that, even after adjusting for factors previously established as correlates of regular dental care, acculturation and perceived social status may influence Hispanics’ ability to establish a dental home. In this study, these variables were associated more strongly with having a dental home than was country of origin.

The study findings suggest that it may be beneficial to conduct Spanish-language oral health promotion campaigns. To reduce the oral health disparities that still exist in the United States, individual dentists and organized dentistry can promote investment in education, job training and other social services that would improve socioeconomic conditions in low-income Hispanic communities. Increasing the number of culturally competent dentists may help establish more sources of regular dental care in underserved minority areas.