A society that does not view health as a basic human right is likely to experience disparities in health status and care that parallel other societal disparities in access to economic resources, goods and services. In the developed world, the United States is a prime example of the health disparities that result in a society in which access to health care is not readily available to all without regard to their ability to pay. In 2003, the Agency for Healthcare Research and Quality (AHRQ) issued the first U.S. National Healthcare Disparities Report.1 The report presented a comprehensive national overview of disparities, including oral health disparities, in access to health care services and insurance, in health outcomes and in the quality of care among U.S. racial, ethnic and socioeconomic groups.
It is now well-documented that African-Americans, Hispanics, American Indians/Alaska Natives and other racial/ethnic minority groups bear a disproportionate burden of disease and disability, and that these health disparities result in "lower life expectancy, decreased quality of life, loss of economic opportunities, and perceptions of injustice."2
A major determinant of oral health disparities is limited access to dental care, both preventive and restorative, and a major barrier to dental care access is a lack of dental insurance—private dental coverage, in particular.3 However, while insurance may be a prerequisite for access to care, it may be insufficient by itself to eliminate oral health disparities, as there exist other important barriers to dental care access.
In this regard, the work of Kobayashi and colleagues,4 presented in this issue of JADA, analyzes the effectiveness of a multifactorial intervention, the Access to Baby and Child Dentistry (ABCD) program. Launched in Spokane County, Wash., in 1995, the ABCD program aims to increase the number of Medicaid-eligible children younger than 6 years who see a dentist. At the heart of ABCD is a community-based strategy involving a combination of outreach and linkage, education for parents and dental professionals and delivery of services. With support from district dental societies, ABCD has improved access for children enrolled in Medicaid. The new findings presented here indicate that children in counties with ABCD have better oral health and that the program is cost-effective.
The work of Shiboski and colleagues5 in this issue of JADA reminds us that access barriers also affect people with special health care needs and provides further insights on the role of insurance status. They found higher prevalence of dental care utilization among HIV-infected women, as compared with high-risk but uninfected women, lending support to the value of the Ryan White Comprehensive AIDS Resources Emergency Act program, which provides free dental care for people with HIV infection.
Their findings suggest that extension of coverage to high-risk populations would be effective. However, dental insurance may not be the entire solution. Their multivariate analyses found that the strongest predictors of unmet dental needs and lack of utilization included being of a nonwhite race and having a fear of dentists. This finding highlights the need for behavioral and health services research to better define determinants of oral health disparities and to identify the most effective interventions. Such interventions may include educational programs to enhance the competence of dental care providers to treat culturally diverse populations, as well as community-based educational programs to enhance oral health literacy and to promote behaviors that improve oral health.
The report on Latino oral health in this issue by Ramos-Gomez and colleagues6 describes fruitful avenues for research on determinants and interventions. Their recommendations are relevant to other U.S. populations and complement national efforts to eliminate oral health disparities.7
Hispanics are now the nation’s largest racial/ethnic minority group, accounting for one-half of U.S. population growth between 2000 and 2004.8,9 Along with other racial/ethnic groups that are disproportionately affected by oral diseases, Hispanics also are disproportionately poorer, less well-educated and less likely to have dental insurance. Addressing Hispanics’ lack of insurance coverage is an essential first step, though perhaps insufficient by itself, in any effort aimed at reducing disparities in access to care and improving oral health.
A key point made by Ramos-Gomez and colleagues is that the U.S. Hispanic population is not monolithic. Rather, it is highly varied with regard to national origin, acculturation and socioeconomic status. Unfortunately, there is a paucity of data on major U.S. Hispanic subgroups. The only current national data available on Hispanic health status are limited to Mexican-Americans. While the Hispanic Health and Nutrition Examination Survey (HHANES) sampled the three major U.S. Hispanic subgroups at the time, much has changed over 20 years. The time is long overdue for a national study of oral health and its cultural and behavioral determinants that appropriately samples multiple Hispanic subgroups.
Both patient-level and community-based interventions designed for Hispanics clearly need to be linguistically and culturally appropriate.
The cultural competence of health care providers also merits examination as one point of intervention, to the extent that trust in and comfort with one’s dentist influence effective utilization of care and adoption of preventive behaviors. Furthermore, the role of primary care medical practitioners in oral health promotion needs to be more broadly considered as essential to addressing disparities.10 Similarly, research is needed on the best ways in which to extend, safely and effectively, dentists’ ability to promote oral health, and to prevent and treat disease in diverse populations with health disparities.11,12
A related issue is the importance of diversity in the dental profession. Recently, the Institute of Medicine reviewed the evidence for the value of diversity in the health care work-force and concluded that greater racial and ethnic diversity among health professionals will improve access to and quality of health care for all Americans.13 In regards to dental practice, Brown and colleagues14 studied the racial/ethnic variations of U.S. dentists, finding that minority dentists proportionately saw many more minority patients than did white dentists.
In 2003, the Robert Wood Johnson Foundation launched a multimillion-dollar program, "Pipeline, Profession and Practice: Community-Based Dental Education."15 One of the program’s primary goals is to increase the numbers of under-represented minority and disadvantaged students in dental schools. It is becoming increasingly clear that enhancing the diversity of the dental profession is vital to successfully addressing the oral health needs of our nation’s increasingly diverse population.
TOP
REFERENCES
