The Journal of the American Dental Association
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J Am Dent Assoc, Vol 139, No 3, 326-333.
© 2008 American Dental Association
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RESEARCH

Factors Associated With Access to Dental Care for Children With Special Health Care Needs

Debra Kane, PhD, RN, Nicholas Mosca, DDS, Marianne Zotti, DrPH, MS, FAAN and Renee Schwalberg, MPH


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors examined the relationship between receipt of routine medical care and receipt of dental care among children with special health care needs (CSHCN) who resided in the American Dental Association’s Fifth Trustee District, which includes Alabama, Georgia and Mississippi.

Methods. The authors conducted a cross-sectional study using data from the 2001 National Survey of Children with Special Health Care Needs, a module of that year’s State and Local Area Integrated Telephone Survey (sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention, Atlanta). The authors used bivariate and logistic regression analyses to explore the relationships (n = 2,092) between predisposing, enabling and need factors and receipt of dental care.

Results. The parents of an estimated 76 percent of CSHCN in the district reported that their child had a need for dental care in the previous 12 months. Of these, 13.1 percent did not receive care. Failure to obtain needed dental care was associated with failure to obtain routine medical care, as was having a lower income.

Conclusions. Failure to obtain routine medical care may be a risk factor for failure to obtain dental care. Any income below 400 percent of the federal poverty guidelines appears to be a barrier to receiving dental care for CSHCN.

Practice Implications. Providers of routine medical care may play an important role in linking CSHCN to dental care. Investigators need to examine other barriers to dental care for CSHCN. Strategies to optimize access to dental care for CSHCN at all income levels are needed.

Key Words: Access to dental care; children with special health care needs; health services research; barriers to dental care; dental care

Abbreviations: ADA: American Dental Association. • CDC: Centers for Disease Control and Prevention. • CSHCN: Children with special health care needs. • FPG: Federal poverty guidelines. • SAOHA: State Action for Oral Health Care Access Initiative. • SLAITS: State and Local Area Integrated Telephone Survey. • WIC: Women, Infants, and Children.

In 2003, more than one-quarter of U.S. children had not had a preventive dental visit in the previous year.1 The factors associated with failure to obtain dental care are widely documented and include lack of insurance coverage, poverty, race or ethnicity, the child’s age and rural residence.2–6 The challenges to obtaining access to dental care may be exacerbated for children with special health care needs (CSHCN). These children currently have or are at an increased risk of developing a chronic physical, developmental, behavioral or emotional condition and require health and related services of a type or amount beyond that generally required by children.7 Moreover, CSHCN are more likely to have an unmet need for dental care than are children without special needs.7,8

Although many of the barriers to dental care may not seem amenable to intervention, numerous researchers have reported that access to one type of care may contribute to health-seeking behavior and access to other types of care. Thus, obtaining care of some kind may mediate the barriers to care described earlier. For example, Lee and colleagues9 reported that children who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were more likely to have received dental services than were those not enrolled in the WIC program. In addition, Yu and colleagues2 reported that children’s access to routine medical care had a positive effect on their access to dental care.

In conducting this study, our primary interest was in the factors associated with dental care access in our local jurisdiction, the state of Mississippi. However, we included the entire American Dental Association’s Fifth Trustee District to increase the power of the analysis and because the adjoining states had similar demographic profiles. The ADA has 17 trustee districts that provide both a geographical and a political-administrative context in which to analyze data, make policy recommendations and advocate for action within the ADA House of Delegates. Furthermore, by examining the relationship between access to routine medical care and access to dental care, we hoped to highlight the importance of interprofessional and interdisciplinary collaboration to increasing access to dental care among CSHCN.

Aday and Andersen’s10 Behavioral Model of Health Services Use provides a useful framework through which to examine factors that may influence access to dental care (FigureGo). Researchers have used this robust model to examine the factors related to health care access among vulnerable populations11–15 and, more importantly, to examine access to care for children16 and CSHCN.17 Specifically, Yu and colleagues16 reported that lack of a dental care visit among adolescents was associated with male sex, black or mixed race/ethnicity and lack of health insurance. Mayer and colleagues17 reported that CSHCN have higher levels of unmet needs with regard to routine medical care, particularly among children living in poverty. In the Behavioral Model of Health Services Use, three types of factors (predisposing, enabling and need) are asserted to influence access to care. We used the same typology to categorize the variables thought to influence access to dental care for CSHCN.


Figure 1
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  		Figure. Factors associated with access to dental care.

 

   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Sample and design. The 2001 National Survey of Children with Special Health Care Needs, conducted from April 2001 to October 2002, a module of the State and Local Area Integrated Telephone Survey (SLAITS) series, was a cross-sectional study designed to collect data about children’s access to dental care, insurance coverage and its adequacy, household income relative to the federal poverty guidelines (FPG) and the financial effect of having a CSHCN, as well as to collect demographic information.18 The study was sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention (CDC), Atlanta.

This was the first survey, to our knowledge, to specifically assess the health care needs of CSHCN. Professional telephone interviewers, working on behalf of the CDC, interviewed approximately 750 families of CSHCN in each state and the District of Columbia as part of this random-digit-dial survey. The interviewers used a screening process to determine if a child had a special health care need. A child had a special health care need if he or she had a physical, developmental, behavioral or emotional condition that required health care and related services of a type or extent beyond that generally required by children of the same age, and the condition was expected to last more than 12 months.18 We selected the ADA’s Fifth Trustee District (Alabama, Georgia and Mississippi [n = 2,092]) for our analysis to ensure an adequate sample size and because of our interest in promoting the application of research findings in a local geographical and political-administrative grouping for which organized policy actions might be implemented.

The SLAITS survey was designed to produce state-level population estimates, using the weights provided.19 Weights were adjusted to account for noncoverage of households without telephones and were based on population controls from the 2000 U.S. Census according to age, sex, race/ethnicity, household composition and education of the mother. Because of the low proportions of "non-Hispanic other race" (weighted proportion = 2.3 percent) and Hispanics (weighted proportion = 2.4 percent) in the ADA’s Fifth Trustee District, we limited our analysis to non-Hispanic blacks and non-Hispanic whites.

Description of variables. Predisposing factors. Predisposing factors (FigureGo), which exist before the onset of illness, generally are not amenable to intervention and may affect both access to services and their use.10,19 Demographic characteristics commonly are considered to be predisposing factors, and in this study we included the child’s age, sex, race, residence (metropolitan versus nonmetropolitan) and the mother’s educational level as such factors. To describe the characteristics of CSHCN in the ADA’s Fifth Trustee District, we based age categories on common programmatic classifications (birth to five years, elementary school and high school). We examined the mother’s educational level as a three-category variable (less than high school, high school, some college or a degree).

Enabling factors. Enabling factors serve as a means to using health care services and may be amenable to intervention. For this reason, we included family income based on the FPG, having a usual source of care and medical insurance status as enabling factors. We also included having obtained needed routine medical care as an enabling factor. Specifically, all survey respondents were asked this question: "During the past 12 months, was there any time when your child needed routine preventive care, such as a physical examination or well-child check-up?" Those who answered "yes" then were asked, "Did your child receive all the routine preventive care that he or she needed?" We examined type of medical insurance coverage (public versus private) and current insurance status (insured versus uninsured). In addition, we included out-of-pocket costs as an enabling factor. Because of the survey question’s structure, we examined costs in categories of $500 or less or more than $500.

Need factors. In the Aday and Andersen10 model, need refers to the level of illness, which can be perceived by the child’s parent or determined by a health care professional. In this study, the parent or guardian who was most knowledgable about the child’s health and health care ranked the severity of the child’s medical or dental condition on an 11-point scale (0–10). We report the rankings in three categories (0–3, 4–6, 7–10) for descriptive and analytic purposes. Respondents reported the stability of their children’s illness according to one of three categories: "usually stable," "changes once in awhile" or "changes all of the time."

The dependent variable in this analysis was whether the child obtained needed dental care. The survey asked all respondents this question: "During the past 12 months, was there any time when your child needed dental care, including check-ups?" Those who answered "yes" then were asked, "Did your child receive all the dental care that he or she needed?" We examined the independent factors associated with the child’s not having received needed dental care.

Statistical analysis. We created the data set and recoded the variables using statistical software (SAS Version 8.2, SAS Institute, Cary, N.C.).20 We obtained all final results using SUDAAN Release 9.0 (Research Triangle Institute, Research Triangle Park, N.C.), a statistical software package developed to accommodate the data produced by complex survey designs.21,22 We used {chi}2 analysis to test for statistically significant differences between children who received needed dental care and those who did not receive such care, examining differences in predisposing, enabling and need factors. We examined several variables for interaction, including health insurance coverage and income, receipt of routine medical care and insurance coverage, poverty level and mother’s educational level, and receipt of routine medical care and poverty level. None of these interactions was statistically significant.

We used logistic regression to examine the effects of predisposing, enabling and need factors on the child’s not having received needed dental care. We explored variables for modeling up to the .15 significance level; the final model included variables significant at the P = .05 level after we controlled for confounding variables, as well as for those variables historically associated with access to care (for example, age and race). We assessed variables for confounding through stratified analysis and judged a variable to be a confounder if the crude and adjusted odds ratios (ORs) differed by more than 10 percent. We used the Wald test to determine the significance of the model variable. We reported ORs, 95 percent confidence intervals (CIs) and P values for the multivariable analysis.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Sample characteristics. Table 1Go presents the distribution of sampled CSHCN in the ADA’s Fifth Trustee District according to the variables that compose our conceptual framework, as well as the proportion of respondents who reported a need for dental care during the previous year. The parents of an estimated 76 percent of CSHCN in the Fifth Trustee District reported that their child had a need for dental care in the previous year. The children primarily were school-aged non-Hispanic whites living in metropolitan areas. Almost four-fifths of the children’s mothers had obtained at least a high school education (79.1 percent). Family income was 200 percent FPG or below for nearly one-half of the children (45 percent).


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  		TABLE 1 American Dental Association’s Fifth Trustee District population estimates.

 
The majority of the children had a usual source of care (94.2 percent) (Table 1Go). Perhaps reflective of this result was that just 4 percent of the children had not received needed routine medical care in the previous year. Three-fourths of families spent more than $500 on out-of-pocket costs. More than one-half of the children experienced illnesses that usually were stable, while 8.6 percent experienced illnesses that changed all of the time. Illness severity was centered on the middle range of 4 to 6 (39.4 percent of children).

Bivariate analysis. Table 2Go (page 331) presents the characteristics of the children who did not receive needed dental care (n = 169) and the bivariate results. Among predisposing factors, only the mother’s educational level was associated significantly with a failure to obtain needed dental care. Among enabling factors, income, health insurance coverage and not having received needed routine medical care were associated significantly with a failure to obtain needed dental care.


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  		TABLE 2 Prevalence of unmet need for dental care, according to population characteristics (with bivariate results).

 
Logistic regression analyses. Table 3Go (page 332) shows the results from the logistic regression model examining CSHCN in the ADA’s Fifth Trustee District who did not obtain routine medical care, as well as relevant independent variables. Consistent with the bivariate results, income and an unmet need for routine medical care remained predictors of an unmet need for dental care. In contrast, the mother’s educational level and health insurance coverage were no longer predictive of an unmet need for dental care.


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  		TABLE 3 Adjusted odds ratios for the association between selected population characteristics and an unmet need for dental care.*

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
In this study, we found that an unmet need for routine medical care was a strong predictor of an unmet need for dental care. This result supports the findings of other researchers who have found that access to one type of care may influence health-seeking behavior for another type of care.2,9 Even so, the mechanism or process through which either access to dental care or failure to obtain such care is related to obtaining routine medical care is not clear. Perhaps providers of routine medical care assisted families in obtaining needed dental care, or perhaps families who seek out routine medical care also are motivated to obtain dental care for their children. This question warrants further research in view of the American Academy of Pediatric Dentistry’s announced support of dental homes for CSHCN.23

The relationship between an unmet need for dental care and family income has been well-documented. In our study, the relationship between an unmet need for dental care and family income held true for incomes up to 400 percent of the FPG. However, this result leaves unanswered questions. For example, if low-income families obtain Medicaid coverage, including its dental care coverage, what other factors prevent these families from obtaining needed dental care for their children with special needs? Although most dentists report that they treat children,24 a number of researchers have reported that few dentists serve Medicaid-insured children.24–26

Medicaid-insured children. In a study of Medicaid-insured children,6 caregivers reported a number of barriers to dental care access. These barriers included difficulty finding providers who accepted Medicaid, limited choices in appointment times and transportation difficulties. Care-givers who were successful in getting to the dental appointment encountered long waiting times and judgmental treatment by office staff because of the client’s race and public assistance status. Therefore, insurance coverage alone may not overcome the barriers to dental care access among low-income families and those with CSHCN.

In contrast, insurance status no longer was predictive of an unmet need for dental care when we applied the multivariable analysis. Although it was not possible to study the relationship between insurance coverage for dental care and an unmet need for dental care in this sample, it is worth noting that Medicaid typically provides comprehensive dental care coverage for people younger than 21 years through the Early and Periodic Screening, Diagnosis, and Treatment program.26 Medicaid coverage for dental care may have contributed to the nonsignificant relationship between health insurance coverage and an unmet need for dental care. However, as noted above, insurance coverage alone does not guarantee access to needed dental care.

Unlike other research2,3 and inconsistent with the bivariate analysis in our study, the child’s age was not significantly associated with an unmet need for dental care in the logistic regression analysis. In studies based on national samples, race tends to be associated with a failure to obtain dental care. In our final model, we did not find this to be the case. Our results, however, are consistent with a recently published state-level analysis of Mississippi CSHCN.27 These results emphasize the importance of state- and regional-level data collection and analyses. However, we limited our analysis to non-Hispanic blacks and non-Hispanic whites because of the low proportion of Hispanics in the ADA’s Fifth Trustee District.

Policy and program development. The relationship between an unmet need for dental care and an unmet need for routine medical care may be of particular relevance to policy and program development. Specifically, this finding underscores the importance of policies and programs that promote interdisciplinary and inter-professional collaboration and referral mechanisms among medical and dental care providers. The State Action for Oral Health Care Access Initiative (SAOHA) has developed numerous strategies to improve access to oral health care for Medicaid-insured children28; many of them may be applicable to CSHCN and serve to increase interdisciplinary collaboration. For example, through the SAOHA, South Carolina implemented programs that created direct links between medical and dental care providers. South Carolina also implemented a curriculum for medical care providers to incorporate a discussion of the importance of oral health in a child’s medical care visit. The importance of interdisciplinary collaboration also needs to be included in medical and dental school curricula.

Treating children with disabilities. A number of other factors may be of particular relevance to future research regarding CSHCN, as well as to policy and program development. These factors include the paucity of specific information about the prevalence of dental care needs among CSHCN.29,30 Data from the 2001 National Survey of CSHCN focused on health and medical care needs and access for CSHCN. Thus, we have limited information about the true dental care needs of CSHCN and whether or how those needs are being met. Little is known about the willingness of dentists to provide services to CSHCN.

In a New Mexico study of dentists’ willingness to treat patients with disabilities, the majority of dentists (90 percent) reported that they would be willing to treat these patients.30 However, their willingness varied according to the type of disability. For example, dentists were more willing to treat a patient with epilepsy than a patient with mental retardation or a bleeding disorder. In other words, willingness to treat may not translate into actual dental treatment. What the New Mexico study also highlights is that CSHCN are not a homogeneous group.

On the other hand, in a 2004 study of dental students’ experience with and attitudes toward people with mental retardation, 50.8 percent of the students reported that they did not receive any clinical training in how to care for patients with mental retardation.29 More than 60 percent of the students reported that they had little confidence in caring for patients with mental retardation. Therefore, in addition to research, programs and policies to increase training and dental education for new and established dentists may be needed to address the dental care needs of CSHCN.

Study limitations. One limitation of this study is that researchers collected the data via a telephone survey. People without telephones may encounter more barriers to accessing care and, therefore, be at an increased risk of failing to receive needed dental care.31 However, we adjusted the sample weights to account for non-coverage of households without telephones. In addition, the need for dental care was based on parental perceptions and may have been understated if parents were unaware of their children’s need for such care.8,17 Lack of knowledge about children’s oral health care needs is not uncommon: an analysis of the National Survey of Children’s Health, another module of the SLAITS survey, found that the parents of 11.1 percent of children who did not receive preventive dental care in the previous year believed that their children did not need this care, despite the standard recommendation that all children have preventive dental visits twice a year.28 Moreover, the results may have been influenced by recall bias in that parents were asked to answer questions based on the previous 12 months.

In addition, the relatively small sample size contributed to the wide CIs found in the regression analysis and, thus, reduced the power of the statistical models. Therefore, we need to interpret the results of this study with caution. These results cannot be generalized beyond the ADA’s Fifth Trustee District. Furthermore, we cannot attribute a cause-and-effect relationship between the independent variables and the outcomes because the data were cross-sectional. Even so, these results may guide program and policy development by the ADA’s Fifth Trustee District and others working on behalf of CSHCN.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Access to dental care is an ongoing problem among CSHCN, especially those in low-income families. The relationship between access to routine medical care and dental care implies that a comprehensive approach to improving access to primary health care services and to dental care may be more effective than focusing on either service individually. ADA trustee districts may offer effective political-administrative frameworks through which to analyze data that inform decision making about policy that, in turn, improves access to dental care for CSHCN.


   FOOTNOTES
 

At the time this study was conducted, Dr. Kane was a postdoctoral fellow at the Mississippi State Department of Health. Her fellowship was sponsored by the Centers for Disease Control and Prevention, Atlanta. She now is a maternal and child health epidemiologist, Centers for Disease Control and Prevention, Atlanta, and an assignee to the Iowa Department of Public Health, Bureau of Family Health, 321 E. 12th St., 5th Floor, Des Moines, Iowa 50319–0075, e-mail "dkane{at}cdc.gov". Address reprint requests to Dr. Kane.


Dr. Mosca is the dental director, Mississippi State Department of Health, Office of Oral Health, Jackson.


At the time this study was conducted, Dr. Zotti was a Centers for Disease Control and Prevention assignee to the Mississippi State Department of Health. She now is the team leader, Services Management, Research and Translation Team, Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta.


Ms. Schwalberg is the director, Maternal and Child Health Information Resource Center, Rockville, Md.


Disclosures: None of the authors reported any disclosures.


The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, Atlanta.


The institutional review boards at the Centers for Disease Control and Prevention and the Mississippi State Department of Health approved this study.


Dr. Mosca presented a version of the study analysis and a report at the National Oral Health Conference, Little Rock, Ark., May 2006.


   REFERENCES
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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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