Oral Health-Related Quality of Life Among Publicly Insured Mental Health Service Outpatients With Serious Mental Illness.

OBJECTIVE: The study investigated factors associated with unmet need for dental care and oral health-related quality of life (OHQoL) among individuals with serious mental illness receiving outpatient care in a public mental health program serving a largely low-income population, mostly from racial-ethnic minority groups. METHODS: Cross-sectional interview data were collected from a convenience sample (N=150) of outpatients. Adjusted risk ratios (ARRs) and adjusted risk differences (ARDs) were estimated by logistic regression models to examine the independent contribution of sociodemographic and clinical factors to low OHQoL and past-year unmet dental need, defined as inability to obtain all needed dental care. RESULTS: More than half of participants reported low OHQoL (54%) and a past-year dental visit (61%). Over one-third (39%) had past-year unmet dental need. Financial barriers (ARR=3.16) and nonfinancial barriers (ARR=2.18) were associated with greater risk for past-year unmet dental need after control for age, gender, high dental anxiety, and limited English proficiency. ARDs for financial and nonfinancial barriers indicated absolute differences of 40 and 27 percentage points, respectively. Unmet dental need (ARR=1.31), xerostomia severity (ARR=1.20), and a schizophrenia spectrum diagnosis (ARR=1.33) were associated with low OHQoL, after control for age and current smoking, with ARDs ranging from 11 to 15 percentage points. CONCLUSIONS: Improving oral health promotion, oral health service access, and the integration of the mental and oral health systems may help reduce the high prevalence of low OHQoL in this population, given that low OHQoL is partly driven by unmet dental need.

Does Medicaid Coverage Modify the Relationship between Glycemic Status and Teeth Present in Older Adults?

Understanding the relationships among diabetes, teeth present, and dental insurance is essential to improving primary and oral health care. Participants were older adults who attended senior centers in northern Manhattan (New York, N.Y.). Sociodemographic, health, and health care information were obtained via intake interviews, number of teeth present via clinical dental examinations, and glycemic status via measurement of glycosylated hemoglobin (HbA1c). Complete data on dental insurance coverage status for 785 participants were available for analysis (1,015 after multiple imputation). For participants with no dental insurance and any private/other dental insurance, number of teeth present is less for participants with diabetes than for participants without diabetes; however, for participants with Medicaid coverage only, the relationship is reversed. Potential explanations include the limited range of dental services covered under the Medicaid program, inadequate diabetes screening and monitoring of Medicaid recipients, and the poor oral and general health of Medicaid recipients.

"Seniors only want respect": designing an oral health program for older adults.

AIM: Persistent socioeconomic disparities in the oral disease burden contribute to pain and suffering among vulnerable and underserved populations who face systemic barriers to access oral health care, including older adults living in disadvantaged urban neighborhoods. The aim of this study is to gain the views of racial/ethnic minority older adults regarding what they believe would support them and their peers in visiting the dentist regularly. METHODS AND RESULTS: Focus groups were conducted and digitally audio-recorded from 2013 to 2015 with 194 racial/ethnic minority women and men aged 50 years and older living in northern Manhattan who participated in one of 24 focus group sessions about improving oral health for older adults. Analysis of the transcripts was conducted using thematic content analysis. The majority of recommendations from racial/ethnic minority older adults to help older adults go to the dentist regularly were centered at the organization and provider level. The preeminence of respectful treatment to racial/ethnic minority older adults may be useful to underscore in oral health programs and settings. CONCLUSION: There is a need for greater engagement of and attention to patients and other stakeholders in developing, testing, and disseminating interventions to close the gaps in oral health care disparities.

Estimating peer density effects on oral health for community-based older adults.

BACKGROUND: As part of a long-standing line of research regarding how peer density affects health, researchers have sought to understand the multifaceted ways that the density of contemporaries living and interacting in proximity to one another influence social networks and knowledge diffusion, and subsequently health and well-being. This study examined peer density effects on oral health for racial/ethnic minority older adults living in northern Manhattan and the Bronx, New York, NY. METHODS: Peer age-group density was estimated by smoothing US Census data with 4 kernel bandwidths ranging from 0.25 to 1.50 mile. Logistic regression models were developed using these spatial measures and data from the ElderSmile oral and general health screening program that serves predominantly racial/ethnic minority older adults at community centers in northern Manhattan and the Bronx. The oral health outcomes modeled as dependent variables were ordinal dentition status and binary self-rated oral health. After construction of kernel density surfaces and multiple imputation of missing data, logistic regression analyses were performed to estimate the effects of peer density and other sociodemographic characteristics on the oral health outcomes of dentition status and self-rated oral health. RESULTS: Overall, higher peer density was associated with better oral health for older adults when estimated using smaller bandwidths (0.25 and 0.50 mile). That is, statistically significant relationships (p < 0.01) between peer density and improved dentition status were found when peer density was measured assuming a more local social network. As with dentition status, a positive significant association was found between peer density and fair or better self-rated oral health when peer density was measured assuming a more local social network. CONCLUSIONS: This study provides novel evidence that the oral health of community-based older adults is affected by peer density in an urban environment. To the extent that peer density signifies the potential for social interaction and support, the positive significant effects of peer density on improved oral health point to the importance of place in promoting social interaction as a component of healthy aging. Proximity to peers and their knowledge of local resources may facilitate utilization of community-based oral health care.

Racial/Ethnic Minority Older Adults' Perspectives on Proposed Medicaid Reforms' Effects on Dental Care Access.

To examine how proposed Medicaid reform plans are experienced by racial/ethnic minority older adults and what the implications are for their ability to access dental care through Medicaid, from 2013 to 2015 we conducted focus groups in northern Manhattan, New York, New York, among African American, Dominican, and Puerto Rican adults aged 50 years and older. Participants reported problems with affording copayments for care, complicated health and social issues, the need for vision and dental care close to home, and confusion about and stigmatization with Medicaid coverage. Federal, state, and local public health agencies can help by clarifying and simplifying Medicaid plans and sustaining benefits that older adults need to live healthy and dignified lives.

Recruitment of racial/ethnic minority older adults through community sites for focus group discussions.

BACKGROUND: Despite a body of evidence on racial/ethnic minority enrollment and retention in research, literature specifically focused on recruiting racially/ethnically diverse older adults for social science studies is limited. There is a need for more rigorous research on methodological issues and the efficacy of recruitment methods. Cultural obstacles to recruitment of racial/ethnic minority older adults include language barriers, lack of cultural sensitivity of target communities on the part of researchers, and culturally inappropriate assessment tools. METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), this study critically appraised the recruitment of racial/ethnic minority older adults for focus groups. The initial approach involved using the physical and social infrastructure of the ElderSmile network, a community-based initiative to promote oral and general health and conduct health screenings in places where older adults gather, to recruit racial/ethnic minority adults for a social science component of an interdisciplinary initiative. The process involved planning a recruitment strategy, engaging the individuals involved in its implementation (opinion leaders in senior centers, program staff as implementation leaders, senior community-based colleagues as champions, and motivated center directors as change agents), executing the recruitment plan, and reflecting on the process of implementation. RESULTS: While the recruitment phase of the study was delayed by 6 months to allow for ongoing recruitment and filling of focus group slots, the flexibility of the recruitment plan, the expertise of the research team members, the perseverance of the recruitment staff, and the cultivation of change agents ultimately resulted in meeting the study targets for enrollment in terms of both numbers of focus group discussions (n = 24) and numbers of participants (n = 194). CONCLUSIONS: This study adds to the literature in two important ways. First, we leveraged the social and physical infrastructure of an existing program to recruit participants through community sites where older adults gather. Second, we used the CFIR to guide the appraisal of the recruitment process, which underscored important considerations for both reaching and engaging this underserved population. This was especially true in terms of understanding the disparate roles of the individuals involved in implementing and facilitating the recruitment plan.

Modeling Social Capital as Dynamic Networks to Promote Access to Oral Healthcare.

Social capital, as comprised of human connections in social networks and their associated benefits, is closely related to the health of individuals, communities, and societies at large. For disadvantaged population groups such as older adults and racial/ethnic minorities, social capital may play a particularly critical role in mitigating the negative effects and reinforcing the positive effects on health. In this project, we model social capital as both cause and effect by simulating dynamic networks. Informed in part by a community-based health promotion program, an agent-based model is contextualized in a GIS environment to explore the complexity of social disparities in oral and general health as experienced at the individual, interpersonal, and community scales. This study provides the foundation for future work investigating how health and healthcare accessibility may be influenced by social networks.

Third Places for Health Promotion with Older Adults: Using the Consolidated Framework for Implementation Research to Enhance Program Implementation and Evaluation.

This study extends the concept of third places to include community sites where older adults gather, often for meals or companionship. The Consolidated Framework for Implementation Research guided program implementation and evaluation. Depending upon health promotion program needs, the physical infrastructure of a site is important, but a supportive director (champion) can often overcome identified deficits. Senior centers may be locally classified into four types based upon eligibility requirements of residents in affiliated housing and services offered. Participants who attend these centers differ in important ways across types by most sociodemographic as well as certain health and health care characteristics.

Reasons for Apical Surgery Treatment in an Underserved New York City Population.

Endodontic retreatment often involves remaking restorations. The total cost may steer the treatment towards surgery. The aim of this study was to retrospectively record the reasons for performing apical surgery in an economically deprived patient population. The clinical reasons (59%) for apical surgery were most common, but the nonclinical (financial) reasons (41%) emerged as a major cause. The finding that 41% of the apicoectomies were performed because of nonclinical constraints is a high figure and may not reflect the situation generally. Still, economic factors potentially play a major role in the selection of surgical versus nonsurgical endodontic retreatment.

The Impact of Medicaid Expansion on Oral Health Equity for Older Adults: A Systems Perspective.

This paper uses a collaborative, interdisciplinary systems science inquiry to explore implications of Medicaid expansion on achieving oral health equity for older adults. Through an iterative modeling process oriented toward the experiences of both patients and oral health care providers, complex feedback mechanisms for promoting oral health equity are articulated that acknowledge the potential for stigma as well as disparities in oral health care accessibility. Multiple factors mediate the impact of Medicaid expansion on oral health equity.

Evidence From ElderSmile for Diabetes and Hypertension Screening in Oral Health Programs.

The ElderSmile clinical program was initiated in northern Manhattan in 2006. ElderSmile is a comprehensive community-based program offering education, screening and treatment services for seniors in impoverished communities. Originally focused on oral health, ElderSmile was expanded in 2010 to include diabetes and hypertension education and screening. More than 1,000 elders have participated in the expanded program to date. Quantitative and qualitative findings support a role for dental professionals in screening for these primary care sensitive conditions.

A community-based oral public health approach to promote health equity.

OBJECTIVES: We explored the interrelationships among diabetes, hypertension, and missing teeth among underserved racial/ethnic minority elders. METHODS: Self-reported sociodemographic characteristics and information about health and health care were provided by community-dwelling ElderSmile participants, aged 50 years and older, who took part in community-based oral health education and completed a screening questionnaire at senior centers in Manhattan, New York, from 2010 to 2012. RESULTS: Multivariable models (both binary and ordinal logistic regression) were consistent, in that both older age and Medicaid coverage were important covariates when self-reported diabetes and self-reported hypertension were included, along with an interaction term between self-reported diabetes and self-reported hypertension. CONCLUSIONS: An oral public health approach conceptualized as the intersection of 3 domains-dentistry, medicine, and public health-might prove useful in place-based assessment and delivery of services to underserved older adults. Further, an ordinal logit model that considers levels of missing teeth might allow for more informative and interpretable results than a binary logit model.

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

Racial/ethnic and socioeconomic disparities regarding untreated oral disease exist for older adults, and poor oral health diminishes quality of life. The ElderSmile program integrated screening for diabetes and hypertension into its community-based oral health activities at senior centers in northern Manhattan. The program found a willingness among minority seniors (aged ≥ 50 years) to be screened for primary care sensitive conditions by dental professionals and a high level of unrecognized disease (7.8% and 24.6% of ElderSmile participants had positive screening results for previously undiagnosed diabetes and hypertension, respectively). Dental professionals may screen for primary care-sensitive conditions and refer patients to health care providers for definitive diagnosis and treatment. The ElderSmile program is a replicable model for community-based oral and general health screening.

Types of dental fear as barriers to dental care among African American adults with oral health symptoms in Harlem.

To examine the types of dental fear experienced by African American adults and the role of these fears in the utilization of dental care, in-depth interviews were conducted with a street-intercept sample of 118 African Americans living in Harlem, New York City, who had experienced at least one oral health symptom in the past six months. Despite their oral symptoms, participants delayed or avoided dental care (often for years) due to a variety of dental fears, including fears of: 1) pain from needles; 2) the dental drill; 3) having teeth extracted; 4) contracting an illness (e.g., HIV/AIDS) from unsanitary instruments; 5) X-rays; 6) receiving poor quality care or mistreatment. These findings provide insights into the situations that provoke fears about dental treatment among African Americans and suggest strategies to address these fears in order to remove these barriers and increase the utilization of dental care by African American adults.

Insurance-related barriers to accessing dental care among African American adults with oral health symptoms in Harlem, New York City.

Although ability to pay is associated with dental care utilization, provision of public or private dental insurance has not eliminated dental care disparities between African American and White adults. We examined insurance-related barriers to dental care in interviews with a street-intercept sample of 118 African American adults in Harlem, New York City, with recent oral health symptoms. Although most participants reported having dental insurance (21% private, 50% Medicaid), reported barriers included (1) lack of coverage, (2) insufficient coverage, (3) inability to find a dentist who accepts their insurance, (4) having to wait for coverage to take effect, and (5) perceived poor quality of care for the uninsured or underinsured. These findings provide insights into why disparities persist and suggest strategies to removing these barriers to dental care.

Research productivity of members of IADR Behavioral Sciences and Health Services Research Group: relationship to professional and personal factors.

This report describes the research productivity of the members of the International Association for Dental Research (IADR) Behavioral Sciences and Health Services Research Group and examines personal and professional factors related to greater productivity. The findings from previous studies suggested there might be gender discrimination in opportunities for women faculty. Members on the active membership list for this IADR group were surveyed by email. Most were dentists, and three-quarters had external funding for their research. The primary outcome measure was the number of self-reported published articles in PubMed in the preceding twenty-four months. The mean number of these publications was 4.9 (SD=5.1). Gender and time in research were the best predictors of research productivity of this population. There was no difference in time for research between the men and women in this study. Controlling for gender, the best single predictor of research productivity remained percent time spent in research. Overall, the members of the IADR group spent almost three times as much time in research and were more than twice as productive as faculty members as a whole as described in earlier studies. In view of the current emphasis in many countries on addressing the social and behavioral determinants of oral health disparities, the productivity of this area of dental research is very important. Trends toward clinically oriented, non-research-intensive dental schools in the United States and reductions in time and funding available to conduct research should be of concern.