Are oral health-related self-efficacy, knowledge and fatalism indicators for non-toothbrush ownership in a homeless population?

AIM: To determine if the social cognitive theory (SCT)-constructs of oral health-related efficacy, knowledge and fatalism were indicators of non-toothbrush ownership in a metropolitan-based homeless population in Australia. METHODS: Self-report data were collected from a convenience sample of 248 homeless participants located in Adelaide, Australia. Log binomial regression was used to estimate the strength of the association of the SCT constructs efficacy, knowledge and fatalism with the frequency of non-ownership of a toothbrush before and after adjusting for selected characteristics and associated factors. RESULTS: Of the study population (aged 17-78 years, 79% male) just over one-fifth (21%) did not own a toothbrush. In an unadjusted model, low self-efficacy (PR = 1.18) and low knowledge (1.27) were indicators for non-toothbrush ownership. These relationships were attenuated by 5.2% and 3.2% respectively after adjusting for social determinants, health factors, substance use and dental service utilisation-related factors, but remained statistically significant in the final model. CONCLUSIONS: Poor oral health-related self-efficacy and knowledge were both indicators for non-ownership of a toothbrush among a homeless population. This relationship held even after adjustment for relevant social and behavioural factors. Fatalism was not an indicator for non-toothbrush ownership in this population.

Health-related quality of life and income-related social mobility in young adults.

BACKGROUND: To assess the association of income-related social mobility between the age of 13 and 30 years on health-related quality of life among young adults. METHODS: In 1988-89 n = 7,673 South Australian school children aged 13 years were sampled with n = 4,604 children (60.0%) and n = 4,476 parents (58.3%) returning questionnaires. In 2005-06 n = 632 baseline study participants responded (43.0% of those traced and living in Adelaide). RESULTS: Multivariate regressions adjusting for sex, tooth brushing and smoking status at age 30 showed that compared to upwardly mobile persons social disadvantage was associated (p < 0.05) with more oral health impact (Coeff = 5.5), lower EQ-VAS health state (Coeff = -5.8), and worse satisfaction with life scores (Coeff = -3.5) at age 30 years, while downward mobility was also associated with lower satisfaction with life scores (Coeff = -1.3). CONCLUSIONS: Stable income-related socioeconomic disadvantage was associated with more oral health impact, and lower health state and life satisfaction, while being downwardly mobile was associated with lower life satisfaction at age 30 years. Persons who were upwardly mobile were similar in health outcomes to stable advantaged persons.

Child maltreatment, dating perpetration of physical assault, and cortisol reactivity among disadvantaged female adolescents.

OBJECTIVE: Few studies have examined hypothalamic-pituitary-adrenal axis stress reactivity and its relationship to histories of child maltreatment and physical aggression. We examined the relation of a history of childhood sexual abuse (CSA) and perpetration of dating violence to patterns of cortisol change before (resting) and after (reactivity) exposure to a laboratory stressor. METHODS: In a sample of 40 disadvantaged sexually active female adolescent patients (ages 14-17 years), we collected self-reports of lifetime child maltreatment (5 types) and past-year female perpetration of physical assault (PA) acts toward a romantic partner. We assessed changes in salivary cortisol trajectories during resting and reactivity phases following the viewing of a teen dating violence vignette. RESULTS: Reports of CSA (CSA+ group) were associated with reports of perpetration of severe dating PA (PA+ group), but the relation of these reports to laboratory-assessed patterns of cortisol changes following the stressor was opposite. As compared with subjects without victimization or perpetration histories (referent group), the CSA+ group showed the most pronounced positive slope (reactivity), whereas the PA+ group showed the least positive slope following the laboratory stressor after the overlap between these groups was statistically adjusted. While showing less reactivity to the laboratory stressor, the PA+ group had higher levels of resting cortisol, which stayed high during reactivity as compared to the referent group. CONCLUSION: The laboratory paradigm to elicit neuroendocrine stress-related cortisol reactivity appears to be a promising tool for identifying altered cortisol physiology among female adolescents with mixed histories of CSA and perpetration of dating PA.

A social and academic enrichment program promotes medical school matriculation and graduation for disadvantaged students.

INTRODUCTION: This study assessed the impact of a pre-medical pipeline program on successful completion of medical school and the capacity of this program to address achievement gaps experienced by disadvantaged students. The University of North Carolina (USA) Medical Education Development (MED) program provides intensive academic and test skills preparation for admission to medical, dental, and other allied health professions schools. METHODS: This retrospective study evaluated the academic progress of a longitudinal sample of 1738 disadvantaged college students who completed MED between 1974 and 2001. Data sources included MED participant data, medical school admissions data for the host school, aggregate data from the Association of American Medical Colleges (AAMC), and individual MED participant data from AAMC. Methods of analysis utilized Chi-square, independent samples t test, and logistic regression to examine associations between factors. RESULTS: Of the 935 students in MED from 1974 to 2001, who had indicated an interest in medical school, 887 (94.9%) successfully matriculated and 801 (85.7%) successfully earned the MD degree. Using logistic regression, factors that were significantly correlated with earning the medical degree included the student's race, college undergraduate total and science grade point averages, with Hispanic, African American, and Native American participants earning the medical degree at rates comparable to Caucasian participants. MED students successfully earned the MD degree despite having significantly lower Medical College Admissions Test (MCAT) scores and undergraduate grade point averages compared to all United States medical school applicants: MCAT scores had little relationship with student's success. CONCLUSIONS: These findings suggest that an intensive, nine-week, pre-medical academic enrichment program that incorporates confidence-building and small-group tutoring and peer support activities can build a foundation on which disadvantaged students can successfully earn matriculation to and graduation from medical school.

Dentists' experience with low-income patients benefiting from a public insurance program.

France has a system of public coverage that guarantees low-income earners full payment of basic dental health costs. In spite of this coverage and major needs for care, deprived populations have lower access to dental care. The aim of this qualitative study was to explore dentists' experience with low-income patients benefiting from the French universal healthcare coverage system. This study is based on 17 one-on-one semistructured interviews carried out with French private dentists. Dentists distinguished two categories of low-income patients: 'good patients', described as being regular attenders; and 'bad patients', whose main characteristic is irregular attendance. Dentists explained that they have difficulties in dealing with patients who do not keep their appointments. First, dentists feel that they fail in conducting their mission of being a care provider (therapeutic failure). The absence of the patient is also seen as a lack of recognition (relationship failure). Furthermore, dentists do not earn money when patients miss their appointments (financial failure). In this context, many dentists feel discouraged and powerless (personal failure). Moreover, dentists do not understand why patients renounce the dental-care opportunities offered under the system of public coverage (failure of the system). Dentists who repeatedly experience failures related to irregular attendance tend to adopt exclusion strategies.

Equitable access to dental care for an at-risk group: a review of services for Australian refugees.

OBJECTIVE: Despite the poor dental health of refugees, few specific services are available. This review maps public dental services for refugees across Australian jurisdictions, identifies gaps in provision, identifies barriers to accessing dental care, and provides recommendations for improving access and oral health promotion for this group. METHODS: Data were sought from the State and Territory services for: a) the survivors of torture; b) oral health care units; and c) auditors-general reports of dental services. Eligibility criteria and estimated waiting times for general dental services, criteria for access to emergency care and availability of interpreter services were reviewed. RESULTS: Marked variation exists across Australian jurisdictions in available dental services and criteria for access to public dental care for refugees. There is limited priority access to general dental services for refugees. Waiting times for public dental treatment in most, if not all, jurisdictions are unacceptably long (range 13-58 months). Few interpreter services exist for refugees seeking to access dental services. CONCLUSIONS: Access to dental services for refugees across Australia remains fragmented and limited, particularly in rural and regional areas. Refugees are not using services because of several barriers, including long waiting times, variation in assessment criteria, different eligibility criteria and limited interpreter services. Consequently, their pattern of service use does not accurately reflect their needs. IMPLICATIONS: Australia needs better co-ordinated, more extensive dental services that are easily accessible for this very high risk group. Identification of refugees as a special needs group and provision of targeted interventions addressing barriers to care are needed to establish adequate dental care.

The management of abuse: 4. Abuse of vulnerable adults.

Vulnerable adults include those who, for reasons of age or illness, are unable to protect themselves from significant harm. The role of the GDP and the dental team in the recognition and management of abuse of vulnerable adults is discussed. Information on the current legislation and protocols for referral are provided.

The dental care pathway of welfare recipients in Quebec.

IN Quebec (Canada), the utilization of dental care services varies greatly from one social class to another: whereas the well-to-do visit the dentist often for check-ups, those most in need demonstrate a "wait-and-see" attitude. The objective of our research was to describe the dental care pathway of the underprivileged when confronted with symptoms, and to understand how this pathway might be interrupted and possibly lead to tooth extractions. We arranged 16 one-on-one interviews with adult Montrealers who had experienced a dental problem during the 12 months preceding the interview. These participants, 9 women and 7 men aged between 30 and 48, lived in great poverty: all were welfare recipients, and as such, enjoyed the benefits of a government programme that entitled them to free basic dental care. During the interviews, the interviewers asked the participants to describe their latest dental problem and their subsequent behaviour. The dental care pathway of our participants was characterized by a strategy of adapting to the symptoms. This process of adapting, which can last several months, is essentially an individual process in which the individuals often resort to self-medication to soothe their pain. They decide to visit a dentist when the pain is too great and self-medication is no longer effective. Once this decision is made, their dental care pathway may nevertheless be interrupted in two ways: first, in the failure to find a dentist, and second, later, in the failure to complete treatments that are not covered by the welfare program, such as endodontic treatment. The fragmented character of these dental care pathways refers us to two features of accessibility: financial accessibility and acceptability. With regard to financial accessibility, our study shows that the public coverage intended for welfare recipients presents major gaps. As for acceptability, our participants are strongly critical of the dental profession, and develop a culture of rejection of it.

Community-based dental education and dentists' attitudes and behavior concerning patients from underserved populations.

The objectives of this study were to explore how dentists with well-structured vs. not well-structured community-based dental education (CBDE) experiences differ in perceptions of their CBDE and its impact on their professional lives and in their professional attitudes and behavior related to treating patients from underserved populations. The relationships between CBDE evaluations and impact on the dentists' professional lives and professional attitudes and behavior were explored as well. Data were collected from 254 dentists who participated in CBDE before graduating from the University of Michigan School of Dentistry between 1970 and 2011. The results showed that the alumni with well-structured experiences rated the quality of their CBDE more positively and its impact on their professional lives as stronger than those with less well-structured experiences. They also had more positive attitudes concerning treating underserved patients and were more likely to treat underserved patients than their peers with less well-structured experiences. These dentists' perceptions of the quality of CBDE and impact on their professional lives correlated significantly with their attitudes and behavior concerning treating underserved patients. Their perceptions of the quality of their CBDE experiences and perceptions of benefits from these experiences were significantly related to their professional attitudes and behavior related to providing care for patients from underserved populations.

Adult cognitive ability and socioeconomic status as mediators of the effects of childhood disadvantage on salivary cortisol in aging adults.

In this longitudinal study we investigate the influence of childhood disadvantage on midlife hypothalamic-pituitary-adrenal (HPA) axis regulation. Two mechanisms by which early life stress may affect later pathophysiology are through its influence on cognitive functioning or later socioeconomic (SES) disadvantage. We predicted that individual differences in young adult cognitive ability and midlife SES would mediate the influence of childhood disadvantage on midlife cortisol. On each of three nonconsecutive days, participants provided five salivary cortisol samples corresponding to their diurnal rhythm (N=727 men; mean age 55, SD=2.6). We calculated three measures of cortisol regulation (area-under-the curve cortisol reflecting total daytime cortisol output; cortisol-awakening-response; and wake-to-bed slope), averaging scores for each measure across multiple days. Childhood disadvantage combined four dichotomous indicators used previously by Rutter (1985): father low SES; mother education less than 12th grade; major family disruption/separation before age 18; and large family size (more than 5 siblings). The two mediators were a measure of general cognitive ability assessed at age 20 and highest achieved midlife SES. Men from more disadvantaged childhoods were significantly more likely to have dysregulated cortisol at midlife, with higher daytime cortisol levels decades after their childhood experience. Effects of childhood disadvantage were both direct and indirect. Cognitive ability and adult SES, however, only partially mediated the associations between early life stress and midlife cortisol. Specific indirect effects accounted for 33.8% of the total effect of childhood disadvantage [ß=0.12 (0.05; 0.18)] on total daytime cortisol. Associations remained significant after accounting for ethnicity, smoking status, and self-reported depressive symptoms.

Life-course socioeconomic trajectories and diurnal cortisol regulation in adulthood.

Although the health risk of socioeconomic disadvantage over the life-course is fairly established, the mechanisms are less studied. One candidate pathway is long-term dysregulation of cortisol. This study assesses whether socioeconomic trajectories from adolescence to adulthood influences the regulation of cortisol in mid-adulthood, and further investigates the importance of adolescence as a critical period and of accumulation of socioeconomic disadvantage. Participants were drawn from a 27-year prospective cohort study (n=732, 68% of the original cohort). Information on socioeconomic status (SES) was collected at the ages of 16 (based on parental occupation), 21, 30 and 43 (based on own occupation) years, and at 43 years participants collected one-day salivary cortisol samples at awakening, after 15min, before lunch and at bedtime. We found that the cortisol awakening response (CAR) differed with respect to SES trajectory; those with stable low or early low/upwardly mobile SES tended to display higher CAR than those with early high/downwardly mobile, highly mobile or stable high trajectories. Further analyses revealed that early low SES was related to higher CAR, and in women low SES was related to lower bedtime cortisol, independently of later SES and potential confounders. We found no support for a linear effect of accumulation of socioeconomic disadvantage. In conclusion, our study gives support for an independent effect of low socioeconomic status early in life, on the regulation of cortisol in adulthood.

Self-esteem: a hidden concern in oral health.

Little is known about the impact of oral health on self-esteem. The purpose of this descriptive study was to identify the frequency of low self-esteem in vulnerable persons who received oral health care at an academic nursing center. Participants (N = 86) completed the Index of Self-Esteem (Hudson, 1982b), answered open-ended questions concerning oral health care practices, and participated in an oral health examination. We found that 53% demonstrated low self-esteem, 67% (n = 58) had minor dental problems, and 33% (n = 28) had major dental problems. Oral health problems were ranked in importance along with cancer, diabetes, high blood pressure, and asthma. Oral hygiene included no tooth brushing, infrequent tooth brushing, flossing, chewing gum, and using mouth wash. This study emphasizes the roles of the community health nurse in assessing oral health (particularly among a vulnerable population), advocating for policy change, and providing education.