Perceived social status, socioeconomic status, and preventive dental utilization among a low-income Medicaid adult population.

OBJECTIVES: Perceived Social Status (PSS) is a measure of cumulative socioeconomic circumstances that takes perceived self-control into account. It is hypothesized to better capture social class compared to socioeconomic status (SES) measures (i.e., education, occupation, and income). This study examined the association between PSS and dental utilization, comparing the strength of associations between dental utilization and PSS and SES measures among a low-income adult Medicaid population. METHODS: A cross-sectional survey was administered to a random sample of low-income adults in Iowa, United States with Medicaid dental insurance (N = 18,000) in the spring of 2018. Respondents were asked about PSS, dental utilization, and demographics. A set of multivariable logistic regression models examined the relative effects of PSS and SES measures on dental utilization, controlling for age, sex, health literacy, whether the respondent was aware they had dental insurance, transportation, and perceived need of dental care. RESULTS: The adjusted response rate was 25%, with a final sample size of 2252. Mean PSS (range 1-10) was 5.3 (SD 1.9). PSS was significantly associated with dental utilization (OR = 1.11; CI = 1.05, 1.18) when adjusting for control variables, whereas other SES measures-education, employment, and income-were not. CONCLUSIONS: PSS demonstrated a small positive association with dental utilization. Results support the relative importance of PSS, in addition to SES measures, as PSS may capture aspects of social class that SES measures do not. Results suggest the need for future research to consider the effects of PSS on oral health outcomes and behaviors.

Motivations and experiences among dentists in rural private practice: A qualitative study.

OBJECTIVES: Despite the critical importance of access to dental care for rural residents and concerns about a shrinking rural dentist workforce, few studies have examined rural dentist motivations to practice in rural areas. The aim of this study was to explore practicing rural dentists' motivations and experiences qualitatively through semi-structured interviews to help inform and guide recruitment and retention efforts in rural areas. METHODS: Dentists were included in the sample frame if they were general dentists in private practice and had a primary practice located in a rural Iowa county. Rural dentists with publicly available email addresses were contacted by email to participate. Semi-structured interviews were administered to 16 private practice general dentists. All interviews were audio recorded, transcribed, and coded using pre-set and emergent codes. RESULTS: Participants were most commonly male (75%), under age 35 (44%), white (88%), and practiced in a partnership arrangement (44%). The main codes regarding dentists' experiences and motivations to practice in a rural area included familiarity with a rural area, community, financial factors, and clinical care delivery. Having been raised in a rural area was a major influence in most dentists' decisions about where to locate. CONCLUSIONS: The importance of rural upbringing in this study underscores the need to consider rural upbringing in dental student admissions. Additional findings, such as financial benefits of a rural practice and other practice-related factors can be used to inform recruitment efforts.

Access to dental insurance and oral health inequities in the United States.

While the oral health status of the United States (U.S.) population has improved over the years, racial/ethnic inequities are pervasive with Black Americans carrying a greater burden of oral diseases in most measured outcomes. Access to dental care is a major structural and societal determinant of oral health inequities rooted in structural racism. From post-Civil War-era to present day, this essay presents a series of examples of racist policies that have shaped access to dental insurance for Black Americans both directly and indirectly. Additionally, this essay explains the unique challenges of Medicare and Medicaid highlighting the specific disparities that these public insurance programs face, and proposes policy recommendations aimed to reduce racial/ethnic inequities in dental coverage and access to advance the nation's oral health with comprehensive dental benefits in public insurance programs.

Dentist attitudes toward an annual benefit maximum in Iowa's adult Medicaid program.

OBJECTIVES: The Dental Wellness Plan (DWP) provides dental coverage for adult Medicaid enrollees in Iowa. In September 2018, a $1000 annual benefit maximum (ABM) was implemented in the DWP program. The aim of this study was to explore private dentists' attitudes toward ABMs and factors associated with ABM attitudes. METHODS: The data source was a mailed survey administered in spring 2019 to all private practice dentists in Iowa. The two dependent variables were (1) attitude toward the $1000 ABM and (2) attitude toward any ABM generally. Independent variables included demographic and practice-related factors, and participation in and attitudes toward the DWP. Descriptive, bivariate, and multivariable analyses were conducted. RESULTS: While over half (56%) of providers reported a positive attitude toward "Any ABM," less than half (40%) reported a positive attitude toward the "$1000 ABM." Attitudes toward both "$1000 ABM" and "Any ABM" were significantly and positively associated with attitudes toward DWP overall and toward DWP structure. Independent variables that were significantly associated with both the "$1000 ABM" and "Any ABM" included overall attitude toward the DWP, attitude toward DWP structure, and practice busyness. CONCLUSIONS: Utilizing an ABM, particularly one set at $1000 for a Medicaid program, elicits mixed attitudes among dentists. Future research should evaluate the impact of Medicaid ABMs on long term dentist participation and patient's ability to receive needed care.

Randomized experiment on the effect of incentives and mailing strategy on response rates in a mail survey of dentists.

OBJECTIVES: Response rates for mail surveys of dentists and other health care providers have declined appreciably over the past several decades. The objective of this study was to update evidence about the impact use of incentives and different mail strategies on response rates in a mail survey of dentists. METHODS: We randomized private practice dentists in Iowa (N = 1267) into six study groups to test the effects of incentives and mail strategy on response rate. Survey incentives included either a $2 bill or a customized pen/stylus; a control group with no incentive was included. Mail strategies included bulk mail or first-class stamps. RESULTS: The overall survey response rate was 43%. A $2 bill incentive was associated with significantly higher likelihood of returning a survey compared to the control group with no incentive (48% response rate vs. 40%, respectively). A non-monetary incentive was not significantly associated with likelihood of response. Use of first-class stamps compared to bulk mail did not significantly affect response rate. CONCLUSIONS: This study demonstrated the effectiveness of a $2 incentive to increase response rate in a mail survey of dentists. Given the background trend of declining survey participation rates, researchers should consider use of monetary incentives and explore new strategies to increase participation among dentists and other health care providers.

Patient centered dental home: Building a framework for dental quality measurement and improvement.

INTRODUCTION: This article presents results of the second phase of a project to develop a patient-centered dental home (PCDH) model. Aims of PCDH model development include broadening the scope of prior dental home definitions to include populations across the lifespan, developing a quality measurement framework to facilitate quality assessment and improvement, and promoting opportunities for medical-dental integration through alignment with existing PCMH models. This phase determined the components, or conceptual subdivisions, associated with a previously developed PCDH definition and characteristics. METHODS: We used a modified Delphi process to obtain structured feedback and gain consensus among the project national advisory committee (NAC). The process included a web-based survey that asked NAC members to rank the importance of each potential component on a scale of 1-9. Criteria for consensus on component inclusion/exclusion combined a median rating and measure of disagreement. Respondents were also encouraged to provide open-ended feedback regarding rationale for component ratings and additional suggested components. RESULTS: A total of 47 out of 51 members completed the survey. All 34 components met the quantitative criteria for inclusion in the PCDH model. Changes were made to components based on open-ended feedback. CONCLUSIONS: This project phase further developed a PCDH measurement framework that aims to guide practice transformation, quality measurement and improvement in dental care delivery, as well as integration between medicine and dentistry. Using a Delphi approach with a broad group of stakeholders ensured that components had face validity and were conceptually aligned with the PCDH definition and characteristics.

Predictors of Multiple Jobholding among Dental Hygienists in the State of Iowa.

Purpose: Little is known about the prevalence of multiple jobholding practices among dental hygienists or the factors contributing to these employment patterns. The purpose of this exploratory study was to examine predictors of multiple jobholding practices among dental hygienists in the state of Iowa.Methods: A mailed paper survey was sent to all licensed dental hygienists (n=2080) in Iowa in May 2018. The dependent variable was whether hygienists worked more than one job in dental hygiene. Key independent variables included individual, family, and practice-related factors. Descriptive, bivariate, and binary logistic regression analyses were completed.Results: A total of 1215 dental hygienists participated in the survey, for a response rate of 58%. Among respondents, 12.2% worked more than one job overall, with 10.7% working 2 jobs and 1.5% working three or more. Respondents who had at least a bachelor's degree, did not have children in the household, were not married, had worked more years at their primary job, and worked more hours per week, were more likely to hold multiple jobs after adjusting for other factors.Conclusions: Consistent with national estimates, there was a high multiple jobholding rate among dental hygienists in Iowa. Multiple individual, family, and practice characteristics were found to be related to multiple jobholding, with the strongest predictors being the hygienist's highest level of education and the number of hours worked at the primary job.

Predictors of having a dentist among older adults in Iowa.

OBJECTIVES: Oral health plays an important role in the general well-being of older adults, yet older adults experience unique barriers to dental care. In the United States, almost two-thirds of older adults are dentally uninsured - a reflection of the exclusion of dental benefits from Medicare. The aim of this study was to investigate potential predictors of having a dentist among older adults receiving services funded through the Iowa Department on Aging (IDA). METHODS: This was a cross-sectional analysis on a convenience sample (n = 2692) of adults age 65+ who completed a required survey to determine eligibility to receive services from the IDA. Data from questionnaires completed between March and December 2017 were used to generate multivariable logistic regression models that identified predictors of having a dentist. The dependent variable, having a dentist, was gathered by self-report in the survey. Explanatory variables eligible for inclusion in the models included demographic and geographic factors, indicators of access to dental care, and factors related to activities of daily living. RESULTS: Fewer than half (46.2%) of the respondents reported having a dentist. In the final regression model, individuals with dental insurance were more than twice as likely to have a dentist than those without insurance. Conversely, individuals with a tooth/mouth problem and who need help with housekeeping and with transportation were significantly less likely to have a dentist than their counterparts. CONCLUSIONS: These results align with known insurance-related barriers and identify certain activities of daily living that might influence older adults' ability to access care. The finding that individuals with oral health problems were less likely to have a dentist underscores the need to reduce barriers to care for this population.

Who provides open-ended comments? Assessing item nonresponse bias in Medicaid surveys of members and dentists.

OBJECTIVES: This aim of this study was to examine factors associated with survey item nonresponse to open-ended items in mailed surveys. METHODS: Data sources include two surveys conducted in Iowa in 2016 - one to a random sample of Medicaid dental program members and one to private practice dentists. Item nonresponse bias for open-ended comments was examined by comparing differences between commenters and noncommenters. Bivariate and logistic regression analyses examined differences based on demographic characteristics, attitudes, and experiences with the program, and survey mode. RESULTS: Among members, respondents who were Black, older, unemployed, had a recent dental visit, rated the plan poorly, and completed the survey on paper were significantly more likely to provide comment. Among dentists, those who participated in the plan and those who completed the survey online were significantly more likely to provide comment. CONCLUSIONS: Members and dentists with direct experiences with the Medicaid dental program were more likely to provide open-ended survey comments, whereas we found inconsistent results between members and dentists with regard to the impact of demographic characteristics, survey mode, and attitude toward the plan.

Member and dentist narratives about a dental programme for the Medicaid expansion population: A content analysis.

OBJECTIVES: In the United States, the 2010 Affordable Care Act's Medicaid expansion improved financial access to dental care for new Medicaid enrollees in states with Medicaid dental benefits for adults. Using an existing theoretical framework, we explored dentist and Medicaid member narratives concerning a state's redesigned dental programme for the Medicaid expansion population. METHODS: Data sources include two surveys conducted in 2016-one to a random sample of Medicaid members and one to private practice dentists in Iowa. A qualitative content analysis approach was used to quantify and describe themes present in open-ended comment data. RESULTS: The most common themes among Medicaid member narratives were related to oral health needs and status, availability of dentists who accept Medicaid, and Medicaid coverage for dental care. Among dentists, the programme's administrative burden was the most common theme, with coverage and reimbursement commonly cited as well. An emergent theme among both member and dentist comments was patient confusion or lack of knowledge about programme enrolment and coverage. CONCLUSIONS: Member awareness about enrolment and coverage in public dental benefit plans should be further explored to determine the impact on access to care. Effectively communicating the intent, programme design and expectations of a Medicaid programme to both providers and Medicaid members is important to the success of the programme.

A tale of two public dental benefit programs: Iowa dentist participation in traditional Medicaid versus a Medicaid expansion program.

BACKGROUND: In Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs. METHODS: Authors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP. RESULTS: Overall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas. CONCLUSIONS: Dentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.

Evaluation of enrollee satisfaction with Iowa's Dental Wellness Plan for the Medicaid expansion population.

BACKGROUND: Dental coverage for Iowa's Medicaid expansion population is provided through the Dental Wellness Plan (DWP), implemented in May 2014. The plan targets healthy behavior incentives via an earned benefits structure, whereby additional services are covered if enrollees return every 6-12 months for routine dental visits. This study examines enrollee satisfaction with the DWP. METHODS: We surveyed a random sample of DWP enrollees 1 year after program implementation about their experiences. Survey items covered dental plan satisfaction, self-rated measures of health, and knowledge and attitudes toward the earned benefits approach. RESULTS: Dental plan satisfaction was rated as low by 38 percent of respondents (n = 416), moderate by 25 percent (n = 276), and high by 37 percent (n = 402). A majority of respondents (66 percent) did not know about the earned benefits structure. Regression analysis indicated that respondents most likely to have low plan satisfaction were those who felt it was difficult to earn benefits (OR 3.66, P < 0.001) and those who were unable to find (OR 3.17, P < 0.001), or did not try to find (OR 3.51, P < 0.001), a regular dentist in the plan. CONCLUSIONS: Satisfaction with a new model of dental insurance was influenced by whether enrollees had a regular source of care and their perceived ability to return for regular checkups in order to earn covered benefits.

Public Dental Safety Net in Iowa: Capacity and Readiness for Health Care Reform.

OBJECTIVE: Examine the current capacity of Iowa's public dental safety net and organizational readiness for implementation of the Affordable Care Act (ACA). METHODS: We surveyed Iowa Community Health Center (CHC) dental clinics for factors related to clinic capacity and organizational readiness for ACA-related change. RESULTS: With 14 clinics (93%) responding, clinics had means of 13,064 patient visits and 23% broken appointments in 2012. Seventy percent of clinics reported high confidence in their ability to respond to changes associated with health care reform. However, over 60% agreed that current circumstances limited their ability to respond to these challenges. CONCLUSIONS: CHC dental clinics in Iowa understand ACA-related changes regarding their patient population, but are limited in their ability make needed changes in response to increased demand. This may affect the clinics' transition into an environment with increased demand for dental services as a result of Medicaid expansion in Iowa.

Neighborhood and family social capital and parent-reported oral health of children in Iowa.

OBJECTIVES: A growing body of evidence supports the impact of social factors on oral health disparities in children in the United States. The goal of this study was to examine the relationship between two types of social capital-family and neighborhood-and the parent-reported oral health of Iowa's children. METHODS: We analyzed results from a 2010 cross-sectional statewide health survey. The outcome was parent-reported child oral health status, and the five primary independent variables were neighborhood social capital and four separate indicators of family social capital. Data were analyzed using a mixed-effects linear regression with a random effect for zip code. RESULTS: Significant positive associations were found between child oral health status and neighborhood social capital (P = 0.005) and one indicator of family social capital, family frequency of eating meals together (P = 0.02), after adjusting for covariates. CONCLUSIONS: This study adds to the growing body of literature around the social determinants of oral health. Our findings indicate that the oral health of children may be influenced by broad social factors such as neighborhood and family social capital.

"Baby? Baby Not?": Exploring Women's Narratives About Ambivalence Towards an Unintended Pregnancy.

Unintended pregnancy among adult women is a significant public health challenge in the United States. Research has identified ambivalence as a risk factor for not using contraceptives. The qualitative study presented here examined women's narratives about ambivalence toward unintended pregnancy. In-depth interviews were conducted in 2012 with 28 women aged 20-45 years old who were recruited primarily via flyers in family planning clinics in a rural, Midwestern state. The interviews were coded for salient themes. Almost 40 percent of the women said that they had experienced an unintended pregnancy. All but two women expressed ambivalence, stating that they had both good and bad feelings about getting pregnant unintentionally. Women expressed if a pregnancy did occur, they would just have to step up and "deal with it." They recognized a baby was something special but not without negative aspects. Those who were less ambivalent (and more negative) had compelling reasons why, but even those women expressed some positive feelings. At times, ambivalence was expressed by negative reactions about having a child that coincided with believing that becoming a parent or having another child would have a positive impact on themselves. This study provides an examination of women's narratives about ambivalence toward pregnancy. Overall, women's narratives constructed ambivalence as arising from both positive and negative emotions, as well as beliefs about costs and benefits, associated with unintended pregnancy. Given its association with a lack of contraceptive use, understanding the components of ambivalence (e.g., feelings, beliefs) is important to bolstering interventions aimed toward decreasing ambivalence and increasing contraceptive use.

The relationship between altruistic attitudes and dentists' Medicaid participation.

BACKGROUND: The authors investigated the role of private practitioners in the dental safety net, including the provision of care for Medicaid enrollees and attitudinal factors that affect participation. METHODS: In 2013, the authors sent a mixed-mode survey to all general dentists in Iowa assessing their current Medicaid participation and factors affecting participation, including attitudinal statements about altruism, the Medicaid program, and the government's role in providing access to dental care. RESULTS: Fifty-six percent of responding dentists accepted new Medicaid-enrolled patients; dentists living in nonmetropolitan areas were significantly more likely to accept Medicaid than were those in metropolitan areas. Results from a logistic regression model demonstrated that participating dentists scored significantly higher in altruistic attitudes and perceived problems with Medicaid as less important. CONCLUSIONS: Dentists who accepted Medicaid-enrolled patients had significantly more positive attitudes about Medicaid administration and altruistic attitudes in general. Investigators in future studies should examine how these attitudes are shaped by educational and professional experiences. PRACTICAL IMPLICATIONS: Dentists' perceptions about Medicaid potentially are modifiable by changing program policies in ways to improve access for vulnerable populations, including new Medicaid enrollees.