Addressing Oral Health Disparities Via Educational Foci on Cultural Competence.

An ever-present challenge for the oral health profession is to reduce the extent of oral disease among racial and ethnic minority populations. Adding to this complex dilemma is the linkage between oral health and systemic health. We describe enhanced cultural competency, in the context of individual cultural beliefs, values, language, practice, and health behaviors, among dental professionals, as one approach to meeting the dental care needs of the underserved. An overview and examples of teaching methods used by University of Florida dental educators to enhance student cultural competency is provided. Evidence-based evaluation results provide evidence of methodology efficacy. We conclude by describing actions that can be implemented by academic dental institutions to facilitate development of culturally competent practitioners.

Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change.

OBJECTIVES: After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time. METHODS: We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms. RESULTS: Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men. CONCLUSIONS: We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.

Sexual behaviors and other risk factors for oral human papillomavirus infections in young women.

BACKGROUND: Oral human papillomavirus (HPV) is associated with a rising incidence of certain head and neck cancers, and oral sex has been associated with oral HPV. This study sought to identify more specific patterns of oral sexual activity, including self-inoculation, that are associated with oral HPV infections in young women. METHODS: A total of 1010 women attending a large university completed a computer-based questionnaire and provided oral specimens that were tested for any oral HPV using a Linear Array assay that detects any HPV as well as 37 HPV genotypes. Twenty-seven women provided additional samples up to 12 months after enrollment. Bivariable and multivariable analyses were conducted to identify oral sexual patterns and other risk factors associated with prevalent oral HPV. RESULTS: Nineteen women had prevalent oral HPV (1.9%), with 10 women (1%) having a type-specific infection. Oral HPV was significantly associated with lifetime coital sex partnership numbers (P = 0.03), lifetime and yearly oral sex partnership numbers (P < 0.01), and hand and/or sex toy transfer from genitals to mouth (P < 0.001). Oral HPV was also associated with greater use of alcohol, cigarettes, marijuana, and sharing of smoking devices, lipstick, or toothbrushes (P < 0.05 for each), with an apparent dose-response for alcohol use and smoking behavior, stratified by number of sexual partners. Of 7 women with prevalent HPV who provided follow-up samples, none had evidence of a persistent type-specific infection. CONCLUSIONS: These data provide additional evidence of transmission of oral HPV from oral sexual activity and also suggest possible transmission from self-inoculation or sharing of oral products.

Health literacy: a pathway to better oral health.

OBJECTIVES: We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient-dentist communication and dental care patterns. METHODS: We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009-2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799). RESULTS: Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient-dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01). CONCLUSIONS: Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient-dentist communication on oral health status. Improved patient-dentist communication is needed as an initial step in improving the population's oral health.

Increasing screening intentions for oral and pharyngeal cancer.

BACKGROUND: Oral and pharyngeal cancer is a serious health threat that goes unnoticed by most people. Increasing screenings for oral and pharyngeal cancer is essential to achieving early detection when the disease is most treatable. PURPOSE: We tested the effectiveness of a media campaign designed to increase intentions to seek an oral and pharyngeal cancer screening. We further examined whether concern and knowledge of oral and pharyngeal cancer mediated screening intentions. METHODS: Participants in the intervention condition received messages on posters, handheld fans, pamphlets, and magnets displayed on the sides of cars or trucks. Participants in the intervention and comparison conditions (N = 1,790) were surveyed prior to and after the intervention. RESULTS: Intervention participants reported greater intentions to seek free oral and pharyngeal cancer screenings. Concern about oral and pharyngeal cancer partially mediated the effect whereas knowledge did not. CONCLUSIONS: Our media campaign successfully increased screening intentions by heightening concerns.

The burden of chronic diseases in a rural North Florida sample.

BACKGROUND: The degree of health disparities present in rural communities is of growing concern and is considered "urgent" since rural residents lag behind their urban counterparts in health status. Understanding the prevalence and type of chronic diseases in rural communities is often difficult since Americans living in rural areas are reportedly less likely to have access to quality health care, although there are some exceptions. Data suggest that rural residents are more likely to engage in higher levels of behavioral and health risk-taking than urban residents, and newer evidence suggests that there are differences in health risk behavior within rural subgroups. The objective of this report is to characterize the prevalence of four major and costly chronic diseases (diabetes, cardiovascular disease, cancer, and arthritis) and putative risk factors including depressive symptoms within an understudied rural region of the United States. These four chronic conditions remain among the most common and preventable of health problems across the United States. METHODS: Using survey data (N = 2526), logistic regression models were used to assess the association of the outcome and risk factors adjusting for age, gender, and race. RESULTS: Key findings are (1) Lower financial security was associated with higher prevalence of cardiovascular disease, arthritis, and diabetes, but not cancer. (2) Higher levels of depressive symptoms were associated with higher prevalence of cardiovascular disease, arthritis, and diabetes. (3) Former or current smoking was associated with higher prevalence of cardiovascular disease and cancer. (4) Blacks reported higher prevalence of diabetes than Whites; Black women were more likely to report diabetes than all other groups; prevalence of diabetes was greater among women with lower education than among women with higher education. (5) Overall, the prevalence of diabetes and arthritis was higher than that reported by Florida and national data. CONCLUSIONS: The findings presented in this paper are derived from one of only a few studies examining patterns of chronic disease among residents of both a rural and lower income geographic region. Overall, the prevalence of these conditions compared to the state and nation as a whole is elevated and calls for increased attention and tailored public health interventions.

Psychosocial factors associated with mouth and throat cancer examinations in rural Florida.

OBJECTIVES: We examined the knowledge and prevalence of mouth and throat cancer examinations in a sample drawn from rural populations in north Florida. METHODS: Telephone interviews were conducted across rural census tracts throughout north Florida in 2009 and 2010, in a survey that had been adapted for cultural appropriateness using cognitive interviews. The sample consisted of 2526 respondents (1132 men and 1394 women; 1797 Whites and 729 African Americans). RESULTS: Awareness of mouth and throat cancer examination (46%) and lifetime receipt (46%) were higher than reported in statewide studies performed over the past 15 years. Only 19% of the respondents were aware of their examination, whereas an additional 27% reported having the examination when a description was provided, suggesting a lack of communication between many caregivers and rural patients. Surprisingly, anticipated racial/ethnic differences were diminished when adjustments were made for health literacy and several measures of socioeconomic status. CONCLUSIONS: These findings support the notion that health disparities are multifactorial and include characteristics such as low health literacy, lack of access to care, and poor communication between patient and provider.

5-HTTLPR genotype and associations with intoxication and intention to drive: results from a field study of bar patrons.

The serotonin transporter promoter polymorphism (5-HTTLPR) has been linked to a number of human behavioral traits and disorders. The variants of 5-HTTLPR are commonly reported in three forms, L/L, S/L and S/S, with the latter most often associated with emotional distress and/or behavioral dysfunction. Missing from the research literature are investigations that assess event-level associations between 5-HTTLPR genotype and specific incidents of risk behavior in natural drinking settings. This study reports associations between 5-HTTLPR, alcohol intoxication and intention to drive among young adult patrons exiting on-premise drinking establishments (i.e. bars) at night. Self-report measures, breath alcohol concentration (BrAC) readings and saliva samples for DNA analysis were collected from 477 bar patrons. Analyses were performed on 225 patrons likely to be near their peak intoxication level for the night. Results from a linear regression revealed that the 5-HTTLPR genotype was associated with exiting patron BrAC, after adjusting for random and fixed effects of other variables. An interaction effect involving 5-HTTLPR and bar-sponsored drink specials also had an independent association with BrAC, suggesting that selection of price-discounted alcoholic beverages increased intoxication in patrons with an L allele. In addition, results from logistic regression indicated that patrons with the S/S genotype were three times more likely to intend to drive a motor vehicle (after drinking on the night of study participation) compared with those with the L/L genotype. The 5-HTTLPR genotype may play an important role in the etiology of problems associated with on-premise drinking establishments.

Alcohol price and intoxication in college bars.

BACKGROUND: Many population studies find that alcohol prices are inversely related to alcohol consumption and alcohol-related problems, including among college students and young adults. Yet, little is known about the "micro-level" effects of alcohol price on the behavior of individual consumers in natural drinking settings such as college bars. Therefore, we assessed patron's cost per gram of ethanol consumed at on-premise drinking establishments and its association with intoxication upon leaving an establishment. METHODS: On 4 consecutive nights during April 2008, data were collected from 804 patrons exiting 7 on-premise establishments in a bar district located adjacent to a large university campus in the southeastern United States. Anonymous interview and survey data were collected as well as breath alcohol concentration (BrAC) readings. We calculated each patron's expenditures per unit of ethanol consumed based on self-reported information regarding the type, size, number, and cost of consumed drinks. RESULTS: A multivariable model revealed that a 10-cent increase in cost per gram of ethanol at on-premise establishments was associated with a 30% reduction in the risk of exiting an establishment intoxicated (i.e., BrAC > or = 0.08 g/210 l). CONCLUSIONS: The results are consistent with economic theory and population-level research regarding the price elasticity of alcoholic beverages, which show that increases in alcohol prices are accompanied by less alcohol consumption. These findings suggest that stricter regulation of the drink discounting practices of on-premise drinking establishments would be an effective strategy for reducing the intoxication levels of exiting patrons.

Associations between physical activity and reduced rates of hopelessness, depression, and suicidal behavior among college students.

OBJECTIVE: The authors explored associations among types of physical activity and hopelessness, depression, and suicidal behavior among college students. PARTICIPANTS: Participants included 43,499 college students aged 18 to 25 who completed the 2005 National College Health Assessment conducted by the American College Health Association. METHODS: The authors used logistic regression modeling to compare the odds of experiencing hopelessness, depression, and suicidal behavior in students who engaged in various levels of aerobic and strength or toning activity with students who did not perform these activities. RESULTS: Men and women who engaged in some physical activity each week demonstrated a reduced risk of hopelessness, depression, and suicidal behavior compared with their inactive counterparts. CONCLUSIONS: This study provides empirical evidence that establishes the association between physical activity, especially aerobic activity, and reduced risk of hopelessness, depression, and suicidal behavior among college students.

An exploratory study of bar and nightclub expectancies.

OBJECTIVE: The authors identified the principal components of bar and nightclub expectancy in college students and the associations between these factors and the risk behavior of night-clubbing. PARTICIPANTS: A total of 4,384 undergraduates enrolled at a large, public university participated. METHODS: In the first phase (July-September 2007), the authors collected preliminary data from a convenience sample. In the second phase (March 2008), the authors collected data from a separate probability sample. RESULTS: A principal components analysis revealed 4 reliable and distinct expectancy factors. Regression analyses revealed that after adjusting for the effects of alcohol and demographic variables, expectancies explained a significant proportion of variance in bar/nightclub attendance. Different expectancy profiles distinguished high-frequency nightclubbers from the most common bar attendance practice and nonmonogamous nightclubbers from monogamous nightclubbers. CONCLUSIONS: From a developmental perspective, nightclubbing appears to assist young adults with establishing and maintaining social networks, romantic and sexual relationships, and collegiate acculturation.

Spiritual well-being and suicidal ideation among college students.

OBJECTIVE: This study explored whether specific dimensions of spiritual well-being (religious well-being and existential well-being) relate to reduced suicidal ideation, and whether associations persisted after controlling for religiosity and psychosocial variables associated with suicide. PARTICIPANTS: Participants were 457 college students who completed measures that assessed spiritual well-being, religiosity, hopelessness, depression, social support, and suicidal ideation. METHODS: The authors used linear regression modeling to assess religious and spiritual correlates of suicidal ideation. RESULTS: After controlling for demographic variables and psychosocial factors, neither involvement in organized religion nor religious well-being significantly contributed to suicidal ideation. However, even after controlling for significant correlates, existential well-being remained a significant predictor of suicidal ideation. CONCLUSIONS: This investigation highlighted existential well-being as an important factor associated with lower levels of suicidal ideation among college students. Findings from this study focusing on the association between spiritual well-being and suicidality may prove especially beneficial to suicide prevention efforts.

Event-specific analyses of poly-drug abuse and concomitant risk behavior in a college bar district in Florida.

OBJECTIVE: The authors describe the epidemiology of risk behavior associated with poly-drug use in a college bar district of a large campus community. PARTICIPANTS: A total of 469 bar patrons participated in the study. METHODS: The authors used self-report data and biological measures collected from patrons outside bars in July and August of 2007. RESULTS: The mean breath alcohol concentration of the exiting patrons was 0.09. Illicit and prescription drug use on the nights of data collection and in the recent past were significant features of the profile of patron risk behavior. About one-quarter of the patrons using only alcohol reported an intention to drive a vehicle within 60 minutes of leaving an establishment, compared with almost one-half of those using both alcohol and marijuana. CONCLUSIONS: A substantial amount of high-risk behavior was generated from the bar district on 4 typical nights. College bar districts should be a priority focus for prevention efforts.

Reimbursement as a legitimizing strategy for health education.

The health education profession has made significant advances throughout the past few decades. However, health education is still described as an emerging profession. This article suggests strategies to move health education from its status as an emerging profession into that of an acknowledged profession. The authors assert that actively seeking direct third-party reimbursement will advance health education's emergence as a profession as well as increase its legitimacy in the eyes of other professions. The benefits of direct third-party reimbursement, experiences of the nursing profession's pursuit of direct third-party reimbursement, and the current status of health education are discussed. The article concludes by offering strategies for pursuing direct third-party reimbursement.

Impact of the promotora model on the improvement of oral health knowledge of caregivers.

OBJECTIVE: The objective of this quasi-experimental study was to determine the impact of the Promotora Model (PM) as an educational strategy to increase oral health knowledge in parents/caregivers of children aged 2-5 years at high risk for dental caries. MATERIALS AND METHODS: Sixty-three caregivers who provided informed consent were included in the study. A structured 37-item survey was administered prior to conducting the Promotora educational intervention (PEI) that covered oral health topics and behaviors. Three (3) months after the PEI session, during their child's next dental visit, the same instrument was administered to 46 of the parents/caregivers that had completed the first instrument. RESULTS: Most caregivers were Hispanic (73.9%) and 50% reported completing high school. Before PEI, 56.5% of participants scored as having "good" general knowledge. Three months after PEI, 82.6% achieved that score (paired sample T-test, p< 0.00001). CONCLUSION: Based on the results, it was concluded that the PM significantly increased caregivers' oral health knowledge.

Classification Tree Analysis of Factors Associated with Oral Cancer Exam.

Objective: In this study, we performed a classification tree analysis (CTA) to identify population subgroups that are less likely to have an oral cancer examination (OCE). Methods: We conducted telephone surveys (N = 2401) of adults residing in north Florida to collect data on OCE status and potential OCE predictors including demographics, medical and dental experience, and psychosocial factors. The CTA algorithm exhaustive chi-square automatic interaction detector (E- CHAID) was employed to determine the relationships between OCE status and the predictors. Results: The overall OCE rate was 46.8% in our sample. Participants' rating of the dentist was the first level splitting variable, leading to 15 unique participant subgroups: (1) high dentist rating (N = 1269) led to 5 splits and 11 subgroups; (2) low dentist rating (N = 308) led to zero splits; and (3) no regular dentist (N = 824) led to 2 splits and 3 subgroups. Conclusions: The CTA has identified unique population subgroups that could be targeted in future tailored public health interventions. Among underserved populations, it is important to develop and implement community-based interventions that encourage regular dental visits and provide oral cancer self- examination education..

Oral cancer in African Americans: addressing health disparities.

OBJECTIVES: To explore factors underlying African Americans' perceptions of oral cancer and the oral cancer exam. Study findings were used to guide development of oral cancer messages designed to increase oral cancer exams among African Americans. METHODS: Focus groups were conducted to understand African Americans' attitudes and expectations regarding oral cancer and oral cancer exams. RESULTS: Respondents lacked knowledge of personal susceptibility to and the severity of a late-stage oral cancer diagnosis. Participants had limited knowledge of risk factors. DISCUSSION: Findings point to the need for improved patient education and communication between the public and dental providers.

Dental Visits Mediate the Impact of Smoking on Oral Health.

OBJECTIVES: We explored the mediational relationships among smoking, dental visits, and oral health in a longitudinal study. METHODS: We selected a sample of adult residents of rural communities of North Central Florida and followed them for 3 years (final N = 1170). We examined the impact of smoking on oral health across time and conducted mediation analysis to quantify the effect of dental visits on the relationship between smoking and poor oral health. RESULTS: Our results showed that oral health declined across time for smokers but not for nonsmokers. The mediation analysis found that 18.3% of the difference in followup oral health between smokers and non-smokers was explained by smokers not having any dental visits in the last year. CONCLUSIONS: Our findings suggest that, given the low success rate of quitting smoking, promoting dental visits can help limit the negative effects of smoking on oral health. Future community prevention studies could encourage dental visits among smokers and provide educational materials that aim to increase knowledge of oral self-care.