Inyang A. Isong

An examination of racial/ethnic disparities in children's oral health in the United States

OBJECTIVE To assess the extent factors other than race/ethnicity explain apparent racial/ethnic disparities in childrens oral health and oral health care. METHODS Data were from the 2007 National Survey of Childrens Health, for children 2-17 years (n=82,020). Outcomes included parental reports of childs oral health status, receiving preventive dental care, and delayed dental care/unmet need. Model-based survey-data-analysis examined racial/ethnic disparities, controlling for child, family, and community/state (contextual) factors. RESULTS Unadjusted results show large racial/ethnic oral health disparities. Compared with non-Hispanic White people, Hispanic and non-Hispanic-Black people were markedly more likely to be reported in only fair/poor oral health [odds ratios (ORs) (95% confidence intervals) 4.3 (4.0-4.6), 2.2 (2.0-2.4), respectively], lack preventive care [ORs 1.9 (1.8-2.0), 1.4 (1.3-1.5)], and experience delayed care/unmet need [ORs 1.5 (1.3-1.7), 1.4 (1.3-1.5)]. Adjusting for child, family, and community/state factors reduced racial/ethnic disparities. Adjusted ORs (AORs) for Hispanics and non-Hispanic Blacks attenuated for fair/poor oral health, to 1.6 (1.5-1.8) and 1.2 (1.1-1.4), respectively. Adjustment eliminated disparities for lacking preventive care [AORs 1.0 (0.9-1.1), 1.1 (1.1-1.2)] and in Hispanics for delayed care/unmet need (AOR 1.0). Among non-Hispanic Blacks, adjustment reversed the disparity for delayed care/unmet need [AOR 0.6 (0.6-0.7)]. CONCLUSIONS Racial/ethnic disparities in childrens oral health status and access were attributable largely to socioeconomic and health insurance factors. Efforts to decrease disparities may be more efficacious if targeted at social, economic, and other factors associated with minority racial/ethnic status and may have positive effects on all who share similar social, economic, and cultural characteristics.

Addressing Dental Fear in Children With Autism Spectrum Disorders: A Randomized Controlled Pilot Study Using Electronic Screen Media

Background. Dental care is a significant unmet health care need for children with autism spectrum disorders (ASD). Many children with ASD do not receive dental care because of fear associated with dental procedures; oftentimes they require general anesthesia for regular dental procedures, placing them at risk of associated complications. Many children with ASD have a strong preference for visual stimuli, particularly electronic screen media. The use of visual teaching materials is a fundamental principle in designing educational programs for children with ASD. Purpose. To determine if an innovative strategy using 2 types of electronic screen media was feasible and beneficial in reducing fear and uncooperative behaviors in children with ASD undergoing dental visits. Methods. We conducted a randomized controlled trial at Boston Children’s Hospital dental clinic. Eighty (80) children aged 7 to 17 years with a known diagnosis of ASD and history of dental fear were enrolled in the study. Each child completed 2 preventive dental visits that were scheduled 6 months apart (visit 1 and visit 2). After visit 1, subjects were randomly assigned to 1 of 4 groups: (1) group A, control (usual care); (2) group B, treatment (video peer modeling that involved watching a DVD recording of a typically developing child undergoing a dental visit); (3) group C, treatment (video goggles that involved watching a favorite movie during the dental visit using sunglass-style video eyewear); and (4) group D, treatment (video peer modeling plus video goggles). Subjects who refused or were unable to wear the goggles watched the movie using a handheld portable DVD player. During both visits, the subject’s level of anxiety and behavior were measured using the Venham Anxiety and Behavior Scales. Analyses of variance and Fisher’s exact tests compared baseline characteristics across groups. Using intention to treat approach, repeated measures analyses were employed to test whether the outcomes differed significantly: (1) between visits 1 and 2 within each group and (2) between each intervention group and the control group over time (an interaction). Results. Between visits 1 and 2, mean anxiety and behavior scores decreased significantly by 0.8 points (P = .03) for subjects within groups C and D. Significant changes were not observed within groups A and B. Mean anxiety and behavior scores did not differ significantly between groups over time, although group A versus C pairwise comparisons showed a trend toward significance (P = .06). Conclusion. These findings suggest that certain electronic screen media technologies may be useful tools for reducing fear and uncooperative behaviors among children with ASD undergoing dental visits. Further studies are needed to assess the efficacy of these strategies using larger sample sizes. Findings from future studies could be relevant for nondental providers who care for children with ASD in other medical settings.

Parental Perspectives of Early Childhood Caries

Background. Parental perspectives of children with early childhood caries may help inform the development and improvement of caries prevention strategies. Objectives. This study aimed to explore parents’ experiences, perceptions, and expectations regarding prevention and management of early childhood caries. Methods. The authors conducted semistructured interviews with 25 parents of children aged 2 to 5 years, with a known history of caries. All interviews were transcribed and coded, and iterative analyses were conducted to identify key emergent themes within the data. Results. Parents had limited knowledge of behaviors contributing to early childhood caries and when to first seek regular dental care. Parents expected pediatricians to provide education on how to prevent childhood caries, conduct preliminary oral health assessments, and help establish early linkages between medical and dental care. Conclusion. The findings make a strong case for pediatricians to take responsibility for engaging and educating parents on fostering optimal oral health and helping to access early childhood dental care.

Racial Disparity Trends in Children’s Dental Visits: US National Health Interview Survey, 1964–2010

BACKGROUND AND OBJECTIVE: Research that has repeatedly documented marked racial/ethnic disparities in US children’s receipt of dental care at single time points or brief periods has lacked a historical policy perspective, which provides insight into how these disparities have evolved over time. Our objective was to examine the im-pact of national health policies on African American and white children’s receipt of dental care from 1964 to 2010. METHODS: We analyzed data on race and dental care utilization for children aged 2 to 17 years from the 1964, 1976, 1989, 1999, and 2010 National Health Interview Survey. Dependent variables were as follows: child’s receipt of a dental visit in the previous 12 months and child’s history of never having had a dental visit. Primary independent variable was race (African American/white). We calculated sample prevalences, and χ2 tests compared African American/white prevalences by year. We age-standardized estimates to the 2000 US Census. RESULTS: The percentage of African American and white children in the United States without a dental visit in the previous 12 months declined significantly from 52.4% in 1964 to 21.7% in 2010, whereas the percentage of children who had never had a dental visit declined significantly (P < .01) from 33.6% to 10.6%. Pronounced African American/white disparities in children’s dental utilization rates, whereas large and statistically significant in 1964, attenuated and became nonsignificant by 2010. CONCLUSIONS: We demonstrate a dramatic narrowing of African American/white disparities in 2 measures of children’s receipt of dental services from 1964 to 2010. Yet, much more needs to be done before persistent racial disparities in children’s oral health status are eliminated.

Provision of Fluoride Varnish to Medicaid-Enrolled Children by Physicians: The Massachusetts Experience

OBJECTIVES To evaluate the impact of a 2008 Medicaid policy in Massachusetts (MA), regarding reimbursing physicians for providing fluoride varnish (FV) to eligible children in medical settings. DATA SOURCE Survey of a sample of primary care physicians in MA. STUDY DESIGN Cross-sectional survey of a sample of physicians who provide care to MassHealth (MA Medicaid) enrolled-children. DEPENDENT VARIABLES history of completed preventive dental skills training, and FV provision. INDEPENDENT VARIABLES oral health knowledge, FV-attitudes, and physician and practice characteristics. PRINCIPAL FINDINGS Overall, 19 percent of respondents had completed the training required to be eligible to bill for FV provision. Only 5 percent of physicians were providing FV. Most respondents (63 percent) were not familiar with the new policy, and only 25 percent felt that FV should be provided during well-child visits. Most physicians (60 percent) did not feel that the reimbursement rate of U.S.

Racial and Ethnic Disparities in Early Childhood Obesity

26/application was sufficient; 17 percent said that they would not provide FV, regardless of payment. Most common barriers to FV provision were a lack of time and logistical challenges. CONCLUSIONS Our findings suggest that simply reimbursing physicians for FV provision is insufficient to ensure provider participation. Success of this policy will likely require addressing several barriers identified.

Oral Health Disparities and Unmet Dental Needs among Preschool Children in Chelsea, MA: Exploring Mechanisms, Defining Solutions

We decomposed racial and/or ethnic disparities in preschool-aged children’s BMI z scores according to contributing socioeconomic and behavioral risk factors to highlight modifiable risk factors that could be prioritized in interventions. OBJECTIVES: The prevalence of childhood obesity is significantly higher among racial and/or ethnic minority children in the United States. It is unclear to what extent well-established obesity risk factors in infancy and preschool explain these disparities. Our objective was to decompose racial and/or ethnic disparities in children’s weight status according to contributing socioeconomic and behavioral risk factors. METHODS: We used nationally representative data from ∼10 700 children in the Early Childhood Longitudinal Study Birth Cohort who were followed from age 9 months through kindergarten entry. We assessed the contribution of socioeconomic factors and maternal, infancy, and early childhood obesity risk factors to racial and/or ethnic disparities in children’s BMI z scores by using Blinder-Oaxaca decomposition analyses. RESULTS: The prevalence of risk factors varied significantly by race and/or ethnicity. African American children had the highest prevalence of risk factors, whereas Asian children had the lowest prevalence. The major contributor to the BMI z score gap was the rate of infant weight gain during the first 9 months of life, which was a strong predictor of BMI z score at kindergarten entry. The rate of infant weight gain accounted for between 14.9% and 70.5% of explained disparities between white children and their racial and/or ethnic minority peers. Gaps in socioeconomic status were another important contributor that explained disparities, especially those between white and Hispanic children. Early childhood risk factors, such as fruit and vegetable consumption and television viewing, played less important roles in explaining racial and/or ethnic differences in children’s BMI z scores. CONCLUSIONS: Differences in rapid infant weight gain contribute substantially to racial and/or ethnic disparities in obesity during early childhood. Interventions implemented early in life to target this risk factor could help curb widening racial and/or ethnic disparities in early childhood obesity.

Childcare Attendance and Obesity Risk

Background Significant disparities exist in children’s receipt of preventive dental care (PDC) in the United States. Many of the children at greatest risk of dental disease do not receive timely PDC; when they do receive dental care, it is often more for relief of dental pain. Chelsea is a low-income, diverse Massachusetts community with high rates of untreated childhood caries. There are various dental resources available in Chelsea, yet many children do not access dental care at levels equivalent to their needs. Objective Using Chelsea as a case-study, to explore factors contributing to forgone PDC (including the age 1 dental visit) in an in-depth way. Methods We used a qualitative study design that included semi-structured interviews with parents of preschool children residing in Chelsea, and Chelsea-based providers including pediatricians, dentists, a dental hygienist and early childhood care providers. We examined: a) parents’ dental attitudes and oral health cultural beliefs; b) parents’ and providers’ perspectives on facilitators and barriers to PDC, reasons for unmet needs, and proposed solutions to address the problem. We recorded, transcribed and independently coded all interviews. Using rigorous, iterative qualitative data analyses procedures, we identified emergent themes. Results Factors perceived to facilitate receipt of PDC included Head-Start oral health policies, strong pediatric primary care/dental linkages, community outreach and advertising, and parents’ own oral health experiences. Most parents and providers perceived there to be an adequate number of accessible dental services and resources in Chelsea, including for Medicaid enrollees. However, several barriers impeded children from receiving timely PDC, the most frequently cited being insurance related problems for children and adults. Other barriers included limited dental services for children <2 years, perceived poor quality of some dental practices, lack of emphasis on prevention-based dental care, poor care-coordination, and insufficient culturally-appropriate care. Important family-level barriers included parental oral health literacy, cultural factors, limited English proficiency and competing priorities. Several solutions were proposed to address identified barriers. Conclusion Even in a community with a considerable number of dental resources, various factors may preclude access to these services by preschool-aged children. Opportunities exist to address modifiable factors through strategic oral health policies, community outreach and improved care coordination between physicians, dentists and early childhood care providers.

Assessing Preschoolers’ Beverage Consumption Using the Theory of Planned Behavior:

BACKGROUND AND OBJECTIVES: Several observational studies have revealed that children who receive nonparental childcare are at increased risk of obesity. However, this may be due to unmeasured confounding or selection into different types of childcare. It is not well established whether this association reflects a causal effect of childcare attendance on obesity risk. We examined the effect of attending childcare on children’s BMI z scores, using nationally representative data of ∼10 700 children followed from age 9 months through kindergarten entry. METHODS: We first employed ordinary least squares regression to evaluate longitudinal associations between childcare attendance at 24 months and BMI z scores at kindergarten entry, controlling for child, family, and neighborhood characteristics. Because type of childcare is associated with unobserved confounding factors, we repeated the analysis by using 2 quasi-experimental approaches: (1) individual fixed effect models, which control for all observed and unobserved time-invariant confounders; and (2) instrumental variable (IV) analysis. RESULTS: At 24 months, 48.7% of children were in nonparental childcare, and 35.1% of children were overweight/obese at kindergarten entry. In ordinary least squares models, compared with children in parental care, children in nonparental childcare at 24 months had higher BMI z scores at kindergarten entry (0.08 [SE 0.03], P = .01). By contrast, fixed effects and IV models revealed no significant effect of childcare on BMI z score (fixed effects model: β = 0.02 [SE 0.02], P = .62); IV model: β = 1.12 [SE 0.76], P = .14). CONCLUSIONS: We found no consistent associations between nonparental childcare and obesity. Previously reported significant associations may be confounded by unobserved family circumstances resulting in selection into different types of childcare.

Association Between Parents' and Children's Use of Oral Health Services

Childhood obesity and caries are linked to sugar-sweetened beverage (SSB) and excessive juice consumption. We assessed psychosocial factors influencing children’s beverage consumption and strategies to promote healthier choices. Using a quantitative and qualitative approach guided by the theory of planned behavior, we surveyed and interviewed 37 parents of preschool-aged children on barriers and facilitators of children’s beverage consumption. Most children (83.8%) consumed SSBs, 67.6% drank >4 to 6 oz of juice per day. Parent’s self-efficacy was the strongest correlate of parent’s behavioral intention to limit SSB (0.72, standard error 0.08, P = .03). Parents’ motivations to limit their child’s SSB intake extended beyond simply preventing caries and obesity; they also considered the implications of these conditions on children’s self-image, future health, and quality of life. Yet, the influence of multidimensional barriers made it difficult to reduce children’s SSB consumption. Interventions that address parental attitudes, values, and self-efficacy to address external factors could help reduce children’s SSB consumption.