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Factors Associated With Access to Dental Care for Children With Special Health Care Needs
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Factors associated with access to dental care for children with special health care needs Debra Kane, PhD, RN; Nicholas Mosca, DDS; Marianne Zotti, DrPH, MS, FAAN; Renee Schwalberg, MPH
n 2003, more than one-quarter of U.S. children had not had a preventive dental visit in the previous year.1 The factors associated with failure to obtain dental care are widely documented and include lack of insurance coverage, poverty, race or ethnicity, the child’s age and rural residence.2-6 The challenges to obtaining access to dental care may be exacerbated for children with special health care needs (CSHCN). These children currently have or are at an increased risk of developing a chronic physical, developmental, behavioral or emotional condition and require health and related services of a type or amount beyond that generally required by children.7 Moreover, CSHCN are more likely to have an unmet need for dental care than are children without special needs.7,8 Although many of the barriers to dental care may not seem amenable to intervention, numerous researchers have reported that access to one type of care may contribute to health-seeking behavior and access to other types of care. Thus, obtaining care of some kind may mediate the barriers to care
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ABSTRACT Background. The authors examined the relationship between receipt of routine medical care and receipt of dental care among children with special health care needs (CSHCN) who resided in the American Dental Association’s Fifth Trustee District, which includes Alabama, Georgia and Mississippi. Methods. The authors conducted a cross-sectional study using data from the 2001 National Survey of Children with Special Health Care Needs, a module of that year’s State and Local Area Integrated Telephone Survey (sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention, Atlanta). The authors used bivariate and logistic regression analyses to explore the relationships (n = 2,092) between predisposing, enabling and need factors and receipt of dental care. Results. The parents of an estimated 76 percent of CSHCN in the district reported that their child had a need for dental care in the previous 12 months. Of these, 13.1 percent did not receive care. Failure to obtain needed dental care was associated with failure to obtain routine medical care, as was having a lower income. Conclusions. Failure to obtain routine medical care may be a risk factor for failure to obtain dental care. Any income below 400 percent of the federal poverty guidelines appears to be a barrier to receiving dental care for CSHCN. Practice Implications. Providers of routine medical care may play an important role in linking CSHCN to dental care. Investigators need to examine other barriers to dental care for CSHCN. Strategies to optimize access to dental care for CSHCN at all income levels are needed. Key Words. Access to dental care; children with special health care needs; health services research; barriers to dental care; dental care. JADA 2008;139(3):326-333.
At the time this study was conducted, Dr. Kane was a postdoctoral fellow at the Mississippi State Department of Health. Her fellowship was sponsored by the Centers for Disease Control and Prevention, Atlanta. She now is a maternal and child health epidemiologist, Centers for Disease Control and Prevention, Atlanta, and an assignee to the Iowa Department of Public Health, Bureau of Family Health, 321 E. 12th St., 5th Floor, Des Moines, Iowa 50319-0075, e-mail “[email protected]”. Address reprint requests to Dr. Kane. Dr. Mosca is the dental director, Mississippi State Department of Health, Office of Oral Health, Jackson. At the time this study was conducted, Dr. Zotti was a Centers for Disease Control and Prevention assignee to the Mississippi State Department of Health. She now is the team leader, Services Management, Research and Translation Team, Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta. Ms. Schwalberg is the director, Maternal and Child Health Information Resource Center, Rockville, Md.
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described earlier. For example, Lee and colleagues9 reported that children who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were more likely to have received dental services than were those not enrolled in the WIC program. In addition, Yu and colleagues2 reported that children’s access to routine medical care had a positive effect on their access to dental care. In conducting this study, our primary interest was in the factors associated with dental care access in our local jurisdiction, the state of Mississippi. However, we included the entire American Dental Association’s Fifth Trustee District to increase the power of the analysis and because the adjoining states had similar demographic profiles. The ADA has 17 trustee districts that provide both a geographical and a politicaladministrative context in which to analyze data, make policy recommendations and advocate for action within the ADA House of Delegates. Furthermore, by examining the relationship between access to routine medical care and access to dental care, we hoped to highlight the importance of interprofessional and interdisciplinary collaboration to increasing access to dental care among CSHCN. Aday and Andersen’s10 Behavioral Model of Health Services Use provides a useful framework through which to examine factors that may influence access to dental care (Figure). Researchers have used this robust model to examine the factors related to health care access among vulnerable populations11-15 and, more importantly, to examine access to care for children16 and CSHCN.17 Specifically, Yu and colleagues16 reported that lack of a dental care visit among adolescents was associated with male sex, black or mixed race/ethnicity and lack of health insurance. Mayer and colleagues17 reported that CSHCN have higher levels of unmet needs with regard to routine medical care, particularly among children living in poverty. In the Behavioral Model of Health Services Use, three types of factors (predisposing, enabling and need) are asserted to influence access to care. We used the same typology to categorize the variables thought to influence access to dental care for CSHCN. METHODS
Sample and design. The 2001 National Survey of Children with Special Health Care Needs, conducted from April 2001 to October 2002, a module
of the State and Local Area Integrated Telephone Survey (SLAITS) series, was a cross-sectional study designed to collect data about children’s access to dental care, insurance coverage and its adequacy, household income relative to the federal poverty guidelines (FPG) and the financial effect of having a CSHCN, as well as to collect demographic information.18 The study was sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention (CDC), Atlanta. This was the first survey, to our knowledge, to specifically assess the health care needs of CSHCN. Professional telephone interviewers, working on behalf of the CDC, interviewed approximately 750 families of CSHCN in each state and the District of Columbia as part of this random-digit-dial survey. The interviewers used a screening process to determine if a child had a special health care need. A child had a special health care need if he or she had a physical, developmental, behavioral or emotional condition that required health care and related services of a type or extent beyond that generally required by children of the same age, and the condition was expected to last more than 12 months.18 We selected the ADA’s Fifth Trustee District (Alabama, Georgia and Mississippi [n = 2,092]) for our analysis to ensure an adequate sample size and because of our interest in promoting the application of research findings in a local geographical and political-administrative grouping for which organized policy actions might be implemented. The SLAITS survey was designed to produce state-level population estimates, using the weights provided.19 Weights were adjusted to account for noncoverage of households without telephones and were based on population controls from the 2000 U.S. Census according to age, sex, race/ethnicity, household composition and education of the mother. Because of the low proportions ABBREVIATION KEY. ADA: American Dental Association. CDC: Centers for Disease Control and Prevention. CSHCN: Children with special health care needs. FPG: Federal poverty guidelines. SAOHA: State Action for Oral Health Care Access Initiative. SLAITS: State and Local Area Integrated Telephone Survey. WIC: Women, Infants, and Children. JADA, Vol. 139
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Enabling Factors
Usual Source of Care
Predisposing Factors
Insurance Out-of-Pocket Costs Income Obtained Routine Medical Care
Age Sex Race Residence Mother’s Educational Level
Need Factors
Illness Severity (Rank) Illness Stability
Figure. Factors associated with access to dental care.
of “non-Hispanic other race” (weighted proportion = 2.3 percent) and Hispanics (weighted proportion = 2.4 percent) in the ADA’s Fifth Trustee District, we limited our analysis to non-Hispanic blacks and non-Hispanic whites. Description of variables. Predisposing factors. Predisposing factors (Figure), which exist before the onset of illness, generally are not amenable to intervention and may affect both access to services and their use.10,19 Demographic characteristics commonly are considered to be predisposing factors, and in this study we included the child’s age, sex, race, residence (metropolitan versus nonmetropolitan) and the mother’s educational level as such factors. To describe the characteristics of CSHCN in the ADA’s Fifth Trustee District, we based age categories on common programmatic classifications (birth to five years, elementary school and high school). We examined the mother’s educational level as a three-category variable (less than high school, high school, some college or a degree). Enabling factors. Enabling factors serve as a means to using health care services and may be amenable to intervention. For this reason, we included family income based on the FPG, having a usual source of care and medical insurance status as enabling factors. We also included having obtained needed routine medical care as an enabling factor. Specifically, all survey respondents were asked this question: “During the past 12 months, was there any time when your child needed routine preventive care, such as 328
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a physical examination or well-child check-up?” Those who answered “yes” then were asked, “Did Health Behavior your child receive all the routine preventive care that he or she needed?” We examined type of medical insurance coverage (public versus private) Obtained and current insurance Dental Care status (insured versus uninsured). In addition, we included out-of-pocket costs as an enabling factor. Because of the survey question’s structure, we examined costs in categories of $500 or less or more than $500. Need factors. In the Aday and Andersen10 model, need refers to the level of illness, which can be perceived by the child’s parent or determined by a health care professional. In this study, the parent or guardian who was most knowledgable about the child’s health and health care ranked the severity of the child’s medical or dental condition on an 11-point scale (0-10). We report the rankings in three categories (0-3, 4-6, 7-10) for descriptive and analytic purposes. Respondents reported the stability of their children’s illness according to one of three categories: “usually stable,” “changes once in awhile” or “changes all of the time.” The dependent variable in this analysis was whether the child obtained needed dental care. The survey asked all respondents this question: “During the past 12 months, was there any time when your child needed dental care, including check-ups?” Those who answered “yes” then were asked, “Did your child receive all the dental care that he or she needed?” We examined the independent factors associated with the child’s not having received needed dental care. Statistical analysis. We created the data set and recoded the variables using statistical software (SAS Version 8.2, SAS Institute, Cary, N.C.).20 We obtained all final results using SUDAAN Release 9.0 (Research Triangle Institute, Research Triangle Park, N.C.), a statistical software package developed to accommodate the data produced by complex survey designs.21,22 We used χ2 analysis to test for statistically significant
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differences between children who received needed dental care and those who did not receive such care, examining differences in predisposing, enabling and need factors. We examined several variables for interaction, including health insurance coverage and income, receipt of routine medical care and insurance coverage, poverty level and mother’s educational level, and receipt of routine medical care and poverty level. None of these interactions was statistically significant. We used logistic regression to examine the effects of predisposing, enabling and need factors on the child’s not having received needed dental care. We explored variables for modeling up to the .15 significance level; the final model included variables significant at the P = .05 level after we controlled for confounding variables, as well as for those variables historically associated with access to care (for example, age and race). We assessed variables for confounding through stratified analysis and judged a variable to be a confounder if the crude and adjusted odds ratios (ORs) differed by more than 10 percent. We used the Wald test to determine the significance of the model variable. We reported ORs, 95 percent confidence intervals (CIs) and P values for the multivariable analysis. RESULTS
Sample characteristics. Table 1 presents the distribution of sampled CSHCN in the ADA’s Fifth Trustee District according to the variables that compose our conceptual framework, as well as the proportion of respondents who reported a need for dental care during the previous year. The parents of an estimated 76 percent of CSHCN in the Fifth Trustee District reported that their child had a need for dental care in the previous year. The children primarily were school-aged non-Hispanic whites living in metropolitan areas. Almost four-fifths of the children’s mothers had obtained at least a high school education (79.1 percent). Family income was 200 percent FPG or below for nearly one-half of the children (45 percent). The majority of the children had a usual source of care (94.2 percent) (Table 1). Perhaps reflective of this result was that just 4 percent of the children had not received needed routine medical care in the previous year. Three-fourths of families spent more than $500 on out-of-pocket costs. More than one-half of the children experienced illnesses that usually were stable, while 8.6 percent
experienced illnesses that changed all of the time. Illness severity was centered on the middle range of 4 to 6 (39.4 percent of children). Bivariate analysis. Table 2 (page 331) presents the characteristics of the children who did not receive needed dental care (n = 169) and the bivariate results. Among predisposing factors, only the mother’s educational level was associated significantly with a failure to obtain needed dental care. Among enabling factors, income, health insurance coverage and not having received needed routine medical care were associated significantly with a failure to obtain needed dental care. Logistic regression analyses. Table 3 (page 332) shows the results from the logistic regression model examining CSHCN in the ADA’s Fifth Trustee District who did not obtain routine medical care, as well as relevant independent variables. Consistent with the bivariate results, income and an unmet need for routine medical care remained predictors of an unmet need for dental care. In contrast, the mother’s educational level and health insurance coverage were no longer predictive of an unmet need for dental care. DISCUSSION
In this study, we found that an unmet need for routine medical care was a strong predictor of an unmet need for dental care. This result supports the findings of other researchers who have found that access to one type of care may influence health-seeking behavior for another type of care.2,9 Even so, the mechanism or process through which either access to dental care or failure to obtain such care is related to obtaining routine medical care is not clear. Perhaps providers of routine medical care assisted families in obtaining needed dental care, or perhaps families who seek out routine medical care also are motivated to obtain dental care for their children. This question warrants further research in view of the American Academy of Pediatric Dentistry’s announced support of dental homes for CSHCN.23 The relationship between an unmet need for dental care and family income has been welldocumented. In our study, the relationship between an unmet need for dental care and family income held true for incomes up to 400 percent of the FPG. However, this result leaves unanswered questions. For example, if lowincome families obtain Medicaid coverage, including its dental care coverage, what other facJADA, Vol. 139
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that few dentists serve Medicaid-insured American Dental Association’s Fifth Trustee District children.24-26 population estimates. Medicaid-insured CHARACTERISTIC/VARIABLE UNWEIGHTED n WEIGHTED % children. In a study of (n = 2,092)* Medicaid-insured 1,622 76.0 Reported a Need for Dental Care children,6 caregivers reported a number of bar169 13.1 Did Not Receive Needed Dental Care riers to dental care access. Predisposing Factors These barriers included Age (years) difficulty finding providers 421 21.0 Birth to 5 who accepted Medicaid, 843 43.5 6-11 825 35.5 12-17 limited choices in appointment times and transSex 847 39.3 Female portation difficulties. Care1,245 60.7 Male givers who were successful Race in getting to the dental 596 34.5 Non-Hispanic black appointment encountered 1,296 65.5 Non-Hispanic white long waiting times and Residence judgmental treatment by 847 36.4 Nonmetropolitan 1,245 63.6 Metropolitan office staff because of the client’s race and public Mother’s educational level 269 20.9 Less than 12 years assistance status. There541 28.3 Completed high school fore, insurance coverage 1,218 50.8 Some college or a degree alone may not overcome Enabling Factors the barriers to dental care Income based on FPG† (%) access among low-income 380 18.6 < 100 families and those with 453 26.4 100 to ≤ 200 626 35.1 > 200 to < 400 CSHCN. 419 19.9 ≥ 400 In contrast, insurance 1,968 94.2 Had a usual source of care status no longer was predictive of an unmet need Health insurance coverage 570 30.7 Public for dental care when we 1,425 65.4 Private applied the multivariable 82 3.9 Uninsured analysis. Although it was 45 4.0 Did not receive needed routine care not possible to study the Out-of-pocket costs ($) relationship between 557 24.9 ≤ 500 insurance coverage for 1,500 75.1 > 500 dental care and an unmet Need Factors need for dental care in this Illness stability sample, it is worth noting 1,294 58.4 Usually stable that Medicaid typically 636 33.0 Changes once in awhile 153 8.6 Changes all of the time provides comprehensive dental care coverage for Illness severity (0-10 scale) 606 26.5 0-3 people younger than 21 824 39.4 4-6 years through the Early 652 34.1 7-10 and Periodic Screening, * Not all totals equal 2,092 because some respondents did not answer all questions. † FPG: Federal Poverty Guidelines. Diagnosis, and Treatment program.26 Medicaid covtors prevent these families from obtaining needed erage for dental care may have contributed to dental care for their children with special needs? the nonsignificant relationship between health Although most dentists report that they treat insurance coverage and an unmet need for children,24 a number of researchers have reported dental care. However, as noted above, insur-
TABLE 1
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TABLE 2 ance coverage alone does not guarantee access to Prevalence of unmet need for dental care, according needed dental care. to population characteristics (with bivariate results). Unlike other research2,3 and inconsistent with the CHARACTERISTIC/VARIABLE UNMET NEED FOR DENTAL CARE* bivariate analysis in our Weighted % P Value study, the child’s age was Predisposing Factors not significantly associated with an unmet need for Age (years) .63 10.8 Birth to 5 dental care in the logistic 12.9 6-11 regression analysis. In 14.2 12-17 studies based on national Sex samples, race tends to be .82 13.5 Female 12.9 Male associated with a failure to obtain dental care. In our Race .17 16.0 Non-Hispanic black final model, we did not 11.8 Non-Hispanic white find this to be the case. Residence Our results, however, are .59 12.1 Nonmetropolitan consistent with a recently 13.7 Metropolitan published state-level Mother’s educational level analysis of Mississippi < .05 25.1 Less than 12 years 27 13.2 Completed high school CSHCN. These results 10.1 Some college or a degree emphasize the importance Enabling Factors of state- and regional-level data collection and Income based on FPG† (%) < .01 19.4 analyses. However, we lim- < 100 18.8 100 to ≤ 200 ited our analysis to non15.6 > 200 to < 400 1.2 ≥ 400 Hispanic blacks and nonHispanic whites because of .59 13.2 Had a usual source of care the low proportion of HisHealth insurance coverage panics in the ADA’s Fifth < .01 18.1 Public 10.1 Private Trustee District. 33.7 Uninsured Policy and program < .01 51.3 Did not receive needed routine care development. The relationship between an unmet Out-of-pocket costs ($) .14 14.1 ≤ 500 need for dental care and 10.1 > 500 an unmet need for routine Need Factors medical care may be of particular relevance to Illness stability .22 10.9 Usually stable policy and program devel16.6 Changes once in awhile opment. Specifically, this 15.2 Changes all of the time finding underscores the Illness severity (0-10 scale) importance of policies and .11 8.8 0-3 13.5 4-6 programs that promote 16.1 7-10 interdisciplinary and inter* Unweighted sample size equals 169. professional collaboration † FPG: Federal Poverty Guidelines. and referral mechanisms among medical and dental care providers. The State Action for Oral Health increase interdisciplinary collaboration. For Care Access Initiative (SAOHA) has developed example, through the SAOHA, South Carolina numerous strategies to improve access to oral implemented programs that created direct links health care for Medicaid-insured children28; many between medical and dental care providers. South of them may be applicable to CSHCN and serve to Carolina also implemented a curriculum for medi-
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TABLE 3
willing to treat these patients.30 However, their Adjusted odds ratios for the association between willingness varied selected population characteristics and an unmet according to the type of need for dental care.* disability. For example, dentists were more willing CHARACTERISTIC/VARIABLE ODDS RATIO 95% CONFIDENCE P VALUE INTERVAL to treat a patient with epilepsy than a patient Predisposing Factors with mental retardation or Age (years) a bleeding disorder. In 0.74 0.3-2.1 .49 Birth to 5 1.0 1.0 6-11 other words, willingness to 1.3 0.6-2.7 12-17 treat may not translate Race into actual dental treat0.8 0.4-1.7 .61 Non-Hispanic black ment. What the New 1.0 1.0 Non-Hispanic white Mexico study also highMother’s educational level lights is that CSHCN are 2.1 0.8-5.3 .30 Less than 12 years 1.5 0.7-3.4 Completed high school not a homogeneous group. 1.0 1.0 Some college or a degree On the other hand, in a Enabling Factors 2004 study of dental students’ experience with and Income based on FPG† (%) 13.5 3.1- 59.2 < .01 < 100 attitudes toward people 10.8 3.1-37.9 100 to ≤ 200 with mental retardation, 13.6 4.1-44.8 > 200 to < 400 1.0 1.0 ≥ 400 50.8 percent of the students reported that they Health insurance coverage 1.2 0.5-2.8 .94 Public did not receive any clinical 1.0 1.0 Private training in how to care for 1.2 0.3-5.6 Uninsured patients with mental retar6.6 < .01 1.8-23.4 Did not receive needed routine dation.29 More than 60 percare cent of the students * Unweighted sample size equals 1,622; children who obtained needed dental care equaled 1,453 versus those reported that they had who did not obtain needed dental care equaled 169. † FPG: Federal Poverty Guidelines. little confidence in caring for patients with mental cal care providers to incorporate a discussion of retardation. Therefore, in addition to research, the importance of oral health in a child’s medical programs and policies to increase training and care visit. The importance of interdisciplinary coldental education for new and established dentists laboration also needs to be included in medical may be needed to address the dental care needs of and dental school curricula. CSHCN. Treating children with disabilities. A Study limitations. One limitation of this number of other factors may be of particular relstudy is that researchers collected the data via a evance to future research regarding CSHCN, as telephone survey. People without telephones may well as to policy and program development. These encounter more barriers to accessing care and, factors include the paucity of specific information therefore, be at an increased risk of failing to about the prevalence of dental care needs among receive needed dental care.31 However, we 29,30 CSHCN. Data from the 2001 National Survey adjusted the sample weights to account for nonof CSHCN focused on health and medical care coverage of households without telephones. In needs and access for CSHCN. Thus, we have limaddition, the need for dental care was based on ited information about the true dental care needs parental perceptions and may have been underof CSHCN and whether or how those needs are stated if parents were unaware of their children’s being met. Little is known about the willingness need for such care.8,17 Lack of knowledge about of dentists to provide services to CSHCN. children’s oral health care needs is not uncomIn a New Mexico study of dentists’ willingness mon: an analysis of the National Survey of Chilto treat patients with disabilities, the majority of dren’s Health, another module of the SLAITS dentists (90 percent) reported that they would be survey, found that the parents of 11.1 percent of 332
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children who did not receive preventive dental care in the previous year believed that their children did not need this care, despite the standard recommendation that all children have preventive dental visits twice a year.28 Moreover, the results may have been influenced by recall bias in that parents were asked to answer questions based on the previous 12 months. In addition, the relatively small sample size contributed to the wide CIs found in the regression analysis and, thus, reduced the power of the statistical models. Therefore, we need to interpret the results of this study with caution. These results cannot be generalized beyond the ADA’s Fifth Trustee District. Furthermore, we cannot attribute a cause-and-effect relationship between the independent variables and the outcomes because the data were cross-sectional. Even so, these results may guide program and policy development by the ADA’s Fifth Trustee District and others working on behalf of CSHCN. CONCLUSIONS
Access to dental care is an ongoing problem among CSHCN, especially those in low-income families. The relationship between access to routine medical care and dental care implies that a comprehensive approach to improving access to primary health care services and to dental care may be more effective than focusing on either service individually. ADA trustee districts may offer effective political-administrative frameworks through which to analyze data that inform decision making about policy that, in turn, improves access to dental care for CSHCN. ■ Disclosures: None of the authors reported any disclosures. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, Atlanta. The institutional review boards at the Centers for Disease Control and Prevention and the Mississippi State Department of Health approved this study. Dr. Mosca presented a version of the study analysis and a report at the National Oral Health Conference, Little Rock, Ark., May 2006. 1. U.S. Department of Health and Human Services. The oral health of children: A portrait of states and the nation 2005. Rockville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2005. “http://mchb.hrsa.gov/oralhealth/index.htm”. Accessed Feb. 3, 2008. 2. Yu SM, Bellamy HA, Kogan MD, Dunbar JL, Schwalberg RH, Schuster MA. Factors that influence receipt of recommended preventative pediatric health and dental care. Pediatrics 2002;110(6):e73-e80. 3. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2002;2(2 suppl):141-147. 4. Byck GR, Walton SM, Cooksey JA. Access to dental care services for Medicaid children: variations by urban/rural categories in Illinois. J Rural Health 2002;18(4):512-520.
5. Watson MR, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. JADA 2001;132(11): 1580-1587. 6. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think? Am J Public Health 2002;92(1):53-58. 7. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics 2000;105(4 Pt 1):760-766. 8. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health care needs of America’s children. Pediatrics 2000;105 (4 Pt 2):989-997. 9. Lee JY, Rozier RG, Norton EC, Kotch JB, Vann WF. Effects of WIC participation on children’s use of oral health services. Am J Public Health 2004;94(5):772-777. 10. Aday LA, Andersen RM. A framework for the study of access to medical care. Health Serv Res 1974;9(3):208-220. 11. Dobalian A, Andersen RM, Stein JA, Hays RD, Cunningham WE, Marcus M. The impact of HIV on oral health and subsequent use of dental services. J Public Health Dent 2003;63(2):78-85. 12. Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los Angeles. Med Care 2004;35(8):814-830. 13. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care uses and outcomes for homeless people. Health Serv Res 2000;34(6):1273-1302. 14. Goodwin R, Andersen RM. Use of the Behavioral Model of Health Care Use to identify correlates of use of treatment for panic attacks in the community. Soc Psychiatry Psychiatr Epidemiol 2002;37(5): 212-219. 15. Kilbourne AM, Andersen RM, Asch S, et al. Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus. Med Care Res Rev 2004;59(1):36-58. 16. Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with the use of preventive dental and health services among U.S. adolescents. J Adolesc Health 2001;29(6):395-405. 17. Mayer ML, Skinner AC, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Pediatrics 2004;113(2):e109-e115. 18. Blumberg SJ, Olson L, Frankel M, et al. Design and operation of the National Survey of Children with Special Health Care Needs, 2001. Vital Health Stat 1 2003;41:1-136. 19. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36(1):1-10. 20. SAS Institute. SAS/STAT user’s guide, version 8. Cary, N.C.: SAS Institute; 1999. 21. Research Triangle Institute. SUDAAN example manual, release 9.0. Research Triangle Park, N.C.: Research Triangle Institute; 2004. 22. Research Triangle Institute. SUDAAN language manual, release 9.0. Research Triangle Park, N.C.: Research Triangle Institute; 2004. 23. American Academy of Pediatrics, Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111(5):1113-1116. 24. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. JADA 2003;134 (12):1630-1640. 25. Lieberman W, Paul DP. Who shall care for the children of the poor and uninsured? Pediatric dentistry in the United States. Hosp Top 2002;80(2):15-20. 26. The Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Dental coverage and care for lowincome children: the role of Medicaid and SCHIP. “www.kff.org/ medicaid/7681.cfm”. Accessed Jan. 14, 2008. 27. Kane DJ, Zotti ME, Rosenberg D. Factors associated with health care access for Mississippi children with special health care needs. Matern Child Health J 2005;9(2 suppl):S23-S31. 28. Ballard C, Highsmith N. Catalyzing improvements in oral health care: best practices from the State Action for Oral Health Access Initiative. Hamilton, N.J.: Center for Health Care Strategies; 2006. “www. chcs.org/publications3960/publications_show.htm?doc_id=390279”. Accessed Feb. 3, 2008. 29. Wolff AJ, Waldman HB, Milano M, Perlman SP. Dental students’ experiences with and attitudes toward people with mental retardation. JADA 2004;135(3):353-357. 30. Siegal MD. Dentists reported willingness to treat disabled patients. Spec Care Dent 1985;5(3):102-108. 31. Ahmed SM, Lemkau JP, Nealeigh N, Mann B. Barriers to healthcare access in a non-elderly poor American population. Health Soc Care Community 2001;9(6):445-453.
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Factors associated with access to dental care for children with special health care needs Debra Kane, PhD, RN; Nicholas Mosca, DDS; Marianne Zotti, DrPH, MS, FAAN; Renee Schwalberg, MPH
n 2003, more than one-quarter of U.S. children had not had a preventive dental visit in the previous year.1 The factors associated with failure to obtain dental care are widely documented and include lack of insurance coverage, poverty, race or ethnicity, the child’s age and rural residence.2-6 The challenges to obtaining access to dental care may be exacerbated for children with special health care needs (CSHCN). These children currently have or are at an increased risk of developing a chronic physical, developmental, behavioral or emotional condition and require health and related services of a type or amount beyond that generally required by children.7 Moreover, CSHCN are more likely to have an unmet need for dental care than are children without special needs.7,8 Although many of the barriers to dental care may not seem amenable to intervention, numerous researchers have reported that access to one type of care may contribute to health-seeking behavior and access to other types of care. Thus, obtaining care of some kind may mediate the barriers to care
I
ABSTRACT Background. The authors examined the relationship between receipt of routine medical care and receipt of dental care among children with special health care needs (CSHCN) who resided in the American Dental Association’s Fifth Trustee District, which includes Alabama, Georgia and Mississippi. Methods. The authors conducted a cross-sectional study using data from the 2001 National Survey of Children with Special Health Care Needs, a module of that year’s State and Local Area Integrated Telephone Survey (sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention, Atlanta). The authors used bivariate and logistic regression analyses to explore the relationships (n = 2,092) between predisposing, enabling and need factors and receipt of dental care. Results. The parents of an estimated 76 percent of CSHCN in the district reported that their child had a need for dental care in the previous 12 months. Of these, 13.1 percent did not receive care. Failure to obtain needed dental care was associated with failure to obtain routine medical care, as was having a lower income. Conclusions. Failure to obtain routine medical care may be a risk factor for failure to obtain dental care. Any income below 400 percent of the federal poverty guidelines appears to be a barrier to receiving dental care for CSHCN. Practice Implications. Providers of routine medical care may play an important role in linking CSHCN to dental care. Investigators need to examine other barriers to dental care for CSHCN. Strategies to optimize access to dental care for CSHCN at all income levels are needed. Key Words. Access to dental care; children with special health care needs; health services research; barriers to dental care; dental care. JADA 2008;139(3):326-333.
At the time this study was conducted, Dr. Kane was a postdoctoral fellow at the Mississippi State Department of Health. Her fellowship was sponsored by the Centers for Disease Control and Prevention, Atlanta. She now is a maternal and child health epidemiologist, Centers for Disease Control and Prevention, Atlanta, and an assignee to the Iowa Department of Public Health, Bureau of Family Health, 321 E. 12th St., 5th Floor, Des Moines, Iowa 50319-0075, e-mail “[email protected]”. Address reprint requests to Dr. Kane. Dr. Mosca is the dental director, Mississippi State Department of Health, Office of Oral Health, Jackson. At the time this study was conducted, Dr. Zotti was a Centers for Disease Control and Prevention assignee to the Mississippi State Department of Health. She now is the team leader, Services Management, Research and Translation Team, Division of Reproductive Health/National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta. Ms. Schwalberg is the director, Maternal and Child Health Information Resource Center, Rockville, Md.
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described earlier. For example, Lee and colleagues9 reported that children who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were more likely to have received dental services than were those not enrolled in the WIC program. In addition, Yu and colleagues2 reported that children’s access to routine medical care had a positive effect on their access to dental care. In conducting this study, our primary interest was in the factors associated with dental care access in our local jurisdiction, the state of Mississippi. However, we included the entire American Dental Association’s Fifth Trustee District to increase the power of the analysis and because the adjoining states had similar demographic profiles. The ADA has 17 trustee districts that provide both a geographical and a politicaladministrative context in which to analyze data, make policy recommendations and advocate for action within the ADA House of Delegates. Furthermore, by examining the relationship between access to routine medical care and access to dental care, we hoped to highlight the importance of interprofessional and interdisciplinary collaboration to increasing access to dental care among CSHCN. Aday and Andersen’s10 Behavioral Model of Health Services Use provides a useful framework through which to examine factors that may influence access to dental care (Figure). Researchers have used this robust model to examine the factors related to health care access among vulnerable populations11-15 and, more importantly, to examine access to care for children16 and CSHCN.17 Specifically, Yu and colleagues16 reported that lack of a dental care visit among adolescents was associated with male sex, black or mixed race/ethnicity and lack of health insurance. Mayer and colleagues17 reported that CSHCN have higher levels of unmet needs with regard to routine medical care, particularly among children living in poverty. In the Behavioral Model of Health Services Use, three types of factors (predisposing, enabling and need) are asserted to influence access to care. We used the same typology to categorize the variables thought to influence access to dental care for CSHCN. METHODS
Sample and design. The 2001 National Survey of Children with Special Health Care Needs, conducted from April 2001 to October 2002, a module
of the State and Local Area Integrated Telephone Survey (SLAITS) series, was a cross-sectional study designed to collect data about children’s access to dental care, insurance coverage and its adequacy, household income relative to the federal poverty guidelines (FPG) and the financial effect of having a CSHCN, as well as to collect demographic information.18 The study was sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention (CDC), Atlanta. This was the first survey, to our knowledge, to specifically assess the health care needs of CSHCN. Professional telephone interviewers, working on behalf of the CDC, interviewed approximately 750 families of CSHCN in each state and the District of Columbia as part of this random-digit-dial survey. The interviewers used a screening process to determine if a child had a special health care need. A child had a special health care need if he or she had a physical, developmental, behavioral or emotional condition that required health care and related services of a type or extent beyond that generally required by children of the same age, and the condition was expected to last more than 12 months.18 We selected the ADA’s Fifth Trustee District (Alabama, Georgia and Mississippi [n = 2,092]) for our analysis to ensure an adequate sample size and because of our interest in promoting the application of research findings in a local geographical and political-administrative grouping for which organized policy actions might be implemented. The SLAITS survey was designed to produce state-level population estimates, using the weights provided.19 Weights were adjusted to account for noncoverage of households without telephones and were based on population controls from the 2000 U.S. Census according to age, sex, race/ethnicity, household composition and education of the mother. Because of the low proportions ABBREVIATION KEY. ADA: American Dental Association. CDC: Centers for Disease Control and Prevention. CSHCN: Children with special health care needs. FPG: Federal poverty guidelines. SAOHA: State Action for Oral Health Care Access Initiative. SLAITS: State and Local Area Integrated Telephone Survey. WIC: Women, Infants, and Children. JADA, Vol. 139
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Enabling Factors
Usual Source of Care
Predisposing Factors
Insurance Out-of-Pocket Costs Income Obtained Routine Medical Care
Age Sex Race Residence Mother’s Educational Level
Need Factors
Illness Severity (Rank) Illness Stability
Figure. Factors associated with access to dental care.
of “non-Hispanic other race” (weighted proportion = 2.3 percent) and Hispanics (weighted proportion = 2.4 percent) in the ADA’s Fifth Trustee District, we limited our analysis to non-Hispanic blacks and non-Hispanic whites. Description of variables. Predisposing factors. Predisposing factors (Figure), which exist before the onset of illness, generally are not amenable to intervention and may affect both access to services and their use.10,19 Demographic characteristics commonly are considered to be predisposing factors, and in this study we included the child’s age, sex, race, residence (metropolitan versus nonmetropolitan) and the mother’s educational level as such factors. To describe the characteristics of CSHCN in the ADA’s Fifth Trustee District, we based age categories on common programmatic classifications (birth to five years, elementary school and high school). We examined the mother’s educational level as a three-category variable (less than high school, high school, some college or a degree). Enabling factors. Enabling factors serve as a means to using health care services and may be amenable to intervention. For this reason, we included family income based on the FPG, having a usual source of care and medical insurance status as enabling factors. We also included having obtained needed routine medical care as an enabling factor. Specifically, all survey respondents were asked this question: “During the past 12 months, was there any time when your child needed routine preventive care, such as 328
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a physical examination or well-child check-up?” Those who answered “yes” then were asked, “Did Health Behavior your child receive all the routine preventive care that he or she needed?” We examined type of medical insurance coverage (public versus private) Obtained and current insurance Dental Care status (insured versus uninsured). In addition, we included out-of-pocket costs as an enabling factor. Because of the survey question’s structure, we examined costs in categories of $500 or less or more than $500. Need factors. In the Aday and Andersen10 model, need refers to the level of illness, which can be perceived by the child’s parent or determined by a health care professional. In this study, the parent or guardian who was most knowledgable about the child’s health and health care ranked the severity of the child’s medical or dental condition on an 11-point scale (0-10). We report the rankings in three categories (0-3, 4-6, 7-10) for descriptive and analytic purposes. Respondents reported the stability of their children’s illness according to one of three categories: “usually stable,” “changes once in awhile” or “changes all of the time.” The dependent variable in this analysis was whether the child obtained needed dental care. The survey asked all respondents this question: “During the past 12 months, was there any time when your child needed dental care, including check-ups?” Those who answered “yes” then were asked, “Did your child receive all the dental care that he or she needed?” We examined the independent factors associated with the child’s not having received needed dental care. Statistical analysis. We created the data set and recoded the variables using statistical software (SAS Version 8.2, SAS Institute, Cary, N.C.).20 We obtained all final results using SUDAAN Release 9.0 (Research Triangle Institute, Research Triangle Park, N.C.), a statistical software package developed to accommodate the data produced by complex survey designs.21,22 We used χ2 analysis to test for statistically significant
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differences between children who received needed dental care and those who did not receive such care, examining differences in predisposing, enabling and need factors. We examined several variables for interaction, including health insurance coverage and income, receipt of routine medical care and insurance coverage, poverty level and mother’s educational level, and receipt of routine medical care and poverty level. None of these interactions was statistically significant. We used logistic regression to examine the effects of predisposing, enabling and need factors on the child’s not having received needed dental care. We explored variables for modeling up to the .15 significance level; the final model included variables significant at the P = .05 level after we controlled for confounding variables, as well as for those variables historically associated with access to care (for example, age and race). We assessed variables for confounding through stratified analysis and judged a variable to be a confounder if the crude and adjusted odds ratios (ORs) differed by more than 10 percent. We used the Wald test to determine the significance of the model variable. We reported ORs, 95 percent confidence intervals (CIs) and P values for the multivariable analysis. RESULTS
Sample characteristics. Table 1 presents the distribution of sampled CSHCN in the ADA’s Fifth Trustee District according to the variables that compose our conceptual framework, as well as the proportion of respondents who reported a need for dental care during the previous year. The parents of an estimated 76 percent of CSHCN in the Fifth Trustee District reported that their child had a need for dental care in the previous year. The children primarily were school-aged non-Hispanic whites living in metropolitan areas. Almost four-fifths of the children’s mothers had obtained at least a high school education (79.1 percent). Family income was 200 percent FPG or below for nearly one-half of the children (45 percent). The majority of the children had a usual source of care (94.2 percent) (Table 1). Perhaps reflective of this result was that just 4 percent of the children had not received needed routine medical care in the previous year. Three-fourths of families spent more than $500 on out-of-pocket costs. More than one-half of the children experienced illnesses that usually were stable, while 8.6 percent
experienced illnesses that changed all of the time. Illness severity was centered on the middle range of 4 to 6 (39.4 percent of children). Bivariate analysis. Table 2 (page 331) presents the characteristics of the children who did not receive needed dental care (n = 169) and the bivariate results. Among predisposing factors, only the mother’s educational level was associated significantly with a failure to obtain needed dental care. Among enabling factors, income, health insurance coverage and not having received needed routine medical care were associated significantly with a failure to obtain needed dental care. Logistic regression analyses. Table 3 (page 332) shows the results from the logistic regression model examining CSHCN in the ADA’s Fifth Trustee District who did not obtain routine medical care, as well as relevant independent variables. Consistent with the bivariate results, income and an unmet need for routine medical care remained predictors of an unmet need for dental care. In contrast, the mother’s educational level and health insurance coverage were no longer predictive of an unmet need for dental care. DISCUSSION
In this study, we found that an unmet need for routine medical care was a strong predictor of an unmet need for dental care. This result supports the findings of other researchers who have found that access to one type of care may influence health-seeking behavior for another type of care.2,9 Even so, the mechanism or process through which either access to dental care or failure to obtain such care is related to obtaining routine medical care is not clear. Perhaps providers of routine medical care assisted families in obtaining needed dental care, or perhaps families who seek out routine medical care also are motivated to obtain dental care for their children. This question warrants further research in view of the American Academy of Pediatric Dentistry’s announced support of dental homes for CSHCN.23 The relationship between an unmet need for dental care and family income has been welldocumented. In our study, the relationship between an unmet need for dental care and family income held true for incomes up to 400 percent of the FPG. However, this result leaves unanswered questions. For example, if lowincome families obtain Medicaid coverage, including its dental care coverage, what other facJADA, Vol. 139
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that few dentists serve Medicaid-insured American Dental Association’s Fifth Trustee District children.24-26 population estimates. Medicaid-insured CHARACTERISTIC/VARIABLE UNWEIGHTED n WEIGHTED % children. In a study of (n = 2,092)* Medicaid-insured 1,622 76.0 Reported a Need for Dental Care children,6 caregivers reported a number of bar169 13.1 Did Not Receive Needed Dental Care riers to dental care access. Predisposing Factors These barriers included Age (years) difficulty finding providers 421 21.0 Birth to 5 who accepted Medicaid, 843 43.5 6-11 825 35.5 12-17 limited choices in appointment times and transSex 847 39.3 Female portation difficulties. Care1,245 60.7 Male givers who were successful Race in getting to the dental 596 34.5 Non-Hispanic black appointment encountered 1,296 65.5 Non-Hispanic white long waiting times and Residence judgmental treatment by 847 36.4 Nonmetropolitan 1,245 63.6 Metropolitan office staff because of the client’s race and public Mother’s educational level 269 20.9 Less than 12 years assistance status. There541 28.3 Completed high school fore, insurance coverage 1,218 50.8 Some college or a degree alone may not overcome Enabling Factors the barriers to dental care Income based on FPG† (%) access among low-income 380 18.6 < 100 families and those with 453 26.4 100 to ≤ 200 626 35.1 > 200 to < 400 CSHCN. 419 19.9 ≥ 400 In contrast, insurance 1,968 94.2 Had a usual source of care status no longer was predictive of an unmet need Health insurance coverage 570 30.7 Public for dental care when we 1,425 65.4 Private applied the multivariable 82 3.9 Uninsured analysis. Although it was 45 4.0 Did not receive needed routine care not possible to study the Out-of-pocket costs ($) relationship between 557 24.9 ≤ 500 insurance coverage for 1,500 75.1 > 500 dental care and an unmet Need Factors need for dental care in this Illness stability sample, it is worth noting 1,294 58.4 Usually stable that Medicaid typically 636 33.0 Changes once in awhile 153 8.6 Changes all of the time provides comprehensive dental care coverage for Illness severity (0-10 scale) 606 26.5 0-3 people younger than 21 824 39.4 4-6 years through the Early 652 34.1 7-10 and Periodic Screening, * Not all totals equal 2,092 because some respondents did not answer all questions. † FPG: Federal Poverty Guidelines. Diagnosis, and Treatment program.26 Medicaid covtors prevent these families from obtaining needed erage for dental care may have contributed to dental care for their children with special needs? the nonsignificant relationship between health Although most dentists report that they treat insurance coverage and an unmet need for children,24 a number of researchers have reported dental care. However, as noted above, insur-
TABLE 1
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TABLE 2 ance coverage alone does not guarantee access to Prevalence of unmet need for dental care, according needed dental care. to population characteristics (with bivariate results). Unlike other research2,3 and inconsistent with the CHARACTERISTIC/VARIABLE UNMET NEED FOR DENTAL CARE* bivariate analysis in our Weighted % P Value study, the child’s age was Predisposing Factors not significantly associated with an unmet need for Age (years) .63 10.8 Birth to 5 dental care in the logistic 12.9 6-11 regression analysis. In 14.2 12-17 studies based on national Sex samples, race tends to be .82 13.5 Female 12.9 Male associated with a failure to obtain dental care. In our Race .17 16.0 Non-Hispanic black final model, we did not 11.8 Non-Hispanic white find this to be the case. Residence Our results, however, are .59 12.1 Nonmetropolitan consistent with a recently 13.7 Metropolitan published state-level Mother’s educational level analysis of Mississippi < .05 25.1 Less than 12 years 27 13.2 Completed high school CSHCN. These results 10.1 Some college or a degree emphasize the importance Enabling Factors of state- and regional-level data collection and Income based on FPG† (%) < .01 19.4 analyses. However, we lim- < 100 18.8 100 to ≤ 200 ited our analysis to non15.6 > 200 to < 400 1.2 ≥ 400 Hispanic blacks and nonHispanic whites because of .59 13.2 Had a usual source of care the low proportion of HisHealth insurance coverage panics in the ADA’s Fifth < .01 18.1 Public 10.1 Private Trustee District. 33.7 Uninsured Policy and program < .01 51.3 Did not receive needed routine care development. The relationship between an unmet Out-of-pocket costs ($) .14 14.1 ≤ 500 need for dental care and 10.1 > 500 an unmet need for routine Need Factors medical care may be of particular relevance to Illness stability .22 10.9 Usually stable policy and program devel16.6 Changes once in awhile opment. Specifically, this 15.2 Changes all of the time finding underscores the Illness severity (0-10 scale) importance of policies and .11 8.8 0-3 13.5 4-6 programs that promote 16.1 7-10 interdisciplinary and inter* Unweighted sample size equals 169. professional collaboration † FPG: Federal Poverty Guidelines. and referral mechanisms among medical and dental care providers. The State Action for Oral Health increase interdisciplinary collaboration. For Care Access Initiative (SAOHA) has developed example, through the SAOHA, South Carolina numerous strategies to improve access to oral implemented programs that created direct links health care for Medicaid-insured children28; many between medical and dental care providers. South of them may be applicable to CSHCN and serve to Carolina also implemented a curriculum for medi-
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TABLE 3
willing to treat these patients.30 However, their Adjusted odds ratios for the association between willingness varied selected population characteristics and an unmet according to the type of need for dental care.* disability. For example, dentists were more willing CHARACTERISTIC/VARIABLE ODDS RATIO 95% CONFIDENCE P VALUE INTERVAL to treat a patient with epilepsy than a patient Predisposing Factors with mental retardation or Age (years) a bleeding disorder. In 0.74 0.3-2.1 .49 Birth to 5 1.0 1.0 6-11 other words, willingness to 1.3 0.6-2.7 12-17 treat may not translate Race into actual dental treat0.8 0.4-1.7 .61 Non-Hispanic black ment. What the New 1.0 1.0 Non-Hispanic white Mexico study also highMother’s educational level lights is that CSHCN are 2.1 0.8-5.3 .30 Less than 12 years 1.5 0.7-3.4 Completed high school not a homogeneous group. 1.0 1.0 Some college or a degree On the other hand, in a Enabling Factors 2004 study of dental students’ experience with and Income based on FPG† (%) 13.5 3.1- 59.2 < .01 < 100 attitudes toward people 10.8 3.1-37.9 100 to ≤ 200 with mental retardation, 13.6 4.1-44.8 > 200 to < 400 1.0 1.0 ≥ 400 50.8 percent of the students reported that they Health insurance coverage 1.2 0.5-2.8 .94 Public did not receive any clinical 1.0 1.0 Private training in how to care for 1.2 0.3-5.6 Uninsured patients with mental retar6.6 < .01 1.8-23.4 Did not receive needed routine dation.29 More than 60 percare cent of the students * Unweighted sample size equals 1,622; children who obtained needed dental care equaled 1,453 versus those reported that they had who did not obtain needed dental care equaled 169. † FPG: Federal Poverty Guidelines. little confidence in caring for patients with mental cal care providers to incorporate a discussion of retardation. Therefore, in addition to research, the importance of oral health in a child’s medical programs and policies to increase training and care visit. The importance of interdisciplinary coldental education for new and established dentists laboration also needs to be included in medical may be needed to address the dental care needs of and dental school curricula. CSHCN. Treating children with disabilities. A Study limitations. One limitation of this number of other factors may be of particular relstudy is that researchers collected the data via a evance to future research regarding CSHCN, as telephone survey. People without telephones may well as to policy and program development. These encounter more barriers to accessing care and, factors include the paucity of specific information therefore, be at an increased risk of failing to about the prevalence of dental care needs among receive needed dental care.31 However, we 29,30 CSHCN. Data from the 2001 National Survey adjusted the sample weights to account for nonof CSHCN focused on health and medical care coverage of households without telephones. In needs and access for CSHCN. Thus, we have limaddition, the need for dental care was based on ited information about the true dental care needs parental perceptions and may have been underof CSHCN and whether or how those needs are stated if parents were unaware of their children’s being met. Little is known about the willingness need for such care.8,17 Lack of knowledge about of dentists to provide services to CSHCN. children’s oral health care needs is not uncomIn a New Mexico study of dentists’ willingness mon: an analysis of the National Survey of Chilto treat patients with disabilities, the majority of dren’s Health, another module of the SLAITS dentists (90 percent) reported that they would be survey, found that the parents of 11.1 percent of 332
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children who did not receive preventive dental care in the previous year believed that their children did not need this care, despite the standard recommendation that all children have preventive dental visits twice a year.28 Moreover, the results may have been influenced by recall bias in that parents were asked to answer questions based on the previous 12 months. In addition, the relatively small sample size contributed to the wide CIs found in the regression analysis and, thus, reduced the power of the statistical models. Therefore, we need to interpret the results of this study with caution. These results cannot be generalized beyond the ADA’s Fifth Trustee District. Furthermore, we cannot attribute a cause-and-effect relationship between the independent variables and the outcomes because the data were cross-sectional. Even so, these results may guide program and policy development by the ADA’s Fifth Trustee District and others working on behalf of CSHCN. CONCLUSIONS
Access to dental care is an ongoing problem among CSHCN, especially those in low-income families. The relationship between access to routine medical care and dental care implies that a comprehensive approach to improving access to primary health care services and to dental care may be more effective than focusing on either service individually. ADA trustee districts may offer effective political-administrative frameworks through which to analyze data that inform decision making about policy that, in turn, improves access to dental care for CSHCN. ■ Disclosures: None of the authors reported any disclosures. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, Atlanta. The institutional review boards at the Centers for Disease Control and Prevention and the Mississippi State Department of Health approved this study. Dr. Mosca presented a version of the study analysis and a report at the National Oral Health Conference, Little Rock, Ark., May 2006. 1. U.S. Department of Health and Human Services. The oral health of children: A portrait of states and the nation 2005. Rockville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2005. “http://mchb.hrsa.gov/oralhealth/index.htm”. Accessed Feb. 3, 2008. 2. Yu SM, Bellamy HA, Kogan MD, Dunbar JL, Schwalberg RH, Schuster MA. Factors that influence receipt of recommended preventative pediatric health and dental care. Pediatrics 2002;110(6):e73-e80. 3. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2002;2(2 suppl):141-147. 4. Byck GR, Walton SM, Cooksey JA. Access to dental care services for Medicaid children: variations by urban/rural categories in Illinois. J Rural Health 2002;18(4):512-520.
5. Watson MR, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. JADA 2001;132(11): 1580-1587. 6. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think? Am J Public Health 2002;92(1):53-58. 7. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics 2000;105(4 Pt 1):760-766. 8. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health care needs of America’s children. Pediatrics 2000;105 (4 Pt 2):989-997. 9. Lee JY, Rozier RG, Norton EC, Kotch JB, Vann WF. Effects of WIC participation on children’s use of oral health services. Am J Public Health 2004;94(5):772-777. 10. Aday LA, Andersen RM. A framework for the study of access to medical care. Health Serv Res 1974;9(3):208-220. 11. Dobalian A, Andersen RM, Stein JA, Hays RD, Cunningham WE, Marcus M. The impact of HIV on oral health and subsequent use of dental services. J Public Health Dent 2003;63(2):78-85. 12. Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los Angeles. Med Care 2004;35(8):814-830. 13. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care uses and outcomes for homeless people. Health Serv Res 2000;34(6):1273-1302. 14. Goodwin R, Andersen RM. Use of the Behavioral Model of Health Care Use to identify correlates of use of treatment for panic attacks in the community. Soc Psychiatry Psychiatr Epidemiol 2002;37(5): 212-219. 15. Kilbourne AM, Andersen RM, Asch S, et al. Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus. Med Care Res Rev 2004;59(1):36-58. 16. Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with the use of preventive dental and health services among U.S. adolescents. J Adolesc Health 2001;29(6):395-405. 17. Mayer ML, Skinner AC, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Pediatrics 2004;113(2):e109-e115. 18. Blumberg SJ, Olson L, Frankel M, et al. Design and operation of the National Survey of Children with Special Health Care Needs, 2001. Vital Health Stat 1 2003;41:1-136. 19. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36(1):1-10. 20. SAS Institute. SAS/STAT user’s guide, version 8. Cary, N.C.: SAS Institute; 1999. 21. Research Triangle Institute. SUDAAN example manual, release 9.0. Research Triangle Park, N.C.: Research Triangle Institute; 2004. 22. Research Triangle Institute. SUDAAN language manual, release 9.0. Research Triangle Park, N.C.: Research Triangle Institute; 2004. 23. American Academy of Pediatrics, Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111(5):1113-1116. 24. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. JADA 2003;134 (12):1630-1640. 25. Lieberman W, Paul DP. Who shall care for the children of the poor and uninsured? Pediatric dentistry in the United States. Hosp Top 2002;80(2):15-20. 26. The Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Dental coverage and care for lowincome children: the role of Medicaid and SCHIP. “www.kff.org/ medicaid/7681.cfm”. Accessed Jan. 14, 2008. 27. Kane DJ, Zotti ME, Rosenberg D. Factors associated with health care access for Mississippi children with special health care needs. Matern Child Health J 2005;9(2 suppl):S23-S31. 28. Ballard C, Highsmith N. Catalyzing improvements in oral health care: best practices from the State Action for Oral Health Access Initiative. Hamilton, N.J.: Center for Health Care Strategies; 2006. “www. chcs.org/publications3960/publications_show.htm?doc_id=390279”. Accessed Feb. 3, 2008. 29. Wolff AJ, Waldman HB, Milano M, Perlman SP. Dental students’ experiences with and attitudes toward people with mental retardation. JADA 2004;135(3):353-357. 30. Siegal MD. Dentists reported willingness to treat disabled patients. Spec Care Dent 1985;5(3):102-108. 31. Ahmed SM, Lemkau JP, Nealeigh N, Mann B. Barriers to healthcare access in a non-elderly poor American population. Health Soc Care Community 2001;9(6):445-453.
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