Utilization of Health Services & Level of Unmet Dental Need Within a Rural School-Based Population

1. Utilization of Health Services & Level of Unmet Dental Need Within a Rural School-Based Population Tracy M. Carter, M.S. College of Community Health Sciences College of Human Environmental Sciences The University of Alabama Tuscaloosa, Alabama

2. Abstract Oral Health among youngsters is a topic of concern and the long-term consequences of poor oral health negatively impact quality of life. The assumption that children having less access to dental health services have increased dental needs than children with improved access is based on Aday & Anderson’s behavioral framework for health service utilization, which incorporates predisposing, enabling, and health system factors. The current study examined a school-based cohort to (1) assess dental needs, (2) examine the utilization of dental services, and (3) determine the influence of health insurance coverage on unmet needs and utilization across time. Results revealed dental need among the study population, which was reduced over time as access to services increased within the community. Specifically, dental referrals declined from 47.7% in 1996 to 10.9% in 1998. At the same time the percent of children not covered by health insurance decreased from 12.3% in 1996 to 7.3% in 1998. Multivariate analyses indicated that both the time since last dental visit and the level of unmet dental need differed significantly across time. Findings are supportive for continuing efforts for developing community-based responses to problems in oral health and access to care. Community-based responses for assuring access will be discussed. Tracy M. Carter: APHA Poster Session II 4063.0

3. Purpose of Study …to determine among a rural, school-based cohort: • the extent of unmet dental health needs • utilization of dental health services • the role of health coverage on unmet dental health need and utilization Tracy M. Carter: APHA Poster Session II 4063.0

4. Theoretical Basis • Aday & Anderson’s Behavioral Framework for Health Service Utilization (1975) • predisposed to service utilization based on sociodemographic characteristics, e.g., age, race, values regarding health • utilization facilitated by enabling factors, e.g., health coverage and presence of a regular provider • need-based factors, e.g., illness level • health-system factors, e.g., access to services and/or providers Tracy M. Carter: APHA Poster Session II 4063.0

5. Methods: Data Source • Child Caring Initiative • community-based health access initiative in partnership with • The University of Alabama • College of Community Health Sciences • Capstone College of Nursing • The Rural Alabama Health Alliance • Blue Cross Blue Shield of Alabama • data collected from a single rural school-based cohort, 1996-1998, N=754 • Parent-completed descriptive surveys of family characteristics, health utilization, and insurance status • noninvasive head-to-toe health evaluations (with parent consent) Tracy M. Carter: APHA Poster Session II 4063.0

6. Results: Predisposing Factors Table 1 Distribution of predisposing factors among participating students Variable ‘96 (%) ‘97 (%) ‘98 (%) X (%) value Gender male 48.8 48.0 48.5 48.4 female 51.2 52.0 51.5 51.6 Race white 53.0 53.2 53.2 53.2 non-white 47.0 46.8 46.8 46.8 Annual family < income $15,999 44.1 44.3 44.3 $16,000 -$23,999 15.5 14.2 14.2 $24,000 - $31,999 13.7 12.9 12.9 > $32,000 26.7 28.7 28.7 Head of household education level <high school 11.5 12.2 12.7 12.7 high school 53.6 53.6 52.1 52.1 >high school 34.9 34.2 35.3 35.3 *1996 family income data was requested with different income increments than that used in 1997 and 1998. Tracy M. Carter: APHA Poster Session II 4063.0

7. Results: Enabling Factors Table 2 Distribution of Enabling Factors for Participating Students Variable value ‘96 (%) ‘97 (%) ‘98 (%) X (%) Regular Provider No 26.9 29.5 26.4 27.6 Yes 73.1 70.5 73.6 72.4 Insurance Coverage No 12.3 9.2 7.3 9.6 Yes 87.7 90.8 92.7 90.4 Tracy M. Carter: APHA Poster Session II 4063.0

8. Results: Need-Based Factors Table 3 Distribution of Need-Based Factors for Participating Students Variable value ‘96 (%) ‘97 (%) ‘98 (%) X (%) Health Status excellent/good 95.1 93.2 93.0 93.8 fair/poor 4.9 6.8 7.0 6.2 Unfilled Cavities no 73.1 85.3 84.0 80.8 yes 26.9 14.7 16.0 19.2 Missing no 79.7 79.3 79.4 79.5 yes 20.3 20.7 20.6 20.5 Discoloration no 82.6 89.4 91.3 87.8 yes 17.4 10.6 8.7 12.2 Mouth Abnormalities no 93.7 93.2 89.4 92.1 yes 6.3 6.8 10.6 7.9 Dental Needs Score* 0 48.3 62.5 57.3 56.0 1 36.5 25.8 32.2 31.5 2 11.7 8.5 8.6 9.6 3 3.2 3.1 1.6 2.6 4 0.4 0.1 0.3 0.3 Provided Dental Referrals 48.7 21.4 10.9 27.0 Tracy M. Carter: APHA Poster Session II 4063.0

9. Statistical Analyses • T-Test for Independent Samples • conducted for the for the time since last dental visit (measured in months) for each of the three years, by insurance status • conducted for a computed unmet dental need score (cavities, discoloration, abnormal missing teeth, and mouth abnormalities) for each of the three years, by insurance status Tracy M. Carter: APHA Poster Session II 4063.0

10. Statistical Analyses Table 4 T-Test Results for Time Since Last Dental Visit (LDV) and Unmet Dental Needs Score (UDN) by Insurance Status Variable Value Mean T-Value df Sig. 1996 LDV insured 1.02 1.27 459.00 0.21 uninsured 0.77 1997 LDV insured 1.59 2.61 45.39 0.01 uninsured 0.80 1998 LDV insured 1.96 2.53 36.11 0.01 uninsured 1.00 1996 UDN insured 0.75 0.46 713.00 0.65 uninsured 0.71 1997 UDN insured 0.74 2.01 72.68 0.05 uninsured 0.49 1998 UDN insured 0.59 0.49 689.00 0.63 uninsured 0.54 Tracy M. Carter: APHA Poster Session II 4063.0

11. Statistical Analyses • General Linear Model – Repeated Measures Design • Examined school-based cohort differences for the following: • time since last dental visit • significant differences in time since last dental visit across study years (F=55.106, df=1, p=.000) • no differences noted between school-based cohorts • unmet dental needs score • significant differences in unmet dental needs score across study years (F=19.588, df=4, p=.000) • significant differences noted among school-based cohorts—with younger children having a higher mean unmet dental need score than older grades—a finding consistent across study years Tracy M. Carter: APHA Poster Session II 4063.0

12. Discussion • Community-based efforts to identify, enroll, and assure access among its children resulted in • Decreased % of children reporting no health coverage, from 12.3% to 7.3% across years • recruitment of a Medicaid dental provider • fund-raising activities to provide dental services to uninsured and underinsured children with identified need between 1996 and 1997 • reduction in dental referrals from 48.7% to 10.9% across study years Tracy M. Carter: APHA Poster Session II 4063.0

13. Discussion The road to 100% caries free mandates active participation from communities, patients, dental providers, and insurance agents—including Medicaid and S-CHIP. We can eliminate the dental divide and children’s associated pain and suffering due to oral disease, but not without improving access to services. This research demonstrates that communities have the ability and indeed the potential to reverse the effects of the “dental divide”, but they need the support of and participation from insurers and dental providers if they are to be successful beyond one-shot campaigns. Tracy M. Carter: APHA Poster Session II 4063.0

14. References • Aday, L. & Anderson, R. (1975). Development of indices of access to medical care. Ann Arbor, MI: Health Administration Press. • DHHS (2000). Oral health in America: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. • Edelstein, B. (1998). Racial and income disparities in pediatric oral health. Children's Dental Health Project: Policy Brief. • GAO (2000a). Oral health: dental disease is a chronic problem among low-income populations (GAO Publication No. HEHS-00-72). Washington, DC: U.S. GAO. • GAO (2000b). Oral Health: Factors contributing to low use of dental services by low-income populations (GAO Publication No. HEHS-00-149). Washington, DC: U.S. GAO. • Gulzar, L. (1999). Access to care. Image: Journal of Nursing Scholarship, 31(1), 13-19. • Kaste, L. Selxitz, R., Oldakowski, J., Brunelle, J., Winn, D., & Brown, L. (1996). Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United tates, 1998-1991. Journal of Dental Residency, 75 (Spec Iss): 631-641. • Keane, C., Lave, J., Ricci, E., & LaVallee, C. (1999). The impact of a children's health insurance program by age. Pediatrics, 104 (5), 1051-1058. • Klaus, R. (2000). Parity for the Cavity. Chicago, IL: Oral Health America. • McCormick, M., Kass, B., Elixhauser, A., Thompson, J., & Simpson, L. (2000). Annual report on access to and utilization of health care for children and youth in the United States--1999. Pediatrics, 105 (1), 219-230. Tracy M. Carter: APHA Poster Session II 4063.0

15. References Continued • Milgrom, P., Hujoel, P., Gremboski, D., & Fong, R. (1999). A community strategy for Medicaid child dental services. Public health Reports, 114, 529-532. • Mueller, C., Schur, C., & Paramore, L. (1998). Access to Dental Care in the United States, Estimates from a 1994 survey. Journal of the American Dental Association, 129, 429-437. • Newacheck, P., Brindis, C., Cart, C., Marchi, K., & Irwin, C. (1999). Adolescent health insurance coverage: recent changes and access to care. Pediatrics, 104 (2), 195-202. • Newacheck, P., Hughes, D., Hung, Y., Wong, S., & Stoddard, J. (2000). The Unmet Health Needs of America's Children. Pediatrics, 105, (4), 989-997. • Polivka, B., & Ryan-Wenger, N. (1999). Health promotion and injury prevention behaviors of elementary school children. Pediatric Nursing, 25 (2), 127-134. • Pollack, R., Fish-Parcham, C., & Hoenig, B. (1997). Unmet needs: The large differences in health care between uninsured and insured children. Washington, DC: Families USA. • Rowland, D. & Lyons, B. (1989). Triple jeopardy: rural, poor, and uninsured. Health Services Research, 23 (6), 975-1004. • Simpson, G., Bloom, B., Cohen, R., & Parsons, P. (1997). Access to health care, Part 1: Children, National Center for Health Statistics. Vital Health Series 10(196). • Tang, J., Altman, D., Robertson, D., O'Sullivan, D., Douglass, J., & Tinanoof, N. (1997). Dental caries prevalence and treatment levels in Arizona preschool children. Public Health Reports, 112 (4), 319-330. • Weidler, M. (2000). Children's Access to Dental Care. Alabama Arise Citizens' Policy Project: Fact Sheet: Tracy M. Carter: APHA Poster Session II 4063.0