Variations in the social impact of oral conditions among older adults in South Australia, Ontario, and North Carolina

Previous studies among older adults have demonstrated that oral disease frequently leads to dysfunction, discomfort, and disability. This study aimed to assess variations in the social impact of oral conditions among six strata of people aged 65 years and older: residents of metropolitan Adelaide and rural Mt Gambier, South Australia; residents of metropolitan Toronto-North York and non-metropolitan Simcoe-Sudbury counties, Ontario, Canada; and blacks and whites in the Piedmont region of North Carolina (NC), United States. Subjects were participants in three oral epidemiological studies of random samples of the elderly populations in the six strata. Some 1,642 participants completed a 49-item Oral Health Impact Profile (OHIP) questionnaire which asked about impacts caused by problems with the teeth, mouth, or dentures during the previous 12 months. The percentage of dentate people reporting impacts fairly often or very often was greatest among NC blacks for 41 of the OHIP items. Two summary variables of social impact were used as dependent variables in bivariate and multivariate least-squares regression analyses. Among dentate people, mean levels of social impact were greatest for NC blacks and lowest for NC whites, while people from South Australia and Ontario had intermediate levels of social impact (P < 0.01). Missing teeth, retained root fragments, root-surface decay, periodontal pockets, and problem-motivated dental visits were associated with higher levels of social impact (P < 0.05), although there persisted a two-fold difference in social impact across the six strata after adjustment for those factors Among edentulous people, there was no statistically significant variation in social impact among strata. The findings suggest that there are social and cultural factors influencing oral health and its social impact, and that those factors differ most between dentate blacks and whites in NC.

Resource allocation, health policy, and rationing craniofacial care

The United States allocates health care without an overt system of rationing. This article analyzes the forces that guide resource allocation to craniofacial care. Various possible allocation systems are reviewed for how decision makers might evaluate proposed programs for legislative funding. Using a case-based exercise, readers are asked to weigh the potential costs and benefits of six health and social programs. These programs are also systematically examined for factors that are likely to affect resource allocation decisions. Eleven factors that affect decision-making are utilized in the analysis, ranging from the cost per client to emotional or human interest content of the proposed programs. Decisions about preventive programs are compared with those involving therapeutic programs. The allocation of resources to craniofacial programs, including those for children with rare major craniofacial conditions, is considered in the context of social justice and broad contemporary ethical and health care delivery issues.

Differences between racial groups in the impact of oral disorders among older adults in North Carolina

OBJECTIVES

This study investigated variations in impact of oral disorders between older black adults and older white adults living in North Carolina.

METHODS

Using the Oral Health Impact Profile (OHIP) questionnaire, 440 participants aged 70 and older provided data on their perceptions of the impact of oral disease on aspects of their lives during the previous 12 months.

RESULTS

For 22 of the 49 items queried in the OHIP questionnaire, older blacks reported more frequent impact than older whites (P < .05). For none of the OHIP items did whites report more frequent impact. The impacts reported were diverse and included items reflecting pain, physical disability, psychological disability, and social disability. When the number of items occurring fairly often or very often were summed for dentate participants, blacks reported more items than did whites (3.7 vs 1.1, P < .0001). This difference decreased to 2.7 vs 2.0 (P < .346) after controlling statistically for greater mean periodontal pocket depth, more unreplaced missing teeth, and more episodic dental visits among blacks.

CONCLUSIONS

Older dentate blacks reported more impact from oral problems than older dentate whites. The differences in reported impact likely are linked to differences in oral status and dental visit history between these two racial groups in North Carolina.

Physicians and the communication of "bad news": parent experiences of being informed of their child's cleft lip and/or palate

OBJECTIVE

Physicians often are called on to deliver "bad news" in the form of a diagnosis with unhappy implications. Few guidelines exist for practitioners who wish to meet patient and family expectations for clear and caring communication. To develop recommendations for physicians, this study was undertaken to document how biologic parents of children born with a specific, non-life-threatening birth defect perceive the encounter with a physician during which they were informed of their children's diagnosis. The study also examines parental preferences for how this communication might best be managed and compares those with parent reports of their actual experiences.

METHODOLOGY

Biologic parents of children born with cleft lip and/or palate (n = 100) were studied with a self-administered questionnaire about the diagnostic encounter in which they rated theoretically derived dimensions of physician communication. Their experiences, as well as their preferences for communication in a hypothetical case, were compared through the use of ratings and open-ended qualitative narratives.

RESULTS

Parents learned the diagnosis at birth (90%) from a physician (96%). Many report positive experiences, but there are significant differences between what parents experienced and what they desire in the informative interview. Parents wanted more opportunity to talk and to show their feelings and wanted the physician to try harder to make them feel better. As compared with their experiences, parents indicated a desire to have more information and more of a discussion about the possibility of mental retardation. They wanted the physician to show more caring and confidence, and wanted more referral to other parents, than they had experienced. Dimensions of physician behavior were more positively perceived by parents who were informed by a physician whom they felt they knew well.

CONCLUSIONS

It is possible for physicians to effectively deliver bad news, such as the diagnosis of a birth defect, to parents. This study suggests specific communicative and educational approaches that are likely to improve parental satisfaction with such physician communications.

Effects of visible and invisible orofacial defects on self-perception and adjustment across developmental eras and gender

Self-ratings of satisfaction with appearance and accomplishment of psychosocial tasks were examined by age and gender among school aged children with visible defects (cleft lip and/or palate, n = 272), or invisible defects (cleft palate only, n = 159), and dental patients (n = 128) without clefts. Using weighted least squares ANOVA and logistic regressions, the results revealed that subjects with visible defects expressed greater dissatisfaction with their appearance than those subjects with invisible defects (p < .001). Subjects with invisible defects consistently expressed lower problem solving ability than subjects with visible defects (p < .001) and dental patients with no defects (p < .05). Both groups with clefts expressed less social independence (p < .001); and subjects with clefts reported having more friends than other children (p < .01). Implications for clinicians and further research are discussed.

Sociodemographic correlates of health beliefs among black and white community dwelling elderly individuals

This study examined the hypothesis that sociodemographic characteristics such as age, education, race, and gender would be predictive of Multidimensional Health Locus of Control Subscale scores in a population-based sample of 342 community dwelling elderly individuals. Bivariate analysis revealed associations between black race, lower socioeconomic status, and lower education on the Chance and Powerful Others Subscales. While the multivariate analysis revealed no predictors for the Internal Subscale, a higher socioeconomic status, white race, and a higher level of education continued to predict low scores on the Chance Subscale when controlling for all other variables. Scores on the Powerful Others Subscale appeared to be a function of socioeconomic status and gender. Of note, the higher the education level for both men and women, the lower the scores on the Chance and Powerful Others Subscales. This sex by education interaction term reached statistical significance for the Chance Subscale. The results demonstrate the measurable influence of sociodemographic variables on the health beliefs of community dwelling elderly individuals.

Health policy and craniofacial care: issues in resource allocation

The distribution of health care services, including craniofacial services in the United States, is examined. The U.S. has a unique health care financing and organizational system in which persons are most commonly covered by health insurance as a benefit of their employment. Current estimates are that nearly 40 million Americans have no health insurance (Himmelstein et al., 1992). Approximately half of the uninsured persons are in low-wage employment that does not provide health insurance benefits nor allow them to qualify for Medicaid (Pepper Commission, 1990). Personal health care costs now exceed 11% of the U.S. gross domestic product, a significantly higher percentage than that found in other industrialized nations (Consumer Reports, 1990b). Within the current system, is health care distributed in a fair or moral manner? What are the effects of the allocation scheme? Possible changes in health care financing and delivery are examined and basic ethical and social issues associated with a changing U.S. health care delivery system are explored.

Children with cleft lip/palate and mental retardation: a subpopulation of cleft-craniofacial team patients

This study compares a subpopulation of persons with cleft lip/palate who have mental retardation (n = 56) to those with normal learning (n = 420), at a large university-based cleft-craniofacial center. Many of the patients identified as having mental retardation in this sample have the diagnosis of isolated cleft palate (46.8%). Nearly half (46.3%) of the patients with mental retardation were found to have multiple anomalies, syndromes or associated medical findings. Common findings included cardiopulmonary defects, seizures, and deviations in head size. In this clinic population, mental retardation was found more commonly among African-American patients with clefts, than among Caucasian patients with clefts. Higher rates of facial disfiguration and impaired speech were found in patients with clefts and mental retardation. This research demonstrates that among a population of persons with cleft lip and/or cleft palate, there is a subpopulation of children who also have mental retardation. Craniofacial-cleft teams will need to develop strategies to address the special needs of this group of patients.

Pulsed dye laser therapy for port-wine stains in children: psychosocial and ethical issues

The port-wine stain is a disfiguring vascular birthmark that commonly occurs on the face. Amelioration of this condition in children was difficult or impossible until the introduction of the flashlamp-pumped pulsed dye laser in the late 1980s. This article provides an interdisciplinary social and ethical examination of pulsed dye laser therapy for port-wine stain in childhood. Specific issues raised relate to the management of pain during therapy, rationale for care, expectations of treatment, the high costs of care, equity, marketing pressures, and therapeutic activism. Laser therapy in the dermatologic care of children is an exciting innovation that has transformed clinical practice and raised important social, ethical, and health policy issues.

Understanding the value of teeth to older adults: influences on the quality of life

Understanding the value of teeth to older adults is important in marketing dental services and motivating patients to care for their teeth. The authors surveyed more than 1,000 older adults in North Carolina to determine how teeth affect the quality of their lives.

Ethical and health policy issues in the treatment of children with major craniofacial deformities

The advent of craniofacial surgery and neonatal intensive care has made it possible for children with serious craniofacial deformities to live and possibly to experience effective habilitation. These therapeutic innovations also raise important social and ethical issues that are rarely examined. This paper reviews the dilemmas that relate to the gatekeeper role for physicians, the impact of prenatal diagnosis, and the allocation of scarce fiscal and health resources to craniofacial care. The high degree of cost, the intense investment of medical resources, and the uncertain outcomes in the care of children with major craniofacial deformities, must be considered in the distribution of resources within a health system. The rationing of health resources is discussed as a future determinant of how care for major craniofacial deformities may be delivered in the United States.

Communicating medical bad news: parents' experiences and preferences

Parents (N = 189) of children enrolled in 15 developmental day care centers completed questionnaires that examined the experience of being told bad news and elicited preferences for physician behavior in a hypothetical situation (communicating the diagnosis of Down syndrome). Parents, in comparison with their experiences, preferred (p < 0.001) more communication of information and feelings by their physician. Their strongest preferences were for physicians to show caring (97%), to allow parents to talk (95%), and to allow parents to show their own feelings (93%). They wanted physicians to share information (90%) and to be highly confident (89%). Most parents (87%) desired parent-to-parent referral, but only a few (19%) were referred. We conclude that there is a difference between what parents experience and what they desire in physicians who communicate bad news. Physicians control the interaction and are highly confident, but parents especially value physicians who show caring and allow parents to talk and share their feelings.

Habilitation of patients with clefts: parent and child ratings of satisfaction with appearance and speech

This study examined ratings regarding satisfaction with facial appearance and speech performance from 495 parent-child pairs. Data were obtained from school-aged children (5-18 years old) and their parents using standardized independent interviews. Results revealed that 54 percent of the children with cleft lip (CL) or cleft lip and palate (CLP) were very pleased with their appearance, and 62 percent of the cleft palate or CLP subjects were very pleased with speech. Low, but statistically significant correlations exist between the female subjects and their parents in satisfaction with appearance. Although older cleft lip and/or palate patients reported increased satisfaction with speech, no age differences in patient satisfaction with appearance were observed in subjects with CL/CLP. Parents of females expressed more concern about their daughters' appearance than parents of males, while parents of males were more concerned about speech. Implications for craniofacial habilitation teams and research suggestions are discussed.

Cognitive and attitudinal impacts of a university AIDS course: interdisciplinary education as a public health intervention

This paper describes an interdisciplinary, variable credit-bearing university course on acquired immunodeficiency syndrome (AIDS) that enrolled 429 students. Pre- and post-course questionnaires were used to assess knowledge and attitudes relative to AIDS and these were compared to National Health Interview Survey findings. Considerable cognitive and attitudinal changes occurred over the course period. University courses, taught annually, were found to be an efficient mechanism for educating large numbers of future community leaders and professionals about AIDS.

Directions and issues in psychosocial research and methods as applied to cleft lip and palate and craniofacial anomalies

Psychosocial research into cleft lip and/or palate and craniofacial conditions has historically employed a "medical model" of research that sought to clarify whether patients experienced psychopathology as a consequence of the birth defect. In recent years, this paradigm has been replaced by a "social science model" of research that posits that most individuals with clefts do not manifest psychological pathology. The "social science model" examines adjustment and adaptation in the patients and their families. Research questions may consider the social, cultural, and psychological ramifications of being different in terms of speech, appearance, or identity. The authors suggest that an expanded set of research questions be considered, and that researchers from sociology, anthropology, ethics, economics, health services research, as well as psychology, become engaged. This paper proposes a range of possible research topics and indicates likely trends in research design and methodology.

Culture, health care, and birth defects in the United States: an introduction

Culture impacts both professional practice and patient health behaviors. This paper introduces the concept of culture and examines how it may be of importance to health professionals engaged in craniofacial care. The taking of a cultural history is presented as a way of assessing cultural differences. This paper is the first in a series of interrelated papers that define cultural perspectives toward health and craniofacial care in United States subpopulations.

Prenatal detection and fetal surgery of clefts and craniofacial abnormalities in humans: social and ethical issues

Sophisticated prenatal diagnostic imaging has facilitated the progression of fetal surgery from the experimental possibility to a clinical therapy for several life-threatening congenital conditions. Guidelines for such fetal surgery include the expectation that the child will be reasonably healthy as a result and that the in utero approach will improve the outcome or is safer than postnatal intervention. Prenatal ultrasound detection of craniofacial anomalies is now common. Reports of experimental cleft repairs in animal fetuses suggest advantages including diminished scarring, improved health and nursing. While fetal craniofacial surgery has not been attempted in humans, speculations exist about the psychological and social benefits of being born with a repaired defect. Fetal surgery is an emerging technology that may alter experimentation, cleft treatment, and the allocation of scarce resources. This paper examines the social and ethical implications of prenatal diagnosis and fetal surgery, focusing on fetal/maternal rights, and clinical decision making.

The accuracy of oral self-perceptions in a dentate older population

A random sample of 1,016 subjects aged 65 and older were interviewed and examined in their own homes. The sample was stratified by race and place of residence. As part of the interview, the 821 dentate subjects were asked to rate their mouth appearance, chewing ability, and mouth health. Most subjects responded positively to these questions. The self-perception of mouth health was most related to the presence of anterior teeth. Perception of chewing ability was most related to the number of anterior teeth present, total number of teeth present, and the need for extractions. Subjects also were asked about their perceived dental needs. A small proportion of subjects thought they needed restorations, periodontal treatment, or teeth replacement. Subjects generally were not able to define the extent of their treatment needs, but their self-perceptions of mouth appearance, chewing ability, and mouth health had some relationship to their oral health.

Self-concept of early primary school age children with visible or invisible defects

This study compares self-concept scores on the Primary Self-Concept Inventory (PSCI) of 58 7-year-old children. The experimental groups included the three following subgroups: those with visible defects (cleft lip), mixed visible and invisible defects (cleft lip and palate), and invisible defects (cleft palate). The control consisted of first grade students with no physical defects. Significant differences between the subjects with clefts and controls were found. Children with cleft lip and palate (visible and invisible defects) demonstrated the lowest self-concept scores. These test results suggest that early primary school age children experience significant stigma. Therefore, early evaluation of psychosocial stress factors for children with clefts is suggested. School personnel can contribute to addressing self-concept concerns of children with defects. Suggestions for further research are presented.

Psychosocial responses to oral and maxillofacial surgery for head and neck cancer

This study involved extensive interviews with 28 patients who had disfiguring oral and maxillofacial surgery for head and neck cancer. The patients, ages 42 to 76 years, had all been informed of their diagnosis and were in 2- to 5-year postoperative follow-up. Findings pertain to how patients deal with the interpersonal and social ramifications of diagnosis and surgical treatment. Fatalism, delays in help-seeking, responses to diagnosis, postsurgical anxiety, and adjustment were reported. Reassurance prior to surgery was sometimes found to limit understanding of postoperative impairment. Oral and maxillofacial surgeons were seen in heroic or imposing roles that impacted on their capacity to be supportive to patients coping with life change and "handicap." The patient treatment decisions were found to be determined by attitudes about death, which motivated patients and surgeons to make difficult or extreme choices. Suffering, social changes, and postoperative uncertainty were patient concerns. Patient strategies for adjusting to disfiguration are examined, and specific recommendations for the oral and maxillofacial surgeon are made.

Perceptions of appearance and speech by adolescent patients with cleft lip and palate and by their parents

This study surveyed 102 patients with cleft lip, cleft palate, or cleft lip and cleft palate (ages 13 to 19) and their parents to assess satisfaction with appearance, speech ability, and intelligibility. The data were based upon standardized interviews conducted at a cleft palate treatment center, using simple questions with high face validity. Surgical experience was high among this sample, as reflected by the finding that the majority of patients (55.7%) had had three or more operations on the face or mouth. Patient ratings of facial appearance showed that most patients were very pleased (59.3%) or moderately pleased (13.2%); others were somewhat (18.7%) or very (8.8%) disappointed. Many parents indicated that their children expressed occasional (22.0%) or frequent (27.5%) concerns about appearance. Nearly all patients (91.9%) felt that their operations had accomplished what they expected, though some of the cleft lip patients (35.7%) and their parents (43.9%) were less than very pleased with the appearance of the lip. When asked how pleased they were with the way they presently talked, most patients (69.1%) were very pleased, though some disappointment was expressed. Although often pleased with their current speech status, many patients rated themselves as only moderately understandable (19.1%) or as not understandable (8.5%). No significant gender effects were found in satisfaction, appearance, or speech ratings. There were no significant differences found between parent and child ratings. The findings indicate that at a center delivering team-based cleft palate care, both adolescent patients and their parents have considerable concerns about appearance and speech results.