Use of dental services by immigration status in the United States

An ethnographic study of a community dentistry network serving Latine migrant farmworkers in Vermont: Barriers and access to care during the COVID-19 pandemic and beyond

BACKGROUND AND OBJECTIVES

Primary dental healthcare services are not accessible for a majority of Latino/a/e migrant farmworkers in the United States. Unmet dental health needs are well documented in larger states like California, Florida and New York, but the dental healthcare picture in smaller states is not well understood. The goal of this qualitative ethnographic study was to understand the delivery model of a free dentistry network serving Latine farmworkers in rural Vermont and specific barriers experienced at the network during the COVID-19 pandemic.

METHODS

Semi-structured ethnographic interviews were carried out with clinicians and transcripts were analysed using the constant comparison method to identify salient concerns and recommendations about barriers and delivery of care.

RESULTS

Clinicians highlighted structural issues including farmworkers' lack of time off work and absence of transportation to attend appointments, concerns about COVID-19 safety, concerns about immigration surveillance and language barriers. Providers outlined steps for improved service delivery including mobile care at local farms, enhanced intercultural training for providers, recognizing dentistry as essential healthcare at the state level and the leverage of existing appointments for preventive health. Drawing on anthropological frameworks of place-based care and deservingness of healthcare, our ethnographic findings emphasize the role of community dentistry in bridging gaps in migrant healthcare during and beyond the COVID-19 pandemic.

Oral Health, Health Service Utilization, and Age at Arrival to the U.S. among Safety Net Patients

Background: Immigrants’ oral health disparities have not been adequately investigated using a lifecourse approach, which investigates the cumulative effects of risk and protective exposures among other considerations. Methods: We examined self-reported oral health outcomes and health care appointment outcomes among a sample of patients enrolled at a federally qualified health center in Richmond Virginia (N = 327) who were categorized into three groups by approximate age at arrival to the U.S. Results: Study participants who arrived to the U.S. prior to age 18 had better retention of natural dentition, better oral health related quality of life, and a lower proportion of dental appointments to address pain than those who arrived after age 18 or were born in the U.S. Conclusions: Im/migrants’ differentiated oral health outcomes by age at arrival to the U.S. suggest the relevance of lifecourse factors, for example the cumulative effects of risk and protective exposures, and confirm the merits of lifecourse studies of im/migrants’ oral health.

Predictors of Limited Access to Dental Health Care Among NYC Taxi/FHV Drivers

Taxi and for-hire vehicle (FHV) drivers are a largely immigrant, low-income occupational group at increased cardiovascular disease (CVD) risk. Poor dental health is a CVD risk factor, and dental care access is an unexamined taxi/FHV driver CVD risk factor. A cross-sectional survey was administered to 422 taxi/FHV drivers (2016-2017) to identify predictors of access to dental health care among drivers. One-third (n = 128, 30.3%) reported needing dental care/tests/treatment within the past six months, and nearly one-half (n = 61, 48%) were delayed/unable to obtain care. Only 57.6% (n = 241) had past-year dental cleanings. Not having enough money to cover household expenses was a significant predictor of being delayed/unable to obtain needed dental care/tests/treatment in the prior six months (0.5 OR; 95% CI, 0.28-0.89; p < .05). Lack of dental insurance coverage (2.72 OR; 95% CI, 1.60-4.63; p < .001) or lack of primary care provider (2.72 OR; 95% CI, 1.60-4.63; p < .001) were associated with lack of past-year dental cleaning. Seventeen percent of drivers with Medicaid were unaware of their dental coverage, which was associated with both inability to access needed dental care/tests/treatment in the past 6 months (p = .026) and no past-year dental cleaning (p < .001). Limited understanding of dental coverage was associated with both an inability to access needed dental care/tests/treatment in the past 6 months (p = .028) and lack of past-year dental cleaning (p = .014). Our findings can inform targeted intervention development to increase taxi/FHV driver dental care access/uptake, potentially improving their CVD risk.

Medicare Enrollment Rates Across Six Asian Subgroups in the USA

OBJECTIVES

Although Medicare is a vital source of health insurance coverage for older Americans, little is known about Medicare enrollment among older Asians. This study aimed to examine heterogeneity in Medicare enrollment across the six largest subgroups of Asian Americans (Chinese, Japanese, Filipino, Indian, Korean, and Vietnamese), in relation to their citizenship status and labor force participation.

METHODS

Data from the American Community Survey Public Use Microdata Sample (2014-2018) were analyzed for older foreign-born Asians aged 65 or older (N = 83,378). A two-level multilevel logistic regression model (states > individuals) was used to model the probabilities of Medicare enrollment, accounting for state-level residential clustering by Asian subgroup and, thus, for nonindependence among respondents from the same state.

RESULTS

The results indicated a substantial amount of heterogeneity in Medicare enrollment across the six Asian subgroups. Although the overall Medicare enrollment rate was low (90.2%), the rates varied from 85.5% among Indians to 93.8% among Koreans and Japanese. Naturalized citizens and those not in the labor force were associated with greater probabilities of Medicare enrollment. However, the relative differences in the Medicare enrollment rates across the six Asian subgroups were different by individuals' naturalization status and labor force participation (i.e., significant three-way interactions).

DISCUSSION

These results highlight that aggregated data cannot accurately represent Medicare and health insurance status of older Asians with different sub-ethnic backgrounds. Intragroup and intergroup differences in Medicare enrollment among foreign-born older Asians should be considered for targeted policy approaches for this group of older adults.

Prevalence and Patterns of Dental Care Utilization among US-Born and Non-US Born Hispanics in the Hispanic Community Health Study/Study of Latinos

OBJECTIVES

Access to routine dental services is important to maintaining good oral health. The aims of this study were to describe the dental care utilization patterns of a diverse group of Hispanic/Latino men and women and assess differences in dental care utilization by perceived need for dental care and proxy measures of acculturation.

METHODS

Data from 13,792 participants of the Hispanic Community Health Study were analyzed with SAS 9.4. Time since last dental visit was dichotomized into <1 and ≥1 y. Acculturation measures included the language and social subscales of the Short Acculturation Scale for Hispanics, the Multiethnic Study of Atherosclerosis nativity subscore, and immigrant generation. Survey logistic regression adjusted for demographic (age and sex) and health-related variables, estimated associations among perceived need for dental care, acculturation measures, and dental care utilization.

RESULTS

About a quarter (23%) of the participants were born in the 50 US states, excluding territories, while 77% were non-US born. Overall, 74% perceived a need for dental care. Upon covariate adjustment, perceiving a need for dental care was associated with reduced odds of reporting a past-year dental visit (odds ratio, 0.32; 95% CI, 0.28 to 0.37), while there appeared to be no meaningful association between proxy measures of acculturation and past-year dental visit. Having health insurance was significantly associated with a past-year dental visit (odds ratio, 2.23; 95% CI, 1.99 to 2.49) for all groups combined and among the different Hispanic/Latino background groups.

CONCLUSIONS

Acculturation affects general health and contributes to general health disparities; however, its role in dental care utilization remains questionable. Given that acculturation is a process that occurs over several years, longitudinal studies that evaluate oral health trajectories along the acculturation continuum are needed.

KNOWLEDGE TRANSFER STATEMENT

The results of this study are valuable for dental public health program planning and implementation for minority groups, as it describes the varying patterns of dental care utilization among US-born and non-US born Hispanics/Latinos and identifies factors that may partly explain dental care utilization patterns, such as acculturation.

Oral Health and Oral Health Service Utilization in Native and Immigrant Population: A Cross-Sectional Analysis from the PELFI Cohort in Spain

This study analyzes associated factors to self-perceived oral health and use of oral health services in native and immigrant adults from the PELFI cohort in Spain. A cross-sectional analysis was conducted (401 adults ≥ 18 years, from Spain, Ecuador, Colombia and Morocco). Frequencies for sociodemographic, self-perceived general and oral health variables were calculated. The association between oral health/oral health services use and origin country was estimated by logistic regression (adjusted odds ratio-aOR-; 95% confidence intervals -95%CI-). Ecuadorian men were more likely to report dental caries (aPR 2.75; 95%CI 1.30-5.80) and Moroccan women were more likely to report gingival bleeding (aPR 3.61; 95%CI 1.83-7.15) and the use of oral health services ≥ 1 year/never (aPR 1.69; 95%CI 1.06-2.69). Colombian women were less likely to report missing teeth (aPR 0.73; 95%CI 0.56-0.95). Poor self-perceived oral health indicators were observed in immigrants and were modified for sociodemographic and general health variables.

Immigration and Oral Health in Older Adults: An Integrative Approach

The aim of this study was to develop an integrative framework on aging, immigration, and oral health. The methodology was a critical review that used immigration as a social determinant framework through which to evaluate its impact on the oral health of older immigrants. We reviewed recent empirical evidence on factors related to oral health in older immigrants. In a systematic search across multiple databases, we identified 12 eligible studies in this review. Among the eligible studies, most were conducted among East Asian immigrants (8 articles), followed by non-Hispanic White/European origin (2 articles), Mexican origins (1 article), and Iran and other Middle East regions (1 article). The research revealed knowledge gaps in the evidence base, including the dynamic relationship between acculturation and oral health, the role of environmental factors on oral health for immigrants, psychosocial stressors and their relationship with oral health, and oral health literacy, norms, and attitude to dental care utilization and oral hygiene practices. The development of the integrative framework suggests the pathways/mechanisms through which immigration exerts influences on oral health in later life. This provides opportunities for researchers, practitioners, and policy makers to gain greater insights into the complex associations between immigration and oral health among older adults.

Association Between Opioid Prescriptions and Non-US-Born Status in the US

IMPORTANCE

Overdose from opioids causes nearly 50 000 deaths in the US each year. Adverse consequences from opioid use are particularly pronounced among low-income and publicly insured individuals. However, little is known about patterns of opioid prescribing among non-US-born individuals in the US.

OBJECTIVE

To examine the association of opioid prescriptions with non-US-born status, particularly among patients clinically diagnosed with pain.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis assessed opioid prescriptions among US-born and non-US-born adults using the 2016-2017 Medical Expenditure Panel Survey. Data were analyzed from January 1, 2016, to December 31, 2017.

MAIN OUTCOMES AND MEASURES

Practitioner-verified binary variable for any opioid prescription, number of prescriptions received, and a count variable for number of days of prescribed medicine. Multivariable logistic and negative binomial regression adjusted for sex, age, race/ethnicity, marital status, educational level, poverty, insurance status, clinical diagnoses for acute or chronic pain, census region, and survey year.

RESULTS

Among all 48 162 respondents (mean [SD] age, 47.0 [18.1] years; 25 831 [53.6%] female), 14.2% of US-born and 7.0% of non-US-born individuals received at least 1 opioid prescription within a 12-month period. For those diagnosed with chronic pain, 25.5% of US-born individuals and 15.6% of non-US-born individuals received at least 1 opioid prescription within a 12-month period. In multivariable logistic regression, non-US-born individuals had 35% lower odds of receiving an opioid prescription than US-born individuals (adjusted odds ratio, 0.65; 95% CI, 0.56-0.74). In negative binomial regression adjusting for confounding factors, non-US-born individuals with chronic pain who were prescribed opioids received significantly fewer days' supply (50.0; 95% CI, 40.0-59.9) than US-born individuals (77.2; 95% CI, 72.7-81.6). Differences between US-born and non-US-born individuals were not statistically significant for patients with acute pain (16.7% [95% CI, 14.9%-18.4%] of US-born individuals received opioids vs 12.5% [95% CI, 9.3%-15.6%] of non-US-born individuals). Non-US-born individuals with less than 5 years of residency in the US were significantly less likely to receive a prescription for opioids than were those with longer residency after adjustment for type of pain and other confounding factors (adjusted odds ratio, 0.51; 95% CI, 0.30-0.88).

CONCLUSIONS AND RELEVANCE

The findings suggest that non-US-born individuals, particularly those with shorter US residency, are less likely to be prescribed opioids than US-born individuals.

Oral Care Experiences of Latino Parents/Caregivers with Children with Autism and with Typically Developing Children

As a result of various barriers, several pediatric populations are at risk for poor oral health, including children with disabilities and children from under-represented populations, such as Latinos. To this end, this study aimed to better understand the factors that affect the oral health experiences of 32 Latino parents/caregivers from 18 families (n = 8 with a typically developing child and n = 10 with a child with Autism). Using a qualitative descriptive methodology, each family was interviewed twice. Interviews were audio-recorded, transcribed verbatim, and coded thematically to identify the individual, social, systemic, and culturally rooted factors contributing to oral health disparities in the families. The three themes that arose were "Why would I want to start trouble?": Latino parents' dissatisfaction with dental treatments, costs, and fear of the dentist and health care providers because of their ethnic minority status as key factors inhibiting receipt of dental care; "We have to put our children first": prioritizing the oral care activities of their children over their own individual oral care needs; and "We always keep baking soda around": familial and cultural influences on oral care habits. Understanding the oral health beliefs and experiences of Latino parents and caregivers of children with and without autism is critical for developing targeted prevention and intervention programs and reducing oral health disparities.

Racial/Ethnic Disparities in Dental Service Utilization for Foreign-Born and U.S.-Born Middle-Aged and Older Adults

This study examines racial/ethnic disparities of dental service utilization for foreign-born and U.S.-born dentate residents aged 50 years and older. Generalized linear mixed-effects models (GLMM) were used to perform longitudinal analyses of five-wave data of dental service utilization from the Health and Retirement Study (HRS). We used stratified analyses for the foreign-born and U.S.-born and assessed the nonlinear trend in rates of dental service utilization for different racial/ethnic groups. Findings indicate that Whites had higher rates of service utilization than Blacks and Hispanics regardless of birthplace. For all groups, the rates of service utilization decreased around age 80, and the rates of decline for Whites were slower than others. The U.S.-born showed the trend of higher rates of service utilization than the foreign-born for all racial/ethnic groups. These findings suggest the importance of developing culturally competent programs to meet the dental needs of the increasingly diverse populations in the United States.

Dental care use by immigrant Canadians in Ontario: a cross-sectional analysis of the 2014 Canadian Community Health Survey (CCHS)

BACKGROUND

Ontario is home to the largest number of immigrants in Canada. However, very little is known about their dental care utilization patterns. The purpose of this study is to determine the prevalence of poor dental health care use among the immigrant population of Ontario and how various socio-demographic, socio-economic and health-related factors are associated with it.

METHODS

Analysis was performed on a total of 4208 Ontarian immigrants who participated in the dental care module of the 2014 cycle of the Canadian Community Health Survey. Poor dental care use was defined by the two variables: not visiting the dentist in the past year and/or visiting the dentist only for emergency purposes. Multivariable logistic regression was performed to assess the associations between the two outcomes and the socio-demographic, socio-economic and health-related factors.

RESULTS

Thirty three percent of immigrants reported not visiting the dentist in the past year and 25% reported visiting only for emergencies. The leading components associated with poor dental care utilization were being a new immigrant, of male gender, having low educational attainment, low household income and lacking dental insurance.

CONCLUSIONS

This study is the first to highlight oral health care use patterns amongst immigrants in Ontario. Given that a large proportion of the immigrant population in Ontario have poor dental care use, education and outreach programs informing incoming immigrants of preventative dental care may improve overall dental health.

The effect of diabetes on tooth loss caused by periodontal disease: A nationwide population-based cohort study in South Korea

BACKGROUND

Our purpose was to compare the risk of tooth loss caused by periodontal disease between diabetic and nondiabetic individuals and to estimate the relative risk of tooth loss according to the severity and control of diabetes.

METHODS

We selected 10,215 individuals who were diagnosed as diabetics in the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) database in 2003 and the same number of individuals who had never been diagnosed with diabetes during the period covered by the NHIS-NSC (2002-2013) with propensity score matching. Diabetic individuals were divided into two groups according to the treatment modality. We counted the number of teeth lost in each group to determine the difference in the risk of tooth loss among groups and used the Cox proportional hazards model to calculate hazard ratios (HRs) of tooth loss caused by periodontitis.

RESULTS

Diabetic individuals had a higher risk of tooth loss than nondiabetic individuals (HR = 1.298, 95% confidence interval [CI]: 1.233 ≤ HR ≤ 1.366; P < 0.01). The severer the degree of diabetes, the higher the risk of tooth loss. As the number of dental visits increased, the risk of tooth loss declined (HR = 0.998, 95% CI: 0.996 ≤ HR ≤ 0.999; P < 0.01).

CONCLUSIONS

Within the limits of this retrospective cohort study, the risk of tooth loss among diabetic individuals was higher than that among nondiabetic individuals. The risk of tooth loss declined with increasing numbers of dental visits and increased with the severity of diabetes.

Preventive Dental Care Utilization in Asian Americans in Austin, Texas: Does Neighborhood Matter?

Although dental care is an essential component of comprehensive health care, a substantial proportion of the U.S. population lacks access to it. Disparities in dental care are most pronounced in racial/ethnic minority communities. Given the rapid population growth of Asian Americans, as well as the growing attention of neighborhood-level effects on health care use, the present study examines how individual-level variables (i.e., age, gender, marital status, ethnicity, education, place of birth, length of stay in the U.S., dental insurance, and self-rated oral health) and neighborhood-level variables (i.e., poverty level, density of Asian population, dentist availability, and Asian-related resources and services) contribute to predicting the use of preventive dental care in a sample of Asian Americans in Austin, TX. This study adds to the growing literature on the effect of neighborhood-level factors on health care as sources of disparities. Those living in the Census area with higher level of available dentists were more likely to use preventive dental care services. Findings suggest the importance of the location (proximity or accessibility) to dental clinics. In a planning perspective for health care policy, identifying the neighborhood with limited healthcare services could be a priority to diminish the disparity of the access.

Immigrants' Use of eHealth Services in the United States, National Health Interview Survey, 2011-2015

OBJECTIVES

Little is known about the use of electronic health (eHealth) services supported by information technology in the United States among immigrants, a group that faces barriers in accessing care and, consequently, disparities in health outcomes. We examined differences in the use of eHealth services in the United States by immigration status in a nationally representative sample.

METHODS

We used data from the 2011-2015 National Health Interview Survey to assess use of eHealth services among US natives, naturalized citizens, and noncitizens. Our outcome variable of interest was respondent-reported use of eHealth services, defined as making medical appointments online, refilling prescriptions online, or communicating with health care professionals through email, during the past 12 months. We analyzed use of eHealth services, demographic characteristics, socioeconomic status, and health status among all 3 groups. We used multivariate logistic regression models to examine the association between immigration status and the likelihood of using eHealth services, adjusting for individual demographic, socioeconomic, and health characteristics.

RESULTS

Among 126 893 US natives, 18 763 (16.1%) reported using any eHealth services in the past 12 months, compared with 1738 of 15 102 (13.0%) naturalized citizens and 1020 of 14 340 (7.8%) noncitizens. Adjusting for socioeconomic factors reduced initial gaps: naturalized citizens (adjusted odds ratio [aOR] = 0.81; 95% confidence interval [CI], 0.75-0.87) and noncitizens (aOR = 0.81; 95% CI, 0.72-0.90) had approximately 20% lower odds of using eHealth services than did US natives. However, the differences varied by type of eHealth service. Immigrants with higher English-language proficiency were more likely to use eHealth services than were immigrants with lower English-language proficiency.

CONCLUSIONS

Targeted interventions that reduce socioeconomic barriers in accessing technology and promote multilingual electronic portals could help mitigate disparities in use of eHealth services.

Fewer immigrants have preventable ED visits in the United States

OBJECTIVE

The aim of this study is to examine differences in having preventable emergency department (ED) visits between noncitizens, naturalized and US-born citizens in the United States.

METHODS

We linked the 2008-2012 Medical Expenditure Panel Survey with National Health Interview Survey data to draw a nationally representative sample of US adults. Univariate analysis described distribution of preventable ED visits identified by the Prevention Quality Indicators across immigration status. We also assessed the association between preventable ED visits and immigration status, controlling for demographics, socioeconomic status, health service utilization, and health status. We finally applied the Oaxaca-Blinder decomposition method to measure the contribution of each covariate to differences in preventable ED services utilization between US natives, naturalized citizens, and noncitizens.

RESULTS

Of US natives, 2.1% had any preventable ED visits within the past years as compared to 1.0% of noncitizens and 1.5% of naturalized citizens. Multivariate results also revealed that immigrants groups had significantly lower odds (adjusted OR: naturalized citizen 0.77 [0.61-0.96], noncitizen 0.62 [0.48-0.80]) of having preventable ED visits than natives. Further stratified analysis by insurance status showed these differences were only significant among the uninsured and public insurance groups. Race/ethnicity and health insurance explained about 68% of the difference in preventable ED service utilization between natives and noncitizens.

CONCLUSION

Our study documents the existing differences in preventable ED visits across immigration status, and highlights the necessity to explore unmet health needs among immigrants and eliminate disparities.

The Association Between Immigration Status and Office-based Medical Provider Visits for Cancer Patients in the United States

OBJECTIVES

We examined differences in cancer-related office-based provider visits associated with immigration status in the United States.

METHODS

Data from the 2007-2012 Medical Expenditure Panel Survey and National Health Interview Survey included adult patients diagnosed with cancer. Univariate analyses described distributions of cancer-related office-based provider visits received, expenditures, visit characteristics, as well as demographic, socioeconomic, and health covariates, across immigration groups. We measured the relationships of immigrant status to number of visits and associated expenditure within the past 12 months, adjusting for age, sex, educational attainment, race/ethnicity, self-reported health status, time since cancer diagnosis, cancer remission status, marital status, poverty status, insurance status, and usual source of care. We finally performed sensitivity analyses for regression results by using the propensity score matching method to adjust for potential selection bias.

RESULTS

Noncitizens had about 2 fewer visits in a 12-month period in comparison to US-born citizens (4.0 vs. 5.9). Total expenditure per patient was higher for US-born citizens than immigrants (not statistically significant). Noncitizens (88.3%) were more likely than US-born citizens (76.6%) to be seen by a medical doctor during a visit. Multivariate regression results showed that noncitizens had 42% lower number of visiting medical providers at office-based settings for cancer care than US-born citizens, after adjusting for all the other covariates. There were no significant differences in expenditures across immigration groups. The propensity score matching results were largely consistent with those in multivariate-adjusted regressions.

CONCLUSIONS

Results suggest targeted interventions are needed to reduce disparities in utilization between immigrants and US-born citizen cancer patients.

Oral Health and Dental Care in Older Asian Americans in Central Texas

OBJECTIVES

To examine factors associated with dental health insurance, self-rated oral health, and use of preventive dental care services in older Asian Americans.

DESIGN

Cross-sectional survey.

SETTING

The Asian American Quality of Life Survey was conducted with 2,614 Asian Americans living in central Texas using questionnaires available in English and six Asian languages.

PARTICIPANTS

Asian American Quality of Life Survey participants aged 60 and older (N = 533; mean age = 69.4 ± 6.9).

MEASUREMENTS

Participants were asked whether they had insurance that covered the cost of any dental visit, how they would rate their overall oral health status, and whether they had visited a dental clinic for a routine examination in the past 12 months. Information was also collected on sociodemographic and immigration-related variables.

RESULTS

More than 61% of the sample had no dental health insurance, 45% reported that their oral health was fair or poor, and 44% had not used preventive dental care services. A series of logistic regression analyses identified factors posing a significant risk to oral health and dental care. For example, those with limited English proficiency were 3.5 times as likely to lack dental health insurance and 3.2 times as likely to rate their oral health as fair or poor. The odds of not using preventive dental care services were 6.4 times as great in those without dental health insurance.

CONCLUSION

The overall findings call attention to efforts to promote oral health and dental care in older Asian Americans.