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Article Excerpt
CHILDREN'S ORAL HEALTH in the United States has improved over recent decades, yet numerous studies have documented profound disparities. (1) Eighty percent of dental disease among children is found in 20% to 25% of children (~18 million), and these are primarily children from black, Hispanic, American Indian/Alaskan Native, and low-income families. (2) Poor children experience nearly 12 times as many restricted activity days from dental diseases as do children from higher income families. (3)
Disparities in access to dental care reflect family income, parental education, race/ethnicity, and urban/ rural residence. (4-6) In 2004, an estimated 6,6% of American children 2 to 17 years of age had an unmet dental need, and 13.1% had not seen a dentist in >5 years. (7) Dental care was identified as the most prevalent unmet health need in US children, (8) and rural children have greater unmet dental need than do their urban peers. (4,6) Failure to obtain preventive dental care was more common among the children who came from low-income families, who were uninsured and non-Hispanic white, and who had a parent with less than a college education. (9,10) Yet, Oral Health in America: A Report of the Surgeon General (1) specifically calls for more data on dental care among diverse segments of the US population to eliminate health disparities, including racial and ethnic minorities, rural population, individuals with disabilities, immigrants, migrant workers, and the very young.
Our research examined disparities in dental insurance coverage and dental care among US children by race/ ethnicity, socioeconomic status, and urban/rural residence. Our secondary goal was to examine factors associated with dental care among US children. Dental care is a major component of child health care costs, representing approximately one quarter of US dental spending. (11) Better understanding of disparities in access to care among children, and subsequent development of intervention programs, will ultimately help save health costs and improve overall health for the next generation.
DATA AND METHODS
Data Sources and Population
We used cross-sectional data from the National Survey of Children's Health (NSCH) (N = 102 353), a telephone survey described briefly by Kogan and Newacheck in this issue, (12) with in-depth information available elsewhere. (13) To obtain information on the supply of dentists at county level, we supplemented the NSCH with the data from the Area Resource File (ARF).
Children 1 through 17 years of age who had natural teeth at the interview time were the population of interest. We excluded 5873 children who were <1 year old or had no natural teeth, 2769 with no parental responses to dental outcomes, and 3619 with missing information on any covariates except household income. After linking the NSCH data to the ARF data, another 1021 children were excluded because of missing data on the urban/rural residence definition in the ARF. No significant changes in sample characteristics before and after this ARF linkage were observed. Thus, the final sample included 89 071 children. Human subjects review was not required for this study.
Outcome Measures
Dental Insurance Coverage
Parents or guardians of the child were asked whether the child has insurance that helps pay for routine dental care, including cleanings, radiographs, and examinations. Although health insurance was characterized in the NSCH as public, private, and none, information on type of coverage was not available for dental insurance.
Preventive Dental Care
The respondents were asked "during the past 12 months ... did the child see a dentist for any routine preventive dental care, including checkups, screenings, and sealants? Include all types of dentists such as orthodontists, oral surgeons and all other dental specialists." A negative response was classified as failure to receive preventive dental care in the past 12 months.
Parentally Perceived Unmet Need for Dental Care
This measure combined responses to 2 questions. The first question is "during the past 12 months.... was there any time when the child needed routine preventive health care?" An affirmative response was followed with another question "did he/she receive all the routine preventive dental care he/she needed?" A child was determined as having parentally perceived unmet need for preventive dental care if parents answered that the child needed the care but did not receive it.
Primary Independent Variables
Race/Ethnicity
Children were grouped into Hispanic, non-Hispanic white, non-Hispanic African American, and non-Hispanic others (hereafter, Hispanic, white, black, and others, respectively). (13)
Urban/Rural Residence
Residence information is not available in the public use data set to protect respondent confidentiality. We accessed residence data through the Research Data Center at the National Center for Health Statistics. "Urban" was defined as living in a metropolitan statistical area; all other places were classified as "rural".
Socioeconomic Status
Socioeconomic status (SES) was measured by household poverty status and the highest level of parental education. Poverty status used 4 categories based on the federal poverty guidelines: poor (<100% of the federal poverty level), near poor (100%-199 %), middle income (200%-399%), and higher income ([greater than or equal to] 400%). A fifth category, missing, was used to retain approximately 9% of children with missing information on household income. Parental education was examined in 3 categories: low (less than high school), medium (high school), and high (above high school).
Analytical Model
We adopted the health behavior model proposed by Aday and Andersen as the conceptual framework for the analysis. (14) According to this model, the use of health services depends on characteristics that predispose individuals to use services, enable individuals to secure services, or create a need for their use. In our analysis, the predisposing factors included were age, gender, race/ ethnicity, total number of children in the household, family structure, parental education, nativity, and primary language spoken at home. For enabling factors, we included household poverty status,...
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