© 2013 Springer Publishing Company
Hispanic Health Care International, Vol. 11, No. 2, 2013
http://dx.doi.org/10.1891/1540-4153.11.2.87
Early Childhood Experiences, Cultural Beliefs, and Oral Health of Mexican American Women Helen B. Miltiades, PhD California State University, Fresno This qualitative article examines how financial resources, cultural beliefs, and early childhood experiences affect perceptions of oral health and dental utilization of middle-aged and older Mexican American women. Fourteen in-depth qualitative interviews were conducted. The women’s ages range from 49 to 87 years. Most had not visited the dentist in more than 2 years. Most women’s early childhood experiences did not include dental visits or dental instruction. Some believed tooth loss was a normal aging process. Misconceptions regarding preventive care, the belief that dental visits were only necessary when experiencing pain, and finances were the primary reasons for not visiting the dentist. The results lend insight into the oral health, self-care practices, and dental utilization of middle-aged and older immigrant Mexican American women. En este artículo cualitativo, examino cómo los recursos financieros, las creencias culturales y experiencias de la infancia afectan las percepciones de la salud oral y el uso dental de mujeres México Americanas de la mediana y de la tercera edad. Se llevaron a cabo catorce entrevistas cualitativas en profundidad. Las edades de las mujeres variaron entre los 49 y 87 años de edad. La mayoría no había visitado al dentista por más de dos años. Entre las experiencias de la infancia, la mayoría de las mujeres no incluyeron visitas al dentista o instrucciones dentales. Algunas creían que la pérdida de dientes es un proceso de envejecimiento normal. Los malentendidos sobre el cuidado preventivo, la creencia que las visitas al dentista eran necesarias sólo cuando se experimenta dolor, y sus finanzas fueron las razones principales para no ir al dentista. Los resultados ayudan a comprender la salud bucal, las prácticas de autocuidado y el uso dental de las mujeres inmigrantes México-Americanas de mediana y tercera edad. Keywords: aging; Mexican Americans; oral health; health seeking
H
ispanics are the largest and fastest growing minority group in the United States (The Pew Hispanic Center, 2005). More than 32 million Hispanics comprise 14.4% of the U.S. population (U.S. Census Bureau, 2001). The Hispanic population is also increasing in age diversity. Currently, 6% of the older adult population is Hispanic, although by 2025, estimates indicate that one in five older adults will be Hispanic (Federal Interagency Forum on Aging-Related Statistics, 2006). California is home to the largest concentration of Hispanics, and more than half are of Mexican heritage (Valdez & Arce, 2000). Even as the population is increasing in ethnic diversity, evidence suggests that oral health disparities persist among ethnic/racial groups,
and furthermore, that socioeconomic status does not fully account for these differences (Agency for Healthcare Research and Quality, 2010). Hispanics underutilize dental care, with only 22%–25% of older adults visiting the dentist annually (Ahluwalia & Sadowsky, 2003; Randolph, Ostir, & Markides, 2001; Skaar & Hardie, 2006). Older Hispanics are more likely than their White counterparts to have untreated oral disease and missing and/or decayed teeth (Borrell, Burt, & Taylor, 2005; Hudson, Stockard, & Ramberg, 2007; Watson & Brown, 1995). Mexican Americans have even lower dental utilization rates than other Hispanic groups, and higher unmet dental need (Scott & Simile, 2005; Wall & Brown, 2004). It is not surprising then that 66%–88% 87
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of Hispanic adults report a need for either preventive or restorative dental care (Luciano, Overman, Frasier, & Platin, 2008; Vazquez & Swan, 2003). An extensive body of literature focuses on individual factors that determine access to dental care and predict dental health. It is well documented that for Hispanic adults, socioeconomic factors such as higher educational attainment, income, dental insurance, and employment are associated with increased dental utilization, having a usual source of dental care, and improved oral health (Ahluwalia & Sadowsky, 2003; Graham, Tomar, & Logan, 2005; Reid, Hyman, & Macek, 2004; Sabbah, Tsakos, Chandola, Sheiham, & Watt, 2007; Stewart, Ortega, Dausey, & Rosenheck, 2002; Vazquez & Swan, 2003; Wall & Brown, 2004). Advocates recommend expanding dental coverage under Medicare and Medicaid for low-income and disadvantaged groups as a means of equalizing dental utilization (Ahluwalia & Sadowsky, 2003; Jones & Wehler, 2005; Tomar, Azevedo, & Lawson, 1998). However, researchers have shown that ethnic/racial differences persist in dental utilization patterns and oral health status even after controlling for traditional socioeconomic determinants (Hudson et al., 2007; Manski & Mager, 1998; Watson & Brown, 1995). Similar patterns have been observed for Mexican Americans in accessing health care (Durden & Hummer, 2006; Sabbah, Tsakos, Sheiham, & Watt, 2009). Community demonstration programs providing free dental services were insufficient to remove disparities for ethnic/racial minority children (Nairi Maserejian, Trachtenberg, & Link, 2008) and low-income older adults (Kuthy, Strayer, & Caswell, 1996). The Municipal Health Services Program removed financial barriers to dental care; still, 40% of older adults who used the medical services did not avail themselves to the free dental services (Kuthy et al., 1996). Clearly, there is a need to begin to identify the sociocultural and attitudinal factors that contribute to ethnic differences in oral health. Acculturation is the process of adjusting to the cultural values, beliefs, and behaviors of a new culture (Berry, 2003). Two recent reviews of the literature concluded that acculturation affects Latino health and health care use (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005; Wallace, Pomery, Latimer, Martinez, & Salovey, 2010). Most of the empirical literature on oral health conceptualizes acculturation in terms of nativity and language preference, which might act as a proxy for lower income and educational attainment. The Hispanic Health and Nutrition Examination Survey (HHANES) in the early 1980s revealed that preferring to speak English was associated with preventive health care use (Solis, Marks, Garcia, & Shelton, 1990). English speakers and Mexicans born in the United States are more likely to have a dental home and receive dental care than their less acculturated counterparts (Graham et al., 2005; Stewart et al., 2002; Vazquez & Swan, 2003; Wall & Brown, 2004). Other
studies have not found an association between speaking Spanish and oral health (Randolph et al., 2001) or with dental utilization after controlling for socioeconomic factors (Jaramillo, Eke, Thornton-Evans, & Griffin, 2009). In one of the latest studies of acculturation and oral health, Cruz, Chen, Salazar, and Geros (2009) concluded that “acculturation attributes are more relevant to [the] oral health experience than are most known risk factors for oral disease, including socioeconomic status” (p. S479). In proposing a framework for Hispanic oral health care, Mejia and colleagues (2008) note, “Researchers who have studied the dental health care utilization of Hispanics have failed to incorporate important factors such as cultural values” (p. 5). The purpose of this article is to examine how financial resources, cultural beliefs, and early childhood experiences affect perceptions of oral health and dental utilization of middle-aged and older Mexican American women in Fresno, California. To gain an in-depth understanding of cultural influences on oral health behavior, 14 qualitative interviews were conducted. The interviews were used to identify cultural beliefs about oral health, cultural values that affect oral health behavior, and to understand how early childhood experiences affect oral health beliefs and dental utilization.
Methods This study was approved by the California State University, Fresno Department of Social Work Education Review Board. In-depth qualitative interviews were conducted with 14 middle-aged and older Mexican American women. Given limited research on middle-aged and older Latina’s oral health, this study used targeted ethnographic interviews (Henderson, Gutierrez-Mayka, Garcia, & Boyd, 1993) to provide a starting point in understanding Latina oral health without preconceived notions and to explore sociocultural characteristics in depth (Berg, 2001). Given the small sample size, qualitative methods are optimal for generating rich subjective accounts of personal experience. The interviews were conducted by a nontraditional Mexican American woman who is a graduate student. Evidence suggests that the quality of responses is higher on culturally sensitive items when an ethnically similar interviewer conducts the interview (Reese, Danielson, Shoemaker, Chang, & Hsu, 1986; Webster, 1996). Interview outlines are recommended as a method of structuring interviews for minority elders who are unfamiliar with standardized survey questions (Miltiades, 2008; Yang, 2003). An interview outline was developed based on Kleinman’s (1981) questions for understanding cultural interpretations of health. The format allowed for probing. Questions centered on the shared meanings and values regarding oral health, typical oral health behaviors, and childhood experiences with oral health care. 88
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Examples and stories were elicited that revealed how the women viewed their oral health (Rubin & Rubin, 1995). Questions included (a) How healthy is your mouth?; (b) How do you take care of your mouth?; (c) What are the dental/oral health problems you have experienced?; (d) Talk about the last time a dentist examined your mouth.; (e) What are the reasons you visit a dentist/Why don’t you visit the dentist?; and (f) What did your parents teach you about the dentist? The interviews were audiotaped and verbatim transcriptions were produced in Spanish and English for 13 interviews. Only one interview was conducted entirely in English. In many interviews, the conversation seamlessly transitioned between English and Spanish. The Spanish translation into English was done by the Mexican American graduate student; consultation was provided by a Mexican American doctoral researcher, thus they were both familiar with colloquialisms and cultural nuances (Squires, 2009). Because Spanish and English are compatible in terms of grammatical structure, and because the participants interspersed English with Spanish, the decision was to translate the participants’ words literally. This offers justice to their worldview (Honig, 1997). During the interview, the interviewer asked for clarification when she was unsure of the respondent’s meanings. These clarifications are presented in brackets. The interviews were analyzed with QSR NVIVO software (QSR International Pty Ltd, 2008)—a qualitative data analysis package that allows for in-depth exploration of detailed interviews. Analysis of the qualitative data involved two distinct approaches. A qualitative inventory assessed the responses to specific questions posed during the interview and can be conceptualized as gross level categorization (Brenner, 1985). The second analytic focus was on themes that underlie or unify the responses found across the interviews (Luborsky, 1994). Themes are useful in discovering cultural beliefs and subcultural variations. The women’s statements are taken as a direct representation of their childhood experiences and current views of dental health.
to be frequented by older low-income Mexican American adults (Muhib et al., 2001). Recruitment from dental clinics and federally qualified health centers was not considered because this would produce a sample of individuals who are connected to formal health care systems.
Results There were 14 Mexican American female participants. Their age at immigration ranged from late teens to their early 30s. Their ages ranged from 49 to 87 years (M 5 66). One woman was in her 40s, 3 were in their 50s, 5 were in their 60s, 3 were in their 70s, and 1 was in her 80s. Seven were married; 1 woman resided with her spouse only. The other women, in addition to living with their spouse, 1 lived with a niece, 3 lived with their children, 1 with only their grandchild, and one with their adult children and grandchildren. Three widows and one divorced woman lived alone. One widow lived with her adult child and her grandchildren. One divorced woman resided with her mother. One woman declined to provide demographic information. In terms of educational attainment, nine women went to grammar school for several years, one finished middle school, two finished high school, and two had some college education. All described their household income as less than $20,000 a year. Four had a household income of less than $10,000. Four had a household income of more than $10,000 but less than $16,000. Finally, three women had a household income of more than $16,000 but less than $20,000. Only one woman would only say that her household income was less than $20,000. In describing their financial situation, seven women indicated that they were barely able or unable to afford daily necessities. Only three women indicated that they felt their financial situation was “comfortable.” Three women were currently employed. One woman was a merchandise handler in a warehouse, one worked in day care, and the other worked in laundry services. Past occupations included three field workers, one machine operator at a raisin packing house, four housewives, one office worker, one seamstress, and one babysitter “without pay.”
Sample
Oral Health Status
Low-income Mexican Americans are often not readily recruited for study participation because of literacy, language barriers, and privacy concerns (O’Hegarty et al., 2010). Thus, a face-to-face approach was employed because it is generally believed to be most effective in successfully recruiting Mexican American adults (O’Hegarty et al., 2010). Snowball sampling in the form of referrals by other study participants was also used. Similar to other studies, about half of the sample was obtained through referrals (Nacif de Brey & Gonzalez, 1997; Whitehorse, Manzano, Baezconde-Garbanati, & Hahn, 1999). Some participants were recruited at a local senior center known
Eight of the women described their oral health as “good.” Five described their oral health as being “so-so” or “not so good.” Five were dentate and nine either had missing teeth, both on the top and bottom dentures, or partials. In describing their last dental visit, five women went to the dentist routinely, four had not visited the dentist in 2–3 years, one had not visited the dentist in 4 years, one had not visited the dentist in 10 years, one last visited the dentist in 1976, and the other two had a recent emergency dental visit. Concerning the last dental visit, only three had routine cleanings. Two had fillings, one had a broken 89
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tooth capped, two had extractions, and four were fitted for or had denture repairs. One woman could not recall her last dental visit.
I’m going to tell you the truth. We were not raised with no doctors, no dentist, or nothing. We were raised on a ranch where there was nothing. And we would only rinse our mouths [with water] and chewing gum and that’s all. Well, only rinse because there were no toothbrushes and that’s it.
Reasons the Women Did Not Visit the Dentist
Another said,
The women who did not visit the dentist routinely were asked to discuss the reasons they did not utilize the dentist. Some women provided multiple reasons. Eight women mentioned economic concerns as reasons they did not frequent the dentist. One woman said,
My parents would only tell us to rinse our mouths. They would say with bicarbonate soda. So just like this [gestures], with our finger. Yes, we would wipe our teeth. And then rinse our mouths. Because we did not have toothbrushes, there was no toothpaste.
Because Medi-Cal doesn’t cover nothing anymore nor Medicare. Only extractions and cleanings, and what are they going to clean? Four [teeth] over here, and three [teeth] over here. What are they going to clean now? But, when I had my Medi-Cal, well, I would go every 6 months.
The women described their early childhood beliefs regarding oral health care. Misconceptions about the importance of oral hygiene were common in many recollections. Some women recalled they were taught that brushing led to irritated and/or bleeding gums. One said,
Another said, “I have been wanting to go, but first I want my husband to go because he has been having pain in his molars. Because we have no money to be going often.” Eight women believed dental visits were only necessary if they were experiencing dental problems. One said, “Because I do not need it, and if I don’t need it, well, I would rather use that money for something else. If my teeth do not hurt, for what [should I go]?” There was also the belief that dental care was not necessary in later life. One woman lost her dentures and did not replace them because she thought she was too old to need dentures. Another woman when talking about replacing her dentures said,
My parents didn’t even believe in brushing their teeth. Because that made your gums, you know, irritated. They thought that so much brushing your gums would go up [recede], you know? And you’d have long teeth! That’s what they used to think. And so I thought maybe that was true.
Another recalled that “they never brushed their teeth . . . because they thought that . . . you ruined your teeth if you would brush them too young!” When asked when their parents sought dental care, eight women responded that dental care was utilized only when the parents or daughters experienced oral pain. One said, “If there was someone whose molar was hurting, they would go into town to extract it, and that’s it.” One woman reflected that her parents taught her “that we shouldn’t suffer because of a toothache or molar ache. They would take us to the dentist when we would have a problem, when we were little.”
I haven’t done them because it’s really not that important. I’m 87 so, who cares? (Laughs) It doesn’t hurt or anything. I have a little bit more problem chewing. But not because my gums hurt. Because I think my dentures have already been dull or worn out.
One woman experienced dental anxiety and was worried that visiting a dentist would cause dental pain. Finally, one woman mentioned that she thought her physical health would be negatively affected by receiving oral health care. She said, “I have diabetes and high blood pressure. Then I had kidney problems and I thought maybe that [extraction] will affect my kidneys, and the dentist said ‘No, the kidneys don’t have anything to do with your teeth.’”
Oral Health Care Beliefs Some women were unsure how unhealthy behaviors, such as smoking, affected oral health. In describing her sister, one woman said, “She started to smoke very young. But I do not know if it damages the teeth.” Others believed tooth loss was inevitable with age. “My grandpa, figure this, his teeth fell off in old age, but I never knew that he went to a dentist. Well, poof, a tooth fell off, well, he was old, my grandpa.” There was also a lack of understanding regarding preventive oral care. Three women used baking soda as part of their daily oral hygiene routine. As one woman explained the use of baking soda, she said, “It was recommended to me, so then I wouldn’t have to go to the dentist.” She and the other women who used baking soda believed it prevented dental carries. The women with dentures and/or partials believed routine dental visits were not required for dentures. When asked why she didn’t utilize a dentist, one woman with dentures responded, “Because my teeth are not my teeth, that’s why I don’t have to go.”
Childhood Influences on Oral Health To determine how childhood experiences affect lifelong oral health care, the women were asked to describe their experiences with the dentist and oral health care at home when they were children. Only two women recalled visiting the dentist as children. The others all described growing up without dental access and without parental instruction in oral hygiene. One said, “Over there in Mexico, what dentist? There was no dentist. We didn’t even brush our teeth. We would only rinse with a liquid, named Astringosol [mouthwash], it is very good. Well, we had not even toothbrushes.” Another said, 90
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Perhaps because many of the women believed oral pain was a primary reason to seek dental care, they also believed extractions were the most efficient way to alleviate oral pain. Six women mentioned they chose extractions in lieu of dental fillings/crowns when experiencing oral pain. When discussing her last dental visit, one woman said, “So they could extract a molar because it was rotten and I had pain. So the pain could go away. And he [the dentist] took it out, and the pain was gone.” Other women described choosing extractions because they were in pain and were worried about financing dental care. In the following extreme case, one woman had all her teeth extracted even though the dentist advised against it and was willing to accept installment payments. This case illustrates how lifelong poverty negatively impacts oral health.
She took us [to the dentist] after we came here to the United States. She started to take us to the dentist, because from the school . . . the youngest ones [siblings] started to tell our mother that she had to take us to the dentist. So that’s when she started to take us, and to see the importance of going to a dentist. It was when there was more help [financial], because she started to receive Medi-Cal. And that is when . . . the school . . . you know how the schools . . . [have dental checks] for the children? Well, they would send a note telling her that she needed to take her children for dental care.
Discussion This article examined early childhood experiences with oral hygiene, oral health beliefs, and oral health practices of 14 Mexican American women. Similar to other studies, women mentioned lack of insurance and low income as reasons they did not utilize the dentist. However, this study also uncovered sociocultural reasons that affect dental utilization. Many women did not receive oral health care as young children; in fact, some of their parents believed routine oral hygiene practices, such as brushing, negatively affected oral health. This lack of early childhood training taught the women that preventive care was not necessary. Second, many women were taught that oral pain was the primary reason to visit the dentist. Once again, the focus is on emergency and not preventive care. Ageism also affected dental utilization. Several women believed tooth loss was a natural part of aging. Other women believed dental visits were not necessary in later life because they were too old to benefit from dental care. There were misconceptions regarding oral health care. Some women who wore dentures thought dental visits were not necessary for false teeth. Several other women thought the use of bicarbonate soda would prevent dental carries. These misconceptions affect preventive care. Encouragingly, this study points to the importance of education in the lives of children and the intergenerational transmission of knowledge and values. School nurses can be instrumental in promoting oral health by serving as a significant source of information and participating in dental health education prevention programs. School nurses in states with legislation requiring a kindergarten dental checkup can use the opportunity to provide parents with educational information including an emphasis on the importance of lifelong oral care. Considering most women in this study did not receive parental oral hygiene instruction, it is reasonable to posit that they did not emphasize oral hygiene when raising their children. Thus, multiple generations benefit by the dental checkups provided by the schools. The misconceptions regarding oral health care and the importance of preventive dental care point to the need for health education. Public health nurses who visit senior centers can educate older adults concerning oral health
I had many fillings, almost all of them. And I was tired of paying and paying, and one time I had so much pain that I did not know which one was hurting me and I went to my dentist, a very good dentist, and I told him, “You know, how much would it cost me to take all my teeth out?” And he said “Oh, no!” Because he was the one doing all of my [teeth] work, “You have fillings there that are going to last you all of your life!” And I told him to take a look at them because I felt pain in all my face, like an infection, and I told him I had never felt that way before, even my eyes, and my nose. I was 40 years old. He told me, “Okay, I’m going to have to take out the fillings and replace them.” And I told him, “No, no, no! I have no money and I have no insurance.” Because in those days I had nothing. I told him, “I cannot make [pay] all that expense. I want you to extract them all.” He said, “No, no! I will give you credit. I will wait for you.” I said “No, take them out!” I had so much pain, and it had been days [of pain]. Well, how crazy of me! He didn’t want to and I told him to take them. He took them out. He took all, all, all of my teeth that I had. Anyways, he gave me credit, and put in all my teeth [dentures].
When the expense of medical or dental care is prohibitive, some Mexican Americans will return to Mexico for dental/medical care (Rodriguez-Bencosme, 2007). One woman gave such an example: The doctor told me that I needed to get dentures. But because I did not have money, I suffered from this. They would have been $3,000–$5,000. So then, I went to my country and in my country they made them. Do you know how much? Three hundred dollars [USD].
To afford dental care, one woman frequented the emergency room. She said, “I go right over here . . . to the hospital to have my tooth pulled for $80.” Only two women visited the dentist as children. The other women’s first visits to the dentist occurred after they immigrated to the United States. Two women discussed the central role that the public school system played in their introduction to the dentist. In describing her mother, one woman said, 91
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conditions. The need for health information in Spanish is necessary to reach primarily Spanish-speaking older adults. For older adults who do not have access to care, public health nurses can also provide basic oral screening services and refer them to locally available dental programs. The clinical implications of impaired oral health include diet-related chronic disease, stroke, and coronary heart disease (Joshipura, Hung, Rimm, Willett, & Ascherio, 2003; Joshipura et al., 1996; Sheiham et al., 2001). Oral health disease can complicate the management of diabetes. There is growing consensus that promoting oral health requires a broad-based multidisciplinary approach inclusive of nurses (Bailey, Gueldner, Ledikwe, & Smiciklas-Wright, 2005). Historically, however, oral health has not been emphasized in nursing (Clemmens & Kerr, 2008). Older Hispanics are more likely to visit a general practitioner than a dentist. General practitioners and their nursing staff are at the front line of treatment and often the only health care providers who will have contact with older immigrants. There is a need to increase awareness among medical practitioners of the important role they can play in screening and educating patients regarding oral health. Nurses in general practice settings can provide culturally sensitive dental education, cursory basic risk assessments, referrals, and assist in obtaining needed dental care. Insurance coverage alone does not guarantee access to dental care (Hudson et al., 2007). A major barrier to dental utilization for Hispanics is oral health literacy; referrals from medical offices are critical to influencing dental utilization in the Latino population (Kane, Mosca, Zotti, & Schwalberg, 2008; Ramos-Gomez, Cruz, Watson, Canto, & Boneta, 2005). The findings are limited by the voluntary nature of the sample. Because the sample is nonrandom, it is unclear whether the sample is representative of the Mexican American population. Generalizability is furthermore limited to the characteristics of the study participants. The 14 respondents were primarily gathered through referrals and did not include males. It is generally accepted that Hispanic men are less likely than their female counterparts to receive recommended health care (Cheng, Chen, & Cunningham, 2007). Literature regarding gender differences in dental utilization and oral health of Hispanics is inconclusive and contradictory. Even though Hispanic women are more likely to have a dental home and visit the dentist than Hispanic men (Graham et al., 2005; Wall & Brown, 2004), they have more missing teeth than men (Jimenez, Dietrich, Shih, Li, & Joshipura, 2009; Randolph et al., 2001). Other researchers have not found gender differences in dental utilization (Davidson, Rams, & Andersen, 1997) and have found higher rates of oral health disease in men than women (Borrell et al., 2005). It is notable that many of these studies confound cultural backgrounds and age differences by lumping Hispanic subgroups together and combining various age groups. The decision to study only women draws attention to
the gender inequality within ethnic groups (Cooper, 2002) and the sociocultural aspects that can create gender inequalities (Dunlop, Manheim, Song, & Chang, 2002). Future academic research should include male respondents and probe deeper into cultural beliefs and the impact of early childhood influences on later life dental utilization and oral health. Out of 14 women, one refused to provide demographic information. The reason might have been because she was undocumented; however, only 1% of undocumented Hispanic immigrants in Fresno County are aged 65 years or older (Schur, Berk, Good, & Gardner, 1999). Therefore, it is highly unlikely that she or any of the other study participants were undocumented. This study is also limited by the focus on low-income older adults. Whereas some researchers urge studying Hispanics from the entire socioeconomic spectrum (Ramos-Gomez et al., 2005), the decision to focus on low-income older adults was made because of the recent changes in Medi-Cal, which curtailed dental payments for low-income older adults. It should be noted that Fresno has dental providers who serve low-income and Spanish-speaking populations. Fresno has one federally qualified health center look-alike and three comprehensive health centers with dental clinics. Almost 70% of dental clinics in Fresno have Spanish-speaking staff and 19% provide free services to low-income individuals (Capitman, Cortez, Lighthall, Primavera, & Traje, 2009). Although low-income Spanish speakers have access to dental care, a 2003 survey estimated that roughly 40% of Hispanic older adults in Fresno do not utilize dental care (California Health Interview Survey [CHIS], 2004). In this study, several women mentioned that they do not visit the dentist because Medi-Cal coverage of preventive care was eliminated. It is possible that other ethnic minority and low-income older adults face similar barriers to accessing dental care. The inability to afford preventive dental care might mean that low-income older adults will resort to using hospital emergency rooms for dental care. Information from this preliminary study can be used to develop a more comprehensive questionnaire measuring attitudes and beliefs toward dental and oral health care in quantitative research. Development of a larger study with random sample selection could shed insight into the complex relationship between financial status and attitudes and perceptions toward oral care.
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Early Childhood Experiences Bailey, R., Gueldner, S., Ledikwe, J., & Smiciklas-Wright, H. (2005). Interdisciplinary care. The oral health of older adults: An interdisciplinary mandate. Journal of Gerontological Nursing, 31(7), 11–17. Berg, B. L. (2001). Qualitative research methods for the social sciences (4th ed.). Boston, MA: Allyn and Bacon. Berry, J. W. (2003). Conceptual approaches to acculturation. In M. Chun & G. Marín (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 17–38). Washington, DC: American Psychological Association. Borrell, L. N., Burt, B. A., & Taylor, G. W. (2005). Prevalence and trends in periodontitis in the USA: The NHANES, 1988 to 2000. Journal of Dental Research, 84(10), 924–930. Brenner, M. (1985). Intensive interviewing. In M. Brenner, J. Brown, & D. Canter (Eds.), The research interview (pp. 147– 162). London, United Kingdom: Academic Press. California Health Interview Survey (CHIS). (2004). CHIS 2003 Adult Public Use File. Release 1 [Computer file]. Los Angeles, CA: UCLA Center for Health Policy Research. Capitman, J. A., Cortez, A., Lighthall, D., Primavera, L., & Traje, D. (2009). Access to oral health care in Central California. Fresno, CA: California State University. Cheng, E. M., Chen, A., & Cunningham, W. (2007). Primary language and receipt of recommended health care among Hispanics in the United States. Journal of General Internal Medicine, 22(Suppl. 2), 283–288. Clemmens, D. A., & Kerr, A. R. (2008). Improving oral health in women: Nurses’ call to action. MCN, American Journal of Maternal Child Nursing, 33(1), 10–14. Cooper, H. (2002). Investigating socio-economic explanations for gender and ethnic inequalities in health. Social Science and Medicine, 54(5), 693–706. Cruz, G. D., Chen, Y., Salazar, C. R., & Geros, R. Z. L. (2009). The association of immigration and acculturation attributes with oral health among immigrants in New York City. American Journal of Public Health, 99(Suppl. 2), S474–S480. Davidson, P. L., Rams, T. E., & Andersen, R. M. (1997). Sociobehavioral determinants of oral hygiene practices among USA ethnic and age groups. Advances in Dental Research, 11(2), 245–253. http://dx.doi.org/10.1177/08959374970110020701 Dunlop, D. D., Manheim, L. M., Song, J., & Chang, R. W. (2002). Gender and ethnic/racial disparities in health care utilization among older adults. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 57(4), S221–S233. Durden, T. E., & Hummer, R. A. (2006). Access to healthcare among working-aged Hispanic adults in the United States. Social Science Quarterly, 87(5), 1319–1343. Federal Interagency Forum on Aging-Related Statistics. (2006). Older Americans update 2006: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Graham, M. A., Tomar, S. L., & Logan, H. L. (2005). Perceived social status, language and identified dental home among Hispanics in Florida. Journal of the American Dental Association, 136(11), 1572–1582. Henderson, J. N., Gutierrez-Mayka, M., Garcia, J., & Boyd, S. (1993). A model for Alzheimer’s disease support group development in African-American and Hispanic populations. The Gerontologist, 33, 409–414. Honig, H. (1997). Positions, power and practice: Functionalist approaches and translation quality assessment. Current Issues in Language and Society, 4(1), 6–34.
Hudson, K., Stockard, J., & Ramberg, Z. (2007). The impact of socioeconomic status and race-ethnicity on dental health. Sociological Perspectives, 50(1), 7–25. Jaramillo, F., Eke, P. I., Thornton-Evans, G. O., & Griffin, S. O. (2009). Acculturation and dental visits among Hispanic adults. Preventing Chronic Disease, 6(2), 1–7. Jimenez, M., Dietrich, T., Shih, M.-C., Li, Y., & Joshipura, K. J. (2009). Racial/ethnic variations in associations between socioeconomic factors and tooth loss. Community Dentistry and Oral Epidemiology, 37, 267–275. Jones, J. A., & Wehler, C. J. (2005). The elder’s oral health summit: Introduction and recommendations. Journal of Dental Education, 69(9), 957–960. Joshipura, K. J., Hung, H.-C., Rimm, E. B., Willett, W. C., & Ascherio, A. (2003). Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke, 34(1), 47–52. Joshipura, K. J., Rimm, E. B., Douglass, C. W., Trichopoulos, D., Ascherio, A., & Willett, W. C. (1996). Poor oral health and coronary heart disease. Journal of Dental Research, 75(9), 1631–1636. Kane, D., Mosca, N., Zotti, M., & Schwalberg, R. (2008). Factors associated with access to dental care for children with special health care needs. Journal of the American Dental Association, 139(3), 326–333. Kleinman, A. (1981). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, CA: University of CA Press. Kuthy, R. A., Strayer, M. S., & Caswell, R. J. (1996). Determinants of dental user groups among an elderly, low-income population. Health Services Research, 30(6), 809–825. Lara, M., Gamboa, C., Kahramanian, M. I., Morales, L. S., & Hayes Bautista, D. E. (2005). Acculturation and Latino health: A review of the literature and its sociopolitical context. Annual Review of Public Health, 26(1), 367–397. Luborsky, M. R. (1994). The identification and analysis of themes and patterns. In J. F. Gubrium & A. Sankar (Eds.), Qualitative methods in aging research (pp. 189–210). Thousand Oaks, CA: Sage. Luciano, M., Overman, V., Frasier, P., & Platin, E. (2008). Survey of oral health practices among adults in a North Carolina Hispanic population. Journal of Dental Hygiene, 82(2), 1–14. Manski, R. J., & Mager, L. S. (1998). Demographic and socioeconomic predictors of dental care utilization. Journal of the American Dental Association, 129, 195–200. Mejia, G. C., Kaufman, J. S., Corbie-Smith, G., Rozier, R. G., Caplan, D. J., & Suchindran, C. M. (2008). A conceptual framework for Hispanic oral health care. Journal of Public Health Dentistry, 68(1), 1–6. Miltiades, H. (2008). Interview as a social event: Cultural influences experienced while interviewing older adults in India. International Journal of Social Research Methodology, 11(4), 277–291. Muhib, F. B., Lin, L. S., Stueve, A., Miller, R. L., Ford, W. L., Johnson, W. D., . . . Community Intervention Trial for Youth Study Team. (2001). A venue-based method for sampling hard-to-reach populations. Public Health Reports, 116(Suppl. 1), 216–222. Nacif de Brey, V., & Gonzalez, V. M. (1997). Recruiting for arthritis studies in hard-to-reach populations: A comparison of methods used in an urban Spanish-speaking community. Arthritis Care Research, 10(1), 64–71. 93
Miltiades Nairi Maserejian, N., Trachtenberg, F., & Link, C. (2008). Underutilization of dental care when it is freely available: A prospective study of the New England Children’s Amalgam Trial. Journal of Public Health Dentistry, 68(3), 139–148. O’Hegarty, M., Pederson, L. L., Thorne, S. L., Caraballo, R. S., Evans, B., Athey, L., & McMichael, J. (2010). Customizing survey instruments and data collection to reach Hispanic/ Latino adults in border communities in Texas. American Journal of Public Health, 100(Suppl. 1), S159–S164. The Pew Hispanic Center. (2005). Hispanics: A people in motion. Washington, DC: Pew Research Center. QSR International Pty Ltd. (2008). NVivo qualitative data analysis software. (Version 8) [Computer software]. Doncaster, Australia: Author. Ramos-Gomez, F., Cruz, G. D., Watson, M. R., Canto, M. T., & Boneta, A. E. (2005). Latino oral health: A research agenda toward eliminating oral health disparities. Journal of the American Dental Association, 136(9), 1231–1240. Randolph, W. M., Ostir, G. V., & Markides, K. S. (2001). Prevalence of tooth loss and dental service use in older Mexican Americans. Journal of the American Geriatrics Society, 49(5), 585–589. Reese, S. D., Danielson, W. A., Shoemaker, P. J., Chang, T. K., & Hsu, H. L. (1986). Ethnicity-of-interviewer effects among Mexican-Americans and Anglos. The Public Opinion Quarterly, 50(4), 563–572. Reid, B. C., Hyman, J. J., & Macek, M. D. (2004). Race/ethnicity and untreated dental carries: The impact of material and behavioral factors. Community Dentistry and Oral Epidemiology, 32, 329–336. Rodriguez-Bencosme, J. (2007). Oral health concerns of the Hispanic population in the United States: Dental hygienists making a positive impact in this population. Access, 21(7), 26–29. Rubin, H. J., & Rubin, I. S. (1995). Qualitative interviewing: The art of hearing data. Thousand Oaks, CA: Sage. Sabbah, W., Tsakos, G., Chandola, T., Sheiham, A., & Watt, R. G. (2007). Social gradients in oral and general health. Journal of Dental Research, 86(10), 992–996. http://dx.doi .org/10.1177/154405910708601014 Sabbah, W., Tsakos, G., Sheiham, A., & Watt, R. G. (2009). The effects of income and education on ethnic differences in oral health: A study in U.S. adults. Journal of Epidemiology Community Health, 63, 516–520. Schur, C. L., Berk, M. L., Good, C. D., & Gardner, E. N. (1999). California’s undocumented Latino immigrants: A report on access to health care services. Bethesda, MD: The Project HOPE Center for Health Affairs. Scott, G., & Simile, C. (2005). Access to dental care among Hispanic or Latino subgroups: United States, 2000–03. Hyattsville, MD: National Center for Health Statistics. Sheiham, A., Steele, J. G., Marcenes, W., Lowe, C., Finch, S., Bates, C. J., . . . Walls, A. W. G. (2001). The relationship among dental status, nutrient intake, and nutritional status in older people. Journal of Dental Research, 80(2), 408–413. http://dx.doi.org/10.1177/00220345010800020201 Skaar, D. D., & Hardie, N. A. (2006). Demographic factors associated with dental utilization among community dwelling elderly in the United States, 1997. Journal of Public Health Dentistry, 66(1), 67–71.
Solis, J. M., Marks, G., Garcia, M., & Shelton, D. (1990). Acculturation, access to care, and use of preventive services by Hispanics: Findings from HHANES 1982–84. American Journal of Public Health, 80(Suppl), 11–19. http://dx.doi .org/10.2105/AJPH.80.Suppl.11 Squires, A. (2009). Methodological challenges in cross-language qualitative research: A research review. International Journal of Nursing Studies, 46(2), 277–287. Stewart, D. C., Ortega, A. N., Dausey, D., & Rosenheck, R. (2002). Oral health and use of dental services among Hispanics. Journal of Public Health Dentistry, 62(2), 84–91. Tomar, S. L., Azevedo, A. B., & Lawson, R. (1998). Adult dental visits in California: Successes and challenges. Journal of Public Health Dentistry, 58(4), 275–280. U.S. Census Bureau. (2001). Table 15: Resident population by Hispanic origin status, 1980 to 2000, and projections, 2005 to 2050. Washington, DC: U.S. Department of Commerce, Economics and Statistical Administration, Census Bureau. Valdez, R. B., & Arce, C. (2000). A profile of Hispanic elders. In Horizons project: Nationwide demographic report (pp. 32). San Antonio, TX: Cutting Edge Communications. Vazquez, L., & Swan, J. H. (2003). Access and attitudes toward oral health care among Hispanics in Wichita, Kansas. The Journal of Dental Hygiene, 77(2), 85–96. Wall, T. P., & Brown, L. J. (2004). Dental visits among Hispanics in the United States, 1999. Journal of the American Dental Association, 135(7), 1011–1017. Wallace, P. M., Pomery, E. A., Latimer, A. E., Martinez, J. L., & Salovey, P. (2010). A review of acculturation measures and their utility in studies promoting Latino health. Hispanic Journal of Behavioral Sciences, 32(1), 37–54. http://dx.doi .org/10.1177/0739986309352341 Watson, M. R., & Brown, L. J. (1995). The oral health of U.S. Hispanics: Evaluating their needs and their use of dental services. Journal of the American Dental Association, 126(6), 789–795. Webster, C. (1996). Hispanic and Anglo interviewer and respondent ethnicity and gender: The impact on survey response quality. Journal of Marketing Research, 33(1), 62–72. Whitehorse, L. E., Manzano, R., Baezconde-Garbanati, L. A., & Hahn, G. (1999). Culturally tailoring a physical activity program for Hispanic women: Recruitment successes of la vida buena’s salsa aerobics. Journal of Health Education, 30, S18–S24. Yang, K. (2003). Hmong Americans: A review of felt needs, problems, and community development. Hmong Studies Journal, 4, 1–23. Acknowledgment. The author wishes to thank Laura Quezada for her research assistance. Correspondence regarding this article should be directed to Helen B. Miltiades, PhD, California State University, Fresno, Department of Social Work Education, 5310 N. Campus Dr. M/S PH102, Fresno, CA 93740. E-mail: [email protected]
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Hispanic Health Care International, Vol. 11, No. 2, 2013
http://dx.doi.org/10.1891/1540-4153.11.2.87
Early Childhood Experiences, Cultural Beliefs, and Oral Health of Mexican American Women Helen B. Miltiades, PhD California State University, Fresno This qualitative article examines how financial resources, cultural beliefs, and early childhood experiences affect perceptions of oral health and dental utilization of middle-aged and older Mexican American women. Fourteen in-depth qualitative interviews were conducted. The women’s ages range from 49 to 87 years. Most had not visited the dentist in more than 2 years. Most women’s early childhood experiences did not include dental visits or dental instruction. Some believed tooth loss was a normal aging process. Misconceptions regarding preventive care, the belief that dental visits were only necessary when experiencing pain, and finances were the primary reasons for not visiting the dentist. The results lend insight into the oral health, self-care practices, and dental utilization of middle-aged and older immigrant Mexican American women. En este artículo cualitativo, examino cómo los recursos financieros, las creencias culturales y experiencias de la infancia afectan las percepciones de la salud oral y el uso dental de mujeres México Americanas de la mediana y de la tercera edad. Se llevaron a cabo catorce entrevistas cualitativas en profundidad. Las edades de las mujeres variaron entre los 49 y 87 años de edad. La mayoría no había visitado al dentista por más de dos años. Entre las experiencias de la infancia, la mayoría de las mujeres no incluyeron visitas al dentista o instrucciones dentales. Algunas creían que la pérdida de dientes es un proceso de envejecimiento normal. Los malentendidos sobre el cuidado preventivo, la creencia que las visitas al dentista eran necesarias sólo cuando se experimenta dolor, y sus finanzas fueron las razones principales para no ir al dentista. Los resultados ayudan a comprender la salud bucal, las prácticas de autocuidado y el uso dental de las mujeres inmigrantes México-Americanas de mediana y tercera edad. Keywords: aging; Mexican Americans; oral health; health seeking
H
ispanics are the largest and fastest growing minority group in the United States (The Pew Hispanic Center, 2005). More than 32 million Hispanics comprise 14.4% of the U.S. population (U.S. Census Bureau, 2001). The Hispanic population is also increasing in age diversity. Currently, 6% of the older adult population is Hispanic, although by 2025, estimates indicate that one in five older adults will be Hispanic (Federal Interagency Forum on Aging-Related Statistics, 2006). California is home to the largest concentration of Hispanics, and more than half are of Mexican heritage (Valdez & Arce, 2000). Even as the population is increasing in ethnic diversity, evidence suggests that oral health disparities persist among ethnic/racial groups,
and furthermore, that socioeconomic status does not fully account for these differences (Agency for Healthcare Research and Quality, 2010). Hispanics underutilize dental care, with only 22%–25% of older adults visiting the dentist annually (Ahluwalia & Sadowsky, 2003; Randolph, Ostir, & Markides, 2001; Skaar & Hardie, 2006). Older Hispanics are more likely than their White counterparts to have untreated oral disease and missing and/or decayed teeth (Borrell, Burt, & Taylor, 2005; Hudson, Stockard, & Ramberg, 2007; Watson & Brown, 1995). Mexican Americans have even lower dental utilization rates than other Hispanic groups, and higher unmet dental need (Scott & Simile, 2005; Wall & Brown, 2004). It is not surprising then that 66%–88% 87
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of Hispanic adults report a need for either preventive or restorative dental care (Luciano, Overman, Frasier, & Platin, 2008; Vazquez & Swan, 2003). An extensive body of literature focuses on individual factors that determine access to dental care and predict dental health. It is well documented that for Hispanic adults, socioeconomic factors such as higher educational attainment, income, dental insurance, and employment are associated with increased dental utilization, having a usual source of dental care, and improved oral health (Ahluwalia & Sadowsky, 2003; Graham, Tomar, & Logan, 2005; Reid, Hyman, & Macek, 2004; Sabbah, Tsakos, Chandola, Sheiham, & Watt, 2007; Stewart, Ortega, Dausey, & Rosenheck, 2002; Vazquez & Swan, 2003; Wall & Brown, 2004). Advocates recommend expanding dental coverage under Medicare and Medicaid for low-income and disadvantaged groups as a means of equalizing dental utilization (Ahluwalia & Sadowsky, 2003; Jones & Wehler, 2005; Tomar, Azevedo, & Lawson, 1998). However, researchers have shown that ethnic/racial differences persist in dental utilization patterns and oral health status even after controlling for traditional socioeconomic determinants (Hudson et al., 2007; Manski & Mager, 1998; Watson & Brown, 1995). Similar patterns have been observed for Mexican Americans in accessing health care (Durden & Hummer, 2006; Sabbah, Tsakos, Sheiham, & Watt, 2009). Community demonstration programs providing free dental services were insufficient to remove disparities for ethnic/racial minority children (Nairi Maserejian, Trachtenberg, & Link, 2008) and low-income older adults (Kuthy, Strayer, & Caswell, 1996). The Municipal Health Services Program removed financial barriers to dental care; still, 40% of older adults who used the medical services did not avail themselves to the free dental services (Kuthy et al., 1996). Clearly, there is a need to begin to identify the sociocultural and attitudinal factors that contribute to ethnic differences in oral health. Acculturation is the process of adjusting to the cultural values, beliefs, and behaviors of a new culture (Berry, 2003). Two recent reviews of the literature concluded that acculturation affects Latino health and health care use (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005; Wallace, Pomery, Latimer, Martinez, & Salovey, 2010). Most of the empirical literature on oral health conceptualizes acculturation in terms of nativity and language preference, which might act as a proxy for lower income and educational attainment. The Hispanic Health and Nutrition Examination Survey (HHANES) in the early 1980s revealed that preferring to speak English was associated with preventive health care use (Solis, Marks, Garcia, & Shelton, 1990). English speakers and Mexicans born in the United States are more likely to have a dental home and receive dental care than their less acculturated counterparts (Graham et al., 2005; Stewart et al., 2002; Vazquez & Swan, 2003; Wall & Brown, 2004). Other
studies have not found an association between speaking Spanish and oral health (Randolph et al., 2001) or with dental utilization after controlling for socioeconomic factors (Jaramillo, Eke, Thornton-Evans, & Griffin, 2009). In one of the latest studies of acculturation and oral health, Cruz, Chen, Salazar, and Geros (2009) concluded that “acculturation attributes are more relevant to [the] oral health experience than are most known risk factors for oral disease, including socioeconomic status” (p. S479). In proposing a framework for Hispanic oral health care, Mejia and colleagues (2008) note, “Researchers who have studied the dental health care utilization of Hispanics have failed to incorporate important factors such as cultural values” (p. 5). The purpose of this article is to examine how financial resources, cultural beliefs, and early childhood experiences affect perceptions of oral health and dental utilization of middle-aged and older Mexican American women in Fresno, California. To gain an in-depth understanding of cultural influences on oral health behavior, 14 qualitative interviews were conducted. The interviews were used to identify cultural beliefs about oral health, cultural values that affect oral health behavior, and to understand how early childhood experiences affect oral health beliefs and dental utilization.
Methods This study was approved by the California State University, Fresno Department of Social Work Education Review Board. In-depth qualitative interviews were conducted with 14 middle-aged and older Mexican American women. Given limited research on middle-aged and older Latina’s oral health, this study used targeted ethnographic interviews (Henderson, Gutierrez-Mayka, Garcia, & Boyd, 1993) to provide a starting point in understanding Latina oral health without preconceived notions and to explore sociocultural characteristics in depth (Berg, 2001). Given the small sample size, qualitative methods are optimal for generating rich subjective accounts of personal experience. The interviews were conducted by a nontraditional Mexican American woman who is a graduate student. Evidence suggests that the quality of responses is higher on culturally sensitive items when an ethnically similar interviewer conducts the interview (Reese, Danielson, Shoemaker, Chang, & Hsu, 1986; Webster, 1996). Interview outlines are recommended as a method of structuring interviews for minority elders who are unfamiliar with standardized survey questions (Miltiades, 2008; Yang, 2003). An interview outline was developed based on Kleinman’s (1981) questions for understanding cultural interpretations of health. The format allowed for probing. Questions centered on the shared meanings and values regarding oral health, typical oral health behaviors, and childhood experiences with oral health care. 88
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Examples and stories were elicited that revealed how the women viewed their oral health (Rubin & Rubin, 1995). Questions included (a) How healthy is your mouth?; (b) How do you take care of your mouth?; (c) What are the dental/oral health problems you have experienced?; (d) Talk about the last time a dentist examined your mouth.; (e) What are the reasons you visit a dentist/Why don’t you visit the dentist?; and (f) What did your parents teach you about the dentist? The interviews were audiotaped and verbatim transcriptions were produced in Spanish and English for 13 interviews. Only one interview was conducted entirely in English. In many interviews, the conversation seamlessly transitioned between English and Spanish. The Spanish translation into English was done by the Mexican American graduate student; consultation was provided by a Mexican American doctoral researcher, thus they were both familiar with colloquialisms and cultural nuances (Squires, 2009). Because Spanish and English are compatible in terms of grammatical structure, and because the participants interspersed English with Spanish, the decision was to translate the participants’ words literally. This offers justice to their worldview (Honig, 1997). During the interview, the interviewer asked for clarification when she was unsure of the respondent’s meanings. These clarifications are presented in brackets. The interviews were analyzed with QSR NVIVO software (QSR International Pty Ltd, 2008)—a qualitative data analysis package that allows for in-depth exploration of detailed interviews. Analysis of the qualitative data involved two distinct approaches. A qualitative inventory assessed the responses to specific questions posed during the interview and can be conceptualized as gross level categorization (Brenner, 1985). The second analytic focus was on themes that underlie or unify the responses found across the interviews (Luborsky, 1994). Themes are useful in discovering cultural beliefs and subcultural variations. The women’s statements are taken as a direct representation of their childhood experiences and current views of dental health.
to be frequented by older low-income Mexican American adults (Muhib et al., 2001). Recruitment from dental clinics and federally qualified health centers was not considered because this would produce a sample of individuals who are connected to formal health care systems.
Results There were 14 Mexican American female participants. Their age at immigration ranged from late teens to their early 30s. Their ages ranged from 49 to 87 years (M 5 66). One woman was in her 40s, 3 were in their 50s, 5 were in their 60s, 3 were in their 70s, and 1 was in her 80s. Seven were married; 1 woman resided with her spouse only. The other women, in addition to living with their spouse, 1 lived with a niece, 3 lived with their children, 1 with only their grandchild, and one with their adult children and grandchildren. Three widows and one divorced woman lived alone. One widow lived with her adult child and her grandchildren. One divorced woman resided with her mother. One woman declined to provide demographic information. In terms of educational attainment, nine women went to grammar school for several years, one finished middle school, two finished high school, and two had some college education. All described their household income as less than $20,000 a year. Four had a household income of less than $10,000. Four had a household income of more than $10,000 but less than $16,000. Finally, three women had a household income of more than $16,000 but less than $20,000. Only one woman would only say that her household income was less than $20,000. In describing their financial situation, seven women indicated that they were barely able or unable to afford daily necessities. Only three women indicated that they felt their financial situation was “comfortable.” Three women were currently employed. One woman was a merchandise handler in a warehouse, one worked in day care, and the other worked in laundry services. Past occupations included three field workers, one machine operator at a raisin packing house, four housewives, one office worker, one seamstress, and one babysitter “without pay.”
Sample
Oral Health Status
Low-income Mexican Americans are often not readily recruited for study participation because of literacy, language barriers, and privacy concerns (O’Hegarty et al., 2010). Thus, a face-to-face approach was employed because it is generally believed to be most effective in successfully recruiting Mexican American adults (O’Hegarty et al., 2010). Snowball sampling in the form of referrals by other study participants was also used. Similar to other studies, about half of the sample was obtained through referrals (Nacif de Brey & Gonzalez, 1997; Whitehorse, Manzano, Baezconde-Garbanati, & Hahn, 1999). Some participants were recruited at a local senior center known
Eight of the women described their oral health as “good.” Five described their oral health as being “so-so” or “not so good.” Five were dentate and nine either had missing teeth, both on the top and bottom dentures, or partials. In describing their last dental visit, five women went to the dentist routinely, four had not visited the dentist in 2–3 years, one had not visited the dentist in 4 years, one had not visited the dentist in 10 years, one last visited the dentist in 1976, and the other two had a recent emergency dental visit. Concerning the last dental visit, only three had routine cleanings. Two had fillings, one had a broken 89
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tooth capped, two had extractions, and four were fitted for or had denture repairs. One woman could not recall her last dental visit.
I’m going to tell you the truth. We were not raised with no doctors, no dentist, or nothing. We were raised on a ranch where there was nothing. And we would only rinse our mouths [with water] and chewing gum and that’s all. Well, only rinse because there were no toothbrushes and that’s it.
Reasons the Women Did Not Visit the Dentist
Another said,
The women who did not visit the dentist routinely were asked to discuss the reasons they did not utilize the dentist. Some women provided multiple reasons. Eight women mentioned economic concerns as reasons they did not frequent the dentist. One woman said,
My parents would only tell us to rinse our mouths. They would say with bicarbonate soda. So just like this [gestures], with our finger. Yes, we would wipe our teeth. And then rinse our mouths. Because we did not have toothbrushes, there was no toothpaste.
Because Medi-Cal doesn’t cover nothing anymore nor Medicare. Only extractions and cleanings, and what are they going to clean? Four [teeth] over here, and three [teeth] over here. What are they going to clean now? But, when I had my Medi-Cal, well, I would go every 6 months.
The women described their early childhood beliefs regarding oral health care. Misconceptions about the importance of oral hygiene were common in many recollections. Some women recalled they were taught that brushing led to irritated and/or bleeding gums. One said,
Another said, “I have been wanting to go, but first I want my husband to go because he has been having pain in his molars. Because we have no money to be going often.” Eight women believed dental visits were only necessary if they were experiencing dental problems. One said, “Because I do not need it, and if I don’t need it, well, I would rather use that money for something else. If my teeth do not hurt, for what [should I go]?” There was also the belief that dental care was not necessary in later life. One woman lost her dentures and did not replace them because she thought she was too old to need dentures. Another woman when talking about replacing her dentures said,
My parents didn’t even believe in brushing their teeth. Because that made your gums, you know, irritated. They thought that so much brushing your gums would go up [recede], you know? And you’d have long teeth! That’s what they used to think. And so I thought maybe that was true.
Another recalled that “they never brushed their teeth . . . because they thought that . . . you ruined your teeth if you would brush them too young!” When asked when their parents sought dental care, eight women responded that dental care was utilized only when the parents or daughters experienced oral pain. One said, “If there was someone whose molar was hurting, they would go into town to extract it, and that’s it.” One woman reflected that her parents taught her “that we shouldn’t suffer because of a toothache or molar ache. They would take us to the dentist when we would have a problem, when we were little.”
I haven’t done them because it’s really not that important. I’m 87 so, who cares? (Laughs) It doesn’t hurt or anything. I have a little bit more problem chewing. But not because my gums hurt. Because I think my dentures have already been dull or worn out.
One woman experienced dental anxiety and was worried that visiting a dentist would cause dental pain. Finally, one woman mentioned that she thought her physical health would be negatively affected by receiving oral health care. She said, “I have diabetes and high blood pressure. Then I had kidney problems and I thought maybe that [extraction] will affect my kidneys, and the dentist said ‘No, the kidneys don’t have anything to do with your teeth.’”
Oral Health Care Beliefs Some women were unsure how unhealthy behaviors, such as smoking, affected oral health. In describing her sister, one woman said, “She started to smoke very young. But I do not know if it damages the teeth.” Others believed tooth loss was inevitable with age. “My grandpa, figure this, his teeth fell off in old age, but I never knew that he went to a dentist. Well, poof, a tooth fell off, well, he was old, my grandpa.” There was also a lack of understanding regarding preventive oral care. Three women used baking soda as part of their daily oral hygiene routine. As one woman explained the use of baking soda, she said, “It was recommended to me, so then I wouldn’t have to go to the dentist.” She and the other women who used baking soda believed it prevented dental carries. The women with dentures and/or partials believed routine dental visits were not required for dentures. When asked why she didn’t utilize a dentist, one woman with dentures responded, “Because my teeth are not my teeth, that’s why I don’t have to go.”
Childhood Influences on Oral Health To determine how childhood experiences affect lifelong oral health care, the women were asked to describe their experiences with the dentist and oral health care at home when they were children. Only two women recalled visiting the dentist as children. The others all described growing up without dental access and without parental instruction in oral hygiene. One said, “Over there in Mexico, what dentist? There was no dentist. We didn’t even brush our teeth. We would only rinse with a liquid, named Astringosol [mouthwash], it is very good. Well, we had not even toothbrushes.” Another said, 90
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Perhaps because many of the women believed oral pain was a primary reason to seek dental care, they also believed extractions were the most efficient way to alleviate oral pain. Six women mentioned they chose extractions in lieu of dental fillings/crowns when experiencing oral pain. When discussing her last dental visit, one woman said, “So they could extract a molar because it was rotten and I had pain. So the pain could go away. And he [the dentist] took it out, and the pain was gone.” Other women described choosing extractions because they were in pain and were worried about financing dental care. In the following extreme case, one woman had all her teeth extracted even though the dentist advised against it and was willing to accept installment payments. This case illustrates how lifelong poverty negatively impacts oral health.
She took us [to the dentist] after we came here to the United States. She started to take us to the dentist, because from the school . . . the youngest ones [siblings] started to tell our mother that she had to take us to the dentist. So that’s when she started to take us, and to see the importance of going to a dentist. It was when there was more help [financial], because she started to receive Medi-Cal. And that is when . . . the school . . . you know how the schools . . . [have dental checks] for the children? Well, they would send a note telling her that she needed to take her children for dental care.
Discussion This article examined early childhood experiences with oral hygiene, oral health beliefs, and oral health practices of 14 Mexican American women. Similar to other studies, women mentioned lack of insurance and low income as reasons they did not utilize the dentist. However, this study also uncovered sociocultural reasons that affect dental utilization. Many women did not receive oral health care as young children; in fact, some of their parents believed routine oral hygiene practices, such as brushing, negatively affected oral health. This lack of early childhood training taught the women that preventive care was not necessary. Second, many women were taught that oral pain was the primary reason to visit the dentist. Once again, the focus is on emergency and not preventive care. Ageism also affected dental utilization. Several women believed tooth loss was a natural part of aging. Other women believed dental visits were not necessary in later life because they were too old to benefit from dental care. There were misconceptions regarding oral health care. Some women who wore dentures thought dental visits were not necessary for false teeth. Several other women thought the use of bicarbonate soda would prevent dental carries. These misconceptions affect preventive care. Encouragingly, this study points to the importance of education in the lives of children and the intergenerational transmission of knowledge and values. School nurses can be instrumental in promoting oral health by serving as a significant source of information and participating in dental health education prevention programs. School nurses in states with legislation requiring a kindergarten dental checkup can use the opportunity to provide parents with educational information including an emphasis on the importance of lifelong oral care. Considering most women in this study did not receive parental oral hygiene instruction, it is reasonable to posit that they did not emphasize oral hygiene when raising their children. Thus, multiple generations benefit by the dental checkups provided by the schools. The misconceptions regarding oral health care and the importance of preventive dental care point to the need for health education. Public health nurses who visit senior centers can educate older adults concerning oral health
I had many fillings, almost all of them. And I was tired of paying and paying, and one time I had so much pain that I did not know which one was hurting me and I went to my dentist, a very good dentist, and I told him, “You know, how much would it cost me to take all my teeth out?” And he said “Oh, no!” Because he was the one doing all of my [teeth] work, “You have fillings there that are going to last you all of your life!” And I told him to take a look at them because I felt pain in all my face, like an infection, and I told him I had never felt that way before, even my eyes, and my nose. I was 40 years old. He told me, “Okay, I’m going to have to take out the fillings and replace them.” And I told him, “No, no, no! I have no money and I have no insurance.” Because in those days I had nothing. I told him, “I cannot make [pay] all that expense. I want you to extract them all.” He said, “No, no! I will give you credit. I will wait for you.” I said “No, take them out!” I had so much pain, and it had been days [of pain]. Well, how crazy of me! He didn’t want to and I told him to take them. He took them out. He took all, all, all of my teeth that I had. Anyways, he gave me credit, and put in all my teeth [dentures].
When the expense of medical or dental care is prohibitive, some Mexican Americans will return to Mexico for dental/medical care (Rodriguez-Bencosme, 2007). One woman gave such an example: The doctor told me that I needed to get dentures. But because I did not have money, I suffered from this. They would have been $3,000–$5,000. So then, I went to my country and in my country they made them. Do you know how much? Three hundred dollars [USD].
To afford dental care, one woman frequented the emergency room. She said, “I go right over here . . . to the hospital to have my tooth pulled for $80.” Only two women visited the dentist as children. The other women’s first visits to the dentist occurred after they immigrated to the United States. Two women discussed the central role that the public school system played in their introduction to the dentist. In describing her mother, one woman said, 91
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conditions. The need for health information in Spanish is necessary to reach primarily Spanish-speaking older adults. For older adults who do not have access to care, public health nurses can also provide basic oral screening services and refer them to locally available dental programs. The clinical implications of impaired oral health include diet-related chronic disease, stroke, and coronary heart disease (Joshipura, Hung, Rimm, Willett, & Ascherio, 2003; Joshipura et al., 1996; Sheiham et al., 2001). Oral health disease can complicate the management of diabetes. There is growing consensus that promoting oral health requires a broad-based multidisciplinary approach inclusive of nurses (Bailey, Gueldner, Ledikwe, & Smiciklas-Wright, 2005). Historically, however, oral health has not been emphasized in nursing (Clemmens & Kerr, 2008). Older Hispanics are more likely to visit a general practitioner than a dentist. General practitioners and their nursing staff are at the front line of treatment and often the only health care providers who will have contact with older immigrants. There is a need to increase awareness among medical practitioners of the important role they can play in screening and educating patients regarding oral health. Nurses in general practice settings can provide culturally sensitive dental education, cursory basic risk assessments, referrals, and assist in obtaining needed dental care. Insurance coverage alone does not guarantee access to dental care (Hudson et al., 2007). A major barrier to dental utilization for Hispanics is oral health literacy; referrals from medical offices are critical to influencing dental utilization in the Latino population (Kane, Mosca, Zotti, & Schwalberg, 2008; Ramos-Gomez, Cruz, Watson, Canto, & Boneta, 2005). The findings are limited by the voluntary nature of the sample. Because the sample is nonrandom, it is unclear whether the sample is representative of the Mexican American population. Generalizability is furthermore limited to the characteristics of the study participants. The 14 respondents were primarily gathered through referrals and did not include males. It is generally accepted that Hispanic men are less likely than their female counterparts to receive recommended health care (Cheng, Chen, & Cunningham, 2007). Literature regarding gender differences in dental utilization and oral health of Hispanics is inconclusive and contradictory. Even though Hispanic women are more likely to have a dental home and visit the dentist than Hispanic men (Graham et al., 2005; Wall & Brown, 2004), they have more missing teeth than men (Jimenez, Dietrich, Shih, Li, & Joshipura, 2009; Randolph et al., 2001). Other researchers have not found gender differences in dental utilization (Davidson, Rams, & Andersen, 1997) and have found higher rates of oral health disease in men than women (Borrell et al., 2005). It is notable that many of these studies confound cultural backgrounds and age differences by lumping Hispanic subgroups together and combining various age groups. The decision to study only women draws attention to
the gender inequality within ethnic groups (Cooper, 2002) and the sociocultural aspects that can create gender inequalities (Dunlop, Manheim, Song, & Chang, 2002). Future academic research should include male respondents and probe deeper into cultural beliefs and the impact of early childhood influences on later life dental utilization and oral health. Out of 14 women, one refused to provide demographic information. The reason might have been because she was undocumented; however, only 1% of undocumented Hispanic immigrants in Fresno County are aged 65 years or older (Schur, Berk, Good, & Gardner, 1999). Therefore, it is highly unlikely that she or any of the other study participants were undocumented. This study is also limited by the focus on low-income older adults. Whereas some researchers urge studying Hispanics from the entire socioeconomic spectrum (Ramos-Gomez et al., 2005), the decision to focus on low-income older adults was made because of the recent changes in Medi-Cal, which curtailed dental payments for low-income older adults. It should be noted that Fresno has dental providers who serve low-income and Spanish-speaking populations. Fresno has one federally qualified health center look-alike and three comprehensive health centers with dental clinics. Almost 70% of dental clinics in Fresno have Spanish-speaking staff and 19% provide free services to low-income individuals (Capitman, Cortez, Lighthall, Primavera, & Traje, 2009). Although low-income Spanish speakers have access to dental care, a 2003 survey estimated that roughly 40% of Hispanic older adults in Fresno do not utilize dental care (California Health Interview Survey [CHIS], 2004). In this study, several women mentioned that they do not visit the dentist because Medi-Cal coverage of preventive care was eliminated. It is possible that other ethnic minority and low-income older adults face similar barriers to accessing dental care. The inability to afford preventive dental care might mean that low-income older adults will resort to using hospital emergency rooms for dental care. Information from this preliminary study can be used to develop a more comprehensive questionnaire measuring attitudes and beliefs toward dental and oral health care in quantitative research. Development of a larger study with random sample selection could shed insight into the complex relationship between financial status and attitudes and perceptions toward oral care.
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