Sociocultural Influences Upon Preventive Health Behavior and Attitudes Towards Dentistry RONALD P. STRAUSS, DMD, MA
Abstract: One hundred eighty adults who presented for general dental care at an urban dental school clinic were interviewed and given epidemiological screening examinations. The findings presented include a profile of a clinic population with respect to ethnic identity, family income, education, nuclear family structure, and residence. The two major racial groups (black and white) are found to have highly significant differences in their perception of dental services and their experiences with dental disease and treatment. An assessment of dental health status indicates that whites were more likely to have filled teeth, and blacks, decayed or unfilled teeth. This relates to differ-
ent patterns in seeking recent preventive dental services and a marked disparity in utilization early in life. Fear and anxiety about dental care, degree of orientation towards prevention and differences in exposure to preventive information varied with race. Consumerist orientation is examined in terms of willingness to criticize services, be cared for by auxiliary health workers and accept professional fees. The identification of diversity in perception and values with respect to dental health care is characterized as an element in developing understanding between providers and consumers. (Am. J. Public Health 66:375-377, 1976)
The model of dental health behavior provides an excellent opportunity to examine preventive motivation and cultural variations in health actions. The present study was undertaken with the hope that its results will help dental school clinics to include and accomodate to minority group urban patients who so frequently reside in the community surrounding a university center. The dental school clinic selected was in the Northeast and supplied a site for interviews and screening exams.
The dental school clinic is situated in an urban ghetto and university area which according to 1970 Census data is 72 per cent black and 26 per cent white.1 The clinic population sampled proved to be 41 per cent black and 57 per cent white with at least 30 per cent of the total population drawn from suburban areas. The institution's perception of itself as a regional resource leads to a concomitant lesser involvement in the geographically adjacent community, consistent with the alienation that is evident between the university and the community that surrounds it. The racial composition of the clinic population may have been affected by the predominantly middle class and white character of both the institution and the care providers. In keeping with this pattern, white interviewers were employed in this study. Twenty per cent of the population used medical clinics or hospitals when they were in need of medical care. Blacks in the sample tended to be more frequent medical clinic users. Seventy-six per cent of the whites "routinely" used private physicians as contrasted to 43 per cent of the blacks. Eighty-one per cent of the sample had seen a dentist within the last three years, and three-fourths had last seen a private dentist. The dental clinic utilizers tended to be well educated, with 72 per cent completing high school, and a relatively low mean family income of $7,500. Ninety-three per cent of the blacks in the sample were urban residents as opposed to 50 per cent of the whites. Such a skew in residence is at least partially a reflection of differences in family income between the two groups, suburban living being more expensive. Blacks tended to have much lower family incomes than did whites. Thirty-six per cent of the white group earned over $10,000, while only 17 per cent
Sample Characteristics The sample studied here consisted of 180 adults who presented themselves at an urban dental school clinic. Names were randomly selected from a file of patients who had sought general dental care, but had not been seen due to overenrollment at the clinic. General dental care was defined as not including specialized services such as surgical, prosthetic, or orthodontic care. The population seeking general dental services proved to be two-thirds male (65.56 per cent) with 63 per cent of the men and women in their 20's or 30's. Address reprint requests to Dr. Ronald P. Strauss, Department of Dental Ecology, University of North Carolina, Chapel Hill, NC 27514. This paper, presented at the 102nd Annual Meeting of the American Public Health Association, New Orleans, LA, was revised and accepted for publication on December 16, 1975. This study was supported by Grant DE 00240 of the Public Health Service, and was undertaken while the author was studying toward a doctoral degree in Sociology at the University of Pennsylvania.
AJPH, April, 1976, Vol. 66, No. 4
375
STRAUSS
of the blacks did so. Among those earning below $5,000, blacks were significantly over-represented, with 39 per cent of the blacks and 22 per cent of the whites in this category. This earning differential is keenly linked to differences in education. In this rather well educated patient population, whites were twice as likely to have been to college as were blacks. Structural differences in the nuclear family were reflected in the fact that while blacks and whites in the sample had nearly the same likelihood of having been married, 24 per cent of the blacks as opposed to 6.8 per cent of the whites no longer had intact marriages (divorced, separated, or widowed). It is important to note that the sex ratio between the two racial groups differed significantly. Seventythree per cent of the blacks and 59 per cent of the whites were female. Thus it is clear that when we are discussing racial differences, we are in reality considering the impact of a constellation of factors that are associated with ethnic identity and which each play a role in the production of diversity.
Results and Discussion One hundred seventy-six respondents agreed to be screened. There was a significant difference in DMF (decayed, missing, and filled tooth count) between the different racial groups (Table 1). Blacks tended to have lower total scores, but analysis indicates that whites tended to have a larger number of filled teeth, while blacks had a greater number of decayed or unfilled teeth (Tables 2 and 3). No significant difference in the number of missing teeth was found. This clinical care pattern is suggestive of differences in access to care and utilization patterns between urban blacks and whites. These differences may also be reflected in the finding that black patients had significantly different recent dental experiences. They tended to have waited longer between their last dental visit and their presentation to the dental school clinic. Fifty-three per cent of the black patients, as opposed to 18 per cent of the whites had last received only non-preventive emergency, surgical, or prosthetic services. The white group was more likely to have had their most reTABLE 1-Racial Distribution of Decayed, Missing, and Filled Teeth (DMF)
TABLE 2-Racial Distribution of Filled Teeth Alone Filled Teeth Alone
0-4 Low 5-11 Med 12-26 High
RACE
TOTAL
White
Black
(176)
17.6% (18) 32.4% (33) 50.0%
52.7% (39) 37.8% (28) 9.5%
32.4% (57) 34.7% (61) 33.0%
(51)
(7)
(58)
Chi-Square = 38.034, significant under .001 with 2 degrees of freedom Gamma = -0.691, significant under .001
cent dental experience with general dental or preventive services. While both patient groups in the sample were most likely to have last seen a private dentist, 28 per cent of the black patients as opposed to 8 per cent of the whites had last been to public clinics. Differences in early utilization patterns between racial groups are recognized by examining the date of first dental visit. The black patients studied tended to have their first encounters with dental care later than did whites (Table 4). Nearly one-fourth of the black patients had not encountered a dentist until after the teen years. Such marked differences in utilization patterns suggest that different populations may be perceiving the health services differently. Although most blacks and whites in the sample were aware that they had recently needed more dental care, blacks were less likely to rate their own teeth as good or excellent. Black patients were far more likely to anticipate the need of dental extractions. They were also twice as likely (23 per cent) to rate their general health as fair to poor than were the whites in the sample (10.8 per cent). In terms of tooth value, blacks placed a significantly higher value on tooth appearance and its influence upon making friends. More blacks said that they were willing to spend 15 minutes per night caring for their teeth, and they considered this less of a time demand than did the whites in the sample. Thus, it appears that the blacks studied have a high level of awareness of their teeth and place considerable importance upon their maintenance. Considering this finding, it is unfortunate that 36 per cent of the blacks as compared to 9 per TABLE 3-Racial Distribution of Decayed Teeth Alone
Decayed, Missing and Filled
0-14 Low 15-19 Med 20-32 High TOTAL
RACE White
TOTAL Black
28.4%
43.2%
34.7%
(29)
(61) 33.5% (59) 31.8% (56)
57.7%
(32) 40.5% (30) 16.2% (12) 42.3%
100.0%
(102)
(74)
(176)
28.4%
(29) 43.1% (44)
Chi-Square = 13.80, significant at .002 with 2 degrees of freedom Gamma = -0.393, significant under.001 376
0-1 Low 2-5 Med 6-20 High
TOTAL
RACE
Decayed Teeth Alone
White
Black
(176)
37.3%
17.6%
29.0%
(38)
(13)
(51)
42.2%
28.4%
36.4%
(43)
(21)
(64)
20.6%
54.1%
34.7%
(21)
(40)
(61)
Chi-Square = 38.034, significant under .001 with 2 degrees of freedom Gamma = 0.521, significant under .001 AJPH, April, 1976, Vol. 66, No. 4
DENTAL HEALTH BEHAVIOR TABLE 4-Initial Dental Experience According to Race TOTAL
RACE
First Dental Visit
White
Black
(178)
Before Teens During Teens After Teens
83.5% (86) 15.5% (16) 1.0% (1)
45.3% (34) 30.7% (23) 24.0% (18)
67.4% (120) 21.9% (39) 10.7% (19)
Chi-Square = 35.473, significant under .001 with 2 degrees of freedom Gamma = 0.728, significant under .001 No response: 2 persons
cent of the whites did not know what dental floss was, and that far fewer blacks were actually using floss. It appears that the necessary information concerning preventive dental practices has not as yet reached a significant portion of this highly motivated segment of the black community. Sixty-six per cent of the whites as opposed to 37 per cent of the blacks in the sample had decided that fluoride is helpful. Differential exposure to preventive information may have led to the difference between racial groups concerning belief in the efficacy of dental preventive measures. Perceptions of dental care are influenced by how patients relate to dental treatment. Thiry-six per cent of the blacks, as contrasted with 15 per cent of the whites, admitted that they had avoided going to a dentist because they were afraid that the treatment would be painful. They were also far more likely to expect pain upon a dental visit. This was amplified by the finding that nearly twice as many blacks as whites would like anesthesia used all the time by dentists. This certainly emphasized that within the black study group there was a great deal more fear and sensitivity about dental pain than with the white group. That there is a cultural component in pain response has long been recognized,2 but the social components that play a part in this specific case need further definition and research. The black patients in this study seemed to relate to health professionals quite differently than did the whites. Blacks were far more likely to prefer a dentist who "makes a decision about what treatment is necessary and doesn't waste time talking about it." Blacks tended to respect the fully trained health professional and were three times as like-
AJPH, Aprl, 1976, Vol. 66, No. 4
ly to be disappointed if treated by a hygienist or technician instead of a dentist on a clinic visit. Such respect was also shown in the black patient's reluctance to be critical of the dentist. While 43 per cent of the white clinic patients admitted to having seen a dentist in the past who was either rough, cruel, or inconsiderate, only 28 per cent of the blacks admitted to a similar experience. Perhaps this is the result of less contact with the health care system; it may also reflect a social situation defined by a predominantly white professional health clinic that is intimidating to the minority patient and increases his reluctance to be critical or play a decisive part in his own health care. In any case, the fact that such a sizeable portion of the patient community expressed a strong criticism of dentists suggests that the profession re-examine its mechanisms of dealing with individual patients as well as its public image. Important factors in the utilization of dental services are manpower distribution and financial accessibility.3 Black patients, more than whites, felt that there were not enough dentists in their community. Only one-fourth of the total sample thought that dental fees were "about right." Threefourths of the sample thought they would have some difficulty with a sudden $200 dental bill, with blacks more likely to admit that they could not handle such an expense. Fifty per cent of the black patients believed that dental fees depended on who the dentist was. It is important to remember as we consider these findings that the population sample, and the university dental clinic with its white staff in an urban ghetto represent a very special situation. The population studied was one that seeks general dental care, and seeks this care at a dental school clinic. Such clinics are slow, involve much paper work and patience in return for reasonably inexpensive quality dental care. They are not designed to be community health centers at the present time.
REFERENCES 1. 1970 Census, U.S. Department of Commerce, Bureau of the Census-Philadelphia Census Tract Areas. #73-74, 76-80, 85-93, 103-111 included in population analysis. 2. Zborowski, M., Cultural components on responses to pain, J. of Soc. Issues 8:16-30, 1952. 3. Richards, N. D., Utilization of dental services, In Social Sciences and Dentistry-A Critical Bibliography. N. D. Richards and L. K. Cohen, Eds. Federation Dentaire Internationale, 209239, 1971.
377
Abstract: One hundred eighty adults who presented for general dental care at an urban dental school clinic were interviewed and given epidemiological screening examinations. The findings presented include a profile of a clinic population with respect to ethnic identity, family income, education, nuclear family structure, and residence. The two major racial groups (black and white) are found to have highly significant differences in their perception of dental services and their experiences with dental disease and treatment. An assessment of dental health status indicates that whites were more likely to have filled teeth, and blacks, decayed or unfilled teeth. This relates to differ-
ent patterns in seeking recent preventive dental services and a marked disparity in utilization early in life. Fear and anxiety about dental care, degree of orientation towards prevention and differences in exposure to preventive information varied with race. Consumerist orientation is examined in terms of willingness to criticize services, be cared for by auxiliary health workers and accept professional fees. The identification of diversity in perception and values with respect to dental health care is characterized as an element in developing understanding between providers and consumers. (Am. J. Public Health 66:375-377, 1976)
The model of dental health behavior provides an excellent opportunity to examine preventive motivation and cultural variations in health actions. The present study was undertaken with the hope that its results will help dental school clinics to include and accomodate to minority group urban patients who so frequently reside in the community surrounding a university center. The dental school clinic selected was in the Northeast and supplied a site for interviews and screening exams.
The dental school clinic is situated in an urban ghetto and university area which according to 1970 Census data is 72 per cent black and 26 per cent white.1 The clinic population sampled proved to be 41 per cent black and 57 per cent white with at least 30 per cent of the total population drawn from suburban areas. The institution's perception of itself as a regional resource leads to a concomitant lesser involvement in the geographically adjacent community, consistent with the alienation that is evident between the university and the community that surrounds it. The racial composition of the clinic population may have been affected by the predominantly middle class and white character of both the institution and the care providers. In keeping with this pattern, white interviewers were employed in this study. Twenty per cent of the population used medical clinics or hospitals when they were in need of medical care. Blacks in the sample tended to be more frequent medical clinic users. Seventy-six per cent of the whites "routinely" used private physicians as contrasted to 43 per cent of the blacks. Eighty-one per cent of the sample had seen a dentist within the last three years, and three-fourths had last seen a private dentist. The dental clinic utilizers tended to be well educated, with 72 per cent completing high school, and a relatively low mean family income of $7,500. Ninety-three per cent of the blacks in the sample were urban residents as opposed to 50 per cent of the whites. Such a skew in residence is at least partially a reflection of differences in family income between the two groups, suburban living being more expensive. Blacks tended to have much lower family incomes than did whites. Thirty-six per cent of the white group earned over $10,000, while only 17 per cent
Sample Characteristics The sample studied here consisted of 180 adults who presented themselves at an urban dental school clinic. Names were randomly selected from a file of patients who had sought general dental care, but had not been seen due to overenrollment at the clinic. General dental care was defined as not including specialized services such as surgical, prosthetic, or orthodontic care. The population seeking general dental services proved to be two-thirds male (65.56 per cent) with 63 per cent of the men and women in their 20's or 30's. Address reprint requests to Dr. Ronald P. Strauss, Department of Dental Ecology, University of North Carolina, Chapel Hill, NC 27514. This paper, presented at the 102nd Annual Meeting of the American Public Health Association, New Orleans, LA, was revised and accepted for publication on December 16, 1975. This study was supported by Grant DE 00240 of the Public Health Service, and was undertaken while the author was studying toward a doctoral degree in Sociology at the University of Pennsylvania.
AJPH, April, 1976, Vol. 66, No. 4
375
STRAUSS
of the blacks did so. Among those earning below $5,000, blacks were significantly over-represented, with 39 per cent of the blacks and 22 per cent of the whites in this category. This earning differential is keenly linked to differences in education. In this rather well educated patient population, whites were twice as likely to have been to college as were blacks. Structural differences in the nuclear family were reflected in the fact that while blacks and whites in the sample had nearly the same likelihood of having been married, 24 per cent of the blacks as opposed to 6.8 per cent of the whites no longer had intact marriages (divorced, separated, or widowed). It is important to note that the sex ratio between the two racial groups differed significantly. Seventythree per cent of the blacks and 59 per cent of the whites were female. Thus it is clear that when we are discussing racial differences, we are in reality considering the impact of a constellation of factors that are associated with ethnic identity and which each play a role in the production of diversity.
Results and Discussion One hundred seventy-six respondents agreed to be screened. There was a significant difference in DMF (decayed, missing, and filled tooth count) between the different racial groups (Table 1). Blacks tended to have lower total scores, but analysis indicates that whites tended to have a larger number of filled teeth, while blacks had a greater number of decayed or unfilled teeth (Tables 2 and 3). No significant difference in the number of missing teeth was found. This clinical care pattern is suggestive of differences in access to care and utilization patterns between urban blacks and whites. These differences may also be reflected in the finding that black patients had significantly different recent dental experiences. They tended to have waited longer between their last dental visit and their presentation to the dental school clinic. Fifty-three per cent of the black patients, as opposed to 18 per cent of the whites had last received only non-preventive emergency, surgical, or prosthetic services. The white group was more likely to have had their most reTABLE 1-Racial Distribution of Decayed, Missing, and Filled Teeth (DMF)
TABLE 2-Racial Distribution of Filled Teeth Alone Filled Teeth Alone
0-4 Low 5-11 Med 12-26 High
RACE
TOTAL
White
Black
(176)
17.6% (18) 32.4% (33) 50.0%
52.7% (39) 37.8% (28) 9.5%
32.4% (57) 34.7% (61) 33.0%
(51)
(7)
(58)
Chi-Square = 38.034, significant under .001 with 2 degrees of freedom Gamma = -0.691, significant under .001
cent dental experience with general dental or preventive services. While both patient groups in the sample were most likely to have last seen a private dentist, 28 per cent of the black patients as opposed to 8 per cent of the whites had last been to public clinics. Differences in early utilization patterns between racial groups are recognized by examining the date of first dental visit. The black patients studied tended to have their first encounters with dental care later than did whites (Table 4). Nearly one-fourth of the black patients had not encountered a dentist until after the teen years. Such marked differences in utilization patterns suggest that different populations may be perceiving the health services differently. Although most blacks and whites in the sample were aware that they had recently needed more dental care, blacks were less likely to rate their own teeth as good or excellent. Black patients were far more likely to anticipate the need of dental extractions. They were also twice as likely (23 per cent) to rate their general health as fair to poor than were the whites in the sample (10.8 per cent). In terms of tooth value, blacks placed a significantly higher value on tooth appearance and its influence upon making friends. More blacks said that they were willing to spend 15 minutes per night caring for their teeth, and they considered this less of a time demand than did the whites in the sample. Thus, it appears that the blacks studied have a high level of awareness of their teeth and place considerable importance upon their maintenance. Considering this finding, it is unfortunate that 36 per cent of the blacks as compared to 9 per TABLE 3-Racial Distribution of Decayed Teeth Alone
Decayed, Missing and Filled
0-14 Low 15-19 Med 20-32 High TOTAL
RACE White
TOTAL Black
28.4%
43.2%
34.7%
(29)
(61) 33.5% (59) 31.8% (56)
57.7%
(32) 40.5% (30) 16.2% (12) 42.3%
100.0%
(102)
(74)
(176)
28.4%
(29) 43.1% (44)
Chi-Square = 13.80, significant at .002 with 2 degrees of freedom Gamma = -0.393, significant under.001 376
0-1 Low 2-5 Med 6-20 High
TOTAL
RACE
Decayed Teeth Alone
White
Black
(176)
37.3%
17.6%
29.0%
(38)
(13)
(51)
42.2%
28.4%
36.4%
(43)
(21)
(64)
20.6%
54.1%
34.7%
(21)
(40)
(61)
Chi-Square = 38.034, significant under .001 with 2 degrees of freedom Gamma = 0.521, significant under .001 AJPH, April, 1976, Vol. 66, No. 4
DENTAL HEALTH BEHAVIOR TABLE 4-Initial Dental Experience According to Race TOTAL
RACE
First Dental Visit
White
Black
(178)
Before Teens During Teens After Teens
83.5% (86) 15.5% (16) 1.0% (1)
45.3% (34) 30.7% (23) 24.0% (18)
67.4% (120) 21.9% (39) 10.7% (19)
Chi-Square = 35.473, significant under .001 with 2 degrees of freedom Gamma = 0.728, significant under .001 No response: 2 persons
cent of the whites did not know what dental floss was, and that far fewer blacks were actually using floss. It appears that the necessary information concerning preventive dental practices has not as yet reached a significant portion of this highly motivated segment of the black community. Sixty-six per cent of the whites as opposed to 37 per cent of the blacks in the sample had decided that fluoride is helpful. Differential exposure to preventive information may have led to the difference between racial groups concerning belief in the efficacy of dental preventive measures. Perceptions of dental care are influenced by how patients relate to dental treatment. Thiry-six per cent of the blacks, as contrasted with 15 per cent of the whites, admitted that they had avoided going to a dentist because they were afraid that the treatment would be painful. They were also far more likely to expect pain upon a dental visit. This was amplified by the finding that nearly twice as many blacks as whites would like anesthesia used all the time by dentists. This certainly emphasized that within the black study group there was a great deal more fear and sensitivity about dental pain than with the white group. That there is a cultural component in pain response has long been recognized,2 but the social components that play a part in this specific case need further definition and research. The black patients in this study seemed to relate to health professionals quite differently than did the whites. Blacks were far more likely to prefer a dentist who "makes a decision about what treatment is necessary and doesn't waste time talking about it." Blacks tended to respect the fully trained health professional and were three times as like-
AJPH, Aprl, 1976, Vol. 66, No. 4
ly to be disappointed if treated by a hygienist or technician instead of a dentist on a clinic visit. Such respect was also shown in the black patient's reluctance to be critical of the dentist. While 43 per cent of the white clinic patients admitted to having seen a dentist in the past who was either rough, cruel, or inconsiderate, only 28 per cent of the blacks admitted to a similar experience. Perhaps this is the result of less contact with the health care system; it may also reflect a social situation defined by a predominantly white professional health clinic that is intimidating to the minority patient and increases his reluctance to be critical or play a decisive part in his own health care. In any case, the fact that such a sizeable portion of the patient community expressed a strong criticism of dentists suggests that the profession re-examine its mechanisms of dealing with individual patients as well as its public image. Important factors in the utilization of dental services are manpower distribution and financial accessibility.3 Black patients, more than whites, felt that there were not enough dentists in their community. Only one-fourth of the total sample thought that dental fees were "about right." Threefourths of the sample thought they would have some difficulty with a sudden $200 dental bill, with blacks more likely to admit that they could not handle such an expense. Fifty per cent of the black patients believed that dental fees depended on who the dentist was. It is important to remember as we consider these findings that the population sample, and the university dental clinic with its white staff in an urban ghetto represent a very special situation. The population studied was one that seeks general dental care, and seeks this care at a dental school clinic. Such clinics are slow, involve much paper work and patience in return for reasonably inexpensive quality dental care. They are not designed to be community health centers at the present time.
REFERENCES 1. 1970 Census, U.S. Department of Commerce, Bureau of the Census-Philadelphia Census Tract Areas. #73-74, 76-80, 85-93, 103-111 included in population analysis. 2. Zborowski, M., Cultural components on responses to pain, J. of Soc. Issues 8:16-30, 1952. 3. Richards, N. D., Utilization of dental services, In Social Sciences and Dentistry-A Critical Bibliography. N. D. Richards and L. K. Cohen, Eds. Federation Dentaire Internationale, 209239, 1971.
377
