A Community-Based Oral Health Intervention in Navajo Nation Head Start: Participation Factors and Contextual Challenges

Successful interventions require consistent participation by intended recipients. We utilized mixed methods to describe participation of 518 parent–child dyads enrolled in a randomized cluster trial of a 2-year oral health intervention for Head Start (HS) families across Navajo Nation delivered by native Community Oral Health Specialists (COHS). We quantitatively assessed factors that contributed to participation and qualitatively examined barriers and strategies. The intervention offered fluoride varnish (FV) and oral health promotion (OHP) activities for two cohorts (enrolled in 2011, N = 286, or 2012, N = 232) of children in the HS classrooms and OHP for parents outside the classroom. Child participation was good: FV: 79.7 (Cohort 1) and 85.3 % (Cohort 2) received at least 3 of 4 applications; OHP: 74.5 (Cohort 1) and 78.4 % (Cohort 2) attended at least 3 of 5 events. Parent participation was low: 10.5 (Cohort 1) and 29.8 % (Cohort 2) attended at least three of four events. Analysis of survey data found significant effects on parent participation from fewer people in the household, Cohort 2 membership, greater external-locus of control, and a greater perception that barriers existed to following recommended oral health behaviors. Qualitative analysis of reports from native field staff, COHS, community members, and the research team identified barriers (e.g., geographic expanse, constraints of a research trial) and suggested strategies to improve parent participation (e.g., improve communication between COHS and parents/community). Many challenges to participation exist when conducting interventions in rural areas with underserved populations. Working with community partners to inform the development and delivery of interventions is critical.     

Individual and Contextual Factors Associated with Teenage Pregnancy in Colombia: A Multilevel Analysis

Maternal and Child Health Journal - To analyze municipal- and individual-level factors related to the prevalence of teenage pregnancy in Colombia during 2015. We analyzed 660,767 births registers,...     

Health Literacy and Associated Factors Among Hmong American Immigrants: Addressing the Health Disparities

Hmong Americans face a disproportionate health burden ranging from the high prevalence of diabetes to depressive disorders. Little research attention has been paid toward exploring contributing factors to this disparity. As such, the present study seeks to fill the gap in the literature by examining the health literacy levels in Hmong Americans and its associated factors. The present study employed Andersen’s behavioral model of health service as the theoretical framework. A cross-sectional survey research design was used and information was gathered from 168 Hmong American immigrants. Participants were recruited using a purposive sampling strategy. A multiple regression analysis was conducted to identify the factors linked to health literacy. Approximately half of the participants had low health literacy and reported that they did not understand health information well. Health literacy levels were found to differ significantly based on the number of years participants have lived in the U.S., their social or religious group attendance, health status, and whether they had difficulties with activities of daily living. Our exploratory findings could be used prompt more research to help inform the development of interventions aiming to improve health literacy levels and address the health disparities in Hmong American Population.     

Spousal Violence in 5 Transitional Countries: A Population-Based Multilevel Analysis of Individual and Contextual Factors

Objectives. I examined the individual- and community-level factors associated with spousal violence in post-Soviet countries.Methods. I used population-based data from the Demographic and Health Survey conducted between 2005 and 2012. My sample included currently married women of reproductive age (n = 3932 in Azerbaijan, n = 4053 in Moldova, n = 1932 in Ukraine, n = 4361 in Kyrgyzstan, and n = 4093 in Tajikistan). I selected respondents using stratified multistage cluster sampling. Because of the nested structure of the data, multilevel logistic regressions for survey data were fitted to examine factors associated with spousal violence in the last 12 months.Results. Partner’s problem drinking was the strongest risk factor associated with spousal violence in all 5 countries. In Moldova, Ukraine, and Kyrgyzstan, women with greater financial power than their spouses were more likely to experience violence. Effects of community economic deprivation and of empowerment status of women in the community on spousal violence differed across countries. Women living in communities with a high tolerance of violence faced a higher risk of spousal violence in Moldova and Ukraine. In more traditional countries (Azerbaijan, Kyrgyzstan, and Tajikistan), spousal violence was lower in conservative communities with patriarchal gender beliefs or higher financial dependency on husbands.Conclusions. My findings underscore the importance of examining individual risk factors in the context of community-level factors and developing individual- and community-level interventions.Understanding factors that contribute to intimate partner violence (IPV) is essential to reducing it and minimizing its deleterious effect on women’s functioning and health. Most evidence comes from studies conducted in western industrialized countries or in the developing countries of Africa, Latin America, and Asia1–5; there is scarce knowledge available on IPV in the transitional countries of the former Soviet Union (fSU) region,6 which represents different geopolitical, socioeconomic, and cultural environments.7 Studies from other countries often demonstrate mixed findings regarding key risk factors for spousal violence, which suggests that their effects are context specific.8–11 An examination of cross-country similarities and differences within the fSU region may contribute to the understanding of risk factors for spousal violence in a different sociocultural context.As a part of the Soviet Union for approximately 70 years until its collapse in 1991, the fSU countries shared similar sociopolitical contexts,12 with a legacy of well-established public services, stable jobs, and high levels of education dating back to the Soviet era.13 The political turmoil and economic crisis of the 1990s following the collapse of the Soviet Union and the transition from a socialist to a market economy resulted in high unemployment, deterioration of public services, and growth in poverty and social inequalities, which increased family stress.14My study focused on 5 countries of the fSU that included an additional Domestic Violence (DV) module in the Demographic and Health Survey (DHS), which presented the first opportunity for cross-country comparison in this region using recent nationally representative data. The DHS survey was conducted in 2 Eastern European countries of the fSU (Moldova and Ukraine) and 2 countries located in the Central Asian region (Kyrgyz Republic and Tajikistan); the Caucasus region was represented by Azerbaijan. Previous DHS and other nationally representative studies from the fSU region included only individual-level predictors of violence without examining the role of contextual factors and focused predominantly on Eastern European countries of the fSU.8,15–17Despite shared Soviet background, the 5 countries differ in terms of gender norms and current socioeconomic situations (7 Eastern European countries (Ukraine and Moldova) share relatively more egalitarian gender norms, whereas Azerbaijan, Tajikistan and Kyrgyzstan, which are secular Muslim nations, have more traditional values and conservative norms. Women in Kyrgyzstan fall in the middle because of a historically large Russian-speaking population.18–21 Nevertheless, Azerbaijan, Kyrgyzstan, and Tajikistan—where the female literacy rate is close to 100% and polygamous marriages are illegal22—differ from many countries with a traditional Muslim culture because of a history of socialistic ideology, suppression of religion, and universal public education. Although Azerbaijan and Ukraine have exhibited significant economic growth because of rich energy resources, Moldova remains one of the poorest countries in Eastern Europe,23 and Tajikistan maintains the status of the poorest republic in the entire fSU region.

TABLE 1—

Selected Country-Level Indicators for 5 Former Soviet Union Countries: 2005–2012

Individual and Contextual Factors Associated with Immigrant Youth Feeling Unsafe in School: A Social-Ecological Analysis

Despite the increasing proportion of immigrant youth in U.S. school districts, no studies have investigated their perceptions of their school. This study examines factors associated with perceptions of school safety among immigrant youth within individual, family, peer, and school contexts. Data were drawn from Wave II of the Children of Immigrants Longitudinal Study (n = 4288) and hierarchical logistic regression analyses were conducted. African–Americans, females, and youth with limited English proficiency were more likely to perceive their school as unsafe. Youth who reported that family cohesion was important and those who had close friends perceived their school as safe. Also, those who experienced illegal activities in school reported feeling unsafe. Assessment and intervention in schools needs to consider individual and contextual factors associated with perceptions of school safety. Additional research is needed to examine individual and contextual factors related to immigrant youths’ perceptions of school.     

Access to Oral Health Care: The Role of Federally Qualified Health Centers in Addressing Disparities and Expanding Access

Objectives. We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations.Methods. Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience.Results. We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high.Conclusions. These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services.The “silent epidemic” of poor oral health in America was highlighted by the US Surgeon General’s 2000 report, Oral Health in America, which also called attention to the disparities that persist in oral health status, access to care, and unmet need for dental care.1A Government Accountability Office report from the same year echoed the need to address oral health disparities, noting that oral health problems are the most prevalent chronic disease suffered by children despite being largely preventable.2 As with medical care, numerous studies also have found that both disease burden and access to oral health care are associated with income,3 race and ethnicity,4 language,5 and insurance status and type.6 These factors are associated with barriers to access in underserved communities such as affordability, lack of provider availability, inadequate transportation, and low health literacy around the need for oral health care. Whereas nationally almost 60% of individuals with high incomes had a dental visit in the past year, less than 30% of low-income patients (those with incomes below 200% of the federal poverty level) had a dental visit in the past year.7In the 2011 brief Advancing Oral Health in America, the Institute of Medicine (IOM) offered recommendations for improving access to oral health prevention and treatment services through a variety of mechanisms, including expanding the focus on oral health in primary care settings. Components of the strategy included training primary care providers to screen patients for emergent oral health issues, to assess patient risk for oral health problems, and to refer patients to dental professionals when appropriate. The IOM also called for improving oral health literacy through education efforts aimed at individuals, communities, and health care professionals. For example, community-wide public education campaigns were recommended to enhance awareness and knowledge about the causes and implications of oral disease and the importance of preventive oral health services. Building the health literacy of patients and promoting healthy behaviors may increase patient activation around these issues, especially when coupled with guidance on how to access oral health services in the community.8A subsequent IOM report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, suggested ways to narrow or eliminate disparities and improve the oral health status of vulnerable populations, guided by the principles that (1) oral health is essential to overall health and, thus, is an important part of comprehensive health care, and (2) any broad strategy to increase access to care should include components aimed at oral health promotion and disease prevention.9 Building on the existing literature, recommendations for improving access to oral health services for underserved individuals included expanding oral health care capacity by encouraging the integration of oral health services into overall health care.10 Improving dental education and training for nondental primary care providers may facilitate such integration.11 Financial and administrative barriers such as the lack of coverage for dental care need to be addressed, while supporting policies that encourage all professionals to practice to the full extent of their training and licensure.12Federally Qualified Health Centers (health centers) play a key role in these strategies as they are uniquely positioned to increase access to oral health services in the communities experiencing the most acute access problems. Health centers provided comprehensive primary care to 19.5 million patients in 2010, while also serving as an affordable and convenient access point to oral health services for underserved communities and populations. More than 3.8 million patients received dental services at health centers in 2010, and there were more than 9.2 million visits to dental providers employed in health centers.13All health centers are required to provide preventive dental services either on site or by referral, and 4 out of 5 health center grantee organizations provided dental services in at least 1 of their sites in 2010, and 62.0% provided emergency dental services on site.14 By enhancing affordability for needy patients and providing other services such as transportation, translation, and case management, health centers address barriers to access for the most vulnerable and underserved patients in the nation. In the report on underserved populations,9 the IOM specifically calls for health centers to utilize a variety of oral health care professionals in addition to dentists, to educate health center providers about best practices in oral health care, and to provide oral health services as part of outreach efforts beyond the walls of the health center.The oral health objectives in Healthy People 2020 are the guideposts for evaluating efforts to improve access to timely dental care and, ultimately, oral health status.15 The oral health goals in Healthy People 2020 seek to reduce the incidence and prevalence of dental problems by reducing delays and barriers to timely prevention and treatment, and 2 of the 17 oral health objectives specifically call for health centers to expand their role as a source of access to dental services. The first objective seeks to increase the proportion of health centers with on-site oral health care programs from 75% in 2007 to 83% by 2020. The second objective seeks to increase the proportion of health center patients that receive oral health services at their health center from 17.5% in 2007 to 33.3% by 2020.16 By 2010, 80% of grantees offered on-site oral health services in at least 1 site14 and 19.5% of health center patients received oral health services at their health center,13 demonstrating progress toward these goals.We examined data from the 2009 Health Center Patient Survey regarding access to oral health services among health center patients. We examined utilization and unmet need for oral health care, along with satisfaction with oral health care among health center patients.     

The Impact of Both Individual and Contextual Factors on the Acceptance of Personalized Dietary Advice

(1) Background: The aim of the current study is to investigate which between- and within-person factors influence the acceptance of personalized dietary advice. (2) Methods: A repeated measurements design was used in which 343 participants (M (SD) age = 48 (17.3), 49% female) filled out a baseline survey and started with nine repeated surveys. (3) Results: The results show that the acceptance of personalized dietary advice is influenced by both within-person and between-person factors. The acceptance is higher at lunch compared to breakfast and dinner, higher at home than out of home, higher at moments when individuals have a high intention to eat healthily, find weight control an important food choice motive and have a high healthy-eating self-efficacy. Moreover, the acceptance is higher when individuals do not see the eating context as a barrier and when individuals believe that personalized dietary advice has more benefits than risks. (4) Conclusions: Future behavioral interventions that use personalized dietary advice should consider the context as well as individual differences.     

Influences of Socio-Demographic Factors and Health Utilization Factors on Patient-Centered Provider Communication

Patient-centered care has been documented as a measure of quality of health care and has been associated with positive health outcomes. However, the effect of health utilization on improving patient-centered communication has not been investigated. This study examined the effect of three important kinds of health utilization: routine check-up, frequency of provider visits in the last year, and quality of health care to patient-centered provider communication. Cross-sectional data from 3,608 respondents to Health Information National Trends Survey-Cycle 4 2014 were analyzed. Multiple regressions were used to examine the association of sociodemographic factors and health utilization to patient-centered provider communication. Results showed that adults above 50 years and women reported higher patient-centered provider communication. Hispanic and Asian versus White respondents reported poorer patient-centered provider communication. Respondents with routine checkups between 1 and 2 years, 2 and 5 years, 5 or more years and none were all negatively associated with patient-centered provider communication in comparison with routine checkup within 1 year. Respondents who didn’t visit health provider within past year had poorer patient-centered provider communication when compared to those who visited once. Finally, higher quality of healthcare experience was associated with higher patient-centered provider communication. Thus, this study highlights that race and ethnicity, age, and gender are significant factors that influence patient-centered provider communication; and specifically higher quality of healthcare experience, one provider visit within past year, and annual routine checkup as measures of health utilization predicts improved patient-centered provider communication.     

Peer Reviewed: Grading and Reporting Health and Health Disparities

Report cards are widely used in health for drawing attention to performance indicators. We developed a state health report card with separate grades for health and health disparities to generate interest in and awareness of differences in health across different population subgroups and to identify opportunities to improve health. We established grading curves from data for all 50 states for 2 outcomes (mortality and unhealthy days) and 4 life stages (infants, children and young adults, working-age adults, and older adults). We assigned grades for health within each life stage by sex, race/ethnicity, socioeconomics, and geography. We also assigned a health disparity grade to each life stage. Report cards can simplify complex information for lay audiences and garner media and policy maker attention. However, their development requires methodologic and value choices that may limit their interpretation.     

Grandparents Fostering Orphans: Influences of Protective Factors on Their Health and Well-Being

In this study the authors explore the impact of protective factors on the health and well-being of grandmothers who are primary caregivers. Although researchers in Africa have studied grandparents who assume primary caregiving responsibilities, it is rare that they do so from a strength perspective, hence the need to examine the utility of personal, social, and environmental assets on caregiving. Grandmothers are the primary caregivers of orphaned children due to HIV and AIDS deaths; thus it becomes pertinent to establish how they are coping without the provision of social security. The results of this study will be beneficial to all stakeholders interested in the welfare of elders with similar responsibilities. Knowledge about the health and well-being of grandmothers who are caregivers will assist public service and private sectors to formulate viable policies concerning elderly carers who foster orphans, particularly in countries with high HIV prevalence.     

Community Health Workers and Community Advocacy: Addressing Health Disparities

The Community Health Worker model is recognized nationally as a means to address glaring inequities in the burden of adverse health conditions that exist among specific population groups in the United States. This study explored Arizona CHW involvement in advocacy beyond the individual patient level into the realm of advocating for community level change as a mechanism to reduce the structural underpinnings of health disparities. A survey of CHWs in Arizona found that CHWs advocate at local, state and federal political levels as well as within health and social service agencies and business. Characteristics significantly associated with advocacy include employment in a not for profit organization, previous leadership training, and a work environment that allows flexible work hours and the autonomy to start new projects at work. Intrinsic characteristics of CHWs associated with advocacy include their belief that they can influence community decisions, self perception that they are leaders in the community, and knowledge of who to talk to in their community to make change. Community-level advocacy has been identified as a core CHW function and has the potential to address structural issues such as poverty, employment, housing, and discrimination. Agencies utilizing the CHW model could encourage community advocacy by providing a flexible working environment, ongoing leadership training, and opportunities to collaborate with both veteran CHWs and local community leaders. Further research is needed to understand the nature and impact of CHW community advocacy activities on both systems change and health outcomes.     

妇幼口腔卫生保健的家庭影响因素

为探讨家庭因素对幼儿口腔保健行为的影响，2002年6月下旬，江苏盐城市疾病预防控制中心在市机关幼儿园和城区机关幼儿园选择300名幼儿及其家长进行了调查。现将结果报告如下。