Neighborhood Social Capital,Neighborhood Attachment,and Dental Care Use for Los Angeles Family and Neighborhood Survey Adults

Objectives. We tested the hypothesis that neighborhood-level social capital and individual-level neighborhood attachment are positively associated with adult dental care use.Methods. We analyzed data from the 2000–2001 Los Angeles Family and Neighborhood Survey that were linked to US Census Bureau data from 2000 (n = 1800 adults aged 18–64 years across 65 neighborhoods). We used 2-level hierarchical logistic regression models to estimate the odds of dental use associated with each of 4 forms of social capital and neighborhood attachment.Results. After adjusting for confounders, the odds of dental use were significantly associated with only 1 form of social capital: social support (adjusted odds ratio AOR] = 0.85; 95% confidence interval CI] = 0.72, 0.99). Individual-level neighborhood attachment was positively associated with dental care use (AOR = 1.05; 95% CI = 1.01, 1.10).Conclusions. Contrary to our hypothesis, adults in neighborhoods with higher levels of social capital, particularly social support, were significantly less likely to use dental care. Future research should identify the oral health–related attitudes, beliefs, norms, and practices in neighborhoods and other behavioral and cultural factors that moderate and mediate the relationship between social capital and dental care use.Oral health is an indicator of general health and social justice.1,2 Common dental diseases such as tooth decay and gum disease are linked to chronic health conditions, including cardiovascular disease, stroke, diabetes, obesity, and kidney disease.3–7 When left untreated, dental diseases can lead to difficulties chewing food, pain, systemic infections, hospitalization, and, in rare cases, death. Less visible are the social consequences of poor oral health, such as lost work hours,8 functional limitations,9,10 and poor quality of life.11A comprehensive strategy for optimal oral health involves exposure to topical fluorides (e.g., in optimally fluoridated water, toothpaste), limited fermentable carbohydrate intake, tobacco use prevention, and regular dental visits.12 Professional dental care is particularly important because dentists have opportunities to assess a patient’s risk level for oral health problems, provide diagnostic and preventive care as well as needed restorative care, deliver patient-centered anticipatory guidance, and screen for systemic health conditions.13–16 However, not all individuals in the United States have equal access to dental care.17Most dental utilization studies focus on children younger than 18 years and seniors aged 65 years and older, even though data from the National Health and Nutrition Examination Survey indicate a decline in dental care use for US adults aged 18 to 64 years.18 Between 1988 and 1994 and 1999 and 2004, there were significant drops in the proportions of adults who had an annual dental visit for those aged 20 to 34 years (from 63.5% to 54.6%) and those aged 35 to 49 years (from 69.0% to 62.5%).18 The factors related to these declines are unknown.The 2008 World Health Organization report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health calls for policies and interventions targeting the social determinants of health to reduce and eliminate health disparities.19 Social determinants of health are the structural and environmental conditions that shape human welfare and well-being,20 with health inequalities attributed to unequal distribution of and access to power, money, and resources.21 Although social factors contribute to disparities in dental care use,22 relevant studies focus mostly on individual-level determinants.23–37 There has been less emphasis on the area-level social determinants of adult dental care use.Social capital is an important health determinant38–41 and is defined as the material, affective, and informational resources inherent in social networks. Most health research has focused on social capital in neighborhoods. Neighborhood-based social capital can be operationalized into 4 forms: (1) social support (provisions that help residents cope with everyday challenges), (2) social leverage (sharing information on health- and non–health-related issues), (3) informal social control (maintenance of safety and norms), and (4) neighborhood organization participation (organized efforts that address community quality of life and personal well-being).42 Social capital has direct and interactive associations with a range of positive and negative health-related outcomes.43,44 In some cases, these resources may not help individuals pursue a desirable health outcome or may inhibit an individual’s efforts through negative influences in the community.45Although investigators have examined social capital and access to health care services,46 fewer oral health–related studies have focused on social capital. In 2 multilevel studies of elderly persons in Japan, number of teeth was positively associated with higher levels of neighborhood friendship networks47 and a higher prevalence of neighborhood peer group activities.48 Neighborhood social capital also moderated the relationship between income inequality and self-reported oral health but not the number of teeth present among the Japanese elderly.49 A study of Japanese students aged 18 to 19 years found that poor self-reported oral health was associated with lower levels of neighborhood trust and with higher levels of neighborhood informal social control.50 Among Brazilians aged 14 to 15 years, a 5-dimension measure showed that social capital (social trust, social control, empowerment, neighborhood security, and political efficacy) was inversely associated with odds of dental injury.51Although social capital was not the primary focus, there are 2 relevant US publications. The first reported positive associations between neighborhood social capital and self-reported oral health for children younger than 18 years.52 In the second, neighborhood social capital was identified as a potential source of oral health disparities between Black children and White children aged 3 to 17 years (measured as having a dental problem and poor self-reported oral health) but not for disparities in preventive dental care use.53 Collectively, these studies suggest that neighborhood social capital is an important determinant of oral health.54–56 However, they have 2 main limitations: (1) none of the operationalizations of social capital considered the extent of neighborhood social ties, the resources linked to these ties, or unequal access to resources42; and (2) none focused on dental care use for adults aged 18 to 64 years, a US population subgroup that has exhibited declines in dental care use.18We addressed previous limitations by adopting a multilevel conceptual model of social capital42,43,45 to examine how neighborhood social capital is associated with dental care use for US adults (Figure 1). We operationalized neighborhood-level social capital as the 4 forms identified earlier (social support, social leverage, informal social control, and neighborhood organization participation). Individual-level neighborhood attachment is the extent to which an individual knows and socializes with neighbors42–44; this moderates the effects of social capital.57 On the basis of this model, we tested 3 hypotheses: (1) higher levels of each form of neighborhood social capital are associated with greater odds of dental use, (2) neighborhood attachment is associated with greater odds of dental care use, and (3) there are interactions between social capital and neighborhood attachment. This study represents an important first step in understanding the social determinants of an important oral health behavior. Our long-term goal is to develop and test neighborhood-based interventions and policies aimed at improving the oral health of individuals at greatest risk for disparities in dental care use.Open in a separate windowFIGURE 1—Conceptual model and proposed study hypotheses tested using data from the Los Angeles Family and Neighborhood Survey, 2000–2001.Note. H1 = hypothesis 1 (there is a direct relationship between the 4 social capital forms and adult dental care use); H2 = hypothesis 2 (there is a direct relationship between neighborhood attachment and adult dental care use); H3 = hypothesis 3 (in modeling adult dental care use, there is an interaction between the four forms of social capital and neighborhood attachment).