Addressing the Needs of Underserved Populations: One Organization's Experience

By Patricia Billings, DDS, and
Dennis McKee, DDS

Dental decay is the most prevalent and preventable chronic disease of childhood. Underserved populations are at a health disadvantage with greater unmet needs. This article will discuss the components of oral health promotion programs and facilities designed to meet the needs of underserved populations. These components include organization, needs assessment, resource assessment, priority-setting and planning, oral health intervention, and monitoring and evaluation. Examples from the experience of the San Diego Children's Dental Health Association will be presented in the discussion of each component.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

In San Diego County, the dental community, in collaboration with several other organizations, has responded to oral health needs of underserved children. The San Diego Children's Dental Health Association and the San Diego Children's Dental Health Center have been involved in city service to the children of San Diego for the past 45 years. These organizations exist for the sole purpose of providing dental care to economically disadvantaged children and represent thousands of volunteer hours given collectively by the city's business and dental communities. The health association is a subcommittee of the San Diego County Dental Society's Council on Dental Care. It is the owner and community supporting arm of the Children's Dental Health Center; is a corporation of individuals representing local business, dental, county health department, and philanthropic groups; and has a 35-member Board of Directors that meets monthly.

The Children's Dental Health Center, located in the Golden Hill area of San Diego, is equipped with six dental chairs and employs five registered dental assistants, an appointment clerk, an executive director, and six staff dentists. During the past 15 years, patient demand has increased beyond the capacity of a volunteer dentist staff. Six dentists provide some 70 hours of care per week at a rate of pay that can be considered a partial donation of time. This facility is supported primarily by fees collected and income generated by billing Medi-Cal and the Child Health and Disability Prevention Program. Donations of equipment, funds for computers, toothbrushes, and emergency funds for care are received each year from private practitioners, community organizations, and local parent-teacher associations.

The Children's Dental Health Association opened its first satellite dental center this year with support from Price Charities and in collaboration with San Diego city schools. This facility has two dental operatories and provides care several days a week as part of a comprehensive health center at Hoover High School in City Heights.

In this article, we will discuss the components involved in the planning and development of programs and facilities designed to address the oral health needs of underserved populations. At each step, we will present examples from our organization, the Children's Dental Health Association. Our efforts began more than four decades ago as an outreach program of the local dental society.

Statement of the Problem

Although the etiology of dental decay is understood and a majority of dental disease is preventable, dental decay is the most prevalent disease of childhood.1,2 A National Institute of Dental Research survey conducted in 1986-87 showed that by age 17 children had an average of eight decayed, missing or filled tooth surfaces.3

The Maternal and Child Health Branch of the California Department of Health Services contracted to conduct a statewide assessment of oral health needs of California children in 1993-94.5 This epidemiological survey was designed to gain a representative sample of California's children (N = 6,643) in 10 geographic regions of California at three age levels: preschool, kindergarten through third grade, and 10th grade.6 Dental examinations were done in classrooms using a dental explorer and mirror. The assessment found the percentage of California children with untreated caries as follow: 55 percent of children age 6-8, 60 percent of black children age 6-8, 66 percent of Hispanic children age 6-8, and 45 percent of adolescents age 15.6

Oral function can affect quality of life, chewing, eating and speaking, as well as social interactions. Untreated caries cause pain, infection, and oral dysfunction. While dental decay has decreased during recent decades, children of low-income families have not benefited as greatly as others and still remain at significant risk for dental disease.7 Children in the national Head Start Program, who are members of lower socioeconomic groups, have caries rates well above the national averages.8 This is pertinent because socioeconomic status is consistently associated with health outcomes.9 Low family income is a consistent risk factor for poor health among white children.10 Lack of family financial resources can lead to feelings of hopelessness and less optimism for parents.11 Ability to pay is a critical barrier when coupled with culture and language differences that contribute to limited health care access for racial and ethnic minorities at the lower end of the socioeconomic scale.

The National Center for Health Statistics reports that in 1988, 18.1 percent of all children age 3-17 had not seen a dentist in the previous two years.13 Family income influenced dental visits: 54 percent of children from families whose income was less than $19,999 had not seen a dentist in the previous two years. This outcome was also influenced by race: 16.5 percent of white children, 23.6 percent of African American children, 21.2 percent of Asian children, 23.1 percent of Native American children, and 28.9 percent of Hispanic children age 3-17 had not seen a dentist in the previous two years.

Racial, ethnic, and immigrant minority populations are at a health disadvantage with greater unmet needs and less frequent utilization in all types of health care delivery systems.12 Some sociocultural factors are significant in the health status of racial minorities. Social isolation due to language barriers limits information exchange. Ethnicity and associated values affect individual knowledge, attitudes, and behaviors. Race and ethnicity are highly correlated with measures of oral health in the United States, including oral hygiene behavior, use of dental services, and receipt of symptomatic dental care.12

Step One: Organizing

The first step in organizing is mobilization and/or formation of organizations to address oral health issues. One can develop strategies that will improve oral conditions of the target population through education, problem-solving, prevention, and increased access to care. This organizational step requires establishment of:

* The structure of a new or existing organization;

* A purpose or mission; and

* A strategy for improving oral health.

The Children's Dental Health Association was formed, and the dental center opened in 1952 on the City College Vocational School Campus. Bylaws were written regarding purpose, meetings, membership, board of directors committees, officers, and handling of funds, etc. A memorandum of agreement was formulated clarifying the relationship between the health association and the dental center. The current building for the dental center was acquired in 1964, and the mortgage paid off in 1974.

The mission statement of the association is "to help economically disadvantaged children obtain and maintain optimal dental health." Other strategies for improving oral health include fund raising; support of a low-cost dental center for underserved children; a satellite dental center on a high school campus; a school-based mobile sealant program; utilization of volunteer dentists; and collaboration with schools, dental organizations, and service groups.

Step Two: Needs Assessment

Success of oral health promotion depends on knowing what the target population needs, wants, and values. This information may be gained by archival research, original research, epidemiologic surveys, cross-sectional studies, key informant interviews, community forms, or utilization reviews. Target population needs assessment include gathering data regarding caries prevalence, untreated disease, and barriers to care that influence community health behavior patterns.

Supported by a grant from the Alliance Healthcare Foundation in 1996, we were able to document need in our target population. Our statistics, based on classroom dental screening of 5,794 elementary school children in south central San Diego, found visible, untreated caries in 42.4 percent of the children and caries prevalence (past and/or present caries experience as evidenced by presence of caries and/or restorations) of 71.5 percent. Acute or urgent dental need was found in 10.3 percent of the children by the screening dentist.

The association's dental facilities and programs target low-income children who have limited access to dental care. In this population, lack of knowledge as well as cultural and financial barriers affect access to dental care. Other social factors such as fear, poverty, and hopelessness also affect care-seeking behaviors. Because of these barriers, our facilities and programs are located in high-need areas and at school sites, where we provide school-based services.


Step Three: Resource Assessment

As was set forth in Step One, existing organizations may have an interest in oral health promotion. Collaboration with interested parties should begin with the organizational step and be incorporated into all subsequent steps. Resources might include key contacts who are familiar with the target population, such as school nurses, religious or political leaders, the health department, and labor representatives. Other resources include local dental, dental hygiene, dental assistant, medical, university, and public health organizations. Financial resources may be sought from membership drives, nonprofit foundations, charities and donations, and by billing for services. Changes in the health care environment have affected dental practitioners in both the private and public sector. With the development of managed care and the shift from fee-for-service to population-based payment systems, funding health care for underserved populations may be of interest to business, government, and charitable organizations.

Our school-based sealant program applied for and received funding from the Alliance Healthcare Foundation and the Foundation of the Pierre Fauchard Academy. We plan to start billing Medi-Cal for services provided to covered children in order to assist self-sustainment of the program in the future.

Step Four: Priority Setting and Planning

Information gathered from needs and resource assessment is used to set priorities and plan for services to meet the identified needs in the target population. Priority-setting is guided by the mission statement of the organization. It begins by setting goals and general criteria for progress and then prioritizing them. These goals will be the basis for developing specific objectives in Step Five, oral health intervention.

Planning considers what level of intervention your organization wishes to reach. Various levels of interaction may be targeted, including modifying oral health behavior of individuals, modifying health behavior of groups, organizational level interventions (worksite, club, church, school), community-level health promotion (changes in social or physical environment), and policy level interventions (legislation).

Step Five: Oral Health Intervention

This step involves development of specific objectives to meet the goals of the program or organization. Oral health intervention may include education, behavior modification, training, prevention, and treatment. Selection of objectives will be influenced by:

* Available technology;

* Skill and background of the target population;

* Existing practices and beliefs of target population;

* Needs assessment; and

* Resources.

The health association school-based program had the goal of increasing access to dental care for low-income children. Objectives included:

* Classroom dental screening;

* A mobile sealant and hygiene program;

* Referral and linkage with low-cost dental provider;

* Parent education and empowerment of families;

* Follow-up of findings from screenings;

* Referral of severe-needs children to reduced-fee/volunteer dental specialists;

* Financial incentives for initial dental visit;

* Needs assessment and data collection; and

* Evaluation and accountability to schools, grantor, and service population.

Step 6: Monitoring and Evaluation

Oral health promotion monitoring and evaluation are done to measure program progress, impact, and outcomes, and to determine whether continued funding is warranted. This is accomplished by using descriptive data, comparative techniques, explanatory reasoning, and analytic approaches to answer objective questions.

Outcome evaluation for the school-based program were:

* On-site sealant placement for 600 children;

* Linkage of 476 children with a low-cost provider following dental screenings;

* Participation of 313 parents in dental in-service education; and

* Enlistment of 19 dental specialists who offered to donate time or provide reduced-fee services to high-need children.

The grant for this pilot program was $67,000, and donated professional time (in-kind service) was valued at $25,000.

Cornprehensive general dental care is provided at the Children's Dental Health Center, including restorative; oral surgery; endodontics; crown and bridge; preventive and esthetic services; and removable prosthodontics. The dental center now treats more than 2,500 economically disadvantaged children each year with more than 7,000 patient visits being made. These children come from families with a combined annual gross income of less than 200 percent of the federal poverty level.

Conclusion

Planning, implementation, and participation in dental projects for underserved populations may offer unexpected opportunities for dental professionals. Because of the collaborative nature of this type of service, dentists have contact with various community organizations, health organizations, and families that they would not have come to know in private practice. Participation levels might include periodic donations of service, advisory membership in a multidisciplinary service agency, committee membership in dental organizations, or initiation of programs to fulfill unmet oral health needs. This overview demonstrates that community service in our chosen profession can broaden our horizons and enrich our practice of dentistry.

Acknowledgments

We would like to acknowledge the support of the Alliance Healthcare Foundation and the Foundation of the Pierre Fauchard Academy for funding of our school-based program and Price Charities for funding the opening and first three years of operation of Hoover High School Dental Health Center.

Authors

Patricia Billings, DDS, is the Children's Dental Health Association's volunteer school-based program director.
Dennis McKee, DDS, is past president of the Children's Dental Health Association.

References

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3. Oral Health of U.S. Children: The National Survey of Dental Caries in U.S. School Children 1986-1997. National Institute of Health, Bethesda, Md, Publication No 89-2247, 1989.
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5. These Are Our Needs, Report of the California Oral Health Needs Assessment of Children, 1993-94. The Dental Health Foundation, Oct 1994.
6. The Oral Health of California's Children -- A Neglected Epidemic. The Dental Health Foundation, 1997.
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12. Schou L and Blinkhorn A, Oral Health Promotion. Oxford University Press, New York, 1993.
13. Vital and Health Statistics: Health of Our Nation's Children. Publication No (PHS) 95-1519, Series 10, No 191, U.S. Centers for Disease Control and Prevention, Dec 1994.

To request a printed copy of this article, please contact/Patricia Billings, DDS, 14339 Sladon Court, Poway, CA 92064.