文章基本信息

标题：Addressing Oral Health Disparities Via Educational Foci on Cultural Competence
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作者：Linda S. Behar-Horenstein ; Rueben C. Warren ; Virginia J. Dodd 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2017
卷号：107
期号：Suppl 1
页码：S18-S23
DOI：10.2105/AJPH.2017.303721
语种：English
出版社：American Public Health Association
摘要：An ever-present challenge for the oral health profession is to reduce the extent of oral disease among racial and ethnic minority populations. Adding to this complex dilemma is the linkage between oral health and systemic health. We describe enhanced cultural competency, in the context of individual cultural beliefs, values, language, practice, and health behaviors, among dental professionals, as one approach to meeting the dental care needs of the underserved. An overview and examples of teaching methods used by University of Florida dental educators to enhance student cultural competency is provided. Evidence-based evaluation results provide evidence of methodology efficacy. We conclude by describing actions that can be implemented by academic dental institutions to facilitate development of culturally competent practitioners. “Racial and ethnic minorities [people of color] tend to receive less healthcare than nonminorities, even when access-related factors, such as patients’ insurance status and income, are controlled.” — Smedley et al . ¹ Risk factors such as income and education, and risk markers such as race or ethnicity, have resulted in oral and systemic health disparities. 2 Lack of access to health care has worsened the problem, particularly among racial and ethnic minority populations. 1 Increasing evidence links oral and systemic (medical) health, yet oral health care is less available and accessible than systemic care. 3 Moreover, oral diseases are the least likely chronic diseases to be reimbursed by third-party health insurance, including the Affordable Care Act. 4 Aside from oral pharyngeal cancer, widespread beliefs that oral diseases are not life-threatening seem to reflect the low priority placed on oral disease by many US residents and health policymakers. In the United States, oral health disparities are profound. The most affected groups are racial/ethnic minorities in spite of socioeconomic status, gender, age, educational attainment, and geographic location. Limited access to oral health care including acute and preventive services has resulted in oral health disparities and oral health care disparities. Additional strategies are needed if improvement in oral health is expected for vulnerable racial and ethnic population groups. For example, among non-Hispanic Black and Mexican American adults (aged 35–44 years) untreated tooth decay is nearly twice that of their non-Hispanic White counterparts, and periodontal (gum) disease predominantly affects Mexican American and non-Hispanic Black men. Higher rates of periodontal disease are also present in individuals with less than a high-school diploma and adults aged 65 years and older. Similarly, Asian populations self-report higher levels of periodontal disease. Population changes evidenced by US Census Bureau statistics (April 2010–July 2015) indicate an increase in Hispanics and African Americans that are disproportionally adversely affected by oral health disparities. Specifically, the percentage of adults aged 65 years and older increased from 13.0% to 14.9%; the Hispanic/Latino percentage increased from 16.3% to 17.6%; and persons describing themselves as White alone (not Hispanic/Latino) decreased from 63.7% to 61.6%. The 2015 US population, estimated at 321 418 820, is composed of 77.1% White persons (271 million); 61.6% of the total population is not Hispanic/Latino. Black or African Americans make up 13.3% (42 million) of the population; Asians, 5.6% (17.9 million); American Indians/Alaska Natives, 1.2% (3.8 million); Native Hawaiians and other Pacific Islanders, 0.2% (0.6 million); 2 or more races, 2.6% (8.3 million); and Hispanic/Latino, 17.6% (54 million). 5 These population demographics are starkly contrasted with US dentist workforce demographics in which 74.2% of dentists are White, 5.2% Hispanic, 3.8% Black, 15.7% Asian, and 1.25% “other.” Other relevant population statistics include 14.9% adults aged 65 years and older, 13.1% foreign-born adults, 13.7% adults without high-school diploma (28% foreign-born and 8% native-born), and 13.5% persons living in poverty. Thus, innovative strategies are needed to effectively address the oral health of these groups. Future demographic changes will cause exponential growth in these unacceptable levels of oral health disparities. The geographic maldistribution of dentists, many of whom do not practice in rural and otherwise isolated locations with large concentrations of minority and low-income patients, exacerbates this issue. Remediation of oral health disparities requires policy change and public–private sector contributions. One example, advancing the cultural competence of health care providers as described in this article, is a first step toward improving access to care. A second example is the delayed recognition and remediation of oral health workforce diversity to better reflect the current and emerging demographics of the US population. Despite some improvement in dental school diversity, it will not match the changing demographics, thus the need for increased cultural competency in nonminority dentists. Culture, defined as the beliefs, values, knowledge, and skills that guide a people along shared paths, is the nonhereditary memory of a community, a memory expressing itself in a system of constraints and prescriptions. In the context of oral health disparities, culturally competent oral health providers have the ability and delivery system to meet the oral health needs of the underserved in the context of their cultural beliefs, values, language, practice, and health behaviors. 6 The need for cultural competency in the oral health workforce is recognized in Healthy People 2020 ’s expressed goal of increasing cultural diversity content in Doctor of Dental Surgery or Doctor of Dental Medicine–granting colleges and schools of dentistry ( https://www.healthypeople.gov ). Ideally, students would enter dental school with knowledge of cultural competency constructs and relevant communication strategies. In reality, provision of culturally centric care can only be ensured when dental students are encouraged to develop an internalized respect for the importance and advantages of living in a multicultural and increasingly diverse society. One approach to internalizing cultural competency is a community behavioral model called authentic cultural ecology, which accepts a broad perspective of well-being. Rather than “medicalize” health, cultural ecology recognizes these limitations, and promotes the social–cultural importance of issues that have an impact on individual and community well-being. 7 Individuals considering oral health careers must learn and employ cultural competency strategies as they advance in their education and career paths. Moreover, it is reasonable to expect that culturally competent oral health professionals will be more likely to provide acceptable care to diverse populations. An evidence-based methodology to teach, develop, implement, and evaluate cultural competency is needed, especially because future dentists will likely treat patients who differ from them in many ways including racially, ethnically, culturally, first language, care-seeking behaviors, and ideas about dental treatment. 8