In recent years, the relationship between oral health and overall wellness has teetered on the edge of public awareness. Now, the U.S. Department of Health and Human Services is launching an initiative aimed at making it a top priority. Eight HHS agencies, including the Office of Minority Health, the Administration for Children and Families, and the Surgeon General, are collaborating to support and expand oral health education and research. In particular, they hope to make oral health care services more widely available to underserved communities. Racial and ethnic minorities continue to be disproportionately affected by oral disease, and a significant facet of the initiative is working toward eliminating these disparities.
In April, Assistant Secretary for Health Dr. Howard Koh addressed the crowd at the National Oral Health Conference in St. Louis, Missouri, introducing them to the effort and its overall theme: Oral Health is Integral to Overall Health. Dr. Koh called the deficiencies in oral hygiene a “silent epidemic,” noting that 53 million people in the United States currently have untreated decay in their permanent teeth. Working with Dr. Koh in leading the initiative is Dr. Mary Wakefield, the Administrator of the Health Resources and Services Administration, in conjunction with the U.S. Public Health Service Oral Health Coordinating Committee.
Initiative goals and activities include creating campaigns that promote oral health and disease prevention and supporting oral health care professionals. Among individual agencies, the Indian Health Service will strengthen its Early Childhood Caries initiative, including monitoring childhood dental health through community health services and programs like Head Start. The Office of Minority Health plans to offer cultural competency training modules for dental health professionals, which will be available online. (The National Center for Research Resources will also provide Web-based tools for researchers.) And the Centers for Disease Control and Prevention plans to keep track of the overall state of oral health in the United States over the next few years, including the pervasiveness of oral diseases and patterns in dental health behavior. The Centers for Medicare and Medicaid Services, the Office of Women’s Health, and the Health Resources and Services Administration round out the team of collaborators, and each has their own contribution to the initiative.
The foundation of the effort is education, and program coordinators believe that by educating the masses regarding the importance of good oral hygiene and establishing healthy habits at a young age, they can stem the prevalence of tooth decay and oral diseases.
When discussing economic disparities, urban centers often come to mind, and rightfully so, as a greater concentration of people tends to yield more socioeconomic disparities. Cities typically have more resources to help those in need, like food banks and shelters, but hunger, poverty, and health disparities don’t know state lines and city borders.
In the Midwest, Purdue University in West Lafayette, Indiana, has started a new research program, the Center for Poverty and Health Disparities, concerned with reducing health disparities in the state as well as the nation.
Along with the Indiana State Department of Health, Indiana Minority Health Coalition, and Northwest Indiana Health Disparities Initiative, the new center will study the factors contributing to health disparities and will seek partnerships to eliminate those inequalities.
One of the Center’s first initiatives will be to tackle the high rate of heart disease among African Americans. Center representatives say they are working with community groups in Gary and Indianapolis on culturally informed strategies.
Several other research projects are already underway, in addition to the African American-centered heart disease study. Researchers are also looking at patient-physician communication modes and outcomes, as well as the health care delivery process in general and how to improve access for the underserved. Another Center project focuses on improving the lives of those who use food banks.
The Center for Poverty and Health Disparities will be staffed by a number of Purdue professors, and those currently involved bring experience in health care communications, educational studies, health and kinesiology, and African American studies.
What is social capital and can social capital play a role in better asthma outcomes in children residing in homeless shelters? These were some of the questions that guided a research proposal for the Research Infrastructure in Minority Institutions—Career Opportunities in Research (RIMI-COR) grant at Mercy College. Funding for this study was made possible in part by a grant from the National Institute on Minority Health and Health Disparities.
A pilot study was undertaken from October 2008 through August 2009 to quantify if social capital structures existed in three homeless shelters in New York City and if shelter residents were aware of these structures, and to examine parental perceptions about their child’s asthma (controlled/uncontrolled and mild/moderate/severe) and clinician concordance of parental assessment.
Five Mercy College nursing students assisted the researcher in this study with literature reviews and data collection. Engaging nursing students in research is an important venue because it gives students opportunities to examine health issues that are outside of their purview. Further, the students participating in data collection learned about social contributors to health disparities.
Additionally, this research is also being undertaken at a transitional homeless shelter in San Francisco, California. A medical student from University of California, San Francisco has assisted with data collection (anticipated completion in August 2012). To date, 13 parents have participated in the study.
Putnam defined social capital as social relationships (interpersonal trust, norms of reciprocity, and civic responsibilities) within communities that act as resources for individuals and facilitate collective action for mutual benefit.1 Social capital structures are systems of networks, norms, and trust relationships, which allow communities to address common problems.2
Social capital and health linkages are paltry, but research has shown that higher levels of social capital lead to better health outcomes and lower mortality rates in adults and children.3 Asthma prevalence in the United States is about 8.9% and affects more than 6.8 million children and adolescents.4 Asthma is overrepresented in children living in poverty and asthma rates in homeless children are six times the national average.5,6
Social capital in homeless shelters refers to those structures that facilitate social relationships, interpersonal trust, social engagement, and civic responsibilities. Social capital resources were viewed as case managers, onsite medical clinics, educational programs, and shelter governance meetings.
If we consider that homeless shelters might function as a community, structural features that can stimulate social capital may improve childhood asthma outcomes. Further, engaging homeless families in the tenets of social capital may be the means to facilitate participation in community events when they become permanently housed. Active community participation is essential to bring about the social and physical resources necessary to reduce the detrimental environmental exposures in lower income communities.
Self-rated health and psychological well-being are higher in individuals who reported increased levels of community trust and less political participation such as voting has been associated with poorer self-rated health.7,8,9 Therefore, if homeless shelters provided onsite medical clinics (a social capital resource) would parents rate their children’s asthma as controlled? Encouraging patterns of social engagement with the onsite medical clinic would reduce visits to the emergency room. Further, understanding how social capital interacts with the homeless shelter environments (physical and social) could influence how parents understand or perceive their child’s asthma.
The three shelters were identified by an organization that provides onsite medical services at family shelters. Nineteen parents who had asthmatic children (aged six or older) completed a questionnaire adapted from the American Academy of Pediatrics (v. 3.1; 6/02). The questions covered the child’s health, child’s activities, information about the parent, and information about the shelter. The questionnaire was also translated into Spanish. The questionnaire was read to most of the parents because literacy was a problem.
The researcher, a family nurse practitioner, used the National Heart and Lung Institute’s Guidelines for the Diagnosis and Management of Asthma to determine if the child’s asthma was controlled or uncontrolled and the severity of the child’s asthma (mild, moderate, and severe). The social capital indicators examined were voting patterns and if the shelter had case managers, onsite medical clinic, educational programs, town hall meetings, and governance meetings for the shelter residents.
Self-reported demographic characteristics of the study sample can be found in the images accompanying this article. The questionnaire asked about gender, socioeconomic status indicators (income, education, and occupation), insurance information, and if this was their first time living in a homeless shelter.
All of the homeless shelters had case managers, onsite medical clinics, education programs such as GED preparation, town hall meetings, and shelter governance meetings. Respondents were asked if they were aware of these social capital structures and if they voted and if not, their reasons. About 58% of respondents indicated their awareness of town hall meetings; 21% indicated they did not know about these meetings, and 21% answered don’t know. Most parents knew their case managers (90%), 5% indicated they did not know them, and 5% answered don’t know. Most parents knew about the onsite medical clinic (95%) and only 5% responded don’t know. Parents used the medical clinic (32%) for asthma problems and 58% chose not to use the onsite clinic because the clinic was closed; they brought their child to the ER or to their private clinician. Few parents were aware of educational programs (16%); 47% specified no and 37% responded don’t know. A minority of parents were aware of shelter governance meetings (37%); 26% were unaware of these meetings and 37% answered don’t know. Most respondents voted (68%) whereas 32% indicated they did not vote. Reasons given for not voting were (1) not registered, (2) did not know where to vote, (3) did not know about a particular election, and (4) did not want to vote.
Parents were asked to subjectively assess if their child’s asthma was controlled or uncontrolled and to rate if their child’s asthma was mild, moderate, or severe. Mild was defined as not too bad, moderate was considered bad, and severe was considered very bad. Assessment of the child’s asthma by the researcher was based on the parent’s answers about medication usage and types of medication the child had been prescribed. Cross-tabulations were performed to examine clinician and parental concordance of asthma perceptions and asthma severity.
The clinician and the parent agreed at a 91% rate that the child’s asthma was controlled and 25% that the child’s asthma was uncontrolled. The clinician-parent concordance for asthma severity was 70% for mild, 14.3% for moderate, and 50% for severe.
This small-scale exploratory study was able to quantify that social capital structures existed in family homeless shelters in New York City; however, respondents were more aware of some of these structures than others. Additionally, this study investigated parental perceptions about their child’s asthma because data suggested that social capital may be a determinant in self-rated health and thus could potentially be extended to perceptions about a child’s health status. Further, if the parent sought treatment at the onsite medical clinic, did the parent gain a better understanding of asthma triggers and medications leading to decreased visits to an emergency room?
Theoretically, social capital can broadly examine the structural inequalities that contribute to health disparities. Additionally, social capital may increase our understanding of the associations of homelessness and health problems because linking social capital and health may enable homeless shelters to address cultural norms that are detrimental to health, ensure the adequate provision of health care, and collectively build infrastructures that are conducive to better health outcomes.
References
R.D. Putnam, “Bowling alone: America’s declining social capital,” Journal of Democracy 6 (1995):65-78.
P.M. Pronyk, et al., “Is social capital associated with HIV risk in rural South Africa?” Social Science & Medicine 66(2008): 1999-2010.
I. Kawachi, B.P. Kennedy, and R. Glass, “Social capital and self-rated health: A contextual analysis,” American Journal of Public Health 89 (1999): 1187-1193.
E. Forno and J.C. Celedon, “Asthma and ethnic minorities: Socioeconomic status and beyond,” Current Opinion in Allergy and Clinical Immunology 9 (2009): 154-160.
J.J. Cutuli, J.E. Herbers, M. Rinaldi, A.S. Masten, and C.N. Oberg, “Asthma and behavior in homeless 4- to 7-year-olds,” Pediatrics 125 (2010): 145-151.
D. McLean, S. Bowen, K. Drezner, A. Rowe, P. Sherman, S. Schroeder, K. Redlener, and I. Redlener, “Asthma among homeless children: Undercounting and undertreating the underserved,” Archives of Pediatric and Adolescent Medicine 158: (2004):244-249.
T. Nieminen, T. Martelin, S. Koskinen, H. Aro, E. Alanen, and M.T. Hyyppa, “Social capital as a determinant of self-rated health and psychological well-being,” International Journal of Public Health (2010): doi: 10.1007/s00038-010-0138-3.
S.V. Subramanian, D.J. Kim, I. Kawachi, “Social trust and self-rated health in US communities: A multilevel analysis,” Journal of Urban Health 79(2002): S21-S34.
T.A. Blakely, B.P. Kennedy, and I. Kawachi, “Socioeconomic inequality in voting participation and self-rated health,” American Journal of Public Health, 91(2001): 99-104.
According to a report by the U.S. Bureau of the Census, although the number of Americans who are without health insurance declined since 1998, Hispanics and other racial and ethnic groups continue to comprise a disproportionate number of the overall uninsured.
Hispanics are more than three times as likely to be uninsured than whites and African Americans and Asian Americans are almost twice as likely to be uninsured. Additionally, American Indians were almost three times as likely to be uninsured as whites.
And it isn’t because they aren’t trying. More than 80% of the uninsured hold jobs and work year round, mostly in small businesses, according to the Census Bureau.
Enter the Fair Care for the Uninsured Act of 2001. This bill, which is being circulated in Congress, will provide a refundable credit to workers who are not covered by health insurance through their employers. The plan would be of greatest benefit to those who are not quite poor enough to qualify for Medicaid but too poor to buy health insurance on their own.
“Poor but not poor enough. That’s the phrase we’ve been trying to get across,” says Robert Deposada, executive director of the Hispanic Business Roundtable. “You have this demographic because most minorities are working year-round. Because they are working they do not qualify for Medicaid and are left on their own, which makes it extremely difficult for them.
For example, a large concentration of Hispanics work in the service industry or own their own small businesses, both venues historically do not or cannot offer quality health insurance coverage, according to the Census Bureau.
“You need to look at the kind of employment that people have. Overwhelmingly, insurance is employer-based, and when you, as an individual, do not get insurance from your job, it is extremely expensive [to purchase on your own],” says Deposada.
The bill creates a new tax credit for the purchase of private health insurance, effective Jan. 1, 2002, of $1,000 for individuals and $500 for dependents, with a maximum $3,000 for a family. The credit would automatically be provided through either reduced withholding or estimated tax payments. The individual could opt to have the credit assigned to the insurance company.
“Three thousand dollars toward health insurance would help a whole hell of a lot,” says Deposada.
Ethnicity and insurance coverage may determine the kind of anesthesia a woman receives during labor, according to a recent study at the University of New York at Buffalo.
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The study showed that Medicaid recipients in New York state are less than half as likely to receive epidurals for vaginal delivery than patients with private coverage or an HMO. The ethnicity of the patients also determined the anesthesia they received. The study indicated that white mothers were more likely to receive an epidural for vaginal delivery and a spinal or epidural for a Cesarean delivery than African-American mothers. Disparities were not cited among other ethnic and racial minority groups because they were not well represented in the study.
The researchers also found that Medicaid mothers who have Cesarean sections are twice as likely to receive a general anesthesia, which numbs the entire body and causes the mother to lose consciousness. This increases the risks to both baby and mother, according to assistant professor of anesthesiology at the University of Virginia, Paul Ting, PhD. An epidural is a far favorable option during a Cesarean because it has no effect on the baby and allows the mother to stay awake.
Thomas E. Obst, director of the Nurse Anesthesia Program at the University of New York at Buffalo School of Nursing and lead author of the study says, “The research points out the need for a national assessment of the availability of pain control options for obstetrical patients. We need to understand how much patients’ preferences and cultural mores influence the use of a particular anesthesia intervention.”
