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RESEARCH REPORT |
1 Department of Epidemiology and Health Promotion, New York University College of Dentistry, 345 East 24th Street, New York, NY 10010, USA;
2 New York University School of Medicine; and
3 The Forsyth Institute, Boston, MA, USA;
* corresponding author, gdc1{at}nyu.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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4 mm, and the number of missing teeth. Results suggest a positive impact of acculturation on the oral health status of these individuals.
KEY WORDS: acculturation • oral health • immigrants
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Acculturation has been shown to serve as a proxy for cultural norms and behaviors that affect care-seeking, preventive as well as hygiene behaviors, and, ultimately, health outcomes (Angel and Cleary, 1984; Hazuda et al., 1988; Balcazar et al., 1995). Studies of the effect of acculturation on the general health of immigrants to the US have suggested that acculturation can be beneficial to some health behaviors and outcomes and detrimental to others (Franzini et al., 2001).
Acculturation, especially for immigrants from low-income developing countries such as Haiti, can potentially have these opposing effects on their oral health. On one hand, it may benefit their oral health due to preventive and health care products and services available in the US; on the other hand, they could negatively affect their oral health by adopting negative behavioral practices such as cariogenic diets, experiencing social stress due to their disenfranchised status, and encountering barriers to oral health care services.
Studies of the effect of acculturation on immigrants have been limited, yielding somewhat contradictory results. A study of Mexican-Americans, utilizing a brief acculturation index based on language preferences and self-identification (Ismail and Szpunar, 1990), showed that individuals with low acculturation status had a higher prevalence of decayed and missing teeth and higher periodontal disease levels than those with high acculturation. However, only differences in periodontal status remained significant after adjustment for age, sex, education, and income levels. More recently, another study (Stewart et al., 2002) of the same dataset (HHANES, 1982–1984) suggested that acculturation influenced the care-seeking behaviors of Mexican-Americans, Cuban-Americans, and Puerto Ricans.
A study of Hispanic Americans and African-American adults, utilizing a three-item language competency scale, found that a higher acculturation level in the Hispanic group was associated with better self-reported measures of general but not oral health (Atchison et al., 1998). Furthermore, a study of Hispanic immigrants utilizing a similar language-based scale showed that acculturation had a direct association with the oral health status index (OHSI) of participants: Those with a high acculturation had better OHSI scores than those with low acculturation (Spolsky et al., 2000).
Using a more comprehensive scale comprised of behavioral and psychological variables, a study of Vietnamese immigrants in Australia showed that both dimensions of acculturation added a significant explanation to the variance of the three oral health outcomes studied: dental caries, knowledge of preventive measures, and dental visits (Mariño et al., 2001).
Studies on the effect of acculturation on the oral health of different immigrant groups can add to our understanding of the existing oral health disparities in the US. Thus, the purpose of this study was to assess the effect of acculturation on several objective measures of oral health in Haitian immigrants in New York City (NYC).
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MATERIALS & METHODS |
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Clinical Examinations
Oral health examinations were conducted with the use of a plane glass mirror, a sharp #23 explorer, a standard 10-mm periodontal probe, and artificial light. Teeth were not dried or cleaned prior to the examination, and no radiographs were taken. NIDCR diagnostic criteria, used in the Oral Health Survey of US Adults for both the dental and periodontal measures, were utilized (Miller et al., 1987). Coronal caries data were collected on all teeth except third molars. Decayed, missing, and filled surface (DMFS) scores were calculated for all participants. We calculated DFS, DS, and %DS/DFS only on dentate individuals, to correct for the possible inclusion of teeth extracted due to periodontal disease.
Two quadrants, one maxillary and one mandibular, were randomly selected for each participant for the periodontal assessment. To improve the estimates of severity, we modified the NIDCR design by adding the disto-lingual site to the two sites included in their exam: mesio-buccal and buccal. Pocket depth and attachment level (distance from the cemento-enamel junction to the free gingiva level) were recorded at each site, and the attachment loss was calculated as pocket depth minus the attachment level. In addition, bleeding upon probing was recorded for all sites. The oral health examinations were conducted in the field by a team of calibrated examiners. Calibration exercises were held prior to the onset of the study and on an ongoing basis, with an experienced examiner as the "gold standard". Inter-examiner reliability was calculated for all the examiners at the tooth surface level. The intraclass correlation coefficient (Fleiss, 1986) was over 0.95 for all examiners for the dental caries scores. For the periodontal measurements, the intraclass correlation coefficients were 0.88 and 0.91 for attachment loss and pocket depth, respectively.
We administered a questionnaire to assess the participants’ age, sex, education and income levels, marital status, years in the USA, and age at immigration. The questionnaire was translated and back-translated into and from Haitian Creole according to standard methodology (Brislin, 1970).
Acculturation Scale Construction and Validation Analysis
We developed a behavioral and self-identification acculturation scale comprised of language knowledge and use, media use and preferences, social interactions, food preference, and self-identification items by modifying existing instruments (Mariño et al., 2000). We examined the dimensionality of the putative acculturation scale by performing a factor analysis. To characterize the degree of consistency in the acculturation scale, we calculated the Cronbach alpha coefficient (Cronbach, 1951). The associations between the acculturation scale and sociodemographic variables were examined by tabulations of quartiles on the acculturation scale by the categories of the sociodemographic variables. To clarify which of the sociodemographic variables (with the categories treated as ordinal) were independent predictors of acculturation, we conducted stepwise regression analyses.
Statistical Methods for Measures of Oral Health and Acculturation Analysis
The acculturation score was divided into quartiles for some tabulations and analyses, but was treated as a continuous variable in the overall logistic regression analyses. Specifically, the logistic-regression-derived odds ratios were calculated per 10 points on the acculturation scale.
Because subjects had variable numbers of teeth that could be evaluated because of missing teeth, several of the dental and periodontal scores had to be presented as the percentage of surfaces that could be scored. Most of the measurements of dental and periodontal health were skewed, so it was inappropriate for them to be used as continuous variables in the analysis. On the other hand, simply dichotomizing them would lose much of the information about the wide range of scores and, in effect, introduce measurement error (Lagakos, 1988). To capture more of the dispersion of scores, we created three ordinal categories for each variable based on its distribution, where the categories for each variable were chosen so as to have a reasonable number of subjects in each category (Appendix A, online only). These categories served as the main dependent variables and were analyzed as ordered categories with the use of the cumulative logistic model (Agresti, 1984; SAS, 2000). This model yields a cumulative odds ratio, where the cumulative odds can be interpreted as the odds of being in a particular category or a higher one vs. being in lower ones. So, for example, if the cumulative odds ratio for DS/DFS were 0.80 per 10 points on the acculturation scale, then, on average, those with a score of 25 on the acculturation scale would be only 80% as likely to be in the highest category of DS/DFS as those with a score of 15. Similarly, those with a score of 25 would be only 80% as likely as those scoring 15 to be in categories 2 and 3 of DS/DFS rather than in category 1. The same logic applies to other scores (e.g., 33 vs. 23, or any other 10-point spread).
The cumulative odds ratios are also given by individual quartiles of scores on the acculturation scale. We estimated these by forming indicator variables for quartiles 2, 3, and 4 and entering these variables simultaneously into a cumulative logistic regression model. The cumulative logistic regressions were adjusted for several variables that might be confounders. Because age and sex were considered to be primary variables to control for, they were included in all the logistic models as covariates. Since education, income, and marital status might reflect socio-economic or life-style aspects of health behaviors, models were considered that also contained these as covariates. Years in the USA and age at immigration were not included in the models, because we hypothesized that these variables are correlated with, but secondary to, acculturation. All analyses were conducted with the use of either SPSS (1994) or SAS (2000).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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The study sample consisted of 425 individuals, of whom 43% were male. Most of the individuals were between 30 and 59 yrs of age; 49% had fewer than 12 yrs of education, and the majority reported annual income levels of less than $10,000. Most of the individuals had been in the US for fewer than 19 yrs and had immigrated to this country at a relatively young age (Table 1
). Dental caries scores, indicating past and present caries prevalence as well as the number of missing teeth, decrease as acculturation scores increase. The scores for the periodontal variables follow a similar pattern (Table 2).
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). There was no indication that acculturation was associated with DFS in either model. There was a significant association with DMFS when we adjusted for age and sex, but not when income, education, and marital status were included in the model. Those with greater acculturation had better scores in both models for DS/DFS, DS, and number of missing teeth. A similar analysis for the periodontal health variables showed evidence of an inverse association of acculturation with percent of sites with attachment loss 4 mm (Table 4). In the model that included all the covariates, those with a higher acculturation level were less likely to have attachment loss 4 mm than those with lower acculturation scores.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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For periodontal health, acculturation was associated only with attachment loss 4 mm. Since this index only partially measures periodontal disease, the results cannot be easily interpreted. Nevertheless, it is possible that those individuals with higher acculturation scores may have experienced less periodontal disease.
Our results seem to contradict earlier findings suggesting a lack of association between acculturation and the number of decayed teeth, and a positive association with periodontal pocketing and gingival status (Ismail and Szpunar, 1990). They also contradict findings of an association between behavioral acculturation and dental health status as measured by the DMFS index (Mariño et al., 2001). The contradictory results may be due to the different samples and measurements used as well as the different levels of disease among the populations. Nevertheless, both of these studies as well as the present one suggest an overall positive impact of acculturation on oral health.
Previous studies have suggested that immigrants who have resided in the US for longer periods tend to have worse general health than recent arrivals (Stephen et al., 1994). This study does not corroborate that commonly held notion as it pertains to oral health. Although this group of immigrants was shown, in another study, to exhibit relatively lower levels of caries and higher levels of periodontal disease than the majority of the US population (Cruz et al., 2001), the present study suggests that their overall oral health does not worsen as they become more acculturated. On the contrary, the more acculturated they became, the more oral health benefits were seen.
Another possible concern is that the acculturation scale might be merely a reflection of age at migration to the US or length of time living in the US. Further analyses (not shown) found that age at migration to the US was not statistically significantly related to any of the nine dental or periodontal health variables shown in Tables 3
and 4, but length of time living in the US was associated with higher DMFS scores and greater numbers of missing teeth. However, for both DMFS and missing teeth, there was an effect of acculturation that remained statistically significant after "years in the US" was introduced into the model, so acculturation is clearly not just a surrogate for length of time since emigration, but has effects independent of time.
This study is limited in its generalization due to its sampling methodology. Nevertheless, this is the first study of its kind conducted in the US on a group of adult immigrants who are not of Hispanic origin. Thus, it provides valuable information on the effects of acculturation on the oral health outcomes of a less-established group of individuals.
In summary, acculturation was associated with some but not all objective measures of oral health in this group of immigrants to the USA. Results suggest that acculturation positively influences the oral health of these individuals by mediating their access to preventive and restorative oral health care. Acculturation is an important factor that should be considered in the examination of existing oral health disparities in the USA and in the development of oral health promotion programs.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Received December 2, 2002; Last revision October 14, 2003; Accepted November 4, 2003
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Angel R, Cleary PD (1984). The effects of social structure and culture on reported health. Soc Sci Q 65:814–828.
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