Milieu in Dental School and Practice
Influence of Contextual Environment and Community-Based Dental Education on Practice Plans of Graduating Seniors Pamela L. Davidson, Ph.D.; Daisy C. Carreon, M.P.H.; Sebastian E. Baumeister, Ph.D.; Terry T. Nakazono, M.A.; John J. Gutierrez, B.A.; Abdelmonem A. Afifi, Ph.D.; Ronald M. Andersen, Ph.D. Abstract: This study investigated senior dental students’ plans to provide care to underserved racial/ethnic minority populations. Three sets of determinants were analyzed: contextual environment, community-based dental education (CBDE), and student characteristics. We analyzed data from the ADEA Survey of Dental School Seniors and administrative data sources to construct contextual variables. Multivariable results show three contextual variables predicted practice plans: greater numbers of federally qualified health centers, higher percentages of underrepresented minorities, and attending a California Pipeline dental school. Regarding CBDE predictors, it was alarming to find seniors who viewed the cultural competency curriculum as inadequate and perceived themselves as less prepared to provide oral health care to diverse populations were also those most likely to serve minority patients. Significant student characteristics included racial/ethnic minority, female gender, older age, lower parent’s income, and socially conscious orientation. The study provides evidence that contextual environment, CBDE, and student characteristics were significantly associated with plans to care for underserved patients. Findings suggest if the Pipeline initiative is successful in stimulating reform in U.S. dental schools, future students will develop greater awareness regarding critical access problems and the competencies required to effectively care for diverse populations. In the long term, addressing the problem of dental care access will require the creation of policy, financial, and structural interventions to motivate providers to care for the underserved. Dr. Davidson is Associate Professor, Department of Health Services, School of Public Health, University of California, Los Angeles, and Project Director and Co-Investigator for the National Evaluation Team; Ms. Carreon is Research Associate, Department of Health Services, School of Public Health, University of California, Los Angeles; Dr. Baumeister is Research Epidemiologist, Institute of Epidemiology and Social Medicine, University of Greifswald, Germany; Mr. Nakazono is Programmer Analyst, Department of Health Services, School of Public Health, University of California, Los Angeles; Mr. Gutierrez is Project Manager, Department of Health Services, School of Public Health, University of California, Los Angeles; Dr. Afifi is Professor, Department of Biostatistics, School of Public Health, University of California, Los Angeles; and Dr. Andersen is Principal Investigator of the National Evaluation Team and Professor Emeritus, Department of Health Services, School of Public Health, University of California, Los Angeles. Direct correspondence and requests for reprints to Dr. Pamela L. Davidson, University of California, Los Angeles, Department of Health Services, CHS 31-293, 650 C.E. Young Drive South, Campus Box 951772, Los Angeles, CA 90092-1772; 310-825-7188 phone; 310-206-3566 fax;
[email protected]. Key words: dental practice intention, dental education, access to dental care Submitted for publication 7/31/06; accepted 11/7/06
T
he nation’s dental care safety net is inadequate to serve the population in need, and access problems are likely to intensify. 1,2 Access barriers are created on several fronts not the least of which are the following: 1) so few underrepresented minorities enter dentistry; 2) a general apathy regarding societal responsibility to care for underserved populations among dental schools, faculties, and the students they historically recruit; 3) little or no government reimbursement to provide care to low-income, uninsured populations; and 4) sizeable educational debt incurred by dental school seniors, March 2007 ■ Journal of Dental Education
which immediately accrues interest upon graduation. Minority representation in the dental and other health professions remains a concern.3-5 The shortage of dentists is particularly critical in African American and Hispanic communities.6-8 This study analyzed dental school senior students’ plans to provide care to underserved racial/ ethnic minority populations. The Robert Wood Johnson Foundation (RWJF) and The California Endowment (TCE) funded the Pipeline, Profession, and Practice: Community-Based Dental Education program to address the critical shortage of oral 403
health care services for underserved and disadvantaged populations by changing dental education in the United States. RWJF funded competitive grants proposed by eleven of the fifty-six accredited U.S. dental schools, and one year later, TCE funded four additional dental schools in California to design and implement a Pipeline program. Additionally, TCE required all five of California’s dental schools to develop a regional recruitment program for underrepresented minorities and a collaborative statewide health policy effort to sustain the Pipeline initiative after funding ends. The three Pipeline objectives are: 1) increase recruitment and retention of underrepresented minority and low-income students; 2) revise didactic and clinical curricula to support community-based educational programs; and 3) establish communitybased clinical education programs that provide dental students and residents with sixty days of experience in a patient care environment.9,10 This study examines student characteristics (e.g., race/ethnicity), community-based dental education (e.g., curriculum and clinical rotations), and contextual environment (e.g., number of federally qualified health centers in the county) on a longer-term outcome, the practice plans of senior dental students. Data were analyzed from the 2003 American Dental Education Association (ADEA) Survey of Dental School Seniors and a set of contextual variables. To our knowledge, this study is the first to include individual and contextual-level variables to investigate plans to provide care to underserved minority patients upon graduation; no other studies were found in the literature combining these levels of data. From a methodological perspective this study advances the use of contextual variables in dental education and dental health services research and provides detailed information on constructing contextual variables. The study examines baseline measures before the Pipeline program was implemented in academic year 2002-03. Future evaluation research will analyze data collected in the 2007 ADEA survey, when foundation funding culminates, to examine the impact of the Pipeline program on practice plans of graduating seniors.
Literature Review Articles were identified from medical and health services research journals using PUBMED
404
database and the following keywords: plans upon graduation, early and long-term career decisions, practice decisions, preferences, motivations, and interests. Research has emphasized different aspects of practice plans, such as practice location,11-14 practice arrangement (solo versus group practice),4,15-17 and postdoctoral education and specialization.18,19 Six studies specifically investigated factors influencing plans to provide care to underserved and minority populations.4,20-24 Several researchers focused on the personal characteristics of students or dentists, such as gender and race/ethnicity;4,15-18,24 only a few explored variables that influence the individual, i.e., educational program and economic factors.12,21,22 The following sections summarize findings from the research literature on determinants of practice plans including student characteristics, community-based dental education, and contextual variables.
Student Characteristics In part, the Pipeline initiative was promulgated on the belief that workforce diversity may help to alleviate disparities in oral health care for low-income and underserved populations. Minority providers may be more culturally sensitive to their minority patients’ needs. Our review yielded only a few studies examining the relationship between race/ethnicity and plans to provide care for minority patients. One study showed African Americans compared to whites were more likely to establish practices in underserved communities, provide care to uninsured and Medicaid beneficiaries, and continue service after participation in the National Health Service Corps.4,15,21 In studying the supply of dentists in California, Hayes-Bautista et al.5 found Latino dentists comprised 4.6 percent of the total dental supply in 2000. Although Latinos comprise about a third of the state’s population, only one out of every twenty dentists was Latino. Our search yielded no literature on practice plans of American Indians. Clearly, more research is needed to understand recruitment of underrepresented minorities to dentistry and implications for practice upon graduation. The root problem for the underrepresented minority groups (African American, American Indian, and Hispanic) appears to be that so few apply for and are accepted into dental school. A report issued by ADEA found underrepresented minorities comprised 12.4 percent of the applicant pool and 11.6 percent of first-year enrollees in 2004.25 Asian/ Pacific Islanders and whites comprised 69.7 percent of applicants and
Journal of Dental Education ■ Volume 71, Number 3
71.1 percent of first-year enrollees (see Table 3 in Weaver et al. for more detailed information).26 Other student characteristics, such as gender and age, have been found to influence dental students’ preferences for type and specialty of practice.15,19,27,28 For instance, males have consistently rated the solo owner practice arrangement more favorably than females.15-17,29 Age significantly influences the decision to enter into an academic career, with younger individuals finding income of an academic dentist to be a deterrent.19 However, the search yielded no studies indicating gender or age was associated with providing care to the underserved. Our search yielded few studies showing the relationship between attitudes and beliefs and practice plans. Medical students when compared to dental students were found to demonstrate greater altruism and a sense of intellectual challenge as motivating factors in career choice; dental students demonstrated more commitment to personal and financial gain.18 In studying attitudes of family physicians, Eliason et al.24 found an association between universalism values (i.e., motivation to enhance and protect all people) and the number of indigent patients served. Li et al.23 found primary care providers who had a “strong sense of service to humanity” were more satisfied with their work. Some believe inequities are compounded in dentistry more than medicine due to tensions within the dental profession between the moral values traditionally identified with the health professions and the commercial values of practice achieved through entrepreneurial self-interest.30 In summary, although the literature is limited, research suggests certain student characteristics (race/ethnicity, attitudes, and beliefs) do predict practice plans.
Community-Based Dental Education In a descriptive study, Smith et al.20 found a positive relationship between curricular emphasis on treating patients from diverse backgrounds and student and alumni intentions to care for these patients in their practices. Findings from another study showed greater time spent in rotations was a significant predictor of perceived ability to provide care to diverse groups.31 In a third study, Mofidi et al.21 found 46 percent of alumni who participated in the National Health Service Corps continued to provide care to underserved groups. In contrast, DeCastro et al.22 found no significant differences in alumni
March 2007 ■ Journal of Dental Education
attitudes towards practicing in underserved areas or accepting Medicaid patients between a communityoriented dental education program and a traditional program. Although results are somewhat equivocal, the literature does suggest some correlation between preparation in the academic programs (didactic and clinical rotations) and the extent to which care is provided to underserved patients in future practice.
Contextual Environment Contextual variables represent the social, economic, structural, and public policy environment influencing access to care.32,33 As noted, much of the literature on practice plans focuses on the characteristics of the decision maker (student or dentist) and a few on the educational program. Our search yielded only one study testing the effects of contextual variables on plans to provide care to underserved patients. Beazoglou et al.12 found size of population, per capita disposable income, and cost of operating a dental practice were significantly associated with number of practicing dentists in 140 Connecticut townships. The study examined distribution of dentists in the state, but did not analyze the influence of individual characteristics or academic program on the decision-making process; only contextual variables were analyzed in this study.
Materials and Methods The following sources of data were used to investigate senior dental students’ plans to provide care to underserved racial/ethnic minority populations. From the ADEA Annual Survey of Dental School Seniors, questionnaire items were identified that best represent student characteristics and components of community-based dental education using a conceptual and analytical model to guide variable selection (Figure 1). The ADEA survey administers an annual questionnaire to graduating seniors in accredited dental schools. The survey collects information about social and demographic characteristics, educational financing, indebtedness, adequacy of time in predoctoral instruction, preparedness for practice, and practice and postdoctoral plans.25 Additionally, starting in 2003 the survey began collecting information related to the Pipeline initiative and community-based dental education, e.g., recruitment, curriculum, and extramural clinical rotations. Each school uses its own survey distribution and collection system. Surveys are returned annually to 405
Contextual Environment Policy Population Delivery System Dental School
Pipeline Status at Dental Schools California Pipeline Non-Pipeline (n=5) (n=38)
National Pipeline (n=10)
Community-Based Dental Education RECRUITMENT Factors affecting decision to pursue dentistry career
CBDE CURRICULA
EXTRAMURAL CLINICAL ROTATIONS
Time devoted to cultural competency Preparedness for providing care to diverse groups
Influence of practice location (positive or negative) # Weeks in extramural rotations
Student Characteristics Education Expenses & Debt
Demographic Race/Ethnicity Age
Gender Marital
Attitudes & Beliefs
Socioeconomic Parent’s income
Participation in loan repayment Debt upon graduation
Father’s education
Socially oc conscious Cultural awareness Service orientation Entrepreneur
Plans to Care for Underserved Minority Patients
Figure 1. Measurement model for predicting plans to care for underserved minority patients
ADEA for reporting and analysis. Additionally, a set of constructed contextual variables came from administrative data sources measuring policy, population, dental care delivery system, and dental school environment. (See Table 1 for a detailed list of data sources and references used to construct contextual variables.) Figure 1 presents a measurement model for predicting plans to care for underserved minority 406
patients. The model posits contextual environment, community-based dental education (CBDE), and student characteristics influence practice plans of graduating seniors. ���������������������������������� The variables selected to measure the various constructs, along with their definitions and distributions, are provided on Table 1. The dependent variable for students’ practice plans was measured using the following ADEA questionnaire item: “When you enter practice, about Journal of Dental Education ■ Volume 71, Number 3
what percent of your patients do you expect will be from underserved racial/ethnic minority populations?” The variable included five response categories (or cut points): 0 percent (n=177, 4.8 percent), 1-10 percent (n=1460, 39.5 percent), 11-24 percent (n=1246, 33.7 percent), 25-50 percent (n=291, 7.9 percent), and greater than 50 percent (n=234, 6.3). We combined the 25-50 percent and greater than 50 percent categories for the analysis (n=525, 14.2 percent). A practice plans intervening variable was included and constructed into a categorical measure indicating primary activity immediately upon graduation: 1) private practice (49.9 percent), 2) community clinic or government service (9.9 percent), and 3) postdoctoral or academic appointment (40.2 percent). Independent variables in the measurement model are discussed in the sections below: contextual environment, CBDE, and student characteristics (Figure 1). The contextual environment included policy, population, dental care delivery system, and dental school characteristics (Table 1). Federal, state, and local health policies influence dental care financing and the percent of the population with public insurance. Racial/ethnic representation in the state legislature can influence resources for medical and dental education and the availability of services for vulnerable populations. Two state policy variables were measured: percent underrepresented minorities in the state legislature (mean=16.8, range 0-100 percent because the study includes Puerto Rico); and adult Medicaid dental coverage: no benefits (15 percent), emergency only (18.2 percent), partial coverage (39.4 percent), and full coverage (27.3 percent). Contextual variables can be used to measure population characteristics and their collective effect on access. For example, when large numbers of low-income, racial/ethnic minority groups and/or uninsured persons reside in a geographic area, access barriers are magnified for individuals competing for limited services and resources.32 When dental students have the opportunity to train in communitybased settings, potentially they will become more aware of access barriers and better trained to respond to population oral health needs. Two county-level population variables were measured: percent underrepresented minorities (ranging from 4.6 to 98.3 percent because the study includes Puerto Rico); and percent population with income less than 200 percent of the federal poverty level (ranging from 15.8 percent to 63.6 percent). Three contextual variables measured the dental care delivery system: 1) practicing dentists
March 2007 ■ Journal of Dental Education
per 10,000 population for each state and District of Columbia (ranging from 3.9 to 12.6); 2) number of federally qualified health centers (FQHCs) in the county providing dental care (ranging from 0-10); and 3) number of federally qualified health centers (FQHCs) in the county per 100,000 low-income residents (ranging from 0 to 81.7). The final set of contextual variables measured dental school environment (Table 1). Data collected by the American Dental Association (ADA) were used to show university ownership (public or private). Two variables were constructed from dental school mission statements: commitment to recruiting diverse students and providing health care to underserved populations. Two school-level variables were measured: percent underrepresented minority (URM) dental students (years 1-5); and average total educational cost for first-year students. The final contextual variable measured the dental school’s aggregate cultural and social environment using average values at the school level from the following ADEA questionnaire item: “The cultural and social environment of your school promotes acceptance and respect of students and patients of different races, ethnicities, and cultures,” measuring level of agreement using a four-point Likert scale. Additionally, the measurement model (Figure 1) included a critical program evaluation measure showing Pipeline program status among the accredited dental schools: 1) “National Pipeline” schools funded by the Robert Wood Johnson Foundation; 2) “California Pipeline” schools funded by The California Endowment; and 3) non-Pipeline dental schools. The University of California, San Francisco (UCSF) was funded by both foundations. However, we included UCSF in the “California Pipeline” category because all schools in the state of California received Pipeline program funding and are engaged in collaborative statewide recruitment and health policy initiatives. In addition to contextual environment, we investigated a set of community-based dental education (CBDE) variables hypothesized to influence practice plans (Figure 1). Specifically, we examined variables representing 1) recruitment of underrepresented minority students, 2) CBDE curricula, and 3) extramural clinical rotations. Recruitment measures tested included “Importance of the following factors in influencing the decision to pursue dentistry as a career”: a) high school or college counselor, b) recruitment by a dental school, c) pre- or post-baccalaureate dental career program, and d) awareness
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Table 1. Description and distribution of independent and dependent variables Domain and Definition Indicator
Geographic % or Mean Unit of (Standard Observation Deviation)
Range*
Contextual Environment Policy % URM in State Legislature1
This state level variable reflects the percent of African American and Latino senate and house members in the legislature. The numerator is the number of African American and Latino persons and the denominator is the total number of legislative seats.
State
Adult Medicaid States were categorized according to Medicaid dental State Dental Benefits2 coverage provided to adults, 21+ years in 2002. The constructed variable reflects the level of dental benefits provided: 0 for no benefits, 1 for emergency-only, 2 for partial/limited coverage to adults, and 3 for full coverage.
16.8 (18.2)
0-100
No benefits=15.1% — Emergency only= 18.2% Partial coverage= 39.4% Full coverage=27.3%
Population Characteristics % URM population3
Census data were used to construct a variable reflecting the percent of the total population in the dental school’s county that was URM (AA, Hispanic, AI/AN). The numerator is the total number of URM persons in the county. The denominator is the total population in the same county.
% Federal Poverty The numerator includes those with low-income Level
