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Welfare Dental Intervention Improves Employment and Quality of Life

¹ Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, School of Dentistry, 3333 California Street, Suite 495, San Francisco, CA 94143-1361, USA; and
² Division of Epidemiology and Biostatistics, University of California, Berkeley, School of Public Health

Correspondence: ^* corresponding author, shyde{at}itsa.ucsf.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
Chronic, untreated oral disease adversely affects one’s systemic health, quality of life, and economic productivity. This study evaluated the effect of rehabilitative dental treatment on the oral-health-related quality of life and employment of welfare recipients. Three hundred and seventy-seven participants in a novel welfare dental program received oral examinations, questionnaires, and rehabilitative dental treatment. Seventy-nine percent of participants exhibited improvement in their oral-health-related quality-of-life scores following dental treatment. Improved OHIP-14 change scores were associated with being Caucasian or African-American, initial poor general health, severity of treatment urgency, worse baseline oral-health-related quality-of-life scores, subsequent patient satisfaction with the Dental Program, and resolution of their chief complaint (all p < 0.04). Those who completed their dental treatment were twice as likely to achieve a favorable/neutral employment outcome (OR = 2.01, 95%CI = 1.12, 3.62). Thus, oral health improved the quality of life and employment outcome for this welfare population.

Key Words: oral-health-related quality of life • dental program • dental treatment • welfare • employment

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
The Surgeon General’s Report on Oral Health revealed oral health disparities in some population groups, as classified by age, sex, income, and race/ethnicity (US Department of Health and Human Services, 2000). However, the oral health and oral-health-related quality of life (OHRQoL) of those marginalized through extended unemployment are unknown. Compromised nutrition, hygiene, and access to care in this underserved population likely result in extensive dental caries, tooth loss, and periodontal diseases. Chronic, untreated oral disease adversely affects one’s systemic health, quality of life, and economic productivity (Gift et al., 1992; Hollister and Weintraub, 1993; US Department of Health and Human Services, 2000). Facial attractiveness has been found to affect social attitudes and actions, and is important in employment situations (Oosterhaven et al., 1989; Eli et al., 2001).

The San Francisco Department of Human Services (SFDHS) offers the Personal Assisted Employment Services (PAES) program as a Temporary Assistance to Needy Families benefit directed toward employable, single, indigent adults. As compared with the general population of San Francisco, PAES recipients are almost six times as likely to be African-American (46% vs. 8%), and 19 times as likely to be homeless (38% vs. 1–2%) (San Francisco Department of Human Services, 2003). In contrast to Caucasian adults, African-American adults are twice as likely to have untreated dental caries (48% vs. 24%), more likely to have missing teeth (78% vs. 69%), and less likely to have visited a dentist in the preceding year (54% vs. 66%) (Dental, Oral, and Craniofacial Data Resource Center). Homeless adults are at even higher risk for poor oral health, since 91% have untreated decay, 89% have missing teeth, and only 27% have had a dental visit in the preceding year (Gelberg et al., 1988; Kaste and Bolden, 1995).

The PAES Dental Program began in 1999 as a collaboration between the San Francisco Departments of Human Services and Public Health, and is the only program of its kind in the United States. The goal of the Dental Program is to eliminate severe dental problems that pose a barrier to employment and self-sufficiency. The Program includes an oral health needs assessment, measurement of the OHRQoL, treatment planning, rehabilitative dental treatment, and program evaluation.

Based on data from a cohort of participants in the PAES Dental Program, this study evaluated the intervention effects of rehabilitative dental treatment on the OHRQoL and employment of welfare recipients.

	MATERIALS & METHODS

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This research project was reviewed and approved by the University of California, San Francisco, and the University of California, Berkeley, Institutional Review Boards. All participants provided signed informed consent prior to entering the study.

Participants
Eligibility criteria for the Dental Program included those welfare recipients who had been working cooperatively with their welfare social worker for at least 3 mos and had either self-identified or been identified by their social worker as needing extraordinary dental services. Dental Program participants could not be eligible for California’s Medicaid or for other dental insurance. The minimum age was 21 yrs old, and an interpreter was provided for those participants who did not speak English.

Measures
One investigator (SH), trained and calibrated for the clinical methods and diagnostic criteria used by the National Institute of Dental and Craniofacial Research (US US Department of Health and Human Services, 1991), conducted all interviews, clinical examinations, and treatment planning. Demographic information was obtained for age, sex, race/ethnicity, education, employment, and housing. The medical history was limited to (1) an assessment of whether antibiotic prophylaxis would be required for dental treatment and (2) 3 general questions about overall health. The clinical examinations were conducted in the welfare building with portable dental equipment. Universal precautions were used for infection control, and no radiographs were exposed. Clinical measures included the Community Periodontal Index (World Health Organization, 1997), the Decayed Missing Filled Index (Klein et al., 1938), and the American Dental Association’s Classification of Treatment Urgency (Council on Dental Health and Bureau of Dental Health Education, 1956). Treatment plans were rehabilitative (e.g., scaling and root planing, restorations, extractions, dentures) rather than involving full-mouth reconstruction. Four private-practice dentists, two university clinics, and one city clinic provided the treatment prescribed by the treatment plan. After completion of the dental treatment, participants were asked to return to the PAES Dental Program for an evaluation of their satisfaction with the Program and a reevaluation of their OHRQoL. The satisfaction survey included process (e.g., appointment scheduling, telephone interaction) and outcome (e.g., Dental Program satisfaction, chief complaint resolution) measures.

Oral-health-related Quality of Life
The Oral Health Impact Profile (OHIP) was used to measure the OHRQoL (Slade and Spencer, 1994). The OHIP measures the social impact of oral health according to 7 hierarchical subscales of oral health outcomes. A five-point Likert scale captured the responses, in categories of never, hardly ever, occasionally, fairly often, and very often, and with scores of 0 to 4, respectively. The OHIP has been found to have excellent internal reliability ( = 0.90) and validity (p < 0.001) (Locker and Slade, 1993; Locker and Jokovic, 1996; Slade et al., 1996; Allison et al., 1999; Locker et al., 2001). It has been in worldwide use since 1994, and translated into 8 languages (Allison et al., 1999; Wong et al., 2002; Ekanayake and Perera, 2003; Kushnir et al., 2004). The OHIP’s responsiveness to detect change in the quality of life over time, or following an intervention, was determined to be sensitive to both improvement and deterioration in scores (Slade, 1998; Awad et al., 2000; Allen et al., 2001). Although item weights were developed for the OHIP, they were not used in the calculations for this study, since Allen et al.(2001) found that the poorest sensitivity to change in quality of life was associated with the weight-standardized scores. A short-form version was subsequently developed (OHIP-14), consisting of 14 rather than 49 questions, which also possessed high internal reliability ( = 0.88) and comparable construct validity (Slade, 1997). Due to the constricted appointment scheduling of the Dental Program, the short-form OHIP-14 was used in this study.

Employment Outcome
Employment outcomes were recorded by the SFDHS as a complex series of codes. Over 50 different codes were used to characterize the disposition of the PAES participants. Favorable outcomes were assigned to participants who gained employment or transferred to other benefit programs, such as Social Security or Veteran’s Affairs. Neutral outcomes were given to participants who voluntarily left PAES, continued to remain compliant in the PAES program, or were ineligible to receive benefits due to institutionalization, death, or moving out of the county. Unfavorable outcomes were assigned to participants who became ineligible to receive benefits due to non-compliance or fraud. Differentiating between favorable and neutral outcomes was somewhat ambiguous. Classifications such as "client’s request", "program change request", "decline services", and "other" could apply to either favorable or neutral outcomes. Therefore, to minimize misclassification bias, we grouped favorable and neutral outcomes together.

Data Analysis
We calculated change scores by subtracting the OHIP-14 scores at baseline from those at follow-up. We calculated the effect size by dividing the change scores by the OHIP-14 baseline standard deviation. Cohen (1988) has defined an effect size of 0.2 as small, 0.4 as moderate, and 0.8 as large.

The independent variables for the regression model explaining the OHIP-14 change scores fell into 5 categories: demographics, clinical measures, treatment needs, baseline OHIP-14 scores, and follow-up patient satisfaction. Bivariate associations were assessed with one-way analysis of variance and linear regression. Those independent variables that were found to be statistically significant in bivariate analysis ( = 0.05) were added to a stepwise multivariate regression model. We assessed interaction by grouping together a cross-product term with its precedent terms, and decided to enter it into the model on the basis of the significance of the group’s joint F test (SAS Institute Inc., 2001). Subsequently, we assessed confounding factors by comparing the regression coefficients with and those without the addition of a potential confounder to the model. Covariates with an 0.20 were considered for control as potential confounders, and confounding was deemed present if the adjusted coefficients differed by more than 10% of their crude value (Kleinbaum et al., 1998).

We performed the chi-square test and logistic regression using demographic and clinical variables to determine whether any significant differences existed between those who completed their rehabilitative dental treatment and those who did not, as well as for those who were lost to follow-up. Chi-square analysis was also done for rehabilitative dental treatment and employment outcome. All data entry and analyses were conducted with the JMP Version 4 statistical analysis software from SAS Institute Inc. (Cary, NC, USA).

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
During the 18-month enrollment period (October, 1999–March, 2001), there were 2930 PAES welfare recipients, of whom 379 were referred or sought dental services. Of these, 377 (99.5%) agreed to participate in this study. Two hundred and sixty-five (70%) study participants completed their dental treatment, while 54 (14%) were discontinued from either PAES or the Dental Program prior to completing their treatment. Fifty-five participants (15%) failed to keep their first and all subsequent dental treatment appointments, and three (1%) died due to unrelated causes prior to completion of their treatment. Of the 265 participants who completed their dental treatment, 173 (65%) returned their oral-health-related quality-of-life questionnaires, and 92 (35%) were lost to follow-up. Employment status was ascertained for the entire cohort (n = 377), while changes in the OHRQoL were measured for those 173 participants who returned the questionnaires following completed dental treatment.

Seventy-one percent of the participants were male, ages ranged from 21 to 63 yrs old, 46% were African-American, 22% did not complete high school, 45% lived in a welfare-subsidized hotel room, 11% were homeless, and 26% rated their general health as either fair or poor (Table 1). Thirty-one percent had 6 mm periodontal pocket depths, 85% were missing one or more teeth, 84% had one or more untreated decayed teeth, and 63% had severe or emergency dental treatment urgency.

Oral-health-related Quality of Life
After receiving rehabilitative dental treatment, 79% of participants exhibited improvement in their OHIP-14 change scores, 18% showed deterioration in their scores, and 3% exhibited no change. Large effect sizes were found for the change scores of the psychological discomfort (1.09), psychological disability (1.00), and handicap (0.74) subscales (Table 2). Moderate effect sizes were seen for the change scores of the physical pain (0.63), social disability (0.62), and physical disability (0.41) subscales. Only functional limitation exhibited a small effect size (0.26). The OHIP-14 total score had a large effect size (0.87) for the change score.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

Since 57% of the cohort were either homeless or provisionally housed, the loss to follow-up of participants who completed their dental treatment was high (35%). Since the OHRQoL was re-assessed only for those who completed their dental treatment, future research could assess changes in OHRQoL more fully by re-surveying those who neither completed nor started their dental treatment.

In their analysis of the effect of literacy on health survey measurements, Al-Tayyib et al.(2002) found that self-administered questionnaires required not only literacy, but also ’forms-literacy’, or the ability to implement survey instructions and select consistent responses. Due to the difficulty in scheduling the participants who had completed their dental treatment for a follow-up examination, the assistance of the welfare social workers had to be enlisted to obtain the follow-up questionnaires. It was not possible to train and calibrate the social workers to administer the questionnaires, and no tracking was done regarding which questionnaires were self-administered vs. which received help from the social worker. However, since only 22% of this study population had less than a high school education, and less than 5% of the follow-up questionnaires contained errors such as circling more than one answer or omitting a question, it is not likely that information bias was introduced by the follow-up questionnaires being self-administered.

As discussed in MATERIALS & METHODS, the SFDHS employment outcome codes were complex and contained some ambiguity. Additional analysis of a subgroup of codes that most closely represented gaining employment (n = 56) was compared with the 136 unfavorable outcome codes that reflected non-compliance or fraud. Other than wider confidence intervals, this subgroup analysis yielded results similar to those found in Table 4. Therefore, to minimize misclassification bias associated with the ambiguous employment outcome codes, and to maximize the number of subjects included in the analysis, the authors reported the results in Table 4 for the entire cohort (n = 377), using a combination of outcome codes.

The employment outcome codes reflected only the most recent disposition of the participant, and were overwritten when the outcome status changed. A previous study of the PAES program found that participants flowed back and forth between unfavorable and favorable employment status (San Francisco Department of Human Services, 2003). Ideally, future research could allow the employment outcomes to capture employment stability by providing a running tally of the participant’s case disposition, rather than overwriting the employment codes whenever the status changed. Future research could also assess the financial sustainability provided by employment by recording the wage information.

The oral health and OHRQoL have not been previously assessed in a welfare population, nor has a Dental Program ever been offered as a welfare intervention. The improved OHRQoL and employment outcomes found for the participants who completed their dental treatment indicate that, for some welfare recipients, oral disease poses as significant a barrier to employment and self-sufficiency as do problems with general or mental health. Thus, oral health treatment can contribute to the goals of the Federal Personal Responsibility and Work Opportunity Reconciliation Act by eliminating barriers to employment and improving OHRQoL.

	ACKNOWLEDGMENTS

 
This study was supported by grant K16 DE 00386 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, US Department of Health and Human Services. The PAES Dental Program was funded by the San Francisco Department of Human Services, including remuneration of consulting dentist services for S. Hyde. This paper is based on a dissertation submitted by S. Hyde to the graduate faculty, University of California, Berkeley, in partial fulfillment of the requirements for the PhD degree.

Received for publication July 22, 2004. Revision received July 13, 2005. Accepted for publication September 8, 2005.

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Journal of Dental Research, Vol. 85, No. 1, 79-84 (2006)
DOI: 10.1177/154405910608500114


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