Minorities in dental hygiene: helping to close the gap in underserved areas.
--Mary McLeod Bethune
Disparities in Health Care
Issues regarding disparities in health and oral health care are nothing new. In 1999, Congress made a request to the Institute of Medicine (IOM) to study and report on the causes of and major concerns about health disparities. The IOM report assessed the extent of health disparities among United States minorities and non-minorities. The study revealed that "the underlying causes of disparity among minorities in health care stem from, bias, prejudice, and stereotyping by healthcare providers. There was significant variation in the rates of medical procedures by race even when insurance status, income, age, and severity of the condition were the same." (1)
A lack of access to services is a problem in health care for many minorities, according to the IOM report. Cultural and linguistic barriers also exist for some, because there is a shortage of health care providers with ethnic and cultural backgrounds similar to their own." (1) Recent research points to the associations between overall health and oral health. We now understand that oral health has been linked to certain diseases and disorders in the body. In 2000, the Surgeon General stated in his report on oral health in America that "there may be a relationship between diabetes, heart and lung diseases, stroke, premature births, and chronic oral infections." (2)
According to the American Dental Educator's Association (ADEA), the oral health status of Americans has dramatically improved over the past 30 years overall, but certain segments of the population have experienced barriers to receiving care, causing them to have greater need of oral health. (3) For the underserved in America, there are many opportunities to improve oral health, eliminate health disparities and improve the overall quality of life. More understanding and awareness of the problems are beginning steps in the right direction.
Minorities in Dental Hygiene Practice
When examining the issue of disparities in oral health care, it is important to consider the percentage of minority dental hygienists in the general population of the United States. Increasing the supply of minority dental hygienists can help close the gap in providing needed dental services to underserved areas. Greater efforts must be made to recruit and increase minority enrollment in dental hygiene programs. Table I, from The United States Census Bureau Report (2000), reflects the disproportionate number of minorities in the general population compared to the supply of minority dental hygiene graduates in the United States, as reported by the American Dental Association. (4,5)
The American Dental Association reports that only 15.8% of dental hygiene graduates in the United States were minorities in 2006, while 82.3% were Caucasian. According to these figures, minority graduates of dental hygiene programs in the United States have not increased by any significant amount. Figures increased slightly from 14.1% in 2002-2003 to 15.6% in 2005 (Table II). (5)
According to IOM, one of the "reasons racial and ethnic diversity is important in health fields is because minority health care professionals are more likely than their White peers to serve minority and medically underserved communities by a significant degree." (6) Satcher observed that one of the reasons for oral health disparity is because of the "lack of racial and ethnic diversity in the oral health workforce." (7) There is a great need to have minority oral health providers in percentages more representative of the general population. Dental hygiene professionals who are from minority populations can have a significant role in preventing disease and providing care to those who need it most. Patients like to feel a sense of trust with professionals who are treating them, and having access to practitioners who are more sensitive and aware of their cultural differences is important for many. As reported by the Kaiser Family Foundation, "There is greater satisfaction and adherence to treatment among patients when they are of the same race as their provider." (8)
Minorities are among the most underserved groups in society, and some are affected by poor dental health. Many suffer needlessly from periodontal disease, tooth decay and loss of teeth that are left untreated, causing painful negative health consequences. (3) Oral health disparities result from variables such as access to treatment, socioeconomic status, age, race and ethnicity. Along with the challenges of addressing oral health disparities, a lack of care in minority communities is further exacerbated by the supply of underrepresented minority students and faculty in dental hygiene. (9)
Minorities in Dental Hygiene Education
Dental hygiene is an allied health profession in which minority populations (African American/black, Hispanic/Latino, American Indian/Alaska Native) are underrepresented. According to Nunn, Amyot, Battrell, Bruce, Hanlon and Kaiser, "There is a lack of diversity in allied dental faculties, especially in dental hygiene programs." (10) This lack of diversity among oral health educators contributes to the existing problem of oral health disparities in the United States. Concerns over faculty shortages in dental hygiene are recently being discussed with more urgency since many current faculty are approaching retirement. (9) Another reason for the shortage is the "decline in bachelor's and master's degree dental hygiene programs." (9) According to Majeski, "There is a current shortage of dental hygiene faculty nationwide, especially culturally diverse educators." (9) Taking these factors into consideration, minority dental hygienists should begin to seek opportunities for continuing their education beyond the associate's degree for expanded roles as educators and administrators in oral health care.
Dental hygiene and other allied health disciplines have always had a relatively small percentage of minority representation. According to Nunn (2004), the dental hygiene profession in particular is an allied dental profession that is almost exclusively Caucasian. (10) IOM also reported, that "Black/African Americans, Hispanic/Latinos and American Indian/Alaska Natives are minorities that are underrepresented not only in dentistry but also medicine and nursing." (6,11) On the other hand, the Sullivan Commission reports that "Asians are overrepresented in the medical and dental student populations, but are also considered an underrepresented group in nursing." (11)
One reason for the shortage of minorities in dental hygiene is an insufficient level of academic preparation for entry into these fields. As reported by ADEA, "allied health programs require strong test scores and good preparation in science and math." (3) This lack of preparation creates barriers for many minorities. Health professions schools and colleges must implement more effective strategies for increasing cultural diversity and competency within their institutions. This does not mean standards should be lowered, but it does mean creating an environment that is welcoming, inclusive and tolerant of individuals who are racially and ethnically different from the majority.
The Importance of Mentoring
The short supply of mentors available to encourage and coach minorities towards a career in allied health and dental hygiene places them at an even greater disadvantage. (12) As reported by Abriam-Yago, "many minority students face special challenges in successfully navigating their way to graduation and transitioning into a professional career." (12) From elementary school through high school, many students do not receive the mentoring and guidance needed early on for success in these fields. According to ADEA, dental hygiene is not often considered when making a career choice because "minority students are not as familiar with this profession and do not think they would fit or have the qualifications for this type of field." (3) More exposure to dental care and dental professionals during one's youth is one way to learn about a career in dental hygiene. To have professional role models and mentors to consult and ask questions about dental hygiene, types of jobs, salaries, places to work and requirements to enter into these fields is essential for minorities and strongly needed.
Mentoring programs and leadership development opportunities could help prepare minority graduates for roles as faculty, researchers and administrators. Faculty should encourage students to consider career mobility and advanced opportunities in dental hygiene. Faculty can help by mentoring current students and graduates and cultivating the desire for upward mobility in the profession.
Steps designed specifically to make the profession of dental hygiene more visible are also needed. Some examples would be articulation agreements with area high schools; career fairs in elementary, middle and high schools with a large minority population; using dental hygienist spokespersons and role models who are members of the minority community and inviting parents to workshops about careers in dental hygiene. Grant-funded internships or externships can provide opportunities for high school students in pre-college programs to gain insight and experience in the field of dental hygiene. High school students can engage with senior dental hygiene students, meet with faculty, do laboratory work, and learn about clinical and didactic aspects of dental hygiene education. Several programs currently in existence and designed to provide youth with early exposure to allied health are the HRSA "Kids into Health Careers program, Centers of Excellence, and Health Careers Opportunities programs.'" (3) In addition, efforts continue to be made by minority dental organizations such as the National Dental Association (NDA) and the National Dental Hygienists' Association (NDHA). Bolden reported that NDA and NDHA both aim to "improve the oral health status of African American communities and other underserved communities." (13) One of their goals is to recruit underrepresented minorities into the profession. NDA held its 92nd Annual Convention in August 2005 in Las Vegas, Nevada, with the theme, "Working Together to Eliminate Oral Health Disparities." (13)
Ethnic Balance Between Dental Hygiene Students and Faculty
It seems rare to find a college program with ethnic diversity of faculty that matches the ethnic diversity of the student population. One such program is the dental hygiene unit at Eugenio Maria de Hostos Community College, located in the South Bronx of New York City. (14) The college was established in 1968 as a two-year undergraduate institution with a mission to increase educational and employment opportunities for Hispanics, blacks and low-income residents of the South Bronx and New York City who have experienced barriers to higher education. The belief is that by eliminating barriers to education and increasing employment opportunities, this mission will increase socioeconomic mobility among minorities.
Minority dental hygiene faculty (black/African American and Hispanic/Latino) and students, are the majority over Caucasian faculty and students at Hostos Community College. Initially, most of the students at Hostos were Hispanic, with some blacks. Over the years, the college consistently made efforts to foster diversity and a multicultural environment. The population of today is very diverse, and students of African, Asian and Slavic descent have increasingly enrolled as they have arrived to join the local population. Since the dental hygiene program's inception over 30 years ago, more minorities have been educated and trained as dental hygienists in New York City, yet the supply of minority students and graduates remains small overall.
The Growing Concern over Faculty Shortages in Dental Hygiene
A report by Nunn, et al, discusses concern over the "shortage of dental hygiene faculty nationwide." (10) Some reasons given by Majeski for this shortage are "faculty retirements, and a short supply of dental hygienists with advanced degrees who qualify for faculty positions" (9) To increase the number of educators, minority students should be encouraged to pursue advanced studies. By the student's senior year in dental hygiene, faculty can encourage and recruit certain individuals as potential educators, thus perpetuating a continuing supply of competent dental hygiene faculty. Overall, if more effort is made to recruit minority faculty, this may also attract more minority students to dental hygiene education.
Associate-degree dental hygiene programs can be completed in two to three years. Some dental hygiene students who also have family or work obligations may prefer this type of short educational program, which enables them to work and earn a comfortable salary as soon as possible. Other dental hygienists may decide to work for several years and then return to college to further their studies. Minority dental hygienists have an opportunity to make significant contributions to reducing disparity and improving people's lives in underserved areas of oral health care. An advanced degree beyond the associate level, such as a bachelor's or master's in health, education or administration, can increase opportunities to become educators, researchers and practitioners. These are significant roles for having a greater impact on serving where the need is greatest.
Recommendations and Conclusion
Minority dental hygienists in traditional practice settings can increase their opportunities to serve others by working in areas of the profession where they are underrepresented, such as education, research, legislation and community outreach. It is especially important now, more than ever, for minorities to pursue advanced degrees. One of the goals mentioned by the Surgeon General in his Healthy People 2010 report is to "increase access to oral health care in underserved areas." (15) People most affected by lack of access are minorities in low-income communities and rural areas. Now is the time to increase the presence of minority dental hygienists at the administrative level where policies are set that affect the health status of other minorities. There are not enough dentists available to meet the needs of the underserved population. (3) Making oral health care more accessible to the underserved is a goal that should concern all dental hygienists across the country, especially minority dental hygienists. Having increased flexibility to provide preventive and restorative services is one way to increase the manpower needed to remedy the issues of disparity.
Another priority for minorities in dental hygiene is to have greater input when decisions are made that affect the profession of dental hygiene and the provision of oral health care. There needs to be more minority representation on dental hygiene boards and in the legislature where major decisions are made about the oral health care professions and about the state practice act. Practice acts vary by state and determine what a hygienist can and cannot do in that state, as well as the type of supervision that is required to provide specific services. (3) According to ADEA, "One of the major challenges to full utilization of allied dental professionals is state laws and regulations that limit practice settings and impose restrictive supervision requirements." (3) ADEA further reports, "Many state practice acts presently do not reflect what dental hygienists have been trained to do competently." (3)
Being a member of the American Dental Hygienists' Association (ADHA) provides an opportunity for the dental hygienist to be represented and stay current about issues concerning the profession. ADHA represents the interests of the dental hygienist and provides opportunities for leadership in community service and legislative activities.
Efforts are being made to advance the profession of dental hygiene, and opportunities have steadily increased for some dental hygienists to address the problem of oral health disparities. Minority dental hygienists can make contributions to research by writing articles that serve to educate the public and increase awareness about oral health issues and disparities in oral health care in addition to other important information that affect underserved populations and underrepresented communities.
The American Dental Hygienists' Association (ADHA) has a National Dental Hygiene Research Agenda that provides opportunities for registered dental hygienists to research, write and contribute to the field of knowledge in dental hygiene. Further, in June 2004, the ADHA House of Delegates approved an official policy to address oral health disparities in the United States and created the Advanced Dental Hygiene Practitioner (ADHP) to carry out expanded roles and responsibilities of providing preventive, restorative and therapeutic services to meet the needs of the unserved and underserved population. (16) These are tremendous gains for the profession of dental hygiene and the ADHP provides a great opportunity to involve dental hygienists in working towards eliminating barriers and reducing oral health disparities.
American Dental Hygienists' Association. American Dental Hygienists' Association adopts official policy to address U.S. oral health disparities. Available at www.adha.org/media/releases/070804_adhp.htm. Accessed Sep. 14, 2005.
Community Voices Network. The big cavity: decreasing enrollment of minorities in dental schools. March 2001. Available at www.Community Voices.org.
(1.) Institute of Medicine. Unequal treatment', what healthcare providers need to know about racial and ethnic disparities in healthcare. 2002. Available at www.amsa.org/minority/IOM_unequal_HCP.pdf. Accessed March 4, 2008.
(2.) United States Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General--Executive Summary. Rockville, MD: HHS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
(3.) American Dental Education Association. Improving the Oral Health Status of all Americans: Roles and Responsibilities of Academic Dental Institutions. The Report of the ADEA President's Commission, March 2003.
(4.) United States Census Report (2000). Available at www.census.gov. Accessed Apr. 11, 2005.
(5.) American Dental Association. Survey of Allied Dental Education 2002/2003 and 2001/2002). Chicago: American Dental Association.
(6.) Institute of Medicine. In the nation's compelling interest: ensuring diversity in the health care workforce. February 2004. Available at www.iom.edu/report.asp?id=18287. Accessed Mar. 17, 2005.
(7.) American Federation of Teachers: Professional issues: minority report. Available at www.aft.org/pubs-reports/healthwire/issues/janfeb05/ minority.htm. Accessed Mar. 10, 2005.
(8.) Health care and the 2004 elections: race, ethnicity and health care, 2004. Available at www.kff.org/minorityhealth/upload/ Elections-2004-Race-Ethnicity-and-Health-Care. Accessed Sep. 21, 2005.
(9.) Majeski J. The educator shortage. Access 2004; 18(9): 16-22.
(10.) Nunn PJ, Gadbury-Amyot CC, Battrell A, et al. The current status of allied dental faculty: a survey report. J Dent Educ 2004; 68(3) 329.
(11.) Sullivan L. Missing persons: minorities in the health professions. The Sullivan Commission, 2004; 3-6.
(12.) Abriam-Yago K. Mentoring to empower--featured stories. Minority Nurse 2002. Available at www.minoritynurse.com. Retrieved Apr. 6, 2005.
(13.) Bolden A. Flossline 2005; January/February.
(14.) Strategic Plan. (2003-2008). New York: Eugenia Maria de Hostos Community College.
(15.) Healthy People, 2010. Available at www.healthyPeople.gov/Document? HTML/Volume2/21Oral.htm. Accessed Mar. 15, 2005.
(16.) Majeski J. ADHP: an update. Access 2005; 19(7):20-4.
By Joyce Dais, RDH, BA, MPH, MSEd
Joyce Dais, RDH, BA, MPH, MSEd, is a tenured assistant professor and senior clinic coordinator for the dental hygiene unit at Hostos Community College in Bronx, N.Y. Didactically, she teaches Community Dental Health, and Nutrition, and has experience working in community outreach and on various research projects. She has published several recent articles in relation to oral health.
Table I. U.S. Population, 18 Years or Older, by Ethnicity/Race Percent of Dental United Hygiene States Graduates Ethnicity/Race Number Percent in 2006 Hispanic or Latino 22,963,559 11.0 6.6 Not Hispanic or Latino: White alone 150,525,687 72.0 82.3 Black or African American alone 23,337,573 11.2 3.5 American Indian and Alaska Native alone 1,382,972 0.7 0.7 Asian alone 7,702,895 3.7 5.0 Native Hawaiian and Other Pacific Islander 244,010 0.1 Unknown Some other race alone 275,444 0.1 Unknown Population of two or more races: 2,695,954 1.3 Unknown Total: 209,128,094 100.0 100.0 Source: 2000 U.S. Census. (4) American Dental Association, Survey Center, 2006-07. Survey of Allied Dental Education. (5) Table II. Total Graduates in U.S. Dental Hygiene Programs by Ethnicity/Race, 2006, 2005, 2002-2003 Number of Percent Percent in Graduates Percent in 2005 2002-2003 in 2006 in 2006 Comparison Comparison White 5,161 82.3 81.9 84.3 Black 222 3.5 3.9 3.3 Hispanic 416 6.6 6.5 5.6 American Indian 47 0.7 0.6 0.9 Asian 316 5.0 4.6 4.3 Unknown 111 1.8 2.5 1.6 Total 6,273 100.0 100.0 100.0 Source: American Dental Association, Survey Center, 2006-07, 1005-06, 2002-03. Surveys of Allied Dental Education (5) Used by permission