The effect of community-level unemployment on preventive oral health care utilization.

Oral health is necessary for many functions: eating, nutrition, communication, disease prevention, appearance, and overall health. Marked advances have been made in the quality and level of oral health over the past 50 years. However, the benefits have not been shared by all Americans and considerable room for progress remains (Evans and Kleinman 2000). One critical element in the ongoing improvement of oral health is preventive care. Preventive dental services are typically provided during a routine check-up.1 They represent a direct and low-cost route to improved oral health. Preventive services include prophylaxis, sealants, and fluoride treatments, as well as screenings for tooth decay, periodontal disease, orthodontic disorders, and oral cancer. Regular care also allows providers to stop oral diseases from occurring and to diagnose and treat developing problems (Doty and Weech-Maldonado 2003). Preventive dental care is important from two standpoints. First, regular preventive services yield health-related benefits. Individuals with at least one periodic visit annually are significantly less likely to have plaque, gingivitis, and calculus than individuals with no visits (Lang, Ronis et al. 1995). Moreover, adults who accessed preventive dental services in the past year reduced their risk of tooth loss by 27 percent (Kressin, Boehmer et al. 2003). Utilization of preventive services is also important financially. Most preventive dental services are inexpensive and cost-effective, representing a fraction of the cost of care for advanced conditions, such as endodontic therapy, fixed prosthodontics, or dental implants (Brown and Lazar 1998). Researchers have found that utilization of preventive dental care services leads to significant savings over time for children (Savage, Lee et al. 2004,Quinonez, Downs et al. 2005). Reflecting these savings, total health care costs in the United States have been increasing dramatically, but spending on oral health has increased only slightly (Brown, Wall et al. 2002,Brown and Manski 2004;,Heffler, Smith et al. 2004) Despite the importance of preventive dental care, evidence suggests that utilization of preventive services is far from universal. Estimates using the 1996 Medical Expenditure Panel Survey (MEPS) indicate that only 32 percent of all Americans had visited the dentist for a preventive visit during the previous year (Goodman, Manski et al. 2005). The important nature of preventive dental services raises questions about the factors that influence utilization patterns. Many studies have examined the association between individual-level economic, demographic, and socioeconomic factors and utilization. However, there may also be community-level forces that affect utilization. Some research on the effect of community-level factors appears in the literature (Davidson, Andersen, et al. 2004,Brown, Davidson, et al. 2004), yet this area is largely understudied. One community-level factor that may affect utilization is unemployment.2 Unemployment can affect utilization of preventive oral health care through the mechanisms presented in Table 1 (Catalano and Satariano 1998,Catalano, Satariano, and Ciemins 2003). Along the first dimension, unemployment can have direct or indirect effects. Direct effects act on unemployed individuals and indirect effects act on those who are not unemployed, but who are economically tied to the unemployed individual. Along the second dimension, unemployment can have impedance and distraction effects. The impedance mechanism assumes that unemployment creates obstacles to accessing care. The distraction mechanism predicts that in stressful times, such as in periods of high unemployment, those items that typically receive little attention will receive even less attention. Table 1 Mechanisms That Connect Unemployment to Preventive Oral Health Care Utilization In Cell I, the direct impedance mechanism predicts that unemployment affects utilization for unemployed individuals by creating barriers, preventing them from utilizing care they would otherwise have accessed. For example, unemployment may impede utilization through the loss of dental insurance. Unemployment may also pose barriers to care by reducing financial resources, limiting the ability to purchase care out-of-pocket or needs like transportation and childcare. In Cell II, the indirect impedance mechanism predicts utilization may be curtailed for all family members by the loss of insurance and depleted resources, not simply the unemployed individual. The effects of unemployment may also extend to others who rely economically on the unemployed individual (Catalano et al. 2003). Cells III and IV describe the distraction mechanism. This mechanism assumes individuals have a limited amount of time, energy, and attention for their daily activities. During stressful periods, the distraction mechanism predicts that the resources needed to cope with life's challenges leave too little time or energy for nonurgent activities (Catalano et al. 2003). Thus, routine check-ups that are received normally would be postponed or foregone altogether during periods of high unemployment. The distraction mechanism can be particularly acute for utilization of preventive care because of its seemingly discretionary nature. It is important to note that the impact of the indirect distraction mechanism can extend to periods of high community-level unemployment when fears of anticipated unemployment for working individuals are high. In these times, individuals may become distracted because high community-level unemployment may be interpreted as a warning sign of pending unemployment (Catalano et al. 2003). Some evidence suggests that the stress associated with economic downturns may affect utilization of preventive dental care. Levit and Lazenby (1991) observed a drop in dental expenditures between 1989 and 1990, speculating it reflected the period's recession. They theorized that dental services were sensitive to changes in the economy because concerns about economic outlook may delay discretionary purchases. Kuthy et al. (1996) argued that reduced utilization may be explained by dental care being “crowded out” by other concerns such as physical health, leaving too little time or energy to seek care. Other studies suggest that high-stress situations may make preventive dental care a lower priority (Carlos 1973,Okada and Wan 1979,Broder, Russell et al. 2002,Kelly, Binkley et al. 2005). Unemployment-related stress may also reduce utilization by rearranging short-and long-term priorities (Carlos 1973). The objective of this study was to determine the effect of community-level unemployment on preventive dental care utilization by a dentally insured population in two metropolitan areas in Washington. The primary research question was: Does preventive oral health care utilization decline during periods of increased community-level unemployment? More specifically, the study asked whether the number of preventive dental care visits in the Seattle and Spokane metropolitan areas varied inversely with the unexpected number of unemployed individuals in those areas over time.3