Oral health needs of Wampanoag elders on Martha's Vineyard: A comprehensive assessment

Abstract

Objectives

Evaluate oral health care access and utilisation, while identifying the specific oral health needs of the Native American Elders within the Wampanoag Tribe of Gay Head (WTGH) on Martha's Vineyard Island.

Background

Elders, particularly the WTGH face notable issues in obtaining oral health care. This study addressed the oral health gaps within the WTGH Elders through a comprehensive community needs assessment.

Methods

Employing a mixed‐methods approach, qualitative concept mapping interviews with stakeholders and tribe members, a quantitative survey was conducted, and deidentified billing codes were analysed.

Results

Concept mapping revealed limited availability of services, accessibility and transportation, insurance challenges, lack of a centralised database, tribal/national policy and health‐related self‐sufficiency. Quantitative data indicated that 65% of Elders faced challenges in accessing oral health care, and 48% reported experiencing an oral health issue in the last 12 months. Additionally, 23% did not receive oral health care during this period, with a significant portion having previously utilised services at the Martha's Vineyard Hospital Oral Health Clinic.

Conclusion

Establishing a formal relationship between the WTGH and an academic institution for creating a portable oral health clinic supervised by faculty and developing a structured referral system is essential. This initiative aims to dismantle barriers to oral health care, improve access, and meet the oral health needs among Elders while offering valuable educational experiences for students regarding diverse patient populations and access‐to‐care factors.

1. INTRODUCTION

Martha's Vineyard Island, a small island situated off the coast of Cape Cod in New England, is a sought‐after summer destination for the affluent and renowned due to its beautiful scenery. During the peak summer season, the population swells to around 200 000. In the off‐season, approximately 23 000 residents inhabit the island. The Wampanoag Native American Tribe (WTGH) has resided on Martha's Vineyard for thousands of years. ¹ Published reports indicate that Native Americans experience some of the most severe health disparities in the United States, including higher rates of physical and mental illness, as well as lower life expectancy compared to other US populations. ² Societal and economic factors have been identified as contributing up to 80% of an individual's overall health status. ³ Limited access to oral health care has been linked to a significant impact on oral health, particularly in terms of the prevalence of dental decay. ⁴

The WTGH residing on Matha's Vineyard consists of approximately 360 individuals, with a significant population of Elders. ¹ Native American Elders, defined by Indian Health Services (IHS) as individuals aged 60 and over, face inequities in accessing and utilising healthcare that profoundly impacts their quality of life. ⁵ These inequities arise from intersecting factors at various levels, including personal and interpersonal circumstances, community, and organisational dynamics, as well as tribal, state, and national policies. ⁶ At the individual level, factors such as race, ethnicity, age, education, employment, housing status, geography, income and health history contribute to disparities in healthcare access and utilisation among Elders. ⁷ Moreover, low health literacy is particularly common among Elders, due to cognitive aging and impairments in vision and hearing. ⁸ Martha's Vineyard is recognised by the Health Resources and Services Administration (HRSA) as a medically underserved area, with a Dental Health Professional Shortage Area score of 11. ⁹ Until November 2020, Martha's Vineyard Hospital (MVH) operated an oral health clinic that provided services to 1550 patients in the community and was the only oral health clinic on the island to accept Massachusetts (MA) Medicaid, MassHealth. ¹⁰ However, following the departure of the dentist, the MVH oral health clinic closed.

At present, there are no oral health practices on Marth's Vineyard that accept public third‐party dental insurance, and the majority do not accept private third‐party insurance. WTGH residing on Marth's Vineyard can access oral health care services through IHS Health Services Center located on the Cape Cod Peninsula in Mashpee, MA. ¹¹ However, despite the accessibility of the Mashpee Wampanoag Health Service Unit, Elders within the WTGH still face challenges in accessing primary and oral health care due to transportation issues, travel requirements, financial constraints, shortage of dentists, appointment availability, limited services offered, and perceived substandard care and lack of trust.

Past studies have indicated that the availability of medical providers and place of residence strongly influence the utilisation of healthcare services by Native Americans. ¹² While previous community needs assessments have been conducted for the WTGH on Martha's Vineyard, there is currently a lack of up‐to‐date information regarding their access to care and oral health needs since the closure of the MVH Clinic. The needs assessment aimed to achieve a comprehensive understanding of the oral health and systemic needs, as well as the challenges faced by the WTGH. The objectives of this community needs assessment were to: (1) evaluate the access and utilisation of oral health care among Tribe members and to identify barriers that hinder access to oral health care; (2) identify and evaluate the oral health and medical health needs of the Tribe; and (3) provide recommendations aimed at enhancing access to oral health care for the Tribe and develop specifically tailored interventions in order to create oral and overall health producing positive outcomes.

2. METHODS

This research study was deemed exempt by the Institutional Review Board of the Harvard Faculty of Medicine, IRB22‐1134. Martha's Vineyard is home to approximately 360 WTGH members, with roughly 50% comprising of Elders. To conduct the community needs assessment, there was collaboration with key WTGH stakeholders, including the Chairwoman, Tribal Chief, Tribe Council, and community members. The community needs assessment used a mixed‐methods approach, combining stakeholder interviews and a quantitative survey for WTGH members. Additionally, medical billing codes were collected from the tribal council's medical reimbursement system to assess healthcare procedures, expenditures and overall health status. This comprehensive approach aimed to understand community needs and challenges and propose targeted healthcare interventions for WTGH members (Table 1).

TABLE 1.

Data collection methods for the Wampanoag community needs assessment.

Review of previous Wampanoag community needs assessments surveys
	Previous Wampanoag community needs assessment surveys from 2016 and 2019 were reviewed.
Stakeholder and tribe member interviews
	Concept mapping. Obtained general background information on the available community health services, identifed gaps, relevant social services, and access to health services. Provided in‐depth information of the current climate in terms of access to care.
Wampanoag community needs assessment self‐reported survey
	Validated survey questions were used including the 2021–2022 National Health and Nutritional Examination Survey (NHANES), the Cambridge Health Alliance Oral Health Assessment, the Revised Brief Diabetes Knowledge Test, and the Patient Health Questionnaire 2 (PHQ‐2). Data collected included demographics, socioeconomic status, oral and medical care utilisation, access to care, oral hygiene, health status, diabetes literacy levels, and a depression score. A medical records release form for ICD‐10, CPT and CDT codes from MVH were provided, but records did not end up being released.
MVH billing codes
	Deidentified ICD‐10, CPT and CDT billing codes were collected from the tribal council's medical reimbursement system to assess their top healthcare expenditures and overall oral and systemic health.

2.1. Stakeholder interviews

As part of the community needs assessment process, interviews were conducted with 14 key stakeholders from the WTGH community. The purpose of the stakeholder interviews was to gather in‐depth information about various aspects related to the community's healthcare landscape and gain an understanding of the WTGH community's healthcare situation. The stakeholder interviews also aimed to obtain a general understanding of the community's background, including its location and demographics. This information helped provide context for the survey assessment and allowed the survey to be tailored to the specific needs and characteristics of the WTGH community.

2.2. Self‐reported questionnaire

The survey for the community needs assessment included specific inclusion criteria, targeting enrolled WTGH who were 18 years or older and residing on Martha's Vineyard. Recruitment for the survey was carried out through electronic means, such as Wampanoag Tribe email blasts, as well as in‐person at WTGH community events.

The survey was developed based on the concept mapping created through interviews with WTGH stakeholders and validated survey questions were incorporated into the questionnaire, including items from the 2021‐2022 National Health and Nutritional Examination Survey (NHANES), a well‐established programme assessing health and nutritional status in the United States. ¹³ Additionally, validated questions from the Cambridge Health Alliance Oral Health Assessment, the Revised Brief Diabetes Knowledge Test, and the Patient Health Questionnaire 2 (PHQ‐2) surveys were included to collect relevant data on various aspects of participants' health. ¹⁴ , ¹⁵ , ¹⁶

The survey covered a wide range of topics, including demographics, socioeconomic factors, oral and medical care utilisation, access to care, oral hygiene practices, health status, diabetes literacy levels, and a depression score. The survey instrument was reviewed and approved by the Tribal Chief and council to ensure its appropriateness and alignment with the goals of the community needs assessment.

2.3. Data analysis

Concept mapping was utilised as a qualitative data analysis method for the stakeholder and community member interviews. This approach allowed for the organisation and interpretation of the data, identifying key themes and clusters related to the factors influencing the overall health of the WTGH population.

For the quantitative data collected through the survey, the analysis was stratified based on age groups. The respondents were stratified into two groups: those aged 59 and younger, and those over 60 years old, in alignment with the definition of Elders by the IHS. Descriptive statistical analyses were conducted using Fisher's exact tests to examine the distribution and prevalence of the assessed variables in the survey data (P = .05).

Deidentified billing codes from the tribe's medical reimbursement system were collected from the Tribal Council and were analysed to identify the most frequent medical expenditures and provided an understanding of their health and healthcare utilisation patterns. Community assets and available resources for the tribe were also assessed.

The detailed methodology is explained in Appendix A.

3. RESULTS

The study uncovered various challenges related to healthcare access and factors affecting both oral and overall health for Elders. These issues included: (1) limited availability of services, (2) transportation difficulties, (3) insurance‐related obstacles, (4) the absence of a centralised data system, electronic health records (EHR) (5) tribal and national policy considerations and (6) health‐related self‐sufficiency (Table 2 and Figure 1). Survey findings indicated that a significant proportion of both adults and children encountered problems accessing oral health care and experienced oral health issues within the past year. Additionally, an analysis of billing codes revealed that MVH Oral Health Clinic played a substantial role in providing oral health procedures, including those that can be financially burdensome for many individuals.

TABLE 2.

Concept mapping: cluster themes and factors affecting the oral health of the WTGH.

Cluster theme category	Statements included in cluster
Availability of services	Most oral health providers on island do not accept third‐party private or public insurance
	Average wait time for an oral health appointment is 3 months
	Must go off island for paediatric oral health services
	Not satisfied with the quality of care from medical or oral health providers
	Lack of awareness of where to receive oral health care
	MVH Oral Health Clinic closure in 2020 created a huge burden on the community
	Island federally qualified health centre does not have an oral health provider
	IHS clinic is off island in Mashpee, MA, travel issues
	Lack of herbal care provider
Transportation	High cost and time to obtain oral health care
	Need to travel off island to obtain oral health care
	Not having reliable transportation to get to appointments
	Lack of community health programmes that provide Elders with transportation
Difficulties using insurance	MVH Oral Health Clinic, the sole MassHealth‐accepting clinic on the island, closed in 2020
	Challenges filing insurance claims due to most island oral health providers not billing insurance directly
	Complex insurance and IHS reimbursement process
Centralised database (lack of)	Still using paper charts at island clinic, no EHR
	Need to document health information in three different places
	Need to coordinate care with New Bedford Clinic
Tribal/national policy	IHS is payer of last resort
	IHS does not cover implants
	Direct service tribe, has more control over allocations of funds
	Healthcare is a high priority for the Wampanoag Tribal Council
	Tribe reimburses for transportation costs off the island
Health‐related self‐sufficiency	Reluctance to use services provided by IHS due to perception of substandard care and lack of trust
	Lack of awareness on where to go to receive care
	Lack of coordinated and structured referral system
	Need for restarting diabetes education and nutrition programmes
	Oral health literacy
	Chronic disease literacy

FIGURE 1.

Concept map of factors affecting oral and overall health of the WTGH. [Colour figure can be viewed at wileyonlinelibrary.com]

3.1. Concept mapping—stakeholder and community member interviews

The analysis revealed several key themes that impact healthcare access and quality for the WTGH community. Each of these themes will be discussed in detail in the following sections:

1. Limited availability of services: The scarcity of oral health and medical services on the island.

2. Accessibility and transportation: The geographical dispersion of services and the transportation challenges faced by WTGH members.

3. Difficulties using insurance: The complexities and barriers related to insurance use.

4. Lack of a centralised database: The issues arising from the absence of a unified EHR system.

5. Tribal/national policy: The influence of tribal and national policies on healthcare access and delivery.

6. Health‐related self‐sufficiency: The community's capacity for managing health independently and the factors affecting this ability.

3.1.1. Limited availability of services

The limited availability of oral health and medical service providers on the island that accept third‐party insurance, exacerbated by retirements during the pandemic, has led to extended wait times for healthcare appointments, affecting access to care. While the presence of a Federally Qualified Health Center (FQHC) is beneficial, it lacks an on‐site dentist, requiring MassHealth patients to seek oral health care off the island. Concerns about the quality of care have emerged following Mass General Brigham's acquisition of MVH, with reports of some doctors displaying a perceived lackadaisical attitude. Nonetheless, telemedicine visits have been introduced since the acquisition, potentially improving access to medical services. Addressing the limited availability and quality of oral health and medical services on the island is essential to ensure that WTGH community members can receive timely, comprehensive and satisfactory care.

3.1.2. Transportation and accessibility

Accessibility and transportation pose significant challenges for the WTGH community. The tribal land in the southwest area of Aquinnah is approximately a 45‐min drive from major town centres like Oak Bluffs and Edgartown, where most healthcare providers are located and where the ferry departs. This geographical dispersion creates significant barriers to accessing healthcare and the ferry, particularly for WTGH members who rely on cars. Many Elders no longer drive, further limiting their access to healthcare services.

While year‐round bus routes have expanded on the island, most public bus stops are too far for Elders to walk comfortably, especially after invasive procedures like extractions. Ride‐sharing services like Uber and Lyft are prohibitively expensive for many WTGH members. Some opt to go off the island for healthcare services, but transportation off the island poses an even greater challenge. Various attempted solutions have proven unsustainable.

The Martha's Vineyard Commission currently collaborates with the Cape Cod Regional Transit Authority to explore options for Elders traveling off the island for healthcare services. However, these options may not always align with the specific needs and timing of WTGH appointments, often requiring advanced scheduling.

3.1.3. Difficulties using insurance

The utilisation of insurance for healthcare services presents challenges for WTGH. Currently, 95% of WTGH have medical insurance, while only 27% have dental insurance, according to the Tribal Medical Committee. As a self‐governing, direct‐service tribe, WTGH has control over healthcare fund allocation. The high percentage of medical insurance holders allows for more funds to be allocated to oral health services, with no individual spending cap. Covered oral health procedures include prevention, diagnosis, major and minor restorative procedures, root canals, and up to two implants per year.

However, since most Martha's Vineyard oral health providers do not directly bill third‐party insurance, WTGH must submit claims to insurance companies. Health insurance literacy is lacking, making this process challenging for tribe members, especially for Elders. Required supporting documents include an explanation of benefits, proof of payment, and an itemised statement. WTGH members often seek assistance from the Clinic Receptionist/Medical Biller/Enrollment Coordinator or the Purchased Referred Care Coordinator to navigate insurance claims, coverage details, and out‐of‐pocket expenses. This process can be time‐consuming and burdensome, especially for those unable to afford upfront payments. Nonetheless, the Tribe has established direct billing arrangements with four on‐island and two off‐island oral health clinics.

3.1.4. Lack of centralised database

The WTGH currently lacks a centralised EHR system and relies on hardcopy documentation for healthcare information. This data is scattered across three locations, causing inefficiencies and duplications in documentation. The WTGH Martha's Vineyard nurse is responsible for managing and copying data between these locations, taking up a significant portion of their work time. Although the tribe has discussed implementing an EHR system, progress has been delayed, leading to continued reliance on hardcopy records.

This absence of a centralised database and continued use of paper‐based systems can hinder accessibility, information sharing, data analysis, and overall healthcare management and coordination within the tribe.

3.1.5. Tribal/national policy

The WTGH, as a self‐governed Direct Service Tribe, can choose to receive primary and oral healthcare from the IHS in Mashpee, MA. However, our survey found that none of the WTGH community members use the IHS clinic due to access issues. Additionally, concept mapping revealed concerns about lack of services offered, substandard care and a lack of trust in the IHS services. To address these challenges, the Wampanoag Tribe plans to establish a community clinic in New Bedford, near the IHS Mashpee Clinic.

This clinic aims to expand healthcare and community services on the mainland, providing comprehensive and coordinated care to the WTGH members. The envisioned site will incorporate medical and oral health clinics, a commercial kitchen, and a food pantry, underscoring a comprehensive healthcare approach. Moreover, the Tribe aims to designate the clinic as a patient‐centred medical home, fostering a patient‐centred coordinated care model that includes transportation to and from the clinic from Martha's Vineyard Island.

3.1.6. Health‐related self‐sufficiency

Through stakeholder interviews, several health‐related self‐sufficiency issues were identified within the WTGH community. These include reluctance to use IHS services, lack of awareness about care options, absence of a structured referral system, need for renewed diabetes education and nutrition support, and limited knowledge about oral health and chronic diseases. Addressing these issues necessitates a comprehensive approach involving collaboration among healthcare providers, tribal leaders, community organisations, and stakeholders. By implementing targeted interventions, educational initiatives, and improving access to care specifically for Elders, WTGH can enhance health literacy, access appropriate healthcare and enhance overall well‐being.

3.2. Needs assessment quantitative survey

Sixty‐three respondents completed the survey. It is worth noting that the survey respondents' demographics aligned with the WTGH population, suggesting a representative sample, and enhancing the validity of the findings. Sociodemographic, oral health and medical characteristics of the WTGH are in Table 3.

TABLE 3.

Sociodemographic, oral health and medical characteristics of the WTGH.

Category	Age 18–59 n (%)	Age 60+ n (%)	Total n (%)
Total	32 (50.8)	31 (49.2)	63 (100.0)
Sex
Male	16 (50.0)	11 (36.7)	27 (43.6)
Female	16 (50.0)	19 (63.3)	35 (56.4)
Educational level
Less than high school	1 (3.1)	2 (6.7)	3 (4.8)
High school/GED	8 (25.0)	12 (40.0)	20 (32.3)
Certificate program/trade school	2 (6.25)	2 (6.7)	4 (6.5)
Some college or 2‐year degree	8 (25.0)	8 (26.7)	16 (25.8)
College degree	12 (37.5)	4 (25.8)	16 (25.8)
Graduate/doctoral degree	1 (3.1)	2 (6.7)	3 (4.8)
Child under 21 living in household
Yes	14 (77.8)	4 (22.2)	18 (29.0)
No	18 (40.9)	26 (59.1)	44 (71.0)
Location of receiving oral health care
On‐island	17 (53.1)	13 (41.9)	30 (47.6)
Off‐island	9 (28.1)	11 (35.5)	20 (31.8)
Emergency department	3 (9.4)	0 (0.0)	3 (4.8)
Does not go to the dentist	3 (9.4)	7 (22.6)	10 (15.9)
Former patient at Martha's Vineyard hospital oral health clinic
Yes	4 (12.5)	9 (29.0)	13 (20.6)
No	28 (87.5)	22 (71.0)	50 (79.4)
Most recent dental visit
Within the last 12 mos.	20 (62.5)	19 (61.3)	39 (61.9)
1–5 years ago	9 (28.1)	7 (22.6)	16 (25.4)
More than 5 years ago	1 (3.1)	3 (9.7)	4 (6.4)
Don't know/unsure	2 (6.3)	2 (6.7)	4 (6.4)
Difficulties seeing an oral health provider
Long wait for appointment	19 (59.4)	6 (19.4)	25 (39.7)
Cost of care	13 (40.6)	9 (29.3)	22 (34.9)
Dental phobia	3 (9.4)	3 (9.4)	6 (9.5)
Cannot find a professional who provides services needed	10 (31.3)	4 (12.9)	14 (22.2)
Time	6 (18.6)	1 (3.2)	7 (11.1)
Travel	6 (18.6)	3 (9.7)	9 (14.9)
No difficulties	4 (12.5)	11 (35.5)	15 (23.8)
Other	6 (18.8)	2 (6.5)	8 (12.7)
Oral health issues in the last 12 months
Difficulty biting/chewing	4 (15.4)	7 (35.0)	11 (23.9)
Lost teeth	4 (15.4)	8 (40.0)	12 (26.1)
Cavities	20 (76.9)	6 (30.0)	26 (56.5)
Sensitivity to hot/cold	9 (34.6)	8 (40.0)	17 (37.0)
Painful or bleeding gums	6 (23.1)	1 (5.0)	7 (15.2)
Worried by dental Problems	7 (26.9)	4 (20.0)	11 (23.9)
Missed work	3 (11.5)	1 (5.0)	4 (8.7)
Difficulty sleeping	1 (3.85)	2 (10.0)	3 (6.5)
Dry mouth	2 (7.7)	3 (15.0)	5 (10.9)
Pain/aching	5 (19.2)	3 (15.0)	8 (17.4)
ER visit due to pain/infection	3 (11.5)	1 (5.0)	4 (8.7)
None	1 (3.6)	4 (8.7)	4 (8.7)
Average brushing
Once a day	9 (28.1)	11 (35.5)	20 (31.8)
Twice a day	20 (62.5)	15 (48.4)	35 (55.6)
A few times a week	2 (6.3)	3 (9.7)	5 (7.9)
Weekly	0 (0.0)	2 (6.5)	2 (3.2)
Never	1 (3.12)	0 (0.0)	1 (1.6)
Average flossing
Once a day	6 (18.6)	6 (19.4)	12 (19.1)
Twice a day	4 (12.5)	(10, 32.3)	14 (22.2)
A few times a week	9 (28.1)	7 (22.6)	16 (25.4)
Weekly	6 (18.8)	3 (9.7)	9 (14.3)
Never	7 (21.9)	5 (16.1)	12 (19.1)
Last time visiting a doctor, nurse practitioner or physician assistant
Within the last 12 mos.	21 (65.6)	24 (77.4)	45 (71.4)
Within last 2 years	3 (9.4)	4 (12.9)	7 (11.1)
2–5 years ago	3 (9.4)	2 (6.5)	6 (9.5)
More than 5 years ago	2 (6.3)	0 (0.0)	2 (3.2)
Don't know/unsure	2 (6.3)	1 (3.1)	3 (4.8)
Difficulties in maintaining health
Cost of medication/medical devices	2 (7.1)	2 (7.1)	4 (7.1)
Access to mental healthcare	5 (17.9)	4 (14.3)	9 (16.0)
Long appointment wait	15 (53.6)	6 (37.5)	21 (37.5)
Care coordination	4 (14.3)	4 (14.3)	8 (14.3)
Cultural beliefs do not coincide	1 (3.6)	0 (0.0)	1 (1.9)
Accessibility/cost of rehab and medications for substance use disorder	1 (3.6)	0 (0.0)	1 (1.9)
No need for medical care	4 (14.3)	1 (3.6)	5 (8.9)
Other difficulties	4 (14.3)	1 (3.6)	5 (8.9)
No difficulties	9 (32.1)	14 (50.0)	23 (41.1)
Healthcare professional diagnoses
Asthma	5 (15.6)	6 (19.4)	11 (17.5)
Anxiety or depression	10 (31.3)	5 (16.1)	15 (23.8)
Cancer	0 (0.0)	3 (9.7)	3 (4.8)
Coronary heart disease	0 (0.0)	2 (6.5)	2 (3.17)
Diabetes/prediabetes	4 (12.5)	9 (29.0)	13 (20.6)
Hypertension	8 (25.0)	19 (61.3)	27 (42.9)
Overweight or obesity	11 (34.4)	15 (48.4)	26 (41.3)
Kidney stone, bladder	0 (0.0)	3 (9.7)	3 (4.8)
COPD	0 (0.0)	3 (9.7)	3 (4.8)
Arthritis, gout, fibromyalgia	3 (9.4)	11 (35.5)	14 (22.2)
Other	1 (3.1)	4 (12.9)	5 (7.9)
No medical conditions	10 (31.3)	2 (6.5)	12 (19.1)
Smoker
Yes	6 (18.8.0)	0 (0.0)	6 (9.7)
No	26 (81.3)	30 (100.0)	56 (90.3)
Alcoholic drinks per week
1–3	6 (18.8)	6 (20.0)	12 (19.4)
4–7	6 (18.8)	4 (13.3)	10 (16.3)
8–11	2 (6.3)	0 (0.0)	2 (3.2)
12–14	0 (0.0)	0 (0.0)	0 (0.0)
15+	1 (3.1)	1 (3.1)	2 (3.2)
None	17 (53.1)	19 (63.3)	36 (58.1)
Currently or ever used the following substances
Cannabis	13 (36.1)	8 (32.0)	22 (34.9)
Heroine/opioids	0 (0.0)	1 (3.6)	1 (1.8)
Cocaine	3 (10.7)	4 (14.3)	7 (12.5)
Stimulants	2 (7.1)	5 (17.9)	7 (12.5)
Sedative/sleeping pills	0 (0.0)	3 (10.7)	3 (5.4)
Hallucinogens	3 (10.7)	1 (3.6)	4 (7.1)
Inhalants	1 (3.5)	1 (3.7)	2 (3.6)
Do not/never used	14 (50.0)	17 (60.7)	31 (55.4)
Having little interest or pleasure in doing things
Not at all	20 (62.5)	24 (77.4)	44 (69.8)
Several days	9 (28.1)	3 (9.7)	12 (19.1)
More than half the days	1 (3.2)	1 (3.1)	2 (3.2)
Nearly every day	2 (6.3)	3 (9.7)	5 (7.9)
Feeling down, depressed, or hopeless
Not at all	24 (77.4)	23 (79.3)	47 (78.3)
Several days	4 (12.9)	5 (17.2)	9 (15.0)
More than half the days	1 (3.2)	0 (0.0)	1 (1.7)
Nearly every day	2 (6.5)	1 (3.5)	3 (5.0)

The survey data showed 65% of Elders encountered challenges in accessing oral health care with the largest barriers being cost of care (29.3%) and a long wait for an appointment (19.4%). Forty‐eight percent (48.4%) reported having an oral health issue in the last 12 months with caries (76.9%) being the biggest issue. Thirty‐six percent (35.5%) had to seek oral health care off the island and 22.6% did not go to the dentist. A large portion, 50% of Elders who used to receive care at the MVH Oral Health Clinic no longer go to the dentist (P = .036).

In evaluating the systemic health of tribal Elders, a statistically significant association was observed, with 61.3% reporting a diagnosis of hypertension (P = .004) and 48.4% reporting arthritis (P = .013). Additionally, 29.0% reported a diagnosis of being overweight or obese and having diabetes.

According to the survey, a significant number of Elders (56.7%) expressed dissatisfaction with the lack of convenience of the oral health reimbursement system. Among those respondents, 32% indicated that upfront payment was a concern, while 39% reported delays in reimbursement as an issue.

3.3. Billing codes (see Appendix B)

Deidentified billing codes for WTGH between 2014 and 2019 were assessed. The services provided at MVH Oral Health Clinic constituted 44.2% of the procedures billed to the tribe between 2014 and 2019. The hospital provided all of the root canal treatments and emergency encounters to WTGH. They also provided the majority of basic restorative (97.7), major procedures (88.5%) and extractions (94.1%). Major procedures are prosthodontic procedures. The majority of the billing codes from MVH consisted of oral health procedures that cost a considerable amount and are not affordable to the average US population.

The medical conditions documented during visits at the tribe's medical clinic over the past 3 years (2020–2022) indicated the most frequent visits were for hypertension, obesity and diabetes diagnoses.

3.4. Community assets and available resources

The WTGH community possesses several assets that uniquely contribute to their ability to prioritise and address healthcare needs, particularly for Elders on the Martha's Vineyard. These assets include strong leadership, a dedicated clinical space staffed by medical professionals, a community centre, financial support, a sense of autonomy, potential for contracts with local healthcare providers, transportation options and travel reimbursement (Table 4).

TABLE 4.

Community assets and resources of the WTGH.

Asset	Description
Leadership	The Tribal Council and Medical Committee have placed a strong emphasis on health as a priority for the Tribe. Their leadership and commitment play a crucial role in driving healthcare initiatives and advocating for the well‐being of the community
Clinic	The island clinic, supported by IHS, is a significant built asset that provides essential healthcare services to the community. It serves as a primary healthcare facility, ensuring accessibility to medical care for the WTGH members
Medical professionals	The presence of the WTGH Marth's Vineyard nurse and a visiting physician from Cambridge Health Alliance (CHA) further enhances the human assets available to the community. The involvement of a dentist from CHA, who provides house visits and teledentistry services. This service is particularly beneficial for the elderly members of the Tribe, as they receive prioritised attention and care
Community centre	The community centre offers a versatile space that can be utilised to deliver oral health care services using a portable dental chair and unit This flexibility allows for oral health care to be provided conveniently during social events and gatherings for the WTGH community
Financial support	HRSA grants to CHA, enables house and teledentistry visits for the WTGH community. This funding helps cover the costs associated with providing healthcare services to individuals who may face barriers in accessing care IHS also supports the island clinic
Political influence and autonomy	Political influence and financial autonomy as a direct service tribe. Their control over the allocation of medical funds allows them to establish a reimbursement system for procedures not covered by insurance This system ensures that oral health procedures are covered for WTGH members who lack dental insurance
Healthcare contracts	Contracts with dental offices provide another financial asset, enabling the Tribe to be directly billed for services. This arrangement simplifies the process of accessing oral health care and streamlines the financial aspects for the WTGH community
Transportation	Built assets like public transportation on the island, including bus routes and ferry services, enhance the community's ability to access healthcare services beyond the island. These transportation options facilitate travel to off‐island healthcare facilities, ensuring that community members can receive necessary medical care
Travel reimbursement financial asset	The Tribe's financial asset of providing travel expense reimbursements for medical visits through a request form for transportation/medical visit reimbursement, along with proof of payment, helps alleviate the financial burden of travel for healthcare purposes

Additional results can be found in Appendix B.

4. DISCUSSION

The study identified several key challenges that impact healthcare access and quality for the WTGH community, particularly among Elders. These challenges include limited availability of oral health and medical services, transportation difficulties, insurance‐related obstacles, the absence of a centralised data system, tribal and national policy considerations, and health‐related self‐sufficiency issues. Survey findings revealed that a significant proportion of Elders encountered problems accessing oral health care and experienced oral health issues within the past year. Additionally, an analysis of billing codes showed that the MVH Oral Health Clinic played a substantial role in providing oral health procedures, including financially burdensome ones for many individuals.

4.1. Recommendations to improve oral health

Based on concept mapping, self‐reported surveys and billing codes, six key priorities have been identified to enhance health‐related self‐sufficiency within the WTGH community: (1) access to care, (2) transportation, (3) efficient reimbursement systems for medical and oral health services, (4) health literacy materials, (5) a structured coordinated referral system and (6) community water fluoridation.

Improving access to healthcare services on the island is essential. This includes enhancing the availability of medical and oral health services, reducing wait times for appointments, and addressing the barriers faced especially by Elder members in accessing care.

Due to the heavy reliance on the MVH Oral Health Clinic, especially among tribal Elders, and findings from the community needs assessment, it is necessary to implement a portable oral health clinic to facilitate house visits as a more immediate and practical solution. Approximately half of the WTGH members being 60 years and older, this demand will continue to grow as the tribe ages. A portable oral health clinic would address the challenges faced by older patients experiencing physical and cognitive decline, enabling outpatient oral health care through house visits, clinic appointments, and tele‐dentistry. ¹⁷ This approach is especially advantageous for individuals facing mobility and transportation challenges, and would mark the inaugural model of care on tribal land. ¹⁸

The portable oral health clinic addresses these barriers by bringing oral health services directly to community members' homes or local community centres. This approach reduces transportation challenges, especially since most oral health providers and the FQHC are located 45 min away. It provides care in a comfortable, familiar environment and fosters trust. The portable clinic's flexibility allows for immediate implementation, delivering essential oral health care without the delays of establishing a fixed facility.

Establishing a formal relationship between the Wampanoag Tribal Health and a dental school would enable students to provide clinical care within their scope of practice. Community‐based clinical education programmes have proven effective in delivering care to underserved populations, including low‐income individuals, racial/ethnic minorities, rural populations, special needs patients, geriatrics, and paediatrics. ¹⁹ Participation in community‐based clinical education programmes enhances students' confidence in treating underserved populations, while also providing valuable clinical skills, interprofessional experience and an understanding of practice management. Graduates who engage in community‐based clinical education are more willing to serve underserved populations and may even choose to practice in rural settings. ²⁰

Additionally, community‐based clinical education programmes foster cultural awareness and help students develop an understanding of the structural factors that influence access to care, including social, economic, political and professional factors. ²¹ Recent studies have demonstrated the positive impact of community‐based clinical education rotations on students' comprehension of the healthcare system and their intent to incorporate community health and outreach in their future practice. ²¹

It is advised that the island's FQHC hire a dentist trained in cultural competency for those without transportation barriers and explore reopening the MVH Oral Health Clinic to serve WTGH members with transportation options, providing access to a fixed oral health facility. Additionally, qualitative data from stakeholder interviews revealed a lack of trust and perceived substandard care received from IHS services, contributing to the community's reluctance to utilise such facilities, including the FQHC. This distrust has led to the creation and implementation of their own patient‐centred medical home in New Bedford, MA.

The tribe can also establish a dedicated reliable transportation service which would greatly enhance access to healthcare services both on and off the island. It would ensure that WTGH, especially Elders have a convenient and accessible means of reaching healthcare facilities, appointments, and other necessary healthcare‐related destinations. This initiative would also alleviate the burden associated with being reimbursed for transportation costs.

Establishing a more efficient reimbursement system is crucial to simplify the process for Tribe members. Streamlining administrative procedures and ensuring timely reimbursement will alleviate the burden on WTGH. The WTGH could explore the possibility of establishing more contracts with oral health providers on the island. By establishing these contracts, the tribe would be able to be directly billed for oral health services rendered, alleviating the need for upfront payment by tribal members.

Implementing an EHR system will enable the WTGH to centralise healthcare information, thereby improving care coordination, enhancing access to medical records, and identifying population health issues. This initiative aligns with the Tribe's objective of delivering comprehensive, coordinated care to its community members across various healthcare disciplines and social services. Moreover, the EHR system will facilitate better coordination of care for Elders with complex medical histories and issues.

Tailoring health literacy materials to the specific needs of the WTGH, particularly focusing on Elders with lower health and computer literacy levels, will empower this demographic to comprehend health‐related information and make informed decisions about their well‐being. This initiative involves classes addressing common health concerns in Elders, such as hypertension and obesity, and promoting overall health literacy. Additionally, reinitiating targeted diabetes education and nutrition programmes will support those with prediabetes and diabetes among the Elder population. The low computer literacy levels, especially among Elders, creates a barrier in understanding how to access and use health apps, highlighting the need for education in both health and digital literacy.

Creating a structured coordinated referral system will ensure seamless coordination between different healthcare providers involved in oral health and medical care. This will optimise the utilisation of resources and improve access to oral health and medical services for Elders of the WTGH.

The region encompassing the tribal land in Aquinnah currently lacks community water fluoridation (Figure 2). It's worth noting that fluoridated water is recognised by the Centers for Disease Control and Prevention as a highly effective measure for reducing dental decay. ²²

FIGURE 2.

2021 Martha's Vineyard, MA community water fluoridation status. [Colour figure can be viewed at wileyonlinelibrary.com]

4.2. Sustainability

To support the sustainability of the portable oral health clinic and tele‐dentistry services, a combination of funding sources can be explored. This can include seeking grants from healthcare organisations or foundations that support initiatives targeting the Elder population. Additionally, partnering with local healthcare providers, community organisations, or government agencies can help leverage resources and secure ongoing support for the programme. ²³

One approach is to seek additional grants from HRSA and IHS. These federal funding opportunities can provide financial support for healthcare projects and initiatives aimed at improving access to care and addressing the specific needs identified in the community needs assessment.

The data collected during the community needs assessment can be instrumental in supporting grant applications. By demonstrating the existing gaps and challenges in accessing oral health care, as well as the potential impact of the portable clinic on improving access and oral health outcomes, the tribe can strengthen its case for securing grant funding. The data can be used to highlight the significance of the project and its alignment with the funding agency's priorities.

In addition to grant funding, the establishment of an associateship by the tribe can also contribute to the sustainability of the portable clinic initiative. This involves exploring partnerships and collaborations with oral health professionals or organisations who can provide financial support or resources for the initiative. By leveraging such partnerships, the tribe can secure ongoing support and resources to ensure the long‐term viability of the portable clinic programme.

The medicine wheel, a conceptual framework that is culturally grounded and supported by solid scientific research, is utilised by various Indigenous tribes and was a significant catalyst in initiating and can be utilised in sustaining this journey. ²⁴ Its profound impact, when used appropriately, can enhance overall health and serve as an incentive for Indigenous people to address their health issues. ²⁴ This process not only aids in achieving the status and dignity they seek to regain but also promotes holistic well‐being.

Tribal youth have not been consistently available to help sustain these programmes. The continuity and sustainability of interventions often rely on the presence and involvement of Elders. Once Elders are not around, these interventions might struggle to continue. This issue is prevalent in several tribes, emphasising the need for sustainable models of community involvement. Dental students working with the portable clinic could serve as role models and potentially influence more tribal youth to engage in maintaining and advancing these healthcare initiatives.

By combining efforts to secure grant funding, establishing partnerships, leveraging the medicine wheel's holistic health approach, and actively involving tribal youth, the tribe can develop a robust sustainability plan. This comprehensive strategy will ensure the long‐term success and impact of the portable clinic initiative in improving access to oral health care for its community members.

4.3. Strength and weaknesses

This needs assessment has strengths in its diverse data sources, including concept mapping, surveys and billing code analysis. It actively engaged stakeholders through interviews and surveys, ensuring community perspectives were considered, leading to the identification of six key priorities. However, a notable weakness is the absence of a comprehensive cost analysis for proposed interventions, raising questions about their feasibility and cost‐effectiveness. Additionally, potential response bias from WTGH tribe members may impact data accuracy.

5. CONCLUSION

Numerous barriers impede oral health care access for the Elder members of the WTGH community. Effectively addressing these challenges necessitates tailored interventions, prominently featuring the establishment of a formal relationship with an academic institution. This collaborative effort aims to create a faculty‐supervised portable oral health clinic, specifically designed to cater to the unique needs of Elders. Additionally, the development of a structured referral system, integrated with an EHR, will further enhance oral health care access for this demographic. These interventions are poised to not only overcome oral health care barriers and improve access but also provide valuable educational experiences for students, focusing on diverse patient populations and factors affecting access to care, particularly among Elders.

FUNDING INFORMATION

This needs assessment was funded by the FDI World Dental Federation World Dental Development Fund and the E. “Bud” Tarrson Dental School Student Community Leadership Award.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest related to this research or publication, including no financial or personal affiliations that could affect the interpretation or presentation of the findings herein.

ETHICS APPROVAL STATEMENT

This research study was deemed exempt by the Institutional Review Board of the Harvard Faculty of Medicine, IRB22‐1134.

PATIENT CONSENT STATEMENT

All survey participants were informed that completing the survey constituted their consent.

Supporting information

Appendix A.

Gritzer L, Alqaderi H, Puli A, et al. Oral health needs of Wampanoag elders on Martha's Vineyard: A comprehensive assessment. Gerodontology. 2025;42:233‐245. doi: 10.1111/ger.12788

DATA AVAILABILITY STATEMENT

The data used in this publication has been made available with the permission of the Wampanoag Tribe of Gay Head Tribal Council.