Abstract
Objectives
This study examined how Mexican and Central American immigrants’ location of origin (in their home country) along the rural/urban continuum was associated with four selected dental outcomes among recent immigrants, prior to the 2020 COVID-19 pandemic.
Methods
Using baseline wave data from the 2017-2022 VidaSana study about the health and living environment of Mexican and Central American immigrants living in Indiana, this study used logistic regression models to examine the extent to which rural versus urban differences in location of origin and other sociodemographic variables predicted self-rated oral health, self-rated oral health knowledge, oral pain, and ever having fluoride applied in a dental office.
Results
The present analysis was based on 547 Mexican and Central American immigrant respondents (68% females; mean age, 34.4 years [SD, 11.2]; Central American: 42%; Mexican: 58%). A higher degree of rurality in the geographic location of origin was associated with less desirable oral health features.
Conclusions
The rural/urban divide is significantly associated with oral health impacts of Hispanic/Latinx groups. This may be partly due to the often-lower educational opportunities available and the socioeconomic status in rural areas, in comparison with more affluent urban locations; such disparity is likely to provide fewer opportunities to maintain a healthful status (eg, less access to actionable health maneuvers involving toothpaste, toothbrushes, and dental floss for good oral hygiene; or more limited access to dental offices). The degree of rurality in the location of origin appears to be one element in the complex health disparities landscape.
Keywords: Dental Care, Oral Health, Immigration, Hispanic, Latinx, Rurality
Introduction
In the United States, nearly 90% of adults aged 20 to 64 years have experienced dental caries, a statistic that has remained relatively constant over time.1 The unequal distribution of dental disease is particularly pronounced among racial and ethnic minority populations.2 Factors such as ethnicity, race, age, socioeconomic status (SES), language barriers, and multiple other factors are significantly associated with achieving and maintaining good oral health across ethnic/racialized groups.3 Hispanic/Latinx (H/L) groups represent the largest ethnic minority in the United States with a population of about 63.7 million or 19.1% of the total population,4 including 44.9 million first-generation immigrants.5 The status of oral health among H/L groups is generally lower than most population groups, constituting oral health disparities (OHDs). This situation includes adults and children,6,7 encompassing epidemiologically significant diseases such as dental caries and periodontal conditions.8 SES is often an important factor in poor oral health outcomes,9 as a sign of social disadvantage. OHDs are complex and can be shaped by factors such as limited access to dental care, lack of familiarity with dental care systems, disparate levels of health literacy, and social norms about the importance of oral health and dental care across H/L groups.8,10 Although a better characterization of the relative importance of these (and other) factors has been attained in recent years,11 there is a considerable empirical knowledge gap in this area.
Complex social, economic, and cultural dynamics often underlie disparities in both overall12-14 and oral2 health status. Given the disproportionate impact of oral health issues in H/L communities,10,15 it is important to attain better-delineated knowledge about the underlying factors and mechanisms driving OHDs to design more culturally appropriate and acceptable clinical and public health interventions. The existing literature on the oral health of H/L populations has significant gaps; for example, we lack a comprehensive understanding of how factors such as the recency of immigration to the United States and the degree of rural or urban character in the location of origin are associated with better or worse dental health features.16 However, given significant associations between rurality and access to socioeconomic resources and health, this is an important sociodemographic factor to consider when understanding OHDs. The present study examines how the degree of rurality in H/L immigrants’ locations of origin outside the United States is associated with key OHD aspects such as self-rated oral health, self-rated oral health knowledge, oral pain, and ever having fluoride applied in a dental office.
Materials and Methods
The data for this project were from the baseline wave (data collected in 2017-2020) of the longitudinal VidaSana project investigating relationships between H/L immigrants’ social relationships, physical environment, and health (IRB No. 1703740862A022). Participants’ data were protected by a Certificate of Confidentiality; they signed an informed consent preceded by a thorough, reading level–appropriate explanation in a private, safe space. Participants were compensated for their time. Baseline data were collected prior to the full-blown onset of the SARS-CoV-2 pandemic, concluding exactly when the social distance public health mandates were enacted in March 2020.
Eligible respondents had immigrated to the United States from Mexico, Honduras, Guatemala, or El Salvador either within six months of the baseline wave (recent immigrants) or had been residing in the United States for at least two years (longer-term immigrants). Recent immigrants were primarily recruited through H/L-serving community organizations and faith-based organizations within Indiana, while longer-term immigrants were referred into the VidaSana study by one of the recent immigrants as one of their peers in their social network.
For the present analyses, four oral health outcomes were selected as dependent variables of interest: self-rated oral health, self-rated oral health knowledge, oral pain, and ever having fluoride applied in a dental office. Such variables were chosen as representations of the respondent’s oral health status, experience of mouth disorders, and history of receiving at least one basic preventive dental intervention. Self-rated oral health was collected on a scale of Very Good, Good, Fair, Poor, Very Poor, and a value outside the scale, No Teeth. This variable was collapsed into Very Good or Good (1) versus Fair, Poor, Very Poor, and No Teeth (0). Self-rated oral health knowledge was assessed on a scale of A Lot, Some, A Little, and None. This variable was dichotomized into A Lot and Some (1) versus A Little or None (0). Respondents were also asked how often in the past 6 months they had experienced pain in their teeth, with response options Often, Sometimes, Rarely, and Never. The responses were dichotomized into Often, Sometimes, and Rarely (1) versus Never (0). Fluoride application ever was measured as binary variable of Previous Use (1) relative to No Use (0).
Our independent variable of interest for these analyses was rurality. The notion of collecting data about the size of the location of origin, using a numerical classification, was problematic; most people would not know the population size used, for example, by the National Institute of Statistical and Geographical Information (Mexican federal agency) categories: fewer than 2499 inhabitants; 2500 to 4999; 5000 to 9999; and so on. Instead, respondents were asked to characterize their location of origin. Respondents were asked to classify the area they came from with options Village/Rancho, Small Town, Large Town, City, or State Capital. Partly because of the small sample sizes within the Large Town and State Capital categories, the values for these analyses were dichotomized into City or State Capital (1) compared to Village/Rancho or Small or Large Town (0). Alternative classification strategies were tested, such as grouping Large Town with City and State Capital; results were substantively similar, and therefore only the most parsimonious model is presented. These other models are available from the authors.
We included a binary indicator of whether a respondent was a recent immigrant (within the past six months) or a longer-term immigrant (at least two years in the United States), consistent with recruitment criteria. While such distinction is arbitrary, there is no universal categorization to quantify recency of immigration; however, this categorization has been shown to be meaningful for oral health in our study population.17 Additional variables included were demographic controls known to influence health: sex; age in years; education operationalized as completion of at least a high-school degree in home country (1) versus less than a high-school degree (0); and having current dental insurance coverage (1) or not (0). Owing to multicollinearity issues between education, rurality, and country of origin, a control for the latter was not included.
A total of 33 respondents (6%) had missing data on at least one study variable. To handle these missing data, multiple imputations were used, using chained equations with 10 imputations.18 Consistent with best practices, respondents with missing data on the dependent variable were excluded.19 Descriptive and bivariate statistics were first conducted, followed by four logistic regressions, one for each dependent variable. Additional analyses were conducted for each dependent variable with (1) an interaction term between sex and rurality to examine the extent to which the effect of rurality depends on respondent sex, and (2) an interaction term between recency of migration and rurality for each dependent variable to examine the extent to which the effect of rurality depended on respondent sex and recency of migration. To facilitate interpretation of these categorical interactions, we then conducted the average marginal effects of sex and recency of migration by rurality.20 All analyses were conducted with Stata 18 (College Station, Texas).
Results
Descriptive statistics are presented in Table 1. This study included 547 respondents of whom the majority were females (68%) with an average age of 34.4 years. Only about a third of the sample had resided in the United States for at least two years, whereas most of the sample were very recent immigrants (within six months). Only 38% of respondents completed high school in their country of origin and only 13% were currently covered by dental insurance. Furthermore, 39% of respondents reported being from a City or State Capital, whereas 61% reported being from a Village/Rancho or Large/Small Town.
Table 1.
Descriptive statistics (N = 547)
| Mean/Percentage | n | Standard Deviation | Minimum | Maximum | |
|---|---|---|---|---|---|
| Dependent variables | |||||
| Good or Very Good Self-Rated Oral Health | .41 | 546 | |||
| A Lot or Some Oral Health Knowledge | .43 | 546 | |||
| Oral Pain Past 6 Months | .32 | 542 | |||
| Fluoride Applied in Dental Office | .48 | 528 | |||
| Independent variables | |||||
| Rurality (full scale) | 543 | ||||
| Village/Rancho | .11 | ||||
| Small Town | .41 | ||||
| Large Town | .08 | ||||
| City | .33 | ||||
| State Capital | .06 | ||||
| Rurality (City or State Capital) | .39 | 543 | |||
| Controls | |||||
| Sex (Female = 1) | .68 | 547 | |||
| Age | 34.41 | 545 | 11.15 | 18.0 | 82.00 |
| Longer-term immigrant | .33 | 547 | |||
| Completed high school in country of origin | .38 | 546 | |||
| Currently covered by dental insurance | .13 | 542 |
As seen in Table 2 Model 1, respondents who reported originating from Cities or State Capitals had 1.48 times higher odds of reporting good or very good oral health than individuals from more rural areas, holding all else equal (P<.05). Furthermore, interaction models suggest that females migrating from a City had a significantly higher probability of reporting good self-rated oral health than females who immigrated from more rural areas (Table 3). However, rurality did not significantly impact self-rated oral health for males. Among established immigrants (two years in the United States), originating from a City was associated with increased odds of good oral health when compared to individuals from more rural areas. Rurality did not significantly matter for recently migrated individuals.
Table 2.
Predicted probability of oral health attributes
| (1) | (2) | (3) | (4) | |
|---|---|---|---|---|
| Oral health status | Oral health knowledge | Oral pain past 6 months | Lifetime fluoride use | |
| Females | 0.84 (0.58–1.22) | 0.94 (0.65–1.37) | 1.23 (0.83–1.83) | 1.75a (1.16–2.63) |
| Age, years | 0.97a (0.96-0.99) | 1.00 (0.99–1.02) | 1.01 (0.99–1.03) | 1.03a (1.01–1.04) |
| Established immigrant | 0.71b (0.48–1.05) | 0.95 (0.65–1.39) | 0.69b (0.46–1.05) | 2.55c (1.68–3.88) |
| Dental insurance | 1.73d (1.01–2.95) | 1.91d (1.12–3.24) | 0.92 (0.52–1.63) | 1.21 (0.68–2.15) |
| Completed HS in country of origin | 1.34 (0.92–1.93) | 1.71a (1.19–2.47) | 0.93 (0.63–1.37) | 2.91c (1.94–4.36) |
| Rurality (Village and Towns) | ||||
| City and State Capital | 1.48d (1.02–2.15) | 1.50d (1.04–2.17) | 1.29 (0.87–1.90) | 2.52c (1.70–3.74) |
| N | 546 | 546 | 542 | 528 |
Note: Coefficients are exponentiated and displayed as odds ratios; 95% CIs are in parentheses. All estimates are multiply imputed, using chained equations with 10 imputations
P<.01
P<.1
P<.001
P<.05
Table 3.
Average Marginal Effects of Rurality, Sex, and Recency of Migration on Oral Health Outcomes
|
|
AME | Contrast | ||
|---|---|---|---|---|
| Good or Very Good Self-Rated Oral Health | ||||
| a | Males | Town, Village, or Rancho | .41 | |
| b | City/State Capital | .47 | ||
| c | Females | Town, Village, or Rancho | .35 | d |
| d | City/State Capital | .46 | c | |
| a | New Immigrants | Town, Village, or Rancho | .41 | c |
| b | City/State Capital | .46 | c | |
| c | Established immigrants | Town, Village, or Rancho | .29 | a, b, d |
| d | City/State Capital | .45 | c | |
| A Lot or Some Oral Health Knowledge | ||||
| a | Males | Town, Village, or Rancho | .36 | b |
| b | City/State Capital | .56 | a | |
| c | Females | Town, Village, or Rancho | .40 | |
| d | City/State Capital | .45 | ||
| a | New Immigrants | Town, Village, or Rancho | .39 | b |
| b | City/State Capital | .50 | a | |
| c | Established immigrants | Town, Village, or Rancho | .39 | |
| d | City/State Capital | .47 | ||
| Oral Pain Past Year | ||||
| a | Males | Town, Village, or Rancho | .26 | |
| b | City/State Capital | .33 | ||
| c | Females | Town, Village, or Rancho | .31 | |
| d | City/State Capital | .36 | ||
| a | New Immigrants | Town, Village, or Rancho | .34 | |
| b | City/State Capital | .35 | c | |
| c | Established immigrants | Town, Village, or Rancho | .21 | b, d |
| d | City/State Capital | .35 | c | |
| Lifetime Fluoride Use | ||||
| a | Males | Town, Village, or Rancho | .29 | b, c, d |
| b | City/State Capital | .56 | a | |
| c | Females | Town, Village, or Rancho | .45 | a, d |
| d | City/State Capital | .62 | a, d | |
| a | New Immigrants | Town, Village, or Rancho | .32 | b, c, d |
| b | City/State Capital | .55 | a, d | |
| c | Established immigrants | Town, Village, or Rancho | .56 | a |
| d | City/State Capital | .70 | a, b | |
Note: The “Contrast” column reports which contrasts are significant at P<.05. Established immigrants are individuals who migrated to the United States ≥2 years ago. New Immigrants are individuals who migrated to the United States within the past 6 months
AME, average marginal effect
Table 2 Model 2 presents the odds ratios predicting the effects of sociodemographics on oral health knowledge. Originating from Cities or State Capitals was associated with a 50% increase in the odds of reporting high oral health knowledge (P<.05). However, in interaction models we found this effect was not consistent across sex and recency of migration. While for males being from a City was associated with an increased probability of reporting high oral health knowledge, rurality in the location of origin did not significantly impact oral health knowledge for females. Similarly, recent immigrants from Cities had a higher predicted probability of high oral health knowledge than recent immigrants from more rural areas, yet there was no significant difference for established immigrants (Table 3).
While there was no significant main effect of rurality on reporting oral pain within the preceding six months, interaction models suggested rurality was protective against oral pain for established immigrants. In terms of fluoride use, being from Cities or State Capitals dramatically increased the odds of reporting lifetime fluoride use such that those individuals were 152% more likely to report lifetime fluoride use than individuals from rural areas (P<.001). Indeed, rurality was consistently associated with lower odds of fluoride use regardless of sex or recency of migration (Table 3).
Having dental insurance coverage was also associated with increased odds of reporting high self-rated oral health and oral health knowledge. Completing at least a high school–level education was also predictive of greater oral health knowledge and increased odds of fluoride use. Females and older immigrants were more likely to report fluoride use.
Discussion
This study examined how the sociodemographic characteristics of H/L immigrants living in Indiana were associated with key oral health measures. We found the degree of rurality from which the immigrants migrated is an important factor in oral health four disparities, yet the impact may also depend on sex and the recency of migration. Our results generally reinforce existing literature on OHDs in H/L populations, highlighting key social, economic, and cultural factors that contribute to poorer oral health outcomes. However, no prior mention of rurality in the country of origin of H/L groups has figured prominently in the literature directly relevant to the United States. We propose the effect of rurality on OHDs may be in part because the educational opportunities available and average socioeconomic status in rural areas are generally poorer than in urban areas; the degree of rurality in the location of origin appears to be an important element in the complex health disparities landscape.
Our own prior research in rural Mexico showed that the experience of treated and untreated tooth decay in children increased in proportion to the percentage of paved roads in their living environment, suggesting improved road conditions may have facilitated the transport of cariogenic (decay-inducing) food, snacks, and sugared beverages from the head of the municipality to the surrounding multiple small villages.21 A similar disadvantage in dental health care was found for Australian elders who inhabited remote areas as compared to city dwellers.22 This contrast is a dominant trend for various health conditions in Mexico23-25 and in Central American countries that share similarities.26
Moreover, the impact of rurality is not limited to Latin America. Other studies indicated that rural-based children in the United States were less likely to receive preventive dental care than their urban counterparts,27 and tooth loss was more prevalent in rural counties, where rates of partial and full edentulism were notably higher than in urban areas.28 This geographic divide in the United States seems to be exacerbated by an underresourced rural health care infrastructure, which limits access to dental care.29 While the results in the present report describe the impact of rurality for locations of origin outside the United States, particularly for recent immigrants, it is reasonable to expect that their experiences with limited access to dental care and limited use of self-care in their countries of origin may contribute to their attitudes toward seeking and receiving dental care in the United States.
Our findings provide further evidence that the H/L population in the Midwestern United States faces significant challenges in achieving and maintaining good oral health. SES has often emerged as a pivotal factor associated with oral health outcomes in H/L subgroups; this is a limiting factor since a substantial proportion of Spanish-speaking H/L groups report annual family incomes toward the lower end of the spectrum, with more than one-third earning $19,999 or less per year.30 This economic disadvantage likely limits access to dental services—independently of the low reimbursement rates that discourage many dental providers from accepting patients with lower SES. Other reports pertaining to US-based H/L individuals have found that they often delay or forego dental visits, resulting in higher rates of untreated dental conditions, as seen in both adults and children.31
Acculturation has also figured prominently in OHDs. In previous research, more acculturated parents reported better general and oral health, greater health literacy, and increased frequency of dental visits.32 Moreover, less acculturated parents reported greater barriers to care. Together, these underscore the need for more culturally and linguistically appropriate dental health interventions33 to serve the needs of immigrants across different levels of acculturation.
These data were from a novel and unique sample. Notably fewer studies have targeted H/L populations in the Midwestern United States than in better-established immigrant destinations.34 While the Midwestern United States has had a presence of immigrants mostly from Mexico since the beginning of the 20th century, there has recently been a fast-growing Central American population. Many immigrants continued to flee adverse financial, economic, environmental, security, and political situations in El Salvador, Guatemala, and Honduras at the time data were collected.35 Additionally, because the sample includes many very recent immigrants, it also presents a rare insight into the health of people only recently settled in the United States.
The present research design and data have some limitations, starting with the narrow choices of variables of interest: self-rated oral health, self-rated oral health knowledge, oral pain, and ever having fluoride applied in a dental office. They are reasonable probes into the various dimensions of perceived oral health status, and of access to dental care; however, other variables may exhibit different trends. With data being cross-sectional, the characterization of a causal pathway is unfeasible. New analyses with longitudinal data are in process. There is potential for self-reporting bias whereby participants may inaccurately report oral health behaviors, oral health status, or access to care because of misunderstanding questions, recall errors, or social desirability biases.
We have highlighted trends in a selection of self-reported OHD markers among H/L groups in the Midwestern United States, compared across a self-reported subjective appraisal of the rurality of their location of origin outside the United States. Identifying factors in the variation between locations of origin showed that coming from rural locations was often associated with poorer oral health outcomes, compared to urban locations of origin. This finding added an important description to H/L health, and to immigrant health literature. Future research should focus on identifying the specific mechanisms by which these factors interact, as well as designing targeted strategies to reduce OHDs among the diverse mosaic of H/L population groups in the United States.
Acknowledgments
This work was supported by the National Institute of Dental and Craniofacial Research (NIDCR), Grant R01DE025836 (VidaSana). The content is the sole responsibility of the authors and does not necessarily reflect the views of the NIH. This project was approved by Indiana University IRB #1703740862A022.
Footnotes
Conflict of Interest: No conflict of interest reported by authors.
Author Contributions: Research concept and design: Jones, Brooks, Maupomé; Manuscript draft: Jones, Brooks, Maupomé; Administrative: Jones, Brooks, Maupomé; Supervision: Maupomé
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