Teledentistry Acceptability Among Latina/o/x Adults in Rural Southwest Virginia

Abstract

Inequitable access to dental care remains a barrier to optimal health for rural populations. With the COVID-19 pandemic, teledentistry to improve the delivery of oral health care has been emphasized. Few previous investigations of teledentistry acceptability have included Latina/o/x populations in rural areas of the United States. We recruited Latina/o/x adults (N=91) in rural southwest Virginia to participate in a survey to assess correlates related to teledentistry acceptability. More than half of participants (57%) reported no interest in using teledentistry if it were available. Having a yearly household income above $24,000 and not having dental insurance were positively associated with telehealth acceptability (p=.04 and p=.01, respectively). Inequitable access to dental care may persist even with broad availability of teledentistry services unless there is explicit integration of health equity.

Latina/o/x people are the largest minoritized group living in nonmetropolitan areas, comprising 9% of rural populations in the United States.¹ Demographic trends over the past 30 years reveal this population group has steadily increased in both declining and growing nonmetropolitan counties, underscoring the large demographic footprint that Latina/o/x people have impressed on rural communities.²

This fast-growing population group faces persistent inequities in oral health and access to dental care³ that are further exacerbated in rural areas where populations are more likely to live in dental health provider shortage areas and face geographic barriers to care.⁴ Adults that reside in rural communities have higher rates of dental caries, more extractions of permanent teeth, and are less likely to have received preventive dental procedures than adults residing in urban communities.^5,6 There are also documented ethnoracial disparities in dental care use within rural areas, with White adults being more likely than Latina/o/x adults to have a past year dental visit.⁷

Teledentistry, a subcategory of telehealth, entails the remote delivery of oral health care and education using information technology. It has been promoted as a health care delivery model positioned to help address the inequitable access to oral health care commonplace across rural communities.^8–10 Teledentistry can be used in numerous ways including the provision of two-way consultations between oral health providers and patients via video conference (i.e., synchronous) as well as the transmission of health information (i.e., images, X-rays, video) and records among providers via a secure electronic system to evaluate a patient’s condition or treatment plan without live interaction (i.e., asynchronous or store-and-forward modality).¹¹ There is an emerging trend showing that teledentistry enhances access to care particularly for marginalized populations with limited to no access to oral health care.^12,13 A systematic review assessing the validity of teledentistry utilization in oral health care examination and diagnosis found it comparable to face-to-face visits for oral screening, more so in rural communities and areas with limited access to care.¹⁴ Teledentistry also has the potential to increase access to oral care at a lower cost, as demonstrated by a study reporting cost savings of approximately 10% to 15% for teledentistry in comparison with in-person visits.¹⁵

Overall, adoption of telehealth within the oral health care system has been relatively slow.¹⁶ However, in recent years the COVID-19 pandemic along with greater integration of electronic health records has accelerated the adoption of teledentistry, although barriers to expansion such as the regulatory environment, training of practitioners, and billing processes remain.^17,18 A study of United States dental practice management data from 2019 to 2020 found the demand for teledentistry increased 60-fold during the COVID-19 pandemic dental practice closures and remains approximately 10 times higher than the pre-pandemic levels.¹⁹ Another study found uptake of teledentistry to be higher among rural dwellers than those living in suburban or urban locations.¹⁵

The potential widespread expansion of oral health care in rural communities through the implementation of this modality of health care delivery is particularly critical for Latina/o/x people given the historical and continued maldistribution of Latina/o/x dental providers.^20,21 Furthermore, the pervasive inadequacy and unaffordability of dental insurance coverage options have greatly limited access to dental care for this population.²² Nonetheless, little is known of telehealth’s acceptability in this population group. Most of the current published literature on teledentistry acceptability has focused on oral health care providers.^23–26 The limited literature on patients has assessed perceptions before and after use and have generally found positive attitudes towards teledentistry.^27,28

Although no studies have assessed teledentristry acceptability specifically among Latina/o/x people, there is some published literature that has examined telehealth/telemedicine receptivity in this population group. A study that examined factors that shape behavioral intention to use telehealth services in underserved Hispanic communities along the Texas-Mexico border found positive attitudes towards telehealth with 78.9% of participants reporting being somewhat likely to use telehealth services if offered by a health care provider.²⁹ Another study that assessed pre-experience perceptions about telemedicine among African Americans and Latinos in South Central Los Angeles found Latinos seemed overall more positive and enthusiastic about the prospect of telemedicine than African American participants, but noted concerns about whether telemedicine could be available to individuals that are uninsured and/or undocumented.³⁰ These findings corroborate studies that have shown Latina/o/x people use telehealth at similar or higher rates than other racial and ethnic groups.^31,32 However, there is a body of literature indicating telehealth use among Latina/o/x people is lower than the rate among other racial and ethnic groups,^33–35 underscoring barriers to accessing telehealth among this population such as trust, acculturation, technology, and language.^36–38

Understanding the factors that shape receptivity to teledentistry in this population is a necessary precursor to the development of equity-centered and tailored strategies for introduction, marketing, and implementation. Prior research on telemedicine receptivity among minoritized groups suggests that pre-experience perceptions shape individuals’ initial decision to use this type of technology as does the context in which they will use such services.³⁰ Given the dearth of literature on perceptions about teledentistry among Latina/o/x people living in rural communities, this study examined correlates of teledentistry acceptability among Latino/x/a adults living in rural southwest Virginia.

Methods

Sample.

This cross-sectional study used data from a survey administered through the electronic research data capture system, REDCap.^39,40 The survey included 80 questions spanning several domains including socio-demographics, health and self-rated health, experiences in the community, COVID-19 economic and social impacts, and COVID-19-related media consumption. Questions related to virtual care delivery (teledentistry) to curb the spread of COVID-19 were also included. The inclusion criteria consisted of adults, 18 years of age or older who self-identified as Latina/o/x and resided in 14 ZIP codes within rural southwest Virginia selected by the research team based on the 2020 Census data on the percentage of the Latina/o/x population residing in that region. From May 2020 to February 2021, participants were recruited through social media platforms, at local health fairs, and via community organizations located in southwest Virginia. Participants had the option to complete the survey in English or Spanish, based on their preferred language. Following completion of the survey, each study participant received a $10 gift card as compensation for their time. The study was approved by the Virginia Commonwealth University Institutional Review Board.

Measures.

The main variable of interest assessed in this study was teledentistry acceptability. Survey respondents were provided a description of telehealth followed by a question asking if they would be interested in participating in consultations (check-ups) with their dental provider through video conferencing/internet. A response of yes or no determined acceptability of teledentistry. Covariates assessed in this study included sociodemographic characteristics, acculturation proxy measures, and oral health and health-related variables. Sociodemographic factors included age (≤30, >30), sex (female, male), education (<high school, high school, or >high school), and yearly household income (<$24,999, ≥$25,000). Acculturation was measured using proxy measures that have been used in prior telehealth research including the language the participant took the survey in (Spanish or English), nativity (U.S.-born or born outside the U.S.), and length of time in the U.S. (since birth, less than 10 years, 10 years or more).^41,42 Oral-health related variables included whether participants had dental insurance (yes/no) and dental care utilization within the past year (<one year, ≥one year, or never). Self-rated oral health (dichotomized as excellent/very good/good or fair/poor) was also included since prior research has shown it is associated with dental care utilization.⁴³

Statistical analysis.

Data analysis was limited to descriptive statistics for participants with no missing information on teledentistry acceptability and covariates of interest. There were no meaningful differences in sociodemographic factors for participants without and with incomplete data. Participants with incomplete data (n=8) were thus excluded from all analysis. Descriptive statistics were generated for sociodemographic characteristics overall and according to teledentistry acceptability. Chi-squared tests were used to compare differences in oral health-related variables, participant sociodemographic characteristics, and acculturation proxy measures by teledentistry acceptability. SAS 9.4 (SAS Institute, Cary NC) was used to conduct all statistical analyses.

Results

Sample characteristics.

The characteristics of the 91 Latina/o/x adults who completed the survey are displayed in Table 1. The respondents were mostly female (70.3%), aged 30 years or older (63.7%), and Spanish speakers (54.9%). More than half of respondents were born outside the U.S. (58.2%) with most born in Mexico or Central America (Honduras, El Salvador, Nicaragua). Over half (57.2%) completed at or below a high school-level education or reported an annual household income of less than $24,000 (56%). Although about two-thirds (71.4%) self-rated their oral health as excellent/very good/good, slightly more than half (58.2%) did not have any form of dental health insurance and most had not visited the dentist in the past year (67.3%).

Table 1.

CORRELATES OF TELEDENTISTRY ACCEPTABILITY, N=91

	Teledentistry		Pearson’s Chi2	p-value
	N (%)	Yes (%)
Age years
<30	33 (36.3)	13 (33.3)	.25	.61
≥30	58 (63.7)	26 (66.7)
Sex
Female	64 (70.3)	26 (66.7)	.44	.51
Male	27 (29.7)	13 (33.3)
Educational Attainment
<High School	29 (31.9)	10 (25.6)	1.65	.44
High School/GED	23 (25.3)	12 (30.8)
≥High School	39 (42.9)	17 (43.6)
Yearly household income
<$24,999	51 (56.0)	17 (43.6)	4.22	.04
$25,000 or greater	40 (44.0)	22 (56.4)
Language
English	41 (45.1)	21 (53.8)	2.13	.14
Spanish	50 (54.9)	18 (46.2)
Nativity
U.S. Born	38 (41.8)	19 (48.7)	1.36	.25
Born outside the U.S.	53 (58.2)	20 (51.3)
Length of time in the U.S.
Since birth	38 (41.8)	19 (48.7)	1.98	.37
Less than 10 years	11 (12.1)	3 (7.7)
10 years of more	42 (46.1)	17 (43.6)
Dental insurance
Yes	26 (28.6)	17 (43.6)	7.54	.01
No	65 (71.4)	22 (56.4)
Dental care utilization past year
Yes	37 (40.7)	20 (51.3)	3.19	.07
No	54 (59.3)	19 (48.7)
Self-rated dental health
Excellent/Very Good/Good	65 (71.4)	30 (76.9)	1.01	.32
Fair/Poor	26 (28.6)	9 (23.1)

Teledentistry acceptability.

More than half (57.1%) of study participants reported no interest in undergoing consultations with their dental providers through video conferencing/internet. Those interested in participating in teledentistry were more likely to be women (66.7%) and English speakers (53.8%) and to self-rate their oral health as excellent/very good/good (76.9%). Having a yearly household income above $24,000 and not having dental insurance were the only two factors significantly correlated with finding teledentistry acceptable.

Discussion

This is the first study, to our knowledge, that examines teledentistry acceptability among Latina/o/x adults living in a rural area of the United States. Although this study was not based on a nationally representative sample, our findings provide a preliminary evidence of factors that may influence teledentistry adoption among this understudied population.

Over half of study participants reported no interest in participating in teledentistry consultations. This finding differs from prior literature noting positive and enthusiastic pre-experience perceptions about telehealth/telemedicine among Latina/o/x people^29,30 and adults living in rural communities.⁴⁴ Prior research specific to teledentistry utilization has also shown more uptake among rural dwellers than those living in suburban or urban locations.¹⁵ Given that pre-experience perceptions shape an individuals’ initial decision to use telehealth services,³⁰ our findings suggest the possible presence of ethnoracial disparities in teledentistry utilization within rural communities. Specifically, most participants who were not receptive to teledentistry in this study were Spanish speakers (61.5%) and individuals who were born outside the United States (63.5%), further suggesting that acculturation likely plays a role in teledentistry acceptability. This finding is not unique to teledentistry given published literature noting Latina/o/x people face acculturation and language barriers to telehealth use.^36–38 However, it may be possible that these findings actually reflect the effects of structural forces, including systemic racism and anti-immigrant rhetoric and policies, that shape the context of health care access in the United States.^36,45,46 Future research that uses an intersectional approach to examine how race, class, and gender class shape teledentistry acceptability and uptake among Latina/o/x/immigrants is warranted.

Furthermore, factors significantly correlated with teledentistry acceptability in this sample were household income and dental insurance, suggesting that pre-experience perceptions of teledentistry are influenced by enabling cost-related factors. While a higher income and having dental insurance have been traditionally associated with receipt of dental care, we found that individuals without dental insurance were more likely than those with dental insurance to express an interest in undergoing future teledentistry consultations.^47,48 This finding may be indicative of participants’ perception that teledentistry is a more accessible and an affordable way to access dental care. Savings and convenience factors such as travel time and distance have previously been significantly associated with telemedicine willingness.⁴⁹ We also found that self-perceived oral health is not correlated with teledentistry acceptability. This finding contrasts with published literature stating that self-perception of oral health is associated with dental utilization.⁴³ Future studies should use qualitative methods to understand how enabling factors and perceived need shape pre-experience perceptions of teledentistry among Latina/o/x adults living in rural communities.

The reported low interest in teledentistry consultations within this sample indicates that the accelerated implementation of teledentistry across rural communities in the United States may leave this population behind and further perpetuate inequities in access to dental care. More than half (59.3%) of Latina/o/x adults in this study reported they have not used dental care within the past year. Similarly, nationally representative estimates from the 2019 National Health Interview Survey indicate 54.3% of Latina/o/x adults across rural areas did not have a past year dental visit.⁵⁰ Given the underutilization of dental care use across rural areas, teledentistry has the potential to facilitate early intervention and preventive services for Latina/o/x people while reducing per capita cost with research demonstrating cost savings of approximately 10 to 15% for teledentistry in comparison with in-person visits.¹⁵ However, states vary considerably in their laws and policies on teledentistry and there is still great variation in payment policies among federal, state and private payment systems.⁵¹ Addressing barriers to teledentistry expansion such as the regulatory environment, training of practitioners, and billing processes must be prioritized.^17,18 At the same time, it is important to understand that teledentistry alone will not solve the inequitable access to dental care faced by Latina/o/x people. Simultaneous efforts to continue to expand access to dental care for immigrant populations through state coverage expansions⁵² and workforce innovation strategies⁵³ must not wane, especially given that most study participants (71.4%) reported not having dental insurance.

Addressing the inequitable access to dental care across rural communities further entails explicit prioritization and integration of health equity within this health care delivery model. Equity-centered telehealth, which includes the provision of teledentistry, is accessible to all and centers the needs of communities subjected to oppression across all aspects of implementation.⁵⁴ Anaya et al. suggest that efforts to improve telehealth for Latina/o/x communities includes intentionally refocusing its delivery systems to provide patient-centered care.³⁷ Patient-centered care is defined by the National Academy of Medicine as “care that is planned, delivered, managed, and continuously improved in active partnership with patients and their families to ensure integration of their health and health care goals, preferences, and values.”^37,55[p2] Similarly, scholars in the field of dentistry have called for the transformation of the dental care delivery system through the implementation of person-centered care–an approach related to patient-centered care–where care designers develop value-supported systems that place a person and their social well-being at the center of decision-making to ensure equitable access to desired and required care.⁵⁶ Building structures and processes to support equity-centered teledentistry entails developing and fostering meaningful partnerships with Latina/o/x patients and rural communities.⁵⁴ Strengthening community and intersectoral partnerships with Latina/o/x communities in rural settings further entails building a cadre of bilingual and bicultural people for sustainability of efforts as well as adequate resources and funding to support long-term projects.⁵⁷

Limitations.

Due to the limited sample size of 91, we present only descriptive results as an initial step in characterizing correlates of teledentistry acceptability among a minoritized population with a strong need for oral health care services. Future studies should include larger samples and use prediction modeling to identify the most important correlates that could in turn become the focus for interventions. Correlates of teledentistry acceptability we identified were limited to the variables we collected as part of our survey. It is possible that other factors our survey did not capture might be stronger correlates, therefore, incorporating qualitative interviews of participants in future studies would be important to identify correlates that are common and most salient among this population group. Additionally, we recognize the higher proportion of women that enrolled in this study (70.3%) than men (29.7%), which underscores the need to expand teledentistry acceptability research particularly to difficult to recruit groups such as Latino men who reside in rural communities.⁵⁸

While we provided a definition of teledentistry to study participants, it is unclear how this was interpreted or perceived. For instance, they may not have understood teledentistry’s role in dental consultations and triage for dental care but instead perceived it as providing treatment in an online environment (which is also a possibility given the remote supervision model for certain midlevel dental providers).

Conclusions.

This cross-sectional study conducted during the COVID-19 pandemic identified correlates associated with teledentistry acceptability for rural Latina/o/x adults. Findings suggest that cost-related factors may influence pre-experience perceptions of teledentistry. Future research aimed at assessing barriers and identifying factors that increase teledentistry acceptability among Latina/o/x living in rural areas may suggest intervention targets. Addressing the inequitable access to dental care across rural communities further entails explicit prioritization and integration of health equity within teledentistry. Equity-centered efforts ought to center the needs of marginalized populations across all aspects of implementation as well as prioritize the development of meaningful partnerships grounded in trust.