Development and Testing of a Patient-centered Dental Home Assessment for Low-income Families

Abstract

Objectives:

The purpose of this study was to develop an instrument in English (ENG) and Spanish (SPA) for use in assessing perceptions of dental home characteristics among low-income adults.

Methods:

An expert panel selected 21 items from a pool of 81 items mapped to domains in the American Academy of Pediatrics’ medical home. Pilot testing with mothers (n=795) of children in Early Head Start (EHS) resulted in an expanded 36-item scale, which was field tested in interviews with ENG- (N_ENG=665) and SPA-speakers (N_SPA=116). An exploratory factor analysis of 23 usable items was carried out in an EHS reference group (N_ENG-EHS=272). The selected model was evaluated by confirmatory factor analysis (CFA) in two other subgroups (N_ENG-NonEHS=393; N_SPA=116). We tested measurement and structural invariances using a multiple-group approach. Known-groups validity was examined by testing factor mean differences between two groups defined by whether or not the mother used a single dental office.

Results:

A three-factor CFA model with 10 items was retained for its close fit for all three subgroups. Invariance tests found the two ENG subgroups to be homogenous and were combined. Several item and factor parameters in the SPA group differed from the combined ENG group. The proposed dental home measure demonstrated good known-group validity in that people who used the same dental office reported better dental care experiences.

Conclusions:

An instrument to measure the dental home concept among low-income adults was developed with three domains (accessible-comprehensive, compassionate and health literate care) that demonstrated good validity and reliability.

INTRODUCTION

The term “dental home” has come into common usage in the United States over the last decade. The American Academy of Pediatric Dentistry (AAPD), the American Dental Association (ADA) and the American Academy of Pediatrics (AAP) endorse the concept, defined by the AAPD as: “…the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.” ^1–3 The dental home is the conceptual basis for national and state policies, particularly those that target access to dental care for pediatric and perinatal populations.^{4, 5}

Despite widespread use, agreement on its basic elements and therefore what constitutes a dental home is lacking.⁵ Few attempts have been made to define and test its basic constructs. Mostly, single items in a limited number of domains have been used to assess portions of the dental home concept like usual source of care (place or person), type of care (episodic vs. regular), and continuity of care.^6–8

The trend in implementation of the concept is toward a broader definition and interpretation of what constitutes a dental home, making measurement of the concept more complex. Recommendations have called for the integration of related areas of research like quality of care and health literacy.^{9, 10} Further blurring of the boundaries for the concept is caused by labeling some innovative approaches to address the dental access problem, such as care coordinators, teledentistry and integration of oral health into primary care, as dental home initiatives.^11–13 Most recently, the broadest application of the medical and dental home concept yet is the integration of public health and social services with primary care.¹⁴ The evolving dental home concept is outpacing its initial conceptual development leading to the lack of a firm foundation for its implementation and study.

Advancement of the dental home as an accepted model of dental care requires consideration of a number of issues. Elements need to be defined and quantitative measures developed so that a determination can be made of the benefits of its different components. Once dimensions needing improvement are identified, research can be undertaken on how to effectively implement the concept to improve oral health. The purpose of this study is to develop an instrument for use with English- and Spanish-speaking subjects in population-based surveys that measures patients’ experiences with elements of the dental home concept.

Our focus is on low-income families with preschool-aged children because of their public health priority. This population generally has high need for dental services, low dental utilization, and high levels of dissatisfaction when gaining access to care and with the dental care itself.¹⁵ Closing gaps in the use of dental care between low-income and other population groups will require better insights into those characteristics of the dental care system that disadvantaged populations perceive as barriers.

METHODS

Overview of scale development

We used a mixed methods multiple-step, sequential research design in the development of the dental home scale.¹⁶ The main steps in the process are grouped into three phases as displayed in Figure 1. In the first phase we generated a pool of items in English and selected 21 of them for translation into Spanish and testing. In the second phase, the 21-item scale was pilot tested in a self-completed questionnaire of the target population of low-income mothers of young children. In the final phase, field interviews using the resulting 36-item scale were conducted with the target population. Steps for the first two phases are described only briefly in the paper, but more fully in Appendix 1. The UNC Biomedical Institutional Review Board approved the research.

Figure 1:

Steps in the development and testing of a dental home assessment scale

Initial item generation and pilot testing

Using the AAP conceptual model of a medical home as a guide, the study principal investigator extracted a pool of 81 items in English from the literature, questionnaires used in national surveys and an item bank maintained at the time by the National Institute of Dental and Craniofacial Research.^{9, 17–21} A panel of 3 pediatric dentists, a public health dentist, and 2 public health researchers selected by consensus agreement 21 items suitable for self-completion by low-literacy subjects. Items were mapped to 5 of the 7 AAP domains (accessible, family centered, comprehensive, compassionate, culturally competent).

After translation into Spanish and pretesting, the preliminary scale with 21 items was pilot tested in a self-completed questionnaire of Early Head Start (EHS) parents (N_ENG=671; N_SPA=124). The English version had good construct and criterion-related predictive validity when tested using classical test theory methods. The Spanish version did not meet acceptable standards of reliability and validity so we conducted cognitive interviews with a convenience sample of 30 native Spanish-speaking adults to gain insights into problems with survey instructions, translation and cultural issues.²²

Findings from the first two stages of instrument development were used to produce a dental home scale with 36 items. Items in a new domain (health literate care) were added along with new items in the coordinated care domain. Final modifications were made after pretesting of items in interviews of 9 English- and 7 Spanish-speaking parents.

Field testing of 36-item scale

Data source:

The 36-item scale was field tested using baseline data from Zero Out Early Childhood Caries (ZOE), a longitudinal study to determine the effects of enrollment in EHS on oral health outcomes.²³ ZOE enrolled an intervention group of children (N=636) younger than 19 months of age and their parents from 25 EHS programs in North Carolina, and a control group of parent-child dyads (N=931) randomly selected from Medicaid enrollment files. The two groups are referred to throughout as “EHS” and “Non-EHS”.

Dental home items were included in interviews of ZOE-enrolled parents, which consisted of about 400 items and were conducted in English or Spanish according to caregivers’ preferences. Of the 1,567 respondents, 893 (56.9%) were eligible for the current study because they reported needing dental care (for any reason including check-ups) during the 24 months before the baseline interview and had visited a U.S. dentist about the care needed.

Analytical sample:

To control for the potential impact of demographic variables on response behaviors, we further limited the ZOE sample for this study to the 665 U.S. born mothers who were interviewed in ENG and the 116 non-U.S. born mothers who were interviewed in SPA. We stratified the ENG group for the analysis based on their EHS status (N_ENG-EHS=272; N_ENG-NonEHS=393) because a previous analysis found that EHS and control participants differed on sociodemographic characteristics.²⁴ The SPA group was kept intact because of its small sample size.

Descriptive statistics and missing data.

We excluded 13 of the 36 items because they were used as screeners or because their skip patterns resulted in large proportions of missing data. The remaining 23 items are listed in Table 1. The Spanish version had equivalent interpretations as the English version. Descriptive information for each dental home item is presented by nativity and language subgroup in Appendix 2. Sample characteristics were summarized by key demographic variables for subjects by ENG-EHS, ENG-NonEHS, and SPA groups using the R base package version 3.4.²⁵

Table 1:

Dental Home Items, ZOE Study

Item label	Item stem	Ordered response options
During the last 2 years was there any time when you needed dental care for any reason?
DH-1	Did you get an appointment as soon as you wanted?	Yes/No/DK
DH-2	Did you get all the care you needed?	Yes/No/DK
DH-3	How much of a problem is it for you to get the dental care you need?	Big problem/ small problem/ not a problem/ DK
DH-4	Have you ever needed to see a dentist who specializes in certain types of treatment, such as an oral surgeon, an orthodontist or a periodontist?	Yes/No/DK
DH-5	Is there a particular dental office or dental clinic where you usually go if you needed dental care?	Yes/ No/ DK
DH-6	If more than 1 family member of your family needed dental care, would they need to go to different dentists or dental offices?	Yes/ No/ DK
DH-7	Has anyone in your child’s EHS helped you find a dentist for yourself?	Yes/ No/ DK
DH-8	Has anyone in community (outside EHS) such as a social worker or caseworker helped you get dental care?	Yes/ No/ DK
During the last 2 years, how often did dentists or their staff…
DH-9	…explain things to you in a way you could understand?	Always/ usually/ sometimes/ Never/ DK
DH-10	…show respect for what you had to say?	Always/ usually/ sometimes/ Never/ DK
DH-11	…treat you with courtesy and respect?	Always/ usually/ sometimes/ Never/ DK
DH-12	…spend enough time with you?	Always/ usually/ sometimes/ Never/ DK
DH-13	…treat you unfairly because of the way you pay at the dentist’s office?	Always/ usually/ sometimes/ Never/ DK
During the last 2 years…
DH-14	…how often have you felt that dentists or their staff treated you unfairly because of your race?	Always/ usually/ sometimes/ Never/ DK
DH-15	…how often have you felt that dentists or their staff were not sensitive to your family’s values and customs?	Always/ usually/ sometimes/ Never/ DK
DH-16	Do you have a hard time speaking or understanding dentists or their staff because they speak a language different from your own?	Yes/ No/ DK
During the last 2 years, how often have dentists or their staff…
DH-17	…listened carefully to you?	Always/ usually/ sometimes/ Never/ DK
DH-18	…given you easy to understand instructions about taking care of your dental health?	Always/ usually/ sometimes/ Never/ DK
DH-19	…checked to make sure you understood everything?	Always/ usually/ sometimes/ Never/ DK
DH-20	…used pictures, drawings or models to explain things to you?	Always/ usually/ sometimes/ Never/ DK
DH-21	…talked too fast when speaking with you?	Always/ usually/ sometimes/ Never/ DK
DH-22	…used dental words you did not understand?	Always/ usually/ sometimes/ Never/ DK
DH-23	…given you too much information about your dental care all at one time?	Always/ usually/ sometimes/ Never/ DK

Shading in Column 1 indicates item included in final CFA models.

Responses for each item coded so that higher categories would always indicate a better dental care experience (bolded response in last column) and lowest category was always coded as 0.

EHS=Early Head Start; DK = don’t know (coded as missing data).

Missing data, including “Don’t know” responses, were handled using either an integration-based maximum likelihood estimator or a multiple imputation approach. These methods preserve all observed data and provide unbiased parameter estimates if the missing at random assumption is met.²⁶ For imputed datasets, we adopted the robust diagonally weighted least squares (WLSMV) estimator for categorical items.²⁷

Exploratory factor analysis (EFA).

We started the analysis with EFA rather than CFA because of the limited empirical evidence defining basic elements of the dental home concept. We fit a series of EFA models to the reference group in Mplus using the integration-based maximum likelihood estimator.²⁸ All EFA solutions were rotated using quartimin rotation. The most plausible EFA solution was selected according to published guidelines.^{29, 30}

Single-group confirmatory factor analysis (CFA).

We fit the EFA-informed model to each of the three language-nativity subgroups using CFA. For each item, only its strongest loading found under the EFA solution was freely estimated while all other loadings were constrained to zero (i.e., the variation of an item was explained by only one factor). Latent factors were standardized to set the metric and they were allowed to correlate.

Model fit was evaluated based on strengths of the factor loadings and two global model fit indices including the root mean squared error of approximation (RMSEA <0.6) and comparative fit index (CFI>0.95).³¹ Composite reliability (CR) and average variance explained (AVE) also were computed for each factor. Under published guidelines, CR greater than 0.7 indicates good reliability of a factor, while AVE greater than 0.5 indicates good convergent validity.³² The computation of CR uses factor loadings (as opposed to Cronbach’s alphas which use raw responses) and provides a more accurate measure of internal consistency under CFA, especially when there is a mixture of dichotomous and polytomous items. CFA models were carried out using the lavaan package in R.³³

Measurement and structural invariance tests.

We tested the invariance of item parameters (measurement) and factor distributions (structural) between subgroups. First, we compared the ENG-EHS and ENG-NonEHS subgroups, followed by comparisons between ENG and SPA. For measurement invariance testing, we fit a configural-invariance model and a scalar-invariance model. For structural invariance testing, we fit an equal-factor-covariances model and an equal-factor-means model.

The configural-invariance model essentially combined the single-group CFA models of the two compared groups as one model without additional constraints. Model-data fit of the combined model was evaluated using the same criteria set for the single-group models. The purposes of a configural-invariance model were to ensure that both groups conform to the same factor structure and to set an unconstrained baseline model for the subsequent invariance test.

Building on a satisfactory configural-invariance model, the scalar-invariance model equated item parameters between groups, but freely estimated the factor covariances and means in the non-reference group. The assumption of equivalent item parameters under the scalar-invariance model would be untenable if we observed a significant scaled-χ² difference and a ΔCFI < −0.002 (ΔCFI=CFI_scalar − CFI_configural) when compared to the configural-invariance model.³⁴ If the scalar-invariance model failed, we sought to identify a partial-scalar-invariance model by removing some item parameter equality constraints.

Structural invariance tests were carried out only if scalar- or partial-scalar invariance was established. The equal-factor covariances model equates the factor covariance matrices between groups, and the equal-factor-means model equates the factor means. They were compared, respectively, against the scalar-/partial-scalar-invariance model to test whether covariances or means could be equated without significantly worsening the overall fit.

Known-groups validity.

Question DH-5 (single place for care) was excluded from the CFA because of its weak factor loadings. Nonetheless, people who use the same dental office for all needed care are expected to report better dental care experiences.⁶ Therefore, we tested the known-groups validity of our dental measure by comparing group means defined under DH-5. Due to the sample size limitation of the SPA group, only the ENG group was tested for such a difference.

RESULTS

Descriptive Statistics

Noticeable differences existed across the three subgroups on most demographic variables (Table 2). Only DH-6 (6.2%) and DH-23 (7.4%) had more than 5% missing values.

Table 2.

Characteristics of eligible baseline respondents

Characteristic	ENG-EHS	ENG-NonEHS	SPA
N	272	393	116
Median age (SD; range)	25.9 (5.5; 18-42)	26.6 (5.6; 18-49)	30.1 (5.4; 19-49)
Race %
White	39	63.9	30.2
African American	54.8	32.6	0.9
American Indian/Alaska Native	9.6	6.1	0.9
Asian	0	0	0
Pacific Islander	0.4	0.3	0
Other	5.9	3.1	70.7
Ethnicity %
Hispanic	4.8	2.5	100
Non-Hispanic	95.2	97.5	0
Marital status %
Single/Never married	66.9	58	17.2
Married/common law marriage/live with partner	25.4	34.4	80.2
Separated/Divorced/Widowed	7.7	7.4	2.6
Other/Missing	0	0.3	0
Education %
Some high school or less	23.2	15.8	57.8
High school graduate or GED	27.6	25.2	29.3
Some college or 2-year college degree (community college, technical school)	41.5	45	7.8
4-year college degree or more	7.7	14	5.2
Occupation %
Working full time	21.3	19.8	19
Working part time	22.1	20.4	12.9
Looking for work	39.7	36.4	12.1
Laid off from work	5.5	4.6	6
In school / training	34.9	26.2	4.3
In the Military	0	0.3	0
Keeping house	51.1	59.5	94.8
Something else	7.4	10.2	2.6
Medicaid enrollment %
Yes	68.4	61.1	13.8
No	30.9	38.4	86.2
Don’t know/Missing	0.7	0.5	0

Exploratory Factor Analysis

We estimated and compared four EFA models ranging from two to five factors based on the scree plot shown in Figure 2. The best-fitting four-factor solution with 10 strong items was selected for CFA. The EFA solutions with proposed construct names are presented in Table 3. The culturally appropriate care construct was excluded from further analyses because it was defined by a single item.

Figure 2.

Scree plot generated in Mplus for the 23 dental home items

Table 3.

Factor loadings and communalities from the four-factor EFA quartimin-rotated solution

Item Label	Accessible and Comprehensive care	Compassionate care	Culturally appropriate care	Health literate care	h2
DH-1	0.65	−0.01	0.00	−0.17	0.37
DH-2	0.85	−0.08	−0.03	0.10	0.73
DH-3	0.74	0.07	0.01	−0.15	0.53
DH-4	0.22	0.00	0.28	0.21	0.24
DH-5	0.33	0.26	−0.02	−0.24	0.19
DH-6	0.29	−0.09	−0.25	0.05	0.12
DH-7	−0.12	0.10	0.09	−0.11	0.03
DH-8	−0.04	−0.24	−0.18	0.31	0.12
DH-9	0.07	0.57	−0.04	0.33	0.64
DH-10	0.15	0.78	0.05	0.14	0.88
DH-11	−0.01	1.07	0.06	−0.26	0.98
DH-12	0.21	0.49	−0.04	0.39	0.74
DH-13	0.19	0.36	0.32	0.23	0.55
DH-14	−0.01	0.05	1.00	−0.02	1.00
DH-15	0.08	0.32	0.57	0.29	0.75
DH-16	0.21	−0.14	0.19	0.36	0.23
DH-17	0.13	0.71	0.03	0.25	0.84
DH-18	−0.04	0.71	−0.08	0.33	0.78
DH-19	0.01	0.71	−0.12	0.24	0.69
DH-20	0.05	0.34	−0.73	0.05	0.58
DH-21	0.16	0.24	0.12	0.53	0.61
DH-22	0.03	−0.01	−0.05	0.81	0.65
DH-23	0.08	0.17	0.20	0.64	0.67

h² = communality, which translates to the proportion of variation in each item that is explained by all factors.

Bold items met predefined item selection criteria.

Single-Group Confirmatory Factor Analysis

We imputed missing values 50 times and then estimated the three-factor CFA model for each language-nativity subgroup. All three factors demonstrated good reliability (0.78 < CRs < 0.93) and convergent validity (0.55 < AVEs < 0.77). Fit indices for the single-group models also suggested an excellent fit in all three subgroups (Table 4).

Table 4.

Results from single-group CFA models and invariance tests

Model	Scaled-	df	RMSEA	CFI	test of invariance p value	ΔCFI	Pass/Fail
ENG-EHS vs ENG-NonEHS
ENG-EHS only	39.073	32	0.029	0.997	---	---	Pass
ENG-NonEHS only	70.605	32	0.055	0.986	---	---	Pass
Configural-invariance	112.635	64	0.048	0.990	---	---	Pass
Scalar-invariance	122.232	83	0.038	0.992	0.872	0.002	Pass
Equal factor covariances	116.873	89	0.031	0.994	0.857	0.002	Pass
Equal factor means	124.161	86	0.037	0.992	0.414	0	Pass
ENG vs SPA
ENG only	85.357	32	0.050	0.989	---	---	Pass
SPA only	33.187	32	0.018	0.997	---	---	Pass
Configural-invariance	93.796	64	0.035	0.994	---	---	Pass
Scalar-invariance	168.287	83	0.051	0.984	< 0.001*	−0.010	Fail
Partial-scalar-invariance	75.574	77	0	1	1	0.006	Pass
Equal factor covariances	131.686	83	0.039	0.991	0.005*	−0.009	Fail
Equal factor means	194.725	80	0.061	0.979	< 0.001*	−0.021	Fail

Notes:

• ENG = US-born English-speaking mothers who were interviewed in English.
• EHS = early head start program.
• SPA = non-US-born Spanish-speaking mothers who were interviewed in Spanish.
• Scaled- = scaled chi-square test of model-data fit.
• df = scaled degrees of freedom for the scaled chi-square statistic.
• RMSEA = scaled root mean square error of approximation.
• CFI = scaled comparative fit index.
• test of invariance p value = p value for the scaled chi-square difference test comparing a more restricted model to the preceding less restricted model. Significant p values are marked with an asterisk (*).
• ΔCFI = CFI_{more_restricted} − CFI_{less_restrict}

Invariance Tests

Results from invariance tests conducted between the ENG-EHS and ENG-NonEHS subgroups are presented in the upper section of Table 4. Item parameters and factor distributions could be fully equated without significantly impacting the overall model-data fit. These findings suggest that EHS participation did not bias participants’ scores on the dental home constructs and the two subgroups were homogeneous. Hence, they were combined as one ENG group, which was then compared to the SPA group.

The measurement invariance tests between ENG and SPA showed that item parameters could not be fully equated between the two groups (lower section of Table 4) because of differences in items DH-2 and DH-21. We therefore adopted a partial-scalar invariance model without equating parameters for DH-2 and DH-21.

Moreover, factor covariances and means could not be fully equated between the ENG and SPA subgroups. The ENG group was more than one standard deviation higher on accessible-comprehensive care (${\stackrel{‒}{\theta }}_{\mathit{ENG}}-{\stackrel{‒}{\theta }}_{\mathit{SPA}}=1.203$, p < 0.001) but almost half a standard deviation lower on health literate care (${\stackrel{‒}{\theta }}_{\mathit{SPA}}-{\stackrel{‒}{\theta }}_{\mathit{ENG}}=0.401$, p =0.041). The SPA group also had a larger variance on health literate care (σ_SPA/σ_ENG = 14.39, p = 0.005).

Because of the parameter differences between the ENG and SPA subgroups they were modeled separately with partially-equated item/factor parameters. A path diagram for this final model is shown in Figure 3.

Figure 3. Path diagram of the final multiple-group CFA model.

Notes: ENG = US-born English-speaking mothers who were interview in English; SPA = non-US-born Spanish-speaking mothers who were interview in Spanish; ACCESS = accessible and comprehensive care; COMPASS = compassionate care; LITERATE = health literate care. Factor means are inside parentheses, item thresholds are inside square brackets, and item residuals are not shown. Parameters that are equivalent between groups are omitted on the SPA side.

Known Groups Validity

The ENG group was divided into two groups based on their responses to DH-5 (Single dental office for care?). Measurement invariance tests conducted before mean comparisons (results not shown) found no significant difference in the item parameters, indicating that group means could be compared without bias. As hypothesized, people who usually visit the same dentist had significantly larger means on all three dental home constructs than those who visit multiple offices for care. The difference in standard deviation units was 0.613 (p < 0.001) for accessible/ comprehensive care, 0.455 (p < 0.001) for compassionate care, and 0.289 (p = 0.031) for health literate care.

DISCUSSION

We know of no unifying theory for the public’s perceptions of the dental home and empirical evidence to support the concept is scarce. In the absence of this information, we relied on the main content themes of the AAP medical home for our organizing framework. We depicted the dental home as a multidimensional concept like the medical home, with 6 domains (accessible, comprehensive, coordinated, compassionate, culturally appropriate, health literate) and 23 items.

Our analysis identified a three-factor model (accessible/ comprehensive, compassionate, health literate care) as an interpretable solution that adequately explains variation in a final set of 10 items. The public seems to perceive the dental home as a much simpler concept than the one described in the literature, particularly by professional organizations. Taken as a whole, the 10 items in the final model imply that low-income populations think of a dental home as a place where one can get all the dental care they need, provided in a respectful way by a dental provider who uses communication techniques appropriate for low-literacy populations.

At least two qualitative studies support the importance of these factors to low-income groups. Mofidi et al.²⁰ found that family members of Medicaid-enrolled children got frustrated when securing an appointment, experienced disrespectful and demeaning interactions at their dental visit, and often did not complete care because of their unwillingness to return for follow-up visits after their experiences. More recently, Meyer et al.³⁵ similarly found a high level of dissatisfaction among caregivers when seeking emergency treatment for their children. Core elements of the patient-centered home are designed to address these problems encountered before and during the dental visit.

Three of the communication items (use of jargon, talks too fast, too much information) were retained in the final CFA model. These results confirm that dentist-patient communication is an important aspect of the dental home. However, agreement on the most important elements is lacking. Hays et al¹⁹ included 10 communication items in their analysis of the Consumer Assessment of Healthcare Providers and Systems (CAPHS) dental plan survey of which we had 3 items in common. Two of these (DH-9 explain things; DH-10 show respect) loaded on Compassionate Care in our analysis. Only DH-18 (listen carefully) was recommended in both studies. The “health literate provider” may need to be considered more broadly than we did in ZOE.³⁶

The three factors we identified making up the dental home scale have high internal consistency and convergent validity within different subgroups. However, as revealed by differences in factor loadings and thresholds (Figure 3), the SPA subgroup was more likely than the ENG subgroup to report having all their needs met [DH-2] and more difficulty in communicating with dentists or staff [DH-21]. We speculate that the former is due to the SPA subgroup having lower expectations than the ENG subgroup for the amount of dental care needed, and the latter is due to language barriers.³⁷ We likewise found similar between group bias in our work developing other constructs for the ZOE study.³⁸

After accounting for biases caused by DH-2 and DH-21, we found that the SPA subgroup had lower mean factor scores than the ENG subgroup for the accessible-comprehensive care domain, but a higher mean for health literate care. These somewhat counterintuitive findings likely result from the interaction of the many barriers to dental care experienced by Spanish-speaking populations and interventions designed to address them. Nevertheless, because of differences in items and domains between the ENG and SPA subgroups found in this study, we recommend that domains be interpreted separately when comparing language groups rather than combining them into a global “dental-home” factor.

Future Directions

Development of an instrument is an on-going process using data compiled from application of the measure across populations and time. The three-factor model selected in the current analysis should be tested in different samples. Such research will allow further testing of validity, reliability, and index scoring options.

A single item and two factors—usual source of care [DH-5], coordination of services and culturally appropriate care—did not meet criteria for inclusion in the final scale. However, we believe these concepts should not be discarded at this early stage of instrument development as being unimportant. “Usual source of care” is a cornerstone of quality health care, and sometimes is used as a parsimonious measure of a medical or dental home.^{1, 6}

Data for the current study were derived from baseline interviews of mothers when child subjects were, on average, nearing their first birthday. Similar to what others have found, the percentage of children having experienced dental care was low (EHS=9.6%; NonEHS=2.0%).³⁹ Furthermore, only a small percentage (10.7%) of mothers reported getting help from community resources in accessing dental care. The need for “coordinated services” as we have defined them will increase as children age and become subject to more dental problems, providing a better test of the importance of this dimension of a dental home.

“Culturally appropriate care” was excluded as a factor in the final scale because only one item, “treated unfairly because of race” [DH-14], met the selection criteria. This domain with 3 items was included in our study primarily because of results of the Mofidi et al.²⁰ qualitative study in which minority groups reported in focus groups that they felt discriminated against because of their race and that the quality of dental care suffered as a result. Further research is needed to develop the content validity of this domain.

An important and potentially productive pathway for future research is to explore the dental home from a theoretical perspective. The dimensions of the dental home found to be important in our study are key dimensions of the patient-centered home. Several theoretical models have been used to study patient-centered medical care that might serve as a useful perspective for studying the dental home.⁴⁰

Strengths and Limitations

Features of the study design limit generalizations about dental home perceptions beyond this study population. Subjects were enrolled from 41 of the 100 counties in NC. Although the population-based sample is a strength of the study, the analytical sample is restricted to biological mothers, mostly low-income, who used dental care sometime in the 24 months prior to the baseline interview. Application of the dental use criterion excluded 43% of the overall ZOE sample of adults.

The sample size limited our analytical approach. Ideally, we would have split the reference group into two random halves, run EFA using one-half, and then confirmed the selected model using the other half. Alternatively, we confirmed the EFA-informed model using the ENG-NonEHS group, which was homogenous to the ENG-EHS group, by establishment of full measurement and structural invariance between the two groups.

CONCLUSIONS

Research to develop a measure of people’s perceptions of dental care continues to be relevant to public health practice. Aspects of oral health care that are evaluated poorly by the public and contribute to disparities in oral health need to be known so that they can be addressed. We found a three-factor (accessible/ comprehensive, compassionate, health literate care), 10-item scale to be a valid and reliable assessment of patient-reported dental care experiences of mothers with young children. Usual source of care, coordinated services, and culturally appropriate care, although not meeting criteria for inclusion in our dental home scale, should not be overlooked in future research exploring the dental home concept. Measurement of the dental home is likely to need additional domains as scales are tested in other populations and as the public experiences changes in the delivery of dental services.

Appendix 1: Development and Pilot Testing of the 21-Item Dental Home Assessment Scale

Background

Well-constructed instruments for measuring characteristics of a dental home do not exist, making it difficult to study this important concept. Several instruments for assessing characteristics of a medical home are available, however, that can serve as a conceptual guide for the development of a dental home measure (1, 2). One of the most fully developed and accepted definitions of the medical home was detailed in a policy statement issued by the American Academy of Pediatrics in 2002 (3). This definition identifies 7 dimensions and 37 discrete concepts for determining the presence of a medical home for a child. The definition outlines an ideal model of care for children whereby health care is delivered or directed by well-trained physicians who provide primary preventive, acute, and chronic condition care and that this care is: 1) accessible, 2) continuous, 3) comprehensive, 4) family-centered, 5) compassionate, 6) culturally effective, and 7) coordinated with specialized services provided outside the primary care setting.

The purpose of this supplementary material is to provide additional details about our research on the development and testing of a preliminary dental home scale that could not be included in the main manuscript because of space limitations. We describe the development of a preliminary 21-item Dental Home Assessment Scale (DHS) and examine its reliability (test-retest) and validity (construct and criterion predictive validity). Because the performance of the DHS in Spanish was not as strong as in English, we report on an unpublished qualitative study undertaken to better understand Latino’s perceptions of the dental home (4).

This work related to the dental home was part of a larger project known as “ZOE” funded by the National Institutes of Health to evaluate the impact of enrollment in Early Head Start on oral health outcomes. The target population for the pilot DHS therefore was Early Head Start families. The research described in this appendix is referred to in the manuscript text and Figure 1 as Phase 2, or the “pilot” testing phase for instrument development.

Development of the Dental Home Assessment Scale (DHS)

Item Generation and Selection:

Using the AAP conceptual model of the medical home, the principal investigator with input from an expert panel generated a pool of 81 items in English from literature searches, review of questionnaires used in national surveys and an item bank maintained at the time by the National Institute of Dental and Craniofacial Research (5). Literature searches were done in PubMed using keywords corresponding to the domains specified in the AAP definition. We also relied on a study we had done previously in which we conducted 11 focus groups with low-income families to determine their attitudes toward dental care (6). Results of these focus groups highlighted the importance of “culturally competent dental care” for low-income family members, and provided insights into constructing items for this content theme.

An expert panel consisting of 3 pediatric dentists, a public health dentist, and 2 public health researchers familiar with early education and childcare programs selected items from the pool for use in constructing the DHS. We included items for all the domains in the AAP definition of a medical home for which we could identify questions that would be appropriate for inclusion in a written questionnaire to be self-completed by low-literacy individuals, conditions required by the parent ZOE study. The resulting English version of the DHS contained 21 items by consensus agreement in 5 of the 7 AAP domains (accessible, family centered, comprehensive, compassionate, culturally competent).

Translation into Spanish:

A single bilingual investigator translated the original English scale into Spanish. She sought input on word choices, particularly dental terms, from native Spanish speakers employed by the UNC-CH School of dentistry who interacted regularly with Spanish-speaking patients. She also reviewed Spanish-language written materials prepared by state, federal and non-profit agencies to help with choice of terms for the initial draft. The resulting draft translation was reviewed by a second bilingual investigator and differences resolved by consensus agreement. The review and discussions also included an English-speaking researcher who is not bilingual but knowledgeable about dental care for low-income populations.

Pretesting of DHS:

The DHS was administered to 13 subjects (English=7; Spanish=6) to refine the initial instrument and the data collection methods. Results of the pre-test of the initial instrument were discussed among investigators and changes to the DHS made using consensus agreement.

21-Item Dental Home Assessment Scale

The preliminary DHS contained 21 items in 6 domains (Table 1): Accessible Care (3-items), Comprehensive Care (2-items), Family Centered Care (6-items), Compassionate Care (5-items), Culturally Competent Care (3-items) and Usual Source of Care (2-items).

The objectives and analysis strategy for the pilot study led us to focus on subject-level DHS domain and overall scale scores. Scores for each domain and overall were calculated having a range from 0-100 with higher scores representing more characteristics of the dental home being met. Calculation of the score for each domain used an algorithm that accounted for skip patterns. For example, in the domain “Family Centered Care” we included questions about a family’s dentist providing care for the child. The first question asked: “Has your child ever been a patient at the dental office or clinic that you go to?” If the answer was “yes”, then no more questions needed to be answered and 100 points were awarded. If no, then the next question was: “Would your dentist or clinic see your child if you asked them to?” If the response was “yes”, then no more questions needed to be answered and 100 points were awarded. If “no”, then the next question was: “Has your dentists ever told you that your child needed to see a children’s dentist?” If “yes”, then no more questions needed to be answered and 100 points were awarded. If the response was “no”, then no points were awarded for the child care part of the “Family Centered Care” domain because the dental office for the family was not seeing the child nor was a referral being made to a specialist. The final score for the DHS and the one used for testing of reliability and validity was the mean score for all domains (0-100).

Pilot Testing of 21-Item Dental Home Scale

All EHS programs in the state at the time of the study (n=18) were invited and chose to participate in the pilot study to test the DHS. Our goal was to survey parents of all children enrolled in these programs to provide a test of scale performance among English- and Spanish-speaking parents.

Survey Methods:

Paper questionnaires and consent forms in the appropriate language as determined by EHS staff in consultation with individual parents were distributed by EHS staff, collected, and returned to the project office over a three month period of time. A total of 795 of 1,239 (64.1%) caregivers completed the survey: 671 completed the English version and 124 the Spanish version. The child’s mother was most often the respondent (89%). About one-third of parents were white and over one-half had some college or technical school training beyond high school.

Descriptive information for DHS:

Figure 1 displays the percent distribution of responses to the DHS by domain. The overall mean DHS score was 52.3 (SD±21.5). Parents reported having more compassionate care (72.5%) than family centered care (31.2%).

Validity and Reliability of 21-item Dental Home Scale

Performance of the dental home scale was evaluated for construct validity, criterion-related predictive validity, and test-retest reliability. The analysis first was completed on the entire sample followed by a similar analysis of subgroups of the sample stratified by questionnaire language.

Construct Validity:

Convergent validity was evaluated using Spearman’s rank order correlation coefficients for the association of dental home scores and both parent and child oral health status as reported by the parent. We hypothesized that a parent who reported higher dental home scores (indicating better dental “homeness” ) would be more likely to rate their own oral health and the oral health of his or her child as “good”, “very good” or “excellent” (vs. “fair” or “poor”). Evidence to support convergent validity was provided by the finding that dental home scores were correlated with the oral health status measures at a statistically significant level and in the expected direction (r=0.41 for parent oral health, p<0.001; r=0.25 for child oral health, p<0.001).

For the determination of discriminant validity, we hypothesized that dental home scores would not be associated with parent-reported global health status of the child, a hypothesis that was confirmed (r=.08; p=.09).

Similar results for construct validity were found in the English-speaking sample, but not the Spanish-speaking sample for which no statistically significant correlations were found between dental home scores and self-reported oral health.

Criterion-Related Predictive Validity:

The predictive validity of the DHS was determined by testing three hypotheses based on the assumption that a dental home is associated with dental utilization. We reasoned that those parents who have higher dental home scores are more likely to adhere to recommended preventive recall schedules, and are less likely to use restorative services or seek care for relief of pain than those parents with lower scores.

In bivariate analyses, DHS scores were positively associated with parents’ use of preventive services (r=.32) and negatively associated with their use of restorative services (r=−.11) and visits for dental pain (r=−.25), all statistically significant at p<0.05. Similar results were obtained in the English-speaking sample, but not in the Spanish-speaking sample. No correlations were found for the Spanish-speaking study subjects (Table 2).

Our findings in the bivariate analysis regarding the predictive validity of the DHS were supported by results of multivariate logit regression models controlling for potential confounders (Table 3). As hypothesized, DHS scores were positively associated with parents’ use of preventive dental services and negatively associated with use for restorative care and those services associated with dental pain when controlling for a number of sociodemographic characteristics (parent educational attainment, parent and child, sex, race, ethnicity, and insurance status). Sample size was not sufficient for the Spanish-speaking sample to conduct a multivariate analysis.

Test-Retest Reliability:

Parents who had completed baseline surveys in four EHS programs with demographics characteristics similar to all programs were asked to complete a shorter version of the questionnaire that contained the DHS. A total of 202 surveys were mailed three weeks after the original mailings to the four EHS retest sites. Test-retest reliability was assessed using the intraclass correlation coefficient (ICC) calculated by two-way analysis of variance (7). The test-retest survey was completed by 159 families (78.7%=Response Rate), of which 137 were English speaking and 22 were Spanish speaking. The ICC overall, for English-speaking families and Spanish-speaking families was 0.83, 0.89 and 0.56, respectively.

Conclusions from Survey Pilot Testing of 21-Item Scale

We found the English language version of the DHS to be reliable. Results also suggest that it has good construct and predictive validity. We were unable to confirm validity and reliability of the DHS in the Spanish-speaking sample. The overall test-retest reliability for the DHS among families who completed the Spanish version was lower (r=0.56) than the English version (r=0.89). Hypotheses tested for construct and predictive validity were in the expected direction in the Spanish version of the DHS, but associations were not as strong as for the English version and they did not reach statistical significance.

Follow-up Qualitative Research with 21-Item DHS—Cognitive Interviews

At this point in our research, we concluded that the DHS needed further development and testing, particularly in the Latino population. We chose to conduct cognitive interviews to gain insights into how to improve the DHS so that it would more accurately characterize what is important about the dental home to Hispanic families. In addition, cognitive interviewing techniques would help uncover problems with survey wording and format (8, 9).

Cognitive Interview Methods:

Face-to-face interviews were conducted in Spanish by a single interviewer with 30 parents from native Spanish speaking families. Interviewees averaged 32.1 years of age (range 18-43 years) and had lived in the U.S. between 2 and 20 years. Most respondents reported using “only Spanish” or “more Spanish than English” when reading, speaking, thinking and socializing.

Participants were interviewed after self-completion of the DHS using probes for each of the 21 items in the instrument, taking care to consider potential breakdowns in subjects’ mental processing of information. In addition, think-aloud and paraphrasing techniques were used during the interview to help identify if respondents understood the intended meaning of specific words or phrases, and if questions were culturally appropriated in their opinion. Finally, a series of open-ended questions were asked about any other concepts not included in the DHS that might be important to Latinos when considering dental care in the United States.

Results: Types of Problems Identified:

Interviews were audio recorded, transcribed and coded according to a prescribed protocol. A total of 47 problems were identified. They were distributed across three categories as follows: 38.3% general problems or problems specifically related to survey instructions (i.e., difficulties following item format, skip patterns, or questionnaire layout); 46.8% translation problems from English to Spanish (i.e., grammatical issues, words with differences in meaning among Latinos, closeness in meaning between response options); and 14.9% culturally specific problems (i.e., difficulty in understanding the meaning of words or phrases).

Results: Other Dental Home Concepts Important to Latinos:

Participants identified a number of factors that they believed to be related to dental care that were not included in the DHS. These factors included availability of health insurance, proximity of health care facilities to their residence, bilingual health care providers or the availability of an interpreter, cost of dental services, and the availability of a facility that is open at least on Saturday during the weekend and where they can receive comprehensive care.

Respondents were concerned about the impact of language on their level of trust in, and comfort with, their dentist. Other respondents expressed concerns about the accuracy with which the interpreter conveyed their message to the dentist and feared that important information might have been missed. Some respondents emphasized the importance of dentists’ interest in their patients’ feelings and fears, in addition to their professional experience.

Participants reported that in their native countries a single dentist usually provided dental care for all the members in a family, i.e., a “dentista familiar” (dentist of the family). However, based on their experiences in the United States, they believed that obtaining dental care for the entire family at the same location or the same provider is “impossible”, because of both parents’ lack of dental insurance and the way in which the health care system is organized.

Conclusions from Quantitative and Qualitative Pilot Testing of 21-Item DHS

Research using cognitive interviewing methods helped us to better understand what dental home concepts mean to Latino immigrants. We found the dental home to be an important and understandable concept for Latinos interviewed in this study. But we also found that the psychometric properties of the Spanish language version of the DHS needed improvement. Findings from the pilot testing (Phase 2) were considered in the revision of the preliminary 21-item DHS. The resulting scale was expanded to 36 items and subsequently field tested in English and Spanish as described in the published paper.

REFERENCES

1. American Academy of Pediatrics, Ad Hoc Task Force on Definition of the Medical Home. The medical home. Pediatrics. 1992;90:774.

2. Malouin RA, Merten SL. Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home. National Center for Medical Home Implementation, AAP, March 2010. https://medicalhomeinfo.aap.org/tools-resources/Documents/Monograph_FINAL_Sept2010.pdf

3. American Academy of Pediatrics, Medical Home for Children with Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-86.

4. Garbero I. Cognitive Evaluation and Public’s Perception of the Concepts in a Family Dental Home Index among Hispanics. Dental Public Health Residency Project Report. NC Oral Health Section, Division of Public Health, DHHS. 2008. Unpublished report.

5. Bethel C, Read D, Brockwood K. Using Existing Population-based Data Sets to Measure the American Academy of Pediatrics Definition of Medical Home for all Children and Children with Special Health Care Needs. Pediatrics. 2004; 113: 1529-37.

6. Mofidi M, Rozier RG, King RS. Problems with Access to Dental Care for Medicaid-insured Children: What Caregivers Think. Am J Public Health. 2002 Jan;92(1):53-8.

7. McGraw K, Wong S: Forming Inferences About Some Intraclass Correlation Coefficients. Psychol Methods. 1996;1:30-46.

8. Willis, Gordon. Introduction to Cognitive Interviewing. In: Cognitive Interviewing. A tool for Improving Questionnaire Design. Sage Publication Inc. 2005: 6-7.

9. Nápoles-Springer A, Santoyo-Olsson J, O’Brien H, Steward A. Using Cognitive Interviews to Develop Surveys in Diverse Populations. Med Care 2006; 44:S21-S30.

Table 1:

Items in the Family Dental Home Index (DHS)

Accessible Care (3-items)

Called dental office during regular hours in last 2 years

If yes, got advice needed

Got appointment for dental care when wanted in last 2 years

Usual Source of Care (2-items)

One dental office or clinic to get care

One person that is personal dentist

Family Centered Care (6-items)

Child been patient at family dentist

If no, dentist would see child if asked

Dentist ever told parent to take child to “children’s dentist”

Child has one dentist

Wanted dental care during pregnancy (for biological mothers only)

If wanted care, visited a dentist during pregnancy (for biological mothers only)

Comprehensive Care (2-items)

Needed dental care in last 2 years

If need care, got the care needed.

Compassionate Care (5-items)

Dentist explains things so could understand

Dentist showed respect for what had to say

Treated with courtesy and respect at dental visit

Dentist spent enough time during appointment

Believes that dentist should do more to reduce pain

Culturally Competent Care (3-items)

Hard time speaking or understanding dentist/staff because of language

Needed interpreter in last 2 years

If yes, how often was an interpreter provided

Each domain scored 0-100

DHS score derived as mean scores for all domains (0-100)

Figure 1:

Component Scores for Dental Home Index

Mean DHS score=52.3 (SD±21.5)

Table 2:

Findings for criterion-related predictive validity of Dental Home Assessment Scale

Outcome measure	Preventive Dental Use	Restorative Dental Use	Use of Dental Service for Pain
DHS Score (Full sample =350)	0.3241*	−0.1083*	−0.2541*
DHS Score (English only =312)	0.3540*	−0.1146*	−0.2831*
DHS Score (Spanish only =38)	0.2528	−0.1112	−0.1874

^*Significance P<0.05 level

Table 3:

Findings for criterion-related predictive validity of DHS in the English Speaking sample

Outcome measure	Preventive Dental Use	Restorative Dental Use	Use of Dental Service for Pain
Dental Home Measure
DHS Score	.133* (.006)	−.022* (.0064)	−.028* (0.0056)
Control Variables
Child Race ( Minority vs. White)	−1.06* (0.62)	0.40 (0.64)	0.66 (0.57)
Child Insurance Status (Medicaid vs. Private/none)	−2.18* (0.98)	0.19 (0.34)	.0014 (0.28)
Parent’s Education(HS or less vs. Some college or more)	.099 (0.23)	0.21 (0.80)	−0.34 (0.25)
Parent’s Insurance Status (Medicaid vs. Private/none)	0.29 (0.98)	−0.94 (0.99)	0.34 (0.79)
Parent’s Race ( Minority vs. White)	−0.81 (0.69)	−0.42 (0.64)	−0.16 (0.54)
Constant	−1.86* (.453)	−1.41* (0.53)	1.00* (0.44)

Notes: Separate logit regression models run for each dental use type

Sample size English-speaking subjects only, n=283

Standard Errors on are in parentheses ( )

^*Significance P<0.05 level

Appendix 2: Response to Each of the 23 Items in the Dental Home Assessment Scale

Table A:

Percent distribution of biological mothers’ response to dental home items by nativity and language.

Domain/ Item #	Item	Overall (N=781) Col %	ENG-EHS (n=272) Col %	ENG-NonEHS (N=393) Col %	SPA (N=116) Col %
DH-1	During the last 2 years if there was any time when you needed dental care for any reason, did you get an appointment as soon as you wanted?
	Yes	83.6	85.2	87.0	68.1
	No	16.3	14.7	12.9	31.9
	DK	0	0	0	0
DH-2	During the last 2 years if there was any time when you needed dental care for any reason, did you get all the care you needed?
	Yes	71.5	70.9	74.0	64.6
	No	28.0	28.3	25.9	34.4
	DK	0.3	0.7	0	0.8
DH-3	How much of a problem is it for you to get the dental care you need?
	Big problem	21.5	20.2	15.0	46.5
	Small problem	25.6	23,9	24.4	33.6
	Not a problem	52.7	55.5	60.5	19.8
	DK	0.1	0.3	0	0
DH-4	Have you ever needed to see a dentist who specializes in certain types of treatment, such as an oral surgeon, an orthodontist or a periodontist?
	Yes	50.9	51.8	57.5	26.7
	No	47.7	47.4	41.2	70.6
	DK	1.2	0.7	1.2	2.5
DH-5	Is there a particular dental office or dental clinic where you usually go if you needed dental care?
	Yes	77.3	77.5	78.1	74.1
	No	22.2	22.0	21.6	25.0
	DK	0.3	0.3	0.2	0.8
DH-6	If more than 1 family member of your family needed dental care, would they need to go to different dentists or dental offices?
	Yes	42,7	37.8	38.9	67.2
	No	51.8	55.8	55.9	28.4
	DK	5.3	6.2	5.0	4.3
DH-7	Has anyone in your child’s EHS helped you find a dentist for yourself?
	Yes	4.8	10.2	NA	8.6
	No	36.1	89.7	NA	32.7
	DK	0.1	0	NA	0.8
	Not applicable	58.9	0	NA	57.7
DH-8	Has anyone in the community (outside EHS) such as a social worker or caseworker helped you get dental care?
	Yes	10.7	13.6	8.9	10.3
	No	88.9	86.0	90.8	89.6
	DK	0.2	0.3	0.2	0
DH-9	During the last 2 years, how often did dentists or their staff explain things to you in a way you could understand?
	Always	53.7	55.8	56.7	38.7
	Usually	26.7	28.3	28.5	17.2
	Sometimes	14.0	10.6	11.9	29.3
	Never	1.6	1.4	1.0	4.3
	DK	3.5 *	3.6	1.5 *	10.3
DH-10	During the last 2 years, how often did dentist or their staff Show respect for what you had to say?
	Always	74.0	72.4	78.5	68.9
	Usually	15.3	15.0	16.0	13.7
	Sometimes	7.5	8.8	6.1	9.4
	Never	1.5	2.2	6.7	2.5
	DK	1.5	1.4	0.5	5.1
DH-11	During the past 2 years, how often did dentists or their staff treat you with courtesy and respect?
	Always	81.5	80.8	82.7	79.3
	Usually	13.5	13.6	13.7	12.9
	Sometimes	3.4	3.6	2.8	5.1
	Never	0.7	0.7	0.7	0.8
	DK	0.6	1.1	0	1.7
DH-12	During the past 2 years, how often did dentists or their staff spend enough time with you?
	Always	62.l	60.6	64.3	57.7
	Usually	20.6	22.7	20.3	16.3
	Sometimes	13.3	11.0	13.2	18.9
	Never	2.0	2.9	1.0	3.4
	DK	1.9	2.5	1.0	3.4
DH-13	During the last 2 years, how often do you feel you were treated unfairly because of the way you pay at the dentist’s office?
	Always	2.8	4.0	1.7	3.4
	Usually	2.6	2.9	2.0	4.3
	Sometimes	10.1	9.1	9.6	13.7
	Never	80.1	81.2	81.9	71.5
	DK	4.1 *	2.5	4.3 *	6.9
DH-14	During the last 2 years, how often have you felt that dentists or their staff treated you unfairly because of your race?
	Always	0.1	0.3	0	0
	Usually	0.5	0.3	0	2.5
	Sometimes	2.0	1.8	1.5	4.3
	Never	95.7	95.5	97.2	91.3
	DK	1.5	1.8	1.2	1.7
DH-15	During the last 2 years, how often have you felt that dentists or their staff were not sensitive to your family’s values and customs?
	Always	0.9	2.2	0.2	1.7
	Usually	0.7	1.1	0.2	6.9
	Sometimes	4.2	3.6	3.8	78.4
	Never	89.6	89.7	92.8	12.0
	DK	4.3 *	3.3	2.8	0.8
DH-16	Do you have a hard time speaking or understanding dentists or their staff because they speak a language different from your own?
	Yes	22.5	15.4	15.0	64.6
	No	77.4	84.5	84.9	35.3
	DK	0	0	0	0
DH-17	During the last 2 years, how often have you felt that dentists or their staff listened carefully to you?
	Always	67.4	66.1	67.9	68.9
	Usually	17.8	16.5	19.0	16.3
	Sometimes	11.6	13.6	11.7	6.9
	Never	1.7	2.5	0.7	3.4
	DK	1.1 *	1.1	0.5	3.4 *
DH-18	During the last 2 years, how often have dentists or their staff given you easy to understand instructions about takin care of your dental health?
	Always	71.8	71.6	74.5	62.9
	Usually	19.4	19.8	20.3	15.5
	Sometimes	6.0	5.8	3.8	13.7
	Never	1.2	1.1	0.5	4.3
	DK	1.1 *	1.4	0.2 *	3.4
DH-19	During the last 2 years, how often have dentists or their staff checked to make sure you understood everything?
	Always	56.2	57.7	57.0	50.0
	Usually	22.5	24.2	23.6	14.6
	Sometimes	13.4	10.6	12.4	23.2
	Never	5.8	4.7	5.3	10.3
	DK	1.9	2.5	1.5	1.7
DH-20	During the last 2 years, how often have dentists and their staff used pictures, drawings or models to explain things to you?
	Always	22.1	22.4	17.8	36.2
	Usually	16.1	16.5	16.2	14.6
	Sometimes	30.4	28.3	33.5	25.0
	Never	26.5	28.3	27.2	19.8
	DK	4.7	4.4	5.0	4.3
DH-21	During the last 2 years, how often have dentists or their staff talked too fast when speaking with you?
	Always	2.3	1.8	1.5	6.0
	Usually	4.9	6.6	4.8	1.7
	Sometimes	30.2	33.0	26.9	34.4
	Never	58.1	54.0	61.8	55.1
	DK	4.3	4.4	4.8	2.5
DH-22	During the last 2 years, how often have dentists or their staff used dental words you did not understand?
	Always	5.7	5.5	5.6	6.9
	Usually	9.3	10.2	10.4	3.4
	Sometimes	54.2	56.2	54.7	48.2
	Never	25.9	24.2	25.7	31.0
	DK	4.3 *	3.3 *	3.5	9.4 *
DH-23	During the last 2 years, how often have dentists or their staff given you too much information about your dental care all at one time?
	Always	2.9	2,2	2.2	6.9
	Usually	4.9	5,8	4.3	5.1
	Sometimes	18.4	20.2	18.8	12.9
	Never	66.5	64.3	68.7	64.6
	DK	7.0	7.3	5.8	10.3

ENG-EHS = United States born, English speaking, child enrolled in Early Head Start, interviewed in English

ENG-NonEHS = United States born, English speaking, child not enrolled in Early Head Start, interviewed in English

SPA = Not born in United States, Spanish speaking, interviewed in Spanish

^*Column does not sum to 100% because of missing responses.