Study Notes on Racism in Oral Healthcare Settings

Kalo C. Sokoto MA - Counseling Psychology, Department of Counseling and Learning Sciences, West Virginia University, Morgantown, West Virginia, USA
Lisa F. Platt PhD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University, Pittsburgh, Pennsylvania; Department of Counseling and Learning Sciences, West Virginia University
Linda A. Alexander MEd, EdD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University; Department of Social and Behavioral Sciences, School of Public Health, West Virginia University
Betsy Foxman PhD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University
John R. Shaffer PhD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University
Mary L. Marazita PhD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University
Daniel W. McNeil PhD - Center for Oral Health Research in Appalachia, University of Pittsburgh and West Virginia University; Department of Psychology, West Virginia University

Daniel W. McNeil and Kalo C. Sokoto
- Email: dmcneil@wvu.edu
- Email: kcsokoto@mix.wvu.edu

National Institute of Dental and Craniofacial Research
Racial Justice Grant from West Virginia University, Award Number: R01-DE014889; Grant Award Date: 10.01.2020

Objective: To explore the association between racism in oral healthcare settings, dental care-related fear/anxiety, and dental utilization among Black/African American women in Appalachia.
Methods: Analysis of self-reported measures from 268 pregnant women in the COHRA SMILE cohort; measures included racism experiences, anxiety/fear levels, and dental visit recency.
Results:
- 1/3 reported instances of racism; 24.4% cited “not being listened to” as the main issue.
- 14.3% reported clinically significant levels of dental care-related anxiety/fear.
- Mediation model showed that racism predicts dental fear/anxiety, leading to decreased dental utilization.
Conclusions: The study highlights racist experiences as a determinant of reduced dental utilization through anxiety/fear constructs.

African Americans, Appalachia, Dental Anxiety, Dental Fear, Dental Utilization, Racism

Context of Research: Racism is a significant public health threat linked to health inequities.
- Most reported discrimination in US healthcare.
- Reduced healthcare utilization and negative health outcomes associated with racism.
Specific Issues in Dental Care:
- Clinical disparities: African American patients often receive poorer treatment recommendations and care.
- Current gaps in understanding the relationship between racism and dental anxiety/fear.
Theoretical Framework:
- Krieger’s Ecosocial Theory highlights social forces affecting health, emphasizing “everyday racism” in healthcare settings.
- This study investigates how these experiences contribute to dental anxiety/fear and utilization behaviors.

Definition: Negative anticipatory or procedural arousal related to dental treatment.
Impact: Those with high levels of anxiety/fear are more likely to delay or avoid treatment.
Specific Findings for Black/African American Patients: Unique triggers of anxiety/fear compared to majority cultural groups, often rooted in past negative treatment experiences.

Address gaps in literature regarding racism in dental settings, its association with dental anxiety/fear, and both variables’ impact on dental care utilization.
Use of mediation analysis to deliberate on the paths linking racism to anxiety/fear and ultimately to utilization.

Participants: 268 pregnant women identifying as Black/African American from the COHRA SMILE cohort.
- Criteria: 1st or 2nd trimester, 18 years or older, residing in Appalachia, willingness for follow-up visits.
Measures:
- Sociodemographic Data: Education, income, dental insurance, state of residence.
- Dental Utilization: Time since last dental visit categorized into defined intervals.
- Everyday Racial Discrimination in Dental Care Scale (ERDS-DC): 7-item scale assessing experiences of racism in dental settings with a higher score indicating more frequent experiences.
- Dental Fear Survey (DFS): 20-item measure assessing dental fear/anxiety, higher scores indicating more anxiety.

Used PROCESS macro for SPSS to assess mediation; covariates included socioeconomic status, dental insurance, and residence state.
Outcome measures were evaluated through logistic regression models examining the relationships between racism, anxiety, and dental utilization.
Analyzing relationships involved creating indirect coefficients through bootstrapping methods to assess for significance.

Demographics: Average age: 27.2 (SD = 5.5); most completed high school; high percentage with dental insurance.
Findings on Racism Experiences:
- 37.3% reported experiencing racism in dental settings; most frequent incidents included being treated with less respect and not being listened to.
Dental Anxiety/Fear Levels:
- 44% endorsed some level of anxiety; 14.5% reported clinically significant anxiety.
- Mediation analysis confirmed that the experience of racism predicts higher dental fear/anxiety, influencing lower utilization rates for dental services.

Significance of Findings: Demonstrated clear links between racism and dental anxiety/fear resulting in increased avoidance of dental care.
Implications for Healthcare: Emphasized the role of racism as a social determinant in oral health disparities; the need for anti-racist practices in dental settings.
Comparison with Other Populations: The findings align with broader research on health disparities faced by African Americans in healthcare systems.

Reliance on self-reported data may introduce potential biases.
Focus on a specific demographic (pregnant Black/African American women) may limit generalizability to other populations or regions.
Lack of data concerning the racial/ethnic identity of dental providers.

Call for additional studies focusing on racism's impact on oral healthcare among other racial groups.
Suggestion for qualitative research for deeper understanding of individual experiences related to racism in dental settings.

The study reinforces that experiences of racism in dental care settings contribute significantly to anxiety/fear affecting healthcare utilization.
The findings illuminate the intersectionality of race, gender, and geographic location in understanding disparities in dental health.

Recognition of participants, community partners, and COHRA field staff for their contributions to research and data collection.

Extensive reference list documenting foundational studies and theories related to the research, including works on racism and health equity.