Invisible Children: Access to oral health care for children ...
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Transcript of Invisible Children: Access to oral health care for children ...
Invisible Children:Access to oral health care for children with
developmental disabilities from migrant farm worker families in a Northern California region
Brian Swann, DDSCalifornia Endowment Fellow
Joseph L. Henry Oral Health Fellow in Minority Health Policy
May 18, 2007
2Background• U.S. Surgeon General’s Report on Oral Health (2000)• Children of farm workers experience a rate of tooth
decay 2x the general population of children.• Children with developmental disabilities have
increased risk of – Poor oral hygiene
– Broken teeth
– Filled teeth/extractions
• Untreated dental disease leads to pain, abscesses, decay, infections, malnutrition, death
Source: National Survey of Children with Special Health Care Needs, 2001
California Regions
www.inn-california.com/maps/mapallca.html
4
Background
San Andreas Regional Center• Community-based, private nonprofit corporation for
people with developmental disabilities funded by the state of California
• Four county area- San Benito, Monterey, Santa Clara, Santa Cruz
• Provides diagnostic and prevention services and confidential screening
• Dental referrals• Serves 12,000 clients (adults and children)
5
Objectives
• Gain insight into the oral health care of migrant children with developmental disabilities
• Bring attention to this unreported population
• Identify the barriers that oral health care providers face
6
Definitions
Developmental Disabilities refers to:• A severe and chronic disability that is attributable to a
mental or physical impairment that begins before an individual reaches adulthood
• These disabilities include mental retardation, cerebral palsy, epilepsy, autism and disabling conditions closely related to mental retardation or requiring similar treatment
Source: California Department of Developmental Services
7Definitions
Migrant farm worker refers to:• Hired farm worker• Seasonally changes jobs and seasonal locations• Relocates from country or state• A subpopulation of farm workers
Source: California Research Bureau
8
Methods
• Systematic Literature Review
• Interviews
• Surveys
9
Methods: Literature Review
– Key search words
• Developmental disabilities
• Migrant farmers• Oral health• California• Children
– Resources • PubMed • ERIC• Google• Medline
10Methods: Interviews
– Oral health researchers and specialists• University of California
San Francisco• University of the Pacific
Dental School• Tufts Dental Facilities
Special Needs Program• Children’s Hospital Boston
– Administrators and directors
• Pan American Health Organization
• San Andreas Regional Center
• American Academy of Developmental Medicine and Dentistry
11Methods: Interviews
1) Do you know if the children with developmental disabilities and special needs (CDDSN) you serve are from a migrant farm worker family?
2) Who provides the oral health services to CDDSN in general?
3) Do you have demographic information as it relates to the number of CDDSN of migrant farmers in your region?
4) Do you think it is important to maintain this demographic data on CDDSN?
•Oral health researchers and specialists
12Methods: Interviews
1)Do you know if the children with developmental disabilities and special needs (CDDSN) you serve are from a migrant farm worker family?
2)Who provides the oral health services to CDDSN in general?
3)Do you have demographic information as it relates to the number of CDDSN of migrant farmers in your region?
4)Do you think it is important to maintain this demographic data on CDDSN?
5)How do you establish trust among migrant farm workers who may be undocumented immigrants?
•Administrators and directors
13
Methods: Survey
• Survey– Instrument developed based on
• Literature review• Interviews• Existing surveys
14Methods: Survey
• Identification Process– California Dental Association, Greater Bay Area
Dental Society, References from interviews– Selection Criteria
• Type of facility – Clinics, private practices, hospital-based
• Geographic area – Bay Area, Silicon Valley (sub-region of San Andreas), Central Coast, San Joaquin Valley
• Disciplines – Oral health care providers (generalists, specialists, hygienists) and health administrators
• Survey Distributed to – 22 health administrators– 50 oral health care providers
15Results: Literature Review
• California produces most of the nations fruit and vegetables, wine, and nuts – Strawberries is the largest employer crop– Increased demand for labor– $25 billion agricultural industry
• 2.5 million migrant farm workers in the U.S.– 36% work in California (900,000)
• California farm workers– 4 of 5 workers are males – 29 years median age– 20% under 17 years of age– 80% Latino– 70% are undocumented – 66% children are citizens
16Results: Literature Review
• Oral Health Care Barriers– Major one is cost for the farm worker family
• Farm worker median income for family of 4 = $17,700
• Non-farm worker median California family of 4 = $68,500
– Patients pay out-of-pocket cash for dental services
– 40% uninsured
– 45% of residents are insured (MediCal)
– 38% below poverty level
– 30% not seen by doctor
Source: California Research Bureau
17Results-Literature Review
• Environmental Hazards– Farm work is one of the most hazardous job
• 12 injuries per 100 people annually
• 1/3 injuries are on children
– Exposure to bacteria, viruses, pesticides– Extended work hours– Adverse weather conditions– Repetitive work methods– Family working units
Source: National Survey of Children with Special Health Care Needs
Results: Literature Review
• 2.2% of all California children
• Hispanics/Latinos comprise the second largest group of children with developmental disabilities. (32%)
White
Asian
Polynesian
Other
Black
Filipino
Native American
Hispanic
208,048 California Children with Developmental Disabilities
19Results: Literature Review
• Developmental disabilities California children– 82,001 Female – 39%– 126,047 Male – 61%
• Latino children with developmental disabilities– 22,528 Female - 40% – 33,698 Male – 60% – Underreporting highest in Latino families
Source: National Survey of Children with Health Care Needs
Results: Interviews
Do you know if the children with developmental disabilities and special needs (CDDSN) you serve are from a migrant farm worker family?
No
Who provides the oral health care services to CDDSN in general?
•Private Dental Practices (limited services)
•Community Health Center Clinics
•Hospital Emergency Rooms
•Dental Schools
University of California San Francisco (UCSF)University of the Pacifica Dental School
Results: Interviews
Do you have demographic information as it relates to the number of CDDSN of migrant farmers in your region?
No
Do you think it is important to collect this demographic data on CDDSN?
Yes, it is under consideration to add collection of such data at the time of screening for dental care services
University of California San Francisco (UCSF)University of the Pacifica Dental School
Results: Interviews
Do you know if the children with developmental disabilities and special needs (CDDSN) you serve are from a migrant farm worker family?
No. Question not asked out of respect for patient and family confidentiality.
Who provides the oral health care services to CDDSN in general?
•Private Dental Practices (limited services)
•Community Health Center Clinics
•Hospital Emergency Rooms
•Dental Schools
Administrators and Directors: San Andreas Regional Center
Results: Interviews
Do you have demographic information as it relates to the number of CDDSN of migrant farmers in your region?
No
Do you think it is important to collect this demographic data on CDDSN?
The collection of limited data that is pertinent to health services is collected.
How do you establish trust among migrant farm workers who are undocumented immigrants?
•Culturally sensitive
•Continuity of care
•History of relationship with the community
Administrators and Directors: San Andreas Regional Center
24Results: SurveyOral healthcare providers• 24% response rate to date• Majority identify as private
practices and clinics• 60% currently treating
children with disabilities• 50% have minimal training • 100% have a willingness to
treat
• Barriers– Education – Space– Equipment
• Methods of reimbursement for those seeing children with disabilities– Out of pocket cash payments
(32%)– Private insurance (30%)– Other (DentiCal or free) (38%)
25Conclusions
• Reporting and tracking data for children with developmental disabilities and special needs (CDDSN) are very limited and in most cases, non-existent
• The families of migrant children are the poorest in the state and very vulnerable to causal factors such as environmental hazards
• CDDSN of migrant farmers have limited access to oral healthcare
• More than 60% of migrant children, which includes CDDSN, are eligible for oral, medical, and educational services
• Oral health providers face many barriers that result in limited accessibility to CDDSN
• Greater provider participation may require greater reimbursements
26
Policy Recommendations
• Enhance oral health provider training• Develop comprehensive oral healthcare
models (PAHO)• Direct more funding towards oral healthcare
treatment centers• Identify and track vulnerable populations
with safeguards against deportation• Improve communication between existing
institutions, agencies, and organizations
27
Policy Recommendations
Educate Stakeholders:
To have citizens with developmental disabilities and special needs appropriately recognized as a federally designated medically underserved population.
Source: American Association of Developmental Medicine & Dentistry
28Acknowledgements• Dr. Saskia Estupian-Day, Preceptor, PAHO• Dr. Chester Douglas, Advisor, Harvard School of Dental Medicine • Dr. Joan Reede, Director, Harvard Medical School • DCP Staff • Dr. Paul Glassman, UOP• Dr. Steve Pearlman, AADMD• Dr. John Morgan, Tufts Dental Facilities• Dr. Barry Waldman • San Andreas Regional Center• Dr. Myron Allukian• Drs. Nelson & Ng, Children’s Hospital • Dr. Jane Weintrab, UCSF