African American adults typically have lower rates of dental service utilization when compared to whites. Disparities between these two populations exist but few studies investigate within group differences.The specific aim of this study was to explore the relationship between health and dental insurance status, as well as age, education level, income, marital status, self-reported health status, and a regular health care provider, on having a dental visit in the year prior to study participation. A retrospective data analysis was performed using responses from 6,420 African American adults who participated in the 2009 and 2010 Medical Expenditure Panel Survey (MEPS). The respective predisposing, enabling, and need (PEN) characteristics used as study variables included: age, education, gender, and marital status; income, health insurance status, dental insurance status, and usual source of care; and health status. The outcome variable examined whether or not the individual had experienced a dental visit within one year of study participation. Logistic regression models indicated. The most significant predictors were income (high vs. low, OR = 2.05), usual source of care (yes vs. no, OR = 1.97), and insurance status (private vs. uninsured, OR = 1.94; public vs. uninsured, OR = 1.80). The significant impact that usual source of care had on dental visits was an unanticipated finding. Because of the significance of this variable, future within-group studies should more closely examine additional variables within the MEPS and other representative datasets.

Data suggests that the use of preventive care services has a profound effect on the quality of life and a reduction of premature mortality [1]. The use of preventive care services are shown to have an effect on quality of life as well as the reduction of premature mortality [1]. While preventive care is often associated with prohibiting the development of certain conditions, it is also an important factor associated with managing existing co-morbid conditions such as cancer, cardiovascular disease, hypertension, and other chronic conditions [1]. The positive effects associated with utilization of preventive care services has increased the need to identify factors which contribute to disparities. Within the United States and the public health arena, this issue has become paramount [2].

The recently enacted Affordable Care Act (ACA) is now poised to profoundly affect health insurance coverage in the U.S. coupling individual health status and access to care. The ACA legislation and practices will change financial approaches to U.S. healthcare operations by increasing the number of individuals with insurance [3]. With ACA implementation, studies that identify significant barriers to preventive healthcare for minority populations, as well as within-group variability in these barriers, are likely to become increasingly important.

Dental care utilization among African Americans is specifically lower than it is for Caucasians or white Americans. Cherry-Peppers., et al. [4] indicated that socioeconomic factors such as decreased income, out-of-pocket expenses, decreased access to care, and decreased dental coverage influence lower utilization rates (138). In addition to socioeconomic factors, predisposing characteristics such as age, race, gender, education, and marital status have also been examined in dental care utilization. With respect to age, Okunseri., et al. [5] found that age was significantly related to whether or not one receives preventive dental procedures. The odds of receiving dental services increases for each additional year of age, therefore, increased age leads to more dental care utilization (274). In regards to gender, studies reporting that females have higher levels of health service utilization than males are found for preventive dental care services as well as other forms of healthcare. Manski and Madger [6] indicated that females report a higher frequency of recent dental visits when compared to males (196). Additionally, married respondents report more visits when compared to widowed or single respondents. The likelihood of having a recent dental visit also shows a commensurate increase as education levels increase indicating a directly proportional effect. Doty and Weech-Maldonado [7] found that having at least a high school education increases the odds of having a dental visit when compared to those who had less than a high school education (524).

Enabling characteristics for this research study were income or socioeconomic status (SES), insurance status, dental insurance, and usual source of care. Borrell., et al. [2] demonstrated that African American participants residing in disadvantaged neighborhoods with low incomes were approximately three times more likely to report having fair/poor oral health when compared to more advantaged neighborhoods with high incomes (363). These findings support an earlier study by Dunlop., et al. [8] which found that socioeconomic status was a factor associated with dental service utilization (231). The differential effect of publicly provided insurance coverage is demonstrated in three studies. Long., et al. [9] reported that patients with medicaid, were slightly more likely to have a dental visit within the past year and were those who were uninsured (52). Medicare has a different effect on utilization. This type of coverage does not typically cover dental preventive services [10]; therefore, private dental insurance is essential in the receipt of these types of services. Okunseri., et al. [5] additionally found that publicly provided health plans do have a positive impact on the number of dental visits (4). For usual source of care, Gilbert., et al. [11] assessed racial differences in predictors of dental care use; African Americans were likely to not regularly attend to dental visits as compared to whites, compared to. These results indicate that whites are more likely to have a usual source of care (1498).

Health status was the need characteristic for this study. Reports generally show that patients with a worse self-reported health status demonstrate lower levels of dental service utilization. Kuthy., et al. found participants with increased medical use had a lower level of dental service utilization (809). Similarly, a study by Chen., et al. found predisposing and need factors, such as the co-morbidity index and other health status measures played a role in dental services utilization (202).

This study utilized an exploratory, non-experimental design, modeled on the Behavioral Model of Access to Care developed by Ronald Anderson & Lu Ann Aday in 1974 to examine the relationship of Predisposing, enabling, and need variables (PEN) with utilization of dental services by adult African American 2009-2010 MEPS participants. This was accomplished by using the PEN characteristics as independent variables and using dental visits as the outcome variable [12-15].

The sample used in this study consisted of a total unweighted number of 6,420 African American adult participants, ages 18 to 90 years. These participants represented a total of 37,129, 963 African American adults.

Data analysis
A frequency distribution was created by running an analysis on each independent variable in conjunction with the dependent variable. This procedure yielded the frequency of “yes” and “no” responses within each PEN variable with respect to dental visits. A chi- square test was then performed to examine the relationship between the independent and dependent variables. After successful completion of exploratory data analysis and chi-square testing, the logistic regression models were developed.

All responses were coded as “yes” if the subject had obtained a dental visit within the specified time frame, or “no” if they had not, resulting in the development of both adjusted and unadjusted models.. The reference groups were as follows: education (high school or less), age (young), gender (males), income (low), insurance coverage (uninsured), dental insurance (no), usual source of care (no), health status (good). Versions of the adjusted model were run removing insignificant variables until only significant variables remained in the data set. During this process, the marital status variable was removed.

Predisposing characteristics
The frequency distribution is depicted in table 1 below. In table 2, the results of the adjusted logistic regression model indicate that for age, using participants in the young age group as the reference (18-24 years), compared to those in the middle age bracket (25-40 years) were more likely to have a dental visit (OR = 0.81, p value = 0.041, 95% CI = 0.670686-0.991305) than older participants (41-65 years) (OR = 0.62, p value = 0.00, 95% CI = 0.504777-0.778652). The lowest odds were observed for the elderly group (> 65 years) (OR = 0.35, p value = 0.00, 95% CI = 0.272655-0.473441 demonstrating that as age increases the odds of having a dental visit decreases slightly.

The impact of education level was also demonstrated in this research. In this analysis, participants with high school or less served as the reference group. Those with college or more education were 1.8 times more likely to have had a dental visit (OR = 1.8, p value = 0.00, 95% CI = 1.576587-2.223026). Gender was also a significant predictor of dental service utilization. Using men as the reference group, women were 1.45 times more likely to have a dental visit (OR = 1.45, p value = 0.00, 95% CI = 1.294882-1.626699). The final predisposing characteristic was marital status, and it was insignificant in the first adjusted model; therefore, it was not included in the final model.

Enabling Characteristics
The results of this study found that as income increases the odds of having a dental visit also increases. When compared to the low income category, those in the middle income demonstrated higher odds of having a dental visit (OR=1.50, p value=0.00, 95% CI = 1.262799-1.801938). Those with high incomes have the greatest odds; they are twice as likely to have a dental visit as those with low incomes (OR = 2.05, p value = 0.00, 95% CI = 1.551795-2.72144).

Privately insured participants have the greatest odds of having a dental visit (OR = 1.94, p value = 0.00, 95% CI = 1.587129-2.390536) when compared to the uninsured.Interestingly, these odds decreased slightly for those with public coverage (OR = 1.80, p value = 0.00, 95% CI = 1.467626-2.226472). With respect to dental coverage, those with insurance were 1.6 times more likely than those without coverage to have had a dental visit (OR = 1.63, p value = 0.00, 95% CI = 1.377751-1.934565). Possessing a usual source of care (USC) was also a significant predictor in this study. Participants with a USC were almost twice as likely to have had a dental visit as those without (OR = 1.97, p value = 0.00, 95% CI = 1.684234-2.314887).

Need Characteristics
Self -reported health status served as the need variable for this study. Although this variable was significant, it did not demonstrate the impact that other variables such as income and usual source of care demonstrated. The analysis indicated that as health status declines, the odds of having a dental visit also declines, (OR = 0.6820975, p value = 0.00, 95% CI = 0.571322-0.814351) for those with fair health, and (OR = 0.54, p value = 0.004, 95% CI = 0.360384-0.822392) for those with poor health.

Limitations and recommendations for future research
This study had two main limitations. The first was that it was limited to two years (2009, 2010) and the second was that the data was derived from participant self-reports, which involve administering a questionnaire to a survey participant and allowing them to select the answer that they feel is the most appropriate.Future within group studies are needed to precisely address factors associated with patient-provider trust as well as equal access to dental care among African American participants of differing socioeconomic and cultural backgrounds. These investigations should address levels of patient provider in light of healthcare disparities and ethical violations historically experienced by African Americans. In addition, perceptions of equal access should also be evaluated with hopes to yield successful outreach efforts and quality dental care within African American communities.

The strongest predictors of dental visits among African Americans are income, usual source of care, health insurance status, and education. The significant results from the income and education variables support current literature. An unexpected result from this research was the significance of usual source of care (USC) among African Americans. With respect to oral care, this suggests that there may be other factors, including comfort with clinicians that may need further investigation among this population.As anticipated; another interesting finding was that general health insurance coverage was a stronger predictor than dental insurance coverage. This result was predicted since the number of individuals who have insurance coverage is higher than those with dental coverage. The significance here suggests that the quality and service among private as well as public health plans has increased significantly in recent years. If that same quality and service could be applied to dental coverage plans, utilization of dental care could possibly increase among African Americans, leading to better oral healthamong minority populations in the United States.