Person:

Isong, Inyang

Background: Significant disparities exist in children’s receipt of preventive dental care (PDC) in the United States. Many of the children at greatest risk of dental disease do not receive timely PDC; when they do receive dental care, it is often more for relief of dental pain. Chelsea is a low-income, diverse Massachusetts community with high rates of untreated childhood caries. There are various dental resources available in Chelsea, yet many children do not access dental care at levels equivalent to their needs. Objective: Using Chelsea as a case-study, to explore factors contributing to forgone PDC (including the age 1 dental visit) in an in-depth way. Methods: We used a qualitative study design that included semi-structured interviews with parents of preschool children residing in Chelsea, and Chelsea-based providers including pediatricians, dentists, a dental hygienist and early childhood care providers. We examined: a) parents’ dental attitudes and oral health cultural beliefs; b) parents’ and providers’ perspectives on facilitators and barriers to PDC, reasons for unmet needs, and proposed solutions to address the problem. We recorded, transcribed and independently coded all interviews. Using rigorous, iterative qualitative data analyses procedures, we identified emergent themes. Results: Factors perceived to facilitate receipt of PDC included Head-Start oral health policies, strong pediatric primary care/dental linkages, community outreach and advertising, and parents’ own oral health experiences. Most parents and providers perceived there to be an adequate number of accessible dental services and resources in Chelsea, including for Medicaid enrollees. However, several barriers impeded children from receiving timely PDC, the most frequently cited being insurance related problems for children and adults. Other barriers included limited dental services for children <2 years, perceived poor quality of some dental practices, lack of emphasis on prevention-based dental care, poor care-coordination, and insufficient culturally-appropriate care. Important family-level barriers included parental oral health literacy, cultural factors, limited English proficiency and competing priorities. Several solutions were proposed to address identified barriers. Conclusion: Even in a community with a considerable number of dental resources, various factors may preclude access to these services by preschool-aged children. Opportunities exist to address modifiable factors through strategic oral health policies, community outreach and improved care coordination between physicians, dentists and early childhood care providers.

This dissertation focused on childhood obesity among preschool aged children in the United States, using data from the Early Childhood Longitudinal Study Birth Cohort. Chapter 1 examined racial/ethnic differences in preschool-aged children’s weight trajectories and identified sensitive periods at which disparities emerge, using mixed growth models and nonparametric LOESS curves. Racial/ethnic disparities in US children’s weight-status and growth trajectories emerge at different ages for different racial groups, but they are generally well established by kindergarten age. Our findings indicate that interventions designed to prevent early childhood overweight/obesity should be implemented early in the life-course. Chapter 2 assessed the contribution of behavioral and environmental risk factors to racial/ethnic disparities in preschool children’s weight status, using decomposition analyses to estimate the percent of disparity explained by individual obesity risk factors. Gaps in the prevalence of socio-economic-status (SES) accounted for a substantial part (ranging from 24.4% to 63.3%) of the explained disparities in BMI z-scores between racial/ethnic minority children and their white peers. Apart from SES and its correlates, infant weight gain during the first 9-months of life, lack of breastfeeding, early introduction of solids, and sugar sweetened beverage consumption were additional factors that played important roles in explaining racial/ethnic differences. Interventions implemented early in the life-course that target these key contributory risk factors could potentially help reduce the magnitude of racial/ethnic disparities in early childhood obesity Chapter 3 examined the effect of attending childcare on children’s BMI z-scores, employing OLS regression, as well as two quasi-experimental approaches designed to minimize the effect of selection bias and unmeasured confounding. In linear regression models, compared to children in parental care, children in non-parental childcare at 24 months had higher BMI z-scores at kindergarten entry. However, both quasi-experimental approaches revealed no significant effect of childcare attendance on children’s BMI z-score, suggesting that the link between non-parental childcare and obesity may not be causal. Previously reported associations may be confounded by unobserved family circumstances resulting in selection into different types of childcare arrangement.