Classification Tree Analysis of Factors Associated with Oral Cancer Exam.

Objective: In this study, we performed a classification tree analysis (CTA) to identify population subgroups that are less likely to have an oral cancer examination (OCE). Methods: We conducted telephone surveys (N = 2401) of adults residing in north Florida to collect data on OCE status and potential OCE predictors including demographics, medical and dental experience, and psychosocial factors. The CTA algorithm exhaustive chi-square automatic interaction detector (E- CHAID) was employed to determine the relationships between OCE status and the predictors. Results: The overall OCE rate was 46.8% in our sample. Participants' rating of the dentist was the first level splitting variable, leading to 15 unique participant subgroups: (1) high dentist rating (N = 1269) led to 5 splits and 11 subgroups; (2) low dentist rating (N = 308) led to zero splits; and (3) no regular dentist (N = 824) led to 2 splits and 3 subgroups. Conclusions: The CTA has identified unique population subgroups that could be targeted in future tailored public health interventions. Among underserved populations, it is important to develop and implement community-based interventions that encourage regular dental visits and provide oral cancer self- examination education..

Dental Visits Mediate the Impact of Smoking on Oral Health.

OBJECTIVES: We explored the mediational relationships among smoking, dental visits, and oral health in a longitudinal study. METHODS: We selected a sample of adult residents of rural communities of North Central Florida and followed them for 3 years (final N = 1170). We examined the impact of smoking on oral health across time and conducted mediation analysis to quantify the effect of dental visits on the relationship between smoking and poor oral health. RESULTS: Our results showed that oral health declined across time for smokers but not for nonsmokers. The mediation analysis found that 18.3% of the difference in followup oral health between smokers and non-smokers was explained by smokers not having any dental visits in the last year. CONCLUSIONS: Our findings suggest that, given the low success rate of quitting smoking, promoting dental visits can help limit the negative effects of smoking on oral health. Future community prevention studies could encourage dental visits among smokers and provide educational materials that aim to increase knowledge of oral self-care.

The reliability of psychological instruments in community samples: A cautionary note.

Although researchers norm and validate measures of psychological constructs largely on educated samples, they often use these instruments more broadly, assuming generalizability. We examined whether the assumption of generalizability is warranted. We administered three commonly used psychological measures-the Behavioral Activation/Behavioral Inhibition Scale, the Regulatory Focus Questionnaire, and the Need for Cognition Scale-to a community sample (N = 332) with limited education. For the three instruments, five of seven scales/subscales had unsatisfactory reliabilities. Internal consistency was lowest among participants with less education. The results suggest that instruments normed on educated samples may not generalize to uneducated samples.

The relationships among individual and regional smoking, socioeconomic status, and oral and pharyngeal cancer survival: a mediation analysis.

Poorer survival from oral and pharyngeal cancer (OPC) has been reported for populations of lower socioeconomic status (SES), adjusting for risk factors such as patient and clinical characteristics. Beyond these risk factors, higher rates of tobacco use may be a mediator for the observed poorer OPC survival for low SES populations. In this study, we aimed to examine the impact of the relationships among SES, individual smoking status, and living in a region with a higher smoking rate on OPC survival. We obtained Florida Cancer Data System data from 1996 to 2010 and merged the data with US Census data and Behavioral Risk Factor Surveillance System data from 1996 to 2010. We built multivariable survival models to quantify the mediational effect of individual smoking on overall and OPC-specific survival, adjusting for regional smoking, demographics, and clinical characteristics. We found that lower SES, individual smoking, and living in a region with a higher smoking rate were all strongly associated with poorer survival. We estimated that the indirect effect of individual smoking accounted for a large part (ranged from 13.3% to 30.2%) of the total effect of SES on overall and OPC-specific survival. In conclusion, individual and regional smoking are both significant and independent predictors of poor cancer survival. Higher rate of individual smoking is partially responsible for poorer cancer survival in low SES populations. Results of this study provide rationale for considering a multi-level approach that simultaneously targets both individual and contextual factors for future smoking cessation interventions.

Predicting Scheduling and Attending for an Oral Cancer Examination.

BACKGROUND: Oral and pharyngeal cancer is highly treatable if diagnosed early, yet late diagnosis is commonplace apparently because of delays in undergoing an oral cancer examination. PURPOSE: We explored predictors of scheduling and attending an oral cancer examination among a sample of Black and White men who were at high risk for oral cancer because they smoked. METHODS: During an in-person interview, participants (N = 315) from rural Florida learned about oral and pharyngeal cancer, completed survey measures, and were offered a free examination in the next week. Later, participants received a follow-up phone call to explore why they did or did not attend their examination. RESULTS: Consistent with the notion that scheduling and attending an oral cancer exam represent distinct decisions, we found that the two outcomes had different predictors. Defensive avoidance and exam efficacy predicted scheduling an examination; exam efficacy and having coping resources, time, and transportation predicted attending the examination. Open-ended responses revealed that the dominant reasons participants offered for missing a scheduled examination were conflicting obligations, forgetting, and confusion or misunderstanding about the examination. CONCLUSIONS: The results suggest interventions to increase scheduling and attending an oral cancer examination.

Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change.

OBJECTIVES: After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time. METHODS: We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms. RESULTS: Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men. CONCLUSIONS: We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.

Barriers to Medicaid participation among Florida dentists.

BACKGROUND: Finding dentists who treat Medicaid-enrolled children is a struggle for many parents. The purpose of this study was to identify non-reimbursement factors that influence the decision by dentists about whether or not to participate in the Medicaid program in Florida. METHODS: Data from a mailed survey was analyzed using a logistic regression model to test the association of Medicaid participation with the Perceived Barriers and Social Responsibility variables. RESULTS: General and pediatric dentists (n=882) who identified themselves as either Medicaid (14%) or Non-Medicaid (86%) participants responded. Five items emerged as significant predictors of Medicaid participation, with a final concordance index of 0.905. Two previously unreported barriers to participation in Medicaid emerged: 1) dentists' perception of social stigma from other dentists for participating in Medicaid, and 2) the lack of specialists to whom Medicaid patients can be referred. CONCLUSIONS: This study provides new information about non-reimbursement barriers to Medicaid participation.

Evaluating tablet computers as a survey tool in rural communities.

PURPOSE: Although tablet computers offer advantages in data collection over traditional paper-and-pencil methods, little research has examined whether the 2 formats yield similar responses, especially with underserved populations. We compared the 2 survey formats and tested whether participants' responses to common health questionnaires or perceptions of usability differed by survey format. We also tested whether we could replicate established paper-and-pencil findings via tablet computer. METHODS: We recruited a sample of low-income community members living in the rural southern United States. Participants were 170 residents (black = 49%; white = 36%; other races and missing data = 15%) drawn from 2 counties meeting Florida's state statutory definition of rural with 100 persons or fewer per square mile. We randomly assigned participants to complete scales (Center for Epidemiologic Studies Depression Inventory and Regulatory Focus Questionnaire) along with survey format usability ratings via paper-and-pencil or tablet computer. All participants rated a series of previously validated posters using a tablet computer. Finally, participants completed comparisons of the survey formats and reported survey format preferences. FINDINGS: Participants preferred using the tablet computer and showed no significant differences between formats in mean responses, scale reliabilities, or in participants' usability ratings. CONCLUSIONS: Overall, participants reported similar scales responses and usability ratings between formats. However, participants reported both preferring and enjoying responding via tablet computer more. Collectively, these findings are among the first data to show that tablet computers represent a suitable substitute among an underrepresented rural sample for paper-and-pencil methodology in survey research.

Physical activity behavior, barriers to activity, and opinions about a smartphone-based physical activity intervention among rural residents.

BACKGROUND: Rural Americans engage in less physical activity (PA) and experience higher rates of consequent health problems (i.e., obesity, cardiovascular disease) than urban Americans. Although geographic barriers have historically made this population hard to reach, rural individuals are increasingly gaining access to smartphones. Thus, the purpose of this study was to evaluate PA behavior and barriers to PA among rural residents and to gauge their receptiveness to a smartphone-based PA intervention that is currently in the development stage. MATERIALS AND METHODS: Rural Floridian adults (n=113), 18 years of age and older, completed surveys to assess PA behavior, PA barriers, and opinions about an intervention to increase PA. Specifically, they were asked to imagine a program that would require them to do PA with their mobile phones and whether they viewed intended aspects of the program as helpful. The present work is therefore formative research that sought to determine the feasibility and acceptability of a smartphone-based intervention among rural residents. RESULTS of the survey will inform the development of a tailored, smartphone-based PA intervention. RESULTS: The 37.2% of participants with low PA levels (<600 metabolic equivalent [MET]-min per week) were more likely to report personal and environmental barriers to PA than the 47.8% of participants with moderate PA levels (≥600 MET-min per week). More barriers were reported among participants who self-reported as white and among participants of older age, lower education level, and lower socioeconomic status. Additionally, 75.9% of participants reported features of the intervention as at least somewhat helpful. CONCLUSIONS: The growing ubiquity of smartphones among rural residents, combined with participants' positive response to the program description, supports the acceptability of a smartphone-based PA intervention for rural communities. Given the participants' receptiveness, future research should evaluate the efficacy of smartphone-delivered health behavior interventions among this population.

Perceptions of oral health, preventive care, and care-seeking behaviors among rural adolescents.

BACKGROUND: An asymmetrical oral disease burden is endured by certain population subgroups, particularly children and adolescents. Reducing oral health disparities requires understanding multiple oral health perspectives, including those of adolescents. This qualitative study explores oral health perceptions and dental care behaviors among rural adolescents. METHODS: Semistructured individual interviews with 100 rural, minority, low socioeconomic status adolescents revealed their current perceptions of oral health and dental care access. Respondents age ranged from 12 to 18 years. The sample was 80% black and 52% male. RESULTS: Perceived threat from dental disease was low. Adolescents perceived regular brushing and flossing as superseding the need for preventive care. Esthetic reasons were most often cited as reasons to seek dental care. Difficulties accessing dental care include finances, transportation, fear, issues with Medicaid coverage and parental responsibility. In general, adolescents and their parents are in need of information regarding the importance of preventive dental care. CONCLUSIONS: Findings illuminate barriers to dental care faced by low-income rural adolescents and counter public perceptions of government-sponsored dental care programs as being "free" or without cost. The importance of improved oral health knowledge, better access to care, and school-based dental care is discussed.

Health literacy: a pathway to better oral health.

OBJECTIVES: We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient-dentist communication and dental care patterns. METHODS: We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009-2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799). RESULTS: Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient-dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01). CONCLUSIONS: Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient-dentist communication on oral health status. Improved patient-dentist communication is needed as an initial step in improving the population's oral health.

Comparative effectiveness of instructional methods: oral and pharyngeal cancer examination.

This study compared the effectiveness of different methods of instruction for the oral and pharyngeal cancer examination. A group of thirty sophomore students at the University of Florida College of Dentistry were randomly assigned to three training groups: video instruction, a faculty-led hands-on instruction, or both video and hands-on instruction. The training intervention involved attending two sessions spaced two weeks apart. The first session used a pretest to assess students' baseline didactic knowledge and clinical examination technique. The second session utilized two posttests to assess the comparative effectiveness of the training methods on didactic knowledge and clinical technique. The key findings were that students performed the clinical examination significantly better with the combination of video and faculty-led hands-on instruction (p<0.01). All students improved their clinical exam skills, knowledge, and confidence in performing the oral and pharyngeal cancer examination independent of which training group they were assigned. Utilizing both video and interactive practice promoted greater performance of the clinical technique on the oral and pharyngeal cancer examination.

Demographic and practice characteristics of Medicaid-participating dentists.

OBJECTIVES: The challenges entailed in dental Medicaid programs are well documented. To increase our understanding of Medicaid participation, we surveyed Florida dentists to determine the demographic and practice characteristics of Medicaid-participating dentists. METHODS: Our target population was practicing Florida dentists who treat children, including those who do not currently accept Medicaid as well as those who do. The final sample (n = 882) included (1) pediatric dentists and (2) general dentists who self-reported that they treat children. Participants completed a survey concerning their Medicaid participation. Analyses included survey-sample weighted chi-square tests and multivariable logistic regression. RESULTS: More than two-thirds of the sample dentists are not participating in Medicaid and will not consider doing so. Key findings are that Black dentists across the state and Hispanics in South Florida are more likely to participate in Medicaid than other groups of Florida dentists. Pediatric dentists are more likely to be Medicaid participants than general dentists, but nearly one-fifth of the pediatric dentists might quit participation. Non-Medicaid providers are more likely to report not being busy enough in their practice than Medicaid providers. CONCLUSIONS: If we are to address the shortage of Medicaid dental providers, increasing our understanding of how to capture the excess capacity among general dentists (the reported lack of busyness) in a way acceptable to dentists and to the State of Florida is an important first step. In addition, dental schools should consider implementing a track dedicated to training students for practice success within communities of highest dental need and to seek to increase the number of Black dental students.

A survey of barriers to screening for oral cancer among rural Black Americans.

OBJECTIVE: Research documents a disparity between Black and White Americans in mortality for oral cancer that appears to result in part from behaviors such as lower oral cancer screening among Black Americans. We examined barriers to oral cancer screening among Black Americans. METHODS: We surveyed Black Americans (N = 366) living in rural Florida to identify barriers to getting screened for oral cancer. RESULTS: Low knowledge/social attention, lack of resources, and fear/defensive avoidance predicted screening intentions, with lack of resources emerging as the largest barrier. Participants also reported that a recommendation from their provider was most likely to increase screening intentions, whereas encountering financial barriers was most likely to decrease screening intentions. CONCLUSIONS: Low knowledge/social attention, lack of resources, and fear/defensive avoidance emerged as independent barriers to oral cancer screening, with the latter two barriers accounting for the most variance in intentions to get screened.

The burden of chronic diseases in a rural North Florida sample.

BACKGROUND: The degree of health disparities present in rural communities is of growing concern and is considered "urgent" since rural residents lag behind their urban counterparts in health status. Understanding the prevalence and type of chronic diseases in rural communities is often difficult since Americans living in rural areas are reportedly less likely to have access to quality health care, although there are some exceptions. Data suggest that rural residents are more likely to engage in higher levels of behavioral and health risk-taking than urban residents, and newer evidence suggests that there are differences in health risk behavior within rural subgroups. The objective of this report is to characterize the prevalence of four major and costly chronic diseases (diabetes, cardiovascular disease, cancer, and arthritis) and putative risk factors including depressive symptoms within an understudied rural region of the United States. These four chronic conditions remain among the most common and preventable of health problems across the United States. METHODS: Using survey data (N = 2526), logistic regression models were used to assess the association of the outcome and risk factors adjusting for age, gender, and race. RESULTS: Key findings are (1) Lower financial security was associated with higher prevalence of cardiovascular disease, arthritis, and diabetes, but not cancer. (2) Higher levels of depressive symptoms were associated with higher prevalence of cardiovascular disease, arthritis, and diabetes. (3) Former or current smoking was associated with higher prevalence of cardiovascular disease and cancer. (4) Blacks reported higher prevalence of diabetes than Whites; Black women were more likely to report diabetes than all other groups; prevalence of diabetes was greater among women with lower education than among women with higher education. (5) Overall, the prevalence of diabetes and arthritis was higher than that reported by Florida and national data. CONCLUSIONS: The findings presented in this paper are derived from one of only a few studies examining patterns of chronic disease among residents of both a rural and lower income geographic region. Overall, the prevalence of these conditions compared to the state and nation as a whole is elevated and calls for increased attention and tailored public health interventions.

The decision to counsel adolescents about HPV.

OBJECTIVES: To examine factors influencing dentists' intentions to counsel adolescents. METHODS: Florida dentists (N = 929) responded to 3 descriptions of an office visit by an adolescent patient. In the standard-of-care condition the patient consumed excessive sugar. In the other 2 conditions, a reliable source or patient's mother revealed the patient was sexually active and exposed to HPV. RESULTS: Dentists expressed lower intentions to counsel about HPV than sugar consumption. In the 2 HPV conditions, dentists reported higher intentions to counsel when the mother, rather than another reliable source, disclosed the sexual activity. Perceived social pressure against counseling explained differences between conditions in intention to counsel. CONCLUSIONS: Parent /public approval were primary barriers to HPV-counseling.

Selecting a sample size for studies with repeated measures.

Many researchers favor repeated measures designs because they allow the detection of within-person change over time and typically have higher statistical power than cross-sectional designs. However, the plethora of inputs needed for repeated measures designs can make sample size selection, a critical step in designing a successful study, difficult. Using a dental pain study as a driving example, we provide guidance for selecting an appropriate sample size for testing a time by treatment interaction for studies with repeated measures. We describe how to (1) gather the required inputs for the sample size calculation, (2) choose appropriate software to perform the calculation, and (3) address practical considerations such as missing data, multiple aims, and continuous covariates.