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Dental health services and the aging: a gerontological perspective for social policy

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Dental health services and the aging: a gerontological perspective for social policy

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Content DENTAL HEALTH SERVICES AND THE AGING: A GERONTOLOGICAL PERSPECTIVE FOR SOCIAL POLICY A Dissertation Presented to the Faculty of the School of Social Work University of Southern California In Partial Fulfillment of the Requirements for the Degree Doctor of Social Work by William Charles Albert January 1976 Copyright by WILLIAM CHARLES ALBERT 1976 UMI Number: DP32430 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. DlssaHatioft PobiisWng UMI DP32430 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 This dissertation, w ritte n by WILLIAM CHARL^ ........ under the direction of the C hairm an of the candidate's Guidance Comm ittee, and approved by a ll members o f the Committee, has been presented to and accepted by the F a cu lty of the School of Social W o rk , in p a rtia l fu lfillm e n t of the requirements fo r the degree of D O C T O R O F S O C I A L W O R K M Dean Date. JANUARY 19 7 6 iANCT COMMIT Chairman DEDICATION To Dr. Albert G. Feldman, my faculty advisor, a member of my committee and my friend. PEACE XX ACKNOWLEDGMENTS There are many persons to whom I extend my grati tude. My family has provided assistance and support which exceeded reasonable expectations. My wife, with great tol erance and patience, helped prepare and type several revi sions. My son and daughter cheerfully assumed many respon sibilities which gave us more time to work on what seemed at times like an unending task. The members of my research committee provided sup port and direction essential to the disseration from con ception to final approval. Each in a unique way aided in the development of the project. Most important to me, each gave support in personal and caring ways. The School of Social Work and the Gerontology Center provided an intel lectual community which offered a variety of viewpoints and learning experiences. To faculty, consultants, staff and peers I express my deep appreciation. The National Insti tute of Child Health and Human Development provided finan cial assistance without which my doctoral education would have been impossible. I extend a special note of gratitude to the many dentists who assisted in making this study possible and to the people who so kindly took the time to participate. iii TABLE OF CONTENTS Page DEDICATION ............... ..... ......... ACKNOWLEDGMENTS ........... LIST OF TABLES ................................. Chapter I, INTRODUCTION................... . . . . The Problem Significance of the Problem Plan of the Report II. BACKGROUND OF THE STUDY . . ........... A. Literature Reviewed Psycho-Social Factors Related to the Use of General Health Services Psycho-Social Factors Related to the Use of Dental Health Services B. Some Theoretical Perspectives C. Dental Care of the Aging in the Los Angeles Area D. The Need for a National Policy on the Health Care of the Aging E. Expectations of the Study III. THE RESEARCH DESIGN ............... A. Operationalization of the Major Variables of the Study B. Selection of the Sample C. The Questionnaire D. Plan for Analysis IV. CHARACTERISTICS OF THE SAMPLE ......... 11 iii 12 33 48 IV Chapter Page V. DATA ANALYSIS............... 63 A. Age and Attitudes Toward the Provision of Payment for Dental Health Services B. Age and Attitudes Toward Dental Health as an Area of Social Concern C. Participati on in Pre-Pa Id Plans D. Respondents’ Involvement with Dental Health System E. Esthetic Importance of Dental Care F. Respondents’ Satisfaction with Current Dental Relationship VI. SUMMARY AND IMPLICATIONS . . . . . . . . 126 Implications for Social Policy and Social Work Practice APPENDIX ................... 133 SOURCES CONSULTED ................... . ......... V LIST OF TABLES Table Page 1. Selection of Study Population by Dental Practice, Sex, and age 38 2. Respondents by Age and Sex 49 3. Respondents by Age and Race ...... 52 4. Respondents by Age and Education .... 54 5. Respondents by Age and I n c o m e ......... 55 6. Respondents Status . . , by Age and Insurance 56 7. Respondents Status . . , by Age and Medi-Cal 57 8. Respondents Practice . . by Age and Dental 58 9, Support for More Comprehensive Government Supported Dental Programs ............. 68 10. Age and the Provision of Preventative Dental Health Services by Medi-Cal . . . 70 11. Age by Categories of People for Whom the Government Should Pay for Dental Services................................. 74 12. Preferred Locus of Major Responsibility for Payment for Dental Health Services by Age Group............................ 7 6 13. Preceptions of Dental Services as a Necessary Medi-Cal Program by age Group...................................... 78 14. Age by Responses to the Availability of Dental Programs ............... 81 15. Age by Importance of Choice of Dentist . 83 VI Table Page 16. Age by Attitude Toward Responsibility of Adult Children for Their Needy Parents' Dental Care...................... 84 17. Age by Opinions of Whether or Not Most People Receive Adequate Dental Care . . . 89 18. Age By: Poor People Should Have the Same Access to Dental Care as Rich People ........... 90 19. Age By: Comprehensive Health Care, Including Dental Services, Should be:- Available to Everyone...................... 92 20. Age by the Need for More Comprehensive Dental Programs............................ 94 21. Age by Whether or Not Respondent Agreed That Dentistry is Part of the Medical Profession . ............................. 101 22. Age and Whether or Not Respondents Consider Dental Checkups as Less Important than Medical Checkups...................... 103 23. Age by the Frequency of Following the Dentists' Recommendations ............... 104 24. Age by Number of Dental Visits During 1972 ........................................ 106 25. Age by Dental Expenses Incurred in 1972. . 107 26. Age by Attitudes Toward the Concept That Good Dental Care Can Help Improve Self Confidence........................... Ill 27. Age by Level of Agreement that the Condition of One's Teeth and Mouth are Important to Feelings About Self ..... 112 28. Age by Level of Agreement that one feels After a Certain Age Teeth are Not Important to One's Appearance ,*.*** 114 29. Age by Responses to Item Four: I am Happy With my Relationship With My Dentist . . . 118 Vll Table Page 30. Age by Opinions of Whether or Not Subjects' Dental Fees Are Too High .... 119 31. Age by Opinions Regarding Whether or Not it is Easy to Get an Appointment With Respondents' Own Dentist............... 121 32. Age by Opinions Regarding Whether or Not it is Difficult to Get an Appointment with Most Dentists............. 122 33. Comparison of Age by Preceived Quality of Dental Care Received. ............. 124 Vlll CHAPTER I INTRODUCTION ' THE PROBLEM i The variable of age as it relates to alternatives I for the financing of dental health services and to the I level of awareness of the importance of adequate dental I . 1 health care has been relatively unstudied. The purpose : of this research is to examine the views of young, middle- aged and older adults for similarities and differences ! between and within the age groups toward governmental i ; assistance in the provision of dental health services and itoward the need for comprehensive dental care. There is reason to believe that some areas which are viewed by the health practitioner as central to the individual's well-being are in fact perceived by the latter as peripheral so that awareness of these problems may be low or non-existent. Salience of attitudes is particularly important in the areas of preventative health because of the general absence of overt symptoms and the presumed need for taking action before such symptoms appear. An example of I a health area which seems to be of low salience to major segments of the population is dental health. ' The only health service older people utilize less ithan the young is dental care. Individuals 65 and over 1 J. T. Shuvall, "Methods of Assessing Public Attitudes' ! to Health", The International Journal of Orthodontistry, ^ (March, 1967), p. 63. 2 visit dentists only half as many times per year as younger 'people. Many older people feel that, once their teeth have been extracted and they have been fitted with dentures, the necessity for visiting a dentist ceases. This is, of Îcourse, not the case. Dentures need to be checked period- i ically for proper fit. Structural changes of the mouth occur after teeth are extracted and tissue shrinks as one I ages. As a result of their failure to visit dentists jregularly, many older people suffer annoying denture prob- 'lems which could be ameliorated with proper treatment.^ I To insure the provision of truly comprehensive health services to the elderly, dental care must be included in future programs. Under present Medicare and Medicaid provisions, dental services tend to be limited to acute and emergent care. Medicare provides for dental ‘services only with respect to "(A) surgery related to the jaw or (B) the reduction of any fracture of the jaw or any facial bone.' Specific exclusions include expenses for "services in connection with the care, treatment, I I filling, removal, or replacement of teeth or structures directly supporting teeth.Medicaid programs vary 2 Herman Loether, Problems of Aging (Belmont, Ca.: ! Dickinson, 1967) p. 29-30. j ^Title XVIII of the Social Security Act in Compilation I of the Social Security Laws, Vol. I, (Washington, D. C .: 'U.S. Government Printing Office, 1968), p. 317. "^Ibid, p. 323. 3 according to State plans. They usually permit caries to be filled and the pulling of teeth. Replacement with den- ; tures is often limited to those individuals who can be employed and for whom dentures are justified as a step toward self-sufficiency. What dental services should be provided for the elderly and medically indigent? How should those services be financed? What should be done to inform those indi viduals who can afford more comprehensive health services but to whom dental care is a peripherial health concern? Obviously, to answer the above questions, we need to know considerably more about the dental needs of adults, why they do or do not choose to seek out comprehensive dental services and what attitudes they have regarding how dental health services should be financed. Two other major ques tions need to be asked; First, are there significant differences on the level of use of dental health services between various adult age groups, and if there are, to what might these differences be attributed. Secondly, are there significant differences between these age groups in their attitudes regarding the roles of private dental insurance and/or state or federal programs to help meet the dental expenses of individuals. This explor atory study is an attempt to examine these and other related questions. The subjects for the study were 4 ; selected from five dental practices in the Los Angeles area which were chosen becàuse their patients represent the ethnicity and income levels of the Los Angeles metro politan area as indicated in 1970 census tract data. SIGNIFICANCE OF THE PROBLEM Among those who agree that the dental needs of the elderly and the medically indigent are not being adequately met are Drs. Arthur Rudd and Larry Schwartz, dentists in Spokane, Washington. They report that large segments of our population give low priority to dental care. They expressed special concern for the elderly patients in nursing homes and on the geriatric wards of our mental hospitals. Many of these elderly patients are either in need of dentures or have ill-fitting dentures. Many have nutritional problems which could be related to unmet dental needs.^ Dr. John Ingle, former Dean of the Dental School, ' University of Southern California and Dr. Bernard Levin, a faculty member with special interests in gerodontology (i.e., geriatric dentistry) concurred with Drs. Rudd and Schwartz and added that the lack of portable dental ^The Author served as a consultant to Drs. Rudd and Schwartz in Spokane, Washington in November of 1970. They have provided continuing assistance and information to the Author. 5 facilities add to the seriousness of the problem. It is possible to provide more comprehensive dental services to institutionalized patients with mobile dental practices and there is a growing interest in this area. Unfortu nately, for now, these services are generally not avail able. Such practices are expensive to operate and the travel time is often considered inconvenient. The result is that patients who cannot get out, often receive inade quate dental care. The difficulties are further compli cated by the fact that Medi-Cal generally limits dental services to acute and emergent care with little concern for preventative services.^ There is little information about the dental health of the elderly and about the quality of dental care they receive. There has been little solid research com pleted regarding the provision of dental health services for the aging. The related inadequacies of our level of knowledge seem appreciated by social workers, dentists, and others interested in gerontology. The development of policies and programs to improve the delivery of dental health services requires a better understanding of the needs and desires of the population to be served. If one considers the fact that one-third of those persons over age 65 live on incomes below the poverty ^Drs. Ingle and Levin were interviewed on several occasions in April and May, 1972. Dr. Levin continued to provide advice and information through December, 197 2. 6 level (and many more live close to that arbitrary line of demarcation), the following statement from the Encyclo- I Ipedia of Social Work has special relevance : The poor receive less dental care, they have more ' serious dental diseases, and they have less access to I dental services than other groups. Because dental j care resources and manpower are even more limited than I in the medical field, adequate dental care would also I require a reallocation of resources, reassignment of i responsibilities, new kinds of sub-professional I workers, different mechanisms of payment, and so I forth.7 I This study will shed light on the following; (1) attitudes toward alternative proposals for improving the dental health care delivery systems (2) the order of importance of psycho-social factors related to the level of use of dental health services. Perhaps most significantly, this study can be a beginning .step in the development of improved dental health care delivery systems. Changes in the delivery of services 'should have the support of those who will be affected by 'the changes. This study will provide some data, from a I limited sample, regarding factors relating to support or ; non-support of specific alternatives and social policies to present dental health care delivery systems. ' Social policy refers to a society's system of t I interrelated, yet not necessarily logically consistent, I principles and courses of action which determine the I , i Encyclopedia of Social Work, 1971 ed., s.v. "Health 'As a Social Problem; Illness and Poverty," by George Isilver. 7 nature of intrasocietal relationships among individuals, social units and society as a whole. Social policies regulate the development, allocation, and distribution of statuses and roles and their accompanying constraints, prerogatives, entitlements and rewards among individuals and social units within a society.^ As we develop social policy and programs for comprehensive health care, it is important that we consider the interrelationships of our social policy and the needs and attitudes of the popu lations to be served. Our modernized society has helped produce a health technology which has reduced mortality and has contributed to the general aging of our popu lation. The effects of societal modernization have resulted in social policies and programs which affect the values, attitudes and life sytles of our aging citizens. We have provided Social Security programs to ease the burden of retirement of our elderly, public assistance programs to assist the financially indigent, and Medicare and Medicaid to help meet the rising costs of medical care. For those dependent upon these programs we have not done enough. To meet the needs of our technologically advanced society we have encouraged and enforced retire ment, stripping people of one of their most vital social ^David Gil, "A Systematic Approach to Social Policy Analysis," Social Service Review, Vol. 44, No. 4 (December, 1970) pp. 411-426. 8 roles and substituted income maintenance and health care programs which often result in severe financial hardships. We modified our social policy to include specific types of medical care, but tended to exclude dental health I services. We have been slow and faltering in adopting I our social policy and institutions to the demographic I ! phenomena of our aging population. Many of our early i I fumbling attempts have been compromises between the I interests of youth-oriented society and the needs of old people themselves. The results have been injurious to the I dignity and status of the elderly.^ : During the Ninety-Third session of Congress (1972- i >1973) several bills were introduced to expand health care services. The phrase "comprehensive health care" is now part of the vernacular. If this is indeed the time for I comprehensive health services, let us be cognizant of the needs and desires of the population. Are different age cohorts interested in the same types of health care services and programs? Is the inclusion of dental health : services a salient issue? Should the dental health services include preventative care, or should they be 'limited to acute and emergent care? How should the costs of the programs be met? I ^Donald Cowgill, "The Aging of Populations and Societies," The Annals of the American Academy of Political and Social Sciences, (September, 1974), pp. 1-18. i 9 I I This research explores these and other questions in I ;an attempt to determine the attitudes and interests of some jof the people who would be affected by the development of social policy which would entitle people to comprehensive health care. This particular study is concerned with the salience of dental health care as a part of any program |designed to provide comprehensive health services, This research is relevant to the profession of social work for both practitioners and those involved in forming social policy and developing programs. In terms of social planning and programming for comprehensive health care, knowledge about the parameters of the needs and attitudes of the population to be served are useful and important. At the individual level, concepts of loss, restitution, and self-image are salient. The practitioner can better serve his clients if he is made aware of their specific needs and attitudes (in the case of this study, those related to the provision of dental health services) and if he is aware of public policy and programs affecting his clients. I I PLAN OF THE REPORT I I i This introduction will be followed with a discussion bf the background of the study. The relevant literature reviewed for the study will be presented and we will examine some theoretical perspectives related to an aging popu- 10 lation and their need for dental health services. Chapter i iII will conclude with a discussion of the expectations of the study. , The research design will be presented in Chapter I : III. We will discuss the operationalization of the major I variables in the study, the selection of the sample and the development of the questionnaire. The plan for the ; analysis of the data will also be presented. ; Chapter IV will examine the characteristics of the sample. Specific characteristics of the respondents :will be discussed. Available information about the non- (respondents will be included in the discussion. The data analysis presented in Chapter V will examine relationships between (1) age and attitudes toward the provision of payment for dental health services and (2) age and attitudes toward dental health as an area of social concern. We will look at the respondents' partic ipation in prepaid dental health plans and their involve- 'ment with the dental health system. The respondents' attitudes regarding the esthetic importance of dental care j and their satisfaction with their current dental relation- 'ships are the final areas of consideration in the analysis i 'of the data. i Finally, Chapter VI will present a summary of the I findings, a discussion of the implications for social 11 policy and social work practice, and a discussion of the limitations of the study. CHAPTER II BACKGROUND OF THE STUDY ' This chapter will present a discussion of the relevant literature reviewed for this study. We will : follow the literature review with an examination of some I theoretical perspectives which are related to our aging I ! population, their interest in and their need for compre- Ihensive dental health services. The chapter will conclude with a discussion of the expectations of the study, j There is an increasing awareness of the importance of making comprehensive health services available to all I segments of the population. There is widespread accep tance of the social welfare value of health as something which all members of society should be able to enjoy. To improve health service delivery systems, we need to know: (1) what services are perceived as needed by pro spective patient groups; (2) how these improved delivery systems might be financed; and (3) what variables affect the level of utilization of services. A. LITERATURE REVIEWED The studies reviewed tend to focus on the aged... those sixty-five (sometimes sixty) and over. These 12 i 13 I ' studies do not compare different age groups and therefore I overlook possible age-cohort effects which can be crucial i # , in social planning. I i While information about the provision and utili- I zation of health services tends to be available, there is, > comparatively an absence of information specifically re lated to the utilization and provision of dental health services. Because of this lack of information, it was I ' assumed that the variables and attitudes which have been I ' found to be related to health care would also be related I to dental health care. Selected studies were reviewed to 1 ,provide guidelines and structure for this study. Many of I the studies reviewed were concerned with medical rather than dental care, but many of their findings may hold as ! well for the utilization of dental services. PSYCHO-SOCIAL FACTORS RELATED TO THE USE OF GENERAL HEALTH SERVICES Walsma studied attitudes and knowledge of the I aged regarding old age insurance (OASDHI) and old age I assistance (OAA). His questions relating to medical care ; showed that, j Respondents strongly agreed that it was an appro^^ I priate function of the federal government to help I retired people with their medical expenses under the I social security program...No one mentioned that medi cal care was a governmental responsibility, or that i they had a fundamental right to medical care. Instead, 14 the attitudes expressed indicated that Medicare wag a good idea and that it was something they needed. Walsma found that it was not necessary to raise questions about state responsibility or right to health care since respondents who were recipients all agreed that this is a needed and necessary program for the aged, Cal- Iifornia (where his study was conducted) has had a State- , Federal medical plan in operation since 19 57 and many - respondents had had considerable experience with this I (program. j Taubenhaus and McCormick studied the use of health services of 604 people over sixty-five in a suburban town. ,Differential use of outpatient physician services was found related to the following variables: age, sex, ; living arrangements, religion, education, country of birth, income, and the presence or absence of health insurance and social security benefits. Persons over eighty were most likely to have and use a personal physician. The ,association between possession of health insurance and use of a personal physician was not statistically significant. i I Whether or not social security was one's source of income had no influence on having or using a physician.^ : 1 I John P. Walsma, "Attitudes and Knowledge of the Aged ! Regarding Old Age Insurance and Old Age Assistance" I(Unpublished DSW. dissertation. University of Southern I California, 1970), p. 93. 2 ! L. J, Taubenhaus and J. G. McCormick, "The Use of I Physician Services by the Aging," Geriatrics, (1963) I 18:122. i 1 5 j Larson and Hay found that determining factors in the use of health services included income, age,.-socio- economic status, education, social participation, and residence (rural versus urban).^ ! Kutner, et al, interviewed 500 persons over age sixty in the Kips Bay section of New York City. An attempt was made to evaluate the health status of the subjects. It iwas shown that while health status is an important factor I 'associated with the use of health services, there are other factors of equal or greater importance, some of which may I cancel out the effect of health status. These are age, sex, socio-economic status, marital status, social iso lation, predisposing beliefs and attitudes toward medical facilities, self-image, age conservatism, and neuroticism.^ j These studies consistently reflect the possible influences age,:sex, education and income may have on the psycho-social factors related to the use of general health services. For the purpose of this study these variables jwill be assumed at least equally significant as they relate 'to attitudes toward dental health services. The presence j ' jor absence of private dental insurance or Medi-Cal will lalso be given consideration as possibly significant (variables. j i ^0. F. Larson and D. G, Hay,"Differential Use of Health iResources by Rural People," N.Y. State J. Med.,(1952)52:43. ^B. Kutner, et al. Five Hundred Over 60 (New York : Russel Sage Foundation, 1956) 133-159. r 16 I PSYCHO-SOCIAL FACTORS RELATED TO I THE USE OF DENTAL HEALTH SERVICES with regard to dental diseases and dental services, it is well known that dental caries are so prevalent that i they are hardly regarded as a disability. Nutritional I problems and gastrointestinal disfunctions may be correlated With the condition of the mouth and teeth and mastication. Public concern with dental health and dental care appears |to be relatively late in the evolution of comprehensive personal health services. Dentistry was regarded more a j mechanical than a healing art until it was shown that there was a relationship between caries and bacteria at the turn 5 ;of the century. Further, dental conditions ...caries, missing teeth, gum diseases... appear to have a very dra matic and direct relationship to the usual economic and other indicies of social class. It is usually found that higher socio-economic classes use more physical health services than lower socio-economic classes, but in the case ■of dental care, the difference is especially marked. Close to ninety per cent in the lowest income group had not seen a dentist. Other findings are also of interest: (1) in 1965, according to the U. S. Public Health I Services, eighteen percent of the adults in the United States had none of their natural teeth and; ^O. W. Anderson, "The Social and Medical Matrix of 'Health and Well Being," International J. of Orthodontistry, I(March, 1967) 54-59. ; 17 I I (2) ninety per cent of the general public say they j believe they should see the dentist at least once : per year, and yet only one-third do.^ 'Perhaps the public would place greater salience on dental I health services if they were motivated by a sense of esthet lies and good grooming as well as by health standards. ' Loether found that old people are frequently in Ineed of dentures, but because of limited finances, ignor- lance or fear, they may patronize a quack or order by mail I rather than consult a regular dentist. They often end up 'with inferior, poorly fitting appliances, often at higher I prices. Loether went on to cite a 1961 study of the Amer ican Dental Association which found that 78.3 per cent of IAmericans over age sixty wear dentures or bridges. The 'tragic fact is that persons not properly cared for suffer a needless amount of discomfort and even pain, often suffer injury to gums and surrounding tissue and, in the end, save no money because professional care is necessary to restore oral health and to then fit these individuals properly with -dentures.^ ! ! B. SOME THEORETICAL PERSPECTIVES I Each of us wishes to maintain his physical health I and a psychological sense of well-being. Knowing that j quality health care services will be available if needed ; eases our concerns. The availability of comprehensive and 6Ibid. ! 7 L . .Herman_Leo.ther_,_ .op.,_c i t_,_,__8 2_.__________________________ I {Continuous services becomes more important as the frequency and seriousness of our health problems increase and our in comes prove less adequate. Provisions for comprehensive |health services can be reassuring to those of us who recog- jnize that we may become more physically and financially dependent upon society in our advancing years. ' Dental health services are an integral part of the {health care delivery system. I The mouth is an integral part of the body entity, and any disorder in it may be correlated with a dis order in another part of the body or mind. The oral disorder may be the cause or effect of the systemic ; disorder or both may be related to another bodily aberration --- There is no comprehensive health service unless it includes oral health.& It is inconceivable that one would maintain a sense of physical health and well-being when needed dental care is unavailable. Many nonspecific symptoms seen in the elderly, such as mental confusion, loss of appetite, malaise, and listlessness, may possibly be due to malnu trition. ^ Reviews by Cooke and Stahl have pointed out interrelationships between nutrition and the condition of the oral cavity.The condition of one's oral cavity I ^A. Elfenbaum, "The Burning Tongue In An Elderly Patient - A Case HistoryV" J. of Am. Soc. for Geriatric Dent.(October 1973). I ^A. E. Bender, "Nutrition of the Elderly," Royal [ Society of Health Journal (1971) 91:115.121. ! ^^Brian Ernest Duddly Cooke, "Oral Problems in the jEdlerly," Gerontologia Clinica (Basel) (1971) 13:359.67 land S. S. Stahl, "Nutritional Influences on Peridontal Disease," World Review of Nutrition and Dietetics (1971) 111 : 27_7_..97_________________________________________________________ ! 19 1 •affects the pleasure or displeasure experienced when I |eating, the efficiency of mastication, and the initiation of the digestive process. The condition of the oral cavity has been con sidered as a major factor in the poor eating habits of many I aging persons. By age sixty, about forty-five percent of the people in the United States have lost their teeth. While satisfactory dentition may not be necessary for maintaining a good nutritional status, Elfenbaum has {emphasized that the primary purpose of dentures is as an Lid in enjoying food. For many of us, our eating habits 'provide a setting for the enhancement of interpersonal Irelationships. We eat many of our meals with others, offer our guests food and drink. Serious dental problems can jContribute to feelings of discomfort and embarrassment.^^ Aging is not merely a physical process. The over all aspect of the aging process appears to be loss function, deterioration of organs and tissues, and progressive degen eration. Closely related to biological aging are parallel ^concepts of psychological and social age. Birren states ithat, ; Psychological age refers to the adaptive capacities [ of individuals as observed from their behavior, but it may also refer to subjective reactions or self-aware- I ness. Psychological age is related both to chrono- ^^Stahl, op. cit. ! 1 2 A. Elfenbaum, Personal communication, December 1974. 20 logical and to biological age, but it is not fully described by their combination. Social age refers to the social habits and roles of the individual relative to the expectations of his group and society. Again, an individual's social age is related to but not completely defined by, his chronological, biological, and psychological age. Age is an important factor in determining how individuals behave in relation to one another, and within societies there are often elaborate age-status systems. The age grading of expected behavior is a long-evolving i process in society, and it is only partly related to * the biological and psychological characteristics of ! individuals at a given age. I I j The complexity of the variety of interrelationships ! 'between biological, psychological and social aspects of I jaging, compounded by individual differences and societal jnorms, raises question about the validity of attempting to rely on a single theory of aging. The state of knowledge rests on several attempts to develop useful theories of aging ; two of which received considerable attention are disengagement theory and activity theory. As one shifts through these and other efforts to build a theory of aging, some concepts and constructs stand out in their signif icance to this study. 1 The concepts of continuity and change and their meaning to the individual are examples. The extraction of I teeth may symbolize "growing old" to the individual. The i 'individual may purchase dentures in an attempt to maintain I a sense of continuity, to partially compensate for the i I sense of loss. ' James E. Birren, The Psychology of Aging (Englewood Cliff, N.J.: Prentice-Hall, Inc., 1964) p. 10. I i • 21 i j Whether disengagement is inevitable, desirable, and ■universal, and whether it is a process in which the indi- 'vidual and society disengage from one another by mutual 'consent, have been subject to much debate. Activity theory 1 counters disengagement theory and holds that the healthier I I aging person is the active aging person. Again, there I has been considerable debate. Many authors (Neugarten, I 197 0) have taken the position that personality character- 1istics will predetermine whether, and to what extent, one will disengage or remain active. Through all of the argu ments, the meaning of continuity and change remain impor tant. As the individual ages, he experiences losses with- 'in the personal system and within the social system. People lose physical strength. Family structure changes. 'Retirement, often involuntary, results in loss of job and income. Old age is often accompanied by the loss of other roles and by the loss of status. And people lose their teeth. Theory building in the field of aging will be enhanced by an emphasis on continuity and change, loss and I restitution. Continuity (or at least a sense of conti- I nuity) between life stages is a necessary part of healthy I aging. Drastic and frequent changes threaten continuity, I I and the individual will attempt to avoid or compensate for I : changes as they occur. When change is related to loss, restitution will be attempted. As one approaches old age. 22 I restitution becomes more difficult. For example, a person I who loses his or her job at age thirty will tend to find re-employment less difficult than a person at age fifty, , who in turn, will experience much less difficulty than a I j person over age sixty-five. A person who loses his teeth j ! can maintain some continuity with his self-image and compensate for the loss with dentures; unless he cannot ! afford them, or cannot accept them for attitudinal reasons, ' or is ill-fitted and does not receive proper care. As a matter of fact, the loss of teeth is often not necessary. : Teeth may be extracted because it is less expensive than restorative work or because programs such as Medicare provide limited services. So, for many, lost teeth are not replaced. Furthermore, the level of use of dental : health services may be related to patterns established earlier in life. If a social worker is involved, he might ask what this means to one's self-image and what impact it might have on one's social functioning. C. DENTAL CARE OF THE AGING IN THE LOS ANGELES AREA An interview was held with Dr. Donald McQueen, a Los Angeles dentist, who treats retirees covered by Kaiser insurance. His remarks are of interest to the general problems of this study. Dr. McQueen said failure to meet the dental needs of the elderly is just one example of our I ^ 23 I I society's lack of demonstrated love and kindness for the I elderly. "The elderly want a sense of being something, i and we fall down because we don't show them we care." He J added that he knew of no research that indicated the scope ! of problem (dental needs of the elderly). He said, "The whole issue is too emotionally charged." Dr. Max Schoen has provided considerable infor mation regarding the distribution of dental services in the Los Angeles County area. For example, in Pasadena, i there is a ratio of 131 dentists per 100,000 persons, ! almost 10 times that of 14 dentists per 100,000 in South i Los Angeles. Pasadena has 25 specialists of all types; I South Los Angeles has none, and East Los Angeles has 4 I (all oral surgeons). These latter two areas (and two ; others without specialists) are predominantly black or brown. Out of twenty five health districts, these areas ranked nineteenth, twentieth, twenty-fourth, and twenty- fifth by dentist-population ratios. These same ghetto i areas ranked first, second, fourth, and eighth in per cent ; of families earning less than three thousand dollars per year, and first, second, fifth, and seventh in per cent ' of labor force unemployed. There can be little doubt I about the level of dental care available to the people i living in these areas. Also consider the difficulties I the elderly have in leaving their section of town to secure t dental (or other) services. I 24 } Dr. Schoen has particular concerns about the j impact of Medicaid. "Where Medicaid programs use a fee 1 ■schedule, the structure is such as to favor mutilation of I a mouth and to discourage completion of initial restorative , care and regular maintenance care. He contends that I I Medicaid procedure is obnoxious to both patient and den- ! tist. Delays of at least a month always occur, and the J j efficient, orderly progress of care is interrupted. To ! combat some of these problems, Schoen developed a group ' practice which serves the poor in the neighborhood. Rather i I than a fee-for-service schedule, Medi-Cal makes a monthly per family payment for those being served. Prior author- ' ization for services is not required. During the clinic's : first four months, seventy two per cent of all the target ; population^^^ were seen. The value of services performed < was about fifteen thousand dollars...more than three times the premium earned. Fifty one per cent of those seen and ; thirty six per cent of all individuals over two years of i age had been completed and put on recall. In two years, I I 1967 and 1968, over one hundred thousand dollars of dental J services were provided to Medi-Cal patients. Services i included bridges, crowns, and bridge restorations.^^ Types I ' ^^Max Schoen, "Group Practice and Poor Communities," ; American J. of Public Health, (June, 1970) 1125-1132. I ^^^Target population was defined as those individuals I three years of age and older who lived in households ' delineated as eligible for Medi-Cal. : . 1126._______________________ ! ! of care provided are at or above the level of services : covered by Medi-Cal. Even though crowns and bridges are generally an exclusion and endodontics and periodontics : are restricted, more of these services will be provided I I than under Medi-Cal. When damages are repaired and 1 services reach a level of maintenance and prevention, I ! group practices can operate profitably on an other than : fee-for-service basis. i It is Dr. Schoen's opinion that: 1 A radical overhaul of our entire non-system of I health care is required. Such a change must include, I but not be limited to, a national health insurance ; system supported by both general and social security ! tax dollars. A reorientation of our national prior ities from war and space to our people's needs must ! be involved.17 I It will be of value to examine the attitudes of recipient : groups about such proposed changes. Often the older patient feels that no one can help him and therefore I nothing matters, not even getting his teeth fixed.If comprehensive and coordinated health care programs were I developed to remove financial barriers and make the ser- t , vice delivery system accessible, perhaps the elderly could i realistically adopt a more positive outlook. l^Ibid., 1129. ^^Ibid., 1128. ] ®S. F. Dworkin, "Psychological Aspects of Aging- 1 Implications for Dentistry," Dental Assistant, (November, , 1970) 24. 26 D. THE NEED FOR A NATIONAL POLICY ON THE HEALTH CARE OF THE AGING ! Chronic illnesses are prevalent among the aged, and I the incidence increases steadily with age. In young adult- i I hood, this is, up to 45 years of age, 45.3 per cent of per- ! sons have one or more chronic conditions. These conditions ! produce limitations of activity in 7.4 per cent. Between I the ages of 45 and 64, chronic conditions are present in ; 61.3 per cent and limitations of activity in 18.3 per cent. ! For those 65 and over, chronic disorders affect 78.7 per cent, and disability to 45.1 per cent. From a medical iand social viewpoint chronic disease and disability in- , crease with age and require specialized medical procedures and social assistance. ' McKinney and De Vyver report. It appears that for a number of years a majority of persons aged sixty-five or over has favored a government insurance plan for paying doctor and hos pital bills. A survey in 1957 indicated that fifty four per cent were in favor of a government plan for health protection.21 The proceedings of the 1971 White House Conference On Aging note that attention is now being focused on the adoption of a comprehensive national health plan. The i I l^John C. McKinney and Rank T. De Vyver, editors, [ Aging and Social Policy (New York: Appleton, Century- jcrofts, 1966), 263. ; ^°Ibid., 271. ' 21 ^■^Ibid. ! 27 I ! Co-Chairman of the section on Physical and Mental Health I noted that, ...while many health services are provided to the ; older segment of the population, obvious gaps and deficiencies exist. The identification of these gaps i and inconsistencies will be a major concern (of the section). It should be recognized that a coordinated I system of comprehensive health services is the ob jective, not independent and fragmented services with out provision for continuity of c a r e . 22 That the lack of provisions for dental health ; services may be one of the gaps seems obvious from the failure of the Final Report of the Conference to mention dental health services. That this ommission was not intended can be implied from the participation of the Chairman of the Department of Gerodontology, University of Oregon Dental School, Portland, Oregon, on the technical ^ committee for Physical and Mental Health. The American Dental Association has stated that dental care should be included as an essential health ! service in an H.M.O. (Health Maintenance Organization). The American Dental Association further recommends that a I I I dental health education program with emphasis on prevention I 'should be provided to all enrolled in an H.M.O. p r o g r a m . 23 ' Toward A National Policy On Aging Proceedings of ! the 1971 White House Conference on Aging, by Arthur S. ;Felming, Chairman (Washington, D. C .: Government Printing j Office, November 28 - December 2, 1971), Vol. II, p. 20. ^^Council on Dental Care Programs, "New Policies on Dental Care Programs," JADA, Vol. 86 (January, 1973) 177- : 178. 28 The relationship between age and chronic disorders is one of limited remissions and progressive decline. A national policy and a commitment to provide dental health programs with an emphasis on preventative as well as ameliorative services should lead to self-enhancement and improved functioning of the elderly. Dental problems may be related to the health and nutritional problems of the elderly and in the least may exacerbate other medical disorders. E. EXPECTATIONS OF THE STUDY ’ A purpose of this study is to explore some opinions i and attitudes of three cohort^^ groups and to examine the implications. If a cohort effect exists in relation to attitudes regarding increasing governmental involvement I in the provision of dental health services and/or in the utilization of dental health services, it may be an impor- 24 "An age cohort is a group of people who were born in the same period of historical time and who therefore are of approximately the same chronological age. The term "cohort effect" is used to describe the impact a particu lar historical event has on a group of individuals...Note that members of the same cohort are similar with respect to the two dimensions of time and events we have just discussed; being of the same age. They have experienced roughly the same developmental events, and they have lived through the same historical events. One would expect, therefore, that members of the same cohort would be sim ilar to each other in many aspects of behavior and in some respects different from members of other cohorts." iVern L. Bengston, The Social Psychology of Aging, (New I York : Bobbs-Merrill Company, Inc., 1973) 10-11. i I tant consideration in the formulation of social policy and I program development. Programs offering services large seg- I ments of eligibles will not use could possibly be avoided, i j as could unnecessary lag in program changes as different * cohorts become concerned. Programs could be better de signed to serve the varying needs of different cohorts. I An overall working hypothesis of the study is that : attitudes regarding the provision of dental health services I and the level of use of dental health care resources are I associated with a broad spectrum of psycho-social factors. ; In order of expected importance, these psycho-social fac- : tors are : age, income, sex, the presence or absence of 'dental insurance, and education. Each of these items were treated as antecedent and consequent variables in the : study. The major expectations of the study included : (1) It was expected that the oldest age group would show the lowest use of dental services and the most support for governmental programs to provide ; increased services. The elderly's low use of dental ^ health services is well established. Their assumed I support for private or public dental insurance is based I on the high cost of dental care and the low incomes of i I many elderly people. The elderly will support programs I which provide services they need but cannot afford. 30 (2) It was further expected that the youngest group would generally favor new methods of providing services while the middle group was not expected to support changes in the dental health services delivery system. The youngest group is more likely to have comparatively low incomes and children who require extensive dental care. C3) The middle group was expected to view programs more unfavorably because many of them are more able to pay for services, their children tend to be out of the home, and their higher incomes will cause them to assume they will be required to pay a disproportionate share of the costs of dental insurance programs. This will be especially true of governmental programs. Obviously, age and socio-economic factors are closely related. C4) It was expected that those with higher incomes would place more salience on dental health care than those with lower incomes. More of those who have den tal insurance were also expected to be in the higher income groups. (5) It was expected that those who have dental insurance would be more likely to support changes in the service delivery system. The support for govern mental provision of services was not expected to be as strong as the support for private insurance. This 31 opinion was based on the author's reading of the pub lic's present attitude toward the role of state and federal government in social welfare programs. (6) Women are often credited with holding more liberal views then men, especially in areas of social concern. Traditionally, women might be expected for cosmetic reasons to show a higher level of use of services than men. While the author might have expect ed these findings two or more decades ago, it was expected that there would be more agreement than dis agreement between men and women. C7) Individuals with higher levels of education were expected to show greater support for changes in the service delivery system as well as a higher use of services. It was assumed that those with higher levels of education would be more aware of the inadequacies of the current dental health delivery system and the importance of maintenance and preventative dental health care. Other reasons for their support overlap with variables already mentioned. Individuals with higher levels of education in our society tend to have larger incomes. They are also a younger segment of the population. In summary, the expectations made when this study was undertaken were that the youngest and oldest groups ^ 32 [would be in strongest support of increasing the govern- jnaent's involvement in the provision of dental health I I services. Income and education were also expected to be [important to the extent that those with higher incomes and [education levels would be more willing to support changes I in the dental health delivery system then those with lower jincomes and education levels. Higher levels of agreement ! I were expected to be found between men and women than might 'have been assumed at an earlier point in historical time. CHAPTER III I ; THE RESEARCH DESIGN ! ' As evidenced in the literature review, research j into the problem of dental care needs of the aged and aging 'has been characterized by the following; First, the I research has been largely non-age-comparative in scope, j thereby limiting evaluation of the extent to which the I aged exhibit properties which are in any way different from ! those of other age groups in the population. Secondly, i investigation into the role of factors in addition to age I has been limited, so many of the differences reported may actually be due, wholly or in part, to factors other than i age itself. More thorough analysis of the effects of I differences in psycho-social factors and dental health ■ attitudes in relation to age would constitute a valuable addition to current knowledge. This study, with an ad- { mittedly limited sample of sixty-two respondents who were I purposively selected from dental practices in the Los ' Angeles area, will attempt to identify some of the issues : related to developing a more comprehensive approach to the I problem through the following procedures: i (1) comparison of the aged with younger age groups in this sample; and 33 34 C2I analysis of the relative influence of age in rela tion to other factors. I Younger age groups were used for purposes of com parison with those sixty-five and over throughout the I j analysis to provide some standard for ascertaining the imanner in which the aged differ from other age groups. In I order to establish a range within which comparison can be I made, the three previously stated age groups will be used I (25 to 30, 45 to 50, and 65 and over). This range provides 'a basis for determining whether the aged differ from other ! adult counterparts. It also serves as a means for making I rough assessments of differences between age segments of I the population age twenty-five and over. The fifteen year spread between groups provides for more clarity than would be possible if the entire age range of twenty-five and ; over were included in a small sample. A. OPERATIONALIZATION OF THE MAJOR VARIABLES OF THE STUDY I Age, sex, income, insurance status, and education were each treated as antecedent and consequent variables. I : These variables were operationalized as follows: [ 1. Age was calculated from the date of the subject's ' birth. The subject was considered to be the age I of his nearest birthday, Subjects were, then I grouped according to age. Those aged twenty-five through thirty constituted the youngest group. I Those aged forty-five through fifty constituted ; the middle group. The eldest group was comprised of people sixty-five years of age and older. 35 There were no subjects under twenty-five, none between thrity-one and forty-nine years of age, and none between fifty-one and sixty-four years of age. The reason for age grouping was to facilitate evidence of an age cohort effect in a relatively small sample. 2. Income was treated as a continuous variable measured at various levels. Annual income was determined by asking each respondent to circle that amount of income listed on the questionnaire which came closest to the combined annual incomes of all the members of the respondent's household. The following choices were provided; $ 3,000 - 4,999 19,000 - 20,999 5,000 - 6,999 21,000 - 22,999 7,000 - 8,999 23,000 - 24,999 9,000 - 10,999 25,000 - 29,999 11,000 - 12,999 30,000 - 34,999 13,000 - 14,999 35,000 - 39,999 15,000 - 16,999 40,000 - 49,999 17,000 - 18,999 50,000 or more 3. Sex was coded as male or female. 4. Dental insurance included all forms of dental pay ment which are provided for by prepayment agree ments and for which premiums are paid either directly or indirectly by or for the subject. Thus while often treated separately in this study. Medi care and Medicaid was also classified as forms of dental insurance when appropriate. 5. Education was treated as a continuous variable from one to seven; 1. Grade school (grades 1-6) 2. Junior high (grades 7-9) 3. Some high school (grades 10 - 11) 4. High school graduate (12 grades) 5. Some college (1-3 years) 6. College graduate (4 years) 7. Post graduate degree B. SELECTION OF THE SAMPLE The sample for the study consisted of a stratified 36 random sample of dental patients from four dental practices I {in the Los Angeles area. The four practices were selected j because they tend to reflect the economic and ethnic strata ! of the Los Angeles area and include patients who pay on a Ifee^for-service basis, patients who have private dental { ! insurance and Medi-Cal patients. The sample may be unknow- !ingly biased. While attempting to represent a variety of 'individuals who utilize dental services, no effort was made I I to include individuals who do not. Fifteen patients in { each of three age groups (25'to 30, 45 to 50, and 65 and .over) were selected from each of three dental practices. J ; Thirty patients in each age group were selected from the ' fourth and largest practice. The fourth practice is a clinic in south Los Angeles which provides services to Medi-Cal recipients under a pre-paid program in cooper- ' ation with the State Medical program and to a large number ( of persons who are privately insured. This selection of I subjects provided an n of forty-five patients from each of I three dental practices and an n of ninety patients from ! the clinic for a total N of two-hundred and twenty-five. : The sample was stratified by age and sex, and pro- j vides subjects who have had experience with dental insur- I ance and/or Medicare or Medi-Cal, as well as subjects who I have received all of their dental care on a fee-for-service I basis(fee-for-service simply means that the individual paid I f i 37 I for services out of his own pocket) , To randomize the i I selection of patients, those patients in each of the three t age groups were separated by sex and assigned random num- :bers. These numbers were mixed and fifteen were randomly i drawn for each age group from each practice, seven of each sex. The fifteenth subject was drawn at random after the numbers representing males and females were mixed. For example, if one dentist had fifty-seven patients between I ; the ages twenty-five and thirty, each patient would receive ! ; a random number from one through fifty-seven. The numbers were then separated according to the sex of the subject represented. Seven were then drawn from each group. The [remaining numbers were then mixed and the fifteenth sub- ' ject was drawn. This procedure was completed for each group in each of the four dental practices. The patient sample consisted of seventy-five persons within each of { the three age groups. i The dental practices were chosen to provide a ,patient population which could be assumed to reflect the ■socio-economic and ethnic characteristics of Los Angeles. ^ Dental practices A and B are located in predominately i white, middle class neighborhoods. The third dental prac- I tice, C, is located in Beverly Hills and includes many I upper-middle class and wealthy patients. The dental cli- I I nic, D, (Table I) is located in south Los Angeles with a 1 38 TABLE I SELECTION OF STUDY POPULATION BY DENTAL PRACTICE, SEX, AND AGE Dental Practice Sex Group I Group II Group III (25-30) (45-50) (65+) A Male 7 7 7 , 21 Female 8 8 8 24 B Male 7 7 8 22 Female 8 8 7 23 C Male 7 8 8 23 Female 8 7 7 22 D Male 15 15 15 45 Female 15 15 15 45 75 75 75 225 predominately Black and Mexican-American population. Prac tice D, as mentioned above, provides services to Medi-Cal, privately insured and fee-for-service patients. 1970 Census Tract information was referred to to aid in the selection of dental practices. Members of the faculty of the Dental School of the University of Southern California assisted in locating dentists who would be will ing to cooperate in this study and whose combined practices 39 would reflect the diversified population of Los Angeles. I C. THE QUESTIONNAIRE I Age and sex were treated as antecedent variables I Ithroughout the study. Age was categorized into three groups, respondents twenty-five to thirty years of age com- iprise the first group, those forty-five to fifty are in the i [second group, and those sixty-five and over in the third group. Sex was categorized as male and female. Each of ,these variables was analysed against responses to thirty- Itwo items on the questionnaire. Education, income levels I land insurance status were also treated as antecedent var- liables against all items on the questionnaire. Most re- Isponses required a selection of a number, one through four- , Number one strongly disagree, number four strongly agree. Education, income levels and insurance status were of less concern to the author, but it was felt this procedure would ; aid in determining which of the four variables, when ! treated as antecedent variables, were most significant in iaffecting the subjects' responses to questionnaire items. J Age, sex, education, income and insurance status ! 'were also treated as antecedent variables in analyzing six I j indices developed by grouping questionnaire items. i The thirty-two questionnaire items consist of ques- I tions intended to reflect respondents * opinions and atti tudes regarding the provision of dental health services; 40 that is, whether the subject preferred to purchase dental I services on a fee-for-service basis, through private in- I I surance programs or through governmental programs which ! would pay for services. Some questions were intended to [ reveal under what circumstances governmental programs would ; most likely be supported. A second series of questions Î were related to whether or not the respondent considered ! dental health care as an area of social concern; whether i or not the inadequacies in the provision of services con- I ' stitute a social problem. ; Questions were also directed toward whether or not the respondents were satisfied with the services they presently receive. An indication of the level of utili- I zation of services was sought by securing information about ! dental expenditures and the number of visits during 197 2. Respondents were also asked questions related to their I i sense of the importance of receiving dental services. I Questions related to the esthetic values of dental care I were also asked. ! The questions were then grouped into six indices ! which appeared to have face validity. Index A was com- I prised of eight questions related to provisions for payment I for dental health care services. The primary question is, i I "Are there age differences in the amount of support I respondents show for the provision of dental services on a 41 fee'î^for^service basis as compared to support for insurance programs or governmental provisions for dental health care?" These questionnaire items were : 12, The provision of dental services under Medi-Cal is not a necessary program. 17. Governmental support for more comprehensive dental programs is needed. 18. Medi-Cal should provide for preventative dental health services as well as for acute and emergent care. 20. Adult children should be required to pay for their elderly parents' dental care, if the parents can not afford it. 22. The Federal and/or State government should pay for the dental care of : 1. no one 2. only children whose parents cannot afford to pay 3. only the elderly who cannot afford to pay 4. all who cannot afford to pay 5. all children 6. all elderly 7. all elderly and all children 8. everyone 23. It is important that dental programs allow : 1. free choice of dentists 2. some choice of dentists 3 . choice of dentists is not important 24. Major responsibility for the payment for dental services should rest with: 1. the individual 2. job related insurance 3 . the State 4 . the Federal government 5. a combination of the above, including (Please write in which combination you prefer) 42 26. If an individual cannot pay for his dental care, I dental programs should be available when: I _1. the condition is serious 2. the service is considered necessary by the I dentist 3 , the service is considered desirable by the ' dentist I __________ __4, the service is considered desirable by the ! patient i Index B consists of questions related to the sub- Iject's attitudes regarding dental health care as a social I concern. Index B is concerned with the question, "Are age I differences evident in opinions about the need for more i I comprehensive dental health care services to provide more I adequate care for more people?" Index B was comprised of i questionnaire items : 13, Most people in this country do not receive ade quate dental care, 14, Poor people should have the same access to dental care as rich people, 15, Comprehensive health care, including dental ser vice, should be available to everyone, 19, There is no need in the United States for more comprehensive dental programs, I I 21, The lack of dental care received by many people in I the United States is a serious social problem. Index C consists of those questions related to den- i Ital insurance and Medi-Cal to determine whether or not I participation in such pre-paid programs affected attitudes. I The author was especially curious to know if participation in a pre-paid program made one more likely to support pri- 43 Ivate insurance or governmental programs for the provision ! of payment for dental health services. The items for 'index C include : I 16, Private dental insurance should be readily avail- I able to the public, I ; 30. Do you have any type of dental insurance: I ___1, yes If yes, through whom? _______________ , ___2, no I ; 31, Have any of your dental services ever been paid for by Medi-Cal? 1. yes If yes, when _______________________ (approximate date) 2, no 32, Are you presently covered by Medi-Cal? 1. yes 2, no Index D attempts to examine possible age differ ences in attitudes which might be indicative of one's involvement in the dental health care system. The ques tionnaire items for index D include: 1, Dentistry is part of the medical profession. 6. It is not as important to get dental checkups as it is to get medical checkups. 27, I follow the recommendations of my dentist : I I 1. always I 2, most of the time ■ 3, sometimes ' 4, seldom 5, never 28, During the past year (1972) I visited my dentist times. (number) 44 29. My dental expenses for 1972 came to approximately I $ _ _ _ _ ' * ! Index E is an attempt to measure possible age dif- : ferences regarding the esthetic values of dental care. The I questionnaire items for index E include : I 3, Good dental care can help improve one's self con fidence. 8, After a certain age teeth are no longer important to how one looks. I I 9. The condition of my teeth and mouth is important ' to how I feel about myself. i I 11. Dental care should not be used merely to improve I one's appearance. I Index F examines differences in attitudes regarding . the level of satisfaction with the dental care subjects have received. Index F examines possible age differences j I in responses to items related to the respondents satis faction with the dental health services they have been i receiving. Questions for index F include; 2. It is easy to get an appointment with my dentist. 4. I am happy with my relationship with my dentist. I 5. The fees charged by my dentist are too high. I 7. In my opinion, it is usually difficult to get an ' appointment with most dentists. 10. In my opinion, most dentists do not provide high quality service to their patients. 25, The quality of dental care I have received dur ing the past few years has been; 1. excellent 2. good j 45 I _3, fair I _4 , poor I Other information on the questionnaire included a ; code number which allowed for the identification of the ; subject's age group (according to his/her dental records), jthe name of the subject's dentist, and the respondent. The : first digit of the five digit code identified the respon dent 's age group. If the first digit was "1", the respon dent was twenty-five through thirty; if "2", the respon- jdent was forty-five to fifty; if "3", the respondent was sixty-five or over. The second digit identified the ! respondent's dentist. The dentists names were ordered alphabetically and assigned the numbers four through seven. I ; The final three digits identified the respondent. The I names of each person in the sample had been ordered alpha- ! betically and assigned numbers from 001 through 225. The questionnaire asked for the date of birth to confirm the accuracy of the dental records for the age grouping. Respondents were also asked to identify their : sex, race, education and income. The respondent was also ; asked to indicate whether or not he wanted a summary of I r the findings. The subject identification code made it : possible to comply with this request. I The items on the questionnaire were pre-tested on ' five individuals within each age group. These fifteen : individuals were selected from people living near the j 46 University of Southern California. No attempt was made to I determine whether or not they were similiar to the study's : sample. These individuals were asked to comment upon the jclarity of the questions. As a result of the pre-test, I some items were modified. For example, "Medi-Cal" was ! substituted for the national label "Medi-Caid" because I : while all individuals in the pre-test had some knowledge I of "Medi-Cal," not all were familiar with the term "Medi- I ICaid." Some terms which were considered "too technical" by these individuals were dropped and lay terminology was ; substituted. i i D. PLAN FOR ANALYSIS I Age 25 to 30 was selected as the youngest compar ative group because this group tends to have a higher level of education and an assumed difference in attitude regard ing health and dental care (ie., they are less reluctant to seek out care). This group could provide insight into planning for the older age groups and in anticipating dif ferent requirements when this group has aged. The second 'group (45 to 50) provides data on subjects in their highest ,earning period and with fewer children to support. The oldest group (65 and over) provides data specifically related to the aged and their needs. Using the three age groups...25 to 30, 45 to 50, 47 and 65 and over...the research specifically sought to ex- : plore and describe: (1) relationships within and between I i the three age groups regarding attitudes toward social i j change in the organization and financing of dental health services and to determine the relationship, within each ' age group, between psycho-social factors and level of ! dental care characteristics and differences in attitudes j toward change in the provision of dental care services; j I and C2) relationships within and between the three age i : groups to the dental health care system. Each of the indices (A through F) was examined by ' age, sex, education, income and insurance status to explore j possible associations. With each individual questionnaire ; item and with each index the influence of age is consid- I ered of major importance. The primary research question is to what extent, if any, does one's age influence atti tudes toward the provision for and utilization of dental health services? ! CHAPTER IV I characteristics of the sample I Questionnaires, with cover letters describing the I proposed use of the information provided and acknowledging ^the co-operation of the subjects' dentist, were mailed to ! a total of 225 subjects. Envelopes, pre-addressed and ^stamped, were provided for the return of the question- ■naires. The sample was composed of 113 females and 112 males, each of whom had received dental services between January 1, 1972 and December 31, 1972. Twenty-seven ques- ^tionnaires were returned as undeliverable. One hundred and thirty-six subjects did not respond. Of the non-respon dents, fifty-one were in the youngest age group, fifty-four ; in the middle group and fifty-nine in the oldest group. I ; sixty-two subjects, 2716% of the total sample, responded, i Twenty-four respondents were twenty-five through I thirty: years of age. In this age group, twelve respondents I were men and twelve were women. Twenty-one respondents I were forty-five through fifty years of age. Seven^ in this : group were men and fourteen were women. Seventeen respon- 1 ! dents were sixty-five years of age or older. Of these, ! nine were men and eight were women. One of the male 48 49 respondents in group III did not provide identifying infor mation and was recorded as a "missing observation" on the computer print-out. He was identified by the code number on the returned questionnaire which indicated only age, sex and dental practice. Twenty-seven respondents were male and thirty-four were female. TABLE 2 RESPONDENTS BY AGE AND SEX Age Group Count Row Pet Male Female Row Total I C25 to 30) 12 12 24 50 .0 50.0 39.3 II (45 to 50) 7 14 21 33,3 66.7 34.4 III (65 or over) 8 8 16 50.0 50.0 26.2 COLUMN 27 34 61* TOTAL 44.3 55.7 100.0 *One male respondent from group III did not include identifying information and was listed as a missing observation. In spite of efforts to include individuals from representative racial groups, the respondents were predom inately white. In age group I (25 - 30), one Oriental, ! 50 I j one Mexican-American, two Blacks and twenty Whites re- I sponded. In the second age group (.45 - 50), respondents ' included one Oriental, no Mexican-Americans, four Blacks , and sixteen Whites. The third age group (65 and over) ' consisted of no Oriental respondents, no Mexican-Americans, 'three Blacks and thirteen Whites. The total number of respondents thus included two Orientals (one male and one female), one Mexican-American (male), nine Blacks (three ! male and six female) and forty-nine Whites (twenty-two I male and twenty-seven female). None classified themselves I as members of other ethnic or racial groups. One can only speculate as to why individuals in : this sample chose to return or not return their question- ' naires. As shown in Table 2, equal numbers of men and , women from groups I and III responded, but twice as many : women than men in group II responded. Perhaps the 45 - 50 I year old men in this sample considered the study as an imposition. Perhaps the difference is merely coincidental. i It leaves unanswered whether the men in this age group ! j would have responded as the women did (as was generally ' true in age groups I and III). Perhaps these men would i ' have reflected some of the more conservative views the I author anticipated from age group IT. I Ninety patients were sampled from Dental Practice i D and only eleven responded. (See Table 8). These people 51 are from a predominately Black and Brown section of the ,community. Many from this dental practice are Medi-Cal .recipients. The other dental practices also include some : Medi-Cal recipients, yet only eight respondents identified I themselves as Medi-Cal recipients. (See Table 7). The low response from the Brown community may be related to 'language (all of the questionnaires were in English). Many of the Black and Brown members of the sample and Medi-Cal 'recipients are from a low income area, perhaps the low I response is related to education or a sense of stigma in ; regards to Medi-Cal. i Whatever the reasons for the low response from 'middle aged males, specific ethnic groups and from Medi-Cal recipients, it must be emphasized that this study may not : reflect their opinions, attitudes or interests. Their views warrant closer examination. ' There may be a positive correlation between edu- :cational level and the tendency to complete research ques- ^ tionnaires. The educational levels of the respondents i I were higher than had been anticipated. Only one respondent j in age group I had not at least completed high school. I Three had completed high school, eight had less than two I years of college, seven had from two to four years of I I college, one had from five to six years of college and ' four had more than six years of college. In age group II, 52 TABLE 3 RESPONDENTS BY AGE AND RACE Race Age Group Count Row Pet Oriental White Max-Am Black Row Total I (25 to 30) 1 20 1 2 24 4.2 83.3 4.2 8.3 39.3 II (45 to 50) 1 16 0 4 21 4.8 76.2 0.0 10 .0 34.4 III (65 or over) 0 13 0 3 16 0.0 81.3 0.0 18.8 26.2 COLUMN 2 49 1 9 61* TOTAL 3.3 80.3 1.6 14.8 100.0 *Missxng Observations = 1 two respondents had not gone beyond grade school, but of the remainder, seven completed high school, five had less than two years of college, five had from two to four years of college, one had from five to six years of college, and one had more than six years. The respondents in the third age group either never completed high school or without exception went beyond. Three had not gone beyond grade school, three had gone to junior high, and one had some 53 'high school. Of those who made it through high school and I ; went beyond, three had less than two years of college, four had from two to four years of college, one had from I five to six years of college, and one completed more than j six years. ' Three men had less than a high school education, as compared to seventeen women. Seven men and nine women had ; less than two years of college. Eleven men and five women I 'had from two to four years of college. Two men and one 'woman went to college for five to six years and four men I and two women went more than six years. ! The income levels of the respondents were recorded I as the combined annual incomes of all the members of the ; respondents household. Respondents were provided with ' sixteen continuous income levels to choose from. These categories were later collapsed into three classifications, : low: $4,999 or less, medium : $5,000 to $16,999, and high : $17,000 and above. Three respondents in age group I ' earned $4,99 9 or less, thirteen earned between $5,000 and i ' ! $16,999, and seven earned $17,000 or more. In age group ' II only one respondent earned $4,999 or less, nine earned I between $5,000 and $16,999, and ten earned $17,000 or more. I Respondents in the third age group had the lowest reported I incomes. Six in this group reported incomes of $4,999 or , less, five had incomes from $5,000 to $16,999. None of the S O H EH < CJ O Q W Q " < r S C M H A O' < < H >H A À EH s A Q !S O A A H A 54 A m iH kO A rH O ( d «N . CN • iH • kO -P < T ) VO O O O A A A O A E h d r d rd 0 -P tn œ 0 ; CN CM 00 kO A O Q ) u 1 —1 A • • • A • p >HA O A o o A ^ A A N* S fN u : 1 —1 <N 0 0 t r » 0 d 0 : f! f d1 —1 ü Æ 1 —1 1 —1 00 A iH A 00 MO VO A 4 - ) o iH • A • A • o . A 00 A Æ w A M ; t r » w w ■H Q p ; A A >H . A O ; o ( ü -P +J u O 0 )A : r —1 (N A A r~ CA O A A • • » iH • P4f! o\ ; A ^ g tr», N» ‘ H O Q O A : -p u % P -P A , d A Eh d A O o , O , O E h u A O Çk 0 o M O (U < P 0 > O O O A A P O O O +J -P A A A A A — - i wi H H H Ht H Ht O •H -P ( d > u < u w ê t r » G -H C Q W ■H * 55 respondents in the third group reported higher incomes. Five men and five women reported annual household incomes of $4,999 or less. Nine men and eighteen women reported incomes from $5,000 to $16,999 and ten men and seven women reported incomes of $17,000 and over. Before income categories were collapsed there were no major dif ferences in reported annual household incomes between the men and women. There were eight respondents who did not report their annual income, one from age group I, one from age group II, and six from age group III. TABLE 5 RESPONDENTS BY AGE AND INCOME Income Age Group Count Row Pet 4999 or less 5000 to 16999 17000+ Row Total I (25 to 30) 3 13.0 13 56.5 7 30.4 23 42.6 II (45 to 50) 1 5.0 9 45.0 10 50.0 20 37.0 III (6 5 or over) 6 54.5 5 45.5 0 Ü .0 11 20.4 COLUMN 10 27 17 54 TOTAL 18.5 50.0 31.5 100.0 56 Five out of twenty-four respondents in age group I had dental insurance, six out of twenty respondents in age group II were insured. None of the respondents in age group III were privately insured, Of all those insured. four were men and seven were women. TABLE 6 RESPONDENTS BY AGE AND INSURANCE STATUS Insured Age Group Count Row Pet Yes No Row Total I (25 to 30) 5 20.8 19 79.2 24 40.4 II (45 to 50) 6 30.0 14 70.0 20 33.3 III (65 or over) 0 0.0 16 100.0 16 26.7 COLUMN TOTAL 11 18.3 49 81.7 60* 100.0 *Missing Observations = 2 Two out of twenty-three respondents in age group I reported that they were Medi-Cal recipients. One out of twenty-one so reported in age group II. Five out of four- teen respondents in age group III were on Medi-Cal. Two I 57 ! men and six women were Medi-Cal recipients. One respondent I i in age group I did not respond to this question, three in i age group III did not answer the question. ^ table 7 RESPONDENTS BY AGE AND MEDI-CAL STATUS 1 ! Medi-Cal 1 ! Age Group Count Yes No Row ! Row Pet Total 1 1 I (25 to 30) 2 21 23 i 8.7 91.3 29.7 1II (45 to 50) 1 20 21 1 4.8 95.2 36 .2 I III (65 or over) 5 9 14 1 35.7 64.3 24.1 i COLUMN 8 50 58 TOTAL 13.8 86.2 100.0 *Missing Observations = 4 ! Eighteen of the forty-five patients sampled from I Practice A, located in a predominately white-middle-class ■neighborhood, responded to the questionnaire. Dental prac- ;tice B, which provides services to a large number of pri- Ivately insured patients produced thirteen out of forty-five I respondents. The highest return came from Practice C, 58 in Beverly Hills. Twenty of the forty-five patients I jresponded. The clinic which provides services to Medi-Cal ! recipients under a per-capita contract with California and : to a large number of privately insured patients yielded responses from only eleven out of ninety patients sampled. I ; There were no major differences in the responses when com- I pared by age. I TABLE 8 j RESPONDENTS BY AGE AND DENTAL PRACTICE Dental Practice Age Group Count A B J C D Row Row Pet Total I (25 to 30) 5 7 7 5 24 20.8 29.2 29.2 20.8 38.7 II (45 to 50) 9 5 5 2 21 42.9 23.8 23.8 9.5 33.9 III (65 or over) 4 1 8 4 17 ! 23.5 5.9 47 .1 23.5 27.4 COLUMN 18 13 20 11 62 TOTAL 29.0 21.0 32.3 17 .7 100.0 j In group I, fifty per cent of the twenty-four Irespondents were male and fifty per cent were female, all i ;but four were white. The median level of education was 59 I japproximately two years of college. The median annual jincome, before the final collapsing of data, was between $9,000 and $12,999. 20.8% in this group had private in- ;surance and 8.7% were Medi-Cal recipients. ' 66 2/3% of the twenty-one respondents in group II i were women, all but five were white. The median level of I education was less than two years of college. The median I jannual income was the same as group I, $9,000 to $12,999. I 30% of group II had private dental insurance and one person I ; was a Medi-Cal recipient. I In group III, nine of the seventeen respondents i 1 were male and eight were female, all but three were white. 'Although seven had not completed high school, the median education level was less than two years of college. While ; seven reported incomes of less than $9,000, the median annual income for group III was the same as groups I and II. While median figures are similiar for all three I groups, education levels tended to decrease with age, i group II had the highest number with private dental in- j surance and group III had the highest percentage on Medi- I ICal and the lowest incomes. No one in group III reported I an income over $16,999. One seventy-two year old respon- I dent wrote that he and his wife lived on a total annual I income of $1,200. 1 Statistical means are close, but by rounding to the t I I [ ______________ 60 nearest whole number the group directions of education and income levels are apparent. Educational averages are as I follows : group I, two to four years of college; group II, jless than two years of college ; group III, completion of high school (as stated above, all respondents in group III j reported either less than a high school education or some college). The annual household income means for each group 1 ! were : group I, $9,000 - $12,999; group II, $13,000 - I$20,999; group III, $5,000 - $8,999. The non-respondents included twenty-five men and twenty-six women in group I; thirty-one men and twenty- I jthree women from group II; and twenty-eight men and thirty women from group III. ' Those dental practices serving large numbers of Medi-Cal recipients and privately insured patients yielded ! : the highest percentages of non-respondents, i The number of respondents decreased with age. Group I yielded a response of 24:75, group II a response of 21:75 and group III, 17:25. Approximately 27.5% of the sample returned their questionnaires. SUMMARY It seems reasonable to assume that the respondents . in this study are generally self-sufficient and adequate individuals. 31.5% reported incomes of $17,000 or more I ) I and 81.5% reported incomes over $5,000. Very few respon- I I dents in age groups I and II could be considered living ! at the federally defined proverty level. In age group III : none reported incomes over $16,999 and six reported incomes I at $4,999 or less. One aged respondent wrote that he and his wife had had a total income of $1,0 00 during 1972. I- Educationally 8 9.6% reported they completed high school I and 67.1% had attended college (14.7% completing five or I more years of college). 18.3% of the respondents had den- ital insurance, but none were in age group III. Eight were I jon Medi-Cal, five of those were in age group III. Obvi ously, those respondents aged 65 and over were less advan- Itaged than most younger respondents. Twenty-four of the respondents were 25 to 30 years I of age, twenty-one were between 45 and 50, and sixteen were ! 65 or over. There were an equal number of men and women in age groups I and III (twelve and eight of each respec tively) . In age group II there were seven men and fourteen 'women. 80.3% of all respondents were white, 14.8% were ; black. I In spite of selecting the sample from dental prac- ,tices which had large numbers of patients on Medi-Cal and I private insurance programs, most respondents were from I higher income levels and from among those purchasing dental care on a fee-for-service basis. Efforts made to insure a 62 j * number of respondents from ethnic minorities were also less I than totally successful. The location of the dental prac tices should have resulted in more respondents from among 'the Latin and Black populations in the area. There might I have been a higher return from the Latin community if the ; explanatory letter and the questionnaire had been written I in Spanish. This may have been especially true for the ! older members of the community. Educational levels and 'issues related to relevance (as perceived by the minority 1 I groups) may also have affected return rates. I i A more direct method for sampling Medi-Cal recip ients and ethnic groups, such as direct interviews and Iout-reach efforts, would produce more reliable information I collection from these individuals. i CHAPTER V 1 I DATA ANALYSIS I I INTRODUCTION i There exists in the United States a vast and com- Iplex arrangement of programs and services for our older I population. Within and among these programs and services ! there are gaps and overlaps which seem inevitable in a i I society which values a pluralistic approach to meet the needs of people. Our social policies are concerned with jeconomic progress, economic stability, freedom, and .justice.^ Our social policies reflect a desire to improve I the economic conditions of the disadvantaged and at the same time they promote a gradualism to encourage economic stability. They reflect the value of "freedom" seen as the power to make decisions. They reflect a sense of : justice through an emphasis on the distribution of goods and services to the individual, an emphasis involving I I I society's obligation to the individual and the individual's claims upon society. Obviously the goal of assuring eco- jnomic progress may conflict with the goal of insuring eco nomic security. Mandatory participation in a public pro- ^Kenneth Boulding, Principles of Economic Policy (Englewood Cliff, N.Y.; Prentice-Hall, 1958) 63 I 64 I gram may restrict one's freedom (choice) , but the benefits I from the program may increase freedom (choices). And, of i [ course, there is disagreement about how and to what extent I ! efforts should be made to redistribute resources. Thus, > ! perhaps more than anything else, social policies reflect ; compromises. They are not always the result of an objec- I tive examination of rational data. I I The formulation of social policies and the develop- iment of programs are related to society's attempt to meet I ! human needs within a framework of compromise which gives I ; recognition to a variety of vested interests. In the final analysis, once the compromises have been made, the issues I i addressed, social policies must attend to the needs of the 1 population to be served. Social programs should be cog- I nizant of their irrational elements and should offer their I services with sensitivity and concern for the dignity of their recipients. This study is an exploration of some interest, con- , cerns and desires for securing more adequate dental health ; services for our population. It is an attempt to develop i ! and increase our insights into what services might be pro- i I vided, under what circumstances, and to whom. It should i ' help us to speculate more accurately about the viability I of various governmental interventions. It should help us I ' consider ways to remove financial barriers from more com- j 65 Iprehensive dental health services which will address the needs and interests of the populations to be served. In this chapter we will examine responses on spe cific items from indices "A" through "F". Our discussion ! will be confined to those items which tend to support or I negate our assumptions. Our primary concern is with pos- ! I sible age-links with attitudes and preferences. We will I also include discussion of the significance of sex, edu- I I cation, income, and insurance status when these variables I appear to be important considerations in respect to spe- i cific items. A. AGE AND ATTITUDES TOWARD THE PROVISION OF PAYMENT FOR DENTAL HEALTH SERVICES The questionnaire items in Index A were expected ! to reflect support or non-support for governmental pro- , vision for payment for dental health services. The ques- I tions were coded so numerically higher responses equaled greater support for governmental intervention. For exam ple, on item twenty-two a response that the government , should not provide for the dental care of anyone had a I : numerical value of one. That the government should pro- I vide dental care for everyone had a value of eight. It was hoped that by adding the responses to all items in I 'Index A one would have in the mean scores, an indication t of support for governmental provision of payment and exten 66 siveness of services. An analysis of variance showed no statistically significant difference among the 3 groups in regard to Index A. In view of the lack of significance in regard to Index A a factor analysis was done to determine whether items correlated at a high enough level to actually constitute an index. There were only limited correlations between the items in Index A. (This later proved to be true of the other indices too). Any value of interpre tation must, therefore, rest with responses to each item. Support for governmental intervention in the provision of dental health services or payment thereof appears to be a mixed phenomena and agreement or disagreement on one item may not be related to agreement on another. One of the major research questions of this study is; "Are there age differences in attitudes regarding methods of payment for dental health services?" In other words, do people in different age cohorts support different methods of payment for their dental care. The three meth ods given consideration in this study were fee-for-service, I governmental programs, and private insurance programs. It ! ! was assumed that oldest and youngest age groups would show i ^ the greatest support for governmental programs. Their incomes tend to be lower than those in the middle-age group and their medical and dental expenses are higher. Members of the 25-30 age group often have high dental expenses r ^ I because they tend to have young children among whom caries [ are prevelant and members of the 65 and over age group I often require dentures and suffer more from peridontal ■ diseases. It was assumed the 45 - 50 age group would view ' themselves as having to pay a disproportionate share for the costs of government funded dental health programs be- ; cause they and their children are not in age groups which I normally experience concurrently high dental expenses and I I low incomes, i Questionnaire item number seventeen states: "Gov- ! I ernmental support for more comprehensive dental programs I I is needed." Responses were collapsed from strongly dis- ; agree, disagree, agree and strongly agree to disagree and ‘ agree. As anticipated age groups I and III showed the I : strongest support 87.5% and 81.3% respectively in agreement compared with 66.7% of age group II agreeing. 78.7% of the total sample (48) agree that more governmental support of dental programs is needed. Women were more likely to reply in the affirmative j than men, 88.29% to 66.7% respectively. The higher agree- 1 ment among the women is unaccounted for in this study. ; Their responses to the items related to the esthetic values I I of good dental care (which will be examined later) are not much different then the male respondents. It is more likely a reflection of a tendency for the women in our 68 TABLE 9 SUPPORT FOR MORE COMPREHENSIVE GOVERNMENT SUPPORTED DENTAL PROGRAMS Support for Governmental Programs Age Groups Count Disagree Agree Row Row Pet - Total I (25 to 30) 3 21 24 12.5 87.5 39.3 II (45 to 50) 7 14 21 33.3 66.7 34.4 III (65 or over) 3 13 16 18.8 81.3 26.2 COLUMN 13 48 61 TOTAL 21.3 78 .7 100.0 *Missing Observation = 1 society to be more liberal, in some regards, than men. 1 Income was also a variable of interest. Annual , income levels were collapsed to low ($4,999 or less), i : median $5,000 to $16,999), and high ($17,000 and over), i The differences were not statistically, significant, but as ; income went up affirmative responses decreased. Nine out I. ! of ten low income respondents answered the item affirma- ( ; tively. Positive responses dropped to 7 7.8% (21 out of 27) 69 in the middle income group and to 70.6% (12 out of 17) in the high income group. • There is without doubt strong support for govern- I mental provision of more comprehensive dental health pro- 1 grams. The support is strongest with the youngest and ' oldest age groups, those mose likely to be in the greatest ' need of services and the least likely to be able to afford ! I more comprehensive care. This assumption is further indi- i ' cated by the greater support from lower income groups. I I These findings may also reflect a greater willingness on I the part of age cohorts represented in groups I and III to I look to the government for assistance in meeting the high cost of health services. I Question number eighteen asked whether : "Medi-Cal should provide for preventative dental health services as well as for acute and emergent care." The affirmative , response indicates support for an expansion of Medi-Cal i I services since the existing program is generally limited to providing only acute and emergent care. Responses to I this question were not as anticipated in that age groups I I I and II reflected the highest agreement, 91,7% and 90.0% ^ respectively. Age group III indicated the least support I with 80.0% responding affirmatively. Most importantly, ! however, is that 88.1% of all respondents agreed that Medi- f Cal should provide preventative dental health services. 1 " ■ ■ ■ ■ ' ... TABLE 10 1 AGE AND THE PROVISION OF PREVENTATIVE I DENTAL HEALTH SERVICES BY MEDI-CAL ! 70 i Provision of Preventative 1 Dental Services 1 Age Groups Count Disagree Agree Row Row Pet { Total I (25 to 30) 2 22 24 8.3 91.7 40.7 II (45 to 50) 2 18 20 10.0 90.0 33.9 i 1 III (65 or over) 3 12 15 1 20,0 80 .0 25.4 ' COLUMN 7 52 59* ; TOTAL 11.9 88.1 100.0 i *Missing Observations = 3 Twenty-two of the twenty-six males responding and thirty of the thirty-three females agreed that Medi-Cal ; should provide preventative dental health services. These I. j figures compute to 84.6% of the men and 90.9% of the women ; in agreement with item eighteen. The relationship between ! , educational level and affirmative responses was unremark- I able since only seven respondents disagreed with the item. ' Numerical differences are small, but it is of interest to 71 note that support increased with income. The low income group returned 80.0% in agreement. The middle income group returned 8 8.9% in agreement and the high income group re- I turned 93.8% responses in agreement. This response may ; reflect a tendency for the more affluent to place a higher ' priority on preventative health services, which lower in- ; come groups find it necessary to give their attention to I ! the treatment of more critical conditions. All eleven ! ' respondents who have private dental insurance agree with ! I item eighteen. Nine of them "strongly agreed'." According to 78.7% (48) of the respondents the i government should support more comprehensive dental health ' programs. Expanding Medi-Cal to include preventative den- ' tal health services is supported by 88.1% (52) of the re spondents . Responses on items seventeen and eighteen are consistent with each other and the support for governmental intervention is high. In regard to the issue of to whom should such services be made available, item twenty-two provided for a range of responses ranging from "no one" to "everyone'; ! ' with classifications of children, elderly and I indigent in between. All three age groups gave the great- j est response to number 4, "all who cannot afford to pay." All eleven privately insured respondents so responded. I Only four respondents replied that no one should be pro- I vided governmentally supported dental care. All four were j 72 }men, two of whom had annual incomes over $17,000. One ; earned $4,999 or less. The other's income is unavailable. •All four had had some college education, two had less than ! two years. The other two had two to four years of college. 'While these four men gave the most conservative response, I it is also fair to note that of the eight respondents who I replied that comprehensive, governmentally supported pro- ^grmas should be available to everyone six were men. Five of these men had annual incomes of $17,000 or more. Three j of them had incomes of $4,999 or less. It seems the ex- I ,tremes in support or lack thereof are about equally re- I ■fleeted with extremes in annual income. Of these eight I respondents, one had completed grade school or less, one had completed high school, two had less than two years of jcollege, three had two to four years of college and one ! had more than six years of college. The per centage of respondents choosing response i number four decreased with age. Response number four was j chosen by 70.8% (17) of age group I, 66.7% (14) of age group II, and 50.0% (6) of age group III. There was agree- iment by 64.9% (37) of all respondents that all who cannot Ipay for their dental care should have their dental expenses met by the Federal and/or State government. 16.7% (4) of I ■age group I, 9.5% (2) of age group II, and 16.7% (2) of age 1 I group III responded with number eight, "everyone." Respon- I 73 jdents favoring providing governmental payment for dental 1 j services for everyone followed the previously stated ^assumption that age group II would be less likely to sup port governmental programs than age groups I and III, but I I this is strongly contradicted by age group II's support of I governmental payment for all those "who cannot afford to i I pay," Combining responses which support governmental ,provision for payment for dental services for all who can- i I not afford to pay and for the children of parents who can- I I not afford the cost of dental services we find that 75% of 'age group I, 71.5% of age group II, and 58.3% of age group III replied affirmatively. It seems reasonable to assume ; that there would be wide support for a program which as sured comprehensive dental health services for low income ifamilies, with additional support for programs which em- îphasize services to the children of such families. Questionnaire item number twenty-four is an attempt to determine the locus of major responsibility for the payment of dental services. Should major responsibility I for the payment of dental services rest with the individual I the employer (through job related insurance), the state, I the federal government, or some combination of these? ' As was expected in the original assumption, age ! groups I and III showed the strongest support for govern- i imental payment for dental services. Responses 3 (State) 74 1 ! 1 —1 1 —1 rH CO CN 1 —1 O I ftf CN • CM • 1 —1 • i n • 1 ^ -P fN I VO 1 —1 o o o r o CN o 1 P i Eh 1 —1 ! 1 ( D ) g T P r > CN m CN 00 o I X VO a> VO k rH 1 —1 I—1 : 0 ) 1 > M i C i X Q) , œ «H k M CN CN LO I—1 r o TP O i :w W k ^ • • • • , m u 0 ) 1 —1 ; cr> 00 H «H * k ; ! > « —1 iH C JPÎ ; S P< < H to 0 : 1 O M 1 f f l CQ 1 IS ^ A X Ph ( < 1 —1 o o o o rH r o 1 —1 CO O Eh k • • • • ; s : C D o o CO 1 —1 1 M iH M Q 1 —1 1 —1 < H P4 P i : «H o o : i H H Pu , k 00 T p r ~ VO o P-r O 1 —1 • rH • • 00 • I M >4 rH O o VO o TP k4 k < < P4 VO i n VO pq O P4 , I < E h W Q , c M h4 C D 1 —1 (N «H CO iH 00 00 00 H D k • • • • P i o TO CO i n O M Q) iH 0 [ / ] k ' 6 -H H O O Æ Eh EH k ; 0 0 < iz ; r ) M + j : : 0 ) i n X s (1 ) : c p q P i e , o M CN CN lO 1 —1 00 o I I ' w X . • • • • H > o t P CO C O ! 0 O . p t , c < 0 Q ; • k -P , - p fd i ' Ü S h k > 1 4 - > p4 S • < k c 0 EH Q) 0 1 5 P I O C O 1 O O k O Eh n 1 0 P i 0 ) 0 o > 1 o O ; O lO c r o k •H 04 o O C O j ' O C O o + J i n •H 1 k i n VO 1 0 LO TP ' — ' -K CN i 0 ) H i j r i M H i < H H H I 75 I and 4 (Federal) were collapsed and considered as one. I 45.8% of group I and 43.8% of group III agreed that major i responsibility for the payment of dental services should ! rest with the government, 35% of group II agreed. While these responses are not a majority of any group, govern- I I mental payment for dental services received the greatest percentage of responses from groups I and III. Job re lated insurance received support from 16.7% of group I, 40.0% from group II and 12.5% from group III. The lower response from group III may be attributable to the fact t that persons 65 and over are less likely to be working and 'will not have job related insurance available. 20.8% of the respondents in group I placed major responsibility for payment upon the individual. This compares with 25.0% from group II and 31.3% from group III. At least among these respondents, the older a person is the more likely he will expect the individual to assume responsibility for paying for his own dental care. This may be an indication that older cohorts are more likely to ascribe to a posi tion that there is a strong societal expectation that each individual should be able to provide for himself. An expectation which tends to underestimate how difficult this might be for some members of a technologically com plex society. 25.0% of the total respondents stated that major responsibility for the payment of dental services 1 should rest with the individual; 23.3% preferred job re flated insurance; 41.7% the State; and 10.0% preferred some 1 combination of the alternatives, I TABLE 12 PREFERRED LOCUS OF MAJOR RESPONSIBILITY FOR 1 PAYMENT FOR DENTAL HEALTH SERVICES BY AGE GROUP 1 ! 1 [ Responsibility for Payment ; Age Group Count Indiv. Job Ins. State Comb. Row i Row Pet Total 1 il (25 to 30) 5 4 11 4 24 I 20.8 16.7 45,8 16.7 40.0 II (45 to 50) 5 8 7 0 20 1 25.0 40.0 35.0 0.0 33.3 ! i III (65 or over) 5 2 7 2 16 ; 31.3 12.5 43.8 12.5 26.7 COLUMN 15 14 25 6 60* TOTAL 25.0 23.3 41.7 10.0 100.0 *Missing Observations = 2 ■ There were few differences in the responses be- I tween men and women on this item. The women did reflect I slightly more support for state - federal responsibility. I Income level was also an insignificant factor, but it may be worth noting that four respondents with incomes of i 77 I I $4,999 or less stated that the major responsibility should j rest with the individual. The responses on this item cer- ! tainly do not indicate that any group is expecting ,the I government to take the major responsibility of providing jpayment for dental health services. Rather, respondents ; seem to value the availability and accessibility of ser- I I vices and are willing to support necessary governmental intervention to assure adequate care. In order to further examine attitudes toward the provision of dental services under Medi-Cal, item twelve asked in negative format whether or not dental services should be provided by Medi-Cal. Item twelve stated that the provision of dental services under Medi-Cal is not a necessary program. Responses were collapsed into agree - disagree categories. Only 12.5% agreed with the statement. 87.5% of the respondents felt that Medi-Cal should provide den tal services. Rather than strongest support coming from groups I and III as had been anticipated, support de creased with age. 95.7% of the respondents in group I stated that Medi-Cal should provide for dental services, the responses for groups II and III were 83.3% and 8 0.0% respectively. Twenty-two of twenty-five male respondents and twenty-seven of thirty-one female respondents disagreed 78 TABLE 13 PRECEPTIONS OF DENTAL SERVICES AS A NECESSARY MEDI-CAL PROGRAM BY AGE GROUP Dental Services are Not a Necessary Medi-Cal Program Age Group Count Agree Disagree Row Row Pet Total I (25 to 30) 1 22 23 4.3 95.7 41.1 II (45 to 50) 3 15 18 16.7 83.3 32.1 III (65 or over) 3 12 15 20.0 80.0 26.8 COLUMN 7 49 56* TOTAL 12.5 87 .5 100.0 *Missing Observations = 6 with the statement. Eight of the eleven privately insured respondents disagreed. The other three did not respond. There is a high level of consistency between items twelve and eighteen. 87.5% of the respondents say dental services are a necessary Medi-Cal program and 88.1% of the respon dents say the program should be expanded to provide pre ventative care. These responses should not be construed to indicate that the respondents believe Medi-Cal is the 79 program most favored to provide payment for dental health I services. Rather, the respondents recognize that Medi-Cal I j is an existing governmental program which (without pro- ■ viding other specific alternatives) they believe should I include more comprehensive dental health services. I Item twenty-six did not limit the concept of dental j programs only to those provided by the government. It jmore broadly stated: , j "If an individual cannot pay for his dental care, dental programs should be available when: I I 1. the condition is serious I 2. the service is considered necessary by the I dentist I 3. the service is considered desirable by the j dentist [ 4. the service is considered desirable by the I patient" Collapsing choices 1 and 2, 54.2% of group I re- i sponded that if an individual cannot pay for his dental care, programs should be available when the condition is ' considered either serious and/or necessary by the dentist. i 8 0.0% of group II and 81.3% of group III so responded. I I 33% of group I supported the provision of dental programs ' for services considered desirable by the dentist. Only I i 5.0% of group II and no one in group III supported the j provision of programs considered desirable by the dentist. I When responses are combined to include conditions which : are serious and those considered by the dentist to be ! either necessary or desirable 87.5% of group I, 85% of 80 group II and 96.3% of group III believe that programs should be available to provide those services to those who I cannot pay. 70.0% of the respondents stated that dental 'programs should be available for those who cannot pay to iprovide services considered necessary the dentists. 12.5% I of group I, 15% of group II, and 18.8% of group III (15% : of all respondents) supported the provisions of programs j for services considered desirable by the patient, j When the variables sex, income and education were j held constant the differences were insignificant. In all I cases the strongest support is for providing those services I considered either serious or necessary by the dentist, I followed by support for providing services the dentist considered desirable. None of the respondents who had private dental insurance supported the provision of ser- I vices considered desirable only by the patient. In all I 'other respects the responses of those with private dental insurance were similar to those of the other respondents. As was stated of items twelve and eighteen, it continues I to appear that respondents reflect support for programs ; providing an adequate level of dental care. ; Item twenty-three was addressed to the importance I ^ respondents placed on having free choice or some choice 1 of dentists or whether they consider choice of dentists as unimportant. The item was not limited to governmental L_ 81 TABLE 14 AGE BY RESPONSES TO THE AVAILABILITY OF DENTAL PROGRAMS Programs Should Be Available For Those Who Cannot Pay When Age Group Count Row Pet Serious Con Nec By Dent Con Des By Dent Con Des By Pat Row Total I (25 to 30) 3 12.5 10 41.7 8 33.3 3 12.5 24 40.0 II ( 45 to 50) 1 5.0 15 75.0 1 5.0 3 15.0 20 33.3 III (65 or over) 7 43.8 6 37.5 0 0.0 3 18 .8 16 26.7 COLUMN TOTAL 11 18.3 31 51.7 9 15.0 9 15.0 60* 100 .0 *Missing Observations = 2 programs. The importance of being able to choose one’s own dentist was extremely important to group III. 93.3% of those in group III want to have free choice of dentists, (one person would except limited choice and no one in group I III responded that choice of dentists is not an important ^ factor in dental programs. Groups I and II were more di vided, with group I being more willing to restrict or give I up the opportunity to choose one's own dentist. 33.3% of 82 group I desire free choice of dentists, compared with 50.0 I of group II. 45.8% of group I would prefer at least some I I choice and 20.8% considered choice unimportant. 40.0% of I group II would accept limited choice and 10.0% said choice I is unimportant. The variables of sex, income, education ! and insured status were unremarkable. ! i It seems important that any program, whether public t j or private, should consider how important the elderly con- I sider the free choice of their own dentist to be. The t ! success of any dental program could be related to the de- I ' gree of choice of dentists provided. It is quite possible ' that the elderly would not be as likely to make full use I ' of a program which did not allow them to choose their own I I dentist. It seems logical to conclude that if not the success of the program, at least the levels of patient ; satisfaction in all age groups will be related to whether or not one has an opportunity to select his own dentist. Item twenty is concerned with the concept of rela- ; tive responsibility. Its purpose is to determine to what I , extent different age cohorts agree that adult children j should be held responsible for the dental expenses in- i curred by their elderly parents. Item twenty asked whe- i ther or not adult children should be required to pay for ; their elderly parents' dental care, if the parents cannot ! ' afford it. Responses were collapsed to agree and disagree. TABLE 15 AGE BY IMPORTANCE OF CHOICE OF DENTIST 83 Degree of Choice Important Considered Age Group Count Free Some Not Row Row Pet Choice Choice Important Total I (25 to 30) 8 11 5 24 33.3 45.8 20.8 40.7 II (.45 to 50) 10 8 2 20 50.0 40.0 10.0 33.9 III (65 or over) 14 1 0 15 93.3 6.7 0.0 25.4 COLUMN 32 20 7 59* TOTAL 93.3 33.9 11.9 100.0 *M±sslng Observations = 3 I The strongest disagreement came from the group most likely ! to have living elderly parents,, group II. 81.0% of group II disagreed with the statement,: as compared with 79.2% ! of group I and 75% of group III. Although the percent\ tage differences are not great, it is noted that the group most likely to have parents in need most often dis agreed with the statement, whereas the group most likely to represent elderly parents in need were least likely to disagree with the statement. It would be unreasonable to 1 , , , , .. ! TABLE 16 AGE BY ATTITUDE TOWARD RESPONSIBILITY OF ADULT CHILDREN FOR THEIR NEEDY PARENTS' DENTAL CARE 84 Adult Children Should Be Responsible for Their Needy Parents' Dental Expenses Age Group Count Row Pet Agree Disagree Row Total I (25 to 30) 5 19 24 20.8 79 .2 39.3 II (45 to 50) 4 17 21 19.0 81.0 34.4 III (65 or over) 4 12 16 25.0 75.0 26.2 COLUMN 13 48 61* TOTAL *Missing Observations 21.3 = 1 78.7 100.0 make any assumptions about the parent-child relationships of the respondents. The concern seems to be to avoid a I i financial burden, whether one's own or one's parents. This j is further evidenced by the fact that nine out of ten I I respondents with incomes of $4,999 or less also disagreed , with the statement that they should be responsible for their needy parents dental care. As a matter of fact. I 85 i only three respondents (17.6%) with incomes of $17,000 or j more felt they should have such responsibility. The middle I I income group was more generous. Eight of them (29.6%) felt the responsibilities should be theirs, although a definite ; minority, 22.2% of the respondents supported this concept i I of relative responsibility. SUMMARY : I I Although the age-cohort differences were not as ! j great as anticipated, it is important to note that 78.7% I ! of the total respondents support the concept of govern- I ; mental provision for more comprehensive dental health pro- ! grams. 8 8.1% of the respondents believe Medi-Cal should ' provide payment for preventative dental health services I I rather than limit programs to acute and emergent care, i 87.5% consider dental services a necessary part of the i Medi-Cal program. 64.9% of the respondents believe the Federal and/or State government should pay for dental care for those who cannot afford those services. Only 7.0% believed the government should not pay for anyone's dental health care. 7 0.0% of the respondents believe dental pro grams should provide payment for serious and necessary ser vices, 15.0% are also willing to support programs which provide services for conditions considered desirable by the dentist and the remaining 15.0% would include service I 86 jconsidered desirable by the patient. In other words, 100% ; of the respondents indicated support for the provision of ^ at least some dental services for those who cannot afford ' to pay for those services. 41.7% of the respondents be- Ilieve the State should have major responsibility for the j 'payment of dental services. 23.3% believe that respon- I sibility should be met by job related insurance. Only I 25.0% of the respondents felt that major responsibility I for payment should rest with the individual. There appears I to be considerable support for governmental intervention ! in the provision of payment for dental health services. !a final point worthy of reiteration is that 93.3% of those ' 65 and over consider the freedom to choose their own den- : tist to be important and all three groups prefer at least I some choice of dentists. i While the n's are admittedly small in this study, the consistency with which they support governmental inter vention in the development of and provision for more com- ' prehensive and accessible dental health services seems important. The high agreement within and between age- cohorts may indicate a generally universal desire for im- I proving and increasing accessibility to the system of dental health services. 87 B. AGE AND ATTITUDES TOWARD DENTAL HEALTH AS AN AREA OF SOCIAL CONCERN ! Index B was intended to examine whether or not age is a significant variable in the consideration of dental ihealth care as an area of social concern. Members of age I ; groups I and III are among those most likely to have higher I dental and medical expenses whereas members of age group I III tend to have fewer expenses and higher incomes. It was, I therefore, assumed that respondents in age group I and age I group III would be more likely to believe that there is a I greater need for more adequate dental health care services than would respondents in age group II. I Questionnaire item thirteen asked respondents if they believe that most people in the United States receive I adequate dental care. The responses to item thirteen did not support the original assumption. 79.2% of age group I and 80.0% of age group II strongly agreed that most people in this country do not receive adequate dental care. Only 40.0% of age ; group III strongly agreed. By collapsing the responses to : agree and disagree, agreement decreases with age. 95.8% 'of I age group I and 90.0% of age group II agree that most peo- I i pie do not receive adequate dental care. Only 60% of those > in age group III agree. No respondents in age group I or I II strongly disagreed with the statement. 13.3% of those 88 j in age group III did strongly disagree. In the collapsed I responses disagreement increased with age with only 4.2% ! I in age group I disagreeing, 10% in age group II, and 40% I in age group III. It may be that the respondents in age I group III believe the dental care they have received has I 'been adequate and, therefore, assume the availability of adequate care for others. Perhaps the experiences of those in age groups I and III have been dissimilar to those in age group III. Perhaps it is only their perceptions which are different. Whatever the realities, there is overwhelm ing agreement among those respondents under fifty-five years of age that most people in the United States do not ireceive adequate dental care. 84.7% of all respondents agreed that most people do not receive adequate dental i care. i i Responses of men and women were almost identical, . 85.2% and 84.4% respectively stating that they believe most people do not receive adequate dental care : agreement with I item thirteen increased with income. Six out of nine (66.7%) low income respondents agreed as did twenty-three ! out of twenty-seven (85.2%) of the middle income group and ! I fifteen out of sixteen (93.8%) of the high income group. I Nine of the privately insured respondents agreed with the i statement. I i Questionnaire item fourteen asked respondents if I I they felt the poor and the rich should have the same accès- AGE BY OPINIONS PEOPLE RECEIVE TABLE 17 OF WHETHER OR NOT MOST ADEQUATE DENTAL CARE 89 Age Group Count Disagree Agree Row Row Pet Total I (25 to 30) 1 23 24 4.2 95.8 40.7 II (45 to 50) 2 18 20 10.0 90.0 33.9 III (65 or over) 6 9 15 j 40.0 60.0 25.4 COLUMN 9 50 59* ! TOTAL 15.3 84.7 100.0 *Missing Observations = 3 sibility to dental care. The item was not concerned with the source of payment or the methods by which services might be provided. It does intend to examine a generalized ,attitude about whether or not wealth (income) should be a determining factor in the provision of dental health ser- I vices. I The responses indicate that age is not a signifi- I I cant variable. 91.8% of all respondents believe that both jpoor and rich should have the same access to dental care. Although the percentage differences were slight, age groups 90 I and III did indicate the most agreement, 91.7% and 93.8% respectively. In age group II, 9 0.5% indicated agreement. TABLE 18 AGE BY: POOR PEOPLE SHOULD HAVE THE SAME ACCESS TO DENTAL CARE AS RICH PEOPLE Age Group Count Disagree Agree Row Row Pet Total I (25 to 30) 2 22 24 8.3 91.7 39.3 II (45 to 50) 2 19 21 9.5 90.5 34.4 III (65 or over) 1 15 16 6.3 93.8 26.2 COLUMN 5 56 61* TOTAL 8.2 91.8 100.0 *Missing Observations = 1 : Once again, women were more likely than men to respond on I the more liberal side. Thirty-three of thirty-four (97.1%) I I women agreed with this item as compared to twenty-three of I I twenty-seven (85.2%) of the men. All eleven of the pri- :vately insured respondents supported equal access to dental : care fur Lhe poor and rich. This item could turn out to be one of the more important questions examined in this study. : The support for such an egalitarian position was unexpected 91 There is obviously overwhelming agreement that poor people should have accessibility to comprehensive dental health services. Disagreement is more likely to revolve around how those services might best be financed. : Item fifteen was an attempt to look at the same issue of accessibility from a slightly different perspec tive and was extended to include health care, i Item fifteen stated: "Comprehensive health care, including dental services, should be available to every- 1 one." Only three respondents (two men and one woman) strongly disagreed with the item, two from age group I and one from age group II. No one selected disagreed. The responses were collapsed to agree and disagree. The re sults were similar to the responses on item thirteen. Age groups I and III showed the most agreement but the differ ences are not significant. 83.3% of age group I and 93.8% of age group III agree that comprehensive health care, I including dental services, should be available to all. 80.0% of age group II indicated agreement. 95.0% of all I respondents agree that comprehensive health care, including ; dental services, should be available to everyone. 85.0% I of all respondents "strongly agreed." Ten of the eleven privately insured respondents "strongly agreed." (One privately insured respondent did not answer this item). 92 TABLE 19 AGE BY; COMPREHENSIVE HEALTH CARE, INCLUDING DENTAL SERVICES, SHOULD BE AVAILABLE TO EVERYONE Age Group Count Disagree Agree Row Row Pet Total I (25 to 30) 2 22 24 8.3 91.7 40.0 II (45 to 50) 1 19 20 5.0 95.0 33.3 III (65 or over) 0 16 16 0.0 100.0 26.7 COLUMN 3 57 60* TOTAL 5.0 95.0 100.0 ^Missing Observations ' = 2 To whatever extent these respondents reflect the desires ! of the general population, it appears that the people if not the Congress are ready to support national health pro grams . It seems how these programs should be financed and administered may be at issue, but not the need for such ; programs. It is this author's opinion that the cost of health care has escalated beyond the reach of such a large I segment of our population that many who would have opposed i I national health programs only a few years ago now regard 1 them as an inevitable necessity. 93 Item nineteen was intended to relate to the two I I proceeding items. If respondents felt dental services I : should be equally available to the poor and the rich, and I if they felt comprehensive health care, including dental services, should be available to everyone, would they agree that more governmental support for more comprehensive den- ! tal programs is needed? Item nineteen was negatively I stated as: "There is no need in the United States for more i I comprehensive dental programs." 91.8% of all respondents disagreed with item nine teen. That is, when responses were collapsed to agree and disagree 91.8% indicated that they believe there is a need ! for more comprehensive dental programs. The percentage of ' respondents who disagreed with the statement decreased with I age. 95.8% of the respondents in age group I and 90.5% in age group II disagreed. 87.5% in age group III disagreed. , The decreasing percentages are not significant in them selves but they are of interest when compared with re sponses to item seventeen (Table 9) which is discussed I above. Item seventeen indicated that 87.5% of age group I i and 81.3% of age group III agreed that governmental support for dental programs is needed* 6 6.7% of age group II . agreed. Thus, even though there is agreement between age groups that we need more comprehensive dental programs, i ! age group I and III are in much more agreement that govern- I I 94 TABLE 20 AGE BY THE NEED FOR MORE COMPREHENSIVE DENTAL PROGRAMS There is no Need for More Comprehensive Dental Programs Age Group Count Row Pet Agree Disagree Row Total I (25 to 30) 1 4.2 23 95.8 24 39.3 II (45 to 50) 2 9.5 19 90.5 21 34.4 III (65 or over) 2 12.5 14 87.5 16 26.2 COLUMN TOTAL 5 8.2 56 91.8 61* 100.0 *Missing Observations =-1 ; mental support for such programs is needed. With such strong agreement that more comprehensive j programs are needed, the actual numbers in disagreement I are small. One woman and four men do not believe a need I for more comprehensive programs exists. Again, among the . privately insured there was unaminity. All eleven believe ' such a need exists. 95 Item twenty-one was the final item related to Index B. This statement was intended to determine whether or not j respondents believed that dental services are unavailable i : to many people and that the lack of services is serious j enough to be considered a serious social problem by the I I respondents. I Item twenty-one was stated as; "The lack of dental ; care received by many people in the United States is a I serious social problem." i 67.7% of all respondents either strongly agreed or I ! agreed with the statement. 3 2.2% either strongly disagreed or disagreed. Age group I recorded the lowest level of agreement (60.9%). There was little difference between ' age groups IT and III, 71.5% and 73.3% were in agreement. , The differences may be attributable to the possibility I that respondents in the youngest age cohort may have been ; more likely to receive regular dental care during their I life times. i 1 Women were much more likely to agree that the ! inadequate dental care received by many people constitutes I a serious social problem. Twenty-six of .thirty-three I I women (78.8%) agreed with item twenty-one compared to 1 fourteen of twenty-four (53.8%) of the men. These re sponses have a chi square value of 3.07 9, significant at the 0.079 level. It may be that women place a higher I 96 Ipersonal value on good dental care then do men. The women I jmay also be more sensitive to the need for good dental ! health care since, in addition to their own dental needs, they are also exposed more directly to the dental needs of their children as they arrange for appointments and accom pany their children to the dentist. ' The accessibility of dental care also appears rele vant, Only one half of those privately insured agreed with item twenty-one. Only 52.9% of the respondents with in comes of $17,000 or more agreed. 7 0% of the low income group and 73% of the middle income group agreed. Thus, as I accessibility to dental health services increases the Ilikelihood that one will perceive the lack of these ser vices as constituting a serious social problem decreases. In other words, if you can afford dental services or have insurance to pay for them you are less likely to perceive a problem. SUMMARY As was true with Index A, the items in Index B did Inot prove to be significantly interrelated and can not be ; treated together as ordinal data. The responses to the I I individual questionnaire items do indicate that health care and specifically dental health care is regarded as an area of social concern by the majority of respondents in each of I 97 I the age cohorts. It can be assumed that one appropriate jconclusion is that a large majority of the respondents see la need for additional and more comprehensive dental health ,services to be made available to the public. There is i I less support in age group II for the governmental provision ,of such programs and services but even in this group 66.7% I agree that governmental support of programs and services is needed and when governmental support is not mentioned !90.5% of group II agree more comprehensive programs are Ineeded. I I j C. PARTICIPATION IN PRE-PAID PLANS ! Index C provides a look at the respondents' use of j jdental programs which are not based on fee-for-service (privately insured respondents and those on Medi-Cal), and whether or not respondents feel a need for private (non- I governmental) dental insurance programs. I Item thirty asked whether or not the respondent had any type of dental insurance. : Eleven respondents reported that they have dental I insurance. 81.7% of all respondents reported that they do jnot. Women were slightly more likely than men to have den- Ital insurance. Not one respondent with an annual income of t !$4,999 or less had dental insurance. The differences be- itween groups are remarkable. 100% of those in age group I 98 III reported that they have no dental insurance. 7 9.2% of age group I and 7 0.0% of age group II are without dental I insurance. Item thirty-one asked, "Have any of your dental services ever been paid for by Medi-Cal?" The population being served by the dentists who participated in this study 1 ! should have included approximately seventy-five Medi-Cal recipients. Only four respondents, all women, indicated ! they have ever received any dental services through Medi- ;Cal. 91.3% of the respondents in age group I reported that I Medi-Cal had never paid for any of their dental services. 95.2% of age group II and 92.9% of age group III indicated 'that Medi-Cal had never paid for any of their dental ser vices . Item thirty-two is closely related. It asked, "Are you presently covered by Medi-Cal?" Eight respondents : replied affirmatively. Two respondents in age group I and I ione in age group II replied in the affirmative. Responses I of age group H I indicated that 3 5.7% (5) were Medi-Cal ; recipients, most whom had apparently not received any den- i Ital care under the acute and emergent care provisions of ! the program. The respondents in this study thus comprise a j group of individuals few of whom have had experience with iMedi-Cal or with private dental insurance programs. I There was considerable agreement between the three I age groups in their responses to item sixteen, which L . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 99 stated: "Private dental insurance should be readily avail- I able to the public." I I Agreement with item sixteen is almost unanimous I with only one individual each (both men) in groups II and j jIII in disagreement. The high level of agreement among I the beneficiaries of private insurance programs on many I I issues has been discussed above. Too few respondents par- !ticipate in other than fee-for-service programs to make I jany sweeping generalizations. One can conclude that these ! respondents would purchase private dental insurance if the I jpremiums were within their means. This conclusion may I also be valid for a significant number of the general pop- I 'ulation. I ! SUMMARY As is true with the other indices, relationships I ; between items must be evaluated separately. Of most sig- Inificance among these items is the fact that fifty-nine I out of sixty-one respondents believe that private dental i insurance programs should be readily available to the 1 public. If one recalls the strong support for governmental ' provision of dental health services, it is reasonable to I conclude that the public (to the extent this sample may be I considered a reliable indication) is willing to support dental programs for the poor and should present a ready I market for reasonably priced dental insurance. 100 D. RESPONDENTS' INVOLVEMENT WITH DENTAL HEALTH SYSTEM The items selected for Index D attempt to examine i 'whether or not there are aqe differences related to the ! ! ! respondents involvement in the dental health care system. I I Involvement in the dental health care system included items : related to salience, that is, whether or not the respon- j dents considered dentistry as part of the medical pro- i fession and viewed regular dental checkups as important I as medical checkups. The number of visits to the dentists ! in 1972, the expenditure for dental care, and whether or I i not the respondent followed his dentists' recommendations I were also used to determine the extent of involvement. It I I was assumed that those respondents who tended to equate f i dentistry and medicine, who had more frequent contact with and followed the recommendations of their dentists, and who spent more on dental care could be considered more involved than those who gave lower salience to dentistry than medicine and had less contact with their dentists. Item one on the questionnaire stated: "Dentistry is part of the medical profession." When responses are collapsed to disagree and agree, 98.4% of all respondents agree that dentistry is part of the medical profession. An overwhelming 83.6% of the respondents strongly agreed. Only one respondent, a woman in age group II disagreed r 101 I with the statement. All eleven insured respondents agreed, j i ten strongly agreed. Group differences are significant in 1 that 100% of those in group I strongly agreed, as did : 81.3% of those in group III. Only 66.7% of group II ' strongly agreed. I i TABLE 21 I • AGE BY WHETHER OR NOT RESPONDENT AGREED THAT i DENTISTRY IS PART OF THE MEDICAL PROFESSION Dentistry is Part of the Medical Profession Age Group Count Disagree Agree Strongly Row Row Pet Agree Total I (25 to 30) 0 0 24 24 0.0 0.0 100.0 39.3 II (45 to 50) 1 6 14 21 4.8 28 .6 66.7 34.4 H I (65 or over) 0 3 13 16 0.0 18 .8 81,3 26.2 COLUMN 1 9 51 61 TOTAL 1.6 14.8 83.6 100.0 *Missing Observations = 1 Item six on the questionnaire asked if respondents felt that dental checkups were less important than medical checkups. The statement read, "It is not as important to j 1.02 I get dental checkups as it is to get medical checkups." I Responses were collapsed to agree and disagree. 78.7% of I all respondents believe that dental checkups are as impor- I tant as medical checkups. The percentage of those dis- ! agreeing decreased with age. That is, more older respon- ; dents agreed that it is not as important to get dental ^ checkups as it is to get medical checkups. Whereas 8 7.5% I I of group I and 7 6.2% of group IT disagreed with the state l y I ment, only 68.9% of the respondents in group III disagreed. I i It is possible that respondents in group III are more con- ; cerned with their physical health than respondents in I I group I and II. Inconsistent with the responses on items ! 1 previously discussed which indicated greater concern and generosity on the part of the female respondents, more men than women gave equal priority to dental and medical check- ' ups. Twenty-three of twenty-seven men (85.2%) replied ' that dental checkups are not less important than medical ! checkups. Twenty-five of thirty-four women (73.5%) so i responded. This is the only major item on which the women did not reflect a more concerned interest than the men. The reasons for this shift are unknown. One can speculate that women place a higher value on both dental and medical checkups then do men, but that they place a distinctly higher value on routine physical checkups. Respondents were asked in item twenty-seven if AGE AND WHETHER OR I CHECKUPS AS LESS 103 TABLE 22 NOT RESPONDENTS CONSIDER DENTAL IMPORTANT THAN MEDICAL CHECKUPS 1 Dental Checkups Are Less ! Important than Medical ' Checkups Age Group Count Agree Disagree Row Row Pet ! Total ' I (25 to 30) 3 21 24 1 1 12.5 87 .5 39.3 II (45 to 50) - 5 16 21 23 .8 76.2 34.4 j ; III (65 or over) 5 11 16 - 31.3 68.8 26.2 COLUMN 13 48 61* TOTAL 21.3 78 .7 100.0 *Missing Observations = 1 ■ V they followed the recommendations of their dentists always, 1 I most of the time, sometimes, seldom, or never. Not one ' respondent selected choices "always" or "never" which may I : indicate a rather high degree of honesty among the respon- I I dents. 63.3% of all respondents said they follow their i dentists' recommendations "sometimes," 26.7% said "most of I the time" and 10.0% said "seldom." Differences between L__ 104 groups are not marked. TABLE 23 AGE BY THE FREQUENCY OF FOLLOWING THE DENTISTS' RECOMMENDATIONS I follow the Recominendations Of My Dentist Age Group Count Seldom Sometimes Most of Row Row Rot The Time Total I (25 to 30) 3 16 5 24 12.5 66.7 20.8 40.0 II C45 to 501 ' 1 14 5 20 5.0 70,0 25.0 33.3 III C65 or oyerl 2 8 6 16 12.5 50.0 37,5 26.7 COLUMN 6 38 16 60* TQTAL 10.0 63 .3 26,7 100.0 *Mxssi,ng Observations Differences in responses between men and women were unremarkable except that men were more likely to re spond that they seldom follow their dentists' recommen dations (five men to one woman). This may be another I indication that women place a higher esthetic Cor appear- I ance) value on the results of good dental care than do men. There was again unanimity among the insured respon- 105 dents. All eleven responded that they "sometimes" followed the recommendation of their dentist. Items twenty-eight and twenty-nine asked for the ; number of times the respondent visited his dentist during I 1972 and the amount of dental expenses incurred. Both I items were open-ended. Responses were later grouped for ! I analysis. Since the sample for this study was selected i from the active patients from the practices of the coop- I erating dentists, all respondents had visited the dentist I j at least once during 1972. 52.7% of all respondents I visited their dentists from one to three times during the j calendar year. 29.1% had four to nine appointments and i I 18.2% had ten or more appointments during the year. Dif- ! ferences between groups were not marked, probably because the sample included only active dental patients and did not include individuals who either have no dentist or did not visit the dentist during 1972. The differences between groups in the amount paid for dental care during 19 72 were greater than the number of visits. Dental expenses ranged from zero (for those covered by insurance or Medi-Cal) to over $10,000 for one member of age group II. Twenty-two respondents paid $50 or less for their dental care. Seventeen respondents paid between $51 and $200 and five paid between $201 and $400. Seven respondents paid from $401 to $600. Fifty of the TABLE 24 AGE BY NUMBER OF DENTAL VISITS DURING 1972 106 « Visits Age Group Count 1 - 3 4 - 9 10 + Row Row Pet Total I (25 to 30) 12 8 3 23 52.2 34,8 13.0 41.8 II :(45 to 50) 9 5 5 19 47.4 26,3 26,3 34.5 III (65 or over) 8 3 2 13 61.5 23,1 15.4 23.6 COLUMN 29 16 10 55* TOTAL 52.7 29.1 18 .2 100.0 *Missing Observations = 7 sixty-two respondents paid $600 or less for their dental care in 1972. Seven more paid between $601 and $1,000. Five paid more than $1,000. No one in age group I paid over $1,000 for dental care, 5.9% of those in group III and 19.0% of those in group II paid over $1,000. A total of 8.1% of the respondents incurred dental expenses of over $1,000 during 1972. 35,5% of all respondents in curred expenses of $50 or less. 56.5% paid between $51 and $1,000 for their dental care. 107 TABLE 25 AGE BY DENTAL EXPENSES INCURRED IN 19 72 Dental Expenses Age Group Count $0 - 50 $51 - 1000 Over Row Row Pet $1000 Total I (25 to 30) 9 V 15 0 24 37.5 62.5 0.0 38.7 II (45 to 50) 4 13 4 21 19.0 61.9 19.0 33 .9 III (65 or over) 9 7 1 17 52.9 41.2 5.9 27.4 COLUMN 22 35 5 62 TOTAL 35.5 56 .5 8.1 100.0 ; SUMMARY As was true with previous indices, agreement be- i tween the items was not significant and responses to each item must be evaluated individually. Item responses to Index D do indicate overwhelming agreement among respon dents that dentistry is part of the medical profession and that dental checkups are as important as medical exami nations. Respondents in groups II and III indicate that they are more likely to follow the recommendations of their dentists, but their responses are not markedly dif- 108 ferent than those from group I. Differences in the number of dental visits were not significant between groups, but ; members of group I tended to have fewer dental expendi- ! i tures. Sixty-two per cent of the men visited their den- i tist three or fewer times in 197 2, whereas fifty-five ! I per cent of the women saw their dentists four or more i I times during that year. One-half of the privately insured j saw their dentists one to three times and half visited I their dentists four or more times. Only two of the pri vately insured visited their dentists ten or more times. I Expenditures for dental care during 1972 were I quite similar for men and women, with women tending to spend slightly more. Expenditures for the insured respon- ' dents (the amount paid by the insurance company plus any : co-payments) tended to be slightly lower than for the un insured, but they were more likely to exceed costs of $1,000. Two of the eleven insured respondents exceeds j $1,000 in dental expenses as compared to three of the forty-nine uninsured. Women utilize dental health services more than men and insured patients less than uninsured patients, but the differences are not as great as might be expected of the general population. Generally, women make consider ably greater use of dental services than men and the emphasis on preventative services should decrease utili- 109 zation among the insured. Differences between groups in a random sample of the general population would probably be greater. All respondents in this study are active patients I I who have their own dentist. I E. ESTHETIC IMPORTANCE OF DENTAL CARE I ! Index E attempted to determine if there are age I I differences in respondents' attitudes about the esthetic iimportance of dental care. Younger people were expected Îto yield more positive attitudes about the esthetic values i I of dental care. That is, younger respondents were ex- i pected to indicate greater concern about the importance of 1 * the role dental care can play in improving physical appear- ‘ ance and one's self-concept. ! Questionnaire item three stated: "Good dental care can help improve one's self confidence." 95.1% of all respondents either "agreed" or "strongly agreed. " Only one person (a male respondent in group III) marked "strongly disagree" and two people (both males from group II) marked "disagree*. V All of the women agreed (and all but five "strongly agreed") and all eleven of the privately insured respondents agreed. One of the respondents in disagreement earned $4,99 9 or less in 197 2 and had not gone beyond grade school. The other two had incomes of $17,000 or more, one i 110 I had completed two to four years of college and the other I had completed five to six years of college. A remarkable ; 93.8 of the respondents in group III "strongly agreed," 7 5.0% in group I and 57.1% in group II "strongly agreed.!' jThe remaining 25.0% in group I "agreed" as did 33.3% in I ,group II. Respondents indicated a more positive response ! to the positive relationship between good dental care and iself confidence than had been anticipated. The almost 1 ; total agreement within group III indicates stronger feel- !ings than the three to one split between "agree" and I ! "strongly agree" in group I. Of most significance, how ever, is the fact that only three respondents selected ! negative answers. Item nine on the questionnaire is related to the I proceeding item but personalizes the issue by asking if ! the respondent agrees or disagrees that : "The condition I ; of my teeth and mouth is important to how I feel about myself." While one might expect greater agreement within and between groups on this item than on the proceeding, more generalized item, there was greater divergence. 95.1% of all respondents gave positive replies on the more generalized item compared to 88.3% on this item. Three respondents gave negative replies to the general statement compared with seven responding negatively to the more personally stated item. Respondents in group III were relatively consistent but slightly more tempered in their ' TABLE 26 AGE BY ATTITUDES TOWARD THE CONCEPT THAT GOOD DENTAL CARE CAN HELP IMPROVE SELF CONFIDENCE 111 Good Dental Care Can Help Improve Self Confidence Age Group Count Strongly Disagree Agree Strongly Row Row Pet Disagree Agree Total I (25 to 30) " 0 0 6 18 24 0.0 0.0 25.0 75.0 39.3 IT (45 to 50) 0 2 7 12 21 0,0 9.5 33.3 57.1 34.4 III (65 or over) 1 0 0 15 16 . 6.3 0.0 0.0 93.8 26.2 COLUMN 1 2 13 45 61* TOTAL 1.6 3.3 21.3 73 .8 100.0 *Missing Observation = 1 'responses. 93.8% responded positively on both items but itwo respondents changed their answer. One member of group ■III who "strongly agreed" with item three "agreed" with litem nine. The other negative responses were less empha tic and shifted from "strongly disagree" to "disagree." 87.0% of the respondents in group I and 85.7% in group II gave positive responses. More women agreed than men, thirty-two out of thirty-four women responding positively. AGE BY LEVEL OF TEETH AND MOUTH 112 TABLE 27 AGREEMENT THAT THE CONDITION OF ONE'S ARE IMPORTANT TO FEELINGS ABOUT SELF Age Group Count Strongly Agree Disagree Strongly Row Row Pc t Agree Disagree Total I C25 to 30) 18 2 0 3 23 78.3 8.7 0,0 13,0 38.3 II (4 5 to 50) 15 3 0 3 21 71.4 14.3 0.0 14.3 35.0 III (65 or over) 14 1 1 0 16 87 .5 6.3 6.3 0.0 26.7 COLUMN 47 6 1 6 60* TOTAL 78.3 10.0 1.7 10.0 100.0 *Missing Observations = 2 as compared to twenty-one out of twenty-six men (94.1% to 180.8% respectively). Ten of eleven insured respondents agreed. The variables of incomes and education were un remarkable, perhaps because of the small size of the popu lation. [ Item eight on the questionnaire, while still con cerned with esthetics, introduces a possibility for an age bias to show up within and between groups. The statement is: "After a certain age teeth are no longer important to how one looks." 113 j Only 8.3% of all respondents (three men and two jwomen) strongly agreed with item eight, none marked '"agreed," When income was classified as low, medium and ! high, three of these respondents were in the low class- I I ification and two were in the middle classification. 91.7 I of all respondents gave negative responses. Groups I and I ' II each yielded one response of "disagree;" In other I words, 91.7% of group I, 85.0% of group II, and 87.5% of i I group III "strongly disagreed" with the statement, "After a certain age teeth are no longer important to how one looks,;" The insured respondents were again unanimous, I I all were in strong disagreement with the statement. The i I strong responses indicate few differences of opinion I either between or within the age groups. : Item eleven on the questionnaire was intended to [ elicit responses which reflect esthetic attitudes which are not unnecessarily personalized and which are not equated with respondents' conceptions of need. Item eleven stated: "Dental care should not be used merely to improve one's appearance." Simple observation of the amount of orthodontic and prosthodontic dental care which is done for cosmetic purposes would lead one to expect consider able disagreement with statement eleven. Responses to items three, eight, and nine (discussed above) should also be indicative of disagreement with item eleven. Surpri- 114 1 TABLE 28 I I AGE BY LEVEL OF AGREEMENT THAT ONE FEELS AFTER A ! CERTAIN AGE TEETH ARE NOT IMPORTANT TO ONE'S APPEARANCE Age Group Count Row Pet I (25 to 30) II (45 to 50) III (65 or over) COLUMN TOTAL After A Certain Age Teeth Are Not Important to Looks Strongly Agree Disagree 1 4.2 2 10,0 2 12.5 5 8.3 *Missing Observations 1 4.2 1 5.0 0 0.0 2 3.3 Strongly Disagree 22 91.7 17 85.0 14 87 .5 53 88.3 Row Total 24 40 .0 20 33.3 16 26.7 60* 100 .0 singly, this was not the case. 67.2% (41) of all respon- I dents "strongly agreed" with item eleven and 9.8% (6) "agreed" yielding 77.0% (47) in agreement. Only 19.7% (12) "strongly disagreed" and 3.3% (2) "disagreed," for a total negative response of 23.0% (14). Age group I yielded the highest affirmative response with 83.3% agreeing that den- 'tal care should not be merely cosmetic. 16.7% of the re spondents in group I strongly disagreed with the statement. 115 81.0% of the respondents in group II responded in agree ment. 4.8% of group II disagreed and 14.3% strongly dis- jagreed. The division of responses was most marked in age I group III. 67.2% of the respondents in group III strongly iagreed (an additional 9.8% agreed) with the statement and I ■31.3% strongly disagreed (an additional 3.3% disagreed). 137.5% of the respondents 65 years of age and over appar- 'ently believe dental services should be used for purely I cosmetic purposes compared with 16.7% of those between ’twenty-five and thirty years of age and 19.0% of those ages I I jforty-five through fifty. Men and women were in unusual agreement on this item; 77.8% of the men and 76.5% of the I women agreeing that dental services should not be used I I merely to improve one's appearance. Nine of the eleven insured respondents agreed. Income and education levels I did not appear related to these responses. I The responses to question eleven were not as ex pected before this study was undertaken. The general j public purchases a variety of cosmetic dental services at no small expense. Considering the positive responses to I the other items in this study, the reasons for these par- :ticular findings are all the more nebulous. ! From the standpoint of esthetic value, there is strong evidence that the condition of one's teeth and mouth can affect one's level of self confidence and that adequate dental care is important at all ages. It remains surpris- ! 116 Iing that forty-seven respondents agreed that dental care j should not be used merely for cosmetic reasons. i j SUMMARY i Responses on all items in Index E indicate that a I I high value is placed on the esthetic aspects of dental ! health services. The esthetic value was almost universal i jamong respondents, regardless of age, sex, education, in- I come, or insurance status. The differences which did exist were limited to only a few respondents who differed with I the overwhelming majority. Only item eleven produced any I unexpected results and this may be more a reflection of the I choice of wording in the statement. Had item eleven been ! stated as, "Dental Health services should be utilized to I improve one's appearanceV" responses may have been con sistent with the responses on other items in this index. ’It is possible that other items in this study influenced ! responses. If we had not been concerned with attitudes ; toward governmental provision for dental health services, t there might have been greater support for cosmetic dentis- 1 try. ; Although the significance of each item must be I examined independently of other items in Index E, it is j apparent that the respondents in this study do place con- Isiderable importance on the esthetic and cosmetic aspects j of dental health services. j 117 I j F. RESPONDENTS' SATISFACTION WITH CURRENT DENTAL RELATIONSHIP ) ! I The items constructed for Index F were intended to ! jdétermine whether or not there are age differences in atti- I jtudes related to the level of satisfaction the subjects I have experienced with their dental care delivery system. It was assumed that as age increased the degree of satis faction would decrease. i I Item four on the questionnaire stated: "I am happy }with my relationship with my dentist." Responses were col- ! lapsed to agree and disagree. 91.7% of group I, 85.7% of I group II, and 80.0% of group III agreed with the statement. ! ■ The high percentage of agreement is not unexpected since almost all respondents would be free to choose another den- ,tist if they were dissatisfied. Transportation difficul- ! ties, especially for the aged, and other convenience fac tors may be significant variables. The relevant point of this item is that levels of agreement do decrease with age and age is the only variable of interest on this item. When the variables of sex, income, education and insurance status were held constant differences within those groups were insignificant. While 86.7% of the respondents agreed that they are happy with their relationships with their dentists, 75.4% of the respondents feel their dentists' fees are too ! ... ■ ........ ... j 118 TABLE 29 1 1 AGE BY RESPONSES TO ITEM FOUR: I AM 1 HAPPY WITH MY RELATIONSHIP WITH MY DENTIST 1 Age Group Count Disagree Agree Row 1 Row Pet' ! Total i I (25 to 30) 2 22 24 k 8.3 91.7 40.0 1 11 (45 to 50) 3 18 21 i I 14 .3 85.7 35.0 III C 65 or over) 3 12 15 i i 20.0 80.0 25.0 1 COLUMN 8 52 60* TOTAL 13.3 86.7 100.0 *Missing Observations i = 2 high. Item five on the questionnaire stated: "The fees charged by my dentist are too high." 29.5% of the respon dents strongly agreed, 45.9% agreed. 16.4% of the respon dents strongly disagreed and 8.2% disagreed. When respon ses were collapsed to agree and disagree, 7 0.8% of group I and 71.4% of group II agreed that fees were too high. 87.5% of group III agreed. This marked increase may be a reflec tion of the limited incomes of the elderly and the older populations cognizance of the potential drain medical expenses can have on their often fixed and marginal in- ... ..... comes. TABLE 30 AGE BY OPINIONS OF WHETHER OR NOT SUBJECTS' DENTAL FEES ARE TOO HIGH 119 Age Group Count Agree Disagree Row Row Pet Total I (25 to 30) 17 7 24 70.8 29.2 , 39.3 II (45 to 50) 15 6 21 71.4 28.6 34.4 III ( 65 or over) 14 2 16 87.5 12.5 26.2 COLUMN 46 15 61* TOTAL 75.4 24.6 100.0 *Missing Observations = 1 i As income increased respondents were less likely to feel the fees were too high. The level of the respondents* ! ; education did not effect the responses. Subjects were asked whether or not they considered ! it easy to get an appointment with their dentist and wheth- j er or not they believed it is usually difficult to get an ; appointment with most dentists. Item two was positively stated as, "It is easy to get an appointment with my den- I tist." Responses were collapsed to agree and disagree. 120 It is interesting to note that while respondents in group III were the least likely of the three groups to report I ' that they were happy with their relationships with their I dentists, they had less complaint than group II regarding j the ease of getting an appointment with their dentists. ; 81.3% of group III agree that it is easy to get an appoint- ! ment with their dentist. This is fairly consistent with i I the 8 0.0% who are happy with their dentists. There were ^ more marked changes, and in the opposite direction, for I group I and II. 87.5% of group I and 71.4% of group II ' agreed with the statement. 80.3% of the respondents do ! agree that it is easy to get an appointment with their dentists. The disagreement of the other twelve respondent:^' does not appear to be related to sex or education. Nine out of ten respondents in the low income group reported that they consider it an easy task to secure appointments with their dentists. As income increased respondents were more likely to disagree. This finding was unexpected and unaccounted for. It seems highly unlikely that more affluent patients have greater difficulty getting dental appointments. Item seven on the questionnaire was negatively stated and asked for a generalized opinion about the dif ficulty of getting an appointment with dentists. The statement was, "In my opinion, it is usually difficult to get an appointment with most dentists." The respondents ■ ..■ ........ - ' ........ ■ ' - ......... ...... 121 TABLE 31 AGE BY OPINIONS REGARDING WHETHER OR NOT IT IS EASY TO GET AN APPOINTMENT WITH RESPONDENTS' OWN DENTIST Age Group Count Disagree Agree Row Row Pet Total I (25 to 30) 3 21 24 12.5 87.5 39.3 II (45 to 50) 6 15 21 28.6 71.4 34.4 III (65 or over) 3 13 16 18.8 81.3 26 .2 COLUMN 12 49 61* TOTAL 19.7 80.3 100.0 *Missing Observations = 1 were more divided on this item than on the proceeding one. 50.8% of all respondents agreed that it is usually dif ficult to get an appointment with most dentists, 41.7% of the respondents in group I agreed. 6 0.0% of the re spondents in group II agreed, as did 53.3% in group III. Whether these responses reflect differences in perception or if younger people are given preferential treatment in getting dental appointments is not known. Respondents in group I are most likely to agree that it is easy to get an appointment with their own dentist and dentists in general. 122 TABLE 32 AGE BY OPINIONS REGARDING WHETHER OR NOT IT IS DIFFICULT TO GET AN APPOINTMENT WITH MOST DENTISTS Age Group Count Agree Disagree Row Row Pet Total I (25 to 30) 10 14 24 41.7 58.3 40.7 II (45 to 50) 12 8 20 60.0 40.0 33.9 III (65 or over) 8 7 15 53.3 46.7 25.4 COLUMN 30 29 59* TOTAL 50.8 49 .2 100.0 *Missing Observations = 3 More importantly, many respondents in this study apparently believe it is usually difficult to get appoint ments with most dentists and, therefore, probably consider themselves fortunate that they do not experience such dif ficulty with their dentist. Whether fact or fiction, this perception may increase one's satisfaction with his own dentist. Responses are not related to sex, education or insurance status, but as income increases so does agreement with this statement. Respondents were equally divided in the responses 123 to item ten which stated, "In my opinion, most dentists do I not provide high quality service to their patients." When ! responses were collapsed to agree and disagree, 50.0% agreed. Respondents in group II were the most critical of I 1 the quality of services provided by most dentists, 61.9% I agreed that most dentists do not provide high quality ser- I vice. 43.5% of group I and 42.9% of group III agreed. The ! responses to this item should be of special interest to 'dentists. Exactly one-half of the men and one-half of the I women indicated agreement with the statement. Agreement jremained high regardless of income, education or insurance 1 I I status. I The respondents expressed more faith in the quality of services being provided by their own dentists. Ques- 'tionnaire item twenty-five asked respondents to rank the quality of dental care they had received during the past few years as poor, fair, good, or excellent. 7 0.8% of those in group I rated the quality of care they have re ceived as "excellent" and 20.8% rated their quality of dental care as "good." In group II, 55.0% responded that they have received "excellent" dental care and 30.0% rated their care as "good." Respondents in group III indicated greater dissatisfaction. 56.3% said they have received "excellent" care, but only one rated his care as "good." 25.0% of the respondents in group III rated their quality of dental care as only "fair" and 12.5% of these respond- 124 ents said they have received "poor" dental care. Their Iresponses may be related to early dental experiences when i the level of pain was higher and the extraction of teeth ! ;more frequent. Dental health services have improved over I the past several years and as a result younger people may ihave received significantly better care. i j I TABLE 33 I COMPARISON OF AGE BY PRECEIVED : QUALITY OF DENTAL CARE RECEIVED Quality of Dental Care Age Group Count Poor Fair Good Excellent Row Row Pet Total I (25 to 30) 1 1 5 17 24 4.2 4.2 20.8 70.8 40.0 II (45 to 50) 2 1 6 11 20 10.0 5.0 30.0 55.0 33.3 III (65 or over) 2 4 1 9 16 12.5 25.0 6.3 56.3 26.7 COLUMN 5 6 12 37 60* TOTAL 8.3 10.0 20.0 61.7 100.0 *Missing Observations = 2 Women were more likely than men to rate their care as either "good" or "excellent." Ratings of "good" or "excellent" were also more likely among those with higher I 125 j income and higher education levels. All of the insured I respondents rated their care as "good" or "excellent , " a ; positive statement for dental care on an other than fee- ifor-service basis. I I SUMMARY I I Respondents in group I appear to be most satisfied I with the dental care they have received. They are most ! likely to report that they are happy with their dentists, I they are at least slightly less likely than those in group i I II to report that their dentists' fees are too high (and ! 1 considerably less likely than those in group III to so I report), they apparently have little if any difficulty in getting an appointment with their own dentist and they tend to be of the opinion that it is generally not diffi cult to get an appointment with most dentists. Levels of satisfaction with one's own dentist, the fees charged, and ease of access appear higher when referring to one's own dentist. Whether>or not the younger people (especially the women in this age group) receive preferential treatment by dentists is unknown and presents an area worthy of exploration. i CHAPTER VI I ! SUMMARY AND IMPLICATIONS i I The purpose of this chapter is to draw together the purposes, procedures and results of this study. i i SUMMARY I The major purpose of this study was to determine if j there are age differences in attitudes toward governmental ! intervention in the provision of dental health services. The youngest and oldest age groups (groups I and III) were ; expected to show the most support for governmental pro grams. Respondents forty-five to fifty were expected to show the least support. Other questions were given second ary attention. Respondents were asked questions which attempted to determine possible age differences in (1) attitudes toward the provision of payment for dental health services, (2) attitudes toward dental health as an area of social concern, (3) participation in pre-paid plans, (4) involvement with dental health system, (5) esthetic impor tance of dental care, and (6) satisfaction with current dental relationships. Rather than finding a variety of significant dif ferences within and between age groups, the more important 126 I 127 'discovery is the strong support that exists within and be- Itween age groups for the provision of more comprehensive 'dental health services. Respondents regard dentistry as part of the medical profession. ' 78.7% of the respondents agree that governmental support for more comprehensive dental programs is needed. The least support for govern mental intervention came from group II, and even in group II, 66.7% favored governmental support of dental care pro grams. 88.1% of all respondents agreed that Medi-Cal should include provisions for preventative dental health services. Respondents support the concept of governmental provision of payment for services for those who cannot pay , for their own dental care. One can conclude from the re sponses shown in Table 12 that programs which provide in dividuals with an opportunity to participate in a combi nation of private and public programs would receive strong public support. Programs which provide an opportunity to select one's own dentist would be more favorably received than programs which do not allow for choice. The problems related to receiving adequate dental care do constitute an area of social concern for the re spondents. They perceive that adequate dental services are not readily accessible and availab]e to the public and they believe dental care should be readily available to everyone. It was not surprising that 86.7% of the respondents reported that they were happy with their relationship with ; 128 i their dentists since all were able to choose different den tists had they experienced negative relationships. Re spondents believe it is easier to get an appointment with ■ their own dentist than it is to get an appointment with I dentists in general. Perhaps that is one reason why they are generally happy with their own dentists. Or, perhaps, ; the respondents exaggerate the difficulty people generally have in securing dental appointments. It is noteworthy I 'that in spite of the positive attitudes the respondents have toward their dentists, 75.4% did report that they believe their dentists' fees are too high. Respondents in groups I and III tended to have i fewer dental appointments and lower dental expenses than did members in group II. One could expect to find even ! greater disparities in a sample which included individuals who do not have a dentist or who do not tend to see a den tist regularly. Respondents do have attitudes which indicate that I the condition of one's mouth and teeth are important to one's self-concept. The esthetic value placed on the re sults of adequate dental care may be a factor in the sup=^ port received for the governmental provision for dental 'health care. Fewer respondents participated in either private I dental insurance programs or Medi-Cal and the significance of experience in other than fee-for-service dental care in 129 relation to support for governmental programs cannot be definitively determined from these respondents. The almost unanimous agreement among the privately insured respondents on several items does appear to be an important consid eration. For example, item eighteen which supported pre ventative dental health services in Medi-Cal received unan imous affirmation from this group. Programs to insure equal accessibility to dental health services for rich and poor alike was also unanimously supported. All ten who responded (one privately insured person did not respond) to item fifteen "strongly agreed" that comprehensive health services, including dental care, should be available to everyone. There is considerable support from all respondents for greater participation from the government in providing support for programs and services which will improve the quality of dental health service available to all people, but especially to those who cannot afford to pay for their own dental care. All but five respondents in the total sample agreed that there is a need in the United States for more comprehensive dental health programs (item nineteen). If responses to these and other items in this study are at all representative of the total population there is obvious support for developing barrier-free health services. That is, health services which are accessible, comprehensive and within financial reach of all. 13Û IMPLICATIONS FOR SOCIAL POLICY AND SOCIAL WORK PRACTICE This study was intended to facilitate the explor ation of attitudes and opinions of people toward govern mental intervention in the provision of dental health services and to identify possible differences within and between three age groups. There are readily apparent limitations. The sample is small and it consists of people who do utilize dental services. Their concern and support for related issues may be greater than that of the general population. The findings are useful in strengthening various assumptions, but should be tested on a larger sample. Ages were selected in this study to emphasize difference between age groups. There may be value in look ing for similarities and differences in a much larger popu lation which includes all ages in the sample. The respondents in this study do provide us with information from people who place positive values on dental care and provide responses from people who would utilize the types of programs and services that are indicated by the study. Additional information about the kinds of policies and programs which would bring non-users to these services need to be developed. We need to further deter mine what specific services are deemed desirable by and for specific age groups and still allow for individual choice and flexibility, attributes apparently valued by the 131 ! I majority of respondents in this sample and by almost all of I those sixty-five and over. This research adds empirical evidence to the via- I bility of public policies which delineates among groups of people to facilitate providing assistance to people who are in need. All three age groups showed support on item twenty-two which stated that dental health services should be made available to "all who cannot afford to pay" for their dental care. As previously stated, items sixteen and eighteen indicate strong support for governmental pro vision of such services. Interlocking programs between individuals, employ ers, private insurance and the government to provide for comprehensive dental health services have the greatest sup port. For example, the author would expect the respondents of this study to support governmental subsidies for private dental insurance programs. An employer and employee could contribute toward the premiums and if the earnings of the employee fell below a certain level the government could, on a sliding scale based on earnings, contribute toward the premium. The government could make payment on a per capita basis to a private insurer to cover the premiums of the unemployed or programs such as Medi-Cal could be ex panded to include comprehensive dental health services. Respondents do not want to be dependent upon a single source. Rather, they appear to support those methods of ; 132 1 I providing services which seem to contain the elements of 'checks and balances attributed to pluralistic programs. t The responses of the participants in this study warrant i careful consideration and further study is indicated. , Policy formation and program development should examine and respond to the attitudes, interests and needs of the population to be served. Social workers, aware of the economic, social and ' psychological costs of fragmented and inaccessible services and the limitations of Medicare and Medi-Cal, can begin to identify the need for removing these barriers to dental I health services. The health, attitudes toward self and the , confort of many individuals can be affected by the quality of care they receive. Comprehensive dental health programs are apparently seen by these respondents as desirable and worthy of public support. To date there has been consid erable discussion by the United States Congress advocating various programs of National Health Insurance and Health Maintenance Organization, except for very limited acute care dental health services are excluded from these legis lative proposals. The findings in this study indicate that the exclusion is neither warranted nor desirable. If fur ther research substantiates these conclusions Congress should be urged to respond to the public interest. APPENDIX Ethel Percy Andrus Gerontology Center University of Southern California University Park Los Angeles, California 90007 There is presently much discussion going on about how the medical needs of the people of the United States might best be met. Your dentists and others interested in the provision of health care services are examing possible ways of providing better dental services to more people. In an effort to increase our knowledge and under standing of how we can improve dental services, a research project is being conducted at the University of Southern California to learn more about what dental patients see as their dental needs and concerns. Representatives from the Andrus Gerontology Center, the School of Social Work and the Dental School have been involved in the development and supervision of this project. You have been chosen to participate in this study because of your recent use of dental services. Although your dentist is cooperating in this research, he will not receive the completed questionnaire. All information will be treated with the strictest confidence and will be used only for statistical purposes in conjunction with the responses from all respondents. If you wish, a summary of the findings will be mailed to you. Please complete the questionnaire as soon as con venient and return it in the enclosed envelope. If you have any questions about this research please direct them to me. Thank you for your cooperation. Sincerely, William C. Albert, ACSW 133 134 DENTAL CARE SERVICES SURVEY , This questionnaire is designed to secure information about your experiences with dentists and dental services and your opinions and attitudes about these experiences. There are no right or wrong answers to any of the questions. You are asked to circle the number that best applies to you, or to check one of the blanks provided. In all cases the numbers I mean the following; 1 = strongly disagree with the statement 2 = disagree somewhat 3 — agree somewhat 4 = strongly agree with the statement Date of birth _________' Sex_________ mo./day/yr M or F Race: Oriental White Mexican-American_______ Black ___ Other____ Education : Grade school or less Less than 2 years of college Junior high school ___ 2 to 4 years of Some high school__________ college Completed high school ___ 5 to 6 years of college More than 6 years of college 1. Dentistry is part of the medical profession. Disagree 1 2 3 4 Agree 2. It is easy to get an appointment with my dentist Disagree 1 2 3 4 Agree 135 3. Good dental care can help improve one's self confi dence . Disagree 1 2 3 4 Agree 4. I am happy with my relationship with my dentist. Disagree 1 2 3 4 Agree 5. The fees charged by my dentist are too high. Disagree 1 2 3 4 Agree 6. It is not as important to get dental checkups as it is to get medical checkups. Disagree 1 2 3 4 Agree 7. In my opinion, it is usually difficult to get an ap pointment with most dentists. Disagree 1 2 3 4 Agree 8. After a certain age teeth are no longer important to how one looks. Disagree 1 2 3 4 Agree 9. The condition of my teeth and mouth is important to how I feel about myself. Disagree 1 2 3 4 Agree 10. In my opinion, most dentists do not provide high qual ity service to their patients. Disagree 1 2 3 4 Agree 11. Dental care should not be used merely to improve one's appearance. Disagree 1 2 3 4 Agree 12. The provision of dental services under Medi-Cal is not a necessary program. Disagree 1 2 3 4 Agree ! 136 113. Most people in this country do not receive adequate I dental care. I Disagree 1 2 3 4 Agree 14. Poor people should have the same access to dental care as rich people. Disagree 1 2 3 4 Agree 15, Comprehensive health care, including dental services, should be available to everyone. Disagree 1 2 3 4 Agree ,16. Private dental insurance should be readily available to the public. Disagree 1 2 3 4 Agree 17. Governmental support for more comprehensive dental ! programs is needed. Disagree 1 2 3 4 Agree 18. Medi-Cal should provide for preventative dental health services as well as for acute and emergent care. Disagree 1 2 3 4 Agree 19. There is no need in the United States for more compre hensive dental programs. Disagree 1 2 3 4 Agree 20. Adult children should be required to pay for their elderly parents' dental care, if the parents cannot afford it. Disagree 1 2 3 4 Agree 21. The lack of dental care received by many people in ' the United States is a serious social problem. Disagree 1 2 3 4 Agree I 137 .FOR THE FOLLOWING QUESTIONS, PLEASE CHECK THE ANSWER WITH ! WHICH YOU MOST AGREE. 22. The Federal and/or State government should pay for the dental care of : 1. no one 2. only children whose parents cannot afford to pay 3. only the elderly who cannot afford to pay 4. all who cannot afford to pay 5. all children '6. all elderly 7. all elderly and all children 8. everyone 23. It is important that dental programs allow: 1. free choice of dentists 2. some choice of dentists 3 . choice of dentists is not important 24. Major responsibility for the payment for dental ser vices should rest with : 1. the individual 2. job related insurance 3 . the State 4. the Federal government 5. a combination of the above, including______ (Please write in which combination you prefer). 25. The quality of dental care I have received during the past few; years has been: 1. excellent 2. good 3. fair 4. poor 26. If an individual cannot pay for his dental care, den tal programs should be available when; 1. the condition is serious 2. the service is considered necessary by the dentist 3, the service is considered desirable by the dentist 138 4. the service is considered desirable by the patient I 27. I follow the recommendations of my dentist: 1. always 2. most of the time _3. sometimes 4, seldom 5. never 28. During the past year (1972) I visited my dentist times. (Number) 29. My dental expenses for 1972 came to approximately $ 30. Do you have any type of dental insurance? 1. yes If yes, through whom?___________________ 2. no 31. Have any of your dental services ever been paid for by Medi-Cal? 1. yes If yes, when (approximate date) 2 . no 32. Are you presently covered by Medi-Cal? 1. yes 2. no 33. Annual income (Circle the answer that comes closest to the combined annual incomes of all the members of your household). 13,000 - 14,999 23,000 - 24,999 15,000 - 16,999 25,000 - 29,999 17,000 - 18,999 30,000 - 34,999 19,000 - 20,999 35,000 - 39,000 21,000 - 22,999 40,000 - 49,999 50,000 - or more ! 139 I 34. I would like to receive a summary of the results of I this study. ! __1. yes 2. no 140 1 Ethel Percy Andrus I Gerontology Center I University of Southern California ]University Park I Los Angeles, California 90007 I ' Dear ! Thank you for your cooperation and participation in ; my research on attitudes and opinions toward governmental I intervention in the provision of dental health services. i j When you completed the research questionnaire, you I indicated that you would like a report of the findings. j It is my pleasure to enclose an abstract of the project. ! I sincerely appreciate the assistance you provided. ! Although the number of respondents in this first study ! were small, the study has generated broader interest and 'may be the beginning of efforts to study related data from ‘ a national sample. Without the cooperation of interested ; people like yourself, such research would not be possible. ' Again, I thank you. Sincerely, William C. Albert, ACSW Enc SOURCES CONSULTED Anderson, G, W. "The Social and Medical Matrix of Health and Well Being." International J. of Orthodontistry [March, 1967): 54-59. Bender, A. E. "Nutrition of the Elderly." Royal Society of Health Journal (1971): 91:115.121. Bengston, Vern L. The Social PsychoTogy of Aging. New York: the Bobbs-Merrill Company, Inc., 1973. Birren, James E. The Psychology of Aging. Englewood Cliff, New Jersey; Prentice-Hall, Inc., 1964. Boulding, Kenneth. Principles of Economic Policy. Engle wood Cliff, New Jersey: Prentice-Hall, 1958. Cooke, B. E. D. "Oral Problems in the Elderly." Geron- tologia Clinica (Basel) [1971): 13:359.67. Council on Dental Care Programs. "New Policies on Dental Care Programs." JADA 86 [January, 1973). Cowgill, Donald. "The Aging of Populations and Soci eties." The Annals of the American Academy of Political and Social Sciences [September, 1974). Dworkin, S. F. "Psychological Aspects of Aging-Implica tions for Dentistry." Dental Assistant (November, 1970): 24. Elfenbaum, A. "The Burning Tongue in an Elderly Patient - A Case History." J. of Am. Soc. for Geriatric Dent (October, 1973). Elfenbaum, A. President, American Society for Geriatric Dentistry, Chicago, Illinois. Communications, December, 1974. Encyclopedia of Social Work, 19 71 ed. S.v. "Health As a Social Problem : Illness and Poverty," by George Silver. 141 142 Gil, David. "A Systematic Approach to Social Policy Analysis." Social Service Review 4 4 (December, 1970): 411-426. Ingle, John, Dr. Los Angeles, California. Interviews. April and May 197 2. Kutner, B.; Fanshel, David; Togo, Alice; and Langer, Thomas. Five Hundred QVef 60. Russel Sage Founda tion, 1956. Larson, O. F. and Hay, D. G . "Differential Use of Health Resources by Rural People," N.Y. State J. Med (1952): 52:43. Leven, Bernard, Dr. Los Angeles, California. Interviews. April and May 197 2. Dr. Leven continued to provide advice and information through December, 197 2. Loether, Herman. Problems Of Aging. Belmont, Ca.: Dickin son, 1967. McKinney, John C. and De Vyver, Rank T. editors. Aging and Social Policy. New York: Appleton, Century- Crofts, 1966. Rudd, Arthur, D. D. S. Spokane, Washington. Interviews. November, 1970. Schoen, Max, D. D. S. "Group Practice and Poor Communi ties." American J. of Public Health (June, 1970): 1125-1132. Schwartz, Larry, D. D. S. Spokane, Washington. Inter views. November, 1970. Shuvall, J. T. "Methods of Assessing Public Attitudes to Health." The International Journal of Ortho- dontistry (March, 1967): 63-71. Stahl, S. S. "Nutritional Influences on Peridontal Disease." World Review of Nutrition and Dietetics (1971); 13:277.97. Taubenhaus, L. J. and McCormick, J, G. "The Use of Physician Services by the Aging." Geriatrics (1963): 18:122. Title XVIII of the Social Security Act in Compilation of the Social Security Laws I Washington, D. C .: Government Printing Office, 1968. 143 Toward a National Policy on Aging Proceedings of the 1971 White House Conference on Aging by Arthur S. Felming, Chairman. Washington, D. C .: Government Printing Office, November 28-December 2, 19 71. Walsma, John P. "Attitudes and Knowledge of the Aged Regarding Old Age Insurance and Old Age Assistance." DSW Dissertation, University of Southern Califor nia, 1970.

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Asset Metadata

Creator Albert, William Charles (author)

Core Title Dental health services and the aging: a gerontological perspective for social policy

School School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 1976-01

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest,social sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-18653

Unique identifier UC11632814

Identifier DP32430.pdf (filename),usctheses-c37-18653 (legacy record id)

Legacy Identifier DP32430.pdf

Dmrecord 18653

Document Type Dissertation

Format application/pdf (imt)

Rights Albert, William Charles

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA