ExecutiveSummary 1
Introduction 3
AssessmentMethods 3
SecondaryDataReview 3
AmericanCommunitySurvey,U.S.Census 3
RegionalWellbeingAssessmentCommunitySurvey,CambridgeHealthAlliance(CHA) 3
OralHealthCommunitySurvey 4
CommunityandStakeholderDiscussions 6 FocusGroups 6
KeyStakeholderInterviews 6
Limitations 6
AssessmentFindings 7
SecondaryDataReviewFindings 7 PopulationSize 7
AgeDistribution 7 Racial/EthnicDistribution 8
Foreign-BornPopulation 8
EnglishLanguageProficiency 9 EducationalAttainment 10
IncomeandPoverty 11
AccesstoCare 12
HealthInsuranceCoverage 14
OralHealthCommunitySurveyFindings 16
HealthStatusandSatisfactionwithOralHealth 16
OralHealthBehaviorsandPractices 17
OralHealthPerceptions 19
DifficultiesDuetoProblemswithOralHealth 19
AccesstoOralHealthCare 21
ExperiencewithProviders 24
CommunityandStakeholderDiscussions 26
StrengthsandAssetsoftheCommunity 26
Day-to-dayConcernsforCommunityResidents 26
PerceptionsofOralHealth 26
FrequencyofRegularDentalVisitsorCheck-Ups 28
PerceptionsofAccessandBarrierstoOralHealthCare
inServicesandCommunitySuggestionsfortheFuture
ExecutiveSummary
NeedsAssessmentsareavaluableinstrumentandmeansforindividualsandgroupsto methodicallylearnfrompopulationsabouttheirexperiences,toidentifyneeds,anddevelop solutions.OralHealthhasbeenhistoricallyseparatedfromUnitedStateshealthcarefinancing, education,delivery,andresearch.ThisOralHealthAssessmentisoneinstitution’s(Cambridge HealthAlliance–CHA)experienceinutilizingavailableresourcesfromthestate’sMedicaid sponsoredtechnicalassistancemarketplace(MassHealthDeliverySystemReformIncentive PaymentProgram)topartnerwithaleadingnon-profitorganizationwithsignificantexperience inconductingneedsassessments(HealthResourcesinAction–HRiA)tolearnfromlocal populations(MaldenandEverett)atriskoforalhealthaccessbarriersandinvestigatetheirlikely needs.
ThisOralHealthAssessmentwasdesignedusingavailableliteratureoncommunityoralhealth needsassessmentsandassociatedoralhealthqualityoflifeinstrumentsimplementedinthe UnitedStates,UnitedKingdom,andelsewhereglobally.Populationsofinterestwereidentified usingrecentutilizationclaimsofnon-traumaticdentalconditionsdatafromthelocallyserving hospitalemergencydepartment(CHAEverettHospital).RelationshipswithCHANeeds Assessmentworkers,community-basedorganization,andsubjectmatterexpertswereconsulted withstudyteammemberstodesignandimplementthefollowingOralHealthAssessment:
● KeyInformantInterviews
● FocusGroups(Malden Senior Living Center, Everett Haitian Community Center, CHA Group Based Opioid Treatment, Malden parents of children)
● OnlineOralHealthSurvey(266 Malden or Everett responses transcribed into English, Spanish, Portuguese-Brazilian, Haitian Creole, Mandarin)
● ExpertAdvisoryGroup (Eight Representatives affiliated with state government, non-profit, grant-awarding, oral health advocacy, healthcare, and academic organizations)
Keyfindingsfromthisreport
▪ Pervasivedisparitiesinaccesstooralhealthservicesbyself-identifyingpeopleintheblack, indigenous,andpeopleofcolorcommunitiesofMaldenandEverett.
▪ Barriersassociatedwithaccessingoralhealthservicesarestronglyassociatedtofinancing, provideravailability,andtrustintheoralhealthsystem.
▪ Respondentsreporttheiroralhealthstatusaffectstheirqualityoflifeasitrelatestotheir abilitytofunctionaswellastheirphysical,psychological,andsocialwellbeing.
Opportunitiesforfurtherworkhighlightedfromthisproject
o Therolethatsocialsupportservices,likecommunityhealthworkersorcarecoordination mayhaveinenhancingaccesstooralhealthservices.
o Therolethateducation,communication,andaccesstopreventiveoralhealthservicesplays inempoweringcommunitiestosupporttheiroralhealthwheretheywork,learn,andlive.
o Thevalueinintegratingoralhealthandtrainingalliedhealthworkerstoaddressoralhealth needsincommunitywithaculturallyhumbleapproach.
o Thevalueinmeasuringoralhealthstatusinacommunity-focusedapproachcomparedwith traditionalhealthcaresystemandprovidercentricmethods.
Thisreportmaybeusedtohelpdirectresourcesfororalhealthandcommunitybuildinginthe communitiesofMaldenandEverett.Healthcareagencies,healthcarepayers,community assessmentorganizationsandindividualsinterestedinaddressingoralhealthneedsintheir communitymayalsousetheprocessandfindingsfromthisreportastheyseefit.
TothecommunitiesofEverettandMalden,thisprojectrepresentsahopefulbeginningtofruitful collaborationsaimedatempoweringindividualsandgroupstoreachhealthyandmeaningful lives.
-AlecS.Eidelman,DMD,MPH CommunityDentist,CambridgeHealthAllianceAcknowledgements
Thisreportisawarethatindividualsandgroupsareentitledtotheirownidentitiesandthatthe actofbeingcharacterizedintodistilledcategoriesforthepurposesofreportscanbeharmfuland hurtful.Concertedeffortsweremadetobringthisawarenesstoourprojectactivities,our language,andtheintentofthisreport.Whileconductingtheactionsofthisproject,wealso recognizetheimpacttheCOVID-19pandemicandcommunity-basedresearchplaysinour communitiesandthankthosethatparticipatedfortheirtime,patience,andeffortstolettheir voicebeheard.
Aspecialnoteofgratitudetothefollowingindividualsandorganizationswhohelpedsupportthe workofthisproject:
CambridgeHealthAlliance:
● PopulationHealthManagement
● DepartmentofCommunityHealth,HealthImprovementTeam
● DepartmentofDentalMedicineandOralHealth
TheExpertAdvisoryGroup
HealthResourcesinAction
Introduction
CambridgeHealthAlliance(CHA)undertookanoralhealth focusedcommunityhealthneedsassessment (oralhealthassessment)processinthefallof2021focusingnarrowlyontheoralhealthofresidents withinitsservicearea.HealthResourcesinAction(HRiA),anon profitpublichealthconsultancy organization,wasengagedtoconducttheCHNA.Thisoralhealthassessmentaimstobetterunderstand theoralhealthneedsofcommunitymembersinMaldenandEverett.MeasuringOralHealthperceptions andstatusatthepopulationlevelinMassachusettsandelsewhereintheUnitedStatesofAmericahas beenconductedinavarietyofmethods,thisproject’sapproachblendsexistingandnovelassessment instrumentstogatherinformation.
AssessmentMethods
ThefollowingsectiondetailshowthedatafortheCambridgeHealthAlliance(CHA)oralhealth assessmentwascompiledandanalyzed.Theidentificationofdatasourcesandthedevelopmentof primarydatacollectioninstrumentswereinformedbyaliteraturescanandtheengagementofan AdvisoryGroupcomprisedofexpertsinthefieldsofcommunityhealthand/ororalhealthandhealthcare policy PriortothisprojectEmergencyDepartmentutilizationdatafornon traumaticdentalconditionsat theCambridgeHealthAllianceEverett(Whidden)Hospitalwereanalyzedtohelpidentifypopulationsat riskofhavinghigherbarrierstoaccessibleroutinepreventativeandbasicoralhealthcare This informationalongsideexistingqualityoflifeinstrumentsinoralhealththatwerevalidatedinmultiple languageandforrelatedriskfactorswereusedtohelpdevelopkeyinformantandfocusgroupguides,as wellasonlinesurveys Theseoralhealthassessmentinstrumentsweredevelopedinadditiontosurvey andfocusgroupaccessandperceptionitemsincludedinaregionalwellbeingassessmentdistributedto thegreatercatchmentareasandwillbepresentedinsubsequentpublicationoftheseefforts Primary analysisofaggregatedqualitativeandquantitativeresultsaimedtoidentifyobservationalanddescriptive statisticsfororalhealthinthetargetcommunities
SecondaryDataReview
American Community Survey, U S Census
ThisoralhealthassessmentincorporateddatafromtheAmericanCommunitySurveythroughUS Censustodescribeoverallsocio demographiccharacteristicsofresidentsofEverettandMalden includingageandracial/ethnicdistribution,educationalattainment,andincome Thesedataarepresented byEverett,Malden,andMassachusetts.Forcertainindicators,additionalstratificationbyrace/ethnicity arepresentedtoshowdifferences.Five yearestimateswereusedtoprovideamorestablesamplesizefor localgeographies.
Regional Wellbeing Assessment Community Survey, Cambridge Health Alliance (CHA)
Concurrentwiththisassessment,theHealthImprovementTeamatCHAledaregionalwellbeing assessment,incollaborationwithhealthcareandcommunitypartnersfocusedonMedford,Somerville, Everett,andMalden TheRegionalWellbeingAssessmentinvolveddatacollectionmethodssuchas secondarydatareview,communityfocusgroupdiscussions,andacommunitysurvey Selectsurveydata gatheredaspartofCHA’sRegionalWellbeingAssessmentwereincludedinthisassessmenttoprovide additionalcontextaroundcurrentperceptionsofandexperiencesaccessinghealthcareandoralhealth access TheWellbeingAssessmentsurveyaimedtogatherresidents’perceptionsaboutthecommunity healthstrengthsandchallengesthatmattermosttopeople,andincludedquestionsaskingabout perceptionsoncommunityassets,naturalandbuiltenvironment,economicandeducationalenvironment, healthcareenvironment,andsocialandculturalenvironment ThesurveywasadministeredduringWinter 2021 2022andwasavailableinEnglish,Spanish,HaitianCreole,Portuguese,andSimplifiedChinese Forthisoralhealthassessment,preliminaryWellbeingAssessmentsurveydataonperceptionsof healthcareandoralhealthcareaccessstratifiedbyEverettandMalden,wherepossible,wereincluded
OralHealthCommunitySurvey
Toobtainamorecomprehensivepictureofresidents’perceptionsaboutoralhealthstatus,accesstooral healthservices,andattitudesaboutoralhealth,HRiA,incollaborationwithCHA,developeda communitysurveywithinputfromadvisorygroupmembersandguidedbyexistingvalidatedquestions fromthefieldorusedinotherstudies Thesurveywasweb basedandofferedinEnglish,Spanish, Portuguese,HaitianCreole,andSimplifiedChinese ThesurveywasdisseminatedbyCHAthroughsocial mediaandemail(includingCHATwitter,CityofMalden’sTwitter,CHAPatientNewsletter,andCHAin Brief)andcollectedresponsesbetweenMarchandApril2022 Atotalof340peoplecompletedthe survey,and266responseswereretainedforanalysesbecauserespondentsindicatedthattheyworked, wenttoschool,orreceivedservicesinMaldenorEverett Themajorityofrespondentscompletedthe surveyinEnglish(865%,n=230),followedby68%inPortuguese(n=18),41%inSimplifiedChinese (n=11),and26%inSpanish(n=7) DatawereanalyzedusingSAS94 Respondentcharacteristicsare summarizedinTable1
Sub groupanalyseswerealsoexplored;however,duetosmallsub groupsamplesizes,theassessment findingsfocusonoverallresults Wherepossible,notabledifferencesobservedbyrace/ethnicityand publicinsurancearedescribedinthetext Chi squareandFisher’sExacttestswereconducted,where appropriate
● Fortherace/ethnicitysub groupanalysis,duetosmallsamplesizesforindividual races/ethnicities,respondentswerecategorizedintotwogroups:BIPOCrespondents(N=138), whichincludesanyrespondentidentifyingasatleastoneraceotherthanWhiteoranyethnicity otherthanEuropean,comparedtonon BIPOCrespondents(N=125).
● Forthepublicinsurancesub groupanalysis,respondentswerecategorizedintotwogroups: respondentswithdentalinsurancethroughMedicaidand/orMedicare(N=85),comparedto respondentswithoutdentalinsurancethroughMedicaidand/orMedicare(N=145).
Table1.CommunitySurveyRespondentCharacteristics(N=266)
Characteristics
TownWhereReside(N=266)
Count Percent
Everett 117 44.0% Malden 77 289% Other 72 27.1%
TownWhereWork,GotoSchoolorReceiveServices(N=259)† Everett 112 57.1% Malden 148 432% None 15 5.8%
Race(N=244)†
Asian 26 10.7%
AmericanIndianorAlaskaNative 10 41% BlackorAfricanAmerican 28 11.5% NativeHawaiianorOtherPacificIslander 3 12% White 174 71.3% Additionalracecategory 10 41%
Ethnicity(N=251)†
Asian 23 92%
BlackorAfricanAmerican 32 128%
BrazilianorPortuguese 27 108% European 132 526% Hispanic,Latino,orSpanish 35 13.9%
MiddleEasternorNorthAfrican 6 2.4%
NativeHawaiianorOtherPacificIslander,orAmericanIndian/AlaskanNative 5 20%
Characteristics
Count Percent
Additionalethnicitycategory 6 2.4%
Age(N=237)
Under18yearsold 11 46% 18 24yearsold 46 194% 25 34yearsold 84 354% 35 44yearsold 52 21.9% 45 54yearsold 18 76% 55 64yearsold 18 76% 65+years 8 34%
CurrentDentalInsurance(N=230)†
Employer basedinsurance 74 32.2%
Privateinsurance(notemployer based) 63 27.4%
MedicaidorMassHealth 73 31.7%
Medicareand/orMedicareandsupplement 14 6.1%
Othersource 2 0.9%
None 29 126%
PrimaryLanguageSpokenatHome(N=237)†
Arabic 4 17%
Cambodian/Khmer 1 04%
CapeVerdeanCreole 4 1.7%
Chinese 6 2.5%
English 193 814% French(includingCajun) 1 04%
HaitianCreole 6 2.5%
Korean 2 0.8%
Portuguese 20 8.4%
Spanish 17 7.2% Vietnamese 2 0.8%
Other 5 21%
EducationalAttainment(N=232)
Lessthanhighschoolorsecondaryschool 4 17%
Somehighschoolorsecondaryschool 15 65%
HighschoolorsecondaryschoolgraduateorGED 47 20.3%
Somecollegeor2 yeardegree 56 241%
Certificationprogramortradeschool 21 91%
Collegegraduate 56 241%
Somegraduateschooloragraduatedegree 33 142%
Gender(N=235)
Female 148 63.0%
Male 84 35.7%
GenderqueerorNonbinary 3 13%
Characteristics
SexualOrientation(N=219)
Count Percent
Asexual 4 18%
Bisexual 12 55% Gay 5 2.3%
Lesbian 5 23%
Queer 2 09%
Pansexual 1 05%
Straight/heterosexual 181 827% Notsure/Questioning 6 27%
Prefertoself describe 3 14%
Parent/CaregivertoaChildUndertheAgeof18(N=245)
Yes 87 35.5% No 158 64.5%
AgeofChildren(N=84)
Under7years 36 43.4% 7 12years 32 386%
13 17years 15 181%
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dagger(†)denoteswherequestionsallowedforrespondentstocheckalloptionsthatapply;therefore,totals maynotaddupto100%;Denominatorsdonotincluderespondentswhodidnotanswerthequestionorselected ‘prefernottoanswer’
CommunityandStakeholderDiscussions
Focus Groups
HRiAheldfourvirtualfocusgroupswithatotalof20participants Focusgroupsweredesignedtogather inputfromavarietyofstakeholdersandincludedthoseinrecovery,parentswithyoungchildren, Haitian speakingcommunitymembers,andseniors Focusgrouppopulationselectionwasinformedby emergencydepartmentutilizationdata(ie,fornon traumaticdentalconditions)forthetargetpopulation andcurrentoralhealthtrends Focusgroupswereapproximately60minutesandcoveredseveraltopics includingparticipants’perceptionsofstrengthsofthecommunity,tophealthconcerns,oralhealthstatus andunderstandingoftheconnectionoforalhealthtooverallhealth/wellbeing,frequencyofandreasons fordentalvisits,facilitatorsandbarrierstoaccessingtooralhealthcare,gapsinservices,and recommendationsforserviceimprovement.
Key Stakeholder Interviews
HRiAinterviewedfivestakeholderswhowereselectedfortheirperspectivesonandrelationshipswith EverettandMaldencommunities,aswellastheirexpertiseandknowledgeoncurrentoralhealthneedsin thecommunities.Intervieweesincludedapediatricdentist,anemergencyclinicdentist,acommunity engagementmanagerwithEverettPublicSchools,thechiefoftheDepartmentofDentalMedicineand OralHealthatCHA,aleaderofanon profitorganizationworkingwiththeHaitianCommunity,anda dentalstudentworkingatafreedentalclinic.Interviewsrangedinlengthfrom30to60minutes. Intervieweeswereaskedtosharetheirperspectivesonsimilarissuesaskedaboutinfocusgroups: strengthsofthecommunity;healthconcerns;oralhealthstatusandunderstandingaboutoralhealth; facilitatorsandbarrierstoaccessingoralhealthcare;servicegaps;andneededprogramsandservices.
Limitations
Aswithalldatacollectionefforts,thereareseverallimitationsrelatedtotheassessment’smethodsthat shouldbeacknowledged Regardingsecondarydata,yearsofthemostcurrentdataavailablemaystillbe afewyearsbehind(forinstance,withtheAmericanCommunitySurveydata theestimatesarefrom 2016 2020) Duetothelagintime,thedatamaynotnecessarilyaccuratelyreflectthecurrent demographicsofthecommunities,especiallytakingimpactsoftheCOVID 19pandemicinto consideration Additionally,secondarydataaroundhealthbehaviorsandoutcomeswerenotavailableat thelocallevel(EverettandMalden),whichlimitthecontextprovided
Thecommunityhealthsurveyfieldedspecificallyforthisassessmentusedaconveniencesamplefor gatheringinformation;whilestrongeffortsweremadetodisseminatethesurveytoabroadcross section ofrespondentsfromtheregion,resultsarenotnecessarilystatisticallyrepresentativeofthelarger populationlivinginEverettandMaldenduetonon randomsamplingtechniques Additionally,the currentsurveyburdenoncommunityresidentsandlackofin personoutreachmayhaveinfluencedwho wouldbemorelikelytorespondtothesurvey Itshouldalsobenotedthatsurveyrespondentsdidnot alwaysanswereveryquestiononthesurvey;therefore,percentagesshownbelowreflectonlythose participantswhoansweredeachquestion
Similarly,whilethefocusgroupsandinterviewsconductedforthisassessmentprovidevaluableinsights, resultsarenotstatisticallyrepresentativeofalargerpopulationduetonon randomrecruitingtechniques andasmallsamplesize.RecruitmentforfocusgroupswasconductedbyCHA,workingwithcommunity partners.Becauseofthis,itispossiblethattheresponsesreceivedonlyprovideoneperspectiveofthe issuesdiscussed.Itisalsoimportanttonotethatdatawerecollectedatonepointintime,sofindings, whiledirectionalanddescriptive,shouldnotbeinterpretedasdefinitive.
AssessmentFindings
SecondaryDataReviewFindings
ThesectionbelowprovidesanoverviewofthepopulationofEverettandMalden Wholivesina communityisgreatlyrelatedtotheratesofhealthoutcomesandbehaviorsofthatarea
Population Size
EverettandMaldenaremid sizedMassachusettscities,northofBoston.1 AccordingtotheAmerican CommunitySurvey,Everett’spopulationwasestimatedtobeabout46,000in2016 2020;Malden’s populationisabout30%largerthanEverett’s,slightlyabove60,500in2016 2020(Table2)
Age Distribution
Overall,bothEverettandMaldenhadyoungerpopulationsthanthestateasawhole:646%ofEverett’s
hadahigherproportionofresidentsunder18,whileMaldenhadaslightlyhigherproportionofresidents 75yearsofageorolder.
Table 3.
Geography
Distribution, by Massachusetts and City/Town, 2016-2020
26.9% 9.5% 7.0%
24.1% 6.9% 4.4% Malden
24.3% 6.8% 6.3%
DATASOURCE:US CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020
Racial/Ethnic Distribution
BothMaldenandEverettwereraciallyandethnicallydiversecities(Table4).Whileacrossthestate, about70%ofresidentsidentifiedasWhite,lessthanhalfofresidentsinbothEverettandMalden identifiedasWhite(413%and459%,respectively) OnequarterofMalden’sresidentsidentifiedas Asian(254%),comparedto8%inEverett,whilenearly30%ofEverett’sresidentsidentifiedas Hispanic/Latino,comparedto10%inMalden
Table4.RacialandEthnicDistribution,byMassachusettsandCity/Town,2016-2020
Population
stateoverall(Figure1) HalfofHispanic/LatinoresidentsandalmosthalfofBlackresidentsinthetwo citieswereborninanothercountry Asshownin Table 5,residentsborninBrazilmakeupalmosta quarterofforeign bornresidentsinEverett(234%),followedbyElSalvador(194%),andHaiti(152%) Overthree quartersofAsianresidentsinMaldenwereforeign born(772%) ForMalden,thelargest proportionsofforeign bornresidentswereborninChina(287%),Brazil(115%),andHaiti(106%)
DATASOURCE:U.S.CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020
asonerace),andmayidentifyasHispanic/Latino
CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016
Overhalfofresidentsovertheageof5inEverettandnearlyhalfinMaldenreportedtospeakalanguage otherthanEnglishathome(59.9%and49.0%,respectively),asubstantiallyhigherproportionthanthe state(23.9%)(Figure2).Furthermore,nearly30%ofresidentsinbothcitiesreportedtospeakEnglish lessthanverywell.Asseenin Table 6,Spanishwasthemostcommonlyspokenlanguageamongthose whospeakalanguageotherthanEnglishathomeinEverett(22.4%),whileChinesewasthemost commonlanguageinMalden(14.6%).ManyresidentsintheEverettandMaldenalsoreportedtospeak French,Haitian,orCajun.
asawhole.Over90%ofWhite,non Hispanicresidentsinthestateandineachofthetwocitieshada highschooldiplomaorhigher.About90%ofBlackresidentsinMaldenand86%ofBlackresidentsin bothEverettandthestatehadahighschooldiplomaorhigher EducationrateswerelowerforHispanic andAsianresidentsover25:71%ofAsianresidentsand72%ofHispanicresidentsinEveretthadahigh schooldiplomaorhigher;inMalden,80%ofAsianresidentsand86%ofHispanicresidentshadahigh schooldiplomaorhigher
Figure3.EducationalAttainment,PercentPopulation25YearsandOver,byMassachusettsand City/Town,2016-2020
DATASOURCE:U.S.CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020
Income and Poverty MedianhouseholdincomesinMalden($73,399)andEverett($70,627)werelowerthanthestate ($84,385),althoughtherearedifferingpatternsacrossracialandethnicgroups(Figure4).InEverett, Blackresidentshadthehighestmedianhouseholdincomeacrossgroups($92,903),whileWhiteresidents wereseentohavethehighestinMalden($78,934).
Figure4.MedianHouseholdIncome,byRace/Ethnicity,byMassachusettsandCity/Town, 2016-2020
DATASOURCE:US CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020 NOTE:AsianandBlackcategoriesincludeindividualsidentifyingastheracecategoriesalone(i.e.,onlyidentifying asonerace),andmayidentifyasHispanic/Latino
WhileMassachusettsandEveretthadsimilarratesofpoverty(9.8%and10.9%,respectively),ahigher proportionofMaldenresidents(156%)livedbelowthepovertyline(Figure 5) Asmallerproportion of EverettresidentsacrossmostracialandethnicgroupslivedinpovertycomparedtoMaldenandthestate. TheproportionofAsian(20.1%)residentslivinginpovertyinMaldenwasthreetimeshigherthanin Everett(7.2%),andtheproportionofBlackresidentslivinginpovertyisoverfourtimeshigher(21.3% and4.7%,respectively).MaldenhasahigherrateofHispanicresidentslivinginpoverty(22.7%)than Everett(16.5%),aboutthesamerateasthestate(23.0%).
DataaboutchildreninpovertyrevealedthatMalden(173%)andEverett(150%)sawhigherratesof familieswithchildrenlivinginpovertythanthestateoverall(103%) Mirroringoverallpovertyrates,a higherproportionofchildrenfromAsian,Black,andHispanicfamilieslivedinpovertyinMalden(81%, 154%,and156%,respectively)thaninEverett(24%,25%,and131%,respectively)
Figure 5. Percent Individuals Living Below Poverty Level, by Race/Ethnicity, by Massachusetts and City/Town, 2016 2020
DATASOURCE:US CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020
NOTE:AsianandBlackcategoriesincludeindividualsidentifyingastheracecategoriesalone(ie,onlyidentifying asonerace),andmayidentifyasHispanic/Latino
Access to Care
BasedontheCHAWellbeingAssessmentcommunitysurveypreliminaryfindings,surveyrespondents fromEverettandMaldensharedsimilarviewsonwhetherhealthcareinthecommunitymeetstheir physicalhealthneeds,withabouthalfofrespondentssayingthatitistruethathealthcareinthe communitymeetstheirphysicalhealthneeds(479%and513%,respectively)
(Figure 6). Thefigurealsopresentsthesedataby sub groups.Thereweresomedifferencesinresponses acrossracial,ethnic,andlanguagegroups:forexample,thelowestproportionsofrespondentsfeelingthat healthcareintheircommunitymeetstheirphysicalhealthneedswereseenamongHaitianrespondents (276%),Blackrespondents(343%),andAfricanAmericanrespondents(345%)
Figure 6. Percent Wellbeing Assessment Survey Respondents’Reporting It Is True That Health Care in Community Meets Physical Health Needs, by Select Sub-Groups, 2022
DATASOURCE:CHAWellbeingAssessmentCommunitySurvey,2022
NOTES:AIAN/NHPIstandsforAmericanIndianorAlaskaNative,orNativeHawaiianorPacificIslander;race categoriesincluderespondentsidentifyingasLatinx,withexceptiontoWhite;CentralAmericanincludes respondentsidentifyingasSalvadoran,Guatemalan,orHonduran;sub groupanalysesbyrace,ethnicity,and languageincludeallsurveyrespondents(notlimitedtothoseresidinginEverettandMalden).
TheWellbeingAssessmentcommunitysurveyalsoaskedaboutrespondents’needtoaccessdifferent typesofhealthcare(e.g.,dental(mouth)care). Figure 7 presentsthesedatabyselectsub groups.Over oneinthreerespondentslivinginEverettreportedthattheyneededdentalcarebutwerenotabletoaccess itinthepastyear(390%),comparedtojustoveroneinfourrespondentslivinginMalden(280%) SimilartrendswereseenamongAfricanAmericanrespondents(552%),Blackrespondents(514%),and Haitianrespondents(500%) inthatthelargestproportionsofrespondentswithinthesegroupsreported tohaveneededdentalcarebutwasnotabletoaccessit
DATASOURCE:CHAWellbeingAssessmentCommunitySurvey,2022
NOTES:AIAN/NHPIstandsforAmericanIndianorAlaskaNative,orNativeHawaiianorPacificIslander;race categoriesincluderespondentsidentifyingasLatinx,withexceptiontoWhite;CentralAmericanincludes respondentsidentifyingasSalvadoran,Guatemalan,orHonduran;sub groupanalysesbyrace,ethnicity,and languageincludeallsurveyrespondents(notlimitedtothoseresidinginEverettandMalden).
Health Insurance Coverage
Mirroringpopulationpatterns,bothEverett(125%)andMalden(135%)hadalowerproportionof residentscoveredbyMedicarethanthestate(173%)(Figure 8) Bothcitieshadahigherproportionof residentscoveredthroughMedicaidthanthestate Over40%ofEverettresidentsarecoveredby Medicaid,substantiallyhigherthanMalden(285%)andthestate(224%)
Figure 7. Percent Wellbeing Assessment Survey Respondents’Reporting They Needed Dental (Mouth) Care But Was Not Able to Access in Past Year, by Select Sub Groups, 2022Figure 8. Percent Civilian Noninstitutionalized Population with Public Insurance Coverage, by Insurance Type, by Massachusetts and City/Town, 2016 2020
DATASOURCE:U.S.CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020
NOTE:Civiliannoninstitutionalizedpopulationincludesindividualsnotresidingininstitutionssuchasnursing homes,incarcerationorcorrectionalfacilities,ormentalhospitals;MedicareandMedicaidcategoriesinclude individualswhoonlyhavethecoverageorincombination
Almost70%ofchildreninEverettwerecoveredthroughMedicaid,ahigherproportionthaninMalden (49.1%)andovertwiceashighasforthestate(33.9%)(Figure9).BothEverettandMaldenhadahigher proportionofseniorresidents(27.6%and26.0%,respectively)coveredbyMedicaidcomparedtothe state(16.5%).
Figure9.PercentCivilianNoninstitutionalizedPopulationwithMedicaid,byAge,by MassachusettsandCity/Town,2016 2020
DATASOURCE:U.S.CensusBureau,AmericanCommunitySurvey,5 YearEstimates,2016 2020 NOTE:Civiliannoninstitutionalizedpopulationincludesindividualsnotresidingininstitutionssuchasnursing homes,incarcerationorcorrectionalfacilities,ormentalhospitals;Medicaidincludesindividualswhoonlyhave Medicaidcoverageorincombinationwithothertypesofcoverage
OralHealthCommunitySurveyFindings
Thissectiondescribestheresultsofthecommunitysurveyfieldedaspartofthisoralhealthassessment. Thepurposeofthesurveywastobetterunderstandoralhealthstatus,attitudesandbehaviorsrelatedto oralhealthcare,andbarrierstoaccessingdentalcareacrossabroadrangeofrespondentswholive,work, gotoschool,and/oruseservicesinEverettorMalden Overallsurveyresultsarepresentedbelow Sub groupanalyseswherenotable(and/orstatisticallysignificant)differencesacrosssub groupsare described Itshouldbenoted,however,thatinsomecases,thenumberofrespondentsinthesegroupsis smallandresultsshouldbeinterpretedwithcaution
Health Status and Satisfaction with Oral Health Surveyrespondentsreportedtobelargelyhealthy,withoverhalfreportingthattheiroverallhealthwas verygoodorexcellent,whileover75%ofsurveyrespondentswhowereparentswithchildrenunderthe ageof18describedtheirchildren’shealthasverygoodorexcellent(Figure 10) Furthermore,when lookingwithinsub groups,whilenotstatisticallysignificant,twiceasmanyBIPOCsurveyrespondents (168%,n=22)asnon BIPOCrespondents(88%,n=11)describedtheiroverallhealthasfairorpoor
Figure10.SurveyRespondents’ReportedOverallHealthStatusForThemselvesandTheir Children,2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
Surveyrespondents’assessmentoftheiroralhealthstatusmirroredtheirassessmentofoverallhealth statuswithover50%reportingthattheiroralhealthstatuswasverygoodorexcellent(Figure 11). AmongBIPOCrespondents,32.6%(n=42)reportedtheiroralhealthtobefairorpoor,comparedto 163%(n=20)ofnon BIPOCrespondents whichisastatisticallysignificantdifference(p=0003, chi square)
Similarly,accordingtosurveyrespondentsidentifyingasparents,alargepercentagereportedthattheir childrenhadverygoodorexcellentoralhealth(643%) Nonotabledifferenceswereseenamong sub-groups
Figure 11. Survey Respondents’Reported Oral Health Status For Themselves and Their Children, 2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
Intermsofsatisfactionwiththeirteeth,overhalfofsurveyrespondentsreportedthattheyweresomewhat orverysatisfiedwiththewaytheirteethlooked(675%),withslightlyoveronequarterbeingvery satisfied(289%)(Figure12) Differencesacrosssub groupswereobservedaroundself reported satisfactionwithteeth AlargerproportionofBIPOCrespondentsreportedtobesomewhatorvery unsatisfiedwiththeirteethcomparedtonon BIPOCrespondents(40.0%and24.6%,respectively),which wasastatisticallysignificantdifference(p=0.01,Fisher’sExactTest).Similarly,40%ofrespondentswho werecoveredbyMedicaidand/orMedicarereportedthattheyweresomewhatorveryunsatisfiedwiththe waytheirteethlooked,comparedtooveraquarterofrespondentsnotcoveredbyMedicaidand/or Medicare notastatisticallysignificantdifference(p=0.06,Fisher’sExactTest).
Figure12.SurveyRespondents’ReportedSatisfactionwiththeWayTheirTeethLook,2022 (N=249)
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
Oral Health Behaviors and Practices
Surveyrespondentswerealsoaskedabouthowoftentheycleanedtheirteethormouthviaavarietyof methods(e.g.,brushingteeth,flossing,etc.).Over90%ofsurveyrespondentsreportedthattheyoftenor alwaysbrushtheirteethwithamanualorelectrictoothbrush,followedby70.9%reportedtheyoftenor alwaysflossedtheirgumsandteeth,and60.5%rinsedwithmouthwash(Figure 13).
Figure 13. Survey Respondents’Methods for Cleaning Teeth and/or Mouth (Percent Reporting Often or Always), by Cleaning Methods, 2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dataarearrangedindescendingorderbypercentoften/always
Over80%ofsurveyrespondentsidentifyingasparentsofatleastonechildunder18reportedthattheir childrenbrushtheirteethorhavetheirteethbrushedoftenoralways(Figure14) Aswithadults,methods suchasoilpulling,cleaningwithamiswakorotherplant,orusingafingerorwashclothwereless common
Figure14.SurveyRespondents’Children’s(Under18Years)MethodsforCleaningTeethand/or MouthinTypicalWeek(PercentReportingOftenorAlways),byCleaningMethods,2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dataarearrangedindescendingorderbypercentoften/always Oral Health Perceptions
Additionally,surveyrespondentswerealsoaskedabouttheirperceptionsoforbeliefsaboutoralhealth,as showninFigure15 Overall,surveyrespondentsreportedthattheyvaluegoodoralhealthandhygiene andappreciatetheimportanceoforalhealthtooverallhealth Over90%ofrespondentsreportedthey agreedorstronglyagreed the condition of their teeth is an important part of their overall health (959%), they need to see the dentist twice a year (934%),and regular visits to the dentist will keep them healthy (927%)
However,amajorityofrespondents(727%)agreedorstronglyagreedthat as they grow old, they accept that they will lose some of their teeth andnearlyonequarteragreedorstronglyagreedthat dental visits are only important if they have a dental emergency (242%) Whenlookingatsub groups,almostonein threeBIPOCrespondents(317%)reportedagreeingorstronglyagreeingthat dental visits are only important if they have a dental emergency,comparedto160%ofnon BIPOCrespondents a statisticallysignificantdifference(p=0004,Fisher’sExactTest)
Figure15.PercentSurveyRespondentsAgreedorStronglyAgreedwithOralHealthPerceptions, 2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dataarearrangedindescendingorderbypercentagree/stronglyagree
Difficulties Due to Problems with Oral Health
Manysurveyrespondentsindicatedthattheyfacedlimitationsorqualityoflifeimpactsattributedtotheir oralhealth,asshownin
Figure16.Mostoftenrespondentsreportedemotionalchallengesconnectedtotheiroralhealth:almost halfofsurveyrespondentsreportedthattheyoftenoralways worried about dental or mouth problems (435%)andoneinthreerespondentsreportedthattheyoftenoralways felt tense (363%)or have been embarrassed about their teeth, mouth, or dentures (317%) Surveyrespondentsalsoreported experiencingphysicaldiscomfort:nearlyonethirdofrespondentsreportedthattheyoftenoralways found it uncomfortable to eat any foods (308%)andoveroneinfour had painful aching in their mouths (274%)
WhenexaminingresultsamongBIPOCrespondentscomparedtonon-BIPOCrespondents,therewere somenotabledifferencesseenwithregardtoexperiencesofdifficultiesduetoproblemswithteeth, mouth,ordentures Forexample,overhalfofBIPOCrespondentsreportedtohaveoftenoralways been worried by dental or mouth problems (525%,n=63)comparedtoaboutonethirdofnon BIPOC respondents(345%,n=41) astatisticallysignificantdifference(p=0006,Fisher’sExactTest) Almost halfofBIPOCrespondentsreportedtheyoftenoralways felt tense because of problems with their teeth or mouth (462%,n=54),comparedto286%(n=34)ofnon BIPOCrespondents,whichisastatistically significantdifference(p=0007,Fisher’sExactTest) Additionally,ahigherproportionofBIPOC respondentsreportedtheyoftenoralways found it uncomfortable to eat any foods (417%,n=50) comparedtonon BIPOCrespondents(219%,n=26) astatisticallysignificantdifference(p=0001, Fisher’sExactTest)
Whenlookingbypublicdentalcoverage,onethird(33.3%)ofrespondentswhowerecoveredby MedicaidorMedicarefortheirdentalinsurancereportedthattheyoftenoralways felt life in general was less satisfying because of problems with teeth, mouth or dentures comparedto16.4%ofthosewithout publicinsurance(p=0.006,Fisher’sExactTest).
Figure16.SurveyRespondents’ReportedExperiencesofDifficultiesDuetoProblemswithTeeth, Mouth,orDenturesinPastSixMonths(PercentReportingOftenorAlways),2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dataarearrangedindescendingorderbypercentoften/always
Access to Oral Health Care
Themajorityofallsurveyrespondentsreportedthattheyhavearegulardentist(80.6%).Responses differedacrossdifferentgroups.Whenlookingbyrace/ethnicity,aboutonequarterofBIPOCrespondents reportedthattheydonothavearegulardentistorhygienist(25.8%,n=31),comparedto12%(n=14)for non BIPOCrespondents astatisticallysignificantdifference(p=0.008,Fisher’sExactTest).
AsshowninTable1,over80%ofallrespondentsreportedtohaveatleastoneformofdentalinsurance withnearlyonethirdreportinghavingemployer basedinsurance(32.2%),followedby31.7%reportingto havedentalcoveragethroughMedicaid(orMassHealth),and27.4%reportingtohaveprivateinsurance (notemployer based).Whenlookingbyrace/ethnicity,44.3%(n=50)ofBIPOCrespondentsreportedto havedentalinsurancethroughMedicaidorMassHealthcomparedto20%(n=20)ofnon BIPOC respondents astatisticallysignificantdifference(p=0.0001,Fisher’sExactTest).
Intermsofdentalcaresources,over60%ofsurveyrespondentsreportedthattheyusuallygettheirdental carefromaprivatedentist(65.6%),whileanother33.6%gotoacommunitydentalclinic(
).
Additionally,somenotabledifferenceswereseenwhenlookingatreporteddentalcaresourcesbycertain sub groups.Forexample,oneineightBIPOCrespondentsreportedtonothavealocationwherethey usuallygetdentalcare(125%,n=15)comparedto26%(n=3)oftheirnon BIPOCcounterpart,whichis astatisticallysignificantdifference(p=0006,Fisher’sExactTest) Useofemergencyroomsfordental carewashigheramongrespondentswithpublicdentalinsurance:188%(n=16)ofrespondentswith publichealthinsurance(Medicaidand/orMedicare)reportedthattheygettheirdentalcareformanurgent careprovider,comparedto76%(n=11)ofrespondentsnotcoveredbyMedicaidand/orMedicare (p=002,Fisher’sExactTest)
Figure17.SurveyRespondents’ReportedUsualSourceofDentalCareWhenNeeded,2022 (N=238)
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTE:Dataarearrangedindescendingorder
Nearlythree-quartersofallsurveyrespondentsreportedthattheyhadseenadentistwithinthelast12 months( Figure18) Whiletherewasvariationbetweengroups instratifiedanalyses,fewrosetothelevelof statisticalsignificance Onenotabledifferencewasseeninonespecificsub groups asmaller proportionofBrazilianorPortugueserespondentsreportedtohavehadadentalcheck upwithinthepast year(500%,n=11)comparedtonon BrazilianorPortugueserespondents(794%,n=170)(p=0001, Chi squaretest) However,itisimportanttostatethatthesamplesizeofthisgroupisverysmall,and resultsshouldbeinterpretedwithcaution
Figure18.SurveyRespondents’ReportedTimeSinceLastDentalCheck-Up,2022(N=240)
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
Slightlylessthanonequarterofallsurveyrespondentsreportedthattheyhadnotvisitedadentistor hygienistinthepastyear.Whenaskedaboutreasonsforthis,respondentsmostoftencitedthecostofcare (49.1%),followedbylackofdentalinsurancecoverage(38.6%),andnothavingaregularsourceofdental care(24.6%)(Figure19).
Figure19.SurveyRespondentsReportedReasonsforNotVisitingaDentistorHygienistinPast Year(AmongThoseWhoHaveNotHadaDentalCheck-upinPastYear),2022(N=57)
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTES:Dataarearrangedindescendingorder;reasonswithfewerthanfiveresponses(<10%)arenotpresentedin figure;questionwasonlyaskedtorespondentswhoindicatedtheyhadnothadadentalcheck upwithinthepast12 months
Furthermore,about40%ofsurveyrespondentsreportedthattherewasatimeinthepast12monthsthat theyneededdentalcarebutcouldnotgetit Largerproportionsofsomesub-groupsreportednotgetting dentalcarewhentheyneededit:overhalfofBIPOCrespondents(517%,n=60)vs 306%(n=34)of non-BIPOCrespondents(statisticallysignificant,p=0002,Fisher’sExactTest)and450%(n=36)of respondentswithdentalcoveragethroughMedicaidorMassHealthvs 355%(n=49)ofrespondents withoutcoveragethroughMedicaid(notstatisticallysignificant,p=0195,Fisher’sExactTest) Whenaskedbroadlyaboutchallengesthatmadeitharderforthemtogetcaretheyneededfromadentist orhygienist,aboutonethirdofallsurveyrespondentsreportedtohavenotexperiencedanyissueswhen gettingdentalcaretheyneeded Intermsofbarriers,surveyrespondentsmostoftencitedcostofcare (271%),COVID 19concerns(250%),andlackofdentalinsurancecoverage(165%)asmakingitharder forthemtogetdentalcare(Figure20)
AmongBIPOCrespondents,about80%(n=97)reportedtohaveexperiencedatleastoneofbarrier makingitharderforthemtogetdentalcare,comparedto50%(n=57)ofnon BIPOCrespondents a statisticallysignificantdifference(p<0.0001,Fisher’sExactTest).LargerproportionsofBIPOC respondentsreportedCOVID 19concernsandnothavingaregularsourceofdentalcareasbarriers comparedtonon BIPOCrespondents(34.2%,n=41vs.14.9%,n=17and16.7%,n=20vs.7.0%,n=8,
respectively) bothofthesebeingstatisticallysignificantdifferences(p=0.001andp=0.03,Fisher’s ExactTest,respectively).
Additionally,oneinfiverespondentswithdentalcoveragethroughMedicaidorMassHealth(191%, n=16)citedthelackofeveningorweekendservicesasabarrier,comparedto92%(n=13)ofrespondents whodonothavecoveragethroughMedicaid astatisticallysignificantdifference(p=004,Fisher’sExact Test)
Figure20.SurveyRespondents’ReportedBarrierstoAccessingOralHealthCareinthePast12 Months,2022(N=236)
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTES:Dataarearrangedindescendingorder;reasonswithfewerthantenresponses(<5%)arenotpresentedin figure
Experience with Providers
Lastly,thesurveyaskedrespondentsabouttheirexperienceswithdentistsandhygienists.Overall,survey respondentsreportedpositiveinteractionswiththeirdentalprovidersduringvisits,sharingthatproviders oftenoralways treated them with courtesy or respect (88.9%), spent enough time with them (84.1%), listened carefully (83.2%),and explained things in a way that was easy to understand (80.6%)(Figure 21).
Whenlookingbyrace/ethnicity,anumberofnotabledifferenceswereobserved.Asmallerproportionof BIPOCrespondentsreportedtheirdentistoftenoralways explained things in a way that was easy to understand comparedtonon BIPOCrespondents(79.7%,n=90vs.90.2%,n=101) astatistically significantdifference(p=0.04,Fisher’sExactTest).Furthermore,asmallerpercentageofBIPOC respondentsreportedtheirdentistoftenoralways spent enough time with them (83.3%,n=90)compared to929%(n=104)ofnon BIPOCrespondents alsoastatisticallysignificantdifference(p=004,Fisher’s ExactTest)
Figure21.SurveyRespondents’ReportedExperienceswithDentistorHygienistDuringVisit (PercentReportingOftenorAlways),bySituation,2022
DATASOURCE:CambridgeHealthAllianceOralHealthCommunitySurvey,2022
NOTES:Dataarearrangedindescendingorderbypercentoften/always
CommunityandStakeholderDiscussions
Focusgroupsandinterviewswereconductedtounderstandexistingassets,challenges,andgapsrelatedto oralhealthfromtheperspectivesofresidentsandoralhealthprovidersandcommunityleaderswhowork inEverettandMalden Thissectiondescribeskeythemesthatarosefromtheseconversations
Strengths and Assets of the Community
Acrossfocusgroupsandinterviews,diversityandsocialcohesionwereidentifiedastwoofthemost prominentstrengthsofthecommunities Participantsandintervieweespointedtolarge,hardworking immigrantgroupsinbothcommunities,andinparticular,astrong BraziliancultureinMalden Whileracialandethnicdiversitywere describedmostoftenbyfocusgroupparticipantsandinterviewees, oneintervieweealsonotedthatthereisdiversityinincomeand agewithinthetwocommunitiesaswell
EverettandMaldenwerealsodescribedascommunitieswith strongsocialcohesion Residentspointedtocloseconnections amongneighborsandthroughcommunityinstitutions,suchas churches Intervieweesalsosharedthatthecommunitieshave stronginstitutions,includingschoolsandtheCHAclinic
Day to day Concerns for Community Residents
Whendiscussingday to dayconcernsofresidents,focusgroupparticipantsandintervieweesmostoften mentionedthesocialdeterminantsofhealth,particularlyforlowerincomeresidentsandnewer immigrants.Intervieweesandfocusgroupparticipantsalikestatedthathousingisexpensive,makingit difficultforsomeresidentstoaffordtostayinthearea.Participantssharedthathomelessnesshasbeen growinginthecommunities.Participantsalsostatedthatthehighcostoffoodandlackofaccessto healthyfoodinsomeareasofthecitieshascontributedtofoodinsecurity,poornutrition,andobesity amongresidents.Focusgroupparticipantscitedthelackofwell payingjobs,inabilitytoaccess transportation,andtrafficandpoorroadmaintenanceasadditionalcommunityconcerns.Itwasalso expressedthatthesecommunitychallengeshavebeenexacerbatedwiththeCOVID 19pandemic.
Concernsaboutthecommunities’youthwerementionedinacoupleinterviewsanddiscussedinone focusgroup.IntervieweesnotedthenegativeimpacttheCOVID 19pandemichashadonyoungpeople’s socialandemotionalhealthandthedisruptionstoacademics.Onefocusgroupparticipantdiscussedthe lackofcommunity basedsupportservicesforyouth.
Concernsrelatedtoaccessinghealthcarewerealsosharedininterviewsandduringfocusgroup discussions Thehighcostofhealthcarewasacommontheme Onefocusgroupparticipantshared,“[It’s] not difficult to get care, but costs are high ” Otherhealthcareconcernsmentionedincludedthelackof understandingofhowhealthinsuranceworksandlackofapreventionmindsetthatleadstodelayswhen seekinghealthcare Thesefactors,oneintervieweenoted,allcontributetopoorerhealthoutcomesfor residents
Perceptions of Oral Health
Acrossconversations,poororalhealthstatusamongresidentsofMaldenandEverettwasatheme Several interviewees,allofwhomworkasdentalorcommunityservicesproviders,mentionedahighrateof cariesamongchildren,aswellasmoreseriousissuessuchasbrokenteeth,prematurelossofteeth, driftingdentition,andabscesses Oneintervieweereportedseeingmorebrokenteethandfracturesthan theyhaveseenbefore,whichtheyattributedtoteethgrindinginresponsetothestressandemotionaltoll oftheCOVID 19pandemic Lackofpreventativeoralhealthcareisakeyfactorleadingtomoreserious oralhealthissues,accordingtointerviewees
Participantsinfocusgroupsechoedinterviewees’perceptions,withmanyreportingthattheywerenot satisfiedwiththeirownoralhealth Someparticipantsnotedtheseriousnegativeeffectsofdruguseon theirteethandgums,whileotherparticipantssharedthechallengestooralhealththatcomewithaging Somefocusgroupmembersexpresseddissatisfactionwiththeiroralhealth,despitetakingcareoftheir teeth
Poororalhealthamongchildrenwasmentionedinseveralconversations.Focusgroupparticipantsand intervieweessharedthatparentstendtobelessconcernedabouttheirchildren’sbabyteethsotheyoften donottakestepstocarefortheseteeth.Intervieweesobservedthatsomeparentslackunderstandingabout oralhealth,whichleadstopracticessuchasgivingchildrencandyandsodaandgivingbabiesjuicein theirbottles.Intervieweesprovidingdentalservicestochildrenhaveobservedfillingsandrestorative workinchildren’steeth;onestatedthattheyhavehadtoextractchildren’spermanentteethbecausethey werenotrestorable.Anotherintervieweestatedthatmanychildrenhavehadfillingsandrestorativework, whichtheybelieveddemonstratedthatchildrenhaveaccesstotreatmentwhenneeded,butthatfamilies lackknowledgeabouthowtopreventcaries
Furthermore,focusgroupconversationsrevealedthatparticipants’overallunderstandingofthe connectionbetweenoralandphysicalhealthismixed Somereportedthattheyunderstoodhowimportant goodoralhealthistotheirwellbeingyetalsostatedthattheirprimarycareprovidersdonottalkabout this,whileotherparticipantsreportedthattheydidnotthinkaboutthisconnection Intervieweesalso sharedmixedperspectives Acoupleof intervieweesstatedthattheybelievedresidentsdo understandandappreciatetheoral physicalhealth relationship Oneintervieweesharedanexampleof havingseveralpatientstellthemthattheyfeeltheir oralhealthisaffectingtheirdietanddiabetes However,someintervieweesthoughtthereis insufficientunderstandingofthisvitalconnection
Bothfocusgroupparticipantsandinterviewees sharedthathealthcareprovidersspendlimited,andoftennotime,discussingoralhealthwiththeir patients.Manyfocusgroupparticipantsstatedthattheirprimarycarephysicianshavenotbroughtuporal healthcareforeitherthemselvesortheirchildrenanditispatientswhomustdoso.Onefocusgroup participantsharedthattheyhadtoasktheirdoctoraboutfluoridefortheirchild.Anotherfocusgroup participantstated, “The problem is that [with] the PCP, if you don’t bring up oral health issues yourself, then they won’t get addressed.” FocusgroupparticipantsrecalledthatCHAhadaHaitiandoctoratone timewhodidaskaboutoralhealth,whichtheyappreciated.
Frequency of Regular Dental Visits or Check Ups
Manyfocusgroupparticipantssharedthattheyseeortrytoseeadentistregularly;forsome,thishad beenmoreinconsistentduringtheCOVID 19pandemic Others,however,reportedthattheyseekdental careonlywhenthereisaproblem Someintervieweesnotedthispatternaswell:lowerincomeresidents andothervulnerablegroupstendtotakeamorereactive approachtooralhealthcare Costistheprimaryreason fordelayeddentalcareaccordingtofocusgroup members Afocusgroupparticipantexplained,“[The] problem isn’t that we don’t want [dental] care, it’s the money ” Severalfocusgroupparticipantssharedthat theyhavesoughtdentalcareforonereasonandthen beentoldbyaproviderthatmorework(andmore expenses)wasnecessaryandthatthisisareasonthey donotgotothedentist
Perceptions of Access and Barriers to Oral Health Care
FocusgroupparticipantsandintervieweesstatedthataccessingoralhealthservicesinEverettandMalden canbedifficult Ingeneral,participantsandintervieweesstatedthatitwaseasiertoaccessdentalcarefor childrenthanforadults.AnintervieweenotedthattheHeadStartprogramrequiresadentalexamaspart ofregistrationandalsoofferssomeoralhealtheducationaspartofprogramming.Focusgroup participantswhowereparentsofchildrensharedthatreminderssentforpediatricdentalappointmentsare veryhelpfulinkeepingtheirchildrenup to datewithoralhealthcare.Participantsalsostatedthatthereis lessaccessforthosewhoarelowerincomeandthosewithoutdentalinsurance.Oneintervieweenoted thatseniorsinparticular,are “falling through the cracks” becausemanyarenotcoveredbyMassHealth yetnolongerhavedentalinsuranceandfacesteeporalhealthcosts.Focusgroupparticipantsand intervieweesidentifiedseveralbarriersthatEverettandMaldenresidentsfacewhentryingtoaccess dentalcare,asdescribedbelow.
CostofCare
Asnotedabove,thehighcostofdentalcarewas mentionedasachallengeacrossallfocusgroupsand interviews Acommonthemeinfocusgroup discussionswasadditionalcostbeyondwhat insurancewillcover Onefocusgroupparticipant explainedthechallengebysaying, “Insurance says they’ll cover it, but then the dentist says you also need to pay x, y, z and then you end up paying the same amount the insurance was covering ” Finding lowercostdentalprovidersisaconstantstruggle accordingtoparticipants.Anotherfocusgroup participantshared, “Elderly people sometimes call the senior center [in Malden] to ask where to go. They desperately need care but can’t afford it or don’t know where to go. ” Acoupleoffocusgroupparticipants saidthattheychoosetogotolocaldentalschoolsforcarebecauseitismoreaffordable.Anotherpointed outthatsomeresidentsgobacktotheirhomecountriesfordentalcare.Asthisparticipantstated, “[some] prefer to get their dental treatments in Brazil…it’s much cheaper.” Intervieweesreportedthatsomepeople choosetohaveteethremovedratherthanreplacedorrestoredasthatisthemostcost effectiveoption. Mostoften,participantsstated,peopleforgocare,leadingtomoreseriousissueslateron.
LimitationsofInsuranceCoverage
Lackofcomprehensivedentalinsurancecoveragewas anotherbarrieridentifiedinfocusgroupdiscussions andinterviews Severalparticipantsspecifically mentionedlimitationsonMassHealthdentalcoverage Onefocusgroupparticipantexplained,“For me, MassHealth covers everything because I am pregnant, but [for my husband], it doesn’t cover all and it’s very expensive ” WhileMassHealthcoversbiannual cleanings,fillings,crowns,androotcanals,thedeeper cleaningneededtotreatgumdiseaserequires out of pocketcosts MassHealthdoesnotcover orthodonticwork,makingitmoredifficultforlower incomechildrentogetbraces Medicarelikewisehaslimitationsonoralhealthservicescoveredfor seniors Anadditionalchallengeseniorsface,accordingtofocusgroupparticipants,isunderstandingand navigatingtheirdentalinsurance
ChallengeswithGettingCarefromaDentalProviderorGettingaDentalAppointment Focusgroupparticipantsstatedthatitcanbedifficulttogetoralhealthappointments.Findingaprovider whoacceptsMassHealthisparticularlychallenging.Asonefocusgroupmemberstated,“[I] have a hard time calling providers and asking if they take MassHealth.”Findingstaffisachallengefacingalldental providers,accordingtooneinterviewee Oneintervieweeexplainedthatlowreimbursementforservices byMassHealthcansubstantiallyconstrainsmallprivatepracticesthatwanttocontinuetoservethe underserved Asoneintervieweeexplained, “MassHealth pays providers as if providers are volunteers receiving a stipend ” Asaconsequence,an intervieweeexplained,fewerprovidersparticipatein MassHealth,somelimitthenumberofMassHealth patientstheytake,andothersraisefeesfortheuninsured andself paypatientstomakeupforlowreimbursement Forresidentsthiscanmeanlongwaittimesfor appointments Asonefocusgroupparticipantshared,“I have a broken tooth I have an appointment next week, but I called three weeks ago ”
LowOralHealthLiteracy
Lackofunderstandingabouthowtocareforteeth,theimportanceofprevention,andtheoral physical connectionareallcontributorstopoororalhealthaccordingtointerviewees.Severalalsonotedthat parents,particularlyimmigrantparents,donotunderstandtheimportanceofcaringforbabyteethandthe connectionbetweenchildren’sdietsandtheiroralhealth Anintervieweeobservedthatlackof understandingaboutthebenefitsofwaterfluoridationisalsoachallengeandthatsomeparentsdistrust townwaterandseejuiceasahealthyalternative Intervieweesalsopointedoutthatthelackofa preventionmindsetisalsoafactorthatnegativelyaffectsresidents’oralhealth Culturealsoplaysarole, accordingtoparticipants Severalparticipantsexplainedthatinmanycultures,preventionisnot emphasized,andpeopleseekhealthanddentalcareonlywhentheyhaveaproblem InHaiti,one intervieweeexplained,dentalcareisseenasaluxuryratherthananecessity,somanypeoplewillnot pursueitiftherearebarriers
FearandDentalAnxiety
Fearisalsoabarriertoaccessingoralhealthservices accordingtointervieweesandfocusgroupparticipants DuringtheCOVID 19pandemic,peoplestayedaway fromhealthcareandoralhealthofficesoutoffearof gettingsick Asmentionedearlier,focusgroup participantsalsoreportedthatsomeresidentsdonot accessoralhealthservicesbecausetheyfearlearningthat theyneedmoreextensive andexpensive dentalwork AmemberoftheHaitianfocusgroupexplained,
LackofTrustof/GoodExperiencewithProviders
Lackoftrustinprovidersisafactorthatsubstantiallyaffectshealthcareaccessaccordingtofocusgroup participantsandinterviewees.Amongimmigrantgroups,oneintervieweenoted,fearofengagingwith anyprogramsorhealthcareservicesisasubstantialbarriertoobtainingtimelyhealthandoralhealthcare. Asdescribedabove,severalfocusgroupparticipantsstatedthattheirdentalprovidersfindnewdental issuestoaddressed,atadditionalcost.Thisexperience,participantsshared,oftendissuadesthemfrom seekingdentalcareortrustingdentalproviders.Anintervieweeworkingwithcommunitymembers agreedsayingthatresidentstendtobelievethat ‘If we go [to a dental provider], they will create a problem ’ Concernsaboutdentists’“bedsidemanner” aroseintwofocusgroups.Someparticipantsshared experienceswithunprofessionalandunfriendlyinteractionswiththeirdentists.Otherparticipants reportedthattheirdentistsdidnotexplaininadvancewhattheyweredoing;oneparticipantsaid,“I felt like they just used me as an experiment they were not communicating what they’re going to do ” Intervieweessharedthattimepressuresduringappointmentsoftenpreventprovidersfromsittingdown withpatientsandreallytalkingtothem
Transportation
Althoughnotacommonthemeinconversations,oneintervieweesharedthattransportation,especiallyto lower costprovidersanddentalclinicswhocanprovidemorespecializedtreatment,canbeabarrierfor somepatientsinEverettandMalden.
Gaps in Services and Community Suggestions for the Future
Belowdescribesthegapsidentifiedbyfocusgroupparticipantsandintervieweesincurrentoralhealth servicesandsomesuggestionsforimprovementtheyshared.
MoreAvailabilityofDentalProviders
Focusgroupparticipantsandintervieweessawaneedformoredentalproviders,particularlythosewho acceptMassHealth Severalparticipantssuggestedthatmorecommunity baseddentalproviderswere neededandrecommendedanotherfederallyqualifiedhealthcenter(FQHC)dentalclinicinMalden, emergencydentalservicesinMalden,expandedservicesatSharewood,andcreatingaone stop shopthat providesbothhealthanddentalcare Oneintervieweesawpotentialforincreasingoralhealthservices
accessthroughschoolsbyestablishingon sitedentalclinicsforstudents,expandingsealantprogramsin schools,andengagingorthodontiststogointototheschools.Focusgroupparticipantssuggestedmore up to dateinformationaboutwhichprovidersacceptpublicinsurance Severalparticipantsrecommended thatreimbursementratesshouldbeincreasedtoencouragemoreprivatedentalproviderstoparticipatein MassHealth Attentiontoindividualswithspecialneedsthatareunabletobecaredforbyprivatedentists isasignificantbarrierformanyfamiliescaringforthosewhomayneedadditionalsupportservicesin ordertosafelyreceiveoralhealthcare
MoreAffordableDentalCare
Thecostofdentalcare,asdescribedabove,isasubstantialbarriertoaccessingcare.Focusgroup participantsandintervieweessuggestedthatMassHealthandMedicareexpandtheservicescoveredto reducecostsonresidents.Somefocusgroupmembers,inparticularwithintheHaitiancommunity,anda coupleofintervieweesalsosawaneedforfinancialassistanceprogramstohelplowerincomeresidents payfordentalcareandnon coveredservices.
ExpandedOralHealthLiteracyPrograms
Numerousfocusgroupparticipantssawagapinoralhealthliteracyprogramsandthoughtmoreofthese typesofprogramsandservicesshouldbeavailable Suggestedtopicsincludeddifferenttypesof toothbrushes,andwhicharebestforwhom,thebenefitsofwaterfluoridation,andtheconnectionbetween oralandphysicalhealth FocusgroupparticipantswithintheHaitiancommunityandinterviewees workingwithimmigrantresidentsstressedtheneedtoeducateaboutpreventionandtheimportanceof seekingdentalcarewhenanissuefirstarises.Otherfocusgroupparticipantssuggestedconversationsand educationaboutoralhealthshouldalsofocusonhelpingpeopletofeelmorecomfortablewithgoingto thedentistandbetterequippedtotalkabouttheirteethandmouth.
Focusgroupparticipantsandintervieweesidentifiedavarietyofvenuesthroughwhichtoshareoral healthinformationincludingcommunityeventswithdentalprovidersatpublicparks,workshopsfor residentsatcommunity basedorganizations,andthroughschoolsandschoolnurses.Focusgroup participantswithintheHaitiancommunityalsosuggestededucationaleventsatchurchesandmessaging throughradioandtelevision.Otherfocusgroupparticipantsnotedthatsocialmediaoutreachsuchas throughFacebookcouldbeeffective;theyalsosuggestedthatdiscussingoralhealthatAlcoholics Anonymous(AA)meetingsandduringrecoveryprogramswouldreachthoseovercomingaddiction.One participantrecommendedthatdentalclinicsconductoutreachtopeopleexperiencinghomelessness.Focus groupmembersandintervieweesstressedthatmultiplemodesofinformationsharingare needed written,verbal,visual andthat repeatedmessagingisimportant.Participants suggestedmoreoutreachtochildrenabouthow totakecareoftheirteeth,includingyoung children,anddescribedschoolprincipalsand schoolnursesasvitalpartners Oneparticipant suggestedthatoralhealthbeintegratedinto schoolhealthandphysicaleducationcurricula Anotherrecommendedprovidingoralhealth “kits”tostudentsinmuchthesamewaypersonal protectiveequipment(PPE)kitsweredistributed duringtheCOVID-19pandemic
GreaterEngagementofPrimaryHealthCareProviders
Severalparticipantssawagapinengagementofhealthcareproviders,includingprimarycareproviders andpediatricians,inoralhealthcareandbelievedthatthisshouldbeaddressed.Asoneinterviewee
summedup,“[We] need a broader, upstream view of oral health that is tied to other areas of health.” Varioussuggestionswereprovidedbyintervieweesandparticipants.Oneintervieweerecommendedthe ‘SmilesforLife’programthatisintegratedintomedicalelectronichealthrecords(EHR)andprompts questionsaboutdentalcareaccessanddentalissues Thisintervieweealsonotedpregnancyasagood timetotalktopatientsaboutoralhealthforthemselves,partners,andchildren Severalparticipantsnoted theimportantrolepediatriciansplayinsupportingchildren’shealthandsuggestedthatmoreshouldbe donetoencouragepediatricianstohaveconversationsaboutoralhealthwiththeirpatientsandfamilies Anintervieweealsosuggestedamoresystemicapproachbyfindingawaytobillfordentalservices throughtraditionalhealthcoverage;this,theintervieweestated, “would help establish the importance of dental care for maintaining overall health ”
ParticipantsprovidedseveralspecificsuggestionsforbetterintegrationoforalhealthatCHA Afocus groupparticipantsuggestedhavingcarecoordinatorsorgeneralhealthprovidersatCHAdiscussoral healthwithpatients Anotherfocusgroupparticipantalsosuggestedamoreactiveroleinoralhealthfor healthcareproviderssayingthat,“If doctors are asking about our teeth, CHA doctors could arrange appointments for us with CHA dentists ”
BetterCoordinationAcrossPartners/NewPartnerships
Intervieweespointedtotheneedforcommunity levelapproachesthatconnectdentalcaretoother settingsinordertotakeamoreholisticapproachtohealthandhealthcare Asoneintervieweenoted, schoolsareseenascriticalpartnersinreachingbothstudentsandtheirfamiliesandparticipantssuggested thatschoolsandschoolnursesplayamoreactiveroleinsupportingandmessagingaboutoralhealth Intervieweesandfocusgroupparticipantsalikementionedthattrustedcommunityinstitutions including churchesandotherreligiousinstitutions,theFamilyResourceCenter,andtheParentInformation Center canalsoshareinformationaboutoralhealthandconnectresidentstoneededservices.
EnhanceCulturalCompetency
Severalparticipantssuggestedthatoralhealthproviderscouldtakestepstoenhanceculturalcompetency and,insomecases,overallinteractionwithpatients Acoupleofintervieweesnotedthatneedfor expandedlanguagecapacityincludingmoreprovidersorinterpretersforPortugueseandSpanish Afocus groupparticipantwithintheHaitiancommunity suggestedthatbetterunderstandingofthediets ofdifferentculturescouldbehelpfulinoral healthcare Otherparticipantssuggestedthat dentalprovidersbemoreunderstandingofthe experiencesthatpatientshavehadandthe barrierstheyfaceandhowthisaffectstheiroral health Anintervieweenotedthatproviders couldalsobenefitfromunderstandingthe impactoftraumaonpatients’livesandtheir approachestohealthandoralhealthcare.
Conclusions
Thisoralhealthassessmentbringstogetherquantitativeandqualitativedatafromavarietyofsourcesto provideanoverviewofthecurrentoralhealthstatusandperceptionsofEverettandMaldenresidents,and explorecommunityassets,aswellasoralhealthresourcesandgaps Overarchingthemesthatemerge fromthisassessmentinclude:
● MaldenandEverettarehometopeoplefrommanydifferentplaces Fourintenresidentsare foreign bornandroughlyhalfspeakalanguageotherthanEnglishathome.Haitian,Brazilian, andChineseresidentscomprisesomeofthelargestpopulationgroupsinthecommunities. Communitysurveyresultsanddiscussionswithfocusgroupparticipantsandintervieweessuggest thatBIPOCresidentsinEverettandMaldenexperiencegreaterchallengestoaccessingoral healthcarethantheirnon BIPOCneighbors.
● MaldenandEverettsawlowermedianhouseholdincomesandhigherpovertyrates comparedtothestate.Whendiscussingday to dayconcernsofresidents,focusgroupmembers andintervieweesmostoftenmentionedthesocialdeterminantsofhealth,includingexpensive housingandgrowinghomelessness,foodinsecurity,lackofwell payingjobs,andinabilityto accesstransportation
● ManyEverettandMaldenresidentswerecoveredthroughpublichealthinsurance.Over 40%ofEverettresidentswerecoveredbyMedicaid,substantiallyhigherthanMalden(285%) andthestate(224%) Almost70%ofchildreninEverettwerecoveredthroughMedicaid,a higherproportionthaninMalden(49.1%)andovertwiceashighasforthestate(33.9%).Both EverettandMaldenhadahigherproportionofseniorresidents(27.6%and26.0%,respectively) coveredbyMedicaidcomparedtothestate(165%) Communitysurveyresultsshowthatnearly onethird(317%)ofrespondentshaddentalinsurancethroughMedicaid Challengesassociated withaccessingdentalservicesforthosecoveredbyMassHealthwasafrequenttopicof conversationinfocusgroupsandinterviews.
● Whilemostrespondentstothecommunitysurveyandcommunityfocusgroupmembers describedtheiroveralloralhealthstatusasgood,verygood,orexcellent,somereported beingdissatisfiedwiththeappearanceoftheirteethandworriedorembarrassedabout theirteeth,mouth,ordentures. Physicaldiscomfortsuchasdifficultyeatingsomefoodsand painfulachingintheirmouthswereadditionaloralhealthchallengesreportedbysurvey respondents HigherproportionsofBIPOCrespondentsreportednegativeexperiencesdueto problemswithteethormouththannon BIPOCrespondents.
● Poororalhealthamongchildrenwasmentionedasaconcerninseveralconversations. This wasattributedtolowparentconcernabouttheirchildren’sbabyteeth,andlackofunderstanding aboutoralhealthwhichleadstounhealthypractices.Overall,focusgroupmembersand intervieweessuggestedthatmoreneedstobedonetoreachparentsandchildrenthemselveswith messagingabouttheimportanceoforalhealthandgoodoralhygienepractices
● Focusgroupparticipantsandintervieweescitedthelackofunderstandingaboutthe importanceofprevention,especiallyinsomecommunities,asasubstantialbarriertogood oralhealth.Surveyresultsmirrorthis:nearlyonequarterofsurveyrespondentsbelievedthat dentalvisitsareonlyimportantforadentalemergency Thisperceptionwashigheramong BIPOCsurveyrespondents.Manyfocusgroupparticipantssharedthattheyseeortrytoseea
dentistregularly;others,however,reportedthattheyseekdentalcareonlywhenthereisa problem.Intervieweeswhoweredentalprovidersnotedthispatternaswell:lowerincome residentsandothervulnerablegroupstendtotakeamorereactiveapproachtooralhealthcare Focusgroupparticipantsandintervieweesalsosawpotentialforstrengtheningcarecoordination betweenprimarycareprovidersanddentalproviders,whichmayaddressthisbarriertogoodoral health.
● Over80%ofsurveyrespondentsreportedthattheyhavearegulardentist;over60%of reportedthattheyusuallygettheirdentalcarefromaprivatedentist,whileanother34%go toacommunitydentalclinic.Alargerproportion ofBIPOCsurveyrespondentsreportedto havearegulardentistthantheircounterparts Focusgroupparticipantsandintervieweesstated thataccessingoralhealthservices,especiallyforadults,inEverettandMaldencanbedifficult About18%ofsurveyrespondentsreportedthattheygettheirdentalcarefromanemergency roomoranurgentcareclinic.Useofemergencyroomsfordentalcarewashigheramongsurvey respondentswithpublichealthinsurance(MedicaidorMedicare)
● Amongsurveyrespondents,interviewees,andfocusgroupparticipants,thecostofcarewas themostoften citedbarriertoaccessingoralhealthservices. Acommonthemeinfocusgroup discussionswastheadditionalcostbeyondwhatinsurancewillcover Lackofcomprehensive dentalcoveragewasthesecondmostcommonbarrieraccordingtosurveyrespondentsanda commonbarrierdescribedbyresidentsparticipatinginfocusgroups.LimitationsonMassHealth dentalcoveragewasasubstantialconstrainttooralhealthaccessforthoseresidentswithpublic insurance Slightlylessthanonequarterofsurveyrespondentsreportedthattheyhadnotvisiteda dentistorhygienistinthepastyear
