Adjusting for area-level confounding by neighborhood: Implications for addressing racial and ethnic disparities in dental care

Racial/ethnic disparities in access to oral health care have been documented for decades in the United States, yet little progress has been made in reducing these inequalities. Using 2008 Florida Behavioral Risk Factor Surveillance System data, dramatic changes in the estimates for receiving recent dental cleanings by race/ethnicity were observed after appropriately accounting for neighborhood confounding using conditional pseudolikelihood methods with an ordinal dental cleaning outcome (the methodological aspects of this work  have been published). This analysis revealed that if zip code differences were accounted for, minority populations had equal or better outcomes than Whites.  For example, with income and neighborhood included in the model, in addition to age, gender, education, and health insurance, Hispanics  had significantly higher odds of receiving recent dental cleanings than Whites (OR 3.67, 95% CI: 1.79, 7.52).  These findings highlight the immense impact that area-level factors can have on racial/ethnic differences in dental care utilization.  One way to facilitate progress in identifying and acting upon underlying disparities mechanisms is to make area-level data more accessible for communities to use and easily link to surveillance data.   Regional discussions addressing social disparities across areas are also needed, along with increased awareness among practitioners and communities that determinants of racial/ethnic inequalities in oral health extend beyond behavioral inadequacies.  Significant disparities are likely to persist if we continue to fall short of addressing the underlying structural and social determinants.