skip over navigation

Index

Impact of a Community Dental Fair
on Knowledge and Intentions among
Low-Income Hispanic Colonia Residents
(pdf version)

Brenda S. Hanson, PhD 1
Sharon E. Thompson, MPH, PhD, CHES 2
Eileen Huereque, BS, MS, CHES 3

1 Department of Psychology, The University of Texas at El Paso
2 Department of Health Promotion, The University of Texas at El Paso
3 Child Crisis Center, El Paso, TX

Corresponding Author:
Brenda S. Hanson, Ph.D.Department of Psychology, University of Texas at El Paso, 500 W University Avenue, El Paso, Texas 79968. Email: bshanson@miners.utep.edu.

Suggested citation: Hanson B, Thompson S and Hueruque E. Impact of Community Dental Fair on Knowledge and Intentions among Low-Income Hispanic Colonia Residents. Cases in Public Health Communication & Marketing. 2009; 3:59-91.
Available from: www.casesjournal.org/volume3.

Abstract

All United States residents do not have equal access to effective measures to prevent oral diseases. Disparities are prevalent among minority and underserved populations. For many communities on the U.S./Mexico border, changing unhealthy dental habits may be difficult due to limited knowledge and lack of access to health care. Based on community input, the research team prioritized the need for a community health fair designed to provide education and promotion of dental and oral health issues. Studies have found health fairs to be cost-effective community outreach strategies that increase awareness and disseminate health information. The objective of the community health dental fair was to increase general dental health knowledge and facilitate the adoption of recommended dental health practices among predominantly Hispanic colonia participants. Eighty-two Hispanic females participated in the study to evaluate the dental fair. Demographic information and a 10-item dental health knowledge questionnaire were administered in a pre- and post-test design. The demographic profile was adapted from an existing questionnaire. 1 The researchers developed the knowledge items that were central to the information presented in the dental health fair booths. Knowledge scores at post-test (M = 8.79) were significantly higher than pre-test scores (M =7.89, t (77) = 6.49, p <.001). The majority of participants (n = 74) reported having "learned a lot" by attending the health fair. When queried about whether the participants enjoyed the dental health fair, all participants responded affirmatively. These results provide further support for the use of health fairs to disseminate information among priority populations.

Introduction

Oral Health
Studies indicate that oral bacteria have been associated with heart disease, stroke, diabetes and the birth of pre-term, low-birth-weight babies. 2 More than 90% of all systemic diseases have oral manifestations. 3 Despite a decline in prevalence and severity, dental caries (decay) remain one of the most common unmet health conditions among children in the United States. 4,5 Pediatricians encounter dental decay on a regular basis. 6 Annually, dental problems can contribute to 20-30% of what families spend on health care. 7 Each year, about 30,000 American adults are diagnosed with oral and pharyngeal (throat) cancers, and more than 8,000 people die of these diseases. 5 Additionally, up to 40% of elderly adults do not have their natural teeth. 8 Lack of dental insurance among the elderly may also contribute to the reported decline in receipt of dental services. 10 Furthermore, many U.S. children and adults do not have access to effective measures to prevent oral diseases and conditions. For example, recent research has found that 22.1% of U.S. children lack dental insurance coverage and 26.9% did not have a routine visit in the previous year. 9

Disparities in health care, more specifically dental health care, have been demonstrated in minorities and low income populations (e.g. Hispanics, Medicaid patients). 11-14 For example, individuals with low incomes are significantly less likely to receive dental care than those with higher incomes. 15 Among low income and minority (e.g. Hispanic) children, research has estimated that greater than 50% of tooth decay remains untreated. This percentage remains unchanged over time, resulting in pain, dysfunction, underweight status, and poor appearance. 5,13,16 Dental problems can impair a child's likelihood to succeed, with an estimated cumulative 52 million hours lost from school. 17 Additionally, low income and minority children worldwide are the least likely to have received preventative dental care, even when insurance status is considered.9,18

Research has found that among minorities, Hispanic children are at a greater risk for unmet dental needs. 19 A recent study found that 54.9% of Hispanic children aged 2-11 years had tooth decay. 11 Hispanics are the least likely to have dental insurance despite a higher need for dental health care. 15,20 Focus groups have revealed that many caregivers of children have beliefs that may be counterintuitive to effective dental care, i.e., "primary teeth don't need care since they fall out anyway"; "only necessary if obvious problem"; and "pediatrician is best for dental care". 21 Additionally, older and immigrant caregivers are the most likely to report having experienced negative dental experiences and fear dentists are unethical, i.e. providing unnecessary treatment or over-charging for dental services. 21

Oral health education and promotion programs have been used as effective approaches to prevent oral diseases. 22 Health education programs have been shown to produce improvements in oral health behaviors and reduce plaque levels at sixth-months follow-up. 22 Despite that these preventive programs reliably produce improvements in oral health behaviors and reduce plaque levels, they are often unavailable to underserved priority populations. 11 In some high-risk communities in the U.S. Southwest, changing unhealthy dental habits may be difficult due to limited knowledge and health care services. 11 Therefore, oral health awareness and disease prevention programs should be enhanced so individuals can make informed health-related decisions. It is also important to expand community-based health promotion and disease prevention programs to Hispanic priority populations in order to lessen the gap in access. 23 It is vital that good dental habits are established early in life. Given that dental problems can begin in children as young as 2 years, it is important that oral health promotion and disease prevention be targeted at all ages. 24 If good dental habits are established early, there is less chance of disease. In fact, the three major priorities of Healthy People 20105 address this issue: 1) to reduce the proportion of children, adolescents, and adults with untreated dental decay; 2) increase the proportion of oral and pharyngeal cancers detected at an early stage; and 3) reduce periodontal disease.

Health Literacy

Health literacy has been defined as, "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." 25 Recently, it has been found that low health literacy can interfere with how individuals comprehend a variety of health issues, including oral health. 26 Consequently, individuals with low health literacy are more likely to have poorer health 27 and are less likely to use preventative services, 28 later resulting in increased health care costs at the federal level. 29 Research has found that an individual's health status is best predicted by his literacy skills, even when assessing other potential correlates, e.g. age, education level, race. 30 Therefore, it is of no surprise that improving the health literacy of Americans is another goal of Healthy People 2010. 5 Disparities of health literacy are more common among minorities in general, with low health literacy rates highest among Hispanics (54-66%). 31,32 Thus, it is important when targeting minority groups that health information be culturally relevant and language appropriate. 33

Health Fair
A health fair is a cost-effective strategy to provide community outreach and a common vehicle utilized by health educators to increase awareness and disseminate health information to a variety of priority populations and communities. 34-36 More specifically, health fairs are outreach events that are part of a strategically planned community health intervention that can be tailored to address the needs of a specific segment of a community and increase awareness of a featured health issue. 37 Successful health fairs have been found to include education and screening components, and are one way to provide accurate information to communities regarding pressing health issues and concerns in a familiar, non-threatening, and even, festive environment. 35,38 They can also increase organizational visibility within a community, while examining health behaviors and facilitating positive lifestyle changes. 39,40

Present Study
Based on community input, the research team prioritized the need for a community health fair specifically designed to provide education and promotion of dental and oral health-related issues. Previous use of health fairs in a carnival-type setting has been shown to reduce children's anxieties and apprehensions toward future dental exams. 41 Consistent with recommendations from the Hispanic Dental Association (HDA), culturally relevant values were addressed and incorporated into the information disseminated at the health fair. 42 Additionally, in order to attract and encourage community participation, prominent community members, including officials from local and state health departments, attended the health fair. 43 The objectives of the community dental health fair were to increase general dental health knowledge and facilitate intentions to perform recommended dental health practices among predominantly Hispanic participants. The purpose of this study was to examine the impact of participating in a community health fair on dental health knowledge and intentions among low-income Hispanic colonia residents.

Method

Participants and Setting
The priority population consisted of Hispanic participants of low socioeconomic (SES) status without regular access to routine dental services in the colonias on the U.S./Mexico border. The majority of adult participants who attended the health fair were female.

El Paso County, Texas, is a large urban border center with a population of approximately 800,000 inhabitants, 27% of whom live below the federal poverty line. 44 Montana Vista is a colonia in El Paso with approximately 6,800 people. Montana Vista is located on the U.S./Mexico border and comprised of mainly Hispanic families of low SES who do not have access to regular dental services. A needs assessment performed as part of the Community Outreach Core of a National Institutes of Health (NIH) R24 Export grant determined that dental care was a priority and topic of interest among residents of colonias in four catchment areas in El Paso County.

Instrument
Health fair and study participants were administered a questionnaire containing standard demographic information, including: age, birth place (i.e., city, state, country), education level, marital status, occupation status, income level, number of people living in their household as well as their relation to the participant, and racial and ethnic background. The demographic profile was adopted from an existing questionnaire. 1 Based on a literature review, the researchers developed pre- and post-tests with dental health knowledge items that were central to the information presented in the health fair booths (Appendix A, Table 1). Dental Health Knowledge Questionnaire items were in true/false format and each item was scored "1" if answered correctly and "0" if answered incorrectly. Participants were asked to complete this questionnaire prior to visiting the booths and immediately following attendance at the last booth. Items were summed to yield overall pre- and post-test scores on the measure. Total scores could range from 0 to 10. Scores were used as the dependent variable in subsequent analyses.

Table 1. Items from the Dental Health Knowledge Questionnaire Questions

Participants were also asked about their language proficiency in Spanish and English and if they currently have medical or dental insurance. Dental health care was also assessed through the following questions: "Have you seen a dentist in the last six months?", "Have you replaced your toothbrush in last 3-4 months?", "Do you brush your teeth twice a day?", and "Do you floss once a day?"

Behavioral intent to engage in improved oral health behaviors was assessed at post-test only. Questions assessed the following behaviors: dental examinations for themselves or their children in the next six months, intent to replace their toothbrush in the next six months, and intent to brush teeth twice a day and floss once a day. Participants were asked to rate the amount of information they learned as a result of participating in the dental fair. The last item queried participants about their enjoyment of the dental health fair.

Procedure
After obtaining Institutional Review Board approval and participants' informed consent, the Demographic and Dental Health Knowledge Questionnaire was administered to participants (adults ≥ 18 years) in their preferred language (i.e., English or Spanish). Upon completion of the questionnaire, participants were encouraged to visit all five booths to increase their oral and dental health knowledge.

The community dental health fair was held for four hours on a Saturday at a local high school. Five dental health booths were developed and implemented by community health students enrolled at The University of Texas at El Paso. Students researched selected topics and developed bilingual educational information and visuals aids to address the study's low literacy, priority population. An assignment sheet with delineated expectations and guidelines was distributed to students, who, during a 15-week semester developed a project with literature, educational activities, visual aids, and incentives in Spanish and English to be displayed at the dental fair booths.

Prior to the health fair, the fair coordinator and faculty advisor reviewed the students' materials for cultural appropriateness and educational quality. In addition, students formally presented their booths to two community Certified Health Education Specialists, who are also dental hygienists. These experts provided feedback on students' booths and educational materials, allowing for revision and refinement before the dental fair.

The dental booths included information on five different topics relating to oral and dental health. The prominent messages promoted were: brushing and flossing, oral cancer prevention, promotion of children's dental health, prevention and elimination of halitosis or bad breath, and nutrition to promote oral health. All written and oral information and education was presented in Spanish and English. Approximately 66% of the undergraduate students participating in this project were Hispanic, and the majority was bilingual. Those students who were not bilingual were matched with group members who were bilingual.

In addition, local public health organizations and health promotion prevention programs with foci in oral and dental health were recruited to participate in the health fair. These local organizations included the Texas Department of State Health Services, El Paso Oral Health Commission, and the El Paso City County Health and Environmental District. The community was made aware of the health fair through English and Spanish language flyers distributed around the colonia (Appendix B). Consistent with recommendations for improving health literacy, information promoting the health fair as well as information disseminated at the health fair was presented in a clear and concise manner.45 Education at the dental health booths primarily relied upon oral and visual demonstrations in both Spanish and English. Print materials were written at the fifth grade reading level.

The student health educators interacted with participants and performed brief informational sessions and demonstrations at each booth. Incentives to encourage participation and circulation to the five booths were provided to all participants in the form of toothbrushes, floss, mouthwash, toothpaste, tongue scrapers, and bottles of water. In addition, stickers, buttons, pencils, and notepads with dental health messages were distributed.

Picture 1. Dental Fair participants enjoying interactive demonstrations at booth

At the first booth, information about appropriate brushing and flossing techniques was provided to the participants in informational brochures and displayed graphics. A large model of an open mouth with teeth and an oversized toothbrush were used to demonstrate proper brushing and flossing techniques.

The second booth presented the topic of oral cancer to dental fair participants. The detection, signs, and treatment of oral cancer were delineated. Graphic images showing the ravages of oral cancer were displayed to punctuate the seriousness of the disease. In addition, information in the form of handouts and brochures was distributed to participants.

At the next booth, children's dental health issues were presented with a colorful and eye-catching poster featuring cartoon characters and dental promotion health messaging. A stuffed animal with a full set of teeth was used to demonstrate proper brushing and flossing. Children were also allowed to practice these techniques with the stuffed animal. In addition, coloring books with dental health themes and crayons were distributed to the children.

Information on the prevention and elimination of halitosis was provided in another dental fair booth. Visual aids were utilized and informational brochures were disseminated. Students manning the booths also provided oral education.

Picture 2. Halitosis/Bad Breath Prevention Booth

The theme of the fifth booth was nutrition and dental health, where information about foods and beverages that promote good oral health was presented. Food models were displayed to show appropriate portion sizes, healthy food and beverage choices, and comparisons to unhealthy foods and beverages that cause dental decay.

After dental fair participants visited all five booths, the same knowledge questionnaire, as well as the behavioral intention and dental fair assessment questionnaires, were administered. Post-tests were conducted to assess if the information conveyed was understandable and useful to participants. Upon completion of the post-test, participants were compensated with a five-dollar gift card.

Results

Approximately 180 adults and children attended the dental fair. Of those, 82 adult (≥ 18 years) female community members participated in the present study. Participants were a convenience sample of adults who voluntarily chose to complete the survey. The average participant was 36 years old (SD = 14.93). Twenty-five participants were born in the U.S., while the remaining 57 were born in Mexico. This sample was predominantly Hispanic (n = 79).

Participant's language proficiency ranged from speaking Spanish exclusively (n = 36, 45.5%), speaking Spanish better than English (n = 11, 13.9%), speaking English and Spanish equally well (n = 31, 39.2%), and speaking English better than Spanish (n = 4, 5.0%). Only a small minority of participants spoke English only (n = 4, 5.0%).

Table 2. Ethnicity of 82 Dental Fair Participants Ethnicity

Table 3. Language Proficiency of 79 Dental Fair Participants

Figure 1. Distribution of education levels for 83 participants

The majority of this sample was uneducated, with only 28.0% (n = 36) completing high school.

Many of the women reported being married (n = 57) and not working (n = 58). The most commonly reported occupation was housewife (n = 42), followed by student (n = 13). Seventy-four percent (n = 60) lived with their husband or partner, 82% (n = 67) and had on average 1.64 (SD = 1.22) children while 18.52% (n = 15) reporting having grandchildren living in their house. The average number of individuals living in any given household was 2.98 (SD = 1.48). The mean household income per month prior to taxes was $946 (SD = $1008). A yearly household income less than $21,200 for a family of four is classified below the federal poverty level according to U.S. guidelines.46 Given that many study participant households had four or more people living in them, reported income levels would place these individuals below the U.S. poverty line.44

As expected, only 35% of participants had medical insurance and 16% of participants had dental insurance. Only 20.7% of participants had seen a dentist in the last six months for a check-up. When asked about dental hygiene behaviors, 89% of participants reported replacing their toothbrush in the last 3-4 months, 91% brush their teeth twice a day, and 35% of participants floss their teeth once a day.

Table 4. Dental History of 82 Health Fair Participants Dental

Scores on the 10-item Dental Health Knowledge Questionnaire were analyzed at pre- and post-test, and the differences between the scores were examined. At pre-test the average score was 7.89 (SD = 1.43) and at post-test the average score was 8.79 (SD = 1.25). Both pre- and post-test scores ranged from 4 to 10. Since each item was worth one point, the increase of .81 points between the pre- and post-test indicated that participants were able to answer one more question correctly at post-test than at pre-test. A t-test was used to determine a statistically significant difference between these scores (t (77) = 6.49, p = <.001).

Using McNemar's test, statistically significant improvements in knowledge were found for three of the ten questions. More specifically, knowledge increased for the effects of cheek or lip biting (S (79) = 28.4, p < .001), age at which children should see a dentist (S (79) = 4.5, p < .05), and causes of bad breath (S (79) = 8.05, p < .05).

The majority of participants (84%) visited all five booths. Participants perceived the information provided at the dental fair as useful. The majority of the participants indicated that they "learned a lot" (n = 74). The remaining few participants "learned a little" (n = 3) or "nothing" (n =1). Not only was the dental fair an educational activity, it was also enjoyed by all participants (n = 78), as queried by the item "Did you enjoy the Family Dental Health Fair?".

Discussion

This study is consistent with documented disparities in dental health care among minorities and low-income populations. 6,11 Many of the participants were unlikely to have seen a dentist in the previous year. 20 Given the self-reported lower levels of education and income, in combination with lack of medical or dental insurance, participants may face barriers to visiting a dentist, (i.e., time, money). 20 Although a comprehensive dental examination was beyond the scope of this study, participants were taught proper brushing and flossing techniques, which, if implemented correctly, would aid in preventing the development of dental decay.

The majority of participants reported speaking Spanish with a greater proficiency than English. By providing information in participants' language of choice, the dental fair was able to disseminate educational materials that participants could read and comprehend. By culturally and linguistically tailoring the dental fair, this study was able to increase knowledge and promote dental health behaviors among Hispanics of low SES. While participants' knowledge scores concerning dental health were relatively high at pre-test, attending the dental fair produced a significant increase in knowledge by approximately one survey question. Of particular importance, knowledge was found to increase concerning the age at which children should see a dentist for the first time. Alarmingly, previous studies have found higher rates of tooth decay among Hispanic children, 11 possibly due to the lack of dental office visits for primary teeth. 21 This new knowledge may lead to improved oral health behaviors among participants and aid in establishing healthy dental habits at a younger age, thereby reducing the likelihood of dental disease and decay. Supporting this hypothesis are participants' reported future intentions toward improving their oral health behaviors including check-ups and replacing toothbrushes (Table 5).

Table 5. Reported Intention for Future Maintenance of Oral Care*

*n based on number of respondents for that item.

The relatively high rates of knowledge at pre-test may also suggest that for adults oral health literacy may not be as much of a barrier to seeking services as are financial reasons (e.g., lack of insurance, poverty). Participants' pre-test scores ranged from moderate to high, yet many had not visited a dentist for regular check-ups in the last six months. Given participants' reported intentions, it is likely regular dental check-ups and cleanings would have occurred had these services been more accessible and affordable to colonia residents.

These results support previous research that has found health fairs to be an effective strategy for disseminating health information and promoting health behaviors. 35 Compared to health fairs encompassing many different topics, the design of this health fair was unique in that multiple areas of one central topic was addressed. This design allowed participants to receive specific messages about each area rather than one general message about oral health. Furthermore, student and professional health educators showed improvements in their ability to effectively communicate this information in a culturally relevant and language appropriate manner. 45 It is unknown if following the health fair this new knowledge was further disseminated within the community or translated into healthier oral behaviors among participants, but the initial education and promotion successfully addressed the priorities of Healthy People 2010. 5

Recently, the HDA has stressed the importance of infusing cultural values into health promotion programming tailored for Hispanic populations in order to improve oral health outcomes. 42 Specifically the concept of familismo, which has been described as "collective loyalty to the extended family that outranks the needs of the individual." 47 Future health fairs that capitalize on normative cultural values, such as familismo, may facilitate the adaptation of positive health behaviors within Hispanic communities.

From a theoretical framework, application of the Diffusion of Innovations theory 48 may assist in building culturally appropriate health promotion models. 49 This theory can be used to explain the dental health fair and outcomes described in this case. Information and education was provided to the early majority, the female Hispanic participants, many of whom were the primary caregivers in their households. Diffusion of Innovation suggests that this early majority of women will aid in the diffusion of dental health information to their families and communities. This theory has been tested and determined useful in health communication in culturally diverse populations, and has also been tested in a Mexican-American community in Texas. 50-52 However, a longitudinal study is necessary to verify this assumption.

While the authors feel the health fair and present study were successful in meeting the objectives, a number of obstacles and limitations merit discussion. First, these findings are most applicable in border bi-national settings, among low- and middle-income communities that carry the greatest burden of unmet oral health care. Therefore, generalization of these results may be limited to equivalent populations. Evaluation of the effectiveness of dental fairs in different communities would provide information regarding the impact of these fairs across cultures. Second, the diagnosis of dental and oral health conditions and provision of treatment was beyond the scope and budget of this grant. As such, the extent to which this population is experiencing oral health problems is unknown. The dental health fair was determined to be a viable and effective strategy to increase awareness and knowledge regarding oral and dental health and related area services. Third, this study was a pre- and post-test design. It is unknown whether individuals' reported intentions to improve dental health care (e.g. daily flossing, routine dental appointments) actually transferred to engagement in those behaviors. Future research should continue to assess the effectiveness of health fairs to improve dental knowledge and behaviors in the long term.

Conclusions

By designing and staging a community dental health fair, this study was able to increase oral and dental knowledge and promote healthy behavioral intentions among low-income Hispanics. In doing so, the dental fair addressed several Healthy People 2010 dental health priorities. Additionally, the health fair successfully obtained a receptive audience by addressing specific concerns as voiced by the priority community and by including community Certified Health Education Specialists to aid in the development and dissemination of materials. The use of a culturally sensitive health fair encouraged healthier behaviors among a high-risk population. The ultimate goal of the health promotion intervention was to reduce the risk of oral health problems and promote general health and well-being among this vulnerable population. The results of this study provide evidence for the effectiveness of health fairs in disseminating and improving knowledge about dental and oral health care. Additionally, post-test results suggest positive intentions toward improvement in dental health care among the female colonia residents who attended the fair. In addition to scoring higher at post-test, many perceived the health fair as an enjoyable experience where useful information was conveyed. Perhaps, the greatest lesson learned from this case study is the importance of including culturally relevant concepts when developing community health fairs. Future studies should continue to assess the effectiveness of health fairs to increase knowledge and awareness, as well as to promote healthy lifestyles in priority populations.

Acknowledgments

The authors would like to acknowledge the support received through the National Institutes of Health Grant No. R24 MD000520-02 through the National Center on Minority Health and Health Disparities and the Paso del Norte Health Foundation.

Author Information

Brenda Hanson recently received her PhD in Experimental Psychology, with a focus in Health Psychology, and a specialty in addictive behaviors from the University of Texas at El Paso.

Sharon Thompson is an Associate Professor of Health Promotion at the University of Texas at El Paso with a research emphasis on Latino health concerns.

Eileen Huereque is the program coordinator for the "No Kidding" program at the Child Crisis Center in El Paso, TX.

References

  1. Byrd TL, Peterson S, Chavez R, Heckert, A. Cervical cancer screening beliefs among young Hispanic women. Preventive Medicine. 2004; 192-197.
  2. Emerging Connections Between Oral Bacteria and Overall Health: Researcher Assesses Data. Ascribe Newswire: Health. 2001:19-20.
  3. U.S Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000.
  4. Newacheck P, Hughes D, Hung Y, Wong S, Stoddard J. The Unmet Health Needs of America's Children. Pediatrics. 2000;105(4):989.
  5. U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health (2 vols.). Washington, DC: U.S. Department of Health and Human Services, 2000.
  6. Lewis C, Grossman D, Domoto P, Deyo R. The role of the pediatrician in the oral health of children: A national survey. Pediatrics. 2000;106(6):E84-E84.
  7. Lewit EM, Monheit AC. Expenditures on Health Care for Children and Pregnant Women. The Future of Children. 1992;2(2):95-114.
  8. Gooch B, Eke P, Malvitz D. Public Health and Aging: Retention of Natural Teeth Among Older Adults—United States, 2002. JAMA. 2004;291(3):292-293.
  9. Janes GR, Blackman DK, Bolen JC, Kamimoto LA, Rhodes L, Caplan LS, et al. Surveillance for use of preventive health-care services by older adults, 1995-1997. MMWR Surveill Summ. 1999;48(8):51-88.
  10. Liu J, Probst J, Martin A, Wang J, Salinas C. Disparities in Dental Insurance Coverage and Dental Care Among US Children: The National Survey of Children's Health. Pediatr. 2007;119(Suppl 1):S12-S21.
  11. Beltrán-Aguilar E, Barker L, Canto M, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005;54(3):1-43.
  12. Lewis C, Grossman D, Domoto P, Deyo R. The role of the pediatrician in the oral health of children: A national survey. Pediatrics. 2000;106(6):E84-E84.
  13. Vargas C, Crall J. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. Journal Am Dent Assoc. 1998;129(9):1229.
  14. Shi L, Stevens G. Disparities in Access to Care and Satisfaction Among U.S. Children: The Roles of Race/Ethnicity and Poverty Status. Public Health Rep. 2005;120(4):431-441.
  15. Shi L, Stevens G. Disparities in Access to Care and Satisfaction Among U.S. Children: The Roles of Race/Ethnicity and Poverty Status. Public Health Rep. 2005;120(4):431-441.
  16. Ismail A, Burt B, Brunelle J. Prevalence of Dental Caries and Periodontal Disease in Mexican American Children Aged 5 to 17 Years: Results from Southwestern HHANES, 1982-83. Am J Public Health. 1987;77(8):967-970.
  17. Gift H, Reisine S, Larach D. The Social Impact of Dental Problems and Visits. Am J Public Health. 1992;82(12):1663-1668.
  18. Hjern A, Grindefjord M. Dental Health and Access to Dental Care for Ethnic Minorities in Sweden. Ethnicity & Health. 2000;5(1):23-32.
  19. Newacheck P, Hughes D, Hung Y, Wong S, Stoddard J. The Unmet Health Needs of America's Children. Pediatrics. 02, 2000;105(4):989.
  20. Macias E, Morales L. Utilization of health care services among adults attending a health fair in South Los Angeles County. Journal of Community Health: The Publication for Health Promotion and Disease Prevention. 2000;25(1):35-46.
  21. Hilton I, Stephen S, Barker J, Weintraub J. Cultural factors and children's oral health care: a qualitative study of carers of young children. Community Dent & Oral Epidemiol. 2007;35(6):429-438.
  22. Watt R, Marinho V. Does oral health promotion improve oral hygiene and gingival health? Periodontol 2000. 2005;37(1):35-47.
  23. Harrison R, Wong T. An oral health promotion program for an urban minority population of preschool children. Community Dent & Oral Epidemiol. 2003;31(5):392.
  24. Mouradian W, Berg J, Somerman M. Addressing disparities through dental-medical collaborations, part 1. The role of cultural competency in health disparities: training of primary care medical practitioners in children's oral health. J Dent Educ. 2003;67(8):860-868.
  25. Selden CR, Zorn M, Ratzan S, Parker RM compilers. Health Literacy: Jan 1990 through Oct 1999 [bibliography]. Bethesda, MD: NLM; 2000.
  26. Jones M, Lee JY Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc. 2007;138(9):1199-1208.
  27. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87(6):1027-1030.
  28. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventative health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40(5):395-404.
  29. Baker DW, Parker RM, Williams MV,Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791-798.
  30. Partnership for Clear Health Communication. Available at: http://www.askme3.org/. Accessed January 11, 2009.
  31. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Washington DC: U.S. Department of Education; 2006.
  32. Garmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551.
  33. Andrulis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav. 2007;31(Suppl 1):S122-S133.
  34. Aasen N, Miller M. Health Fairs: a non-traditional introduction to community health nursing. J Nurs Educ. 1986;25(2):72-74.
  35. Mayer G, Connell J, Villaire M. Achieve Outcomes at Community Health Fairs. Nurs Pract. 2004;Sourcebook:29-31.
  36. Schwartz P, Kennedy K, McCormack E, Neve D, Richardson D. Health fair for the homeless. J Pediatr Nurs. 1996;11(6):399-400.
  37. Goldman K, Schmalz K. Top grade health fair: an "A" fair to remember. Health Promotion Pract. July 2004;5(3):217-221.
  38. Bean J, Hutchinson P. Kids Health Day: one community hospital's approach to health education for families. Patient Educ and Counseling. 1996;27(1):53-62.
  39. Pender N, Murdough, C, Parsons, M. Health Promotion in Nursing Practices. 2002. New Jersey: Pearson Ed., Inc.
  40. Jennings-Sanders A. Using Health Fairs to Examine Health Promotion Behaviors of Older African Americans. ABNF Journal. January 2003;14(1):13.
  41. Harn S, Dunning D. Using a children's dental health carnival as a primary vehicle to educate children about oral health. ASDC J Dent Child. 1996;63(4):281-284.
  42. Service, Leadership, and Advocacy for Hispanic Oral Health. 2008 - Hispanic Dental Association. Available at http://www.hdassoc.org. Accessed January 12, 2009.
  43. Ghouri N. Health fair in a mouse: putting policy into practice. Public Health. 2005;119(3):197-201.
  44. U.S Department of Health and Human Services. The 2007 HHS Poverty Guidelines. Federal Register. 2007;72(15):3147-3148.
  45. Health Literacy Tool Kit, A Comprehensive Resource for Policy Makers - The Council of State Governments. Available at http://www.csg.org. Accessed January 10, 2009.
  46. Among nation's poorest cities, El Paso ranks a notorious 4th – Senator Eliot Shapleigh. Available at http://shapleigh.org/news/2140-among-nation-s-poorest-cities-el-paso-ranks-a-notorious-4th. Accessed March 13, 2009.
  47. Flores G. Culture and the patient-physician relationship: Achieving cultural competency in health care. J Pediatr. 2000;1(36):14-23.
  48. Rogers E. Diffusion of innovation. 3rd ed. New York: Free Press; 1983.
  49. Thompson SE, Dempsey H, Hanson B, Huereque EJ, Smith B. Facilitating education, advocacy, and empowerment: Community health fairs can increase perceived competence among health education students. Health Educ Monogr Series. In press.
  50. Borras JM, Fernandez E, Schiaffino A, Borrell C, La Vecchia, C. Pattern of smoking initiation in Catalonia, Spain from 1948 to 1992. A J Pub Health, 2000:90(9):1459-1463.
  51. Svenerud, PJ, Singhal, A. Enhancing the effectiveness of HIV/AIDS prevention programs targeted to unique population groups. J Health Comm. 1998:3(3): 193-217.
  52. Vaughan, P., Rogers, E. A staged model of communication effects: Evidence from an entertainment-education radio soap opera in Tanzania. J Health Comm. 200:5(3): 203-228.

Appendix

Click here for appendix questionnaires

PHC&MLegacyIQ SolutionsNOVA Research
site maintained by MCCM | last updated 10 February 2012 | Site Map