Nursing Health Promotion Interventions Needed to Reduce Oral Health Disparities: The Situation in Israel

Purpose : The World Health Organization (WHO) reminds us that Nursing is a holistic discipline that "encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people."  Yet, despite the well-established link between oral health and cardiovascular disease, nurses rarely consider this important aspect of health care in their disease prevention and health promotion activities.  This omission needs to be corrected.  In the quest to reduce health disparities among different subgroups, public and community health nurses will want to identify subgroups who are at risk for oral health disparities and include oral health education in their health promotion interventions. 

 The Andersen and Aday's Behavioral Model of Health Care Utilization, a commonly used model for identifying characteristics and attributes of adults who use (or do not use) services, has been employed to examine oral health services in the UK, Sweden  and Canada.  The Model proposes that three major components promote or block service use:  predisposing factors (e.g., demographic characteristics and attitudes), enabling factors (e.g., internal resources comprised of personal habits/behaviors and external resources such as socioeconomic status that facilitate service use), and reinforcing/need factors (e.g., reasons to use services such as increased risk of oral health disease).  

Accordingly, this study uses the Andersen and Aday Behavioral Model of Health Care Utilization in a nationwide sample of Israeli adults to:  (1) compare the use of primary dental care services between the years 2000 and 2010, (2) examine the factors associated with using primary dental care services for Israel's two largest ethnic groups, Jews and Arabs, (3) consider approaches for nursing health promotion interventions to reduce oral health disparities.

Methods:   This study used two national, cross-sectional, datasets (years 2000 and 2010) of surveys administered by the Israel Center for Disease control that explored knowledge of eating, smoking and other habits or behaviors; attitudes towards health behaviors; and activities indicating use and practice of health behaviors (KAP).  Institutional Ethics Committee approval was obtained for this secondary data analysis (#13/056).  In 2000, the sample consisted mostly of Israeli-Jews (n=2920); and in 2010, targeted sampling resulted in a nationally representative sample of Israeli-Jews (n=2739) and Israeli-Arabs (n=2,196).   

Results: Primary dental care use increased between 2000 and 2010 in Israel, but many differences were found by ethnic minority status, education, income, immigration and other factors.   Results indicated that primary dental care was sought by Israeli-Jews who:  were born in Israel (OR-1.43, CI-1.17, 1.75); had at least a high school diploma (OR-1.62, CI-1.23-2.13); were employed (OR-1.36, CI-1.09,1.70); reported at least average income (OR-1.78, CI-1.45,2.19); flossed their teeth (OR-1.84, 1.49-2.28); had a normal BMI (OR-1.23, CI-1.02-1.48); and were not smokers (OR-0.78, CI-0.65-0.94).   Primary dental care was sought by Israeli-Arabs who:  were less likely to be age 45-54 (OR-0.62, CI-0.39-0.99) or 65+ (OR-0.46, CI-0.22-0.99), compared to age <24 years; had at least high school education (OR-1.62, CI-1.20-2.20); reported at least average income (OR-1.67, CI-1.29, 2.16); and flossed their teeth (OR-2.22, 1.57-3.15).  

Conclusions:     Like many western countries, increasing numbers of Israelis used primary dental services between 2000 and 2010; and the proportion of Israeli adults using primary dental care use was similar to other western countries with 67.7% of adults in the United Kingdom and 70% in Canada.  However, there were clear ethnic disparities between the Israeli-Jewish majority (72.0%) and the Israeli-Arabs minority (61.7%).  Among Israeli-Jews, being an immigrant versus native-born was significantly associated with lower use of primary dental care in 2000 and 2010.  This same relationship was found in non-native born immigrant citizens of Canada.  Both studies found that being native-born had independent effects from other socioeconomic variables; thus, rather than service cost, potential explanations for lower use of primary dental care could be knowledge or language barriers.  Attitudes towards preventive care also may be a possible explanation.  Almost 20% of Israeli citizens are non-native born and more than 15,000 new immigrants arrive each year. 

Disparities in health habits by income level were found worldwide.  Higher income level may increase exposure to education on preventive oral health habits such as brushing teeth and flossing.  Consistent with our findings, other studies have noted that when dental care services are not a regularly covered service, lower service use results.  Moreover, while possession of health insurance is not always correlated to engaging in better health habits, possession of health insurance is almost always related to use of primary dental care.    Still, cost of services is not the only barrier to primary dental care.  Attitudes also pose barriers to use of services and good health habits.  Current evidence suggests that Israeli adults do not rank dental

All three factors of the Andersen and Aday's Behavioral Model (i.e., predisposing, enabling and reinforcing/need factors) demonstrated a relationship with the use of primary dental services in 2010; however, only enabling factors such as higher level socio-economic status, high school education factors, and positive dental health behaviors factors were associated with use of primary dental care services for both Israeli-Arabs and Israeli-Jews.   

This study's findings show that in Israel, a country with a mixed western and middle-eastern culture, the use of primary dental care is an indicator of health care inequity for vulnerable population subgroups including minorities, immigrants, and those of lower socioeconomic status.  Therefore, the onus is on policymakers, researchers and health professionals to identify methods of raising public awareness in minority and disadvantaged communities, using culturally-appropriate strategies, to reduce the existing disparities in primary dental care services.  Nurses can make a difference to reducing ethnic and socioeconomic disparities by adding oral health education to their health promotion activities, particularly when their interventions target at-risk populations.  

It is important to acknowledge this study's limitations including self-reported responses on cross-sectional surveys, where verification of responses was not possible.  Moreover, due to the uniqueness of the State of Israel, generalizability of these national results may be limited.  Additionally, response bias has been found in reporting personal habits – in particular reports of flossing were found to be biased in Israeli-Arabs.  Still, the samples used by this study are drawn from two nationwide surveys on a topic not commonly studied in the peer-reviewed literature.  In conclusion, although Israelis overall have demonstrated continued improvement in dental outcomes and use of primary dental care services; disparities in use of preventive services that could promote better dental outcomes are apparent in vulnerable subgroups such as ethnic minorities and those with less education and low income.