Doctoral student Sarah Raskin (University of Arizona), supervised by Dr. Susan J. Shaw, will undertake cultural anthropological research on the material and symbolic aspects of the mouth in relation to oral health among central Appalachians, for whom toothlessness is both a stigmatizing cliché and an embodied reality. The goal of the research is to expand social science understanding of stigma, its emobodiment, and its connections to sociopolitical histories of community, state, and nation. The research has been timed to coincide with and collaborate with Virginia initiatives to expand access to basic dental health care in this region.
The researcher will undertake thirteen months of multi-method ethnographic research in southwest Virginia, where 35 percent of adults report loss of many or all teeth, a rate more 7 times that of the rest of the United States. Research methods will include semi-structured interviews; free listing and ranking activities to elicit cultural models of the mouth and its care; structured observation; and media scans. She also will document experiences of tooth loss, oral pain, other dental sequelae, and experiences of home and clinical care. The research data will be analyzed using narrative and cultural consensus techniques. Research questions include: (1) how do healthcare providers, patients, and public health stakeholders conceive of the ideal mouth, ideal oral hygiene, and the possibility of achieving those ideals; and (2) is variability in how stakeholder conceptions correlated with structural, material, political economic, and/or symbolic factors.
This research is significant because it extends narrative and cultural consensus analysis to an illness cluster and site understudied in social science. Through collaboration with local stakeholders, findings from this project will provide baseline data for future studies on the effects of Virginia's pilot project on oral health-care and disease. Funding this project also supports the education of a social scientist.
This project aimed to systematically study the meanings and experiences of oral health and dental care in one federally designated dental health professional shortage area, far southwest Virginia, from the perspectives of people who suffer dental disease and/or poor access to care, and local providers. It proposed to produce baseline data most immediately useful for a pilot program which aimed to increase access to care and improve provider cultural competency and patient health literacy, as well as for future studies. It used interviews, focus groups, media scans, and structured observations to document how different southwest Virginians understand the mouth, teeth, tooth loss, dental pain, oral health and illness, home hygiene, the role of providers, dental insurance, charity care, and other issues in access to dental care, and qualitative analyses to meet these goals. Key findings include: People in far southwest Virginia who experience dental disease describe a range of feelings about their poor dental health, draw on a range of explanations for it, and utilize a range of methods to deal with it. For example, many participants who had broken, missing, blackened, or otherwise "ugly" teeth described feeling overwhelmingly self-conscious, un-presentable, and depressed as a result of their teeth. These feelings impacted their experience of their ability to eat healthful foods, pursue employment and social relationships including romance and love, feel a sense of self-pride and self-efficacy, and even access to health care generally, as they felt their poor dental health stigmatized them in the eyes of their providers. Participants described using a wide range of methods to cope with their dental sequelae, including self-extraction, popping and draining abscesses by hand, using home remedies, and self-medicating with alcohol, tobacco, and narcotic pain medications. Access to dental care is both embedded in and a product of many social, political, economic, and cultural factors that are only somewhat predicted by demographic and other categories. For example, people in far southwest Virginia who lack dental insurance lack access to both preventive care and dental treatment in private settings. But many people in far southwest Virginia who have dental insurance also lack access to care because they cannot find a dentist who will take their insurance plan or the co-payment negotiated by their insurance company is too high for them to afford. This is especially concerning for children, who are guaranteed dental coverage by the state’s Medicaid program but whose parents are unable to find providers willing to take Medicaid. Patchwork solutions such as charity and public health clinics are inadequate to address the problem in term of continuity of care, sustainability, and sheer volume of the need. Similarly, the provision of dental care in the region is also embedded in and a product of many social, political, economic, and cultural factors. For example, most students of dentistry who are from the region and initially planned to return to the region to practice have changed their mind and decided to stay in the urban areas where they train. Primary reasons why dentists decide to not return to their rural locations of origin include student loan obligations too high to be supported by rural practice norms and social/cultural "shifting" away from the norms of rural living and toward the norms of urban living are cited as; student loan repayment options are insufficient incentives at present. Proposed solutions that upset the dental institution norm, such practice law reform to allow Dental Health Aide Therapists or Advanced Dental Hygiene Practitioners to practice semi-autonomously, are supported by patients – who report a preference for the manner, personality, and local origin of dental hygienists to dentists – but unlikely to become a reality given Virginia’s conservative practice law climate. Dental team models, such as remote supervision dental hygienists, is a more acceptable compromise that is supported by both patients and, increasingly, providers, although some providers feel trepidation about perceived competition.
