Overcoming data challenges examining oral health disparities in appalachia

The objective of our study of oral health disparities in Appalachia was to use existing data sources to geographically analyze suspected disparities in oral health status in the 420 counties of Appalachia, and to make sub-state comparisons within Appalachia and to the rest of the nation. The purpose of this manuscript is to describe the methods used to overcome challenges associated with using limited oral health data to make inferences about oral health status.

Oral health data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS). Because the BRFSS was designed for state-level analysis, there were inadequate numbers of responses to study Appalachia by county. We set out to determine the smallest possible unit we could use, aggregating data to satisfy CDC minimum requirements for spatially identified responses. For sub-state comparisons, data were first aggregated to Appalachian and non-Appalachian regions within Appalachian states. Next, urban versus rural areas within Appalachian and non-Appalachian regions were examined. Beale codes were used to define metropolitan and non-metropolitan statistical regions for the United States.

Aggregating the data as described proved useful for smoothing the data used to analyze oral health disparities, while still revealing important sub-state differences. Using geographic information systems to map data throughout the process was very useful for determining an effective approach for our analysis.

Studying oral health disparities on a regional or national level is difficult given a lack of appropriate data. The BRFSS can be adapted for this purpose; however, there is a limited number of oral health questions and because they are also optional, they are not routinely asked by all states. Expanding the BRFSS to include a larger sampling frame would be very helpful for studying oral health disparities.

Novel techniques were introduced to use BRFSS data to study oral health disparities in Appalachia, which provided informative sub-state results, useful to health planners for targeting intervention strategies.