Research​ ​Assessment​ ​#3

Date:​​ ​ ​ ​October​ ​20,​ ​2017

Subject:​​ ​ ​The​ ​Gender​ ​Gap​ ​of​ ​wages​ ​in​ ​Dentistry

MLA​ ​or​ ​APA​ ​citation:

Journal​ ​Articles​,

www.ada.org/en/science-research/health-policy-institute/publications/journal-articles.

Analysis:

Through this fascinating article, I discover that even though the mean gap difference in

men and women has shrunk over time there is still a significant gap between their annual wages.

In today’s society, I was shocked to find out the difference in earning for women is between 62%

and 66%. This major gap would really affect me or any other women in any field they pursue

especially competitive fields like Dentistry or Law. The more astonishing thing about this is that

apparently the gap in their wages in “unexplained,” but I disagree with this because it is very

evident that throughout the year the main reason for this difference in salary is simply because of

their​ ​gender.

Even Though women are increasingly playing an essential role in dentistry the wage gap

is becoming any smaller. The article also discusses the impact of the gender gap in other

professions including Law, Dentistry, and Physicians. This article also opened my eyes to the

fact that there are other factors that play a role in the wage gap between men and women and
when the gap between the two parties are decreased that there will be a direct increase in their

oral​ ​health.

Through the research, they conducted in areas with lower unequal income the people

actually have better oral health. This connection seemed really bizarre and far-fetched to me and

took me a while to comprehend, but I am very impressed with the author who made this direct

connection. The increase in oral health can also be because of the broad economic policy of state

and federal government. Not only that but I also learned that this country is in the middle of a

huge debate over taxation, programs on entitlement, and the general role of the government.

With these factors in place, the impact on oral health can also be drawn from these crucial

decisions.

Through this article, I also have come to the conclusion that these finds will have a major

impact on the decision making of future research and policy. The people who help create the

policies must be extremely cautious when helping to steer our country to reduce the unequal

wage difference between men and women. If they unintentionally take the wrong course of

action without completely familiarizing themselves with the many factors making this significant

difference they could do the exact opposite and intensify the situation. Not only will they have

worsened the gap between men and women income, but they will also cause an increase in poor

oral​ ​health.

(article​ ​starts​ ​on​ ​page​ ​3​ ​and​ ​ends​ ​on​ ​page​ ​10)
Income inequality in the United States—or the unequal distribution of income across US
society—has increased dramatically during the past 4 decades.1 For instance, the share of total
annual income received by the top 1% of earners in the United States more than doubled from
9% in 1976 to 20% in 2011. This increasingly unequal distribution of wealth and income
generally has been attributed to public policy decisions—namely, taxation policies, supply-side
economic models that favor greater individualization of pay over collective bargaining, and
increasing​ ​levels​ ​of​ ​private​ ​and​ ​inherited​ ​wealth.2

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Although an increase in income inequality has been evident in most Organisation for Economic
Co-operation and Development nations during this time, the shift has been particularly
pronounced in the United States.3 The Gini coefficient—a measure of income distribution in
which 0 means complete equality and 1 complete inequality4—affirms this trend. The United
States’ Gini coefficient is considerably higher than both the Organisation for Economic
Co-operation and Development average and that of all but 3 other Organisation for Economic
Co-operation and Development nations: Chile, Mexico, and Turkey.3 The increasing gap
between the rich and poor in these societies and its potential effect is an issue of major public
concern,3and this is especially the case in US political discourse. In 2013, for example, President
Barack​ ​Obama​ ​referred​ ​to​ ​increasing​ ​income​ ​inequality​ ​as​ ​the​ ​“defining​ ​challenge​ ​of​ ​our​ ​time.”5

Particularly concerning is the role of income inequality in perpetuating lower levels of economic
growth and opportunity, increased levels of poverty, and a breakdown in social cohesion and
civic participation.6 Societies with higher levels of income inequality also experience poorer
population health outcomes, including reduced life expectancy and higher rates of obesity,
diabetes, cancer, and heart disease.6 The strongest evidence for the direct health effects of
income​ ​inequality​ ​at​ ​the​ ​population​ ​level​ ​is​ ​observed​ ​within​ ​the​ ​US​ ​population.7

The most germane theories as to how income distribution shapes health outcomes focus on
materialist, cultural-behavioral, and psychosocial pathways, all of which influence or constrain a
person’s health-modifying behaviors.8 The materialist approach explains health inequalities
through differences in a person’s socioeconomic position and, accordingly, through his or her
distinct exposures to environmental factors that may influence his or her health (that is, pollution,
working conditions, and so on). The cultural-behavioral pathway emphasizes that cultural
influences shape a person’s behavioral choices and, as a result, predisposes people to engage in
higher-risk lifestyles that may affect their health, such as smoking, drinking, or adopting an
unhealthy​ ​diet.

In regard to oral health inequalities, however, the psychosocial pathway is particularly salient in
explaining differences in oral health for various populations.9, 10, 11, 12 This approach posits
that a person’s emotional well-being, psychological stability, self-esteem, and relationships with
others are affected directly by his or her economic and social circumstances. In turn,
psychosocial instability can exert physiological pressures on the biological systems that underpin
a person’s health status.11, 12 In this regard, societal income distribution can be considered a
social determinant of health13 or a primary factor that establishes and propagates differences in
health​ ​between​ ​social​ ​groups.

In this study, we explore the relationship between income inequality and oral health in the United
States. Specifically, we examine the relationship between a population’s global ratings of oral
health and oral health–related quality of life measures and the level of income inequality within
that​ ​population​ ​by​ ​using​ ​available​ ​data​ ​from​ ​2,020​ ​counties​ ​throughout​ ​the​ ​United​ ​States.

Methods
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis

Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of

lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography

Sample
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography
The American Dental Association’s Health Policy Institute worked with Harris Poll to obtain a
sample of adults 18 years or older across the United States. We randomly selected survey
respondents from a group of people who had agreed to participate in Harris Poll surveys to create
a large nonprobability sample. The desired sample size was 15,300—specifically, 300 per state
and the District of Columbia. We used the 2014 federal poverty guidelines published by the US
Department of Health and Human Services to categorize people as low, middle, or high income.
Within each state sample, 100 were people of low income, with household incomes at or below
138% of the federal poverty guideline; 100 were people of middle income, with household
incomes between 139% and 400% of the federal poverty guideline; and 100 were people of high
income, with household incomes at or above 401% of the federal poverty guideline. We
structured​ ​the​ ​sample​ ​this​ ​way​ ​to​ ​allow​ ​for​ ​analysis​ ​according​ ​to​ ​income​ ​level​ ​within​ ​states.

Survey​ ​instrument
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography
The Health Policy Institute developed a survey in partnership with oral health experts from the
American Dental Association’s Practice Institute and Science Institute and outside international
experts to measure aspects of oral health such as pain and discomfort, ability to chew and speak,
satisfaction with mouth function and esthetics, and any physical, emotional, and psychological
effects derived from the condition of the mouth.14 We adapted survey questions about these
aspects of oral health from established surveys15, 16, 17 or generated them in-house; then we
consulted international experts on defining and measuring oral health on the basis of
self-reported indicators to review the questions. To our knowledge, investigators have not
measured these person-specific ratings of various aspects of oral health extensively in routine
population-based​ ​national​ ​surveys​ ​in​ ​the​ ​United​ ​States.

We also included questions about insurance status, source of insurance, access to dental services,
and oral health care utilization. We adapted these questions from a survey developed by the
Health Policy Institute in 2014.18 We also included standard demographic questions about topics
such as age, education, household income, and race or ethnicity. Full details about development
of​ ​the​ ​survey​ ​instrument​ ​and​ ​the​ ​full​ ​list​ ​of​ ​survey​ ​questions​ ​are​ ​available​ ​elsewhere.19

Data​ ​collection
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography
Harris Poll piloted the survey questions via telephone and online before data collection to gather
feedback from respondents, test responses, and make revisions to the survey accordingly. We
deployed the final version of the online survey on June 23, 2015. We closed data collection on
August 7, 2015, with a total of 14,962 responses across all 50 states and the District of
Columbia.​ ​We​ ​did​ ​not​ ​reach​ ​the​ ​quota​ ​of​ ​300​ ​responses​ ​in​ ​7​ ​states​ ​and​ ​the​ ​District​ ​of​ ​Columbia.

Measures​ ​for​ ​analysis

Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography

Global​ ​ratings
Global​ ​ratings​ ​of​ ​oral​ ​health​ ​included​ ​responses​ ​to​ ​the​ ​following​ ​questions:

● ⁃

● How would you describe the condition of your mouth and teeth? (Response options
were​ ​poor​,​ ​fair​,​ ​good​,​ ​very​ ​good​,​ ​and​ ​don’t​ ​know.​)
● ⁃

● How often during the past 12 months have you felt that life in general was less
satisfying because of problems with your mouth and teeth? (Response options were
never​,​ ​rarely​,​ ​occasionally​,​ ​very​ ​often​,​ ​and​ ​don’t​ ​know.​)
Global ratings also included an oral health status score created to summarize respondents’
experience with 11 problems related to the condition of the mouth and teeth. The higher the
score, the less frequent the oral health problems. We assigned responses of ​never a value of 3,
responses of ​rarely a value of 2, responses of ​occasionally a value of 1, and responses of ​very
often a value of 0. We used these values to calculate a sum score ranging from 0 (poor oral
health) to 10 (excellent oral health) for each respondent. We weighted all 11 responses for oral
health status equally. We did not calculate the oral health status score for respondents who
answered ​don’t know for 1 or more of the 11 problems (n = 464). Full details about the
development​ ​of​ ​the​ ​oral​ ​health​ ​status​ ​score​ ​are​ ​available​ ​elsewhere.19

Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography

Quality​ ​of​ ​life

Survey questions related to quality of life can be thought of as measures of the functional or
social​ ​effect​ ​of​ ​oral​ ​health​ ​and​ ​include​ ​the​ ​following:

● ⁃

● Have you ever felt that the appearance of your mouth and teeth affected your ability
to​ ​interview​ ​for​ ​a​ ​job?​ ​(Response​ ​options​ ​were​ ​yes​,​ ​no​,​ ​and​ ​don’t​ ​know.​)
 ● ⁃

● How often have you experienced each of the following problems related to your
mouth and teeth during the past 12 months? These problems were difficulty when
biting or chewing foods, difficulty with speech or trouble pronouncing words, dry
mouth, anxiety, taking days off work because of pain or discomfort, difficulty doing
usual activities, problems sleeping, experiencing pain, embarrassment, avoiding
smiling, and reduced participation in social activities. (Response options were ​never​,
rarely​,​ ​occasionally​,​ ​very​ ​often​,​ ​and​ ​don’t​ ​know.​)
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography

Income​ ​inequality
We created an income inequality variable by using the county-level Gini coefficients associated
with each respondent. First, we assigned each respondent a county on the basis of his or her
reported ZIP code. We obtained a ZIP code and county crosswalk file from the Missouri Census
Data Center20 and used it to match a county to each ZIP code represented in the survey
responses. In cases in which a single ZIP code was associated with more than 1 county, we
assigned the county containing the largest proportion of the population (as of 2010) within that
ZIP code to the respondent. ZIP codes were invalid for 4 respondents; therefore, we did not
assign​ ​them​ ​a​ ​county​ ​and​ ​excluded​ ​them​ ​from​ ​the​ ​analysis.

We then assigned each respondent a Gini coefficient on the basis of his or her assigned county.
We obtained county-level 5-year Gini coefficient estimates from the US Census Bureau
American Community Survey.21 A Gini coefficient of 0 indicates complete income equality and
1 indicates complete income inequality. We placed respondents into tertiles of income inequality
by using the assigned Gini coefficients: low income inequality (4,999 respondents with a Gini
coefficient from 0.3440 through 0.4329), medium income inequality (5,069 respondents with a
Gini coefficient from 0.4330 through 0.4637), and high income inequality (4,890 respondents
with​ ​a​ ​Gini​ ​coefficient​ ​from​ ​0.4638​ ​through​ ​0.5975).

Analysis
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis
Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of
lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography
We conducted analyses on specific oral health and well-being measures across the 3 levels of
income inequality (low, medium, and high). We conducted χ2 tests to assess differences between
these groups on ratings of the overall condition of the mouth and teeth, the frequency of feeling
that life in general is less satisfying due to the condition of the mouth and teeth, whether the
ability to interview for a job had ever been affected by the appearance of the mouth and teeth,
and the frequency of experiencing 11 problems related to the condition the mouth and teeth. We
used one-way analysis of variance to assess differences between income inequality strata on oral
health​ ​status​ ​scores.​ ​We​ ​performed​ ​post​ ​hoc​ ​testing​ ​with​ ​the​ ​Tukey​ ​method.

We applied weights to the data for all analyses. Harris Poll generated these weights to bring the
14,962 respondents in line with national and state compositions of the US adult population,
taking into account respondents' race or ethnicity, education, state and region of residence,
household income, sex, age, and propensity to be online. Although results are based on weighted
data,​ ​we​ ​report​ ​the​ ​unweighted​ ​number​ ​of​ ​respondents​ ​with​ ​all​ ​statistics.

For each global rating and quality of life measure, we excluded responses of ​don’t know from
analyses. The proportion of respondents who selected ​don’t know was less than 1% for each
question, with the exception of the appearance of the mouth and teeth affecting the ability to
interview​ ​for​ ​a​ ​job​ ​(4.7%​ ​of​ ​respondents​ ​selected​ ​don’t​ ​know​ ​for​ ​this​ ​item).

Results
Jump to SectionMethods Sample Survey instrument Data collection Measures for analysis

Global ratings Quality of life Income inequality AnalysisResults Global ratings Quality of

lifeDiscussionPublic​ ​Health​ ​ImplicationsSupplemental​ ​DataReferencesBiography

We received responses from 14,962 of the people whom Harris Poll contacted to complete our
survey. Before weighting the data, most of the respondents were female and white and had
completed high school or attended college, and they were distributed evenly in terms of age,
income, and county-level income inequality. The ​table presents proportions for respondent
characteristics​ ​before​ ​and​ ​after​ ​weighting.