Dr Maupomé has a career that has spanned continents. He first received dental training at the Universidad Nacional in México City, before being awarded first an MSc in Oral Pathology then a PhD in Public Health from the University of London. Returning to North America he carried out research in both Vancouver, Canada and Oregon, USA, before settling at Indiana University in 2005. Here he has combined his expertise and interest in both epidemiology, social and behavioural sciences, and dentistry to address the disparities facing underprivileged communities in the US.
The existence of oral health disparities (OHD) among the Latino community is long established and has previously been attributed to lifestyle, biological susceptibility or structural barriers posed by healthcare systems. The role of personal interactions within social networks has largely been ignored, despite widespread recognition that these networks contribute to healthcare decision making and to sharing norms and values that affect health status.
Taking a closer look
A framework for evaluating such personal interactions, called the Network-Episode Model, has been developed for use in epidemiology in an attempt to better understand individual responses to illness. According to this model, episodes of illness should be viewed as affected by formal (professional) and informal networks. Individuals rely on these relationships to understand and address their health problems. Other members of their network can offer support, recommend or provide services, influence health behaviours such as substance use, and either encourage or discourage the following of treatment regimes.
In a pioneer study targeting Mexican-Americans (MA), Dr Maupomé identified experiences of food, oral health behaviours, and dental care in the context of the networks the subjects lived in. This showed that the utilisation of dental services by MAs is moderated by their peers. For example, parents and co-workers were found to encourage the use of urgent dental care, whereas involving members of the extended family (such as grandparents) often contributed to a fatalistic view that oral diseases are inevitable.
The influence and limits of networks
The study found that MAs were more likely to talk to family about oral health issues than discuss them outside the family network. If these members were perceived to have greater dental knowledge then it was more likely that the subject would come up; this was particularly true if the MAs were less integrated culturally. This means that early in the acculturation process, family and peers have a major influence on how MAs access dental services.
Dr Maupomé acknowledges some limitations in the study, which focused on a particular nationality of origin in one ethnic group. The design of the study also precluded any establishment of a causal link. To address the latter issue, and to further investigate the role of social networks in OHD, an expanded team is going back to the field.
A comprehensive approach
Using a longitudinal study design (where subjects are observed repeatedly over a longer time period), Dr Maupomé hopes to begin developing a strong causal model of OHD in MAs. Looking at how networks, oral health culture and dental care attitudes influence one another over time, he hopes to gain an insight into the complex and dynamic mechanisms underlying OHD.
The first aim of the study is one of characterisation. Looking at the customs, attitudes and behaviours around dental care and oral health among MAs, Dr Maupomé hopes to identify these more clearly so that they can be effectively monitored by the team. In this way, they can build up a clearer picture of the associations between these factors and other features of personal networks.
The second aim is to use this information to determine the relationships between the diverse strands of interpersonal networks and behaviours. These include behaviours such as cultural integration, whereby individuals begin to take on the customs of the host country; the dynamics of personal and community networks, as MAs expand and develop their peer groups; and the distribution of customs and resources as these peer groups influence and support each other. These relationships result in the evolution of oral health behaviours, attitudes and outcomes, when all these various factors come to bear on the physical health of the study subjects.
Great challenges bring great rewards
This is as daunting a task as any in complex science methods, but there are good reasons to pursue it with the passion that Dr Maupomé has for the subject. Firstly, to improve both the quality and the quantity of knowledge about the complex and ever-changing mechanisms underlying OHD. Although effective public policy needs to be built on the foundations of accurate understanding of the factors involved, to date this empirical approach has been largely limited to individualistic models of patient motives and circumstances. Clinical guidelines would also benefit from such enhanced perspectives of where, how, and with whom people live, in order to provide culturally sensitive clinical and preventive care strategies. The same is true of research efforts to provide practical solutions to OHD.
Building upon these envisioned assets resulting from network science research, the ultimate goal is to provide the opportunity of tailoring programmes to MA communities, using their existing natural strengths and resources to improve the oral health of the population as a whole.
The Latino population in the US is the fastest growing ethnic group in the country, yet it has particular and significant barriers to dental service provision and access, resulting in large oral health disparities. Using these techniques to map the factors and characterising the effects of relationships over time, Dr Maupomé and his collaborators have the potential to impact positively on this area of public policy and clinical care.
Having had the privilege of living in a few countries and having travelled extensively, it soon became apparent that the root causes of poor health in general, and poor oral health, are rather ubiquitous. And the more appropriate tools to address those challenges go well beyond expensive clinical care repeated over and over again.
Why do disadvantaged communities suffer from such health disparities?
Underprivileged communities such as immigrants are in an extremely precarious situation – challenged by what is often low income, limited access to care, lack of knowledge to navigate health care systems, and the confluence of (new and old) cultural influences that often work against their health status. Considering that our time will be defined by the multiple, evolving, and complex trends underlying immigration movements throughout the world, it is clear that a methodical and multifaceted approach is essential to characterising immigrant health issues.
What did your initial study discover about Mexican American communities?
That the cultural features of population groups moderate the web of influencing factors leading to oral health outcomes. And it is remarkable how many of these influences there are when you think about the vast array of issues present in the health landscape.
What do you hope the VidaSana project will achieve?
To further refine the methods available to understand the evolution of networks in the context of health issues, and to identify culturally specific resources to leverage solutions in an underprivileged population.
How might the results of this research impact public policy and clinical practice?
Simply throwing money at health care problems is expensive and ineffective – even if the fiscal realities of the world would allow for generous funding of health systems. We can harness existing strengths in the communities to create simpler, less expensive solutions if we understand the problems and the clients in the context of the landscape in which they live.
Dr Maupomé’s research focuses on oral health in Latino populations, in particular the influence of social networks on communicating oral health information and sharing social norms about dental care and oral health.
Indiana Clinical and Translational Sciences Institute
W R McConnell; B L Perry; B Pescosolido; E L Pullen; E R Wright; Ann McCranie
Dr Maupomé trained in dentistry at the Universidad Nacional in México City, before being awarded first an MSc in Oral Pathology then a PhD in Public Health from the University of London. Returning to North America he carried out research in both Vancouver, Canada and Oregon, USA, before settling at Indiana University in 2005.
Gerardo Maupomé, BDS, MSc, DDPH RCS(E), PhD
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