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Dental services during pregnancy can improve maternal oral health, reduce mother-child transmission of cariogenic bacteria, and create opportunities for anticipatory guidance. This study aimed to understand why low-income women did or did not utilize dental services in a pilot program to promote dental visits during pregnancy in Klamath County, Oregon.
Sixty women were contacted and 51 participated in semi-structured telephone interviews regarding utilization of dental services during pregnancy. Women were selected randomly from the pilot program: 45 women (88%) utilized dental services and six did not. Transcripts were content analyzed using a mixed method qualitative approach - grounded theory and Stages of Change model - to identify themes and sub-themes.
Most women overcame stress or dentally-related barriers to use care. Stressors included poor domestic relationships, personal finances, and employment. Dentally-related factors included perception of dental experience, attitude toward dental providers, importance/valuing of oral health, perceived ability to pay for care, time constraints, dental providers’ and office staff attitudes toward clients.
Identifying barriers that prevent low-income women from taking action to access dental care during pregnancy provides information essential for enhancing public-private health programs to promote dental visits, reduce mother-child transmission, and provide guidance to new mothers.
Mothers who have a regular source of dental care are more likely to take their child to the dentist and to develop attitudes and behaviors that promote good dental health. 1 This is important because the oral health of preschoolers from low-income families in the US is deteriorating and utilization of preventive care is not at optimal levels. 2 Acting on the link between mother’s and children’s oral health, Milgrom and colleagues have reported on the development of a pilot community program to promote care for pregnant women served by Medicaid in Klamath County, Oregon. 3 According to this report, pregnant women in the program received home or Women Infant and Child center (WIC) visits by a trained counselor and were assigned a dental home under a dental managed care program (DCO). Emergency, preventive and restorative care was provided. The evaluation reported 55.8% of eligible women in this pilot program chose to use care (235/421). In contrast, in 2001 only 8.8% of pregnant women served by Medicaid in Oregon received care. The missed appointment rate was 9%.3
The purpose of this study was to understand why women in the Oregon pilot program did or did not use the dental services offered and provide a basis for planning an expansion of the program in this and other counties in the future addressing the needs of mothers and eventually their children.
In 2006, Klamath County in rural southeast Oregon had a population of 66,438. The racial and ethnic profile of the county in 2005 was 91.7% white, 8.7% Hispanic, 4.1% American Indian or Alaska Native, 0.9% Asian, 0.8% Black and 0.2% Pacific Islander.4 The per capita income in 2005 was $25,997.
Between February 2004 and January 2006, 503 pregnant women enrolled in Medicaid were identified; 421 women were eligible. Of these, 339 received home visits (339/421, 80.5%) and 235 received care (235/339, 69.3%). The women were divided into four strata based on whether they had received at least one dental care visit and whether this was their first baby (primiparous) or not (multiparous). The names within each stratum were randomized and then individuals were contacted in order by telephone to obtain interviews. The interviewer was instructed to call no less than four times in an attempt to reach the person. If a person was not contactable, the next person on the list was called. The Institutional Review Board of the University of Washington approved the evaluation protocol.
A program staff member at the Klamath County Health Department was trained and then conducted the interviews over the phone. Subjects were offered a ten dollar incentive for participation. The interviews were audio-recorded, transcribed, and stripped of any identifying information. Transcripts were reviewed and checked against the audio files for fidelity.
The purpose of the analysis is to identify barriers to dental visits guided by a model that describes the propensity of a person to take action on a specific health problem. The model posits that a person changes behavior by passing through a defined sequence of distinct stages (See Figure 1): Precontemplation (not thinking about changing the behavior); Contemplation (intending to change; weighing the “pros” and “cons”); Preparation (planning to change); Action (making health-relevant changes in the behavior), and Maintenance (having made behavioral changes).8 The importance of this model lies in the fact that strategies and activities to promote change may differ across stages. Individuals in different stages utilize different processes of change and decision making. 9
The interview content analysis was transcript based. Transcripts were reviewed and coded independently by two individuals prior to undergoing detailed analysis. Coding used both inductive (grounded theory approach) 10 and theory-driven (based on Stage of Change model) approaches. 11 Grounded theory was selected for the analysis so that data could be approached without preconceived notions and to ensure the truth emerge from the data. Codes emerging from data were used to generate themes and sub-themes. The a priori themes were based on the stages of change approach: Precontemplation, Contemplation, and Action. After the coders had developed their coding schemes independently, their schemes were compared. Disagreement was resolved through discussion. After the coding scheme framework had been established, the transcripts were coded line by line. Both coders remained blind to the participant’s group.
Table 2 provides a summary of the telephone contacts. Sixty interviews were completed and transcribed. Nine were excluded from the study because the subject was ineligible: transcript not matching with demographic data (3), the mothers currently pregnant (4), miscarriage (1), and child not living with the mother (1). Upon analysis of the transcript content, some misclassifications in the program data were identified where some women had utilized dental services during pregnancy not reflected in the original selection of interviewees. The adjusted response rate is shown in the Table 3. Of the 51 women interviewed, 39 were White, nine were Hispanic, two were Native American, and one was not identified. Most of the first time mothers (primiparous) were less than 25 years old while 50% of the multiparous mothers were less than 25 years old. There were 45 women who were classified in the Action stage and six women in the Contemplation stage.
Two broad areas of barriers to dental care utilization were identified. The two areas of barriers were stress and issues related to the dental care. Stress was caused by problems internal to the individual, including physical and emotional issues as well as external factors including relationship issues, financial concerns, employment, and living condition/environmental factors. Dental factors also were divided into internal and external factors. Internal factors included perception of dental experiences, attitudes toward the dentist, perceived value of oral health, and understanding the importance of oral health. The external factors included financial concerns, time constraints, logistics, and attitudes of the dentist and dental staff members toward clients.
Stress was experienced by all the expectant mothers irrespective of whether or not they utilized the dental services offered. Internal causes had both physical (e.g. the discomfort of hot weather) and emotional (e. g. mood swings) determinants. Most, but not all, of the mothers were affected by the external factors of limited financial resources and difficulty in paying bills and the rent.
“It seemed a little bit more stressful because you’re worrying about what was going to happen when the baby was born, and if we could afford clothes and stuff and diapers and all that other stuff.” [primiparous and utilized dental care]
In most cases, pregnancy strengthened the women’s relationship with their spouses. If, however, the relationship was new or unstable, pregnancy added to the stress. Family and social support was needed.
“I think (stress) was mainly brought on because my ex-husband kind of emotionally and physically abused me, and I was having a really hard time. He’s hurt me when I was pregnant with her, and he let his friends do things to me when I was pregnant with her. I was about probably three and a half, four months pregnant when I finally just left him and went and lived with my parents because he was smoking crystal meth and doing pot, and I was trying to get away from him.” [primiparous and utilized dental care]
Most of the mothers who were in school or employed reported difficulties because of the need to manage school and work. Some also had difficulty with transportation, such as the lack of a car or a driving license or money for gas.
“We go to town as a family because gas is so expensive, and so that’s one of those things [going to the dentist] that’s got to be family-friendly time period.” [primiparous and utilized dental care]
Relocation also brought about stress with the many problems associated with moving and finding new doctors and dentists.
Many internal factors related to dental care served as barriers to obtaining care (“cons”). Negative past dental experiences, anxiety associated with pain, and long waiting times in the dentist’s office affected both those who utilized the care and those who did not.
“The only thing that really you know gets on my nerves is you usually have to wait for like two hours until you’re seen.” [multiparous and did not utilize dental care]
Some of those who utilized the care reported previous positive experiences (“pros”).
“I actually like going to the dentist because since I was a little girl I’ve been going to the dentist. They’re always friendly, and they’re nice, so I guess that’s why I like going to the dentist a lot.” [primiparous and utilized dental care]
Only those who utilized care commented on their attitude toward the dentist. Most, particularly multiparous women were satisfied although some felt the dentist was not attentive to their concerns and that some dental staff members were unpleasant.
“At the dentist that I’m currently supposed to be seeing, it’s the receptionists in the front office. They’re just extremely rude. I don’t think they’re completely honest, and they treat people who don’t have private insurance, who are like on OHP or some other sort of assisted insurance, they treat them differently than they do their other patients.” [primiparous and utilized dental care]
All the mothers who were interviewed made positive comments about the value of oral health, but based on different criteria. Those who did not use the care valued it because of its effect on appearance and symptoms, particularly pain. Those who did use the service provided greater acknowledgement of its health value for themselves and their children. They overcame fear and discomfort to access the service.
“..You’re laying there with your mouth wide open, and you get kind of get self-conscious that they have to look at my nasty teeth…But the more that I go to the dentist and get them cleaned, then the less self-conscious. I’m more confident when I’m laying there with my mouth wide open.” [primiparous and utilized dental care]
Dental care was paid for by Medicaid and there was no out of pocket expense; the financial barrier identified was the cost associated with accessing the service. Financially related barriers, i.e., costs of transportation, gas, child care, and opportunity costs (time constraints such as time taken to visit the dentist and waiting times at the dentist) were encumbrances to care for women in both utilization categories.
“…someone to come watch the kids when I have to be at the dentist because I used to do a lot of my appointments on my husband’s lunch hour and when the kids were napping, but sometimes it takes a few hours.” [multiparous and utilized dental care]
The majority of the mothers who utilized the service reported satisfactory experiences when the dentists and office staff had positive and caring attitudes. When a dentist was not comfortable treating pregnant women, the patient felt uneasy and reluctant to proceed.
“When it comes to dental work, I tried to get my teeth done during my pregnancy, but the dentist wanted me to sign this waiver that if anything happened to my baby during my delivery that he wouldn’t be responsible, and I wasn’t comfortable with that because he really freaked me out.” [multiparous and utilized dental care]
Most of the time, the patient perceived the dental professionals’ competency through how the dentist communicated and related to the patient more than his/her clinical skills. The dental staff and its ability to communicate had a great influence on the success of the dental encounter.
“The experience has been really good. I mean I like my dentist. She explains to me before she does anything, what she’s going to do, and what she’s going to use.” [multiparous and utilized dental care]
A collaboration of the Klamath County Health Department (Oregon) with dental managed care programs and other community partners has developed an outreach program to encourage low-income pregnant women to utilize dental services and put in place strategies to improve maternal oral health, reduce transmission of cariogenic bacteria, and provide anticipatory guidance. 12 In this program, each of the women has a dental home for herself and for her new baby. Some women have taken advantage of the free dental services while others have not. The purpose of this study was to understand factors influencing why eligible pregnant women in the Klamath population have or have not utilized the free dental care and to identify barriers to care.
The Stages of Change model provides a theoretical basis for understanding these findings. Those who do not express much understanding of the benefit of dental care during pregnancy are considered to be in the Precontemplation stage. They do not have a backlog of positive dental experiences to draw from and tend to seek out only symptomatic care. There are few “pros.” People who have not had regular positive contacts with dental health providers have the commonsensical belief that when their teeth do not hurt them, there are no problems that require attention. 13, 14 None of the women interviewed fell into the Precontemplative stage. The women in the Contemplation stage understood and valued the benefit of dental care (“pros”); however, they identified barriers as a deterrent to accepting care (“cons”) and did not move to the Action stage to accept care.
Women who utilized the service recognized and managed to overcome barriers or “cons” (dental fear, lack of childcare) progressed to the Action stage to accept care. These women appeared to have had previous positive dental experiences that impacted their choice to expend scarce resources to access care.
Pregnancy presents prominent stressors. 15 Social supports are important protective factors against the effects of stress 16 and relate to positive health practices in pregnant women.17 Without this support, stress may block progression from the Contemplation to the Action. Discussion of the advantages of dental care (“pros”) can encourage individuals to progress from Precontemplation to Contemplation stage but decreasing/eliminating barriers to change (“cons”) is more likely to move individuals from Contemplation to Action. Stages of Change are dynamic and depend upon environmental as well as personal changes. A person in the Action stage at one point of time may fall back into the Contemplation stage if the environment is not supportive. Motivational interviewing, an approach congruent with the Stages of Change theory, has been used to promote the use of dental care for the parents of preschoolers and can be readily used with pregnant women. 18–20
Motivating mothers to-be to make positive changes and to practice optimum health behaviors can enhance the long-term benefits for both mother and child. The program described in this brief report has taken its first steps to realize this goal. This study has identified barriers to care that mediate against moving toward action regarding dental visits. Diminishing these barriers requires:
The work begun in Klamath County will be extended in several ways in the county itself and in other Oregon counties. First, Klamath County has developed an approach to ensure sustainability of the initial effort without the need for grant funding. Second, a recently funded intervention study to encourage pregnant women to utilize dental services through a brief motivational interviewing approach will be undertaken in other Oregon counties. And third, a large-scale randomized community trial using a brief motivational interviewing approach is being planned for several Oregon counties which will not only promote the utilization of dental services among pregnant women and better oral health but will also assess children’s dental utilization.
We would like to thank the Klamath County Department of Public Health, Klamath Falls, OR and its director Ms. Marilynn Sutherland; Dr. Mike Shirtcliff of the Advantage Dental Plan, Redmond, OR; and Ms. Stefanie Hamamoto for their participation in the study. This study was supported, in part, by Advantage Dental Plans, under Intergovernmental Grant Agreement No. 105709 as part of a grant to the Oregon State Health Department from the Robert Wood Johnson Foundation, and Grant No. U54 DE 14254 from the NIDCR/NIH.