Giving a Voice to the ‘Silent Epidemic’: Examining Existing
Barriers and Oral Health Outreach for Low Income Mexican
American Children
By Victoria Benson
26 May 2009
Advisor: Eunice Rodriguez, Pediatrics
Second Reader: Tania Mitchell, Comparative Studies in Race and Ethnicity
Submitted to the Program in Comparative Studies in Race and Ethnicity in partial
fulfillment of the requirements for the Undergraduate Honors Program
i
Abstract
A 2000 Surgeon General Report declared oral health disparities among children
of low socioeconomic status (SES) a silent epidemic. Research shows Mexican
American children have disproportionately high occurrences of oral disease
compared to their White counterparts. A community intervention of The Health
Trust (THT) is examined using a phone survey (n= 168) and participant focus
groups (n=19) to understand how oral health outreach prepares low SES
Mexican families to address oral health barriers. Cultural oral health practices
and their role in oral health disparities are also explored. Results indicate the
program’s success in teaching preventative oral health practices, but
improvement is needed to address lack of dental insurance (26.4%), language
differences (16.5%), discomfort with available dentists (15.6%), and negative
experiences with dentists. Cultural oral health practices do not appear to
contribute to oral health disparities in Mexican American children; however, these
practices reflect low SES conditions.
ii
Acknowledgements
Writing this honors thesis has been an irreplaceable experience that would not
have been possible had I not had the wonderful support and encouragement
from the following individuals.
To my family who have never stopped believing in me. Everyday I think about
how fortunate I am to have the love and support you all provide.
To Eunice Rodriguez who was bold enough to embark upon this project with me.
Your guidance has allowed me to achieve more than I knew I could.
To Tania Mitchell, your advice and dedicated presence (in the office and at your
home) is greatly appreciated. I enjoyed working with you.
I would not have challenged myself to start this project had it not been for Rand
Quinn and Dr. Jeanne Tsai’s influence and enthusiasm.
To THT, Aimee Reedy, Daryl Nguyen, and Mario Tercero for making this project
possible.
To Odette Avalos, Ernesto Castillo, Karla Martinez and Carlos Fonseca for
providing the link between my participants and me.
To every other CSRE student who embarked upon this project with me. You
provided support and camaraderie just when I needed it.
Thank you all so much.
iii
Table of Contents
1
Introduction
8
Literature Review
31
Methodology
42
Results
62
Discussion
78
Conclusion
82
Appendices
114
Bibliography
iv
Figures and Tables
46
Figure 1: Code Categories for Perception of THT
49
Figure 2: Code Categories for Oral Health Practices of Participants
53
Figure 3: Code Categories for Barriers in Maintaining Children’s Oral Health
61
Table 1: Sample Statements of Cultural Oral Health Related Practices
v
Acronyms and Foreign Words
THT - The Health Trust
SES – Socioeconomic Status
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment dental
services program – EPSDT
Community-Based Participatory Research – CBPR
Promotores(as) – Lay health educators from Latino communities
vi
Introduction
Oral health is often overlooked when considering necessary health care
both by health care providers and by the general population. However, oral
health plays a large role in everyday comfort and can also affect the health of
other systems within the human body. For example, periodontal disease may,
over time, increase the risk of heart disease and stroke. Periodontal disease is
the development of various mixed bacterial infections that affect the soft tissues
and bones supporting the teeth. This bacteria is thought to release toxins into
the bloodstream that contribute to the formation of fatty plaques in the arteries,
which eventually can block blood flow leading to serious health complications
such as blood clots that cause strokes (Simple Steps to Better Dental Health,
Periodontal Disease). Despite connections like this to the overall health of the
body, and the importance of healthy teeth for oral health’s sake, the significance
of dental health continues to be marginalized.
This neglect of oral health has led to what the Surgeon General has
declared as a “silent epidemic” within the United States (U.S. Department of
Health and Human Resources, Office of the Surgeon General, 2000). While oral
health is important to all people, it is the low socioeconomic status (SES)
populations that suffer most from this epidemic. Unfortunately, racial and ethnic
minorities, such as African Americans and Latinos are often hit the hardest by
this health disparity (Watson et al., 34, 2001). For example, a Washington Post
article, in 2007, told the story of a 12-year-old African American boy named
1
Deamonte Driver who died of a toothache. The bacteria from the abscess
spread into his brain, eventually killing him. This was a terrible incident and
should never have happened because oral disease is easily preventable and can
be eradicated through dental procedures. Deamonte came home from school
one day complaining of a headache and soon became very sick. He was rushed
to the hospital and had an emergency brain surgery. He began to have seizures
and underwent another operation and the infected tooth was extracted.
Deamonte spent 8 weeks in the hospital before passing away. Deamonte’s
Medicaid insurance should have covered dental care, however, Medicaid dentists
are extremely difficult to find and at the time of his hospitalization, his insurance
had temporarily lapsed. Incidents like this remind us of the importance of oral
health and how it is far too often overlooked in health care.
Deamonte had a younger brother, named DaShawn, who also suffered
from intense oral pain. The Washington Post discusses his story as well.
DaShawn had seen a dentist for his ailments; however, the dentist discontinued
the treatments because he squirmed too much in the dentist chair. To put into
perspective the severity of DaShawn’s ailments, it is important to know that
DaShawn had abscessed teeth and his condition was so severe that his mother
was so engrossed with getting professional help for his condition that she failed
to realize that Deamonte’s teeth were also infected until he was in critical
condition.
What does this say about the dentist who discontinued treatment with
DaShawn because he “squirmed too much?” DaShawn’s condition was not a
2
trivial one, yet the dentist stopped treatment because of being inconvenienced by
the child’s behavior in response to pain and fear at the dentist office. How often
does this happen? What are the perceptions that dentists have of their patients
and how does this effect access to dental care? Do dentists consciously or
subconsciously provide differential treatment to different patient populations? No
matter what the root reason this dentist discontinued treatment with DaShawn, in
his case, the dentist’s unwillingness to endure his squirming caused him to have
zero access to dental care because his family was poor and his insurance status
fluctuated back and forth from Medicaid to no insurance at all. Because many
dentists do not accept Medicaid, his mother struggled for months to find another
dentist and had to contact a lawyer from the Baltimore-based Public Justice
Center for help in finding one to treat her son (Otto, B01, 2007). By the time she
secured an appointment, they had lost their insurance coverage due to poor
structuring of the Medicaid system. Situations like this should be further
investigated to understand how they contribute to racial and socioeconomic
disparities in oral health.
Fortunately, not every case of untreated dental disease always leads to
death, however Dashawn’s story shows that oral infections can greatly affect the
everyday comfort and interactions children experience. A severe toothache is an
excruciatingly painful experience. The intense pain caused by untreated oral
decay can negatively affect other parts of children’s lives. Dental pain may
interfere with concentration at school, affect self-esteem, and lead to a decrease
in speech, which can affect speech development. Furthermore, dental decay can
3
interfere with children’s eating habits, thus, affecting the overall health of a
growing body, and the child’s energy levels.
Oral decay is the single most prevalent chronic infectious disease of
childhood (National Maternal & Child Oral Health Resource Center Fact Sheet,
2004). Mexican American children between ages 2 to 5 are more likely than their
non-Hispanic white and black peers to experience caries1 in primary teeth
(National Maternal & Child Oral Health Resource Center Fact Sheet, 2004).
Within California, “one-third of preschool children have untreated tooth decay”
(First Smiles Oral Health, 2004). Furthermore, nationally and within Santa Clara
County, minority children in the third grade are more likely to have incidents of
dental caries than white children (Healthy People 2010, Table 21-1a.).
Oral health has become an increasing problem because many dental care
providers do not accept public health insurance and therefore underinsured
children do not have adequate access to dental health care to prevent and treat
oral decay. Furthermore, low SES plays a role in increasing the incidence of
dental caries for many of these children because their parents are often not as
well versed in promoting preventative oral health care. Unfortunately, the
combination of factors influenced by low SES, such as exclusion from
professional dental care and lack of knowledge of the importance of preventative
1
Dental caries: cavity formation in teeth caused by bacteria that attach to teeth and
form acids in the presence of sucrose, other sugars, and refined starches; tooth
decay
4
oral health care, places these children at a greater risk for dental disease.
Additionally, these communities often do not realize that they can prevent the
majority of oral diseases themselves because so many other factors in their lives
seem to present more immediate attention than oral health care. Therefore, it is
important that oral health interventions tailored specifically for the communities
they intend to serve are initiated to confront and suppress this ‘silent epidemic’.
The Health Trust (THT) is a non-profit organization dedicated to
addressing these disparities and has implemented a home-based oral health
program that uses the Promotores de Salud model (to be elaborated on in the
literature review) to combat these inequities. I took a special interest in this
program and chose to focus my research on evaluating it. I am specifically
interested in understanding if the program addressed barriers that these families
face in maintaining their children’s oral health, such as recognizing the
importance of brushing and flossing, paying for dental visits, or even finding a
dentist.
There is a large gap in the literature regarding oral health cultural
practices and often the oral health care systems attribute racial and ethnic
disparities to cultural practices although little is actually known about these
“cultural” practices they reference (Butani et al., 9, 2008). Therefore, I am also
interested in what cultural oral health related practices Mexican Americans are
accustomed to. It is dangerous to make claims that cultural practices of an
already marginalized group led to detrimental oral health outcomes without
having the facts to support it. It places the group at risk for further
5
marginalization by stigmatizing the group. By identifying cultural beliefs, values,
and practices that influence oral health, we can better identify whether or not
Mexican cultural practices actually increase risk of contracting oral disease. If
they do contribute to the disparity, it is important to understand exactly how they
impact this disparity in order to minimize oral disease incidence in this
population. However, if cultural practices do not contribute to the disparity, it is
important to continue to seek answers as to why this disparity is so prevalent
among Mexican American children. By understanding the mechanisms that
contribute to this disparity, we can work to reduce it.
Mexican American children carry a disproportionate burden of oral
disease. Many of these children are either underinsured or uninsured and face
an access barrier to professional dental care services and to preventative oral
health practices due to lack of knowledge. Obstacles generated by low
socioeconomic conditions compound this issue. Existing literature has not yet
identified the barriers at play in this situation in their entirety and therefore, has
not been able to identify a sound method to reducing these disparities. THT’s
intervention program seeks to address this ‘silent epidemic’ and the information
that comes from examining this program’s effectiveness will contribute to
understanding the broader picture. The driving questions for this research are:
(1) How effective is oral health outreach to low SES Mexican families in
addressing barriers parents face in maintaining their children’s oral health? (2)
What cultural oral health related practices do Mexican families use to maintain
oral health?
6
This paper will examine just how severe this disparity is among the Latino
children population, with a focus on Mexican American children, what existing
barriers have been identified, and the interventions that seek to address these
inequities. The study aims to identify barriers that have been under-addressed
and to find out how THT’s intervention can help parents of Mexican descent
overcome these barriers. Cultural oral health related practices are of special
interest because they have been cited as a contributing barrier to this disparity,
yet they are not clearly understood.
7
Literature Review
This section provides a background on the nature of oral health disparities
among Mexican American children, the interventions that have been initiated to
reduce these disparities, and what information is absent from the literature that
could help to better understand this phenomenon. This information will provide
understanding as to the motivations of this study. An overview of the current
state of Latino Oral Health will provide information detailing the extent to which
this disparity exists. The identified barriers parents of Mexican descent face in
maintaining the oral health of their children are outlined. Existing oral health
interventions that aim to address these barriers are discussed. Next, background
information on THT and its oral health intervention are presented. Lastly, this
section discusses what gaps are in the literature and explains the purpose and
motivations of this study in its goal to further explore the barriers contributing to
oral health disparities in Mexican American children.
Current State of Latino Oral Health
The Latino population has become the largest minority group in the
country; therefore, research has been conducted to work to identify the health
needs of this population. Studies show that Latino children are at a greater risk
to have dental caries, untreated oral disease, and decayed and filled tooth
surfaces. According to the 1988-1991 Third National Health and Nutrition
Examination Survey (NHANES III), 10% of Latino children 8 years of age
8
received sealants2, compared with 29% of non-Hispanic white children (RamosGomez et al., 1232, 2005). Furthermore, “only 60% of 12 to 17 year old Mexican
Americans have had their dental caries treated or filled, compared with 87% of
12 to 17 year old white children” (Flores et al., 84, 2002).
Mexican American children have strikingly high occurrences of oral
disease. This group is especially vulnerable because many of these families
have a low SES and even when SES is controlled for, Mexican Americans still
experience a high prevalence of oral disease. Research shows that when
income was controlled for, 57% of non-poor Mexican American children ages 2-9
suffer from untreated decayed teeth as compared to 37% of same aged non-poor
white children (Atchison, 21, 2003). Substantial differences in oral health
outcomes persist even when income level is controlled for and these differences
become more exacerbated when income level is not controlled for. Interestingly,
oral disease is still prevalent when income level is controlled for. This means
that families of Mexican descent who are not poor and most likely have oral
health insurance or can afford to take their children to the dentist for dental
cleanings and dental ailments still experience an oral health disparity. What is
the reason for this? There may be other factors aside from being able to afford
dental care causing this inequity. From this data it is clear that there is an urgent
need to address this disparity, whether it be low SES or higher-income Mexican
American children.
2
Sealants: A plastic resin used in dentistry to coat the chewing surfaces of the
back teeth to prevent the growth of cavity-causing bacteria
9
Although little is known about how this disparity has manifested itself,
practicing preventative oral health can effectively prevent most dental diseases
and while many of these families may not be not fully aware of the importance of
these practices, oral health education and health promotion programs are viable
options for decreasing oral disease (Watson et al., 34, 2001). In order for these
programs to have lasting positive effects, it is important that cultural, social,
economic and other environmental factors that may influence oral health are
considered. Additionally, it is important that community members are recruited
as active participants in identifying their community’s health needs. This will
promote community ownership of the program, which will lead to sustainability
and ensure that the program adequately and appropriately addresses the
community needs.
Research has shown that interventions in which community participation is
valued in the planning and implementation of the program are not only feasible
and helpful for building upon existing local resources, but are a great option for
addressing oral health concerns in populations that do not necessarily have
access to traditional dental care, such as professional services (Watson, 39,
2001). While there is evidence that this specific type of program is effective for
teaching oral health care and can possibly work to reduce oral health disparities,
it is important to acknowledge that not all Latino communities are the same and
each subgroup may require different considerations for designing culturally
appropriate service-delivery models (Ramos-Gomez et al., 1238, 2005). Latinos
differ in political, cultural, socioeconomic, and geographic aspects – which may
10
include variances in expectations regarding dental care needs, leading to
differential access to dental care. Therefore, it is important to unravel exactly
how these differences affect oral health. Despite these differences, there is a
great disparity among health research literature that addresses the specific
subgroups within the Latino population. According to the 2007 Census, the
Latino population consists of 64% Mexican Americans, 9% Puerto Ricans, 3.4%
Cubans, 3.1% Salvadoran, 2.8% Dominican, and other Latinos make up 17.7%
of the U.S. Latino population (2006 American Community Survey, US Census
Bureau). This particular study focuses on understanding oral health dynamics in
Mexican American children with monolingual Spanish speaking parents,
however, this literature review discusses Latino oral health when the subgroup is
not specified in the literature.
Although it is not clear how differences in subgroups directly affect oral
health status, by examining THT’s intervention and the target community, which
is primarily made up of Mexican Americans and first and second Mexican
immigrants, it may be possible to identify the needs of this specific subgroup.
Although a demographic break down of Latino subgroups is not available, as of
2007 25.7 percent of Santa Clara County was made up of Latinos and a large
majority of Latinos in this area are of Mexican heritage (U.S. Census Bureau,
Santa Clara County, California, 2007). It is important to be aware of the
tendency to place all Latino subgroups together and treat them as one
homogenous group. This umbrella effect is dangerous because it ignores the
unique aspects of each group and could lead to poor assessments of subgroup
11
needs. This study specifically focuses on people with Mexican heritage and
Mexican cultural practices and therefore, the findings are not necessarily
universal to all Latino populations.
While research sometimes simplifies the Latino population as a
homogonous group, it lacks richness of information in understanding the
mechanisms that contribute to oral health disparities. Little is known about the
cause for the current oral health epidemic among Latinos, especially among
children, except that there is a great disparity between these children and their
white counterparts. It is apparent, however, that early childhood caries is
especially prevalent among children of low socioeconomic status, and this
includes a large portion of Latino families. Furthermore, these families do not
have easy access to professional dental care due to barriers such as lack of
dental insurance, dentists who do not accept public dental insurance, possible
cultural differences between patient and provider, and lack of parent knowledge
of oral health needs (Flores, 196, 1998). It is important to identify all barriers that
contribute to this disparity and strive to understand how to overcome these
barriers to reduce this largely preventable epidemic.
Existing Barriers: What we know
Mexican American children are more likely to experience access barriers to
dental care than their non-Hispanic white counterparts. Many factors contribute
to this disparity. Although many articles note that a full understanding of this
12
phenomenon has not yet been elucidated, literature identifies “acculturation,
cultural preferences for sugary beverages, putting infants to sleep with bottles,
and mother-child transmission of carries-causing bacteria…lack of insurance,
dearth of dentists accepting Medicaid, shortages of Latino dentists, and cultural
and linguistic obstacles” as possible explanations for this disparity (Flores, et al.,
85, 2002). Most of the barriers contributing to this disparity stem from SES
factors, however for the purpose of examining these barriers, they have been
divided in to several categories: financial barriers, which involve insurance and
ability to pay, cultural and or class differences between the patient and provider,
effects of low SES on family behavior, and knowledge and values of oral health.
Many Mexican American children either do not have dental insurance or are
on public health insurance such as Medicaid – these are considered financial
barriers to dental services. As mentioned previously, many dentists do not accept
Medicaid and even fewer of them are pediatric dentists. In fact, nearly 75
percent of dentists do not participate in the Medicaid program and therefore do
not accept Medicaid-insured patients (Haden et al, 566, 2003). Reasons dentists
have such low Medicaid participation include inadequate reimbursement funds,
slow disbursement of Medicaid payments, arbitrary denials, prior authorization
requirements for routine services, and many non-pediatric dentists are unwilling
to treat young children (Inspector General Brown, 7, 1996 and Gehshan et al. 5,
2008). The low number of dentists willing to treat children and/or accept
Medicaid complicates this financial barrier of access to dental care. Furthermore,
children from immigrant Mexican and Mexican American families with
13
monolingual Spanish speaking parents are at even more of a disadvantage
because they may have a difficult time finding a dentist who speaks Spanish.
Although Medicaid has existed for many years, the implementers have not found
a way to address these persistent issues regarding the difficulties dentists face in
participating in public health insurance. Public policymakers often do not value
oral health as much as general health and therefore marginalize it to a lower
priority (Haden et al., 566, 2003). This is a substantial institutional factor that
contributes to this disparity.
Another barrier that involves institutional factors are cultural and/or class
differences between patients and dentists. It is considered an institutional factor
because the dental system is set in place to serve its patients, and dentists are
paid to provide a service to them. Dental schools are expected to prepare their
students to serve the United States and it is made up of a diverse population with
many different cultures and classes, therefore, they should be prepared to serve
patients from various backgrounds. The majority of the dental workforce does
not possess cultural humility in their care practices for racially and ethnically
diverse populations or even to the very young (Haden et al, 566, 2003).
Therefore, the dental system, including dental schools, should work to prepare
dentists to seek cultural humility in order to accommodate patient differences to
ensure equal quality care. One study found that parents experienced a lack of
concern or respect from dentists when they took their children for a dental check
up. This caused the parents to question the quality of care the dentist was
providing (Riportella-Muller et al. 1996, 76). This could be due to dentist-patient
14
cultural differences and perceptions that the dentist has of the parents due to
SES or ethnic background as this trend has been identified in the medical field
between physicians and patients (Smedley et al. 2003). The problem does not
only stem from institutional factors, barriers due to low SES of the child’s family
also contribute to the disparity.
The following are barriers that stem from the effects low SES has on family
behavior, such as motivation and ability to maintain children’s oral health.
Families living in poor inner cities or even rural areas have difficulty getting time
off from work to take their child to the dentist. Finding transportation, especially if
the dentist is a long distance away, poses as a barrier as well. Furthermore,
these families have a lot to deal with in terms of other medical health needs, bills,
jobs, daycare, etc. and can overlook the importance of oral health, especially if
they are not aware of the significant role it plays in their child’s overall health.
Many low SES families give dental services low priority because they have many
other competing family priorities. This causes parents not to seek services for
dental care (Riportella-Muller et al. 1996, 71-76).
Oral health is often neglected and is not considered an important part of
overall health by the general population. This lack of knowledge and value of
oral health acts as another barrier. This group includes, but is not limited to,
many immigrant Mexican and Mexican American families unaware of its
importance and the practices that can be done to prevent oral decay. This
means that there is a “lack of knowledge about the prevention of oral health
diseases and awareness of their clinical need” (Haden et al., 566, 2003). This
15
lack of knowledge could be exacerbated in communities of need because there
are so many other stressors present due to socioeconomic conditions. Often,
research attributes the lack of knowledge of oral health practices and high
prevalence of oral disease in immigrant Mexican and Mexican American children
to oral health related cultural practices (Flores et al., 85, 2002). However, little is
known about exactly what oral health-related cultural practices are and how they
contribute to increased prevalence of oral disease in children.
Independent of SES, Mexican American children have high incidence of oral
disease. Data previously presented shows that when SES is controlled for,
Mexican American children still have higher incidences of untreated caries over
their non-hispanic white counterparts. Several studies show that “the percentage
of children who had never visited a dentist was highest among Mexican children
(17.7%)” and have had the lowest levels of dental visits in the United States
(Ramos-Gomez et al., 1232, 2005). This suggests that Mexican American
children are more likely to experience access barriers to dental care compared to
non-Hispanic white children. Literature has not clearly elucidated the reasons
why Mexican American children, in particular, experience this barrier. No matter
where this barrier stems from, it is clear that other factors outside of SES
contribute to oral health disparities in this population.
Existing Interventions
As described previously, oral disease is very prevalent among Latino
children, especially those living in low socioeconomic conditions. Interventions
16
and government programs have been initiated to combat this inequity, however,
this problem has persisted for the past 3 decades (CDC, 293, 2007). This
section discusses existing oral health interventions that target low socioeconomic
communities and seek to improve public health. These include government
funded public health programs and non-profit organized interventions. There are
many different methods and structures of community interventions. Examples
include school-based programs that provide health education, fluoride rinse and
tablets, and/or oral examinations and referral, programs that prevent early
childhood caries, and public, professional, and school-based education (CDCMMWR, 3, 2001). These programs may be run by dentists or other dental
professionals and generally take the traditional approach to interventions. This
approach involves a public health expert doing research to assess the
community need, developing an intervention, and implementing it in the target
community. There is little to no collaboration with the community in developing
and executing the intervention.
Medicaid’s oral health program, a community based participatory research
(CBPR) intervention, and THT’s home-based oral health program will be
discussed in greater detail. Medicaid is a program that provides insurance to low
SES children and therefore has the potential to have a major impact on oral
health disparities, whereas other programs lack the power of the government to
offer substantial material aid to a large population. The CBPR intervention is
focused on because it aims to address the issue in a comprehensive manner by
addressing power dynamics and working to empower the community it serves.
17
Lastly, THT’s program is the focus of this paper because it seeks to tailor the
program to a specific community by making it a home-based program that comes
to the community and has a community member disseminate the information,
and therefore, it has similar elements of CBPR. Furthermore, it provides a
vehicle to examine the existing barriers present in this particular community.
In 1967, Congress enacted Medicaid’s Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) dental services program, which was
intended to be a comprehensive health program that would provide initial,
periodic, and medically necessary follow-up examinations in an effort to remove
financial barriers to health for poor children. It has expanded substantially since
its enactment. This program included dental care and was to be provided to
eligible children from birth to age 20 (Inspector General Brown 1996:1). EPSDT
has two primary operational premises, access and utilization.
The EPSDT requirements encompass both coverage and
arranging for care. The benefits required under EPSDT
include preventive dental care, as well as all dental care that
is medically necessary to restore teeth and maintain dental
health (including orthodontics), as well as assistance in
arranging for covered services, including scheduling and
transportation.
Gehshan et al. 2008:4
This means that the program planned to actively conduct outreach services
through mailing, pamphlets, phone calls, and home visits to raise awareness of
EPSDT. Furthermore, it is required to provide transportation for families to their
appointments, health education for parents regarding normal growth and
development of their child, immunizations, and assistance in making
18
appointments. All of this is ‘free of charge’ as long as you qualify for Medicaid
(Riportella-Muller et al. 1996:71-72).
This program undoubtedly has great potential to reduce health and oral
health disparities among poor children, however, over 40 years into the
implementation of the program roughly two-thirds of all children on public health
insurance had not visited the dentist in the last year (Gehshan et al. 2008:5).
Program participation varies from state to state. In 1993, less than 30%
participated in three-fourths of the States, and no State provided care to more
than 50% of qualifying children (Inspector General Brown 1996:6). Even though
the program is having significantly low participation, it has been continued for
almost a half of a century. Revisions to the EPSDT program have been made
(i.e. Omnibus Budget Reconciliation Acts of 1989 and 1990), yet the program
continues to have discouraging participation outcomes.
Why does the EPSDT program have such low participation after being active
for over 40 years? Let’s examine some of the limits and pitfalls of the program to
understand why so few eligible children actually receive preventative dental
services. One primary reason why EPSDT candidates do not receive oral health
care is because a small number of dentists actually participate in Medicaid.
Specifically, “approximately 80% of the States attribute the low utilization rate to
a shortage of dentists willing to accept Medicaid” (Inspector General Brown
1996:7). Why do so few dentists accept public health insurance? Many dentists
do not participate in Medicaid because it has such low payment rates that
dentists end up losing money by serving these patients. What's more, Medicaid
19
is set up in such a way that the administrative requirements are complex and
laborious to complete. These issues detour dentists from committing to the
Medicaid insurance system, thus Medicaid insured children have a difficult time
finding dentists who will serve them. (Inspector General Brown 1996:7 and
Gehshan et al. 2008:5). Although the program has existed for many years, the
implementers have not found a way to address these persistent issues.
Additionally, many children who qualify for Medicaid are from minority groups,
including Mexican American children. This means that the program should have
created strategies to make it a program that includes cultural humility3, however,
the program does not emphasize this important factor in outreach strategies.
EPSDT also failed to provide the transportation and assistance promised
to participants, creating more barriers to accessing a dentist. Many Mexican
families live in rural areas and traveling 15 miles to the dentist without a means of
transportation can make it almost impossible to seek dental care when these
families have many other pressing issues to deal with (Riportella-Muller et al., 78
1996). Limited clinic hours and loss of Medicaid eligibility after making an
appointment, further disrupts access to dental care (Riportella-Muller et al., 75,
1996). These logistical barriers have persisted and must be addressed.
Furthermore, the EPSDT outreach needs to be altered to better inform parents of
3
Cultural humility is distinct from the more commonly used term, cultural
competence, a competence that may never be truly achievable in another
culture. Cultural humility refers to ‘a lifelong commitment to self-evaluation and
self-critique’ to redress power imbalances and ‘develop and maintain mutually
respectful and dynamic partnerships with communities’” (Wallerstein and Duran,
316, 2006)
20
preventative measures they can take to maintain their children’s oral health, and
on the importance of receiving dental care. While EPSDT has many areas that
need improvement, the program has the potential to have a substantial impact on
oral health disparities because it provides financial support for professional
dental care on a national level.
A relatively new form of research developed in the public health field
known as Community Based Participatory Research (CBPR) has emerged in the
past few decades to reduce health disparities. CBPR addresses social,
structural and physical environmental inequities through actively involving
organizational representatives, community members, and researchers in every
aspect of the research process. It uniquely integrates social action, education,
and research strategies to reduce health disparities and improve health. This
form of research focuses on fostering a trusting relationship between the
community and outside researchers. A fundamental element of CBPR is the
significance of the participation and impact of nonacademic researchers in the
process of attaining knowledge and understanding the social phenomenon being
studied. In CBPR, each partner “contribute[s] ‘unique strengths and shared
responsibilities’ to enhance understanding of a given phenomenon and the social
and cultural dynamics of the community, and integrate the knowledge gained
with action to improve the health and well-being of community members” (Israel
et al., 177, 1998). This is unique from other forms of health interventions, which
place the majority of control over the project in the hands of public health
researchers who are considered the health ‘experts’. The community itself is
21
acknowledged as a unit of identity with irreplaceable expertise in terms of
knowledge of the structure of the community, what the community needs, and
how to best address that need. The outside research team is equipped with
expertise in terms of research techniques and resources that may not be readily
available within the community.
CBPR principles stress that the research team, recognizing the community as
a unit of identity, builds on existing resources and strengths within the
community, involves a cyclical and iterative process, and promote co-learning
and empowerment between the research team and the community (Israel, et al.,
1998). Many interventions are adopting this method when working with
communities because it is believed that CBPR “enhances the relevance,
usefulness, and use of the research data by all partners involved,” brings
together partners with a variety of skills and knowledge to address complicated
problems, “strengthens the research and program development capacity of the
partners,” aims to enhance the well-being and health of communities involved by
directly focusing on identified needs and indirectly by giving them more control
and power over the research process. (Israel, et al. 181, 1998). Within the field
of oral health, there have been limited applications of CBPR in reducing oral
disease among at-risk populations. Most oral diseases are preventable without
the assistance of dental professionals; oral health is one realm of health that
individuals themselves can greatly control when given correct information on how
to prevent oral disease. However, many high-risk populations are not aware that
most oral diseases can be prevented and controlled through preventative
22
practices such as daily brushing and flossing. Therefore, the CBPR model is a
particularly good fit for oral health interventions because it focuses on getting the
community members involved and once the information is disseminated, the
community has a great potential to sustain outcomes of the intervention
themselves. This aspect is especially important now, when funding for
community interventions are low and funding for professional dental care is
difficult to accrue.
One such initiative focused on an inner-city Latino community, primarily of
Central American descent located in Mount Pleasant, a neighborhood in
Washington, DC. The intervention was a pilot project with the purpose of
investigating the feasibility of creating and implementing an oral health
community participatory program framework in conjunction with the PRECEDEPROCEED model (Watson et al., 35, 2001). The program focused on early
prevention of caries by targeting parents of children of pre-school age and
pregnant mothers. The program fulfilled eight CBPR principles. Specifically, the
initiative tailored the approach to the specific target population by taking into
account the identity of the community. Existing resources within the community
were built on, and collaborative partnerships from members of the community
were fostered throughout the entire project. This approach facilitated mutual
benefit for all partners involved and promoted co-learning, integrated knowledge
and action, and community empowerment. The program also strived to engage
in a cyclical and iterative framework by constantly fine-tuning the program and
approaching oral health with the comprehensive lens of overall well-being.
23
Additionally, the program disseminated the findings and outcomes to the
community.
The CBPR approach employed in this pilot program provided a useful
foundation in addressing the oral health disparities in Mount Pleasant and
delivering greatly needed oral health advice from dental care professionals to a
community with minimal access to traditional dental care. Not only was the
CBPR approach feasible, but it was also useful in building on existing local
resources and increasing interested and awareness of oral health disparities and
the importance of preventative oral health care. Workers in community-based
organizations recognized the importance of oral health and were motivated to go
beyond their normal boundaries to work with others and get involved in oral
health prevention-related activities (i.e. serving as health promoters). The
program instigated lasting effects such as local community and religious centers
hiring part-time dental hygienists who promote oral health education and apply
sealants and fluorides, incorporating oral health screening in medical well-baby
visit forms, including oral health information in teen-promoters training program
manuals. These small changes on the micro-level may result in large benefits in
the macro-level, however, at the time of publication of the results of the program,
the long-term effects could not be evaluated yet.
Although this initiative was able to recruit local dentists, community
representatives of community-based organizations, and health educators, it was
not as successful in involving lay community members in the steering committee,
which assisted in program planning, implementation, and evaluation. Other
24
limitations of the program were that implementers were not able to utilize a
rigorous process evaluation.
A third intervention is the subject of this research. The Health Trust (THT)
is a nonprofit foundation dedicated to reducing health disparities among
communities of color and has launched one such initiative that serves Latino
communities in Santa Clara County. In an effort to counteract growing
disparities, The Health Trust started several oral health promotion initiatives such
as its partnership with The Children’s Dental Group to open a Children’s Dental
Center in East San Jose that accepts public health insurance companies such as
Denti-Cal.
Another initiative they began was the Home-Based Oral Health Education
Program in which lay oral health educators visit local families in their homes and
advise them of how to prevent oral disease, inform them of the importance of oral
health, as well as provide them with resources to help them access professional
oral health care. THT adopted the Promotores(as) de Salud model for the
intervention. This model recruits lay community members, called Promotores(as),
who become trained in a specific health topic and advocate health in their own
communities. They are unique social workers that provide a link between their
communities and health care services. Promotores(as) have knowledge of their
specific community’s needs and integrate information on health and health
services into their community in a culturally appropriate and comprehensive
manner.
Furthermore, their expertise in understanding their community helps to
make health care systems more responsive to these communities because
25
Promotores(as) can give feedback to medical systems on what is effective in
improving health in the community and what is not.
Specifically for this intervention, THT conducted research to assess the
need for an oral health intervention and to identify which communities were at the
greatest risk of oral disease. The results of this research led to a 5-year grant
from the Knight Foundation to “provide oral health education and preventative,
restorative and specialty dental services to 3,750 medically underserved children
and families in the Mayfair, Seven Trees/Solari and Gilroy neighborhoods of San
Jose” in December 2003. The Health Trust planned to collaborate with local
agencies already serving those communities with the goal of meeting the
requirements stipulated by the grant objectives. Eventually the collaborative fell
apart and THT assumed the major role in achieving the goal of the grant. As the
program progressed, the Knight Foundation awarded THT with another grant to
evaluate the program for the last three years (2005-2008).
The program strategy used the Promotores(as) model and the THT staff
recruited “Hosts”, community members who volunteered to host an oral health
meeting in their home, and recruited family and friends to attend.
Promotores(as) were trained to recruit Hosts and lead the Home Meetings and in
the fourth year of the program pre and post tests were administered during the
Home Meetings. Unfortunately, the ideal structure of the program was not able
to be perfectly executed and THT staff was unable to develop and recruit
Promotores(as) in Mayfair and Gilroy and therefore, THT staff administered the
Home Meetings up until 2008. Another important note is that a standard
26
curriculum was not developed until the fourth year of the program because
initially, the home-based meetings were participant and discussion driven and
therefore the discussion leader focused on oral health issues of interest to the
group.
THT initial program plan captured many CBPR principles, such as working
with existing community agencies, in an effort to build on the strengths of
established resources. The Promotores(as) model de Salud utilizes working with
community leaders to draw on the skills from the non-profit organization
personnel along with the community leader’s skills. The main item that
differentiates THT’s program from CBPR is that THT’s program does not define
itself as a research project, but rather an intervention with the main objective of
disseminating knowledge about preventative oral health practices, rather than
collecting and analyzing data, and then adapting an intervention. However, it is
important to note that research was executed to assess the oral health need of
the target community.
Existing Barriers: What we want to know
While these identified barriers may all play a role in this oral health
disparity, the internal barriers are often emphasized, which focus on the actions
of the community and therefore, place a large degree of fault on the marginalized
group. In fact, most papers mention Latino cultural practices as a primary reason
for this disparity even though little research has been done to examine exactly
how cultural oral health-related practices contribute to this overwhelming inequity
(Butani, et al., 8, 2008). If it is not clear why this disparity exists, and has existed
27
for nearly three decades, why does the literature so frequently point to Latino
cultural oral health-related practices as the cause for oral health disparities?
What is the definition of cultural practices that this literature is working from?
Although most articles do not define cultural practices that contribute to oral
health disparities, a comprehensive definition that could be used to examine oral
health and culture includes five domains of cultural information: 1) General
beliefs about health, 2) diet, 3) beliefs about teeth and oral cavities, 4) helpseeking for oral conditions (i.e. traditional home remedies, going to the dentist),
5) oral hygiene practices (Butani, et al., 9, 2008).
It is possible that cultural oral health-related practices may contribute to
oral health disparities, but it is imperative that quality research is conducted to
confirm this assumption, rather than making inferences about a particular group’s
cultural values of oral health. This can only further marginalize an already
underserved population. In addition, if improvement in the oral health status of
Latinos is to be achieved, understanding exactly what these cultural oral healthrelated practices are is the first step. If it is not known what the cultural practices
are in the first place, it is impossible to understand how they contribute to this
disparity.
More research has been done on understanding racial/ethnic health
disparities than on understanding oral health racial/ethnic disparities.
Mechanisms of the pathway for these disparities have been proposed and often,
the role the medical system and physician play have been linked with
contributing to health disparities, however there is little – if any – oral health
28
literature that points to dentists’ interactions with patients as playing a role in the
low oral health status of Latino populations (and other racial groups for that
matter). Research should be done to examine what external factors, such as
dentist’s perceptions and treatment of Latino patients, contribute to this disparity.
What causes might be contributing to the fact that Mexican American children
have had the lowest dental visits in the U.S. this past year. What are the untold
perspectives of parents of Mexican decent in regards to maintaining their
children’s oral health?
It is apparent that Mexican American children are at a greater risk of
contracting oral disease than all other children. There are existing interventions
in place working to reduce these barriers, but there is substantial information
missing from literature regarding the mechanisms that contribute to this
phenomenon. While some barriers have been identified; for example, low SES
effects the ability to get professional dental care and can make it difficult to
maintain good oral health, other barriers, such as cultural practice barriers, have
been identified as contributing to the disparity without adequate evidence. This
study aims to examine the effectiveness of oral health outreach to low SES
Mexican families in addressing barriers parents face in maintaining their
children’s oral health and how these barriers can be addressed. Additionally, this
study seeks to help identify Mexican cultural oral health related practices used to
maintain oral health and what role they play in oral health disparities in Mexican
American children.
29
Methodology
This project involves a combination of quantitative and qualitative data
collection. The Health Trust conducted an internal evaluation through phone
surveys and I conducted focus groups to collect qualitative data. Utilizing both
types of data collection provides a well-rounded picture of the impact of the oral
health program and the perceptions of the participants. For the purposes of this
paper, the quantitative data from THT will serve predominantly as supporting
data, while the focus group results will serve as the heart of this research project.
In current social and behavioral research, mixed methods are being used
extensively to answer practical research questions. “A major advantage of mixed
methods research is that it enables the researcher to simultaneously answer
confirmatory and exploratory questions, and therefore verify and generate theory
in the same study” (Tashakkori and Teddlie, 15, 2002). This research
methodology uses THT’s quantitative phone survey data as preliminary data to
guide the formation of focus group questions. In this case, the focus groups are
used to help interpret results from the phone survey (Krueger and Casey, 13,
2009). The qualitative data from the focus groups provides information to inform
the phone survey results and also explores new topics not addressed in the
phone survey. Specifically, the focus groups examine cultural practices, which
could not be easily addressed in the phone survey.
Quantitative Data Collection
30
The phone survey was administered by THT, however, for the purposes of
my project, I was able to include four questions in the survey. THT’s motivation
for this evaluation was to collect evidence of the outcomes of the program to the
funder (The Knight Foundation), and provided information for future program
development. THT identified five main evaluation questions to address (Reedy,
4, 2009):
1. To what extent did the oral health home-based education influence
participants’ children’s access to and utilization of dental care?
2. To what extent did the oral health home-based education program
influence participants’ children’s oral health knowledge and practices?
3. What are the participants’ perceptions about home-based health
education?
4. What are the parents’ perceptions about the quality of the health
educator?
5. What are the parents’ interests in future home-based health education
opportunities?
The phone survey was first created in English and was then translated into
Spanish because most participants are English learners. The survey was pilot
tested with three Promotores(as) (community health lay workers) who
participated in the home meetings. Adjustments were made according to their
suggestions (see Appendix A.1 and A.2 for the survey instrument in English and
Spanish).
31
THT’s initial goal was to collect responses from 100 participants from each
of the three years of the program to total 300 responses. The final total was 168
respondents: 20 from year 1 (2006), 40 from year 2 (2007), and 108 from year 3
(2008). The reason for low numbers in years 1 and 2 was largely due to
disconnected or out-of-service home and cell phone numbers. All but 5
respondents reached agreed to participate in the survey (for an acceptance rate
of 97%).
Data from the phone survey was collected from November to December
2008 and the Promotores(as) who conducted the Home Meetings made the calls.
A subsection of the sample (n=32) completed the surveys in person during a
home visit. All surveys were administered in Spanish. THT descriptive statistics
and regression analysis for quantitative survey measures and thematic analysis
for narrative survey items were used for data analysis.
Qualitative Data Collection
For this study, focus groups were chosen as an ideal research method
because the project is looking for a range of ideas/feelings from immigrant
Mexican and Mexican American parents on how the program could better
address barriers they face related to maintaining their children’s oral health and
how the program could address these issues better. Furthermore, as discussed
previously, there is a gap in literature regarding the cultural oral health related
practices of Latino families. Focus groups create space for a wide range of input
from participants on this topic. This is particularly helpful since there is little
32
groundwork on cultural practices/factors that could influence the current status of
Latino oral health. The results from the focus group can help guide future studies
such as survey research.
The purpose of a focus group is to gather a wide range of opinions
between a group of people who have certain characteristics in common that
relate to the focus group topic – in this case, having participated in the homebased oral health program. To prevent limiting of ideas, participants are
encouraged to contribute a wide array of opinions and avoid conforming to a
consensus. The group must be small enough for everyone to have the
opportunity to share their insight, between 5 to 10 participants. This is a more
natural environment than a one-on-one interview because participants are
influencing and are influenced by other participants – as in real life situations
(Krueger and Casey, 6, 2009).
Questions must be open-ended and unguided to be effective. They are
carefully crafted and sequenced after much consideration and feedback. The
questions begin with general ideas on the topic and progress to more specific
ideas and are usually more useful to the researcher. The facilitator and research
focuses on emotions, comments, and thought processes of the participants.
The motivation of focus groups is to help researchers, community leaders,
and organization leaders make informed decisions about a service, product or
opportunity. Decisions are not made during the focus group by the participants,
but after analysis and understanding the range of perspectives on an issue. The
33
focus groups for this research are meant to help understand the effectiveness of
a program and are considered a feedback or outcome evaluation because they
are used to guide decision making for further program development (Krueger,
Casey, 2-13, 2009).
The aim of this study is to reveal barriers that influence behavior and
inhibit parents of Mexican heritage from maintaining the oral health of their
children. Focus groups are particularly useful in this case because they promote
an emergence of ideas from the group. This means that the group provides
more than just the sum of parts, but rather presents concepts that evolve past
what an individual can alone present. The information collected from this
qualitative research will contribute to the literature on an under-examined topic
and will provide more detail on the effectiveness of the home-based oral health
program, complimenting the quantitative data collected by THT.
Preparation for focus groups began in early November to prepare to
submit the focus group questions and the research protocol to the Institutional
Review Board by the beginning of January. The development of the questions
took a cyclical path and revisions were made several times before piloting the
questions and submitting them after making final adjustments. In total, 15
questions were submitted to the IRB, however, before the actual focus groups 3
questions that were considered to be unnecessary and/or redundant were
excluded (see Appendix B.1 and B.2 for English and Spanish versions). Two
focus groups were organized and a $25 gift card for Target was supplied by THT
as an incentive to recruit participants.
34
The majority of participants were first or second generation immigrants
from Mexico and therefore, two moderators were hired to lead focus groups in
Spanish. Two research assistants were also hired to take notes during the focus
groups, watch the participant’s children, and transcribe and translate the audio
from the sessions. This process included working with THT to locate moderators
and interviewing Stanford students who are native Spanish speakers for research
assistant positions. The obligations of the moderators were to recruit
participants, moderate focus groups, take notes and observations, and debrief
after the sessions. The obligations of the research assistants were to translate
all documents necessary for focus group sessions, watch over the participant’s
children during focus groups, facilitate setting up the focus group sessions, take
notes during focus groups, debrief after sessions, and transcribe and translate
audio data. Research assistants were instructed to translate documents as close
to the English version as possible while maintaining the general feel of the
questions. There was an emphasis on using short words and short sentences to
keep the questions jargon-free and easy to understand. In order to pay these
individuals and fund this project I applied for and received a grant from Stanford
Undergraduate Research.
One of the moderators helped to locate and reserve a location (St. Maria
Goretti Church in San Jose) for Friday, February 20, 2009. Both focus groups
were held on the same day with two moderators, one leading discussion and the
other taking notes, and one assistant recording observations. Childcare services
were offered for focus group participants and one of the assistants watched the
35
children in the other room. I planned to remain in the room during the focus
groups to observe the dynamics of the discussion, however, due to unexpected
circumstances, was only present in the room during the first focus group and was
supervising the participant’s children during the second focus group.
THT’s moderators conducted the recruiting process of the participants.
Initially, each focus group was supposed to have 8 participants for each focus
group, for a total of 16 participants. THT advised moderators to recruit 12
participants for each focus group because some participants may choose not to
show up. During the recruitment process, initially it was confirmed that there
would be 12 in the first focus group and 8 in the second focus group. However,
in actuality, the focus groups had 8 participants for the first session and 11 for the
second session. Four participants did not show up to the first session and the
evening before the focus groups, another Health Trust employee made phone
calls to recruit more participants for the second group, which increased the
number to 11.
The focus group staff debriefed on how the sessions went overall and
mentioned any interesting comments/observations they made after the focus
group sessions were completed. The sessions were audio recorded and loaded
onto a computer to be transcribed and translated by the research assistant.
After focus group data was transcribed and translated, a transcript-based
analysis was conducted. Because this study had only two focus groups, a
classical analysis strategy was utilized (Krueger and Casey, 118, 2009). Themes
36
and categories that emerged from the data were identified by systematically
reading through the transcripts, identifying if the participant answered the
question and grouping responses accordingly. Once participant answers were
sorted into categories, comments that were expressed frequently, revealed a
nuanced idea, were specific and provided detail, comments where participants
showed emotion, and extensiveness4 were given more weight and attention. The
results were structured around themes rather than around the focus group
questions.
Limitations
While focus groups were an appropriate data collection method for the
purposes of this research project, there are limitations to this study. One of the
most difficult parts of conducting the primary research for this project has been
that the focus groups had to be in Spanish, which created an element of
separation between the data and myself. This issue became especially prevalent
when reading through the transcripts because I had given directions that were
not adhered to as closely as I would have preferred. Furthermore, because the
moderators were not involved in developing the questions, it made it difficult for
them to know when to probe further and when to push the conversation along.
The majority of the limitations stem from this distance between the primary
researcher and the data collection process.
“Extensiveness is how many different people said something.” It is different
than frequency, which is how many times something is said (Krueger and Casey,
122, 2009).
4
37
Some focus group responses were trivial and did not provide depth on the
issue. These short one-worded answers were especially prevalent when
participants were asked about cultural oral health related practices they used in
their country of origin. In order to understand more about the cultural practices
mentioned in the focus group, it was necessary to do additional research using
Internet search engines, such as Google Scholar, on the hygiene and ailment
remedies participants mentioned.
During the first focus group, the research assistant noted that one
individual in particular tended to dominate the focus group and could have
therefore influenced results. Moderators did their best to suppress this effect to
ensure that all participants could reflect on the questions without feeling pressure
to conform to the individual’s ideas.
After the first focus group, the moderators mentioned that participants had
trouble understanding the language used in one of the questions. This question
was part of the key questions and therefore, this may have stifled some of
participants’ responses. In order to avoid this very situation the research
assistants were asked to proofread each other’s translated documents to make
sure they maintained the jargon-free format of the English version. However, this
problem still occurred. This is another limitation that emerged due to conducting
research in a different language than the researcher’s because it was impossible
to have complete control over the focus groups and therefore made it difficult to
personally check every document before the focus group sessions.
38
Although participants were informed that no THT staff involved in the
home-based oral health program were present at the focus group sessions and
were therefore told to be completely honest about how they felt about the
program, it is possible that participants did not give completely honest opinions
about the program due to feeling pressure to please moderators. Sometimes,
focus groups make it difficult to tap into emotions to find reasons driving behavior
(Krueger and Casey, 13, 2009). In this case, parent and child behavior in
maintaining oral health was the focus. Individuals may not be aware of the
emotions that influence their behavior and even if participants were aware, these
emotions may be considered private and therefore individuals may be disinclined
to share them with a group. To draw out emotions behind behavior the
moderator must ask questions about feelings. Furthermore, if participants feel
comfortable with the moderator and other participants they are more likely to be
willing to share their emotions. The moderators were of Mexican descent and did
their best to make participants feel comfortable.
As mentioned previously in this section, I was not able to be physically
present during the second focus group because one of the research assistants
failed to be present during the second focus group. Therefore, there was no one
to supervise the participant’s children except for myself. This was unfortunate,
however, the research assistant present made sure to pay special attention to
body language and expressions in her observation notes and took time to
discuss them with me in detail.
39
Due to resource and time limitations, it was not possible to conduct more
than two focus groups, although three or more are cited in the literature as the
ideal amount (Krueger and Casey, 21, 2009). Although only two focus groups
were conducted, there is relatively little literature on how interventions aid
immigrant Mexican and Mexican American parents in overcoming barriers in
maintaining their children’s oral health. Furthermore, there is even less
information identifying cultural oral health related practices and how they
contribute to oral health disparities among Mexican American populations.
Therefore, this research provides more information on what the barriers are and
how culture influences (or does not influence) oral health outcomes.
40
Results
The THT’s phone survey data in general suggests an increase in positive
oral health practices for the respondents (n= 168) after participating in the homebased oral health program. Participants appreciated the home-based program
style and the Promotores(as), showed increased knowledge and awareness of
the importance of oral health, and improved their dental practices among
families. The findings from the phone survey will be discussed along with the
results of the focus group study (See Appendix C for phone survey data).
A total of 19 people participated in the study: 16 women and 3 men of
Mexican decent with the mean age of 38.7 years old. Two participants, one
male and one female did not disclose their age. All participants’ primary
language was Spanish and the focus groups were conducted in Spanish.
Predetermined eligible participant criteria included: having participated in the
program within the past two years (2007-2008), having at least one child
between the ages of 2-12, and participation of only one parent from a
household. The criteria was met except: one 58-year-old female participant did
not have a child aged 2-12, however she was a grandmother of children
between the ages of 2-12, and due to an unexpected miscommunication, a
married couple participated. THT home-based oral health program was initiated
in three areas: Mayfair, Seven Trees, and Gilroy.
The participants in this study lived either in Seven Trees or Mayfair where
there is a large population of first and second-generation Mexican immigrants.
41
Therefore, being Mexican is a very salient part of their cultural identity so I will
use the terms Mexican and Mexican-American interchangeably. The three
locations were identified as low SES communities in need of oral health
education by a dental needs assessment report conducted by THT. The report
identified these neighborhoods as low SES and most individuals, if not all are at
or below the federal poverty level ($1,200 a year/individual).
The focus group data was analyzed using the classical analysis strategy
as defined in Krueger and Casey, 4th edition Focus Groups: A Practical Guide
for Applied Research. Participant statements were systematically organized into
themes that emerged from the data and placed into code categories. Analysis of
data shows that overall, participants felt that THT program was successful.
Perceptions of THT program were positive and participants displayed thorough
knowledge of positive oral health practices. Several different themes and code
categories emerged regarding perceptions of THT’s program. The following
describes the code categories that emerged from focus group data and refers to
quantitative findings from phone surveys when appropriate.
Community engaging: the program was described in the focus groups as
engaging with community members for several reasons. The program came to
community member’s homes, which gave participants a sense of comfort
because they could learn about oral health in the comfort of their own
neighborhood or home. Participants liked that children and parents participated
in the program together to learn about the importance of oral health. The
Promotores(as) (health educators), are members of the community and
42
therefore participants felt especially connected to the program. The phone
survey found that more than one-third (n=55) of the participants appreciated the
teaching approach of the Promotores(as) and home venue of the program.
Participants appreciated that people from their own community and ethnicity led
the oral health discussions. This statement illustrates this idea of comfort and
trust that program participants felt:
Well for a while I had an impression of comfort. They go to
your home, you feel comfortable, you don’t have to go out or
anything. That was an impression of community and comfort.
And, well, the people can be confided in, they are from the
community.
- Mother
Program provided helpful incentives: Focus group participants
appreciated receiving toothbrushes as gifts after participating in the program.
Phone survey results also show that participants found this as a positive aspect
of the program (n=12).
Comprehensive Curriculum: Phone survey data showed that participants
recalled knowledge about brushing (89.1%), flossing (63.8%), healthy eating
(43.1%), communication with dentist (38.5%), and seeing a dentist every six
months (3.5%). Focus group participants supported these findings. Information
provided to participants was considered to be comprehensive because
participants showed thorough knowledge of why oral health is important, good
oral health practices, healthy eating, and knowledge of the importance of visiting
a dentist twice a year. Participants were knowledgeable about poor oral health
practices and why they are damaging to teeth.
43
Ways to Improve: While the program provided thorough information on
preventative practices and why oral health is important, focus group participants
voiced more information on the need to know how to find affordable dental
services for their children, especially if they do not have dental insurance.
Phone survey results show that only 54 percent of the participants reported
having taken their childe to the dentist in the past six months. It is not clear from
the survey whether or not the program influenced participants to take their
children for a dental visit or if this is an increase from before the program.
Participants also felt that the program could target the adults as well in order to
help them find more affordable dental care. This statement captures
suggestions for improvement:
Well, I think that I would add that if a family doesn’t have a
medical insurance, then the information needs to be given to
them to help them find… services.
- Mother
Statements falling into code categories for perceptions of THT’s program
occurred with the following frequency: community engaging (5), impressions (2),
program provided helpful incentives (1), ways to improve (4), and a
comprehensive curriculum. Within the comprehensive category, the content
surrounded three basic areas: knowledge of oral health practices, knowledge of
healthy eating, and knowledge of professional dental care. Within the
knowledge of oral health practices, the frequencies of statements are given:
correct brushing (19) and correct flossing (8). The occurrence of responses
regarding the other topics follows: knowledge of healthy eating (10) and
44
knowledge of professional dental care (6). Figure 1 provides the layout of code
categories for perceptions of THT’s home-based oral health program.
Figure 1: Code Categories for Perceptions of THT
This figure displays the code categories identified from focus group discussions
regarding participants’ perceptions of THT. The comprehensive curriculum code
category has three subcategories that emerged from the data as shown in the
figure.
Furthermore, according to self-reports from focus groups, oral health
behavior and attitudes improved for participants after participating in the
program. The following describes the code categories for oral health practices
of participants before and after the program:
45
Oral Health Behavior Pre-Program: Before participating in the program
participants did not focus on incorporating oral health care into the routine of
their children’s lives. Practices varied between not brushing at all and periodic
brushing, sometimes with toothpaste, and sometimes without. Some parents
noted that “in reality, they didn’t do anything,” while others mentioned that they
“where brushing teeth in the wrong way.”
Oral Health Behavior Post-Program: Participants discussed how they
began to incorporate oral health practices into their children’s daily routines after
participating in the program. They also made statements about how their
children would be concerned about eating healthy and brushing their teeth
because it became more important to them. For example, one mother said that
“the kids they say, ‘mommy, I have to brush my teeth,’ and I tell them, ‘well I also
have too.’ Now it is a routine.” Phone survey data supports these findings
showing that 74 percent of participants revealed that after participating in the
home-based oral health program, their children’s frequency of brushing
increased. Frequency of flossing, however, showed only a 56% increase. In
fact, phone survey results show that nearly one out of four participants’ children
never floss.
Attitude Change Post-Program: Parents expressed ultimately feeling
happier about oral health after participating in the program because they knew
the importance of it and learned good oral health practices. Also, they felt that
they now knew how to prevent their children from experiencing pain from
toothaches. Oral health became as important to participants as general health.
46
Parents also mentioned a change in children’s attitude after participating in the
program and “they began to take more responsibility in taking care of their
teeth.” Children were more eager to brush their teeth and had better selfesteem knowing that they were keeping their teeth healthy and white.
Participant statements about oral health practices before participating in
the program (oral health behavior pre-program) emerged 6 times. Frequency of
comments on oral health behavior change occurred in both children (15) and
adults (14). Comments regarding attitude change towards oral health appeared
11 times for children and 10 times for adults. Statements regarding behavior
before partaking in the program emerged 6 times. Figure 2 shows the code
categories that emerged from the influence THT’s program had on oral health
practices.
Figure 2: Code Categories for Oral Health Practices of Participants
47
Figure 2 displays the code categories that emerged from focus group data
analysis on the oral health practices of the participants before and after the
program. Behavior and attitudes about oral health appeared to change after
participating in the program. Both adults and children displayed a change for
behavior and attitude change post-program.
Helpful factors that arose from the discussion regarding the effectiveness
of THT program include the comprehensive information provided to participants
regarding positive oral health practices. A large part of the discussion in the
focus groups concentrated on what good oral health practices are and how
participants incorporate them into their lives now that they and their children
understand the importance of oral health. This statement displays how the
families have incorporated what they learned about oral health into their daily
lives:
48
Well, look. I think that they, well first my children brushed
their teeth, but not with the importance that they saw after
the class. Because, they brush because we send them to,
“wash your teeth because you have to keep washing them”.
But, after taking the class, they saw the importance, how the
teeth can become damaged, and how the bottle, pacifier,
and all that…er…they began to take more responsibility in
taking care of their teeth. But, before they didn’t do it. They
did it because they were told to. They didn’t do it just
because.
- Mother
When asked about barriers in maintaining their children’s oral health,
parents discussed several factors that still hinder them from maintaining their
child’s oral health (see Figure 3 for a layout of the code categories): the cost of
dental visits and dental products (7), having a hectic schedule (10), negative
perceptions of/experiences with dentists (15). Of the barriers discussed,
participants identified these three barriers as the most important in their lives.
The cost of maintaining oral health was difficult to manage in two aspects:
affording dental services (6), and also affording dental products (1). Hectic
schedules were also mentioned for contributing to barriers in maintaining oral
health of children. Parents discussed three main ways in which scheduling
impacts oral health: having to constantly remind children to brush their teeth (5),
not actually being with the child at ideal times to monitor teeth brushing (4), and
remembering when children are due for a dental visit (2). Participants described
negative perceptions of/experiences with dentists in several facets: general
negative experiences (5), perceived negative treatment (by dentist) due to
race/ethnicity (3), and a fear of the dentist on both the part of the parent (2) and
49
the child (5). Each barrier is discussed in greater detail and special attention will
be given to the barrier: negative perceptions of/experiences with dentists in the
following section.
Cost: Participants discussed in the focus groups how the cost of dental
services without insurance was too expensive for them to afford and phone
survey data shows that lack of dental insurance was identified as the number
one barrier (26.4%). Focus group participants noted that purchasing special
toothpaste for children and for adults was also difficult to manage. The following
statements display this view:
Also, the insurance companies should help us. For us it is
extremely expensive. I want to take them regularly but I
can’t. It is a purely economical thing.
- Father
Look, for us, the economic crisis already changed
everything… I can no longer buy the special kid toothpaste…
there is no money…
- Father
Hectic Schedule: Phone survey data show that 15.3 percent of parents
felt that being too busy was a barrier. Focus group data shed light on details of
this barrier. Although participants were aware of how often children should
brush and thought it was important that their children follow those guidelines,
many expressed that it was difficult to ensure that children actually adhered to
these practices. The following account illustrates how getting their children to
brush is a barrier:
50
…my children, that they sometimes don’t want to [brush their
teeth] because they think that rinsing is enough. No. That,
that is enough. A rinse. But since the class, I worry for their
teeth and I explain it to them. Only then do they understand.
Only then do they understand.
- Mother
Participants also expressed that not being able to be with their children
makes it challenging to make sure that they follow good oral health practices.
Parents felt that there was not enough time to be with their children when they
need to brush their teeth because they have to brush “the three times” and often,
during those times, parents “are working.” During lunch, children are at school
and sometimes parents are at work in the evening when the children are getting
ready for bed. Another issue that emerged was remembering when the child is
due for a dental checkup. Parents found it difficult because one has to “write [it]
down” when their child last saw the dentist and remember six months later that
they are due for a check-up again when there are so many other factors in daily
life for parents to take care of.
51
Figure 3: Code Categories for Barriers in Maintaining Children’s Oral Health
This figure provides a visual of the code category breakdown of the barriers
identified as most important to participants in the focus groups. Subcategories
are also displayed in the figure. For example, the code category of hectice
schedules can be subcategoriezed into remembering to go to the dentis and not
being with child at times of brushing.
The most compelling information arising from these focus group
discussions was the interaction between ethnicity and oral health. Two major
concepts in understanding oral health in Mexican families emerged: Negative
perceptions of/experience with dentists and cultural oral health related practices
in Mexican families. Although focus group comments falling into these themes
did not always come up with high frequency, the richness of the statements are
extremely important in understanding and voicing the beliefs, experiences,
52
practices, and ideas of Mexican parents regarding the oral health of their
children. Focusing on these themes will shed light on untold stories that may
contribute to existing oral health disparities in immigrant Mexican and Mexican
American communities.
As described previously, participants expressed having negative
experiences with and perceptions of dentists. Phone survey data found that
language differences (16.5%) and being uncomfortable with available dentists
(15.6%) were the text top barriers after cost. Statements relating to this issue
made in the focus groups are as follows: general negative perception
of/experiences with dentist, perceived negative treatment due to race/ethnicity,
and fear of the dentist from both the parent and child. Specific issues mentioned
included that dentists had failed to provide adequate care to participant’s
children, appeared negligent, and were not good at working with children.
Sometimes these perceptions were deemed attributable to public health
insurance or racism. A few statements attributed harsh treatment of children
due to the race of the dentist, in this case Asian.
Participants discussed past negative experiences with dentists and
believed that they had an essential right to go to the dentist and deserved to
receive adequate treatment. After participating in the program, it became more
apparent whether or not the dentist was providing thorough treatment for their
children. The following statement captures this sentiment:
Really being in the oral hygiene class, I learned a lot. What
impacted me most, were my rights to go to the dentist.
53
Because my boy of 2 years, eh, I took him, since he got his
first tooth. And they always told me, oh he’s fine, he’s fine.
And when I learned that those little black points, my boy had
cavities on all of his teeth and the dentist told me that he
they were fine. And there, they gave me the information.
They helped me to move, to go to a dentist for children.
And…er, well, they helped me a lot. Because they had to
work on all of his teeth. But now, well, now he doesn’t have
any cavities. Through the information we received.
- Mother
This statement shows how THT’s program promoted agency within participants
because they felt that they should and could have more control over the oral
health of their children. This applies in two folds: parents learned that the
majority of oral disease can be prevented through brushing and flossing, and
furthermore, they felt that they had more of a right to question the dental
services their children were receiving.
Phone survey results show that 10.3 percent of respondents found
locating an accessible dentist as a barrier. It is possible that this barrier is due to
the small number of dentists that participate in public health insurance.
Furthermore, focus group participants attributed having public health insurance,
such as Medi-cal, as a reason behind why some dentists were not attentive to
them and their children. This statement demonstrates this opinion:
And sometimes you stay with a dentist, because you have
an insurance like Medi-Cal and where they attend you, they
don’t do their job well...you have to check them out.
- Mother
The literature has identified low quality public health dental service is an access
barrier. This statement shows how marginalized communities are especially
54
subject to poor dental care because many live in low socioeconomic conditions.
Large populations of Mexican Americans and other minority groups either do not
have access to insurance or only have access to public dental health insurance,
which has been identified as truly low quality (see Literature Review), thus,
further marginalizing this underserved community and perpetuating the existing
disparity.
Others felt that negative experiences with dentists were due to the
dentist’s lack of skill in knowing how to work with children. This comment
displays how finding a dentist who is good at working with children was one of
the largest barriers for some parents:
To me the hardest is finding a dentist that knows how to deal
with kids… mine only treats them roughly, and doesn’t even
say hello to them… that I don’t like.
- Mother
It is difficult to find a pediatric dentist and even more difficult to find one that
accepts patients with public health insurance or no insurance at all. Dental visits
for children and parents, as the data from this research shows, can be
unnerving. When dentists are not prepared or trained to work with children, this
further exacerbates this fear, which may deter parents from taking their children
to the dentist.
Some participants even attributed this lack of skill in knowing how to work
with kids to Asian American dentists in particular. They expressed having “bad
experiences with Asian dentists” and felt that the difference in race of the dentist
was a possible factor in contributing to this experience. This perception and
55
possible avoidance of Asian American dentists, although prejudiced, may
contribute to access barriers to dentists. Families of Mexican heritage may be
self-selecting away from Asian American dentists. Furthermore, it may be that
negative interactions with Asian dentists lead patients to perceive them to have
low cultural humility. Therefore, cultural humility may be very important for
parents in taking their children to the dentist.
Other negative perceptions of/experiences with dentists stemmed from
perceptions of the dentist being careless due to racist beliefs held against the
patient. This statement illustrates these feelings:
You have to check the dentist that one goes to a lot,
because sometimes they are very negligent with people and
are racists.
- Mother
This statement expresses the idea that it is important for Mexican parents to be
cautious of what dentist their child sees because there is a substantial
probability that dentists do not provide equal care to their children due to their
Mexican heritage. This may be consciously or subconsciously, but many studies
in the Medical field have identified this phenomenon (see literature review).
Whether or not this is perception is a reality, this is another access barrier
parents feel they must deal with in maintaining their children’s oral health.
Participants voice that one strategy to reduce this barrier would be for parents to
find a dentist who is Mexican. One man said he would like to find an affordable
dentist and had a “preference to a Mexican.” Other participants in this focus
group laughed in agreement.
56
Lastly, many participants expressed fear as a barrier that impedes them
from going to the dentist. Both parents and children felt this fear:
For me, my children, I have to go with them to the dentist.
I’ve also been sent to a children’s specialist and they
say…that time that I went, a dentist told me, she explained
to me, and I even more don’t want to take my children. Well,
there’s a place where they tie them. Well now I’ve struggled
a lot because they say, “Not me, No I won’t go to the dentist.
I’ll just brush my teeth.” Because they are afraid of the
dentist - even the youngest one’s hands tremble when we
are about to take him. That’s the problem that I have, that
they are afraid of going to the dentist.
- Mother
This statement displays the sentiment felt by both parents and children. Ideas
regarding poor treatment of children by dentists, such as tying them down,
whether they are accurate or not, act as a barrier for parents. If a parent does
not trust the dental care system, and they observe pronounced fear in the child,
such as trembling hands, this would lead to a cognitive dissonance for these
parents. Now that they know the importance of oral health, parents would want
to take their child to the dentist, however, if there is still a fear and lack of trust in
available dentists, this could cause parents to have difficulty judging what the
right decision is. It is possible that parents who are not aware of the importance
of oral health would be greatly deterred from taking their children to the dentist if
the fear and lack of trust in dental services is present.
After discussing the barriers that were most important to participants, the
participants we asked to discuss ways in which THT’s program could incorporate
solutions to those barriers in the program. These results and suggests are
discussed in greater detail in the following discussion section.
57
The focus group discussion uncovered cultural oral health related
practices participants recalled their families exercising in Mexico. This theme
was broken down into three categories: oral hygiene (18), help-seeking for oral
ailments (8), and cultural beliefs of oral health (5). Table 1 provides a sample of
quotes for the described cultural oral health related practices.
Oral Hygiene: participants provided examples of practices used to clean
teeth that are commonly used from Mexico, their country of origin. These
practices range from using ground up burnt tortillas (2), cloth (2), soap (1),
dental floss made from stings or leaves of trees (2), soft thin plastic (3), thread
from socks (1), mashed mint leaves and salt (1), aloe vera (1), lime (1), baking
soda (2), and (calcium) carbonate (2). Burnt tortilla grounds, cloth, and soap,
were described as being used to clean the surface of the teeth and strings from
the leaves of trees or the edges of thin plastic bags, or thread from socks are
used to floss. Both mashed mint leaves with salt and aloe vera are used as
homemade toothpaste. Lime, baking soda and (calcium) carbonate are used for
whitening teeth. Participants said carbonate was used for oral health care in
Mexican culture, but the term “carbonate” is commonly used when actually
referring to calcium carbonate. Calcium carbonate, which is often used as a
substitute for baking soda, is another homemade method for whitening teeth.
Help-Seeking for Oral Ailments: Participants gave examples of helpseeking for oral ailments that are used in Mexican culture. These include cloves
(3) avocado seeds (1), alcohol (2), cumin spices (1), and tying a string to one’s
tooth and a doorknob and closing the door to remove the tooth (1). Cloves were
58
mentioned several times for use on a toothache to reduce pain sensations.
Avocado seeds were suggested as being helpful in treating tooth decay. Alcohol
on a piece of cotton is to be placed on the tooth and bit on until pain is relieved.
Wine and cumin spices were also mentioned as reducing pain. Lastly, loose
teeth are removed using string tied to the tooth and the doorknob and then
shutting the door. The participants laughed during this explanation and
mentioned that this does not actually work very often.
Cultural Beliefs of Oral Health: Participants said that oral health was not
emphasized as being important in Mexico (2) and also said that professional oral
health care was less expensive in Mexico (3). After participating in THT
program participants mentioned that they realized that the importance of oral
health was emphasized more in the U.S. than in Mexico. They also mentioned
that it is less expensive to get oral health treatment in Mexico than in the U.S.
and that if possible, they travel to Mexico for that purpose.
59
Table 1: Sample Statements of Cultural Oral Health Related Practices
This table displays the statements participants made that fall into three identified code
categories, oral hygiene, help-seeking for oral ailments, and cultural beliefs of oral health. These
codes are described in detail in the results section.
60
Discussion
The present study sought to identify the effectiveness of THT’s program in
addressing and helping parents overcome barriers in maintaining their children’s
oral health, while also looking to understand Mexican cultural oral health related
practices. This study provides support on previous findings and also identifies
several novel findings. First, participants recognize THT’s home-based oral
health program as helpful, comfortable, and important to their community. It
provided a comprehensive preventative oral health curriculum to participants.
Parents demonstrated a thorough knowledge of the importance of oral health
from brushing and flossing to healthy eating and the importance of visiting the
dentist. Furthermore, participants noted positive changes in the oral health
behavior of their children (and themselves) post-program, including: improved
brushing skills (brushing longer and with the correct circular technique), brushing
more often, eating healthier, and using dental floss. Overall, the THT’s program
proved to be effective in providing oral health education to the target community.
Major barriers discussed in focus groups show that the cost of dental care
still acts as a major barrier for parents after participating in the program. Focus
group data elucidated more information on barriers parents experience that were
listed on the phone survey. Specifically, being too busy was considered a
substantial barrier from phone survey results and focus group data reveals that
having a hectic schedule (i.e. being at work in the evenings) prevents parents
from monitoring children’s oral health practices and remembering when it is time
61
to take children to the dentist. Also, having to constantly remind children to brush
in combination with not being able to be with them to remind them posed as a
barrier as well. Having negative perceptions of and experiences with the dentist
was identified as another substantial barrier that may explain why 15.6 percent of
parents were uncomfortable with available dentists and therefore, found that to
be a barrier. Perceived negative treatment due to race/ethnicity and fear of the
dentist by both the parent and the child were identified as major reasons for
negative perceptions and experiences with the dentist. How do these identified
barriers fit into the broader picture? The following sections discuss how the
barriers identified in this study fit into the barrier categories identified in the
literature review.
Financial Barriers:
Cost
The focus group data provides more information on barriers the parents of
Mexican heritage face in maintaining the oral health of their children, while also
shedding light on barriers that previous literature does not address. Parents
identified the cost of dental care as one of the predominant barriers they face.
Parents who did not have dental insurance expressed an inability to finance visits
to the dentists, children’s toothpaste, and changing toothbrushes every six
months. Parents who had public health insurance felt that they did not receive
adequate dental care from the dentists who accept insurance plans, such as
Medicaid. Therefore, although they were insured, they felt they did not receive
62
quality oral health care for their children. If parents had access to a non-public
health insurance, it is less probable that they would feel that they are receiving
poor dental services. The literature supports this because most dentists do not
accept public health insurance due to the low payment rates and complicated,
non-standard administrative paper work. Therefore, it is not surprising that some
dentists provide a lower quality of care for those on public health insurance. If a
dentist does not feel that they are getting compensated adequately, it is likely
that they will be less motivated to provide quality dental services. In fact, dentists
who accept public health insurance may be so unmotivated to provide quality
care that they neglect patients who appear to be more complicated and/or
stressful to deal with. This could include patients of different cultures, SES, and
age – such as children. While this is a predictable outcome when considering
the difficulties dentists who participate in public health insurance face, it is not
acceptable. Providing unequal treatment due to being inconvenienced by extra
paper work is unethical. Furthermore, this displays a lack of compassion for
patients. It is disheartening to know that low payment rates can lead dentists to
knowingly neglect cavities. Something must be done to reduce this iniquity.
Public health insurance polices and structure should be revamped to
make public health insurance more attractive to dentists. The paper work system
should be simplified to make it easier for dentists to deal with administrative
business. Or, information should be provided to make the paper work process
more clear. Furthermore, an incentive for dentists who participate in public
health insurance should be incorporated into the Medicaid program. Perhaps
63
dental supply companies could collaborate with public health programs, such as
Medicaid’s EPSDT, to make it more affordable for dentists to treat children on
public health insurance.
Let’s revisit the story of Deamonte and DaShawn Driver discussed
previously in the introduction of this paper. Deamonte was an adolescent who
died from a bacterial infection in his tooth that spread to his brain and DaShawn,
his younger brother, lost his dentist because he “squirmed too much” in the seat.
Both boys qualified for Medicaid (EPSTD), however, because of the low number
of dentists participating in public health insurance, it was difficult for them to
locate a dentist, and in Deamonte’s case, this lead to his death. DaShawn
managed to find a dentist accepting Medicaid, however his dentist discontinued
service because he was a difficult patient to deal with, even though DaShawn
had developed abscesses from dental infection.
While focus group data does not provide intimate details of exactly how
and why parents felt that they received poor quality dental services from public
health insurance, the fact that parents mentioned it as a barrier and the stories of
Deamonte and DaShawn provide important evidence that dentist-patient
relationships should be more deeply examined to understand how they play a
role in oral health disparities for different groups, in this case, Mexican American
children. Not having access to private insurance and having perceived negative
experiences with dentists who accept public health insurance acts as a financial
barrier that also could possibly be compounded with cultural and/or class
differences between patient and dentist. Participants voiced having negative
64
experiences with and perceptions of dentists due to other barriers that can be
seen as cultural and/or class differences between patient and dentist.
The limited number of dentists who participate in Medicaid poses as a
problem for white children on Medicaid, but it is even more of an issue for those
who are minorities, in this case, children of immigrant Mexican and Mexican
American parents. Most dentists are white and do not live in highly Latino
populated areas. Specifically, within California, Latino dentists make up only
4.6% of the total dentist workforce, while California is 32.4% Latino. This means
that one in every three Californians are Latino, while only one in every 20
California dentists are Latino (Hayes-Bautista et al., 229, 2007). Participants
mentioned that a way to reduce barriers they face in taking their child to the
dentist would be to have a Mexican dentist. Latino dentists are important in
improving the dental health of the Latino community because they are more likely
to speak Spanish and have offices located in highly Latino-populated areas and
thus, they can reduce language barriers and location/transportation barriers while
increasing dentist-patient concordance (Hayes-Bautista et al., 227, 2007). If the
pool of dentists who accept Medicaid is already small, the pool of Latino dentists
who accept Medicaid is likely to be even smaller, creating a double barrier in
accessing dental care.
Cultural and/or Class Differences as a Barrier:
Negative Perceptions of/Experiences With Dentist
65
Parents expressed having negative experiences with and/or negative
perceptions of dentists as a substantial barrier they faced in maintaining their
children’s oral health. This is an under-examined barrier due to cultural and/or
class differences between the patient and dentist. These results shed light on
data from the phone survey THT conducted. When asked what barriers
participants still face in taking their child to the dentist, 15.6 percent of the
respondents expressed being uncomfortable with the dentist. Focus group
participants expressed general negative perceptions of/experiences with the
dentist and also identified specific negative perceptions, such as the perception
that dentists are racist towards them and a fear of dentists. The statements
mentioned in the focus groups could be the reasons that nearly 16% of phone
survey participants reported being uncomfortable with dentists.
This example of a negative experience one participant had with a dentist
discussed in the results section provides substantial support and justification for
having difficulty in finding a dentist for their child:
…My boy of 2 years, eh, I took him [to the dentist], since he
got his first tooth. And they always told me, oh he’s fine, he’s
fine. And when I learned that those little black points, my boy
had cavities on all of his teeth and the dentist told me that he
they were fine…they had to work on all of his teeth.
-Mother
This example clearly shows that the dentist was neglecting the child. It is
possible that the dentist was taking advantage of the parent’s lack of knowledge
of oral health by seeing the child as a patient, but not actually providing
restorative care to child’s caries. Perhaps this child had public health insurance
66
and the dentist wanted to save money by not filling the cavities since dentists do
not make a large amount of money from public health insured patients. It is also
possible that the dentist was not trained properly and did not detect the caries,
however, considering there was caries on all of his teeth, this is highly unlikely.
Regardless of the reason, the dentist provided inadequate service and allowed a
child to continue on with decaying, untreated caries. The dentist-patient
relationship is surprisingly unexamined in oral health literature, yet, the study of
this dimension of oral health issues may help to better understand the causes of
oral health disparities among marginalized communities.
Perceived Negative Treatment due to Race/Ethnicity
Focus group participants also mentioned that race/ethnicity sometimes
seemed to be the reason dentists did not provide adequate care. Specifically,
one participant expressed the need to “check the dentist that one goes to a lot,
because sometimes they are very negligent with people and are racist.” This
perception of receiving lower quality dental services because of one’s race,
whether it is reality or a perception the patient has, is a significant problem.
Further research must be conducted to understand if dentists are providing
unequal treatment due to race/ethnicity or if this is just a perception Mexican and
Mexican American parents have. If dentists are not providing unequal treatment
(due to racism), it is important to identify why parents feel this way. Language
differences can further complicate this issue of cultural differences between the
dentist and patient and could lead parents of Mexican descent to perceive
67
racism. This barrier demonstrates the importance of stressing cultural humility in
dentistry.
A method to increase cultural humility in dentistry is for dental schools to
initiate required courses on how to serve patients of different social and cultural
backgrounds. Focus group participants also expressed that dental school
students should work in underserved communities during dental school to both
help the community and the students.
…but, also, to ask all of these students that are studying, to
give more services to the community. Like the students,
those who are studying to be dentists, that they give more
services to the community. That way, it helps them and us
also.
- Mother
Increasing public service for dental students will provide them with more
experience in dentistry and help communities receive affordable dental services.
Furthermore, dental schools could initiate CBPR projects in neighboring
communities of the school to better understand how to serve the community,
increase awareness of the importance of oral health, and even possibly increase
the interest of Mexican American youth in seeking professions in the dental field.
Fear
Participants expressed that both they and their children had a fear of the
dentist. While this seems like a common perception people have of dentists, not
specific to culture, perhaps there is a cultural element present. Participants
described the difference on the emphasis of the importance of oral health in
68
Mexico versus the United States. They expressed that oral health was not given
very much importance in Mexico as compared to the United States.
I think that the first impression is that you realize that people
do care about the health of teeth and moreover the health of,
the oral hygiene of the teeth. Because, regularly in our
countries, this isn’t done and the information isn’t available
that, that is presented here.
- Mother
Perhaps this difference in emphasis on oral health contributes to the fear of
dentists and the idea of the unfamiliar Mexican families seemed to express
towards dentists. Possible reasons why oral health is not emphasized as
important in Mexico may be due Mexico’s rural structure. The remoteness of the
country may make access to health care in general difficult and a common trend
among many populations is to prioritize general health over oral health, rather
than include it in the category of general health.
Literature on fear of dentists in children identifies one of the sources as a
fear of strangers in general (Milgrom et al., 318, 1995). Perhaps fear of
strangers as an origin of childhood fear of the dentist is complicated by the added
component of differing cultures between patient and dentist. There is little
research on how race and ethnicity differences between patient and dentist
influence (or do not influence) fear of the dentist. Further research should be
conducted to understand this relationship.
Fear of the dentist has been correlated with “utilization of the dentist
during childhood: relative to children with little fear, children with high dental fear
69
are about twice as likely to not make a dental visit, all other things equal”
(Milgrom et al., 313, 1995). In considering other factors that Mexican and
Mexican American parents face in maintaining their children’s health, such as the
perception that dentists do not treat their child properly, one could imagine that
this would add to fear that both parents and children have of the dentist. If both
child and parent perceive the dentist as unfriendly and harsh, this could deter
Mexican American children from making dental visits. As identified in the
literature review, Mexican American children had the lowest dental visits in the
U.S. during this past year (see literature review). Perhaps one of the reasons for
this is due to a unique fear Mexican American children and their parents have of
the dentist.
THT’s community oriented program made participants feel very
comfortable and even moved participants to want to get more people in their
community involved in the cause:
Well, in my case, the first impression was that the program
was very good and that it was finally arriving to the houses of
the people with information regarding oral hygiene with the
purpose of creating a healthier community… the greatest
part of the programs nowadays are directed towards writing,
towards reading, and very few programs are directed to oral
health. It was a very good first impression, and my intention
was to keep this going, to get more people involved…
- Mother
This statement demonstrates how THT’s approach falls in line with several CBPR
principles and its approach to reducing public health disparities. The homebased structure of the program and the familiarity of the Promotore(a) as a fellow
70
community member with a similar cultural background, promotes community
cohesiveness and motivates participants to instigate further social change.
Research done within the community can raise awareness of the importance of
oral health and “expand social structures and processes that contribute to the
ability of community members to work together to improve health” by building on
strengths and resources within the community (Israel et al., 178, 1998). By
involving the community in the cause to reduce oral health disparities, there is a
greater potential for Mexican American community members to decide to work in
the dental field so that they can play a more active role in oral health awareness.
Additionally, the exposure to oral health care research could lead to increased
diversity in dentistry. If more Mexican Americans become dentists, this could
increase participation in Medicaid because of a desire to reach out to one’s own
community and other low-income children. However, more CBPR and CBPRrelated programs must be initiated and evaluated on a long-term scale to confirm
these potential outcomes.
Effects of Low SES on Family Behavior
Hectic Schedules
Living in low socioeconomic conditions is known to increase stress levels
(McEwen and Seeman, 30, 1999). Increased stress levels are often due to the
increased pressure to provide for the family and maintain it’s overall well-being.
Where does oral health fit in here? As parents have to work more hours to make
ends meet, it becomes more difficult to maintain all aspects of well-being for the
71
family – in this case, oral health. Focus group participants expressed frustrations
in having time to ensure that their children brush their teeth and floss. Reasons
for this include not being with children at ideal times of brushing such as lunch
and the evening time, having to constantly remind children to brush their teeth,
and having difficulty remembering and making time to take children for dental
visits. Living in low SES makes it difficult for parents to juggle all of these issues,
therefore, parents may place less emphasis on oral health, especially if it is not
perceived as being as important as medical health. It is important to raise
awareness that oral health is part of general health and can contribute to other
health complications outside of the oral cavity.
Cultural Oral Health Related Practices
The Mexican cultural oral health related practices identified in this study
did not appear to be poor oral health practices that could increase risks of oral
disease. Oral hygiene practices identified were ones that are considered natural
oral cleansing practices. Using a mashed up burnt tortilla is similar to using
charcoal toothpaste, which is a product made in several other countries, such as
Japan. Using a salt and mint mixture as toothpaste is considered an herbal way
of cleaning teeth (http://www.consultation.ayurvediccure.com/herbal-ways-ofcleaning-teeth/). Aloe vera has been studied for its healing qualities and has
been found to be effective in killing bacteria that develop on the teeth as long as
70% of the mixture contains pure aloe vera
(http://www.enhancedtoothpaste.com/AloeVeraforDentalHealth.htm). Using
string and thin plastic as floss has not been shown to increase risk of oral
72
disease. What these practices do show, are that they are not the ‘mainstream
American way’ of cleaning teeth. And while, they may not be the ideal form of
cleaning teeth, it is apparent that they are not bad oral health practices. Many of
these practices are alternative methods of cleaning teeth when other more ideal
forms are not available for socioeconomic reasons. In fact, some statements
made by participants show that they know the correct technique of brushing
teeth, which is in a circular motion:
With my grandma, “you don’t have a toothbrush? Use a cloth
and with that try to circul…circulate.”
- Mother
Information regarding help-seeking for oral ailments specific to Mexican
culture include using an avocado seed as a natural filling for a decaying tooth.
The avocado seed has natural soothing qualities that provide a temporary filling
for the tooth. Cloves are used as a natural pain reliever for toothaches and can
help ease the pain when a tooth is being removed. Cumin spices have also been
used to relieve oral pain. Many of these practices are not limited to Mexican
culture but are used in other cultures as well. Cumin spices were used in Ancient
Egypt and as mentioned above, charcoal is used in Japan to clean teeth
(http://www.herbco.com/p-353-cumin-seed-powder.aspx). Again, these practices
have not been shown to damage teeth. These home remedy practices could be
a result of cultural differences – or, they could be a result of a difference in
socioeconomic conditions. If one is not in a financial position to replace
toothbrushes for every family member every 3 months and purchase separate
toothpaste for children, using the next best practice is the logical step. Many of
73
these families are living in low SES and come from Mexico, which is in a lower
economic status than the United States; therefore, oral health may seem less of
an urgent need for these families.
This study has some limitations. First, THT’s program did not have a
control group to compare actual oral health practice improvements so it is difficult
to be certain that the participant’s oral health practices actually improved.
Furthermore, the evaluation of changed oral health behaviors was self-reported
and this could lead to inaccurate information due to participants providing
responses that they feel the researcher wants to hear. Another limitation of this
study was that it was done in another language than the researcher’s. This
presented to be difficult in overseeing the quality of the research methods after
documents were translated from English into Spanish. In order to minimize the
compromise of the quality of the research, efforts were made to provide clear
directions to research assistants and moderators (who spoke Spanish) to ensure
that the translated documents delivered the same message as the English
versions. To ensure accurate document translation, other Spanish speakers also
reviewed the translated documents.
Another limitation to this study is that this information cannot be directly
applied to other Latino populations because it is specific to Mexican and Mexican
American populations in Santa Clara County. However, interventions that do not
acknowledge the specific characteristics of target populations are often less
effective in raising awareness of the specific intervention issue. Therefore, in
74
terms of internal validity, the specificity of the target population can also be
viewed as a strength in this study.
This study identified cultural oral health practices that have not been
thoroughly identified in the literature. Additionally, it elucidated more information
regarding barriers Mexican American children and their families face in
maintaining oral health that have not been focused on. This includes negative
perception of and experiences with the dentist, such as fear of the dentist and
feelings of unequal treatment due to race/ethnicity. The collaboration in this
study with THT provided a more in-depth look at the effectiveness of the program
because both quantitative and qualitative data were used to examine the
program and the oral health status of the community.
75
Conclusion
This study found that THT’s home-based oral health program was overall
successful in raising awareness about oral health in immigrant Mexican and
Mexican American communities in Santa Clara County. However, one area of
improvement identified in the focus groups was to include more information on
how to navigate locating an affordable dentist. One participant identified another
oral health program at her child’s school that provides detailed and helpful
information on finding a dentist. The woman explains that the program:
…give[s] us a lot of information there [at her child’s
school]…they tell us where we can go, if we need any help.
If we don’t have insurance…where we can go. They tell us
where our children can be attended. And that helps us.
That’s were we got that plan of the dentist.
- Mother
While THT’s program possesses similar characteristics of CBPR, it could
potentially improve by placing more of an emphasis on partnering with existing
community programs. In particular, THT could collaborate with the school
program mentioned above and therefore bolster their program by using the
school’s curriculum on locating an affordable dentist to other locations not near
the school, such as Gilroy.
THT’s program proved to be successful in tailoring the program to the
specific community and making a positive impact on participants. For example, a
participant was able to identify that her child has caries on every single primary
tooth after participating in the program. Even though the participant was already
76
seeing a dentist before the program, the knowledge she obtained from the homebased meeting about her child’s teeth enabled her to take her child to another
dentist to get her child’s teeth restored (see results). This shows that the
program provided participants with not only oral health knowledge, but a sense of
social motivation to take ownership of their children’s oral health and get involved
in the community.
Cost was emphasized as a continued barrier for parents who participated
in THT’s program. Under-examined barriers were identified in this study as well.
Specifically, negative perceptions of and experiences with dentists stemming
from parent and child fear and perceived as motivated by racism. Hectic family
schedules, such as remembering children are due for a dental visit and not being
with the child to remind and monitor oral health practices, also were identified as
barriers. The cultural oral health practices identified in the focus groups did not
appear to act as a barrier contributing to the prevalence of oral disease in
Mexican Americans. This finding should be taken into account in following
studies in order to limit the possible stigmatization of this already marginalized
group as having poor oral health status due to their cultural practices.
THT could incorporate solutions to these barriers by brainstorming with
parents. Participants from the focus groups felt that the high cost of professional
dental care could be addressed by setting up payment plans with dentist on
dental check-ups and procedures. Furthermore, the government programs, such
as Medicaid could be revamped to manage the issues of complicated paper work
and under paying of dentists. As mentioned previously, increasing dental student
77
community service requirements while at dental school could also make dental
treatment more affordable for these parents. To address hectic schedules, time
management skills were discussed to help make time to brush and take children
to the dentist. Focus group participants noted that “think[ing] about a routine”
and incorporating brushing and flossing teeth into the daily schedule helps
participants to combat having a hectic schedule. Participants also suggested
making brushing teeth a game to encourage children to brush their teeth.
Another form of encouragement in overcoming the barrier of fear is to
motivate children to go to the dentist by taking them somewhere they really enjoy
after going to the dentist and supporting them while they are at the dentist.
Another way to allay child fears of the dentist is by communicating with the
dentist about what the child is afraid of and how to make the child more
comfortable. One parent found this technique to be especially helpful for her little
girl:
I think that one has to talk with the dentist to see what the
fear is. For example, one of my daughters doesn’t like them
to put water and when she sees that they’re going to grab
the little hose, that’s, well, it’s crying and crying and crying.
But, the dentist, I talked to him and he lets her get up and
rinse.
- Mother
Communication with the dentist may also reduce parent’s negative perceptions of
dentists. If part of the negative perception has to do with the parents’ fear as
well, then by becoming more familiar with the child’s dentist, parents may
become less skeptical and more trusting of the provider.
78
While the program was overall successful, there is a glass ceiling that
non-profit out reach programs face in helping underserved communities find
professional dental care. That is, that no matter how much the program works to
help parents navigate locating a dentist, the program has little influence on the
negative perceptions and experiences that these parents have of dentists.
Dental institutions and dentists themselves can only address this dentist-patient
relationship. These systems need to allocate energy into promoting the
importance of making all patients feel comfortable and trusting of the service that
they are receiving. This could be done by requiring dental students to take
courses on cultural awareness and looking for applicants that value cultural
humility. By increasing the awareness of dental disparities in communities of
color among dental institutions and the dissemination of oral health awareness
by interventions, such as THT’s home-based oral health program, it is possible to
remedy this ‘silent epidemic.’
79
Appendix A.1: The Health Trust Internal Evaluation Survey
Note: Questions I contributed are highlighted
START TIME:____________ INTERVIEWER:_______________ INTERVIEW
DATE:_______
HOME MEETING DATE:
Introduction
Hello, my name is ________ and I work for The Health Trust. A while back, you
participated in a home meeting on oral health. We are gathering information from
people who participated in an oral health home meeting to evaluate and improve our
program. Your answers will remain confidential and anonymous and will be
combined with answers from many other participants. Can we take a few minutes of
your time?
If no: Are you sure? It would help us to understand what you think of our services.
If no, again: Thank you for your time. Proceed to next participant on list.
If yes: Proceed with next paragraph.
We have several questions we would like to ask you related to the oral health
education you received. Your feedback is very important to us. Do you have any
questions before we get started?
80
FAMILY INFORMATION
1.
Do you remember participating in a home meeting on oral health?
(REMIND RESPONDENT OF MONTH/YEAR OF HOME MEETING)
Yes…………………………………………. 
No………………………………………….. 
IF YES, CONTINUE WITH INTERVIEW, ASK QUESTION 2.
IF NO, THANK YOU FOR YOUR TIME. END INTERVIEW.
2.
How many children do you have at home?
Number of children………………______
3.
What are their ages?
Child 1 ___ Years ___ Months
Child 2 ___ Years ___ Months
Child 3 ___ Years ___ Months
Child 4 ___ Years ___ Months
Child 5 ___ Years ___ Months
4.
How many adults live in your home?
Number of adults…………………_______
ORAL HEALTH EDUCATION AND ACCESS TO AND UTILIZATION OF DENTAL CARE
5.
When was the last time your child/children visited a dentist? (RECORD FOR MOST RECENT VISIT)
Month ____
Year_____
My child/children has never visited a
dentist……………………………………………...
81
IF NO VISIT, SKIP TO NUMBER 10
6.
Why did you decide to take your child to the dentist? (OPEN ENDED QUESTION, DO NOT READ THE LIST. CHECK
CLOSEST RESPONSE OR WRITE IN OTHER RESPONSE)
Due for a check up……………………………..
Teeth/mouth hurt……………………………….
School/day care recommended or
required…………………………………..……...
Health care provider recommended…………..
Health educator at home meeting
recommended…………………………………...
Other ________________________................
7.
Where did you take your child for dental care? (OPEN ENDED QUESTION, DO NOT READ THE LIST. CHECK
CLOSEST RESPONSE OR WRITE IN OTHER RESPONSE)
Primary Care Dentist…………………………..
Community Dental Clinic..…………………….
Mobile Dental Unit.……………………..……...
Other…………………………………..………..
8.
How did you pay for the dental care? (CHECK ALL THAT APPLY)
82
Dental insurance…………………………………
Self-pay……………..……………………………..
Free service……………………………………….
Other _______________________....................
9.
Before this visit, how long had it been since your child/children visited a dentist? (OPEN ENDED QUESTION; CHECK
CLOSEST RESPONSE; THEN, SKIP TO NUMBER 11)
Less than six months…………………………….
Between six months and one year………………
More than one year ……………………………….
This was first visit………………………………….
10.
Why has your child/children not seen a dentist? (OPEN ENDED QUESTION, DO NOT READ LIST; CHECK ALL THAT
APPLY)
No dental insurance……………………………..
Can’t afford to pay……………………………….
Doesn’t need one ……………………………….
Don’t know how to find a dentist……………….
Other ________________________..................
11.
I’m going to read a list of barriers that sometimes prevent some parents from taking their children to the dentist. Please let
me know, which of the following barriers you have experienced by answering yes or no.
Lack of dental insurance
Yes…………………………………………. 
No………………………………………….. 
Transportation to the dentist
Yes…………………………………………. 
No………………………………………….. 
Language differences
Yes…………………………………………. 
No………………………………………….. 
You are too busy
Yes…………………………………………. 
No………………………………………….. 
Inconvenient dental appointment hours
Yes…………………………………………. 
No………………………………………….. 
Lack of accessible dentists
Yes…………………………………………. 
83
No………………………………………….. 
Finding a dentist you are comfortable with
Yes…………………………………………. 
No………………………………………….. 
Are there other barriers you have experienced?
IF NO BARRIERS CHECKED, SKIP TO #13
12.
On a scale of 1 to 5, with 1 being not at all helpful and 5 being extremely helpful, How helpful was the oral health
program in providing you with information or resources to overcome these barriers? (CIRCLE RESPONSE)
Not at all helpful
Extremely Helpful
1
2
3
4
5
ORAL HEALTH KNOWLEDGE AND BEHAVIOR CHANGE
13.
What is one thing you remember from the home meeting on oral health?
(OPEN ENDED QUESTION, DO NOT READ THE LIST. CHECK ALL THAT APPLY OR WRITE IN OTHER
RESPONSE)
Brushing………………………………………….
Flossing…………..………………………………
Communication with Dentist……………………
Healthy Eating……………………………………
Other ________________________................. 
Can’t remember anything specific…....................
14.
Was this information you remember from the home meeting new information for you? (PROBE: DID YOU LEARN THIS
FOR THE FIRST TIME AT THE HOME MEETING?)
Yes…………………………………………. 
No………………………………………….. 
15.
Does every child in your home own his/her own toothbrush?
(OPEN ENDED QUESTION, DO NOT READ LIST. CHECK CLOSEST RESPONSE OR WRITE IN OTHER RESPONSE.)
Yes, everyone has his/her own toothbrush………
No, children share toothbrushes……………………
No, children don’t have toothbrushes………………
Other______________________________............
84
IFANSWER IS “NO”, ASK WHY NOT?
_____________________________________________
16.
How often does your child/children brush his/her teeth each day? (READ EACH OPTION AND CHECK ONE)
After every meal………………………………………
Three times/day……………………………………….
Two times/day………………………………………….
Once a day……………………………………………..
Other _______________________________...........
17.
Did the number of times your child/children brushes his/her teeth each day (READ EACH OPTION AND CHECK ONE)
Increase after the home meeting? ………………………. 
Decrease after the home meeting? …………………….. 
Remain about the same after the home meeting?.…….
18.
How often does your child/children floss his/her teeth? (READ EACH OPTION AND CHECK ONE)
At least once a day……………………………………
About 5 times/week……………………………………
About 3 times/week……………………………………
About 1 time/week……………………………………..
Less than 1 time/week…………………………………
Never……………………………………………………
19.
Did the number of times your child/children flosses his/her teeth each day (READ EACH OPTION AND CHECK ONE)
Increase after the home meeting? ……………………….
Decrease after the home meeting? ……………………..
Remain about the same after the home meeting?.…….
85
20.
How often does your child/children eat candy or other sweets? (READ EACH OPTION AND CHECK ONE)
At least once a day……………………………………
About 5 times/week……………………………………
About 3 times/week……………………………………
About 1 time/week……………………………………..
Less than 1 time/week………………………………...
Never……………………………………………………
21.
Did your child/children eat candy or other sweets (READ EACH OPTION AND CHECK ONE)
Less often after the home meeting…………………
More often after the home meeting…………………
About the same after the home meeting. ………….
22.
How often does your child/children eat fruits and vegetables? (READ EACH OPTION AND CHECK ONE)
At least three times a day……………………………
About 1 time/day………………………………………
About 3 times/week……………………………………
About 1 time/week……………………………………..
Less than 1 time/week………………………………...
Never……………………………………………………
23.
Did your child/children eat fruits and vegetables (READ EACH OPTION AND CHECK ONE)
More often after the home meeting…………………
Less often after the home meeting………………….
About the same after the home meeting. …………..
PERCEPTIONS ABOUT HOME-BASED HEALTH EDUCATION
24.
Was this the first time you received any kind of health education?
Yes……………………………………………………..
No……………………………………………………....
86
25.
Was this the first time you received health education in someone’s home?
Yes……………………………………………………..
No…………………………………………………….....
26.
Is there anything you didn’t like about the home health education?
(OPEN-ENDED QUESTION; RECORD RESPONSE)
_______________________________________________
27.
Is there anything you especially liked about the home health education? (OPEN-ENDED QUESTION; RECORD
RESPONSE)
________________________________________________
28.
On a scale of 1 to 5, with 1 being POOR and 5 being EXCELLENT, how would you rate the oral health education you
received? (READ NUMBERS AND CIRCLE NUMBER SELECTED)
Poor
1
Excellent
2
3
4
5
87
PERCEPTIONS ABOUT HEALTH EDUCATOR
29.
On a scale of 1 to 5, with 1 being VERY LITTLE KNOWLEDGE and 5 being A LOT OF KNOWLEDGE, how would you rate
the health educator’s knowledge about oral health? (READ NUMBERS AND CIRCLE NUMBER SELECTED)
Very Little
1
30.
A Lot
2
3
4
5
Was the health educator able to answer all your questions?
Yes…………………………………………………….
No……………………………………………………...
If no, do you still have questions? What are they?
31.
Is there anything in particular you remember about the health educator that you would like to share? (OPEN ENDED;
RECORD RESPONSE; if nothing, write “nothing”)
_______________________________________________
32.
On a scale of 1 to 5, with 1 being POOR and 5 being EXCELLENT, how would you rate the COMMUNICATION SKILLS of
the health educator? (READ NUMBERS AND CIRCLE NUMBER SELECTED)
Poor
1
33.
Excellent
2
3
4
5
On a scale of 1 to 5, with 1 being POOR and 5 being EXCELLENT, how would you rate the overall EFFECTIVENESS of the
_______________________________________________
health educator? (READ NUMBERS AND CIRCLE NUMBER SELECTED)
Poor
1
Excellent
2
3
4
5
FUTURE HEALTH EDUCATION OPPORTUNITIES
34.
Are you interested in attending future home health education meetings?
Yes…………………………………………………….
No……………………………………………………...
If yes, what health topics would you like to learn about? (OPEN ENDED)
88
________________________________________________
35.
Would you consider hosting a home health education meeting at your home?
Yes…………………………………………………….
No……………………………………………………...
36.
If yes, can we give your name and phone number to someone to follow-up with you?
(IF YES, NOTE ON THE HOME MEETING LOG)
Yes…………………………………………………….
No……………………………………………………...
37.
On a scale of 1 to 5, with 1 being VERY UNLIKELY and 5 being VERY LIKELY, how likely is it that you would recommend a
home health education meeting to your friends, family, or neighbors? (READ NUMBERS AND CIRCLE NUMBER
SELECTED)
Very Unlikely
1
38.
Very Likely
2
3
4
5
Is there anything else you would like to tell us about your experience with the home meeting on oral health?
(OPEN-ENDED QUESTION; RECORD RESPONSE)
________________________________________________________________________________________________________________________
Thank You
This brings us to the end of our questions. Thank you for providing us with this
important feedback. We greatly appreciate your time.
Would you like to participate in a small group conversation about your experience
with this program? The group would be meeting in a convenient location for about 45
minutes. ($25 gift card was offered for them to participate).
89
IF YES:


Record name and contact information on a separate roster
Tell them: Someone from The Health Trust will call you with more details in
the coming month.
END TIME: _______________
90
Appendix A.2: The Health Trust Internal Evaluation Survey in Spanish
Hora de inicio: ____________ Entrevistador: ____________Fecha de entrevista: _______
Fecha de la reunión en casa:
Introducción
Hola, mi nombre es ________ y trabajo para The Health Trust. Hace algún tiempo, usted
participo en una reunión en casa con información de salud oral. Nosotros estamos recopilando
información de personas que participaron en una reunión en casa para evaluar y mejorar el
programa. Sus respuestas serán confidenciales y anónimas y serán combinadas con respuestas
de otros participantes. ¿Puede usted regalarnos unos minutos de su tiempo?
Si la respuesta es no: ¿Esta usted seguro/a? Nos ayudaría a entender que piensa usted sobre
nuestros servicios.
Si la respuesta en nuevamente, no: Gracias por su tiempo. Proceda con el siguiente participante
en la lista.
Si la respuesta es, si: Proceda con el siguiente párrafo.
Tenemos algunas preguntas que nos gustaría hacerle en relación a la información sobre salud
oral que recibió. Sus respuestas son muy importantes para nosotros. ¿Tiene usted alguna
pregunta antes de que comenzar?
INFORMACION FAMILIAR
1.
Recuerda usted haber participado en una reunión de casa que ofrecía información de salud oral?
(Recuerde al entrevistado el mes y año de la reunión en casa)
Si......................................................................................... .. 
No..........................................................................................
SI LA RESPUESTA ES SI, CONTINUE CON LA
ENTREVISTA, HAGA LA PREGUNTA No. 2
SI LA RESPUESTA ES NO, GRACIAS POR SU TIEMPO. FINALIZE LA ENTREVISTA
2.
¿Cuántos niños tiene usted en su casa?
Número de niños………………______
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3.
¿Quė edades tienen?
Niño 1 ___ Años ___ Meses
Niño 2 ___ Años ___ Meses
Niño 3 ___ Años ___ Meses
Niño 4 ___ Años ___ Meses
Niño 5 ___ Años ___ Meses
4.
¿Cuántos adultos viven en su casa?
Número de adultos……………_______
EDUCACION DE SALUD ORAL Y ACCESO A LA UTILIZACION DE CUIDADO DENTAL
5.
¿Cuándo fue la última vez que su niño (s) visitó al dentista? (ANOTE LA VISITA MAS RECIENTE POR CUALQUIER NIÑO)
Mes ____
Año_____
Mi niño (s) nunca han visitado al
dentista……………………………………………................ .. 
SI NO HA VISITADO, SALTE A LA PREGUNTA NUMERO
10
6.
¿Porquė decidió llevar a su niño (s) al dentista? (PREGUNTA ABIERTA, NO LEA ESTA LISTA. SELECCIONE LA
RESPUESTA MAS CERCANA O ESCRIBA OTRA RESPUESTA)
Para una revisión................................................................... 
Dolor de dientes/boca............................................................ 
Recomendación o requisito de la escuela y/o
guardería................................................................................
Recomendación del proveedor de salud...............................
El educador de salud de la reunión en casa me lo
recomendó............................................................................. 
Otro ________________________...................................... 
7.
¿Donde llevo a su niño (s) para cuidado dental? (LEA ESTA LISTA Y MARQUE LA RESPUESTA)
Su dentista regular................................................................ 
Clínica comunitaria dental.................................................... 
Unidad dental Mobil.............................................................. 
Otro ________________________..................................... 
8.
¿Cómo pago por el cuidado dental? (MARQUE TODAS LAS QUE APLICAN)
92
Seguro dental....................................................................... 
Pago en efectivo................................................................... 
Servicio gratis....................................................................... 
Otro ________________________..................................... 
9.
Antes de la visita, ¿Cuánto hacia que su niño (s) no visitaban al dentista? (PREGUNTA ABIERTA; SELECCIONE LA
RESPUESTA MAS CERCANA; LUEGO,)
Hace menos de seis meses................................................ 
Entre seis meses y un año................................................... 
Hace más de un año............................................................ 
Esta era la primera visita...................................................... 
SALTE A LA PREGUNTA NUMERO 11
10.
¿Porquė su niño (s) no han visto a un dentista? (PREGUNTA ABIERTA, NO LEA ESTA LISTA. MARQUE TODAS LAS
QUE APLICAN)
No tengo seguro dental....................................................... 
No puedo pagar................................................................... 
No necesito un dentista....................................................... 
No se como encontrar a un dentista................................... 
Otro ________________________..................................... 
Continua en el siguente pagina
93
11.
Voy a leerle una lista de impedimentos que algunas veces evitan que los padres puedan llevar a su niño (s) al dentista. Por
favor, dígame contestando a cual de estos impedimentos se a enfrentado.
Falta de seguro dental
Si............ 
No.......... 
Transporte para ir al dentista
Si............ 
No.......... 
Diferencias en el lenguaje
Si............ 
No.......... 
Usted esta muy ocupado/a
Si............ 
No.......... 
Horas inconvenientes para las citas dentales
Si............ 
No.......... 
Falta de dentistas accesibles
Si............ 
No.......... 
94
Dificultad para encontrar un dentista con quien se sienta
cómoda
Si............ 
No.......... 
¿Hay algún otro impedimento que usted ha experimentado?
_______________________________________________
SI NO HAY IMPEDIMENTOS SELECCIONADOS, SALTE A
LA PREGUNTA #13
12.
En una escala de 1 a 5, donde 1 significa que no ha sido de mucha ayuda y 5 significa de mucha ayuda, ¿Cuánta
ayuda y recursos cree usted que le ofreció la información ofrecida por el programa de educación para vencer
esos impedimentos? (CIRCULE LA RESPUESTA)
No de mucha ayuda
De mucha ayuda
1
2
3
4
5
CONOCIMIENTO DE SALUD ORAL Y CAMBIO EN LOS HABITOS
13.
¿Cuál es una de las cosas, relacionadas con higiene oral, que usted recuerda de la reunión en casa?
(PREGUNTA ABIERTA, NO LEA ESTA LISTA. MARQUE TODAS LAS QUE APLICAN)
Cepillado.............................................................................. 
Uso de hilo dental................................................................ 
Comunicación con el
dentista................................................................................ 
Alimentación saludable....................................................... 
Otro ________________________..................................... 
No puede recordar nada específico..................................... 
95
14.
¿Es esta información que recuerda de la reunión en casa, información nueva para usted? (VERIFIQUE: USTED
APRENDIO SOBRE ESO POR PRIMERA VE EN LA REUNION DE CASA?
Si.................................................................................. ...... . .
No................................................................................. ...... . 
15.
Cada uno de sus niños (as) en la casa, ¿Tienen su propio cepillo dental?
(PREGUNTA ABIERTA, NO LEA ESTA LISTA. SELECCIONE LA RESPUESTA MAS CERCANA O ESCRIBA OTRA
RESPUESTA)
Si, cada uno tiene su propio cepillo dental........................ 
No, ellos comparten cepillo dental....................................... 
No, los niños no tienen cepillo dental................................... 
Otro______________________________.......................... 
SI LA RESPUESTA ES “NO”, PREGUNTE ¿Por qué NO?
_____________________________________________
16.
¿Cuántas veces su niño (s) se lavan sus dientes al día (sin o con ayuda suya)?
(LEA CADA OPCION Y SELECCIONE UNA)
Después de cada comida................................................... 
Tres veces al día.................................................................. 
Dos veces al día................................................................... 
Una vez al día.................................................................. .. .. 
Otro _______________________________................... . .. 
17.
El número de veces que su niño (a) se lava sus dientes diariamente (sin o con ayuda suya)
(LEA CADA OPCION Y SELECCIONE UNA)
Aumento después de la reunión en casa..................... ..... .. 
Disminuyo después de la reunión en casa...................... .. .
Continúa igual después de la reunión en casa............... .. 
18.
¿Cuántas veces usa el hilo dental su niño (a) (sin o con ayuda suya)?
(LEA CADA OPCION Y SELECCIONE UNA)
96
Al menos una vez al día...................................................... 
Alrededor de 5 veces a la semana...................................... 
Alrededor de 3 veces a la semana...................................... 
Alrededor de 1 vez a la semana.......................................... 
Alrededor de 1 vez al mes................................................ ... 
Nunca................................................................................ ... 
19.
El número de veces que su niño (a) usa el hilo dental diariamente (sin o con ayuda suya)
(LEA CADA OPCION Y SELECCIONE UNA)
Aumento después de la reunión en casa............................. .
Disminuyo después de la reunión en casa..........................
Continúa igual después de la reunión en casa.... ...............
20.
¿Cuán seguido su niño (s) comen dulces? (LEA CADA OPCION Y SELECCIONE UNA)
Al menos una vez al día...................................................... 
Alrededor de 5 veces a la semana....................................... 
Alrededor de 3 veces a la semana....................................... 
Alrededor de 1 vez a la semana........................................... 
Alrededor de 1 vez al mes.................................................... 
Nunca........................................................................ ........... 
21.
Su niño (s) comen dulce (LEA CADA OPCION Y SELECCIONE UNA)
Mas seguido después de la reunión en casa.................... 
Menos seguido después de la reunión en casa................ 
Continúa igual después de la reunión en casa.................. 
22.
¿Cuán seguido su niño (s) comen frutas y verduras? (LEA CADA OPCION Y SELECCIONE UNA)
Al menos tres veces al día.................................................. 
Alrededor de una vez al día................................................ . 
Alrededor de 3 veces a la semana....................................... 
Alrededor de 1 vez a la semana........................................... 
Menos de una vez a la semana............................................
Nunca................................................ ................................... 
97
23.
¿Come su niño (s) frutas y verduras (LEA CADA OPCION Y SELECCIONE UNA)
Mas seguido después de la reunión en casa................. ... 
Menos seguido después de la reunión en casa................. 
Continúa igual después de la reunión en casa................. 
PERCEPCION ACERCA DE LA EDUCACION DE SALUD DE LAS REUNIONES EN CASA
24.
¿Fue esta la primera vez que usted recibió educación de salud?
Si................. .......................................................................... 
No................. ......................................................................... 
25.
¿Fue esta la primera vez que recibió información de salud en la casa de alguien?
Si................. .......................................................................... 
No................. ......................................................................... 
26.
¿Hubo algo que a usted no le gustara de la educación de salud en casa?
(PREGUNTA ABIERTA; ESCRIBA LA RESPUESTA)
_______________________________________________
27.
¿Hay algo en especial que a usted le haya gustado de la educación de salud en casa? (PREGUNTA ABIERTA; ESCRIBA
LA RESPUESTA)
________________________________________________
28.
En escala de 1 a 5, donde 1 significa POBRE y 5 significa EXCELENTE, como diría usted que fue la educación de salud
oral que recibió? (LEA LOS NUMEROS Y CIRCULE EL NUMERO SELECCIONADO)
98
Pobre
1
Excelente
2
3
4
5
PERCEPCION ACERCA DEL EDUCADOR DE SALUD
29.
En escala de 1 a 5, donde 1 significa MUY POCO CONOCIMIENTO y 5 significa MUCHO CONOCIMIENTO, ¿Cuánto
conocimiento cree usted que el educador tiene sobre salud oral? (LEA LOS NUMEROS Y CIRCULE EL NUMERO
SELECCIONADO)
Muy poco
1
30.
Mucho
2
3
4
5
¿Pudo el educador de salud contestar a todas las preguntas?
Si................. .......................................................................... 
No................. ......................................................................... 
Si la respuesta es no, ¿Tiene usted todavía preguntas?
¿Cuáles son?
_______________________________________________
32.
En escala de 1a 5, donde 1 significa POBRE y 5 significa EXCELLENTE, ¿Cómo definiría LA HABILIDAD DE
COMUNICACION del educador de salud? (LEA LOS NUMEROS Y CIRCULE EL NUMERO SELECCIONADO)
Pobre
1
33.
Excelente
2
3
4
5
En escala de 1a 5, donde 1 significa POBRE y 5 significa EXCELLENTE, ¿Cómo definiría la EFECTIVIDAD del educador
de salud? (LEA LOS NUMEROS Y CIRCULE EL NUMERO SELECCIONADO)
Pobre
1
Excelente
2
3
4
5
OPORTUNIDADES FUTURAS DE LA EDUCACION DE SALUD
34.
¿Esta usted interesada en asistir a reuniones en casa con información de salud?
Si................. .......................................................................... 
No................. ......................................................................... 
Si la respuesta es si, ¿Sobre que tipo de información le gustaría aprender? (PREGUNTA ABIERTA)
99
________________________________________________
35.
¿Consideraría usted invitar a una reunión de información de salud en su casa?
Si................. .......................................................................... 
No................. ......................................................................... 
36.
Si la respuesta es si, ¿Me permite dar su nombre y número de telėfono a alguien para hacer seguimiento con usted?
(SI LA RESPUESTA ES SI, ANOTE EN EL LIBRO DE REUNIONES DE CASA)
Si................. .......................................................................... 
No................. ......................................................................... 
37.
En escala de 1 a 5, donde 1 significa NO ME GUSTARIA y 5 significa ME GUSTARIA, le gustaría recomendar las
reuniones de casa con información de salud a sus amigos, familiares o vecinos? (LEA LOS NUMEROS Y CIRCULE EL
NUMERO SELECCIONADO)
No me gustaría
1
38.
Me gustaría
2
3
4
5
¿Hay algo más que a usted le gustaría añadir acerca de su experiencia en la reunión de salud oral en casa?
(PREGUNTA ABIERTA; ANOTE LA RESPUESTA)
________________________________________________________________________________________________________________________
Hora de finalizada la entrevista: _______________
100
Appendix B.1: Focus Group Questions
Note: The things in brackets are not to be read out loud, they are reminders to
help guide you through the focus group discussion.
[GIVE INTRODUCTION]
[Opening Question (ask all participants to respond – i.e. go around the circle for
responses)]
1. Give your first name, how many children you have, and tell us quickly,
your favorite activity to do with your kids.
[Transition into topic questions]
[Introductory Question]
2. What comes to mind when you think about healthy teeth? [Assistant
moderator writes down people’s different ideas of things that contribute to
healthy teeth and the GOAL is to get array of different ideas. Do not call
on people, but use fingers and eyes]
[Transition Questions]
3. Think back to when you participated in the oral health program. What was
your first impression?
4. Before you participated in the program what practices did your children
use to keep their teeth clean?
5. Now that you’ve participated in the program what practices do your
children use to keep their teeth clean?
101
a. [If oral health practices have changed then PROBE] How do you
feel about these different/new practices your children do?
b. [PROBE] Have you noticed a difference in your child’s attitude
about oral health?
6. Are there any different practices that parents from your country of origin
do to keep their children’s teeth healthy? If so, what are they? OR What
practices do people from your country of origin do to keep their children’s
teeth healthy? [Really try to draw out different ideas on this question if
possible]
7.
a. What are some things that get in the way of keeping your children’s
teeth healthy? [PROBE] They could be things that are in your
control and/or not in your control. Write them on a piece of paper.
These lists are anonymous. You do not need to write your name
on the paper.
i.
[Wait for about 3-5 minutes and THEN tell them] Now, place
the paper in this bowl and _______(either Ernesto or Odette)
will jot down these ideas. [Assistant moderator passes
around bowl and collects participant’s responses]
[Have assistant moderator compile list on a piece of butcher paper. Have
participants expand on the ideas listed that are unique/surprising – I will provide
you with a list/ideas of things that we may see and not want to necessarily focus
on.]
102
[Key Questions]
8. How do these things [listing 3 things that are unique/surprising factors] :
____, _____, and ______ get in the way of keeping your children’s teeth
healthy?
a. [PROBE] Are there any things listed that you disagree with?
9. Is there anything listed that the program helped you with? If so, how?
10. Is there anything from the list that still gets in the way of keeping your
children’s teeth healthy?
a. [PROBE] How do these things get in the way?
b. [PROBE] What could be done to overcome these?
11. Of the three things we’ve been focusing on: _____, _____, _____, how
would you incorporate these issues in an oral health program? First, let’s
talk about _____. [Discuss their ideas, then after a few minutes, move to
the next topic, then finally move on to the last topic]
[Ending Questions]
12. Our big picture goal is to understand what gets in the way for you, as
parents, in keeping your children’s teeth healthy, and how we can help
with these issues. That being said is there anything you would like to add
that we missed?
[CLOSING] Thank you for your participation. Your ideas will help others like
you who participate in the oral health program in the future.
103
Appendix B.2: Focus Group Questions in Spanish
Borrador de Preguntas Para Grupo de Enfoque
Nota: lo que se encuentra en paréntesis cuadrados no se debe de decir en fuerte, son
guías para ayudar a moderar al grupo de enfoca.
[Dar Introducción]
[Pregunta de Apertura (se pide que todos los participantes respondan, por ejemplo, ir
en círculo para que todos den respuestas.)]
1. Díganos su nombre, número de hijos y, de una manera concisa, la actividad
que más le gusta hacer con sus hijos.
[Transición a preguntas del tópico]
[Preguntas de Introducción]
2. ¿Qué es lo que se le viene a la mente cuando piensa en dientes saludables?
[Moderador Asistente escribe las diferentes ideas que contribuyen a dientes
sanos y la meta es tener una gama de ideas diferentes. No se le llama a
personas, pero se usan ojos y dedos.]
[Preguntas de Transición]
3. Pensando en el tiempo en el que participó en el programa de salud oral,
¿Cuál fue su primera impresión?
4. ¿Antes de que participara en el programa, que practicas usaban sus hijos
para mantener dientes saludables?
104
5. ¿Ahora que ya participo en el programa, que practicas usan sus hijos para
mantener dientes saludables?
a. [Si las practicas han cambiando, hacer sondeo] ¿Cómo se siente
acerca de estas nueves practicas que sus hijos hacen?
b. ¿Ha notado alguna diferencia en la actitud de sus hijos con respecto a
la salud oral?
6. ¿Hay prácticas diferentes que los padres de su país de origen usen para
mantener dientes saludables en sus hijos? ¿Cuáles son? Ó ¿Qué practicas usa
la gente de su país de origen para mantener los dientes de sus hijos
saludables?
7.
a. ¿Qué factores hacen que sea difícil mantener la salud oral de sus
hijos? Sondeo: Estos factores pueden estar bajo su control y/o no
estar bajo su control. Escriba sus respuestas en un papel y en un
momento los compartiremos unos con otros. Estas respuestas son
anónimas, no necesita escribir su nombre.
i. [Esperar por 3-5 minutos y después pedirles] Ahora, por favor
pongan sus respuestas en este platón y ____ (Ernesto u
Odette) escribirán rápidamente estas ideas. [Moderador
asistente pasa el platón y recolecta las respuestas]
105
[El moderador asistente escribirá estas ideas en un papel. Haz que los participantes
comenten sobre las ideas que son únicas o sorprendentes. Yo voy a darles una lista de
cosas que queremos o no queremos ver en la lista]
[Preguntas Clave]
8. ¿Cómo hacen estos factores (mencionar 3 factores que fueron únicos o
sorprendentes): ___, ____ y ___, sea difícil mantener la salud oral?
a. Sondeo: ¿hay algo en la lista con lo que usted no esta de acuerdo?
9. ¿Hay algo en la lista con lo que el programa le ayudo?
10. ¿Qué de lo mencionado sigue interfiriendo con que sus hijos tengan dientes
sanos?
a. [Sondeo] ¿Cómo interfieren estas cosas?
b. [Sondeo] ¿Qué se puede hacer para sobrepasar estas dificultades?
11. ¿De las tres cosas en las que nos hemos enfocado: ___, ___ y____, como las
incorporaría usted en un programa de salud oral? Primero, hablemos de ___.
[Se discuten esas ideas y en un par de minutos se pasa al siguiente tema, y
luego al último.]
[Preguntas Finales]
12. Nuestra meta en el panorama completo es entender que dificultades usted
encara como padre en mantener la salud oral de sus hijos, y como podemos
tratar con ellas mejor. ¿Habiendo dicho esto, hay algo que nos haya faltado?
[Clausura] Gracias a todos por su participación. Sus ideas ayudaran a otras personas
como usted que participaran en el programa de salud oral en el futuro.
106
Appendix C – THT Data from Phone Survey
Oral Health Service Utilization
When did you last take your child to the dentist?
N
Percent
Within the last six months
76
53.9%
More than six months ago
59
41.8%
6
4.3%
141
100.0%
My child has never visited a dentist
Total
Why did you decide to take your child to the dentist?
N
Due for a check up
Percent
115
87.8%
Teeth/mouth hurt
6
4.6%
School/day care recommended or required
5
3.8%
Health care provider recommended
1
0.8%
Health educator at home meeting recommended
1
0.8%
Other Reason
3
2.3%
131
100.0%
Total
What barriers have you experienced in taking your
child/children to a dentist?
Percent
of total
N
Lack of dental insurance
37
26.4%
Language differences
22
16.5%
Not being able to find a dentist you are comfortable with
21
15.6%
Your being too busy
21
15.3%
Inconvenient dental appointment hours
18
13.3%
Lack of accessible dentists
14
10.3%
Transportation to/from the dentist
11
7.4%
107
On a scale of 1 to 5, with 1 being not at all helpful and
5 being extremely helpful, how helpful was the oral
health program in providing you with information or
resources to overcome these barriers?
N
Percent
1 - Not at all helpful
1
1.7%
2
0
0.0%
3
1
1.7%
4
8
13.8%
5 - Extremely helpful
48
82.8%
Total
58
100.0%
Knowledge about Oral Health
What is one thing you remember from the home
meeting on oral health?
N
Percent
Brushing
155
92.3%
Flossing
111
66.1%
Communication with Dentist
67
39.9%
Healthy Eating
75
44.6%
168
100.0%
Total
Oral Health Practices
How often does your child/children brush his/her teeth
each day (with or without your help)?
N
Percent
After every meal
5
3.8%
Three times/day
19
14.5%
Two times/day
96
73.3%
Once a day
11
8.4%
131
100.0%
Total
108
How often does your child/children floss his/her teeth
(with or without your help)?
N
Percent
At least once a day
58
44.3%
About 5 times/week
2
1.5%
About 3 times/week
25
19.1%
About 1 time/week
9
6.9%
About 1 time/month
5
3.8%
Never
32
24.4%
Total
131
100.0%
How often does your child/children eat fruits and
vegetables?
N
Percent
At least three times a day
61
46.9%
About 1 time/day
43
33.1%
About 3 times/week
21
16.2%
About 1 time/week
3
2.3%
About 1 time/month
1
0.8%
Never
1
0.8%
130
100.0%
Total
Oral Health Education Delivery Model
On a scale of 1 to 5, with 1 being POOR and 5 being
EXCELLENT, how would you rate the oral health
education you received?
N
Percent
1 - Poor
0
0.0%
2
0
0.0%
3
1
0.6%
4
21
12.8%
5 - Excellent
142
86.6%
Total
164
100.0%
109
On a scale of 1 to 5, with 1 being VERY LITTLE
KNOWLEDGE and 5 being A LOT OF KNOWLEDGE,
how would you rate the health educator’s knowledge
about oral health?
N
Percent
1 - Very little knowledge
0
0.0%
2
0
0.0%
3
1
0.6%
4
19
11.7%
5 - A lot of knowledge
143
87.7%
Total
163
100.0%
On a scale of 1 to 5, with 1 being POOR and 5 being
EXCELLENT, how would you rate the
COMMUNICATION SKILLS of the health educator?
N
Percent
1 - Poor
0
0.0%
2
0
0.0%
3
1
0.6%
4
18
11.0%
5 - Excellent
144
88.0%
Total
163
100.0%
On a scale of 1 to 5, with 1 being POOR and 5 being
EXCELLENT, how would you rate the overall
EFFECTIVENESS of the health educator?
N
Percent
1 - Poor
0
0.0%
2
0
0.0%
3
1
0.6%
4
15
9.3%
5 - Excellent
145
90.1%
Total
161
100.0%
110
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