Journal of Public Health Dentistry . ISSN 0022-4006
Qualitative description of dental hygiene practices within oral health and dental care perspectives of Mexican-American adults and teenagers Gerardo Maupome, BDS, MSc, PhD1; Odette Aguirre-Zero, DDS, MS2; Chi Westerhold, BS1 1 Preventive and Community Dentistry, Indiana University School of Dentistry, Indianapolis, IN, USA 2 Oral Biology, Indiana University School of Dentistry, Indianapolis, IN, USA
Keywords dental hygiene; Hispanics; Latinos; oral health beliefs; health disparities. Correspondence Dr. Gerardo Maupome, Preventive and Community Dentistry, Indiana University School of Dentistry, 415 Lansing St., Indianapolis, IN 46202. Tel.: 317-274-5529; Fax: 317274-5425; e-mail: [email protected]. Gerardo Maupome and Chi Westerhold are with Preventive and Community Dentistry, Indiana University School of Dentistry. Odette Aguirre-Zero is with Oral Biology, Indiana University School of Dentistry. Received: 3/17/2014; accepted: 8/30/2014. doi: 10.1111/jphd.12076 Journal of Public Health Dentistry 75 (2015) 93–100
Abstract Objectives: The objectives of this study were to identify dental hygiene themes voiced by adults and teenagers of Mexican origin [or Mexican Americans (MAs)] and place these themes within the larger landscape of oral health and dental care perceptions. Methods: Interviews with urban-based MAs were analyzed to identify barriers, beliefs, and behaviors influencing engagement in dental hygiene practices. Results: Adult (n = 16, ages 33–52) and teenage (n = 17, ages 14–19) MAs reported themes pertaining to structural factors (financial and economic-related barriers, the dual challenges of reduced access to care vis-à-vis successfully navigating the dental care system, and the effects of reduced social support derived from migration) and to individual factors (different agendas between MAs and health systems for dental care utilization and indications for oral self-care, including limited dental hygiene instruction from professionals and larger impacts from school-based and mass media). Also, prior experiences with dental hygiene, prevention, and associated themes were characterized by a range of attitudes from fatalistic to highly determined agency. Good family upbringing was instrumental for appropriate dental hygiene, anteceding good oral health; and outlining a loose structure of factors affecting oral health such as diet, having “weak” teeth, or personal habits. Conclusions: Themes from adults and teenagers in the Midwest United States were generally similar to other groups of MA parents and younger children. Dental hygiene was not salient relative to other oral health and dental care matters. Several opportunities for improvement of knowledge and enhancing motivation for dental hygiene practices were identified, both within and outside professional resources.
Introduction Many professional sources agree that a daily, consistent program of dental hygiene is highly desirable; adherence to such regimes is commonly heralded as one important component of self-efficacy and self-care in dentistry. There is sparse information in the scientific literature about values and behaviors upheld by some population subgroups when it comes to dental hygiene practices. Because of the opportunity to implement individualized prevention through such practices, it is important to characterize how and why practices take place in people affected by substantial oral health disparities; case in point is the mosaic of ethnic population subgroups broadly categorized as Hispanics in the United States. © 2014 American Association of Public Health Dentistry
Because complex dimensions and multiple variables appear to be at play in the oral health disparities phenomena, existing models ought to have included dental hygiene; however, the conceptual framework for Hispanic oral health care (1) and a cross-ethnic model describing the dimensions of influences moderating oral health and oral health disparities (2) failed to comprehensively describe barriers, beliefs, and behaviors pertaining to dental hygiene. Except for a passing entry in the latter (under individual influences), those models were firstly concerned with dental care, and secondarily with oral health status. A more recent framework describing oral health disparities (3) implied dental hygiene was nested across population-, community-, and person-level factors but did not address relevant barriers, beliefs, and behaviors in detail. 93
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This was not unexpected, considering the emphasis of the framework on the greater weight of structural factors in shaping health disparities. A few publications have started to identify barriers, beliefs, and behaviors pertaining to dental hygiene embraced by Hispanics; some of these studies recruited some or all of their participants from clinical settings. Hoeft et al. (4) conducted a qualitative study in California about beliefs and practices applied to children’s oral hygiene. Interviews were conducted in first- and second-generation urban Latinas with children under 10 years of age. While results from open-ended questions offered a set of beliefs about when to initiate and how to conduct dental hygiene maneuvers in their toddlers, it was clear that medical and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) staff were instrumental in guiding behaviors. Other studies from the same California research group have offered valuable insights, such as finding that rural fathers (from Mexico and El Salvador) had limited information and involvement in their young children’s dental hygiene (5) and that caregivers (6) included poor dental hygiene as one of the causes of early childhood caries. Luciano et al. (7) found in an adult population largely of Mexican origin surveyed in North Carolina that many respondents self-reported daily tooth brushing and flossing. Besides inquiring about links between dental hygiene maneuvers and gum problems, no underlying beliefs were explored in depth. Other publications have quantified stated adherence with practices without pointing to the underlying mechanisms (8). Cortés et al. (9) recently looked into those mechanisms using focus groups and interviews with Hispanics (mostly women) of multiple nationalities in Massachusetts; participants were chosen on the basis of having children aged 6–14. The script primarily focused on oral health problems, although it included some dental hygiene questions. Subsequent qualitative analyses led to a multilevel classification of themes addressing various aspects of oral health and dental care, linked at times with dental hygiene. The more apparent links for dental hygiene were with caries experience (including cariogenic sweeteners and dietary features) and the importance of establishing daily life routines to support appropriate dental hygiene. Most research specifically describing the mechanisms underlying dental hygiene among people of Mexican origin has been limited to adult viewpoints of the situations of their own young and very young children. Data about teenagers have been sparse (10), and more so in the context of both teens and adults being interviewed; a partial exception was a study on Hispanic and African-American teenagers (11), which limited its dental hygiene focus to documenting highly variable frequencies of flossing and brushing. The objectives of the present qualitative research study were to identify 94
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themes pertaining to dental hygiene practices as voiced by adults and teenagers, and to place these practices in the larger landscape of perspectives about oral health and dental care.
Materials and methods The approach followed in the present study was to analyze recorded interviews with urban-based individuals of Mexican origin [or Mexican Americans (MAs)], adults and adolescents (14 years of age and older), to identify barriers, beliefs, and behaviors influencing engagement in dental hygiene maneuvers within the larger context of dental care and oral health. Ethical approval was granted by the Indiana University Institutional Review Board (#1207009118). Teens assented to participate and their parents granted written informed consent. No effort was made to accurately differentiate between first- and secondgeneration immigrants to avoid statements about immigration status, length of time living in the United States, socioeconomic background, or occupation. We purposefully advertised the opportunity for participation and actively recruited both teen and adult MAs, of either gender. We are explicitly abandoning any attempt at using terms connoting the generation, acculturation level, or terminologically correct denomination of these urban-based people of Mexican origin, and for the sake of simplicity they are generically called MAs.
Study design and population The present data are part of a larger investigation aiming to develop a survey targeting an urban-based MA population group in the Midwest United States. In this first phase of the study, individual interviews were used to qualitatively identify salient themes with regard to dental hygiene practices, oral health, and dental care. Participants were recruited through advertising at events that took place in the fall and winter 2012 at health fairs, churches and religious gatherings, the waiting room in the Mexican Consulate in Indianapolis, and community organization functions.
Data collection and variables The approach consisted of one-on-one, semi-structured interviews. Eligibility criteria for interviewees were a) be of Mexican ancestry (any generation); b) able to speak, read, and write either English or Spanish; c) be free of disabilities that would make it unfeasible to be interviewed or agree to participate; and d) be a teen or adult living in an urban environment in central Indiana. Participants were recruited through word © 2014 American Association of Public Health Dentistry
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of mouth and flyers, as well as through partnerships with church and community leaders.
Interviews Participants’ consent/assent was obtained prior to the interview. No personal identifiers were collected. An interview script was created, and it was translated and back-translated to/from Spanish. Participants were encouraged as much as possible to expand in their interpretations above and beyond the script. Besides allowing ample opportunity for participants to dwell on topics in as much depth as they felt it necessary, the script introduced the topics of dental care utilization; experiences with urgent care; dental professional preventive services; dental self-care including tooth brushing, flossing, and use of mouth rinses; and lifestyle and oral health. Participants received US$30 as compensation. Interviews in either English or Spanish lasted 20–45 minutes and were audio-recorded. Each adult and each teenager was interviewed separately.
Data analysis Interviews were analyzed in three stages: initial categorization along groups of themes, followed by a second-stage assessment of the themes identified and categorized initially, cross-checking their fit with other categories, driven by thematic frequency in the interviews. Categorization of the themes was driven by allocating discrete segments of text to an individual category when the theme was explicitly stated, or when the context and the meaning of text made it sufficiently unequivocal to allow certainty in the classification. Finally, themes were assigned to two larger individual or structural levels. Data analyses were undertaken by the same three interviewers who collected data in the field, with calibration and training taking place before interviews and also before data analysis. Differences in interpretation were discussed and resolved by consensus in deliberation sessions. We placed dental hygiene barriers, beliefs, and behaviors in the larger dimensions of oral health and dental care as derived from the interviews and as originally identified in the Mejia et al. model (1); in this way, we portrayed dental hygiene themes in a dynamic relationship of their importance vis-à-vis other oral/dental issues.
Results Thirty-three interviews with people of Mexican origin (MAs) were completed. No new themes seemed to emerge after concluding these interviews, suggesting that we had reached an acceptable level of saturation. The 17 teens (10 females and 7 © 2014 American Association of Public Health Dentistry
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males) were aged 14–19, and the 16 adults (13 females and 3 males) were aged 33–52.
Themes identified: structural factors Financial barriers and barriers indirectly related to economics The most common aspect of dental care and oral health mentioned by participants was the financial issues conditioning their access to sufficient clinical resources: “dental care is way too expensive in the USA.” There were occasional references to differential opportunities to identify oral health and dental care needs because of poor educational resources (“sometimes people do not know when to seek care; let things get much worse, to the point of being beyond their ability to pay for fixing what could have been a small problem to address earlier on”). However, in general, several factors were consistently seen as related to limiting access to care and to maintaining good health: reduced income (“having that [tooth] extracted left us without being able to make rent”), lacking dental insurance or appropriate dental insurance (“without aseguranza [insurance], everything has to be paid up front, and very quickly the cost becomes unmanageable”), or the high cost of dental care (“I see that dentists have to make a living but I can’t see why dental care is so expensive!”). There was a dynamic interaction between seeking dental care and maintaining good oral health: professional-based advice and clinical interventions were seen as essential components of good oral health status. This highly vertical power relationship between dentist and patient was accepted as the natural order of things (“I mean, he’s the expert on how to fix teeth”), perhaps limiting the agency of patients to preserve good oral health, but this respect for the authoritative advice from professionals was moderated by financial barriers when actual implementation of recommendations was at stake. Those financial issues could be monetary or insurance in nature, or adopt a more convoluted form, such as one’s citizenship status (limiting the participant’s ability to purchase care in Mexico at a more affordable cost – “I used to go to [hometown] and have dental care with a cousin but I can’t go back [these days], it is much harder to return”) or even having the type of job that would allow taking time off work to attend dental appointments (“Having to choose between going to work or having teeth fixed, I can’t afford to say I won’t go to work”). While the latter limitation likely pertains to not only MAs but to anyone among the working poor or people in manual, occasional type of employment, this structural situation further conditioned individual-level factors (see below). It is interesting to note that participants who had legal immigration statuses in the United States or were American citizens ordinarily chose to receive dental care in Mexico. 95
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Reduced access to care vis-à-vis successfully navigating the dental care system Although at a secondary level of importance compared with financial considerations above, there were other structural factors posing challenges to seeking dental care or maintaining good oral health. None of these were mentioned by the majority of participants. It is, however, worth mentioning that language barriers – either the ability to understand the staff in the dental office or to make himself or herself understood – created a layer of complexity in accessing dental care. Although this was not an absolute barrier, language issues added uncertainty and apprehension to what was actually said by whom (“Sometimes I do not understand what they are telling me”). In the context of successfully navigating the dental care system, language barriers were compounded by not grasping the actual meaning of some concepts or words when used by dental office staff. At the present level of analyses, it is uncertain whether these may be due to limited language ability, lack of familiarity with disease processes, low health literacy in either Spanish or English, or any combination of such factors. Again cited by a minority of study participants (often women), there were geographical concerns voiced as transportation limitations – either because no readily available, predictable means of transportation existed (“I rely on my sister to take me and the children to dental appointments”) or because dental offices were too distant from their residence addresses. In a few cases, participants were uncertain of where they could find a dental office appropriate for their needs or resources (“You call them and they do not have appointments until next month – or they say they can’t understand what I am saying”). Reduced social support derived from migration – but social support still seen as a resource Separate from immigration statuses – which we did not accurately establish to ensure unbiased participation when the study was advertised – the fact that participants were often born in Mexico posed diverse scenarios of reduced social support or social network. In practical terms, attending dental appointments became problematic for some study participants because arranging for child minding was often difficult, and bringing children to dental offices was perceived to cause tension with dental office staff. A certain ambivalence concerning social supports and social networks was found in other participants: they indicated relying on such networks, on folk hearsay, and on informal information to find sources of dental and non-dental care [very occasionally, resorting to palliative care in emergency departments (EDs) in hospitals] to support care decisions. At its most basic level, those informal resources offered guidance in 96
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terms of factual information (e.g., what type of dental care in what clinics could be found to solve specific problems at what costs). It was apparent that there was a dimension of peer pressure to seek care when a problem appeared to be sufficiently severe. In a more sophisticated interpretation, accessing formal clinical resources was in some cases driven by a prior process of validation by peers, family, and opinion leaders, indicating they concurred that a clinical presentation had in fact become sufficiently serious to warrant the time and money invested in addressing the problem. These situations often were acute clinical problems but also involved social dimensions when the issue at hand was deemed to be salient enough; for example, a missing front tooth or an unsightly dental prosthesis. The factors related to immigration touched upon the issue of various degrees of limited adaptation or “acculturation” to the United States; for those MAs with lower levels of acculturation (as self-reported by participants), being Latino predisposed both clinicians and systems to discriminate against MA patients (“It is very hard to get appointments”). This is not a universal trend of discrimination but rather a generalized perception that MA dental patients do not always feel accepted (“I do not want to go back and see that dentist because I know I will be scolded; she told me to first have those wisdom teeth pulled”) because of many mismatched expectations between patients and clinicians. The individual level factors (below) offer several dimensions where misaligned expectations clashed.
Themes identified: individual-level factors Patterns of dental care utilization and indications for oral self-care: different agendas The patterns to identify the need to seek clinical care and to actually seek it – rehabilitative and surgical but in particular professionally delivered preventive dental care – permeated substantial mismatches between patients and clinicians. Although some of those instances were motivated by financial duress (“Six-month cleanings are for people who have dental insurance”) or justified by reduced income (“I mean, I’d like to have all of these but I can’t pay for this type of care ”), there was little value generally ascribed to professionally delivered prevention. In rare instances, it became apparent that certain skepticism existed about the real need for so many courses of treatment – preventive and other – being proposed (“You have to ask carefully every step of the way what is the cost of each and every item they have in mind . . . you may end up with too much stuff!”). Marketing efforts by dental office staff was an issue but the major underlying mismatch was the perception of dental treatment plans being excessive (“You go there to ask for one tooth to be fixed, and end up with $6,000 worth of treatment they want to do”). © 2014 American Association of Public Health Dentistry
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Against a cultural background and clinical experience based on episodic use of dental care, comprehensive treatment plans rarely fitted patient expectations. Virtually, those large treatment plans were never explained, sequenced, or broken down in pieces that might have been easier to accept. Major gaps resulted from poor communication skills by professionals and by patients, leading to reduced exchange of information: “I went to this dentist because I do not like the [partial denture]. My front teeth don’t look nice; but her attention is on the [back teeth]”. Interestingly enough, some Latino dentists, or Latino staff in dental offices, seemed to have identified the need to break treatment plans in smaller units in order to make them easier to accept (“I go to this dentist – who is [American] – but his assistant speaks Spanish. I talk with her about payment plans, and how we can get things done slowly, and usually it works”). It would be unwarranted to only ascribe reasons for the mismatched expectations on a clinical system that was perceived time and again as convoluted. Several participants implicitly or explicitly indicated they restricted their dental care to only acute episodes; this situation is thought to be derived from both long-standing experience of what dental care involves and clinical options being conditioned by reduced access to care. Having an established primary care provider was rarely a priority. It was apparent, however, that adults were far more interested in their children having periodic, preventive dental care than in their own situation. In the competing schema of affordability, families were more inclined to pay for dental care for the children than for adults. Of note was the consistent finding that no study participant could remember having been trained or seen demonstrations for dental hygiene maneuvers in the dental office. They recalled seeing some of that information in television ads or magazines (36 percent of a total of 33 participants). Such finding reflects the attention foci of marketing media, with predominance of tooth brushing, toothpaste, and mouth rinses but negligible relevance of flossing (see below). Among teenagers, school health education was not uncommonly mentioned as a resource for dental hygiene maneuvers and motivation (12 percent of participants). Prior experiences (self and family) with dental hygiene, prevention, and associated themes MAs – in particular adults – offered rich perspectives of their own experiences with dental care in Mexico and in the United States, and also of their families’ experiences. There were three axes in the prior experiences for self and family: first, a range of attitudes extending from the highly fatalistic toward the inevitability of oral health problems to the highly determined agency indicating that good oral health was a matter of personal discipline. The former were more common; the latter generally ascribed a great deal of impor© 2014 American Association of Public Health Dentistry
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tance to dental hygiene and self-care (brushing, 36 percent; flossing, 12 percent; rinses, 6 percent): “If you are going to pay attention to your teeth, it is really up to you to do the right thing.” Interestingly, almost everyone indicated they brushed their teeth at least once daily (76 percent) and appeared to be committed to a dental prevention mantra hinging upon frequent and thorough tooth brushing. Upon direct questioning, virtually all stated they used toothpaste when brushing (82 percent). The teenage participants were less likely to be as involved as the adults, and in fact some teenagers plainly stated their lack of adherence. It was often implied that appropriate tooth brushing regimes would be an effective way to altogether avoid needing dental care (76 percent). Use of mouth rinses – primarily for grooming and appearance (76 percent) rather than health (15 percent) – was also common among adults (“I gargle every day”). Flossing was not consistent among participants overall (33 percent stated it was difficult to floss every day), but in particular among teenagers; maneuvers involving flossing were driven by specific needs to dislodge food particles on occasion, not as a regular component of dental hygiene regimes. Several participants indicated their concern about lacking in their flossing technique (73 percent), or even doubted the wisdom of flossing at all, given the fact they often saw gingival bleeding when flossing. The second axis commonly quoted good “education” (implying family upbringing, not formal schooling) as a major component promoting adherence with appropriate dental hygiene, which in turn would lead to good oral health status (22 percent). A person may have had good upbringing because his or her family took care of instilling appropriate habits early in life, and yet have enjoyed little formal schooling. Underlying the second axis was a value system equating failure to follow expectations with negative consequences (18 percent) (“when I was young I did not take good care of my teeth, never paid attention, and now I am facing the consequences”). In general, there was considerable importance ascribed to keeping healthy teeth within the overall scheme of life (54 percent), but such perspective would often coexist with having poor oral health, frequent acute dental problems, or substantial unmet needs. The final axis outlined a loosely assembled understanding of certain dietary patterns being noxious to teeth. Holding a varying relationship with the value system of good family upbringing, indulging in foods and beverages rich in “sugars” (essentially signifying simple carbohydrates, and more broadly any sweetener) was considered to be one of the main reasons for poor oral health (88 percent) – tooth decay and gum disease, as well as most oral health conditions. “Weak” teeth, or genetics, also were touted as influencing factors (18 percent of participants quoted either or both options). Some of these noxious foods/beverages were commonly associated with leisure habits, in particular snacking on candy 97
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(88 percent), but many consumables rich in simple carbohydrates were simply not perceived to be in that list of undesirable items. This was the case of highly processed foods and/or staple diet foods not seen as primarily sweet, such as ketchup or sweet rolls (“pan dulce”). Excessive coffee intake, tobacco use, and not drinking milk were also deemed reasons for poor oral health (18 percent of participants quoted at least one of these options). While fluoride per se (in water or toothpaste) was not undesirable (82 percent) on account of toxicity or for health reasons, many participants indicated they did not use tap water. Most water supplies in Indiana have their fluoride content artificially adjusted. Tap water was usually considered to be unreliable or unsafe, and MAs tended to purchase water in large containers for home use, including drinking and even cooking.
Discussion The present qualitative analyses of interviews supplied detailed accounts of perspectives about dental hygiene, and about dental hygiene in the context of other oral health and dental care issues among a sample of MAs in the midwest United States. Themes about dental hygiene barriers, beliefs, and behaviors appear to be rather variable across this specific subgroup of the highly diverse Latino population in the United States. Some participants self-reported good behaviors and exhibited strong agency to adhere to appropriate regimes, while others had much less positive situations. It was evident, however, that dental hygiene was not salient relative to other pressing oral health and dental care matters. In particular, structural factors such as ability to purchase clinical services, having dental insurance, or knowing how to navigate the dental care system were mentioned first and more consistently during the interviews. This scenario is aligned with the structural role of socioeconomic resources as more distal determinants of health disparities (3). Interestingly, findings similar to those reported by Cortés et al. (9) were independently categorized in the present research. Economic hurdles were identified not only in terms of financial resources but in other, more subtle barriers hindering access to the dental care system (12-15). This would be worrisome because a predominant MA perspective appears to be one of dependence of professional interventions to attain good oral health and not so much one of relying on agency to maintain good oral health (16). Looking up to the dental professional as a source of solutions for oral health problems (17) often coexisted with the inability or unwillingness to using the dental care system, creating a cognitive dissonance that was nevertheless accepted as a matter of fact (18). Such reliance on professional advice was moderated by piecemeal selection of clinical indications and plans; in the grand scheme of things, discontinuous implementation of 98
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treatment plans and of professional recommendations fitted with the overall cultural acceptance of episodic dental care. Contrary to what would be expected for this profile, few experiences of seeking treatment in hospital EDs were reported, and even less among teenagers. One important finding concerning dental hygiene was that no study participant could recall having been trained or seen demonstrations for dental hygiene maneuvers in the dental office. Because the study population was purposefully recruited from nonclinical settings, our finding stands in contrast to some previous reports (9). It is uncertain what proportion of the reported behaviors implying MA familiarity with dental hygiene instruction is a result of where the recruitment for those research studies took place. While we have no direct evidence for this explanation, the fact that our participants often mentioned gaining information from commercial ads could contribute to tooth brushing with toothpaste and most likely has expanded the utilization of mouth rinses; the latter can subjectively be considered somewhat rare in Mexico’s general population. (There is no reliable epidemiological mouth rinse data for the country.) The common use of mouth rinses among adults was a surprising finding; while emphasizing the feasibility of using marketing media as a channel to disseminate health messages for this target population (9), mouth rinses may afford the opportunity to enhance exposure to fluorides. It could not be specifically found what proportion of rinses had in fact fluoride in their formulation, as their selection was rather casual and seemed to be driven by grooming, not health reasons. But considering that tap water is not a reliable means (19-21) to have fluoride coverage for this population subgroup in locations with fluoridated community water supplies, rinses may be an alternative to consider. National data suggest that while non-Hispanic whites consumed the most tap water, Mexican Americans consumed the most bottled water (20), even though no significant difference existed in perceptions of bottled water safety (in California) (21). Conversely, the absence of flossing in commercial ads was yet another reason for the casual flossing adherence we found. Flossing was primarily problem oriented, as in using toothpicks or toothpick/floss combination devices to remove impacted food; concerns about bleeding and its significance in the process of adopting consistent flossing behaviors is a prime area for dissemination of adequate information so that behaviors are more likely to be adopted and used correctly (14,18). As in the case of other dental care and oral health issues, attitudes pertaining to dental hygiene ranged from the highly fatalistic to the highly determined agency, but dental hygiene aspects appeared to fall more often in the latter realm, either because of a personal discipline component or because family supported acquiring these habits earlier in life. Similar findings have been previously reported (9). © 2014 American Association of Public Health Dentistry
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Closely related to either dental hygiene behaviors or to knowledge about dental hygiene recommendations were statements indicating that certain dietary patterns are noxious to teeth (6); in this fluid interpretation of some foods and beverages needed to be avoided because they are “sweet,” the intake could be offset by having good dental hygiene regimes (22). Without making specific distinctions across dental or periodontal conditions, offending habits encompassed coffee intake, tobacco use, and not drinking milk. Upon direct questioning, most participants could not identify the underlying mechanisms for those negative effects. This is one of the first in-depth inquiries into how dental hygiene maneuvers sit in the larger context of dental care and oral health beliefs, barriers, and behaviors among community-dwelling adult and teenage MAs. While findings hint at how those themes hold relative importance between categories and thus convey important context to various themes making up oral health and dental care perspectives, it is important to highlight the limitations of the present qualitative study. We limited the study population to only one subgroup of Hispanics – urban-based MAs in the Midwest – and thus the conclusions cannot be extrapolated to other members of this ethnic minority; however, little information has been published for this location and for teenagers. Except age and gender, we did not collect sociodemographic data from study participants; it is therefore problematic to know if these features shaped the information derived from the interviews. Participants were a small, self-selected group responding to an invitation to participate in a study and therefore they may have had more dental issues than nonparticipants (although the study clearly indicated no treatment would be provided); conversely, participants may have had fewer reasons to fear a poor oral health stigma, thus making individuals with better oral health status, better knowledge of dental hygiene recommendations, or better dental hygiene behaviors more willing to take part in the interviews. The wide range of perspectives found suggests none of these three hypothetical biases were likely. We reiterate that no clinical venue was used for recruitment, and thus participants were not self-selected on account of having (immediate) clinical needs. The respondents belonged to family nuclei and were associated with parishes or community organizations; these two features may have made participants more likely to be stable, better established migrants compared with unmarried MAs who had not established networks with parishes or community groups. Despite training and calibration, interviews and analyses were undertaken by three persons and therefore there was potential for bias in either of those two steps of the research. The effect of these methodological caveats on the themes identified cannot be addressed at present time. In conclusion, we report themes and perspectives on dental hygiene that, in the context of the larger schema of © 2014 American Association of Public Health Dentistry
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oral health and dental care, suggest that MA teenagers and adults have multiple interpretations of what dental hygiene is appropriate or necessary, and how it is practiced. Oral health disparities are downstream manifestations of nonclinical inequalities acting as social determinants of health, including ethnic minority status (3). We have placed dental hygiene perspectives in the larger context of oral health and dental care, as opposed to stand-alone factors. We acknowledge that individual-level factors at play in highly personal behaviors such as adherence to dental hygiene regimes cannot be interpreted in isolation from the multilevel dimensions of health disparities (23). The present research adds to the body of knowledge to creating resources to address oral health disparities (18) through informing educational and clinical strategies; such strategies should ideally be culturally appropriate to effectively reduce barriers and better support appropriate beliefs (14) and eventually improve oral health outcomes (12). Future work should further refine our understanding of how these factors become part of the mechanisms used by MAs to assemble dental hygiene beliefs, barriers, and behaviors; complementarily, a more thorough evaluation of the factors and mechanisms would be accrued by adding the perspectives of dental professionals to interpret factors and mechanisms used by MAs.
Acknowledgment This project was supported by a Project Development Team within the Indiana University Center for Urban Health and ICTSI NIH/NCRR Grant Number RR025761.
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16. Hoeft KS, Barker JC, Masterson EE. Maternal beliefs and motivations for first dental visit by low-income Mexican American children in California. Pediatr Dent. 2011;33(5): 392-8. 17. Horton S, Barker JC. Rural Mexican immigrant parents’ interpretation of children’s dental symptoms and decisions to seek treatment. Community Dent Health. 2009;26(4): 216-21. 18. Cadoret CA, Garcia RI. Health disparities and the multicultural imperative. J Evid Based Dent Pract. 2014;14(Suppl):160-170.e1. doi: 10.1016/j.jebdp.2014. 02.003. 19. Scherzer T, Barker JC, Pollick H, Weintraub JA. Water consumption beliefs and practices in a rural Latino community: implications for fluoridation. J Public Health Dent. 2010;70(4):337-43. 20. Drewnowski A, Rehm CD, Constant F. Water and beverage consumption among adults in the United States: cross-sectional study using data from NHANES 2005–2010. BMC Public Health. 2013;13:1068. 21. van Erp B, Webber WL, Stoddard P, Shah R, Martin L, Broderick B, et al. Demographic factors associated with perceptions about water safety and tap water consumption among adults in Santa Clara County, California, 2011. Prev Chronic Dis. 2014;11:130437. doi: 10.5888/pcd11.130437. 22. Hoeft KS, Barker JC, Masterson EE. Urban MexicanAmerican mothers’ beliefs about caries etiology in children. Community Dent Oral Epidemiol. 2010;38(3):244-55. 23. Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol. 2007;35:1-11.
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Qualitative description of dental hygiene practices within oral health and dental care perspectives of Mexican-American adults and teenagers Gerardo Maupome, BDS, MSc, PhD1; Odette Aguirre-Zero, DDS, MS2; Chi Westerhold, BS1 1 Preventive and Community Dentistry, Indiana University School of Dentistry, Indianapolis, IN, USA 2 Oral Biology, Indiana University School of Dentistry, Indianapolis, IN, USA
Keywords dental hygiene; Hispanics; Latinos; oral health beliefs; health disparities. Correspondence Dr. Gerardo Maupome, Preventive and Community Dentistry, Indiana University School of Dentistry, 415 Lansing St., Indianapolis, IN 46202. Tel.: 317-274-5529; Fax: 317274-5425; e-mail: [email protected]. Gerardo Maupome and Chi Westerhold are with Preventive and Community Dentistry, Indiana University School of Dentistry. Odette Aguirre-Zero is with Oral Biology, Indiana University School of Dentistry. Received: 3/17/2014; accepted: 8/30/2014. doi: 10.1111/jphd.12076 Journal of Public Health Dentistry 75 (2015) 93–100
Abstract Objectives: The objectives of this study were to identify dental hygiene themes voiced by adults and teenagers of Mexican origin [or Mexican Americans (MAs)] and place these themes within the larger landscape of oral health and dental care perceptions. Methods: Interviews with urban-based MAs were analyzed to identify barriers, beliefs, and behaviors influencing engagement in dental hygiene practices. Results: Adult (n = 16, ages 33–52) and teenage (n = 17, ages 14–19) MAs reported themes pertaining to structural factors (financial and economic-related barriers, the dual challenges of reduced access to care vis-à-vis successfully navigating the dental care system, and the effects of reduced social support derived from migration) and to individual factors (different agendas between MAs and health systems for dental care utilization and indications for oral self-care, including limited dental hygiene instruction from professionals and larger impacts from school-based and mass media). Also, prior experiences with dental hygiene, prevention, and associated themes were characterized by a range of attitudes from fatalistic to highly determined agency. Good family upbringing was instrumental for appropriate dental hygiene, anteceding good oral health; and outlining a loose structure of factors affecting oral health such as diet, having “weak” teeth, or personal habits. Conclusions: Themes from adults and teenagers in the Midwest United States were generally similar to other groups of MA parents and younger children. Dental hygiene was not salient relative to other oral health and dental care matters. Several opportunities for improvement of knowledge and enhancing motivation for dental hygiene practices were identified, both within and outside professional resources.
Introduction Many professional sources agree that a daily, consistent program of dental hygiene is highly desirable; adherence to such regimes is commonly heralded as one important component of self-efficacy and self-care in dentistry. There is sparse information in the scientific literature about values and behaviors upheld by some population subgroups when it comes to dental hygiene practices. Because of the opportunity to implement individualized prevention through such practices, it is important to characterize how and why practices take place in people affected by substantial oral health disparities; case in point is the mosaic of ethnic population subgroups broadly categorized as Hispanics in the United States. © 2014 American Association of Public Health Dentistry
Because complex dimensions and multiple variables appear to be at play in the oral health disparities phenomena, existing models ought to have included dental hygiene; however, the conceptual framework for Hispanic oral health care (1) and a cross-ethnic model describing the dimensions of influences moderating oral health and oral health disparities (2) failed to comprehensively describe barriers, beliefs, and behaviors pertaining to dental hygiene. Except for a passing entry in the latter (under individual influences), those models were firstly concerned with dental care, and secondarily with oral health status. A more recent framework describing oral health disparities (3) implied dental hygiene was nested across population-, community-, and person-level factors but did not address relevant barriers, beliefs, and behaviors in detail. 93
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This was not unexpected, considering the emphasis of the framework on the greater weight of structural factors in shaping health disparities. A few publications have started to identify barriers, beliefs, and behaviors pertaining to dental hygiene embraced by Hispanics; some of these studies recruited some or all of their participants from clinical settings. Hoeft et al. (4) conducted a qualitative study in California about beliefs and practices applied to children’s oral hygiene. Interviews were conducted in first- and second-generation urban Latinas with children under 10 years of age. While results from open-ended questions offered a set of beliefs about when to initiate and how to conduct dental hygiene maneuvers in their toddlers, it was clear that medical and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) staff were instrumental in guiding behaviors. Other studies from the same California research group have offered valuable insights, such as finding that rural fathers (from Mexico and El Salvador) had limited information and involvement in their young children’s dental hygiene (5) and that caregivers (6) included poor dental hygiene as one of the causes of early childhood caries. Luciano et al. (7) found in an adult population largely of Mexican origin surveyed in North Carolina that many respondents self-reported daily tooth brushing and flossing. Besides inquiring about links between dental hygiene maneuvers and gum problems, no underlying beliefs were explored in depth. Other publications have quantified stated adherence with practices without pointing to the underlying mechanisms (8). Cortés et al. (9) recently looked into those mechanisms using focus groups and interviews with Hispanics (mostly women) of multiple nationalities in Massachusetts; participants were chosen on the basis of having children aged 6–14. The script primarily focused on oral health problems, although it included some dental hygiene questions. Subsequent qualitative analyses led to a multilevel classification of themes addressing various aspects of oral health and dental care, linked at times with dental hygiene. The more apparent links for dental hygiene were with caries experience (including cariogenic sweeteners and dietary features) and the importance of establishing daily life routines to support appropriate dental hygiene. Most research specifically describing the mechanisms underlying dental hygiene among people of Mexican origin has been limited to adult viewpoints of the situations of their own young and very young children. Data about teenagers have been sparse (10), and more so in the context of both teens and adults being interviewed; a partial exception was a study on Hispanic and African-American teenagers (11), which limited its dental hygiene focus to documenting highly variable frequencies of flossing and brushing. The objectives of the present qualitative research study were to identify 94
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themes pertaining to dental hygiene practices as voiced by adults and teenagers, and to place these practices in the larger landscape of perspectives about oral health and dental care.
Materials and methods The approach followed in the present study was to analyze recorded interviews with urban-based individuals of Mexican origin [or Mexican Americans (MAs)], adults and adolescents (14 years of age and older), to identify barriers, beliefs, and behaviors influencing engagement in dental hygiene maneuvers within the larger context of dental care and oral health. Ethical approval was granted by the Indiana University Institutional Review Board (#1207009118). Teens assented to participate and their parents granted written informed consent. No effort was made to accurately differentiate between first- and secondgeneration immigrants to avoid statements about immigration status, length of time living in the United States, socioeconomic background, or occupation. We purposefully advertised the opportunity for participation and actively recruited both teen and adult MAs, of either gender. We are explicitly abandoning any attempt at using terms connoting the generation, acculturation level, or terminologically correct denomination of these urban-based people of Mexican origin, and for the sake of simplicity they are generically called MAs.
Study design and population The present data are part of a larger investigation aiming to develop a survey targeting an urban-based MA population group in the Midwest United States. In this first phase of the study, individual interviews were used to qualitatively identify salient themes with regard to dental hygiene practices, oral health, and dental care. Participants were recruited through advertising at events that took place in the fall and winter 2012 at health fairs, churches and religious gatherings, the waiting room in the Mexican Consulate in Indianapolis, and community organization functions.
Data collection and variables The approach consisted of one-on-one, semi-structured interviews. Eligibility criteria for interviewees were a) be of Mexican ancestry (any generation); b) able to speak, read, and write either English or Spanish; c) be free of disabilities that would make it unfeasible to be interviewed or agree to participate; and d) be a teen or adult living in an urban environment in central Indiana. Participants were recruited through word © 2014 American Association of Public Health Dentistry
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of mouth and flyers, as well as through partnerships with church and community leaders.
Interviews Participants’ consent/assent was obtained prior to the interview. No personal identifiers were collected. An interview script was created, and it was translated and back-translated to/from Spanish. Participants were encouraged as much as possible to expand in their interpretations above and beyond the script. Besides allowing ample opportunity for participants to dwell on topics in as much depth as they felt it necessary, the script introduced the topics of dental care utilization; experiences with urgent care; dental professional preventive services; dental self-care including tooth brushing, flossing, and use of mouth rinses; and lifestyle and oral health. Participants received US$30 as compensation. Interviews in either English or Spanish lasted 20–45 minutes and were audio-recorded. Each adult and each teenager was interviewed separately.
Data analysis Interviews were analyzed in three stages: initial categorization along groups of themes, followed by a second-stage assessment of the themes identified and categorized initially, cross-checking their fit with other categories, driven by thematic frequency in the interviews. Categorization of the themes was driven by allocating discrete segments of text to an individual category when the theme was explicitly stated, or when the context and the meaning of text made it sufficiently unequivocal to allow certainty in the classification. Finally, themes were assigned to two larger individual or structural levels. Data analyses were undertaken by the same three interviewers who collected data in the field, with calibration and training taking place before interviews and also before data analysis. Differences in interpretation were discussed and resolved by consensus in deliberation sessions. We placed dental hygiene barriers, beliefs, and behaviors in the larger dimensions of oral health and dental care as derived from the interviews and as originally identified in the Mejia et al. model (1); in this way, we portrayed dental hygiene themes in a dynamic relationship of their importance vis-à-vis other oral/dental issues.
Results Thirty-three interviews with people of Mexican origin (MAs) were completed. No new themes seemed to emerge after concluding these interviews, suggesting that we had reached an acceptable level of saturation. The 17 teens (10 females and 7 © 2014 American Association of Public Health Dentistry
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males) were aged 14–19, and the 16 adults (13 females and 3 males) were aged 33–52.
Themes identified: structural factors Financial barriers and barriers indirectly related to economics The most common aspect of dental care and oral health mentioned by participants was the financial issues conditioning their access to sufficient clinical resources: “dental care is way too expensive in the USA.” There were occasional references to differential opportunities to identify oral health and dental care needs because of poor educational resources (“sometimes people do not know when to seek care; let things get much worse, to the point of being beyond their ability to pay for fixing what could have been a small problem to address earlier on”). However, in general, several factors were consistently seen as related to limiting access to care and to maintaining good health: reduced income (“having that [tooth] extracted left us without being able to make rent”), lacking dental insurance or appropriate dental insurance (“without aseguranza [insurance], everything has to be paid up front, and very quickly the cost becomes unmanageable”), or the high cost of dental care (“I see that dentists have to make a living but I can’t see why dental care is so expensive!”). There was a dynamic interaction between seeking dental care and maintaining good oral health: professional-based advice and clinical interventions were seen as essential components of good oral health status. This highly vertical power relationship between dentist and patient was accepted as the natural order of things (“I mean, he’s the expert on how to fix teeth”), perhaps limiting the agency of patients to preserve good oral health, but this respect for the authoritative advice from professionals was moderated by financial barriers when actual implementation of recommendations was at stake. Those financial issues could be monetary or insurance in nature, or adopt a more convoluted form, such as one’s citizenship status (limiting the participant’s ability to purchase care in Mexico at a more affordable cost – “I used to go to [hometown] and have dental care with a cousin but I can’t go back [these days], it is much harder to return”) or even having the type of job that would allow taking time off work to attend dental appointments (“Having to choose between going to work or having teeth fixed, I can’t afford to say I won’t go to work”). While the latter limitation likely pertains to not only MAs but to anyone among the working poor or people in manual, occasional type of employment, this structural situation further conditioned individual-level factors (see below). It is interesting to note that participants who had legal immigration statuses in the United States or were American citizens ordinarily chose to receive dental care in Mexico. 95
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Reduced access to care vis-à-vis successfully navigating the dental care system Although at a secondary level of importance compared with financial considerations above, there were other structural factors posing challenges to seeking dental care or maintaining good oral health. None of these were mentioned by the majority of participants. It is, however, worth mentioning that language barriers – either the ability to understand the staff in the dental office or to make himself or herself understood – created a layer of complexity in accessing dental care. Although this was not an absolute barrier, language issues added uncertainty and apprehension to what was actually said by whom (“Sometimes I do not understand what they are telling me”). In the context of successfully navigating the dental care system, language barriers were compounded by not grasping the actual meaning of some concepts or words when used by dental office staff. At the present level of analyses, it is uncertain whether these may be due to limited language ability, lack of familiarity with disease processes, low health literacy in either Spanish or English, or any combination of such factors. Again cited by a minority of study participants (often women), there were geographical concerns voiced as transportation limitations – either because no readily available, predictable means of transportation existed (“I rely on my sister to take me and the children to dental appointments”) or because dental offices were too distant from their residence addresses. In a few cases, participants were uncertain of where they could find a dental office appropriate for their needs or resources (“You call them and they do not have appointments until next month – or they say they can’t understand what I am saying”). Reduced social support derived from migration – but social support still seen as a resource Separate from immigration statuses – which we did not accurately establish to ensure unbiased participation when the study was advertised – the fact that participants were often born in Mexico posed diverse scenarios of reduced social support or social network. In practical terms, attending dental appointments became problematic for some study participants because arranging for child minding was often difficult, and bringing children to dental offices was perceived to cause tension with dental office staff. A certain ambivalence concerning social supports and social networks was found in other participants: they indicated relying on such networks, on folk hearsay, and on informal information to find sources of dental and non-dental care [very occasionally, resorting to palliative care in emergency departments (EDs) in hospitals] to support care decisions. At its most basic level, those informal resources offered guidance in 96
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terms of factual information (e.g., what type of dental care in what clinics could be found to solve specific problems at what costs). It was apparent that there was a dimension of peer pressure to seek care when a problem appeared to be sufficiently severe. In a more sophisticated interpretation, accessing formal clinical resources was in some cases driven by a prior process of validation by peers, family, and opinion leaders, indicating they concurred that a clinical presentation had in fact become sufficiently serious to warrant the time and money invested in addressing the problem. These situations often were acute clinical problems but also involved social dimensions when the issue at hand was deemed to be salient enough; for example, a missing front tooth or an unsightly dental prosthesis. The factors related to immigration touched upon the issue of various degrees of limited adaptation or “acculturation” to the United States; for those MAs with lower levels of acculturation (as self-reported by participants), being Latino predisposed both clinicians and systems to discriminate against MA patients (“It is very hard to get appointments”). This is not a universal trend of discrimination but rather a generalized perception that MA dental patients do not always feel accepted (“I do not want to go back and see that dentist because I know I will be scolded; she told me to first have those wisdom teeth pulled”) because of many mismatched expectations between patients and clinicians. The individual level factors (below) offer several dimensions where misaligned expectations clashed.
Themes identified: individual-level factors Patterns of dental care utilization and indications for oral self-care: different agendas The patterns to identify the need to seek clinical care and to actually seek it – rehabilitative and surgical but in particular professionally delivered preventive dental care – permeated substantial mismatches between patients and clinicians. Although some of those instances were motivated by financial duress (“Six-month cleanings are for people who have dental insurance”) or justified by reduced income (“I mean, I’d like to have all of these but I can’t pay for this type of care ”), there was little value generally ascribed to professionally delivered prevention. In rare instances, it became apparent that certain skepticism existed about the real need for so many courses of treatment – preventive and other – being proposed (“You have to ask carefully every step of the way what is the cost of each and every item they have in mind . . . you may end up with too much stuff!”). Marketing efforts by dental office staff was an issue but the major underlying mismatch was the perception of dental treatment plans being excessive (“You go there to ask for one tooth to be fixed, and end up with $6,000 worth of treatment they want to do”). © 2014 American Association of Public Health Dentistry
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Against a cultural background and clinical experience based on episodic use of dental care, comprehensive treatment plans rarely fitted patient expectations. Virtually, those large treatment plans were never explained, sequenced, or broken down in pieces that might have been easier to accept. Major gaps resulted from poor communication skills by professionals and by patients, leading to reduced exchange of information: “I went to this dentist because I do not like the [partial denture]. My front teeth don’t look nice; but her attention is on the [back teeth]”. Interestingly enough, some Latino dentists, or Latino staff in dental offices, seemed to have identified the need to break treatment plans in smaller units in order to make them easier to accept (“I go to this dentist – who is [American] – but his assistant speaks Spanish. I talk with her about payment plans, and how we can get things done slowly, and usually it works”). It would be unwarranted to only ascribe reasons for the mismatched expectations on a clinical system that was perceived time and again as convoluted. Several participants implicitly or explicitly indicated they restricted their dental care to only acute episodes; this situation is thought to be derived from both long-standing experience of what dental care involves and clinical options being conditioned by reduced access to care. Having an established primary care provider was rarely a priority. It was apparent, however, that adults were far more interested in their children having periodic, preventive dental care than in their own situation. In the competing schema of affordability, families were more inclined to pay for dental care for the children than for adults. Of note was the consistent finding that no study participant could remember having been trained or seen demonstrations for dental hygiene maneuvers in the dental office. They recalled seeing some of that information in television ads or magazines (36 percent of a total of 33 participants). Such finding reflects the attention foci of marketing media, with predominance of tooth brushing, toothpaste, and mouth rinses but negligible relevance of flossing (see below). Among teenagers, school health education was not uncommonly mentioned as a resource for dental hygiene maneuvers and motivation (12 percent of participants). Prior experiences (self and family) with dental hygiene, prevention, and associated themes MAs – in particular adults – offered rich perspectives of their own experiences with dental care in Mexico and in the United States, and also of their families’ experiences. There were three axes in the prior experiences for self and family: first, a range of attitudes extending from the highly fatalistic toward the inevitability of oral health problems to the highly determined agency indicating that good oral health was a matter of personal discipline. The former were more common; the latter generally ascribed a great deal of impor© 2014 American Association of Public Health Dentistry
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tance to dental hygiene and self-care (brushing, 36 percent; flossing, 12 percent; rinses, 6 percent): “If you are going to pay attention to your teeth, it is really up to you to do the right thing.” Interestingly, almost everyone indicated they brushed their teeth at least once daily (76 percent) and appeared to be committed to a dental prevention mantra hinging upon frequent and thorough tooth brushing. Upon direct questioning, virtually all stated they used toothpaste when brushing (82 percent). The teenage participants were less likely to be as involved as the adults, and in fact some teenagers plainly stated their lack of adherence. It was often implied that appropriate tooth brushing regimes would be an effective way to altogether avoid needing dental care (76 percent). Use of mouth rinses – primarily for grooming and appearance (76 percent) rather than health (15 percent) – was also common among adults (“I gargle every day”). Flossing was not consistent among participants overall (33 percent stated it was difficult to floss every day), but in particular among teenagers; maneuvers involving flossing were driven by specific needs to dislodge food particles on occasion, not as a regular component of dental hygiene regimes. Several participants indicated their concern about lacking in their flossing technique (73 percent), or even doubted the wisdom of flossing at all, given the fact they often saw gingival bleeding when flossing. The second axis commonly quoted good “education” (implying family upbringing, not formal schooling) as a major component promoting adherence with appropriate dental hygiene, which in turn would lead to good oral health status (22 percent). A person may have had good upbringing because his or her family took care of instilling appropriate habits early in life, and yet have enjoyed little formal schooling. Underlying the second axis was a value system equating failure to follow expectations with negative consequences (18 percent) (“when I was young I did not take good care of my teeth, never paid attention, and now I am facing the consequences”). In general, there was considerable importance ascribed to keeping healthy teeth within the overall scheme of life (54 percent), but such perspective would often coexist with having poor oral health, frequent acute dental problems, or substantial unmet needs. The final axis outlined a loosely assembled understanding of certain dietary patterns being noxious to teeth. Holding a varying relationship with the value system of good family upbringing, indulging in foods and beverages rich in “sugars” (essentially signifying simple carbohydrates, and more broadly any sweetener) was considered to be one of the main reasons for poor oral health (88 percent) – tooth decay and gum disease, as well as most oral health conditions. “Weak” teeth, or genetics, also were touted as influencing factors (18 percent of participants quoted either or both options). Some of these noxious foods/beverages were commonly associated with leisure habits, in particular snacking on candy 97
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(88 percent), but many consumables rich in simple carbohydrates were simply not perceived to be in that list of undesirable items. This was the case of highly processed foods and/or staple diet foods not seen as primarily sweet, such as ketchup or sweet rolls (“pan dulce”). Excessive coffee intake, tobacco use, and not drinking milk were also deemed reasons for poor oral health (18 percent of participants quoted at least one of these options). While fluoride per se (in water or toothpaste) was not undesirable (82 percent) on account of toxicity or for health reasons, many participants indicated they did not use tap water. Most water supplies in Indiana have their fluoride content artificially adjusted. Tap water was usually considered to be unreliable or unsafe, and MAs tended to purchase water in large containers for home use, including drinking and even cooking.
Discussion The present qualitative analyses of interviews supplied detailed accounts of perspectives about dental hygiene, and about dental hygiene in the context of other oral health and dental care issues among a sample of MAs in the midwest United States. Themes about dental hygiene barriers, beliefs, and behaviors appear to be rather variable across this specific subgroup of the highly diverse Latino population in the United States. Some participants self-reported good behaviors and exhibited strong agency to adhere to appropriate regimes, while others had much less positive situations. It was evident, however, that dental hygiene was not salient relative to other pressing oral health and dental care matters. In particular, structural factors such as ability to purchase clinical services, having dental insurance, or knowing how to navigate the dental care system were mentioned first and more consistently during the interviews. This scenario is aligned with the structural role of socioeconomic resources as more distal determinants of health disparities (3). Interestingly, findings similar to those reported by Cortés et al. (9) were independently categorized in the present research. Economic hurdles were identified not only in terms of financial resources but in other, more subtle barriers hindering access to the dental care system (12-15). This would be worrisome because a predominant MA perspective appears to be one of dependence of professional interventions to attain good oral health and not so much one of relying on agency to maintain good oral health (16). Looking up to the dental professional as a source of solutions for oral health problems (17) often coexisted with the inability or unwillingness to using the dental care system, creating a cognitive dissonance that was nevertheless accepted as a matter of fact (18). Such reliance on professional advice was moderated by piecemeal selection of clinical indications and plans; in the grand scheme of things, discontinuous implementation of 98
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treatment plans and of professional recommendations fitted with the overall cultural acceptance of episodic dental care. Contrary to what would be expected for this profile, few experiences of seeking treatment in hospital EDs were reported, and even less among teenagers. One important finding concerning dental hygiene was that no study participant could recall having been trained or seen demonstrations for dental hygiene maneuvers in the dental office. Because the study population was purposefully recruited from nonclinical settings, our finding stands in contrast to some previous reports (9). It is uncertain what proportion of the reported behaviors implying MA familiarity with dental hygiene instruction is a result of where the recruitment for those research studies took place. While we have no direct evidence for this explanation, the fact that our participants often mentioned gaining information from commercial ads could contribute to tooth brushing with toothpaste and most likely has expanded the utilization of mouth rinses; the latter can subjectively be considered somewhat rare in Mexico’s general population. (There is no reliable epidemiological mouth rinse data for the country.) The common use of mouth rinses among adults was a surprising finding; while emphasizing the feasibility of using marketing media as a channel to disseminate health messages for this target population (9), mouth rinses may afford the opportunity to enhance exposure to fluorides. It could not be specifically found what proportion of rinses had in fact fluoride in their formulation, as their selection was rather casual and seemed to be driven by grooming, not health reasons. But considering that tap water is not a reliable means (19-21) to have fluoride coverage for this population subgroup in locations with fluoridated community water supplies, rinses may be an alternative to consider. National data suggest that while non-Hispanic whites consumed the most tap water, Mexican Americans consumed the most bottled water (20), even though no significant difference existed in perceptions of bottled water safety (in California) (21). Conversely, the absence of flossing in commercial ads was yet another reason for the casual flossing adherence we found. Flossing was primarily problem oriented, as in using toothpicks or toothpick/floss combination devices to remove impacted food; concerns about bleeding and its significance in the process of adopting consistent flossing behaviors is a prime area for dissemination of adequate information so that behaviors are more likely to be adopted and used correctly (14,18). As in the case of other dental care and oral health issues, attitudes pertaining to dental hygiene ranged from the highly fatalistic to the highly determined agency, but dental hygiene aspects appeared to fall more often in the latter realm, either because of a personal discipline component or because family supported acquiring these habits earlier in life. Similar findings have been previously reported (9). © 2014 American Association of Public Health Dentistry
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Closely related to either dental hygiene behaviors or to knowledge about dental hygiene recommendations were statements indicating that certain dietary patterns are noxious to teeth (6); in this fluid interpretation of some foods and beverages needed to be avoided because they are “sweet,” the intake could be offset by having good dental hygiene regimes (22). Without making specific distinctions across dental or periodontal conditions, offending habits encompassed coffee intake, tobacco use, and not drinking milk. Upon direct questioning, most participants could not identify the underlying mechanisms for those negative effects. This is one of the first in-depth inquiries into how dental hygiene maneuvers sit in the larger context of dental care and oral health beliefs, barriers, and behaviors among community-dwelling adult and teenage MAs. While findings hint at how those themes hold relative importance between categories and thus convey important context to various themes making up oral health and dental care perspectives, it is important to highlight the limitations of the present qualitative study. We limited the study population to only one subgroup of Hispanics – urban-based MAs in the Midwest – and thus the conclusions cannot be extrapolated to other members of this ethnic minority; however, little information has been published for this location and for teenagers. Except age and gender, we did not collect sociodemographic data from study participants; it is therefore problematic to know if these features shaped the information derived from the interviews. Participants were a small, self-selected group responding to an invitation to participate in a study and therefore they may have had more dental issues than nonparticipants (although the study clearly indicated no treatment would be provided); conversely, participants may have had fewer reasons to fear a poor oral health stigma, thus making individuals with better oral health status, better knowledge of dental hygiene recommendations, or better dental hygiene behaviors more willing to take part in the interviews. The wide range of perspectives found suggests none of these three hypothetical biases were likely. We reiterate that no clinical venue was used for recruitment, and thus participants were not self-selected on account of having (immediate) clinical needs. The respondents belonged to family nuclei and were associated with parishes or community organizations; these two features may have made participants more likely to be stable, better established migrants compared with unmarried MAs who had not established networks with parishes or community groups. Despite training and calibration, interviews and analyses were undertaken by three persons and therefore there was potential for bias in either of those two steps of the research. The effect of these methodological caveats on the themes identified cannot be addressed at present time. In conclusion, we report themes and perspectives on dental hygiene that, in the context of the larger schema of © 2014 American Association of Public Health Dentistry
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oral health and dental care, suggest that MA teenagers and adults have multiple interpretations of what dental hygiene is appropriate or necessary, and how it is practiced. Oral health disparities are downstream manifestations of nonclinical inequalities acting as social determinants of health, including ethnic minority status (3). We have placed dental hygiene perspectives in the larger context of oral health and dental care, as opposed to stand-alone factors. We acknowledge that individual-level factors at play in highly personal behaviors such as adherence to dental hygiene regimes cannot be interpreted in isolation from the multilevel dimensions of health disparities (23). The present research adds to the body of knowledge to creating resources to address oral health disparities (18) through informing educational and clinical strategies; such strategies should ideally be culturally appropriate to effectively reduce barriers and better support appropriate beliefs (14) and eventually improve oral health outcomes (12). Future work should further refine our understanding of how these factors become part of the mechanisms used by MAs to assemble dental hygiene beliefs, barriers, and behaviors; complementarily, a more thorough evaluation of the factors and mechanisms would be accrued by adding the perspectives of dental professionals to interpret factors and mechanisms used by MAs.
Acknowledgment This project was supported by a Project Development Team within the Indiana University Center for Urban Health and ICTSI NIH/NCRR Grant Number RR025761.
References 1. Mejia GC, Kaufman JS, Corbie-Smith G, Rozier RG, Caplan DJ, Suchindran CM. A conceptual framework for Hispanic oral health care. J Public Health Dent. 2008;68(1):1-6. 2. Patrick DL, Lee RS, Nucci M, Grembowski D, Jolles CZ, Milgrom P. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006;6(Suppl 1):S4. 3. Lee JY, Divaris K. The ethical imperative of addressing oral health disparities: a unifying framework. J Dent Res. 2014;93(3):224-30. 4. Hoeft KS, Masterson EE, Barker JC. Mexican American mothers’ initiation and understanding of home oral hygiene for young children. Pediatr Dent. 2009;31(5):395-404. 5. Swan MA, Barker JC, Hoeft KS. Rural Latino farmworker fathers’ understanding of children’s oral health. Pediatr Dent. 2010;32(5):400-6. 6. Horton S, Barker JC. Rural Latino immigrant caregivers’ conceptions of their children’s oral disease. J Public Health Dent. 2008;68(1):22-9.
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