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PERCEIVED PARENTAL BARRIERS TO PREVENTIVE DENTAL CARE
PROGRAMS FOR CHILDREN
Chapter 1: Introduction to the Study
Introduction
Dental caries is more prevalent in children than asthma (Centers for Disease
Control and Prevention [CDC], 2015). Caries affects children the most between the ages
of 5 and 15 years (CDC, 2015). In the United States, 42% of children aged 2 through 11
years old have had dental caries in their primary (baby) teeth. In fact, 21% of children
have untreated decay in their permanent teeth (National Institute of Dental and
Craniofacial Research [NIDCR], 2014). Dental caries is a preventable disease. A
disproportionate number of dental caries can be found in racial/ethnic groups with
relatively high rates of poverty such as Hispanic, Mexican, and Black (CDC, 2015).
Reducing oral health disparities in children has been on the agenda of the U.S.
Department of Health and Human Services (HHS, 2009) through initiatives such as
Healthy People 2010 and 2020. Dental universities, colleges, and professional
organizations are providing free preventive oral health programs to decrease oral health
disparities affecting vulnerable children. However, the problem of low attendance rates is
increasing due to lack of parental consent; thus, questions arise as to whether this is an
appropriate outlet to reach children who need quality preventive care (Center for health
Care Strategies [CHCS], 2015; Glenny, Worthington, Milsom, Rooney, & Tickle, 2013;
Spence, White, Adamson, & Matthews, 2013). Because free oral health care for the
community is observed as an asset, other possible parental obstacles must prevent
children from joining the sealant program. What are the potential obstacles to preventive
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oral health care besides lack of dental insurance and proximity to dental settings? Is
dental care considered unimportant in the community or by parental caregivers? Inquiry
into perceived barriers is of fundamental importance because university initiatives have
been experiencing a decline in participants rather than gaining new patients. What, if any,
probable obstacles to these programs exist? Decreasing oral health disparities necessitates
an understanding of multiple oral health perspectives. The intent of this study was to
explore parental perceptions of free preventive dental care programs as seen in caregivers
of children between the ages of 5 and 15 years.
Background
According to the U.S. Surgeon General, oral health has a significant impact on the
overall health and well-being of individuals and the nation (Devlin, 2011; National
Institutes of Health [NIH], 2014). Poor oral health leads to illnesses that affect and restrict
individuals’ ability to work, learn in school, and function at home, diminishing quality of
life (Healthy People 2010; Jackson, 2011; Kierce, Boyd, Rainchuso, Palmer, & Rothman,
2016; NIH, 2014). Progress on oral health diseases has been made due to successful
prevention programs (Devlin, 2011). However, not everyone is experiencing
improvement (CDC, 2016; Healthy People 2010; Jackson, 2011; NIH, 2014; Kierce et al.,
2016). Children of Black, Hispanic, and Mexican descent between the ages of 2 and 15
years and from low-socioeconomic backgrounds suffer from oral health disparities.
Dental colleges, universities, and professional organizations develop and promote free
preventive dental care programs to increase awareness, access, and oral health literacy for
these high-risk children. Unfortunately, parental consent becomes a barrier to these
programs when the previously significant barriers of lack of insurance, lack of access to
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care, and lack of transportation are removed (NIH, 2014). Chi (2014) raised the concern
that a significant number of children still do not receive the required informed consent to
attend these programs; without these interventions, high-risk children are exposed to
greater levels of dental disease. Horowitz, Kleinman, and Wang (2013) showed that
Maryland adults were not well informed about how their children’s teeth decay, or how to
prevent decay, indicating a need to increase oral health literacy. Dodd, Logan, Brown,
Calderon, and Catalanotto (2014); Divaris et al. (2013); and Chi (2013) revealed that the
perceived threat from dental disease is low and that caregivers are neglectful of children’s
oral health needs. However, improving dental professional cultural sensitivity and
encouraging parental trust with dental professionals is lacking, as is bolstering and
supporting parental/caregiver care that is integral to improving children’s oral health
(Divaris et al., 2014; Kierce et al., 2016). In fact, research indicated cultural dissimilarity
and sensitivity were missing in private practices and public health clinics (Wallace &
MacEntee, 2012). Researchers have suggested that further qualitative studies need to be
carried out to examine the emotions and attitudes of parents toward their children
attending free preventive dental care programs (Chi, 2013; Divaris et al., 2013; Dodd et
al., 2014). Exploring perceived parental barriers to preventive oral health programs for
children may enlighten dental colleges, universities, and professional programs
concerning the challenges of acceptance and low attendance of high-risk children in
relation to these programs. Understanding parental concerns and barriers to consent may
allow for colleges, universities, and professional organizations to alter preventive oral
health care programs to increase acceptance.
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Problem Statement
Dental colleges, universities, and professional organizations continue to offer
children of at-risk neighborhoods convenient opportunities to take part in free oral health
disease prevention programs, which include exams, dental sealants, and fluoride
treatments (CDC, 2014; Devine, 2011; Devlin & Henshaw, 2011; Olmsted, Rublee,
Zurkawski & Kleber, 2013). These free preventive initiatives are designed to aid in the
reduction of oral health disparities in children. According to health disparities research,
improving access to care automatically leads to an uptake of preventive care (Chi, 2014).
However, a significant number of children still do not receive the required informed
consent to attend these programs and are therefore exposed to greater levels of dental
disease (Chi, 2014). There is a need to examine the emotions and attitudes of parents
toward their children attending these events (Divaris et al., 2014; Dodd et al., 2014).
Comprehending the perspectives of parents on their children’s oral health may help dental
disease prevention programs to be successful in the community (Beck et al., 2014; Chi,
2013; Devlin & Henshaw, 2011; Divaris et al., 2014; Dodd et al., 2014). It is essential for
investigators to expose the intricate reasons why parents do not comprehend the
importance of preventing dental disease in terms of their children’s total health (Dodd et
al., 2014). Uncovering parental awareness of obstructions could allow dental hygienists,
universities, and dental clinics to organize more successful free preventive care dental
programs. This research has implemented qualitative data based on interviews with
parents regarding their feelings toward taking their children to a free oral health disease
prevention event.
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The aim of this research was to assist in the reduction of oral health disparities
among children. Documentation proves that children of families below the poverty level
are at greater risk than other children of developing dental caries (Devlin & Henshaw,
2011; Guarnizo-Herrano & Wehby, 2012). Evidence affirms that there has been a need for
a qualitative study to examine the emotions and attitudes of parents toward their children
participating in these programs (Chi, 2013; Divaris et al., 2013; Dodd et al., 2014). In a
related study on adolescents and dental care, Dodd et al. (2014) found that perceived
threat from dental disease was low. In fact, participants perceived regular brushing and
flossing as superseding the need for preventive care (Chi, 2014; Dodd et al., 2014).
Additionally, some participants believed that esthetic concerns were often a reason to
seek dental care. However, many participants articulated frustrations related to lack of
access to dental care, including those linked to finances, transportation, fear, issues with
Medicaid coverage, and parental responsibility (Wallace & MacEntee, 2011). Dodd et al.
(2014) reported that parents described going to the dentist as “something their family
never did” (p. 807). The purpose of this inquiry was to explore parental perceptions of
barriers to dental care by questioning parents who perceived difficulties in relation to
accompanying their children to free preventive dental care programs. Documentation has
revealed that children of low-income families are at greater risk than other children of
developing dental caries (Devlin & Henshaw, 2011; Guarnizo-Herrano & Wehby, 2012).
For instance, Muller-Bolla, Lupi-Pegurier, Bardakjian, and Velly (2013) suggested that
sealants should be deposited on the permanent molars of children who are susceptible to
caries. However, sealants are underused, particularly among low-income families and
families from racial/ethnic minority groups (Ahovuo‐Saloranta, Forss, Hiiri, Nordblad, &
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Mäkelä, 2016; American Academy of Pediatrics, 2016). This research project was
conducted in an effort to fill gaps in literature indicating a need for further qualitative
studies exploring the emotions and attitudes of parents toward their children attending
these free preventive dental care programs (Chi, 2013; Divaris et al., 2013; Dodd et al.,
2014; Guarnizo-Herrano & Wehby, 2012).
Purpose of the Study
In this research project, a qualitative case study design was used to explore oral
health perceptions and dental care behaviors of parents of children aged 5-15 years in
underperforming Title I New York City elementary schools. Caries affects children’s
permanent teeth the most between the ages of 5 and 15 years (CDC, 2015). This
approach may have distinguished potential barriers to free preventive dental care for
children. Comprehending the numerous oral health perspectives of parents and their
children could allow for free preventive dental care programs to be successful in the
community. Assimilating myself in the community and engaging parents with openended
questions and multiple conversations provided knowledge of the sensitivity surrounding
oral care behaviors. The ultimate goal was to find out whether these programs should
endure with a low success rate or attempt to determine and diminish perceived parental
barriers to care. Understanding perceived parental barriers could aid in increasing rates of
informed consent for the use of these programs and, consequently, increases in the
number of high-risk children receiving preventive dental care. Understanding parental
refusal of preventive care could help in identifying the social, economic, and policy
implications of oral health decision making (Chi, 2014).
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Research Questions
The primary research question for this qualitative inquiry was the following: What
perceived barriers would prevent parents from having their children attend a free
preventive dental care program? I also explored the following subquestions:
1. Is lack of trust an issue for parents?
2. Are cultural issues perceived as a barrier?
3. How can free preventive dental care programs more efficiently reach
children?
4. What are the real-life perceptions of these programs by parents?
5. What other life events prevent children from attending?
6. What is parents’ perception of preventive dental care?
7. How was parents’ dental care addressed when they were children?
With a qualitative case study, the researcher can modify questioning as distinctive themes
materialize during the data collection process.
Theoretical Framework
The identification of an appropriate theory or theories for the framework of a
study originates with establishing the problem, goal, and types of participants (NIH,
2015). This project incorporated Prochaska and DiClemente’s (1983) trans theoretical
model (TTM) of behavior change and Bandura’s (1986) social cognitive theory (SCT) to
facilitate an understanding of how parents from low socioeconomic communities’ access
preventive dental care services for their children.
The social determinants of health and health behavior are based upon
understanding explanatory theories and change theories such as TTM and SCT (NIH,
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2015). Many social, cultural, and economic factors contribute to the development,
maintenance, and change of health behavior patterns (NIH, 2015). Public health and
health promotions are effective if they embrace an ecological perspective and include
upstream approaches (NIH, 2015).
The use of the TTM allowed me to understand how parents perceive their
children’s oral health care needs. Prochaska and Velicer (1997) suggested that at-risk
populations are 40% in precontemplation or have no intention of taking their child to the
dentist, 40% in contemplation, and 20% in preparation. Identifying stages of behavior
allowed me to recognize necessary future planning toward moving parents into different
stages. Parental self-efficacy toward oral health care and parental decision making were
integral to the application of the TTM in this study. Specific procedures can be designed
to reduce resistance and facilitate progress toward parents escorting their children to
preventive oral health programs.
Additionally, SCT helped me to explain how parents observe, imitate, and learn
health care behaviors based upon social surroundings in the neighborhood. SCT helped to
explain how interaction with the environment and self affects parental behaviors.
Both the TTM and SCT helped me to consider the long-term changes in health
behavior that comprise diverse actions and adaptations over time (NIH, 2015). For
example, certain parents or children are not ready to focus on behavioral changes,
whereas others are in the process of changing their oral health behaviors. The TTM
indicates that people are at different stages of readiness to adopt healthful behaviors
(NIH, 2015). The concept of readiness to change, including recognition of stages of
change, has been used in health behavior research for years. The TTM has been helpful in
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explaining and predicting changes for a variety of behaviors, including tooth brushing
and other oral health care habits (NIH, 2015). Using interviews and observations based
upon the TTM and SCT, I attempted to highlight oral health behavior patterns of parents
and how they affect use of preventive oral health care for children.
Nature of the Study
This project was a qualitative study exploring perceptions and potential barriers in
relation to why parents or caregivers do not escort their children to free preventive oral
health programs. I used a case study design because this qualitative approach involved
investigating a real-life bounded system (Creswell, 2013). A case study is an in-depth
look at a single person or group of people and its relationship to a phenomenon
(Creswell, 2013). This study included 20 interviews with parents regarding perceptions of
free preventive dental care programs and perceived parental barriers. It was designed
around examining apprehension and possible obstacles pertaining to why parents do not
guide their children to dental disease prevention programs. Case study designs focus on a
single individual, organization, event, or program (Rudestam & Newton, 2015). It was a
case that has a specific time and place. The study progressed over time with in-depth,
open-ended, detailed data collection involving observations and interviews. The
interviews were audio recorded, and all documents and reports were analyzed (Creswell,
2013). The purpose of the research was to illuminate and apprehend this unique problem
of low preventive dental care program attendance and address concerns of perceived
parental barriers (Creswell, 2013).
The data collection method involved individual interviews and observations, of
parents regarding perceptions of dental care and perceived barriers to free preventive
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dental care programs (Laureate, 2015). Interviews consisted of semi structured,
openended questions situated around the primary research question. The interviews were
audio recorded, and observation and journaling were conducted during interviews; all
information gathered was transcribed verbatim later (Rudestam & Newton, 2015). After
initial observation, interviews were conducted face to face.
I began observations by collecting field notes, first by observing as an outsider,
and then by moving into the school setting and observing as an insider (Creswell, 2013).
Observation is an integral part of qualitative research (Creswell, 2013). Observation
started with parents or caregivers of children who had specific demographic and ethnic
backgrounds. Observation notes highlighted the setting, neighborhood, actions, attitudes,
and behaviors of parents toward preventive oral health programs. Per the University of
California (2015), if researchers want to find out what people do, they should observe
them. The strength of observation is the richness of description (University of California,
2015). Observation was fundamental in discerning the natural setting and was sensitive to
the participants’ perspective (Saldana, 2016). Observation makes it possible to cultivate
an in-depth and rich understanding of people, settings, phenomena, and the behavior of
people in a setting (Saldana, 2016).
Documents reviewed for this study included journals I kept during the study,
documents related to the interview setting and neighborhood, and messages sent during
text or email correspondence with the participants. Finally, I developed audiovisual
materials by recording conversations and all interviews.
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Secondary Data Types and Sources of Information
My plan was to gather extensive data that would provide rich informational
resources (Creswell, 2013). I used notes jotted down during interviews and observations,
as well as social media, texts, emails, and audiovisual materials (Rudestam & Newton,
2015). Additional documents consisted of journals kept during the study and information
on the program setting and neighborhood.
Definitions
For the purpose of this study, the following definitions were used:
Dental health professionals: A team of professionals who provide oral health care.
The team is composed of a dentist, a dental therapist, a dental hygienist, and a dental
assistant who work together to meet the many and varied dental and orally related needs
of the dental patient (Nunn, 2015).
Dental sealants: Thin plastic resin coatings applied to the tiny grooves on the
chewing surfaces of the back teeth (molars) to prevent tooth decay by forming a
protective physical barrier (CDC, 2016).
Healthy People 2020: The nation's framework for improved health for everyone.
The goals of Healthy People 2020 are to increase quality and years of healthy life and
eliminate health disparities (CDC, 2016)
Oral health disparities: Exist for many racial and ethnic groups, as well as groups
defined by socioeconomic status, gender, age, and geographic location. Economic factors
in poor oral health include access to care and an individual's ability to maintain dental
insurance (CDC, 2016).
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Oral heath literacy: The degree to which individuals have the capacity to obtain,
process, and understand basic oral health information and services needed to make
appropriate health decisions (Healthy People, 2010).
School-based dental sealant programs: Provide sealants to children from
lowincome neighborhoods and certain racial and ethnic groups at the highest risk for
tooth decay, who may not receive routine dental care (CDC, 2016).
Socioeconomic status: Generally seen as the social standing or class of an
individual or group. It is considered as a fusion of education, income, and occupation
(APA, 2016).
Untreated dental caries: Tooth decay (dental cavities) that has not received
necessary treatment (CDC, 2016).
Assumptions
The following assumptions were made concerning the implementation of this
study:
1. The parents had the opportunity to participate in a free preventive oral health
care program for their children.
2. The parent participants for the study were cooperative, honest, and able to
follow instructions.
3. The use of purposive selection produced a sample of parents with variations in
dental literacy and levels of knowledge regarding oral health diseases in their
children. This purposive sample of parent participants was indicative of
meeting inclusion criteria such as low socioeconomic status and specific
ethnic backgrounds.
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4. The data collected were a true representation of parent participants’ feelings
and attitudes toward free preventive dental programs for their children.
5. The sample of parent participants produced data saturation when I discerned
that it was no longer possible to obtain new information.
Scope and Delimitations
The study conducted for this dissertation was delimited to 15-30 purposively
selected parents of children who had been denied access to free preventive oral health
programs. Below is a list of requirements that was necessary to meet the objectives of this
project
1. The data were collected from underperforming Title I New York City
elementary schools at a public area such as a health fair, that had a private
place or section, chosen by parent participants based on convenience.
2. Study participants had a child or children aged 5-15 years attending the
underperforming Title I New York City elementary school that served as the
source for recruiting parents. The age of the children was important because
first and second molars erupt at this time, allowing for protective, preventive
dental sealant placement (American Dental Association [ADA], 2006).
Additionally, children of this age have developed adequate motor skills for
proper tooth brushing education techniques (Das & Singhal, 2009).
3. The participants lived in the low-socioeconomic neighborhood of the school
district. The selected parents were of Black, Hispanic, or Mexican descent
because oral health disparities continue to affect these racial and ethnic
groups.
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4. The parent participants spoke and read English fluently.
Limitations
The results of this qualitative study were affected by the following factors beyond
my control as the researcher:
1. Inaccurate reporting of perceived barriers by parents on the open-ended
questionnaire.
2. Incorrect personal information on the sociodemographic questionnaire or
consent form.
3. The arousal of response bias among the parents in the sample, such as the
tendency to agree with positive statements, answer with limited responses, or
respond in ways that are thought to be socially desirable or culturally
appropriate.
4. The limitation of researcher bias was controlled by triangulation of data and
by one other researcher reviewing and analyzing the data.
Significance
The intent of this study was to explore awareness of emotions and attitudes
toward free preventive oral health care programs in parents of children between the ages
of 5 and 15 years. Information from this study could enable universities, colleges, and
professional organizations to adjust program planning to increase the number of children
benefiting from preventive dental services. The only successful way to increase informed
consent and child attendance is to understand parental concerns (Chi, 2013; Divaris et al.,
2013; Dodd et al., 2014). Evidence suggests that school-based dental sealant programs
have been successful in reducing oral health disparities, reducing dental caries, and
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increasing access to care (Devlin & Henshaw, 2011). Examination of the literature
indicates a definite need for designing and implementing more community-based sealant
programs (Chi, 2013; Devlin & Henshaw, 2011; Divaris et al., 2013; Dodd et al., 2014).
This study may help the nation achieve its goal of a 50% reduction in dental caries in
children by 2020. However, if perceived parental obstacles are indicated as a deterrent to
the use of dental programs, school-based initiatives, or professional organizations,
perhaps identifying and eliminating them could encourage policy change. For instance,
trust was a common social and behavioral issue that emerged as a theme; perhaps
tailoring strategies such as alternative preventive treatment, alternating time schedules to
accommodate parents that work, web-based educational programs, participatory
communication, and motivational interviewing could be pursued to improve a
community’s position on positive preventive oral health care (Chi, 2014). Additionally,
parental barriers were seen as complex; a multidisciplinary approach may be necessary
that includes elements such as expanded partnerships with pediatricians and nurses (Chi,
2014; Fontana & Wolf, 2011). This study could promote social change by indicating ways
to positively modify the oral health behaviors of children by teaching them how to take
care of their oral health, such as twice-daily brushing with fluoride toothpaste. This study
was an attempt to highlight the social impact of oral health problems, such as more than
51 million lost work and school hours (Devlin & Henshaw, 2011), to enable the
community to become stronger by increasing acceptance of quality preventive dental care
programs for children.
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Summary
Currently, 1 in 5 children aged 5 to 11 years has untreated dental caries (CDC,
2016). The percentage of untreated caries in children from low-income families is twice
as high as rates for children from high-income homes (CDC, 2016). Numerous studies
show that dental sealants reduce caries in permanent teeth by 81% for 2 years after they
are placed and can continue to be effective 4 years after placement (Ahovuo-Saloranta et
al., 2013). However, perceived parental barriers are preventing high-risk children from
receiving preventive dental care. This qualitative case study was important to explore and
understand the unique perspectives on parental barriers to free preventive dental care
programs for children. Understanding perceived parental barriers to these programs may
afford universities, colleges, and professional organizations the insight necessary to
reevaluate how to elicit more parental consent for at-risk children to use these programs.
A higher attendance rate would mean increases in preventive oral health education,
literacy, and dental sealant placement, ultimately enabling reduction in childhood caries
and oral health disparities.
In the following chapter, literature that influenced the current study is introduced.
The following chapter also presents an exhaustive discussion of literature that has made a
contribution to furthering the investigation of perceived parental barriers to free
preventive dental care programs for children. It provides a synthesis of current research
findings and justifies why this study was necessary.
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Chapter 2: Literature Review
Introduction
In this chapter, an overview of theories and concepts surrounding perceived
parental barriers to free preventive oral health programs is presented. I compare and
contrast elements such as low-socioeconomic status that affect children of various ethnic
descents whose caregivers appear not to provide parental consent for preventive dental
care for their children (Glenny et al., 2013; Spence et al., 2014). I explored past and
current literature on Prochaska and DiClemente’s (1983) trans theoretical model (TTM)
of behavior change and Bandura’s (1986) social cognitive theory (SCT), as well as the
current understanding of how perceived barriers to preventive dental care for low-income
parents relate to children’s oral health. Understanding parental barriers to children’s
preventive oral health programs may help to increase access through signed consent and
ultimately reduction of caries in high-risk low-socioeconomic-status children.
Additionally, dental universities, colleges, and dental organizations may implement
programs that support and acknowledge parental concerns to increase attendance and
child participation.
In this chapter, I present a detailed literature review on the lack of knowledge
surrounding perceived parental concerns regarding free preventive oral health programs.
The first section includes specific search terms applied to establish relevant articles. Next,
I describe the theoretical and conceptual frameworks I applied to understand how
multidimensional parental perceptions, attitudes, and beliefs relate to lack of child
attendance at oral health interventions. Finally, I present an analysis of literature that
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pertains to potential parental barriers to preventive oral health care for children and
establishes the need for this study.
Literature Search Strategy
To obtain credible and current evidence to support this research study, a review of
the literature from multiple sources was conducted. Search engines used included
Medline with full text (EBSCO), PsycINFO (Ovid), ERIC, PubMed, and Google Scholar.
The Walden University Library and New York University College of Dentistry Library
were used to find full-text articles. The main search terms, oral health disparities and
oral health, were used in combination with terms such as children, low socioeconomic
status, attitudes, dental anxiety, self-efficacy, self-care behaviors, barriers to care,
prevention, interventions, and school-based sealant programs. For example, iterative
conjugations of attitudes, dental anxiety, self-efficacy, and self-care behaviors were
searched in PsycINFO and ERIC, and children, low socioeconomic status, barriers to
care, intervention, and school based sealant programs were searched in Medline with full
text (EBSCO), PubMed, and Google Scholar. While reviewing each article, I scrutinized
the reference list for pertinent additions to the literature review. I also engaged the
Internet search engine Google Chrome to locate and access material on relevant topics,
organizations, and governmental statistics. The majority of published articles used in my
review ranged from 2013 to the present. However, one seminal article from 2005 was
used.
Theoretical Foundation
No single theory or conceptual model dictates health behavior research or practice
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(Vernon & Howard, 2015). In fact, health behavior theories tend to evolve over time
(Vernon & Howard, 2015). In dentistry, some of the most popular theories in oral health
revolve around variations of self-efficacy (Jones et al., 2014; Vernon & Howard, 2015;
Zhou et al., 2015). Self-efficacy is the belief that changes in behavior will result in a
positive outcome (Jones et al., 2014). Additionally, if the severity of the perceived threat
is high and the behavior change is manageable, people tend to adopt the modified
behavior (Jamieson et al., 2014).
This project incorporated Prochaska and DiClemente’s (1983) TTM of behavioral
change as well as Bandura’s (1986) SCT to enable understanding of a community’s
attitudes, feelings, and perceptions on accessing quality preventive dental care for
children.
Traditionally, oral health has been influenced by measures such as the presence
and severity of dental caries and periodontal disease (Vernon & Howard, 2015). However,
parents are often unaware of dental caries in their children’s teeth or how to prevent it
(Horowitz et al., 2013). TTM suggests that individuals can fluctuate through six stages of
behavior change before termination of a negative behavior (Jamieson et al., 2014).
Behavior and attitudes associated with each level become apparent as individuals weigh
the pros and cons of change (Jamieson et al., 2014). These stages of change are often
noticeable, allowing for health care workers to successfully move them on toward the
next level (Jamieson et al., 2014). In a study by Jamieson et al. (2014) on a vulnerable
population of pregnant non-Aboriginal women, pre contemplative and contemplative
stage of change constructs were both associated with poor self-rated oral health and oral
health impairment. This evidence suggests that poor self-rated oral health is related to
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both non ideal dental visiting patterns and higher levels of dental disease experience
(Jamieson, 2014). Incorporating TTM into psychosocial interventions might help to
improve oral health outcomes (Jamieson, 2015).
However, oral health behavior change does not happen as the result of one single
event or intervention (Horowitz et al., 2013; Wade et al., 2011), nor does education alone
provide enough information to alter parental perceptions of prevention programs
(Horowitz et al., 2013; Miltiades, 2013). Researchers have shown that ethnic/racial
differences persist in dental-service usage patterns and oral health status, even after
controlling for traditional socioeconomic determinants (Miltiades, 2013).
Much like TTM, SCT constructs include self-efficacy (Jones et al., 2014).
However, SCT also includes other constructs such as knowledge, fatalistic beliefs, and
observational learning (Jones et al., 2014). SCT is a comprehensive approach to
understanding human behavior, motivation, affect, and thought processes (Jones et al.,
2014). SCT suggests that self-efficacy can be attained by multiple methods (Jones et al.,
2014). These methods include experiencing success, vicarious learning, and verbal
persuasion (University of Twente, 2016). Evaluating behavior change depends on the
fluctuating factors of environment, people, and behavior (University of Twente, 2016).
TTM and SCT are two models of behavior change that enable a unique
understanding of a community’s attitudes, feelings, and perceptions on accessing quality
preventive dental care for children. These models offer this through qualitative
exploration of participant parents, as attitudes and oral health behaviors can be assessed
and modified. The research question of what perceived barriers would prevent parents
from having their children attend a free preventive dental care program was addressed
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with the TTM and SCT, including the concepts of self-efficacy and learning through
others (Bandura, 1986; Prochaska & DiClemente, 1983). In a similar study by Dodd et al.
(2014), adolescents’ perception of oral health needs was identified as low (no risk) based
upon their beliefs that brushing eliminated oral disease. The belief that brushing
eliminates disease can be attributed to a learned parental or cultural ideal, which would
best be explored by the TTM and SCT.
Conceptual Construct
Cultural beliefs can have a negative influence on prevention-seeking oral health
care (Miltiades, 2013). For instance, in Black, Hispanic, and Mexican cultures, many
people rely on social networks such as family, friends, church, and neighbors for health
information (CDC, 2015). In a study by Miltiades (2013), false beliefs concerning
preventive oral health care were highlighted, such as the belief that the use of baking soda
prevents dental caries. Miltiades (2013) suggested that future research should further
expand upon cultural beliefs and the impact of early childhood influences on later life
decisions regarding accessing dental care and oral health. In this study, participants did
not receive parental oral hygiene instruction; Miltiades suggested that it is reasonable to
posit that participants’ parents did not emphasize oral hygiene when raising their children.
The current research can benefit from this by exploring additional ethnicities
and cultural beliefs of care-seeking behavior through similar questioning. However,
differences were on how they perceive preventive programs for their children as opposed
to themselves. In a seminal study by Kelly et al. (2005), parents who did not take their
children for preventive oral care were not aware of the consequences of poor oral health.
Kelly et al. (2005), suggested that further investigation was necessary to explore cultural
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factors in order to enable effective community-based interventions. Askelson et al. (2015)
suggested that there is limited evidence-based knowledge regarding how parental
influence affects preventive dental-care-seeking behavior for children. The current study
was an attempt to explore this phenomenon.
Literature Review
Low Socioeconomic Status
Beginning this overview with an understanding of dental caries is important.
Dental caries is the most prevalent childhood disease (CDC, 2015). It affects more
children than asthma (CDC, 2015). In fact, according to a report from the Surgeon
General (2000), childhood caries is 5 times more common than asthma, 4 times more
common than early childhood obesity, and 20 times more common than diabetes
(American Academy of Pediatrics [AAP], n.d.; Ezer, Swoboda, & Farkouh, 2010;
National Children’s Oral Health Foundation [NCOHF]; 2016; NIDCR, 2000). In the
United States alone, 60% of children will have had caries at some point (AAP, 2013;
Ezer, Swoboda, & Farkouh, 2010). Dental caries is preventable. Dental caries
disproportionality affects children from low socioeconomic backgrounds (AAP, n.d.a.;
CDC, 2015; Ezer, Swoboda, & Farkouh, 2010; NIDCR, 2000; NCOHF; 2016). Children
who suffer from dental pain miss more than 51 million school hours due to oral diseases
(Devlin, 2011; Jackson et al., 2011). Numerous studies have indicated that populations
that reside in low socioeconomic neighborhoods are at increased risk of dental disease
(Beck et al., 2014; CDC, 2015; Guarnizo-Herreno & Wheby, 2012; Horowitz et al.,
2013). Further, studies have indicated that parents from low socioeconomic backgrounds
have less education, less access to oral health services, and lower dental health literacy
23
than their middle-class counterparts (Dodd et al., 2014; Rahbari, 2015). Parental
education can be associated with the ability to identify oral health problems, as well as
access to care (Guarnizo-Herreno & Wehby, 2012). Parents in these communities also
have intermittent dental insurance due to employment history (Wallace & MacEntee,
2012). However, in a contrasting study, Chi et al. (2013) indicated that most low-income
children are covered by public insurance such as Medicaid or the Children’s Health
Insurance Program (CHIP) and that lack of dental insurance should not be considered a
barrier to preventive oral health care. Children from low socioeconomic neighborhoods
are 3 times more likely to have untreated dental caries than children living above the
federal poverty line (Devlin & Henshaw, 2011). Neighborhood characteristics that have
been suggested to influence oral health include safety, social networking, information
about dental services, and number of dental providers (Guarnizo-Herreno & Wehby,
2012; Valente, 2015).
Free Preventive Dental Care Programs
Understanding the services provided by free preventive dental care programs will
enable a better understanding of how these programs attempt to increase access to care
and decrease oral health disparities in low-income neighborhoods. A preventive dental
care program always provides a comprehensive oral examination (Ahovuo‐Saloranta.,
2013; Ahovuo‐Saloranta et al., 2016; Beck et al., 2015; CDC, 2015; Children’s Dental
Health Project [CDHP], 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al.,
2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). An oral
examination enables health care providers, specifically dentists, to visualize or clinically
see dental diseases. Dental disease may take various forms, such as a carious lesion in a
24
tooth; a soft-tissue lesion on the lips, buccal mucosa (cheeks), tongue, throat, or gingiva
(gums); a missing tooth or filling; a misaligned bite; or recurrent caries.
If a child has caries or red, inflamed gingiva (gingivitis), the child can be referred
to a local dentist for treatment, such as a restoration (filling) or cleaning (child
prophylaxis). Some programs offer children a fluoride treatment in the form of a varnish
(Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC,
2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al., 2015;
Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Fluoride varnish is
medicine that protects the outer layer of the tooth (enamel) from the effects of bacterial
invasion (caries or decay; CDC, 2015). Fluoride varnish is an effective way to prevent
dental caries (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al.,
2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al.,
2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Fluoride
varnish gets painted on all teeth surfaces, leaving a protective sticky film on the teeth, and
it acts like a vitamin that makes tooth enamel stronger (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al.,
2014; Devlin & Henshaw, 2011; Dye et al., 2015; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010).
Programs that provide fluoride varnish also provide children with oral hygiene
education. Oral hygiene education teaches children how to take care of their teeth, such as
proper brushing techniques (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta,
2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Dye et al., 2015;
25
Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty,
2010). Proper brushing twice daily reduces the incidence of dental diseases
(AhovuoSaloranta et al., 2016; Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015;
CDHP,
2014; Chi et al., 2014; Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al.,
2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Additionally, some programs perform cleanings (child prophylaxis) and apply
protective preventive dental sealants on permanent molars (Ahovuo‐Saloranta et al.,
2016; Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al.,
2014; Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010). Dental sealants are a protective plastic that covers the biting
surfaces of permanent molars and prevents bacteria from residing in the pits and fissures
(grooves) of the teeth, sealing out decay (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013;
Siegal & Detty, 2010). Dental sealants have been proven to be a cost-effective way to
reduce and prevent dental caries in children (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013;
Siegal & Detty, 2010).
Often, the amount of preventive care depends on the facility. Mobile dental units,
universities, colleges, professional organizations, and schools provide all of the
26
aforementioned preventive services for children. Churches and community programs may
only offer dental examinations, referrals to local dentists, fluoride treatments, and oral
hygiene instructions (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck
et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et
al., 2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Regardless of their range of offerings, these services are an excellent way for
communities to increase dental disease awareness and improve oral health
(AhovuoSaloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC, 2015;
CDHP,
2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al., 2015; Northridge et al.,
2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Decreasing Oral Health Disparities
Dental colleges, universities, and professional organizations implement free
preventive dental care programs in an attempt to increase access to dental care and
decrease oral health disparities (CDC, 2015). However, attendance rates are often low
(Divaris et al., 2012; Glenny et al., 2013; Spence et al., 2014). Parents of these high-risk
children do not allow their children access to these programs, thereby increasing
challenges to necessary preventive dental care (Divaris et al., 2012; Glenny et al., 2013;
Spence et al., 2014). Identified barriers to care include lack of transportation, money,
insurance, and access to dentists; loss of wages and time; and fear (Devlin & Henshaw,
2012). However, it has been indicated that even when these barriers have been removed
by reaching children at school, parents have not signed consent forms (Divaris et al.,
27
2012; Glenny et al., 2013; Spence et al., 2014). Children are dependent on parents to
meet their oral health needs (Divaris et al., 2012; Glenny et al., 2013; Spence et al.,
2014).
Culture, Attitudes, and Behaviors
This study explored the perceived parental perceptions of free preventive oral
health programs. It unveiled attitudes and preventive behaviors of parents and cultural
preventive practices of specific ethnic backgrounds. Dodd et al. (2014), adds to the
knowledge base by suggesting that perceptions of dental disease is inadequate in low
socioeconomic neighborhoods. In fact, Dodd et al. (2014), indicated parents as one of the
barriers to adolescent dental absence. Parental responsibility to work, and low selfefficacy
are barriers for adolescent dental health (Dodd et al., 2014). Horowitz et al. (2013),
suggested most adults in Maryland, did not have enough knowledge regarding tooth
caries or how to prevent it. Dodd et al. (2014), determined most adolescents indicated
pain as the main reason for visiting a dentist. In fact, adolescent participants failed to
connect preventive care with lessening of pain or dental disease (Dodd et al.,
2014). A historical study by Kelly et al. (2005), indicated that dental visits were for pain
not treatable at home. Similarly, individuals from low socioeconomic backgrounds felt
dental care was less critical to their overall health, and that medical issues trumped dental
care (Kelly et al., 2005). This study added to knowledge because it specifically addressed
parents’ perceptions, and not that of adolescents. Emphasis was also placed upon how
individuals from low socioeconomic neighborhoods gathered oral health information
(Dodd et al., 2014). Guarnizo-Herreno & Wehby (2012), indicated higher unemployment
rates accounted for parental psychosocial status, and information gathering accounted for
28
cultural preventive practices. According to Dodd et al. (2014), changing current
perceptions of preventive oral health care from a luxury to a necessity required multiple
educational interventions. This study explored current parental perceptions of care
seeking behaviors, to fulfill a gap in the literature of limited evidencebased knowledge,
regarding how parental influence effects the preventive dental care seeking behavior for
their children who supports effective community-based interventions.
Gaps in the Literature
This research project investigated an extensive amount of literature on the topic of
oral health disparities and children. In doing so, multiple gaps in literature were found. I
highlighted them in chronological order to enable understanding of how and why this
current project fulfills the research gap. Kelly (2005), executed a qualitative study on
diverse ethnic/racial backgrounds on caregivers that do not seek preventive care for their
Medicaid enrolled children. The limitations from this study include the lack of diversity
of participants, and future research suggested to explore cultural factors that may be
necessary to enhance community based interventions (Kelly, 2005). The lack of
exploration on cultural factors is considered a gap in the literature. Baldani et al. (2011),
revealed and confirmed that cultural beliefs and perceptions regarding oral health were
important individual barriers. Guarnizo-Herrano & Wehby (2012), quantified
contributions of socioeconomic status, demographic, and neighborhood characteristics to
oral health disparities. Their limitations include the lack of data on maternal attitudes and
behavior of preventive health seeking (Guarnizo-Herrano & Wehby, 2012).
Recommneded future research, and the gaps in literature made it necessary to explore
cultural and maternal attitudes and preventive behavior seeking oral health care. Chi
29
(2014), examined the relationship between caregiver’s refusal of preventive
immunizations and preventive fluoride varnish. The limitations of the study suggested
parents with private insurance had higher response rates than those with publicly insured
or uninsured children. Again, indicative of gaps in literature, future research identified
social and behavioral factors related to parental/caregivers’ refusal of preventive care,
with the goal of developing multidisciplinary strategies to help guardians make optimal
preventive care decisions for their children (Chi, 2014). Rahbari and Gold (2015), in a
pilot study found that a mother’s oral hygiene habits and frequency towards dental visits
were related to the oral hygiene habits and frequency in dental visits of their toddlers.
Again, confirming the need for future research to understand the multiple factors of oral
health relating to women and their children. This study explored current parental
perceptions of preventive care seeking behaviors to fulfill the gaps in the literature
presented by Chi (2014), Guarnizo-Herrano and Wehby (2012), and Rahbari and Gold
(2015), of limited evidence-based knowledge regarding how parental influence affects the
preventive dental care seeking behavior for their children which will support effective
community-based interventions.
Summary and Conclusions
The current literature review includes current research in the area of preventive
dental care, potential barriers to care, attitudes and behaviors that may affect preventive
seeking dental care, effects of low socioeconomics on dental caries, and the increasing
disparities in children’s oral health. Dental sealants, when placed on permanent molars,
are a cost-effective way to reduce childhood caries (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
30
Devine, 2011; Devlin & Henshaw, 2011; Dye et al., 2015; Kierece et al., 2016;
Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Oral health care
interventions attempt to reduce oral health disparities in children by placing free dental
sealants on the biting surface of third-grade children from low-performing Title 1
elementary schools (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al.,
2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devine, 2011; Devlin & Henshaw,
2011; Dye et al., 2015; Kierece et al., 2016; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010). Some parents are increasing the risk and oral health
disparity gap by not allowing their children access to these programs (CHCS, 2015; Chi
et al., 2013; Chi, 2014; Glenny et al., 2013;). Horowitz et al. (2013), and Lee et al.
(2012), among numerous others, confirm barriers to preventive care such as access, low
dental literacy, and low socioeconomic neighborhoods (CDC, 2015; Guarnizo-Herreno &
Wehby, 2012). Attitudes and cultural oral care behaviors of low-income Mexican women
such as brushing with baking soda described as preventive oral care (Miltiades; 2013).
What’s known is that various racial groups such as Black, Hispanic, and Mexican
children from low socioeconomic status face multiple barriers to preventive oral health
care (Askelson, 2014; CDC, 2015; Chi et al., 2013; Chi, 2014; Guarnizo-Herreno &
Wehby, 2012; Miltiades, 2013; Rahbari & Gold, 2015). Multiple gaps in the literature
indicated the need to explore oral health perceptions and dental care seeking behaviors of
parents for their children (Askelson, 2014; CDC, 2015; Chi et al., 2013; Chi, 2014;
Guarnizo-Herreno & Wehby, 2012; Miltiades, 2013; Rahbari & Gold, 2015). This current
study extended knowledge around barriers to children’s care by exploring parental
perceptions of free preventive oral care programs for their children. Understanding the
31
parental barriers and perceptions of free preventive care programs increased the
knowledge base to develop appropriate clinical and policy solutions aimed at optimizing
the oral health of children. In the following chapter, the methodology that was used,
participants, sample size, question design, clarification of coding and analysis procedures,
and interpretation of results towards central themes exploring perceived parental barriers
of free prevention programs for children is discussed in detail.
Chapter 3: Research Method
Introduction
In this research project, a qualitative case study design was used to explore oral
health awareness, emotions, and attitudes in relation to the dental care behaviors of
parents and caregivers of children aged 5-15 years in underperforming Title I New York
City elementary schools. Caries affects children’s permanent teeth the most between the
ages of 5 and 15 years (CDC, 2015). A qualitative design has distinguished potential
barriers to free preventive dental care programs for children. Comprehending the
numerous viewpoints of parents concerning the oral health of their children may allow for
free preventive oral health care programs to be successful in the community. By
assimilating into the neighborhood and engaging parents through open-ended questions
and multiple conversations, I sought to understand sensitivities surrounding preventive
oral-care-seeking behaviors. The goal was to find out whether these programs should
continue with an inferior success rate or attempt to recognize and reduce perceived
parental barriers to care. A greater understanding of perceived parental barriers may assist
32
in efforts to increase rates of informed consent for children to participate in these
programs and consequently promote an increase in rates of high-risk children receiving
preventive dental care. Understanding parental refusal of preventive care may help in
identifying the social, economic, and policy implications of oral health decision making
(Chi, 2014).
In this chapter, a detailed description of the research study design is presented,
including the rationale, the research questions, my role as researcher, the methods for
selecting and recruiting parent participants, data collection procedures, and the strategy
for data analysis. An overview of ethical concerns related to the study and the issue of
trustworthiness is also presented.
Research Design and Rationale
The primary qualitative research question was the following: What perceived
barriers would prevent parents from having their children attend a free preventive dental
care program?
The subquestions were the following:
1. Is lack of trust an issue for parents?
2. Are cultural issues perceived as a barrier?
3. How can free preventive dental care programs more efficiently reach
children?
4. What are the real-life perceptions of these programs by parents?
5. What other life events prevent children from attending?
6. What are parents’ perceptions of preventive dental care?
33
7. How was parents’ dental care addressed when they were children?
In a qualitative study, a researcher can adjust questions as themes emerge during the data
collection process.
A qualitative case study design was undertaken for this inquiry. In this study, I
examined the emotions and attitudes of parents toward preventive oral health programs,
as well as the potential reasons why parents do not escort their children to free preventive
dental care programs. This qualitative case approach was the best fit for this study
because it involved exploring a real-life bounded system in a place and a unit in time
(Creswell, 2013). I sought to investigate parental perceptions with in-depth, detailed data
collection involving observations, open-ended interviews, audiovisual recordings,
documents including emails and texts, and social networks (Creswell, 2013). The aim of
the research was to illuminate and understand this unique problem and concern (Creswell,
2013). The qualitative case study design facilitated exploration of perceived parental
barriers within a context of free preventive dental care programs using a variety of data
sources (Baxter & Jack, 2008). A case study ensured the use of multiple lenses to explore
various facets of the issue, which allowed the phenomenon to be revealed and understood
(Baxter & Jack, 2008; Creswell, 2013). The evidence was analyzed with written
transcription of conversations inside the software program NVivo11 Pro. The goal was to
uncover and identify repeated themes related to the phenomenon (Creswell, 2013).
Culture and low income are important contributors to high dental caries rates.
However, the use of ethnography would not have been appropriate for this study, in that
the group of interest would have been too large. Further, there was more than one ethnic
group in the group or case of interest (CDC, 2015). Rates of dental caries are highest in
34
Black, non-Hispanic and Hispanic of Mexican descent communities, which makes it
challenging to narrow down a specific culture of interest (CDC, 2015). Another reason
that a case study was the best fit is that it provided me with an in-depth understanding of
parents’ perceptions of preventive oral health behaviors as a case rather than a large
disproportionate group. A quantitative study would also not have been appropriate
because it would have led to numerical data or information that could be turned into
numbers (Patton, 2014). A quantitative study would have involved making statistical
inferences from data. A qualitative study was more appropriate because it made it
possible to gain a deeper understanding of feelings, opinions, attitudes, and trends in
thought among parent participants.
Role of the Researcher
Case study research suggests the importance of presenting the researcher’s
position in the study (Creswell, 2013). I have experience in preparing and implementing
preventive oral health programs for children with oral health disparities. I am involved
with this issue both professionally and personally. My professional involvement comes in
the form of helping to initiate free preventive oral health programs with the New Jersey
Dental Hygienists Association (NJDHA). On a personal level, I volunteer my time with
Give Kids a Smile (GKAS) and Wings of a Dove Foundation to offer dental health
education and to implement preventive oral care to decrease oral health disparities in
children. I do not believe that my experience in this area placed me in any supervisory or
power relationship over my parent participants. I will use any knowledge gained from
this study to enhance future preventive programs.
35
For this study, I first entered the community as an outsider researcher, and with
time I began to understand the settings and culture of the participants and assimilated as
an insider researcher. My role as the researcher was to engage myself in the community
for advancement of facial recognition, show my intentions, and encourage free and honest
conversations with the parent participants (Capella University, 2017; Robert Wood
Johnson [RWJ], 2008). Assimilation within the community allowed for credible,
trustworthy interviews, documentation, and audio data collection. Biklen (2010)
suggested that the quality of evidence relates to the credibility of the investigator’s
fieldwork. Per Patton (2014), the credibility of the inquirer depends on training and
presentation. I was personable and professionally prepared because these qualities have
been shown to provide more successful responses. Training and experience ensure
trustworthiness. I had one colleague who culturally matched the participant demographic
assist me with the interview process, but the colleague did not have access to the
interviews due to the need to protect participants’ privacy. Having one colleague with me
who culturally matched the demographic was necessary to gain parent participants’ trust
and assure them of the ability to speak freely.
There was no known researcher bias, and to decrease the potential for future bias,
I had one colleague who was experienced with qualitative data review and code the
information to cross reference for similarity in findings. I coded the data for themes, and
I had my colleague code and triangulate the data to decrease any researcher bias. I
decreased bias by positioning myself ultimately as the narrator of themes and stories
presented by the parent participants. A considerable limitation of qualitative research is
36
that the results can easily be influenced by the researcher’s personal biases and
worldview.
The design was purposefully descriptive thorough understanding of participants’
feelings (Miles, Huberman, & Saldana, 2014). The descriptions developed through this
study are rich, meaningful, and thick (Miles et al., 2014). Ensuring trustworthiness and
alleviating doubt concerning investigator bias began with making sure that the accounts
of the participants made sense, sounded true, and reflected the voice of the participants,
displayed by readers living vicariously through them (Maxwell, 2013; Miles et al., 2014).
For consistency, I ensured that rival explanations were investigated and that the findings
could be reproduced in other studies (Maxwell, 2013; Miles et al., 2014; Patton, 2015).
The data are displayed in a matrix, which shows sequential steps that were used to
link the emerging themes and provide credibility (Maxwell, 2013; Miles at al., 2014).
Triangulation of data for the confirmation of findings was conducted to decrease potential
researcher bias (Maxwell, 2013; Miles et al., 2014). Triangulation enhanced
trustworthiness when I collaborated with another researcher during data analysis
(Maxwell, 2013; Miles et al., 2014).
Justification for Incentives
I interviewed the parents of children living in a low socioeconomic neighborhood.
Money, time, and lack of transportation to the interview were potential problems for the
participating parents (CHCS, 2016; Glenny et al., 2013). To remove these barriers, it was
necessary to offer food (i.e., a light breakfast or lunch), a MetroCard for transportation,
and a small incentive for loss of work wages. A MetroCard for 20 participants maximum
was purchased at $110. Each MetroCard was $5.50 each. A small breakfast or light lunch
37
for 20 participants would cost $100. However, interviews were conducted eight at time
and breakfast/lunch was not necessary. Incentives were necessary to get parents to open
up about the perceived barriers to preventive oral health programs for their children. To
provide such incentives, I offered $15 gift cards for participation, which I estimated
would cost $300 for 20 participants. Incentives may have some implication for
participation bias (Hsieh & Kocielnik, 2016). Participant bias occurs when a study
becomes non representative due to a disproportionate number of participants who have
similar traits (Patton, 2015). However, researchers have argued that incentives provide a
broader participant base (Hseih & Kocielnik, 2016; Singer & Cooper, 2008). The total
cost to run this study was $510.00.
Methodology
Participant Selection
For this study, I reached and interviewed the parents/caregivers of children
between the ages of 5 and 15 years. Parents’ ages ranged from 18 to 60 years. These
parents had incomes below poverty level, which is less than $24,240 for a family of four,
and they resided in low socioeconomic neighborhoods (Office of the Assistant Secretary
for Planning and Evaluation, 2015). The parents came from diverse cultural and ethnic
backgrounds that represented the high-risk demographic for children with oral health
disparities. For instance, they were of Black, Hispanic, Chinese, and Mexican decent.
Although participants’ racial and ethnic backgrounds were significant to this study, the
study was open to anyone who fits the demographic criteria. Participants had one or more
child attending an underperforming Title I elementary public school that provided free
lunch programs. The elementary schools represented in my study offer programs that
38
provide free lunch for children. These Title I elementary public schools are in
communities where residents are living below poverty level and are described as having
low socioeconomic status. Additionally, parent participants in this study never had a
child attend a free preventive oral health program. Parent participants spoke and read
English. Exclusion criteria applied to minors and anyone who was not a parent, guardian,
or caregiver of a child between the ages of 5 and 15 years.
Sampling
In qualitative inquiry, purposeful sampling focuses case selection in sequence with
the investigation’s purpose, questions, and data collected (Patton, 2015). Purposeful
sampling is about selecting participants with information-rich cases to study. Cases are
selected related to the phenomenon of interest (Patton, 2015). The participants were
selected due to the need to explore parents’ perceptions of free preventive oral health
programs and preventive oral-care-seeking behaviors of parents for their children. Parents
were purposefully sampled and asked to participate in the research project by
systematically selecting parents that had one or more children in an underperforming Title
I elementary school, and did not sign the consent form for an oral health program (Cohen
& Crabtree, 2006).
Sample Size
There are no true sample size rules in qualitative research (Marshall, Cardon,
Poddar, & Fontenot, 2013; Patton, 2013). Qualitative research requires continuous
reorganization. Miles (2014), suggested that a chosen sample size may not supply a
researcher with data-rich sources. Qualitative samples need to be purposive rather than
random (Miles, Huberman, & Saldana, 2014). Size defines the ambitiousness of the
39
inquiry, what is affected, what will be beneficial, what will have virtue, and what is done
with the available time and resources (Patton, 2013). A small sample size can produce an
understanding that is rich in data, whereas a large sample size can be useful in exploring
phenomena and documenting diversity (Patton, 2015). Additionally, the size of a sample
can be fluctuated (Patton, 2015). Sample size becomes a matter of subjective judgment
based on making relevant associations, repetitive information, measuring explanations as
well as reaching saturation (Patton, 2015).
Justifying the size of a sample in qualitative research can be accomplished in one
of three ways (Marshall et al., 2013). First, a researcher can cite the recommendations of
qualitative methodologists (Marshall et al., 2013). Second, a researcher can cite
methodologies that have been used in previous studies with similar questions and designs
(Marshall et al., 2013). Finally, a researcher can demonstrate saturation within the data
(Marshall et al., 2013).
According to Miles, Huberman, and Saldana (2014), the minimum sample size for
a multiple case study is five. Creswell (2013) suggested six for a case study and no more
than 20-30 interviews for grounded theory. According to Marshall et al. (2013), for a
single case study, 15-30 interviews are needed, depending on culture and study design.
For this design, I recruited 20 parent participants. My rationale was that if 20 participants
showed up, it could be expected that 20 participants would explain why they did not
escort their children to a free preventive oral health program. This number had been used
in previous studies and modifications can be made for data saturation (Marshall et al.,
2013). Twenty participants were a starting point; this target was decreased when
saturation was reached sooner than anticipated (Creswell, 2013; Huberman, & Saldana,
40
2014; Marshall et al., 2013; Miles,2014; Patton, 2013). With this research, I gained
information-rich data to help future initiatives determine the reasons that parents may
deny consent for their children to attend free preventive oral health programs or may be
“no shows” at these programs. Cultural differences were explored, along with cultural
access to preventive dental services (Marshall et al., 2013). Purposeful strategies leave
the question of sample size open, which is a direct paradigm of qualitative inquiry (Miles,
Huberman, & Saldana, 2014). The principle of saturation was used to determine sample
size. After 20 interviews, it was expected that no new themes would emerge from the data
and that the data would become repetitive (Creswell, 2013; Patton, 2015; Rudestam &
Newton, 2015; Saldana, 2016; Walker, 2012). Saturation ensured that adequate amounts
of quality data had been collected (Walker, 2012). Saturation was reached in this study
when all the data had been analyzed and it was deemed unlikely that new data would add
to the story, phenomenon, theory, or framework (Mason, 2010).
Participant Recruitment
For the purpose of this study, I attempted to contact parents who had not
consented to a dental examination for their children at underperforming Title I New York
City elementary schools. I had access to the location of parents through the New York
University College of Dentistry Pediatric Department, which was currently at the school
providing dental examinations and oral health services for high-risk in children in third
grade whose parents had provided consent. Parents of third grade children had been asked
to sign a form if they did not want their children to participate in a clinical examination
by a dentist during school hours.
41
I posted a recruitment flyer for this study in public places near the
underperforming Title I New York City elementary school, such as grocery stores, cafes.
markets, and public playgrounds, indicating an opportunity and incentive for parents to
discuss their lack of consent if they were willing to do so. Additionally, Wings of a Dove
Foundation, a neighborhood community church program that implements oral health
preventive programs for low-income children, had agreed to post a recruitment flyer
around the vicinity of the church. Parents attending the church fit the same demographic
and inclusion parameters. After receiving all relevant ethics committees’ approvals, I
recruited parents using a flyer posted around the church asking if they would like to
participate in the study. If they were willing to participate and fit the inclusion criteria,
parent participants were asked to sign an informed consent form prior to an interview.
The consent form contained information on participant privacy, the voluntary nature of
participation, the rationale for the study, risks and benefits of being in the study,
incentives, and my contact information.
Instrumentation
The initial data collection instrument; an observation sheet, was inspired by a
template used by Aussie Childcare Network (2016). The observation sheet included two
narrative boxes. I titled the top box observation, and the bottom box interpretation (see
Appendix A). Observations strength is the plentitude of narration and imagery (University
of California, 2015). Observation is the quintessence of appreciating an understanding of
the participant’s natural settings, and their way of viewing the world around them (RWJF,
2008). Observations included body language, attitudes towards the interviewer,
42
preventive programs, and their child’s oral health. The observation checklist allowed me
to visually describe the parent participants during, and after data analysis.
I also used an interview protocol sheet. Interviews were conducted face to face
after upon completion of the informed consent sheet (Maxwell, 2005). Interviews
consisted of semi-structured, open-ended questions, organized around the primary
research question. The goal of the research question was to obtain a comprehensive
understanding of the perceived parental barriers to free preventive dental care programs
for their children (Rudestam, 2011). The interview protocol sheet enabled me to stay
focused, and on track during questioning. The interviews were audio recorded, and I took
interview notes on site. Information gathered was transcribed at a later time (Nalzaro,
2014). I created the questions on the protocol sheet, they were inspired by a similar
seminal qualitative study by Kelly et al. (2005). Kelly et al. (2005), utilized a similar
interview instrument during seven focus group sessions containing an average of nine
participants in each. Kelly et al. (2005), compared White and African American caregiver
utilizers and non utilizers of preventive dental care services for their children. It was
appropriate for me to use this instrument for context, however, modifications were made
to include multicultural specificity which the Kelly et al (2005), study lacked (see
Appendix B for Revised Survey). The interview questions relied upon TTM to show self-
efficacy in parental dental care seeking habits, and self-efficacy of their children’s oral
health. This study ventured to describe what parents find important about oral health that
might make them visit a dentist or take their child to a preventive program. SCT was also
identified from interview questions when parents were asked to express where they
learned about dental care, and when should they take their child to the dentist. Social
43
learning or imitating behaviors played a role in how often children or parents receive
dental care, and for what reasons. Content validity was established by the appropriateness
of the tools, processes, and data (Lueng, 2015). For instance, data collection and analysis
enhanced validity by using triangulation of researchers, resources, theories, and a
welldocumented audit-trail of materials and processes (Lueng, 2015). The current study
aimed to identify and explore any culturally specific issues during the interview, data
collection, and analysis process. The interviews were audio-taped to allow for precision
in data collection, verbatim transcription, and analysis. The observation checklist and
interview protocol questionnaire were two data collection instruments that enabled
collection of parent participant’s feelings and attitudes towards free preventive oral health
care programs.
Procedures for Data Collection
The first question, what perceived barriers would prevent a parent from having
their child attend a free preventive dental care program? Data were collected through
observation such as environment, attire, and ethnicity. To identify body language, tone,
and attitudes, both observation and responses during interviews toward preventive dental
care was be illuminated. Immediately following initial observation questions from the
interview protocol was asked. These questions such as; how acceptable do you find free
preventive oral health programs enabled data collection. Audio recording interviews
allowed for verbatim analysis and triangulation of the data to ensure that consistency in
interpretation of the data occurred. The second question; is lack of trust an issue for
parents? Was answered through interview question since you have never taken your child
to a preventive oral health program, is lack of trust an issue. The third question; are
44
cultural issues perceived as a barrier? Was answered by interview questions Are there any
cultural or racial concerns/reasons why a parent or caregiver would not have their
child/children attend a preventive care program? Question four; how can free preventive
dental care programs more efficiently reach children? Was answered by the interview
question what are some reasons people might not take their children to the dentist. What
are the real-life perceptions of these programs by parents? Was answered by the interview
question; how acceptable do you find these programs. What other life events prevent
children from attending? Was answered by the interview question; what are something
things that might make it difficult to take a child to the dentist. What is the parent’s
perception of preventive dental care? Was answered with the interview question; what are
your experiences with dentists that accept Medicaid for your children. How was the
parents dental care addressed as a child? Was answered by the interview question; how
have you felt about the dental care you received. All interviews were audio recorded.
Data Collection
The data were collected by interviewing parents from underperforming Title I
elementary schools in New York City, in a place of choice by participants; such as a local
library, or facility of parent’s choice. I collected all data. The interviews were conducted
at increments of eight interviews in one day throughout a week. This entailed two to four
interviews a day for one week or longer. I scheduled interviews around convenient times
for the participant parents. The interviews were timed and last for maximum of 20
minutes. The data consisted of journaling during the study, at the program setting, and
around the neighborhood. Audio recording materials recorded conversations and
interviews. Other documentation collected was any other material including messages
45
sent through texts or emails with the participants. If recruitment of participants was low, a
follow-up plan was to recruit parent participants at a Brooklyn Church named Emmanuel
Church of God, through Wings of a Dove Foundation that contains the same cultural
characteristics and demographics as the parents from underperforming Title I elementary
schools. A total of nine parents were recruited through Emmanuel Church of God. Same
interview and data analysis procedures were utilized. As parent participants exited the
interview they were thanked for their time, given incentives for participating, and advised
that their questions were helpful. They were also advised that a 1-2-page summary of
results would be available for their review after the results of the research were analyzed.
Parent participants were asked if interested they may be recruited for additional follow-up
interviews if necessary. However, additional follow-up has not been indicated.
Data Analysis Plan
Qualitative research generates large amounts of documentation. The interview,
researcher’s notes, and observations were transcribed into a matrix and placed into the
software program NVivo11 Pro. The matrix condenses data (Miles, Huberman, &
Saladana, 2015). Data compression at best, condensed, polished, balanced, and organized
data so that conclusions were drawn (Miles et al., 2015). Before the formation of the
matrix, the researcher bolded, highlighted, underlined, or used color rich text, of words
and passages that felt worthy of future consideration (Saldana, 2015). In other words, I
built a logical chain of evidence (Miles et al., 2015). Precoding scrutinized the data by
pointing to deeper issues that deserved attention (Miles et al., 2014). Coding and
categorizing data for themes were done before coding (Miles et al., 2015). Coding and
analysis required continually revisiting the data and scrutinizing the categories of data
46
until I was sure that the themes and categories used to summate and describe the findings
were honest and an accurate reflection of the data, that was gathered (Hancock, 1998).
For this study, I recorded ideas, and journaled in the right column of transcripts that
abetted to make evolving codes more accountable. Any discrepant data was analyzed
further to avoid sticking with first impressions, or clinging to an initial hunch (Saldana,
2015).
Issues of Trustworthiness
To ensure credibility I identified as the role of a skeptic (Northern Illinois
University, 2013). By doing so, rival explanations of phenomena that arose were checked
with the data collected and required further data collection to prove or disprove
phenomenon. This skepticism allowed me to eliminate other confounding variables that
might be a possible causal relationship to perceived parental barriers to free preventive
oral health care programs (Northern Illinois University, 2013). Additionally, I used
method triangulation with observations and interviews. Method triangulation allowed for
double data collection and enhanced the strengths and weakness of each method
(Northern Illinois University, 2013). I also utilized data triangulation in the form of
conducting interviews at different times and in different places. To ensure transferability I
used rich content and contextual description to provide enough information about the
participants, participant selection, sample size, data collection and analysis methods, to
allow for the study to be replicated and conducted again with a different group of people
or in a different setting (Northern Illinois University, 2013; Patton, 2015). The
dependability of the study was maintained through investigator triangulation, and an audit
trail. Investigator triangulation occurred with the use of one additional colleague that
47
reviewed the audio recordings, analyzed the participant behavior from observed data
collection form, and in interpreted the data for uniformity of codes and themes (Northern
Illinois University, 2013). An audit trail also maintained and added continuous
documentation which allowed a colleague to verify descriptions and aid me during
analysis and coding (Northern Illinois University, 2013; Patton, 2015; Saldana, 2015).
Confirmability was insured by journaling during the research process. Constant critical
self-reflection regarding potential bias from me was recorded (Northern Illinois
University, 2013; Patton, 2015; Saldana, 2015). Additionally, inter coder agreement was
done by having one of my colleagues test my codes by evaluating data and providing
their interpretation. Finally, inter coder reliability was ensured with thick rich description
and verbatim information to reflect the meaning of the parent participants (Northern
Illinois University, 2013; Patton, 2015; Saldana, 2015). Collegiate review of data
provided me with solid evidence for interpretation and conclusion of evidence (Northern
Illinois University, 2013; Patton, 2015; Saldana, 2015).
Ethical Procedures
For this study, Walden Institutional Review Board (IRB) reviewed and accepted
the interview questions and research methodology. IRB approval number is 04-21-
170456669 and expires on April 20th, 2018. IRB ensured that all human subject research
be conducted in agreement with all federal, institutional, and ethical guidelines. IRB
safeguards that questions relating to the participation of parents and caregivers in the
study were clear, and did not contain sensitive content. Ultimately IRB protected the
rights and welfare of participants in a study. The ethical concerns regarding parent
48
participants in this study were privacy. I made every attempt to protect the private lives of
parent participants.
In qualitative research, the narrative can cause a divulgence of damaging
representation. This technique can cause uneasiness for participants as the narrative or
dissemination of results can include words or characterizations that intimately mirror the
target group. I was conscious of how this information would portray certain subgroups. I
was cognizant and mindful of conflicts of interest and sensitive issues surrounding
participant’s views, culture, and feelings. Ultimately, I am accountable for protecting the
privacy and interests of all participants.
Every parent participant signed a consent form. The consent form described the study and
explained the research topic. It was written in English, and on a grade level that the
parent participants understood. If at any time during the interview a parent felt
uncomfortable with the line of questioning, they could leave at free will, with no harm to
them. Furthermore, I removed any identifiable and personal information that might be
traced back to the participants. All data collected is kept in my locked desk drawer. After
five years, all data will be destroyed.
Summary
In this chapter, the research procedures for the study regarding perceived parental
barriers to free preventive oral care programs for their children were explained. I have
provided a detailed interpretation of the qualitative research design, and a rationale for a
case study approach appropriate for this study. I presented a sampling plan, study settings,
procedures for recruitment, data collection and analysis methods, based on a case study
approach to qualitative inquiry. I also discussed any potential bias and trustworthiness
49
threats, and described a series of techniques, including the methods of triangulation, to
address these potential threats to the credibility of the research.
Furthermore, I included the observation checklist and an interview questionnaire in
Appendix A and Appendix B. Chapter 4 includes the results of this study, where I
describe the gathered data along with the method of analysis and a discussion of the
results.
Chapter 4: Results
Introduction
The purpose of this qualitative case study was to explore parental perceptions and
potential parental barriers to free oral health prevention programs for children. It was an
attempt to identify any repetitive themes that would prevent a parent from signing a
consent form or allowing a child to participate in oral health initiatives.
The primary qualitative question was the following: What perceived barriers
would prevent parents from having their children attend a free preventive dental care
program?
The sub questions were the following:
1. Is lack of trust an issue for parents?
2. Are cultural issues perceived as a barrier?
3. How can free preventive dental care programs more efficiently reach
children?
4. What are the real-life perceptions of these programs by parents?
5. What other life events prevent children from attending?
50
6. What are parents’ perceptions of preventive dental care?
7. How was parents’ dental care addressed when they were children? This
chapter highlights the setting, demographics of the parent participants, data
collection techniques, data analysis, evidence of trustworthiness, and results.
Setting
Parent participant interviews were conducted at various locations to enable
cultural diversity in the findings. Interviews began in the beginning of May and ended at
the end of June 2017. The first set of interviews was at a Health Fair located in China
Town, NYC, outside Public School (PS) 130. The interviews captured a small, close-knit
Asian community as well as culturally diverse passersby who were interested in
discussing preventive-care-seeking behaviors. The second setting was in Flatbush,
Brooklyn, outside the church of Emmanuel of God. Once again, parent participants were
those who did not allow their children access to free oral health programs. Ethnic
backgrounds of residents in this area of Brooklyn included Haitian, Jamaican,
Dominican, and African American. The final group of parents were recruited outside
Public School 3, in Staten Island, NY, after their children had been escorted onto a school
bus on Staten during an early morning interaction between me and parental guardians.
Parent participants were Hispanic, and those who did not allow their children access to
free oral health programs.
Demographics
There were two men and 18 women parent participants. Parent participants’ ages
ranged from 22 to 49 years. Each parent had at least one child enrolled in an
underperforming NYC public elementary school. Children’s ages ranged from 18 months
51
to 20 years. The average household in the study had two children, but participants had as
many as eight. Parent participants were from low socioeconomic backgrounds and were
living in low-income neighborhoods. In terms of ethnic and cultural background, there
were five Asian American participants, two Caucasian participants, four Hispanic
participants, and nine African American participants.
Data Collection
For this study, I interviewed 20 parent participants using a 22-question openended
questionnaire (see Appendix). Each parent participant read and signed the consent form
and matched the inclusion criteria. Once the parent participants agreed to participate,
they read and signed the consent form. They were asked to agree with being audio
recorded. After parents provided consent for audio recording, the interviews took place.
An initial conversation included a review of the purpose of the study and the particulars
in the consent form. Parent participants were reminded that participation was voluntary.
Participants were also advised that they could end the interview at any time. Their privacy
was emphasized, and they were assured that their identities would be protected and would
never be revealed. The audio recorded interviews lasted between 5 and 15 minutes,
depending on how much the parent participants wanted to elaborate on their answers. The
interview data were audio recorded using a digital recorder. Additionally, notes were
taken as parents spoke, and as parents exited the interview, I wrote down my thoughts
regarding the interaction on the questionnaire and observation form (see Appendix). I
thanked parents for their time and participation and gave each parent a $5.50 MetroCard
and a $15.00 American Express gift card. The audio recordings were immediately
downloaded into the sound organizer on my laptop. These audio recordings were then
52
uploaded into NVivo 11 Pro, where they were transcribed verbatim by me. The
transcribed audio recordings were then highlighted for themes and coded.
Following the coding, a memo was created describing the interview and expanding on
ideas that emerged. The memos were linked to each of the transcribed interviews in
NVivo 11 Pro.
Characteristics of the parent participants are described in Table 1. Cultural
diversity by ethnic background is described in Table 2. Data were collected in the manner
described in Chapter 3 with no variations.
Table 1
Characteristics of Parent Participants
Characteristic
Number of
individuals
Male
2
Female
18
Average age
39
Age group
Under 30
31-41
Over 42
5
7
8
Average number of children
Number of children per parent
2.9
53
2 children
3 children
4 children or more
11
5
4
Table 2
Cultural Diversity of Parent Participants
Ethnic background
Participants
Caucasian
3
Hispanic
4
African American
7
Asian
5
Indian
1
Total
20
Data Analysis
Following the case study methodology described by Saldana (2015), data analysis
consisted of gathering comprehensive and in-depth, detailed, rich information about each
parent participant by precoding, selective coding, creating analytic memos from
observations, and diagramming. Using case study methodology, data collection and data
analysis were done simultaneously, using a process of deduction, validation, and
inductive reasoning (Saldana, 2015). Data collection was stopped at 20 participants, at
which point saturation was achieved. Data analysis continued well after the data
54
collection cycle. The purpose of data analysis was to establish an understanding of why
parents would not allow their child or children to attend a free oral health program.
Precoding
The precoding method consisted of highlighting and bolding notable quotes that
were worthy of attention during transcription (Saldana, 2015). Codes were created as new
concepts emerged. As the coding emerged, sub codes were added that highlighted similar
concepts. A total of 20 interviews were conducted, transcribed, and coded. A total of 23
nodes were created, resulting in nine categories. Table 3 includes the nine categories and
themes and the frequency of coded segments for the parent participants.
Table 3
Table of Codes and Categories and Themes
Categories and themes
Parent participants
Too busy, no time
5
Cost
7
Cultural
17
Immigrants
12
Lack of insurance
4
Lack of trust
21
Scared
9
Transportation
5
Importance of referrals
6
Analytic Memos
Following each interview, I created a memo or preliminary jotting (Saldana,
55
2015) summarizing the interview and commenting on potential concepts and participant
observations. Analytic memos were set up to expand on new or emerging concepts.
Additionally, memos were used to store demographic information such as participants’
age, number of children, and date and time of interview. Memos were then updated to
summarize the interviews and analytic memos. This updated memo began the process of
moving concepts from codes to themes and categories.
Selective Coding
The concluding phase of data analysis was selective coding. This part of the
analysis allowed for inductive reasoning by connecting codes to repetitive themes, and
then final categories of expressed words, descriptions, and repetition of feelings
expressed by parent participants toward free oral health prevention programs. In this
process, direct quotes were taken from the transcribed interviews and original concepts
and narrowed into nodes by adding verbatim feelings of parent participants. The use of
diagrams was developed to describe the frequency of data.
Evidence of Trustworthiness
To ensure credibility, method triangulation was used with observations and
interviews. This double data collection technique enhanced the strengths and weaknesses
of each tool chosen (Northern Illinois University, 2013). Data triangulation in the form of
conducting interviews at different times and in different places was added as well.
Credibility was also assured by using the interview questions as a guide and keeping the
interview focused on the research questions.
To ensure transferability, rich content and contextual descriptions were provided
containing sufficient information about the participants, participant selection, sample size,
56
and data collection and analysis methods. This abundance of description will allow for
the study to be replicated and conducted again with a different group of people or in a
different setting (Northern Illinois University, 2013; Patton, 2015).
The dependability of the study was maintained through investigator triangulation
and a detailed audit trail. Audio recorded interviews, along with transcriptions, were sent
to the committee chair for intercoder agreement. All codes, categories, and themes were
reviewed by the committee chair. Coding began immediately as I transcribed the
interviews. Transcripts were created by listening to each interview and typing each
response to a question word for word, reviewing and rewinding as needed. Transcribing
the recording verbatim allowed me to catch exact words and phrases from parent
participants. Confirmability was ensured by journaling during the research process and
constant self-reflection reduced bias.
Results
This eight research questions organize this results section. At the end of this
chapter, a unified explanation of the potential barriers to free preventive oral health
programs is presented.
Primary Research Question
The primary research question was as follows: What perceived barriers prevent
parents from having their children attend a free preventive dental care program?
The key themes and categories for the primary research question are presented in
Table 4. This question focused on what parents expressed as the reasons their child or
children were not attending free preventive oral health programs. The themes and
categories were supported by comments by parent participants. The themes were called
57
too busy, no time and scared. The categories related to this theme were “not allowed as a
child, don’t care, laziness, time, and not important.” For instance, Mom14 expressed,
“they’re scared, or the parents themselves are scared, or they don’t have the time, it’s not
important, not the number one thing.” Mom14 suggested that parents “don’t gives
themselves enough time to bring their kids there.” Mom13 said, “I would say scheduling,
that it could be transportation and scheduling and staying organized if you have more
than one kid.” Mom16 suggested, “some people might not believe in doctors like
whatsoever, poor time management, no time to take them or they just don’t care.” Mom3
identified the following possibilities: “no insurance and that it’s a stigma that going to the
dentist is scary, and it might hurt.” Mom5 admitted, “sometimes I don’t have time
*laughs* to make an appointment to go there and get it done, that the hardest part.”
Mom6 thought that lack of attendance might occur “because they don’t care first of all or
they don’t understand the consequences or they’re not doing any prevention.” Mom8
offered, “maybe the child is scared, or maybe the parents feel like the work their child
may need might be a lot, say, the health insurance doesn’t cover the expenses for it.”
Mom9’s explanation was “way too busy.” Mom10 cited “convenience, laziness, getting
rest or relaxing.” Mom12 explained, “well, like I said, I think it’s, umm, a lack of
information.” Further, she said, “if kids are parenting young, they don’t have their family
push, left on there on devices it’s not a priority.” Mom12 went on to say that parents
“may not be exposed to it so they don’t think it’s a problem, I think that’s major.” Mom15
remarked, “I would say the way I was brought up, my father would not let us, so my
stance and some others I know, it’s the way we were brought up.”
Table 4
58
Key Themes and Categories for Primary Research Question
Key themes
Categories
Selected extract
Busy, no time
Laziness
Scheduling
Transportation
Mom7: “too busy”
Dad1: “they don’t have the time,
it’s not important, not the
number one thing”
Mom10: “convenience, laziness,
I'm being absolutely honest,
ummmm, parents want
convenience, also a
combination of laziness and
just it’s, it’s for myself”
Mom14: “sometimes I don’t
have time *laughs* to make
an appointment to go there
and get it done, that the
hardest part”
Mom5: “I would say
scheduling, that it could be
transportation and scheduling
and staying organized if you
have more than one kid”
Scared
Might hurt
Concerned about cost
Worried about care
Mom14: “they’re scared, or the
parents themselves are scared”
Mom14: “maybe the child is
scared, or maybe the parents
feel like the work their child
may need might be a lot”
Mom8: “it’s a stigma that going
to the dentist is scary and it
might hurt”
Research Subquestion 1
The first subquestion was as follows: Is lack of trust an issue for parents?
The key themes and categories for Subquestion 1 are presented in Table 5. The
focus of this subquestion was the exploration of trust as a potential barrier to preventive
oral health program attendance. This subquestion was answered by participants from their
perspective as parents. The themes and categories developed are supported by comments
59
from the parent participants. The theme of this research question was; trust is an issue in
the lack of attendance from children at the free preventive oral health program.
Categories included the following: trust is not an issue, communication or language
barrier, lack of education, unsure of the program’s motive, and cultural issues relating to
child participation. However, as Table 6 indicates, the results were mixed, as 10 out of 20
parent respondents suggested that lack of trust was not an issue while the other half
suggested that it was.
Trust is not an issue. Half of the parent participants reported that trust was not an
issue when deciding whether their child or children were attend a free oral health
prevention program. For instance, Dad2 said, “no, trust would not be an issue.” Mom8
remarked, “no, it’s a benefit to the child, and parent, not to run around, and find
someone.” Dad1 expressed, “I would trust, I guess I would trust them, why wouldn’t a
parent.” Mom5 stated, “no, no, I don’t think so.”
Communication or language barrier. Parent participants expressed concern
when describing their feelings towards free preventive oral health programs for their
children. For instance, Mom 3 said, she would be more open to “someone who speaks
their language.” Mom12 remarked, “communication is a barrier, no one speaks the
language in the community, how will you bring awareness to a family if there’s a
communication and language barrier.”
Lack of education. A couple of parents suggested that education or lack of
proper education was a reason they did not allow their child or children to attend an oral
health program. Mom 15 said, “it was trust, and not getting myself educated, because I
thought that it was interns, again going off stuff that I had heard, it was interns, and they
60
didn’t know what they were doing.” Mom9 reported, “parents are not educated on it.”
Unsure of motive. A few parents reported they were unsure of the motive. This
uncertainty led them to the decision to decline their child admission to the free oral health
program. Mom9 said, “they think there’s a catch behind it.” Mom10 remarked, “right,
and what’s the motive, what are they getting out of it, they don’t want to genuinely help
us, when that’s the not the case all the time.” Mom6 reported, “I would have to meet them
first just to know that person first before they start doing health questions.” Mom13
expressed, “I think it’s the trust of confidentiality, we live in a society where it has been
broken a lot, so it’s more so anytime you hear you need to give social or private
information, like, for instance, if that’s done, how do you show client or customer that,
you know there’s a waiver that you signed off, to show its confidential info, or prove to
them your information is secure.” Mom16 remarked, “if they never met the doctor before,
they could be a little iffy about it.”
Cultural. A few parents reported reasons why they did not sign consent forms to
oral health programs for their child or children, were cultural. For instance, Mom10 said,
“someone I know, may not send her children, because she finds that people of color, treat
people of color, I don’t want to say better, for a lack of words, I guess a little bit more
attentive, that’s her experience, something that important to her go to someone.” Dad2
remarked, “culturally, no matter what race you are, pride is always an issue, I have to
share my personal information, there stereotyping the fact that there is something for free,
depending on what neighborhood you’re in, you know, and it’s kind of a shame, that most
African Americans, some people, may not go to that, like, if you put into a mixed
neighborhood, it stupid, its really about pride, because it’s like, we have this, and we have
61
that, and that with all races honestly.” Mom12 expressed, “like this is available, but like I
said, if you have this, umm, that they can’t get culture or group represented, to speak to
the group, it would be an easier connection, we can do this, and have access to it. Like
when a Caucasian comes into an all African American community people pull back, but if
I see someone of my own, or Muslim relating to me, like if I don’t understand the
dynamics of certain cultures, how they’re raised, and their own personal society, but
when they see one of their own, they will be more open to receive.” Mom15 voiced, “the
stories that my father gave us, when he was doing his stuff, and I don’t know if it’s true or
not, it was just my father’s way, that they used to run test on us immigrants, and they
didn’t care about immigrants, and it was just a way of them to doing things, tests on us,
before they gave them to the public, he really put that into our mind, like my brother still
don’t go to the doctor, and he’s a grown man so.”
Table 5
Table of Codes and Categories
Categories
Parent participants
Trust not an issue
10
Communication barrier/language
2
Lack of education
2
62
Unsure of motive
4
Cultural
4
63
Table 6
Is Trust an Issue for Not Participating in a Free Oral Health Program?
Parent participant
Yes
No
Mom 1
X
Mom 2
X
Mom 3
X
Mom 4
X
Mom 5
X
Mom 6
X
Mom 7
Dad 1
X
X
Mom 8
X
Mom 9
X
Mom 10
X
Mom 11
Mom 12
Mom 13
Mom 14
Mom 15
Mom 16
Dad 2
X
X
X
X
X
X
X
Total
10
10
64
Table 7
Key Themes and Categories for Research subquestion 1
Key
themes
Trust not
an issue
Categories
Selected extract
Did it as a child
Recommended
Benefit
Mom7 & Dad1: “grew up in Japan and every year we would see
a different dentist I think every year for me it’s so natural”
Mom6: “I mean if it’s like a dentist I don’t know or not
recommended maybe I would be a little bit more cautious”
Mom19: “Yes at least that’s a reminder to because they check it
and let me know to follow up with a dentist”
Mom8: “it’s a benefit to child and parent not to run around and
find someone”
Trust is
an
issue
Communication/language
barrier
Lack of education
Unsure of motive
Cultural
Mom 3: “would be more open to someone who speaks their
language”
Mom12: “communication is a barrier, no one speaks the
language in the community, how will you bring awareness to
family if there’s a communication and language barrier”
Mom 15: “it was trust and not getting myself educated because I
thought that it was interns again going off stuff that I had
heard it was interns and they didn’t know what they were
doing”
Mom9: “parents are not educated on it”
Mom9: “they think there’s a catch behind it” Mom10: “what’s
the motive, what are they getting out of it, they don’t want to
genuinely help us when that’s the not the case all the time”
Mom6: “I would have to meet them first just to know that person
first before they start doing health questions”
Mom13: “I think it’s the trust of confidentiality, we live in a
society where it has been broken a lot, so it’s more so anytime
you hear you need to give social or private information”
Mom16: “if they never met the doctor before they could be a
little iffy about it”
Mom10: “someone I know may not send her children because
she finds that people of color treat people of color I don’t want
to say better for a lack of words I guess a little bit more
attentive that’s her experience, something that important to her
go to someone”
Dad2: “culturally no matter what race you are pride is always an
issue I have to share my personal information there
stereotyping the fact that there is something for free
depending on what neighborhood you’re in you know and it’s
kind of a shame that most African Americans some people
may not go to that like if you put into a mixed neighborhood
it stupid its really about pride because it’s like we have this
and we have that and that with all races honestly”
Mom12: “like this is available but like I said if you have this
umm that they can’t get culture or group represented to speak
to the group it would be an easier connection we can do this
and have access to it”
65
Research Subquestion 2
The second subquestion was the following: Are cultural issues perceived as a
barrier?
The key codes and categories for Subquestion 2 are presented in Table 8. This
question focused on ethnicity in relation to feelings that parents expressed about being a
patient, experiences with their children, or previous experiences with family members.
The subquestion was asked of all parent participants. Comments from parent participants
supported the themes and categories. Again, a few remarks were mixed; Asian parents felt
that it was natural to see whichever dental professional was available regardless of
culture, whereas parents of other cultures did not feel as comfortable with this. Table 9
presents key themes and categories for Subquestion 2.
Comfortable with their own culture. Parent participants reported feeling more
comfortable escorting their children to free preventive programs when they identified
with oral health professionals from their own culture. For instance, Mom3 said, “I guess
in Chinatown they probably want to stick with someone who speaks their language.”
Mom11 reported, that when she “seen someone up there from their ethnic background
and she felt more comfortable.” Mom12 expressed, “when these free oral health
programs can get culture or ethnic groups represented to speak to the group it would be
an easier connection for the community.”
Cultures’ health-seeking behavior. Parents reported that in certain cultures,
preventive oral health care is not important. In fact, Mom12 said, “minorities if it’s not
bad don’t worry, out of sight out of mind, if it’s not bad no worries, we respond to
emergency situation instead of prevention.” Mom13 remarked, “it’s kind of a shame, that
66
most African Americans, some people, may not go to that, like, if you put into a mixed
neighborhood, it stupid, it’s really about pride.”
Culture affected how they were raised.
Parent participants expressed how their family cultivated the way the used preventive oral
health programs. For instance, Mom12 reported, “if I don’t understand the dynamics of
certain cultures, how they’re raised, and their own personal society, I would not attend a
program, but when they see one of their own, they will be more open to receive.” Further,
Mom15 reported, that her experiences from her childhood effects how she and her
siblings attend preventive initiatives. Mom 15 went on to say, “what I went through with
my father, it’s sad to say, but most of the West Indians just feel like its a way for the
government to find out information so my father was very not wanting us to do it. I still
had that mindset, until I had my children, and until I got educated.”
Culture not seen as a barrier. Most of the Asian parent’s participants expressed how
they felt culture was not, or should not, be considered a barrier to free oral health
preventive services for children. In fact, for Mom7 and Dad1, reported “seeing a different
dentist yearly for a screening, was part of a free oral health program in Japan.” This was
considered a natural process. Other parent participants, such as Mom5 said, “they should
not have any restrictions. Mom8 was so surprised by the question, she reported, “can’t
think of any reason why they wouldn’t take their children to the school.” Mom10 said,
that for most of her life “my dentist is Jewish, I'm African American, Native American.’
Mom10 went on to say, that she now “sees someone from her own culture and is very
happy.”
67
Table 8
Table of Codes and Categories
Categories Parent participants Comfortable with own culture 4
Cultures’ health-seeking behavior 3
Affected how they were raised 3
Culture not seen not a barrier 6
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Table 9
Key Themes and Categories for Research Subquestion 2
Key themes
Categories
Selected extract
Culture as a barrier
Culture not a
barrier
Comfortable with
own
How they were raised
Not an issue
Mom3: “I guess in Chinatown they probably
want to stick with someone who speaks their
language”
Mom11: “seen someone up there from their
ethnic background and felt more comfortable”
Mom12: “that they can’t get culture or group
represented to speak to the group it would be
an easier connection we can do this and have
access to it, like when a Caucasian comes into
an all African American community people
pull back”
Mom12: “minorities may feel like if it’s not
precedence I not their own family if it’s not
bad don’t worry, out of sight out of mind, if it’s
not bad, no worries we respond to emergency
situation instead of prevention”
Mom13: “the fact that there is something for free
depending on what neighborhood you’re in
you know and it’s kind of a shame that most
African Americans some people may not go to
that like if you put into a mixed neighborhood
it stupid it’s really about pride”
Mom12: “if I don’t understand the dynamics of
certain cultures how they’re raised and their
own personal society but when they see one of
their own they will be more open to receive”
Mom15: “I would say the way I was brought up
my father would not let us so my stance and
some others I know it’s the way we were
brought up”
Mom5: “They should not have any restrictions”
Mom8: “can’t think of any reason why they
wouldn’t take their children to the school”
Mom10: “my dentist is Jewish I'm African
American Native American”
Mom15: “for my case no”
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Research Subquestion 3
The third subquestion was the following: How can free preventive dental care
programs more efficiently reach children?
The key codes and categories for research question 4 are presented in Table 10.
This question focuses on various ways parent participants expressed how to improve
child attendance at free preventive oral health programs. The research question was asked
to all parent participants. Comments from parent participants support the themes and
categories. Parents were very vocal in describing improvements towards child and parent
turnout. Table 11 presents key themes and categories for Subquestion 3.
Advertise more.
Parent participants reported that they did not receive enough flyers or handouts from the
program’s advertising when dental professionals would be visiting the children’s school.
For instance, Mom2 said, “wasn’t always aware of when they were coming, only when
they give us information.” Mom8 reported, “they don’t advertise it as much.” Mom15
responded, “I just wish the schools took more time to speak to the parents, I think that’s
what is it mostly.” Mom12 expressed, “a lack of information really parents might not be
aware of what’s available.”
Notices in my language.
Parent participants reported that when they first came to the country they could not read
the notices, or consent forms, their children took home. They expressed frustration, and
what they did with them. Mom15 said, “they would send a paper, and we used to throw it
away, we didn’t even look at it, we can’t read the paper, and some of us can’t read it.”
70
Mom10 responded, “I could not read the language, I did not let my son attend, I regret
that.”
Send reminders.
A portion of lack of child attendance, is related to the child not showing up. One of the
parent participants suggested how to send better reminders, in order to decrease failed
appointments. Mom13 reported, “you know what’s a good idea, sending reminders out,
the texting, that helps, even though I have a phone, tech savvy text messages help better
than the emails, and better than voicemail.” Mom 13 went on to say, “as a parent, when
do we have time to sit down and read all of our emails at the end of the day, and to read
all of them no.”
Table 10
Table of Codes and Categories
Categories Parent participants
Advertise more 4
Notices in my language 3
Send reminders 3
Table 11
Key Themes and Categories for Research Subquestion 3
Key themes
Categories
Selected extract
71
Unaware of
program
Advertise more
Notices or
consent forms in
my language
Send reminder
Mom2: “only when they give us
information”
Mom8: “they don’t advertise it as much”
Mom13: “sometimes when it is so public
people tend not to but when it’s a little
bit private they do attend sometimes
you catch those people that won’t
normally attend”
Mom10: “I could not read the language”
Mom9: “there’s a waiver that you signed
off to show its confidential info or
prove to them you information is
secure”
Mom15: “I just wish the schools took
more time to speak to the parents I
think that’s what is it mostly”
Mom12: “a lack of information really
parents might not be aware of what’s
available”
Mom15: “they would send a paper and
we used to throw it away we didn’t
even look at it we can’t read the paper
and some of us can’t read it”
Mom13: “you know what’s a good idea
sending reminders out the texting that
helps even though I have a phone tech
savvy text messages help better than
the emaid better than voicemail as a
parent when do we have time to sit
down and read our emails at the end
of the day and to read all of them no”
Research Subquestion 4
The fourth subquestion was the following: What are the real-life perceptions of
these programs by parents?
The key codes and categories for Subquestion 4 are presented in Table 12. This
question focuses on any perceived real-life barriers that might prevent a parent from
72
allowing their child or children to attend a free oral health program. The research question
was asked to all parent participants. Comments from parent participants support the
themes and categories. Parents were detailed in describing what they felt was a reallife
issue for non-attendance in these programs. Table 13 presents key themes and categories
for Subquestion 4.
All parent participants reported that these free preventive programs are great for
children. Their own experiences as a child have been mixed as one would assume. Most
parents indicated that they learned about improving their dental health through school.
Location, transportation, and cost, are consistent themes as barriers.
Table 12
Table of Codes and Categories
Categories
Parent participants
Location
4
Transportation
3
Cost
3
Table 13
Key Themes and Categories for Research Subquestion 4
Key themes Categories Selected extract
73
Location
Transportation
Cost
Distance to
event
How will I
get there?
Bus, train,
childcare
Mom12: “I think the location of where they’re
having it, you know, like, a free resource, we
having this program, but commute is great, or size
of family they may not have the resources to take
the whole group over there, and then child care
might be a factor, need someone to watch kid, lots
of other variables, its secondary but a factor of
locale”
Mom10: “have to pay for self and children”
Mom6: “the cost”
Mom9: “they don’t have no funds”
Table 14
Average Experiences for Parent Participant Responses
_______________________________________________________________________
Negative Positive
Their experiences as a child 10 10 Learned about
oral health in school 15 05 Learned about oral health
from family 05 15
Their children’s experience is better 20 0
Experiences with Medicaid 14 06
Believe dental problems are as serious 19 01
as other health problems
Research Subquestion 5
The fifth subquestion was the following: What other life events prevent children
from attending?
The key codes and categories for Subquestion 5 are presented in Table 15. This
question focuses on any other life events that may prevent a parent from allowing their
child or children to attend a free oral health program. The research question was asked to
all parent participants. The themes and categories are supported by comments from parent
participants. Parents were detailed in describing what they felt was a real -life event that
74
might present for non-attendance in these programs. Table 16 presents key themes and
categories for Subquestion 5.
Some parent participants reported that scheduling was a potential issue for not
signing parental consent forms. Scheduling and getting to the event, were described as
being hard. Some parents reported that they feared pain. Parents also indicated that either
they or their child was afraid of pain. One Mom said, it was a stigma, that going to the
dentist is scary, and it might hurt. Once again, cost was an issue. Mom6 said, “the cost,
and also sometime, if they got some work done on the teeth that was difficult or painful,
they don’t want to go back.”
Table 15
Table of Codes and Categories
Categories
Parent participants
Hard to schedule
4
Scared
3
Cost
3
Table 16
Key Themes and Categories for Research Subquestion 5
Key themes
Categories
Selected extract
75
Schedule
Scared
Cost
Difficulties making
appointment
Painful, fear of unknown
Worried about money
Mom16: “no time to take them”
Mom13: “I would say
scheduling and staying
organized if you have more
than one kid to make an
appointment to go there and
get it done that the hardest
part”
Mom5: “to make an
appointment to go there and
get it done that the hardest
part”
Mom2: “hard to schedule”
Mom3: “it’s a stigma that going
to the dentist is scary and it
might hurt”
Mom8: “maybe the child is
scared”
Mom14: “they’re scared or the
parents themselves are
scared”
Mom2: “I don’t have insurance
I don’t care I wouldn’t go as
much it’s just costly”
Mom 8: “health insurance
doesn’t cover the expenses for
it”
Mom12: “if they don’t have the
finances and have to pay out
of pocket might be a
hindrance, if finances are
kind of tight”
Mom6: “the cost, and also
sometime if they got some
work done on the teeth that
was difficult or painful they
don’t want to go back”
Research Subquestion 6
The sixth subquestion was the following: What is the parents’ perception of
preventive dental care?
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The key codes and categories for Subquestion 6 are presented in Table 17. This
question focused on the parent’s perception of preventive dental care. The questions were
asked specifically to understand parents’ experiences as children as well as their
perception of preventive dental services for their children. The research question was
asked of all parent participants. Comments from parent participants supported the themes
and categories. Parents spoke freely and were detailed in describing their personal dental
experience and that of their children. Table 18 presents key themes and categories for
Subquestion 6. All 20 parent participants reported, “dental problems are as serious as
other health problems.”
Table 17
Table of Codes and Categories
Categories
Parent participants
Negative experiences as a child
4
Parents aware of consequences
9
Children are unaware of consequences
10
Table 18
Key Themes and Categories for Research Subquestion 6
Key themes
Categories
Selected extract
77
Negative experiences as a child
Parents aware of consequences
Children are unaware of
consequences
Traumatizing
Make appointments, take them
to the dentist regularly
No idea, don’t realize
importance
Mom3: “I don’t have the best
care when I was a kid they
don’t say what’s going to
happen before it happens they
do things and so it’s a little bit
traumatizing”
Mom15: “for me it was
difficult but for my kids it was
easy”
Dad2: “never went to dentist as
a child”
Mom6: “taking them and
making appointments on a
regular basis”
Mom3: “bring them to a
dentist every 6 months”
Mom2: “prevent them from
eating more too much candy
sweets are not too good once in
a while its ok”
Mom13: “some are and some
aren’t I think the younger
generation is becoming more
aware I think it’s more so like
rather they are aware of it but
do they practice it” Mom3: “I
don’t think they realize that
to get rid of how important it
is to have clean teeth before
they go to sleep” Mom6: “no
I don’t think they know that’s
why it important to take
them”
Research Subquestion 7
The seventh subquestion was the following: How was the parent’s dental care
addressed as a child?
The key codes and categories for Subquestion 7 are presented in Table 19. This
question focuses on how the parent’s dental care was addressed as a child. The
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research question was asked to all parent participants. Comments from parent
participants supported the themes and categories. Parents were detailed in describing
their dental experiences as a child. Table 20 presents key themes and categories for
Subquestion 7. Some parent participants reported never visiting a dentist as a
child. Others reported traumatizing experiences. Mom3 said, “when I was a kid they
don’t say what’s going to happen before it happens, they do things, so it’s a little bit
traumatizing.” Most parents expressed that not having dental insurance would
be a barrier to care. For instance, Mom2 indicated, “I don’t have insurance I don’t care
I wouldn’t go.” Parents reported that the way they learned to take care of their teeth
was at school. In fact, Mom15 responded, “when I was growing up it was from school
not from my parents.”
Table 19
Table of Codes and Categories
Categories
Parent participants
Never taught at home
5
Would not go without insurance
9
Table 20
Key Themes and Categories for Research Subquestion 7
Key themes
Categories
Selected extract
79
Never taught at home
Would not go without
insurance
Oral health
education
Infrequent dental
visits
Mom1: “my dentist first of all
then school”
Mom15: “when I was growing up
it was from school not from my
parents”
Dad2: “health class in school”
Mom11: “I don’t that often
because I might have been I
might be not having insurance I
would be embarrassed that
somebody is not going take me
without it”
Mom12: “it’s just that the
information is not really out
there where people would be
more accessible or more
exposed to it”
Mom2: “I don’t have insurance I
don’t care I wouldn’t go”
Summary
In Chapter 4, the results of this study were presented. The results presented are
associated with the research question and subquestions. To answer the primary research
question, parent participants were asked what perceived barriers would prevent a parent
from having their child attend a free preventive dental care program. The themes
associated with this research question were a lack of time and scared. To answer the first
subquestion, parent participants were asked; is the lack of trust an issue for parents. The
theme associated with this research question was divided, as half of the parents reported
that trust was an issue; while the other half reported a non-issue. To answer the second
subquestion, parent participants were asked if cultural issues were perceived as a barrier.
The themes associated with this research question was either culture was an issue or it
80
was not. Asian parent participants felt comfortable seeing whoever was available,
regardless of the ethnic background, while other cultures do not feel as satisfied. To
answer the third subquestion, parent participants were asked how can free preventive
dental care programs more efficiently reach children. The theme associated with this
research question were unaware of the program, and advertise more effectively. To
answer the fourth subquestion, parent participants were asked what are the real-life
perceptions of these programs by parents. The themes associated with this research
question were location, transportation, and cost. To answer the fifth subquestion, parent
participants were asked what other life events prevent children from attending. The
themes associated with this research question were challenges in scheduling
appointments, scared, and cost. To answer the sixth subquestion, parent participants were
asked what is the parent’s perception of preventive dental care. The themes associated
with this research question were negative parental experiences as a child, parent’s
awareness of dental periodicity, and children unaware of the consequences of poor oral
hygiene. To answer the seventh subquestion, parent participants were asked how was the
parent’s dental care was addressed as a child. The themes associated with this research
question were, never taught how to take care of their teeth at home, and they would not
frequent, or journey to the dentist without dental insurance.
The discussion of the results described in this chapter, recommendations, and
conclusions will be presented in Chapter 5.
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Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
A qualitative case study design was used to explore the oral health perceptions
and dental care behaviors of parents with children aged 5-15 years in underperforming
Title I, New York City, elementary schools. The purpose of the research was to illuminate
and apprehend the unique problem of low preventive dental care program attendance and
to understand perceived parental barriers to the use of such programs. Recognizing the
numerous oral health perspectives of parents regarding their children enabled awareness
of parental refusal of preventive care, which may, in turn, help in identifying the social,
economic, and policy implications of oral health decision making.
Key Findings of the Study
Nine themes emerged from the data relating to perceived parental barriers to free
oral health programs. Of those initial nine, repetition was found in six of the themes: too
busy/scheduling, scared, cultural differences/immigrants, trust, cost, and lack of
insurance.
The first theme, “too busy,” captured the way that some parents described
potential reasons for not escorting their children to preventive oral health programs.
Parents said they just “didn’t have time.” Parents also described either “scheduling an
appointment or keeping a scheduled appointment” as a challenge in attending oral health
services.
The second theme, “scared,” captured a way that parents described either their
feelings about going to the dentist or how they thought the children would feel about
receiving dental care or attending an oral health program.
82
The third theme, “cultural differences,” related to cultural influences on
preventive health care decision making, how cultural dissimilarities weighed decisions on
how parents chose oral health providers, and why parents decide not to seek preventive
services. Lack of trust emerged as parents expressed concerns over dental professionals
not speaking their language, or not looking the way, they did. Parents were hesitant to
attend a program where their “ethnic background was not represented.”
The fourth theme, “unaware of the program,” involved how parents reported lack
of knowledge about a free preventive program for their children. The fifth and sixth
themes were related to cost and money. “Costly” was how parents described how money
was a concern in relation to dental care. Cost and money influenced decisions regarding
transportation and childcare, as well as the way parents felt about dental care.
The seventh theme, “negative experiences or traumatizing as a child, “related to
how some parents described receiving dental care as children.
The eighth theme, “lack of dental insurance,” was expressed as a barrier to dental
care visits. Most parents expressed that they “would not go to the dentist without dental
insurance.”
Themes and categories from each of the eight research questions can be narrowed
down to the following: time, money, scared, cultural differences/lack of trust, and lack of
insurance as potential parental barriers to preventive oral health programs. Time,
money/cost, scared/fear, and lack of insurance are themes that have been reported in
numerous previous studies. Themes of culture and trust are contemporary concepts.
83
Culture and Trust
One of the original themes to emerge from this study is cultural issues and trust.
For instance, parents reported that they “probably wanted to stick with someone who
spoke their language” (Mom3). If they saw someone who “resembled themselves or had a
more familiar face and communication, and values, an individual with high esteem, or
seen as a leader, parents were more willing to attend” (Mom11). One parent participant
questioned the motives of others who were not of the same culture, wondering, “what’s
the motive, what are they getting out of it, they don’t want to genuinely help us when
that’s the not the case all the time” (Mom10). This statement indicates trust issues;
moreover, the parent participant stated that she might not send her children because she
had found that “people of color treat people of color—I don’t want to say better, for a
lack of words, I guess a little bit more attentive, that’s her experience, something that
important to her to go to someone” (Mom10). Parents openly responded that trust and
cultural history were issues for them. Mom15 explained, “it was trust and not getting
myself educated because I thought that it was interns again going off stuff that I had
heard, it was interns and they didn’t know what they were doing.” She reflected, The
stories that my father gave us when he was doing his stuff, and I don’t know if it’s true or
not, it was just my father’s way that they used to run test on us immigrants and they
didn’t care about immigrants, and it was just a way of them to doing things, tests on us
before they gave them to the public. (Mom15)
Parents described “lack of trust and of confidentiality,” remarking that “we live in a
society where it has been broken a lot” (Mom13). Parents also suggested that no matter
what race you are, pride is always an issue; I have to to share my personal information
84
their stereotyping the fact that there is something for free depending on what
neighborhood you’re in, you know, and it’s kind of a shame that most African
Americans, some people may not go to that, like if you put into a mixed neighborhood,
it stupid, it’s really about pride because it’s like we have this, and we have that, and that
with all races honestly. (Mom13)
Unaware of the Program
Another interesting concept arose during the interview regarding ways that oral
health programs can effectively reach parents. This question may have never been asked
before. Parents were more than willing to share insights into ways that these programs
can attract parents and convince them to keep scheduled appointments. For instance,
parents made the following comments: “we are not notified, only when they give us
information” (Mom2); “they don’t advertise it as much” (Mom8); “I just wish the schools
took more time to speak to the parents; I think that’s what is it, mostly” (Mom12); “a lack
of information, really; parents might not be aware of what’s available” (Mom15). Some
parents discussed language barriers: “I could not read the language” (Mom10); “they
would send a paper, and we used to throw it away; we didn’t even look at it, we can’t read
the paper, and some of us can’t read it” (Mom15). Mom19 mentioned a “waiver that you
signed off to show its confidential info or prove to them your information is secure.”
Other participants suggested ways to send reminders:
what’s a good idea, sending reminders out, the texting, that helps, even though I
have a phone, tech-savvy text messages help better than the emails and better than
voicemail. As a parent, when do we have time to sit down and read our emails at
the end of the day, and to read all of them, no. (Mom13)
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Interpretation of the Findings
This study confirms themes of time, cost, lack of insurance, and fear that were
found in previous studies (Baldani, 2011; Chi, 2014; Kelly, 2005; Rahbari & Gold, 2015;
Wallace & MacEntee, 2011). Additionally, it highlights new themes, such as lack of trust
and cultural differences (Baldani, 2011; Rahbari & Gold, 2015). It also confirms that
cultural sensitivity and trust in dental professionals are still lacking (Divaris et al., 2014;
Kierce et al., 2016). It also confirms that encouraging, supporting, and educating
caregivers on oral health care are integral to improving children’s oral health (Divaris et
al., 2014; Kierce et al., 2016). Further, it confirms that cultural compatibility and
sensitivity are needed in public health areas (Wallace & MacEntee, 2012).
In a similar study by Kelly et al. (2005), parents who did not take their children
for preventive oral care were not aware of the consequences of poor oral health. This
study disconfirms Kelly et al. (2005), in that all parent participants responded that they
were aware of the consequences of poor oral health. In fact, all 20 parent participants
indicated an understanding that dental problems are just as serious as other health
concerns. A limitation of the Kelly et al. (2005), study was the lack of diversity in
participants. The current study represents a more diverse group of parent participants.
Guarnizo-Herrano and Wehby (2012), and Askelson et al. (2015), suggested that there
was limited evidence-based knowledge regarding how parental influence affects
preventive dental-care-seeking behavior for children. This study adds to the knowledge
base by highlighting that “minorities may feel like if it’s not precedence, it’s not their
own family, if it’s not bad, dont worry, out of sight, out of mind, if it’s not bad, no
worries; we respond to emergency situation instead of prevention” (Mom12).
86
Baldani et al. (2011), suggested that cultural beliefs and perceptions regarding oral
health are important individual barriers. This study confirms Baldani et al., in that
parental belief systems can positively and negatively influence ways that parents seek
free preventive care. Rahbari and Gold (2015), in a pilot study found that mothers’ oral
hygiene habits and frequency of dental visits related to the oral hygiene habits and
frequency of dental visits of their toddlers. This study disconfirms Rahbari and Gold
(2015), because parents in this study often did not have dental care as children yet
reported they wanted to take their children to the dentist. Additionally, parents often
reported that they had learned about dental care through school or from their dentist, not
from their parents.
Theories
This study incorporated behavioral change theories such as that of Prochaska and
DiClemente (1983) and the TTM of behavioral change, as well as Bandura’s (1986) SCT,
which indicates that self-efficacy is the belief that changes in behavior will result in
positive outcomes (Jones et al., 2014). If the threat of dental caries is high and the
severity of pain or dental disease higher, people tend to adopt behavioral change
(Jamieson, 2014). This study confirms that the perceived threat of dental disease was not
high in parents; therefore, behavior change such as signing a consent form for a free
prevention program for their child or children was not likely during the time of the study.
Both stages of change constructs were associated with poor self-rated oral health and oral
health impairment. This study confirms that poor self-rated oral health is related to both
non ideal dental visiting patterns and higher levels of dental disease experience (Jamieson,
2014). SCT explains how parents observe, imitate, and learn health care behaviors based
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upon social surroundings in the neighborhood. It can be confirmed with responses in this
study indicating that parents seek preventive care from a “referral, someone a friend
recommends, word of mouth.” Asking people such as friends, family, and neighbors for
referrals is critically important, and “referrals says a lot.” Using SCT helped to explain how
the interaction between the environment and self affects parental behaviors. Parents tend
to imitate and follow those they look up to and resemble.
Limitations of the Study
One of the biggest limitations of this study was the discussion of personal
information, such as the oral and dental care habits of parents and their children. There
was the possibility of inaccurate reporting of perceived barriers by parents on the
openended questionnaire. During the interviews, parents decided what they wanted to
share. Most parents said that they would allow their children to attend a preventive oral
health program; however, there was no proof that this was true. In fact, the nurse/health
manager at the school suggested that out of 300 parents, only 30 signed the consent form.
This tied into the arousal of response bias among the parents in the sample, such as the
tendency to agree with positive statements, supply limited responses, or respond in ways
that were thought to be socially desirable or culturally appropriate. Another limitation of
the study may have been the divulgence of incorrect personal information on the
sociodemographic questionnaire or consent form. However, most parents in this study
were honest about their age and ethnicity. The final potential limitation was researcher
bias; however, this was minimized through triangulation of data whereby one other
researcher reviewed and analyzed the data.
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Recommendations
A major finding in this study was how culture and ethnicity contributed to
whether or not parents allowed their children to attend an oral health program. In future
research, culture and ethnicity should be further investigated. Additionally, in future
studies, cultural elements such as familial history, language, immigration status, and the
changing demographics of neighborhoods should be assessed before initiating a
preventive oral health program. There continues to be a need to explore qualitative data
on maternal attitudes and behavior in relation to maternal or caregiver preventive health
seeking (Guarnizo-Herrano & Wehby, 2012). Because this study addressed multiple
ethnicities, it is interesting to note that the majority of Black parents expressed a lack of
trust in free preventive oral health services when compared to their Asian counterparts,
who were exposed to these services as children. Perhaps future research can attempt to
replicate findings to see if early exposure as children and increased attendance can be
generalized or explored further. If Black parents are “skeptical of who’s” running oral
health initiatives, perhaps there is a need to incorporate more leaders and dental
professionals from the neighborhood to increase child attendance.
Social phenomena such as facial recognition of leaders as well as referrals and
recommendations of providers and health services play a part in how members of certain
cultures seek preventive oral health care. Parents identified “referrals, recommendations,
and recognition of community leaders” as ways to encourage parental consent. More
research is needed to better understand how interactions in social networks relate to how
parents seek preventive oral health services (Chi, 2014; Valenti, Palinkas, Czaja, Chu, &
Brown, 2016). Future research is needed for developing multidisciplinary designs to
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understand the social and behavioral phenomena related to parents or caregivers’ denial
of preventive care to help caregivers make optimal preventive care decisions for their
children (Chi, 2014). Parents expressed a lack of preventive education and an “out of
sight, out of mind mindset.”
Parents also mentioned that they “were not educated enough” to understand the
importance of oral health interventions. Dodd et al. (2014) suggested that changing
current perceptions of preventive oral health care so that it is seen as a necessity rather
than a luxury will require multiple educational interventions. Future research should
include the addition of educational intervention for parents to ascertain whether
perceptions change.
Implications
In promoting increased rates of children attending free preventive oral health
programs, this study may help the nation achieve its goal of 50% reduction in dental
caries in children by 2020 (Office of Disease Prevention and Health Promotion, 2017). A
reduction in caries can first be attained by educating children on prevention and proper
oral hygiene, such as brushing twice daily with fluoride toothpaste and having fluoride
varnish applied to teeth to protect them from dental caries. Children can take this learned
information home and help to educate and change the oral health habits of their parents.
For instance, children often read the handouts that are sent into their households from
dental professionals; as one participant remarked, “my daughter reads everything to me”
(Mom15).
Some common social and behavioral issues arose, such as “skepticism of these
programs” and a “lack of trust from those that are not educated” or “immigrants from
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another country.” This knowledge could enable universities, colleges, and professional
organizations to tailor strategies such as using dental professionals who “match
ethnically” with clients or are “leaders in the community” to talk with parents in order to
raise the number of children benefiting from preventive dental services (Mom11). Trying
alternative measures such as “taking more time to speak with parents” (Mom15), learning
about the culture, and languages spoken in the community beforehand can be beneficial
to increasing program sustainability. Additionally, by showing “passion and love for the
community” (Mom11), and demonstrating that they “genuinely want to help” (Mom10)
may increase parental acceptance.
On the community level, and nationally, poor oral health issues contribute to more
than 51 million lost work and school hours (Devlin & Henshaw, 2011; Jackson et al.,
2011; New York State Department of Health, 2017; NIH, 2014). Parents expressed
unawareness of free preventive programs. Parents also made suggestions such as
“sending out more flyers or more media.” Parents suggested that programs “send out
more posters … send more home to parents, a way to send out more information …,
spread the word more” (Mom14). Making more people aware of the program might
enable the community to become stronger in its struggle to increase acceptance of quality
preventive dental care programs for children.
Conclusion
Oral health has a significant impact on the overall health and well-being of
individuals and the nation (Devlin, 2011; NIH, 2014). Poor oral health leads to illnesses
that affect and restrict one’s ability to work, learn in school, function at home, and
diminishes the quality of life (Healthy People, 2010; Jackson, 2011; NIH, 2014; Kierce et
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al., 2016). Dental caries is a preventable disease. However, 42% of children aged 2
through 11 years old have had dental caries in their primary (baby) teeth. Additionally, 21
% of children have distressing untreated caries in their permanent (adult) teeth (NIDCR,
2014). A disproportionate number of dental caries can be found in certain low
socioeconomic communities such as Black, Hispanic, and Mexican (CDC, 2015;
Koppelman & Cohen, 2016). Reducing oral health disparities in children has been on the
agenda of the US Department of Health and Human Services (HHS), dental universities,
colleges, and professional dental associations through initiatives such as Healthy People
2010, 2020, 2030, and free preventive oral health programs (Adesanya, Bailey, Belcher,
Beltran, Branch, Brand, Craft, Donohue, Dye, Thorton-Evans, Garcia, Hyman, Joskow,
Lester, Makrides, Manksi, Mehegan, Mouden, Nelson, Norris, O'Hara, Cherry-Peppers,
Ricks, & Rollins, 2016).
Parents or caregivers should understand the consequences for not taking their
children to the dentist or a free preventive oral health program. This research shows they
still do not. Parents are not receiving the information they need to educate themselves on
the necessity for dental care for their children. In this study, parental concepts such as the
lack of trust and cultural dissimilarities emerged as themes, as did themes of; money, fear,
lack of insurance, unaware of program, transportation, time, and location/access to care.
These findings illustrate the need for dental professionals to be from the
community. Dental professionals need to physically resemble the individuals found in the
neighborhood, or at least have a passion for enabling change. These oral health providers
can be recognized leaders, or come from referrals, which will enhance and encourage
trust, and program sustainability. Dental universities, colleges, and professional
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organizations, need to find more creative ways to educate parents on the importance of
children’s oral health.
Untreated dental caries is painful. Children often do not have a voice or choice in
seeking preventive care. Identifying parental refusal of preventive care can help socially,
economically, and with policy implications towards positive oral health decision-making
for children.
Dental caries is more prevalent in children than asthma (Centers for Disease
Control and Prevention [CDC], 2015). Caries affects children the most between the ages
of 5 and 15 years (CDC, 2015). In the United States, 42% of children aged 2 through 11
years old have had dental caries in their primary (baby) teeth. In fact, 21% of children
have untreated decay in their permanent teeth (National Institute of Dental and
Craniofacial Research [NIDCR], 2014). Dental caries is a preventable disease. A
disproportionate number of dental caries can be found in racial/ethnic groups with
relatively high rates of poverty such as Hispanic, Mexican, and Black (CDC, 2015).
Reducing oral health disparities in children has been on the agenda of the U.S.
Department of Health and Human Services (HHS, 2009) through initiatives such as
Healthy People 2010 and 2020. Dental universities, colleges, and professional
organizations are providing free preventive oral health programs to decrease oral health
disparities affecting vulnerable children. However, the problem of low attendance rates is
increasing due to lack of parental consent; thus, questions arise as to whether this is an
appropriate outlet to reach children who need quality preventive care (Center for health
Care Strategies [CHCS], 2015; Glenny, Worthington, Milsom, Rooney, & Tickle, 2013;
Spence, White, Adamson, & Matthews, 2013). Because free oral health care for the
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community is observed as an asset, other possible parental obstacles must prevent
children from joining the sealant program. What are the potential obstacles to preventive
oral health care besides lack of dental insurance and proximity to dental settings? Is
dental care considered unimportant in the community or by parental caregivers? Inquiry
into perceived barriers is of fundamental importance because university initiatives have
been experiencing a decline in participants rather than gaining new patients. What, if any,
probable obstacles to these programs exist? Decreasing oral health disparities necessitates
an understanding of multiple oral health perspectives. The intent of this study was to
explore parental perceptions of free preventive dental care programs as seen in caregivers
of children between the ages of 5 and 15 years.
Background
According to the U.S. Surgeon General, oral health has a significant impact on the
overall health and well-being of individuals and the nation (Devlin, 2011; National
Institutes of Health [NIH], 2014). Poor oral health leads to illnesses that affect and restrict
individuals’ ability to work, learn in school, and function at home, diminishing quality of
life (Healthy People 2010; Jackson, 2011; Kierce, Boyd, Rainchuso, Palmer, & Rothman,
2016; NIH, 2014). Progress on oral health diseases has been made due to successful
prevention programs (Devlin, 2011). However, not everyone is experiencing
improvement (CDC, 2016; Healthy People 2010; Jackson, 2011; NIH, 2014; Kierce et al.,
2016). Children of Black, Hispanic, and Mexican descent between the ages of 2 and 15
years and from low-socioeconomic backgrounds suffer from oral health disparities.
Dental colleges, universities, and professional organizations develop and promote free
preventive dental care programs to increase awareness, access, and oral health literacy for
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these high-risk children. Unfortunately, parental consent becomes a barrier to these
programs when the previously significant barriers of lack of insurance, lack of access to
care, and lack of transportation are removed (NIH, 2014). Chi (2014) raised the concern
that a significant number of children still do not receive the required informed consent to
attend these programs; without these interventions, high-risk children are exposed to
greater levels of dental disease. Horowitz, Kleinman, and Wang (2013) showed that
Maryland adults were not well informed about how their children’s teeth decay, or how to
prevent decay, indicating a need to increase oral health literacy. Dodd, Logan, Brown,
Calderon, and Catalanotto (2014); Divaris et al. (2013); and Chi (2013) revealed that the
perceived threat from dental disease is low and that caregivers are neglectful of children’s
oral health needs. However, improving dental professional cultural sensitivity and
encouraging parental trust with dental professionals is lacking, as is bolstering and
supporting parental/caregiver care that is integral to improving children’s oral health
(Divaris et al., 2014; Kierce et al., 2016). In fact, research indicated cultural dissimilarity
and sensitivity were missing in private practices and public health clinics (Wallace &
MacEntee, 2012). Researchers have suggested that further qualitative studies need to be
carried out to examine the emotions and attitudes of parents toward their children
attending free preventive dental care programs (Chi, 2013; Divaris et al., 2013; Dodd et
al., 2014). Exploring perceived parental barriers to preventive oral health programs for
children may enlighten dental colleges, universities, and professional programs
concerning the challenges of acceptance and low attendance of high-risk children in
relation to these programs. Understanding parental concerns and barriers to consent may
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allow for colleges, universities, and professional organizations to alter preventive oral
health care programs to increase acceptance.
Problem Statement
Dental colleges, universities, and professional organizations continue to offer
children of at-risk neighborhoods convenient opportunities to take part in free oral health
disease prevention programs, which include exams, dental sealants, and fluoride
treatments (CDC, 2014; Devine, 2011; Devlin & Henshaw, 2011; Olmsted, Rublee,
Zurkawski & Kleber, 2013). These free preventive initiatives are designed to aid in the
reduction of oral health disparities in children. According to health disparities research,
improving access to care automatically leads to an uptake of preventive care (Chi, 2014).
However, a significant number of children still do not receive the required informed
consent to attend these programs and are therefore exposed to greater levels of dental
disease (Chi, 2014). There is a need to examine the emotions and attitudes of parents
toward their children attending these events (Divaris et al., 2014; Dodd et al., 2014).
Comprehending the perspectives of parents on their children’s oral health may help dental
disease prevention programs to be successful in the community (Beck et al., 2014; Chi,
2013; Devlin & Henshaw, 2011; Divaris et al., 2014; Dodd et al., 2014). It is essential for
investigators to expose the intricate reasons why parents do not comprehend the
importance of preventing dental disease in terms of their children’s total health (Dodd et
al., 2014). Uncovering parental awareness of obstructions could allow dental hygienists,
universities, and dental clinics to organize more successful free preventive care dental
programs. This research has implemented qualitative data based on interviews with
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parents regarding their feelings toward taking their children to a free oral health disease
prevention event.
The aim of this research was to assist in the reduction of oral health disparities
among children. Documentation proves that children of families below the poverty level
are at greater risk than other children of developing dental caries (Devlin & Henshaw,
2011; Guarnizo-Herrano & Wehby, 2012). Evidence affirms that there has been a need for
a qualitative study to examine the emotions and attitudes of parents toward their children
participating in these programs (Chi, 2013; Divaris et al., 2013; Dodd et al., 2014). In a
related study on adolescents and dental care, Dodd et al. (2014) found that perceived
threat from dental disease was low. In fact, participants perceived regular brushing and
flossing as superseding the need for preventive care (Chi, 2014; Dodd et al., 2014).
Additionally, some participants believed that esthetic concerns were often a reason to
seek dental care. However, many participants articulated frustrations related to lack of
access to dental care, including those linked to finances, transportation, fear, issues with
Medicaid coverage, and parental responsibility (Wallace & MacEntee, 2011). Dodd et al.
(2014) reported that parents described going to the dentist as “something their family
never did” (p. 807). The purpose of this inquiry was to explore parental perceptions of
barriers to dental care by questioning parents who perceived difficulties in relation to
accompanying their children to free preventive dental care programs. Documentation has
revealed that children of low-income families are at greater risk than other children of
developing dental caries (Devlin & Henshaw, 2011; Guarnizo-Herrano & Wehby, 2012).
For instance, Muller-Bolla, Lupi-Pegurier, Bardakjian, and Velly (2013) suggested that
sealants should be deposited on the permanent molars of children who are susceptible to
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caries. However, sealants are underused, particularly among low-income families and
families from racial/ethnic minority groups (Ahovuo‐Saloranta, Forss, Hiiri, Nordblad, &
Mäkelä, 2016; American Academy of Pediatrics, 2016). This research project was
conducted in an effort to fill gaps in literature indicating a need for further qualitative
studies exploring the emotions and attitudes of parents toward their children attending
these free preventive dental care programs (Chi, 2013; Divaris et al., 2013; Dodd et al.,
2014; Guarnizo-Herrano & Wehby, 2012).
Purpose of the Study
In this research project, a qualitative case study design was used to explore oral
health perceptions and dental care behaviors of parents of children aged 5-15 years in
underperforming Title I New York City elementary schools. Caries affects children’s
permanent teeth the most between the ages of 5 and 15 years (CDC, 2015). This
approach may have distinguished potential barriers to free preventive dental care for
children. Comprehending the numerous oral health perspectives of parents and their
children could allow for free preventive dental care programs to be successful in the
community. Assimilating myself in the community and engaging parents with openended
questions and multiple conversations provided knowledge of the sensitivity surrounding
oral care behaviors. The ultimate goal was to find out whether these programs should
endure with a low success rate or attempt to determine and diminish perceived parental
barriers to care. Understanding perceived parental barriers could aid in increasing rates of
informed consent for the use of these programs and, consequently, increases in the
number of high-risk children receiving preventive dental care. Understanding parental
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refusal of preventive care could help in identifying the social, economic, and policy
implications of oral health decision making (Chi, 2014).
Research Questions
The primary research question for this qualitative inquiry was the following: What
perceived barriers would prevent parents from having their children attend a free
preventive dental care program? I also explored the following subquestions:
8. Is lack of trust an issue for parents?
9. Are cultural issues perceived as a barrier?
10. How can free preventive dental care programs more efficiently reach
children?
11. What are the real-life perceptions of these programs by parents?
12. What other life events prevent children from attending?
13. What is parents’ perception of preventive dental care?
14. How was parents’ dental care addressed when they were children?
With a qualitative case study, the researcher can modify questioning as distinctive themes
materialize during the data collection process.
Theoretical Framework
The identification of an appropriate theory or theories for the framework of a
study originates with establishing the problem, goal, and types of participants (NIH,
2015). This project incorporated Prochaska and DiClemente’s (1983) trans theoretical
model (TTM) of behavior change and Bandura’s (1986) social cognitive theory (SCT) to
facilitate an understanding of how parents from low socioeconomic communities’ access
preventive dental care services for their children.
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The social determinants of health and health behavior are based upon
understanding explanatory theories and change theories such as TTM and SCT (NIH,
2015). Many social, cultural, and economic factors contribute to the development,
maintenance, and change of health behavior patterns (NIH, 2015). Public health and
health promotions are effective if they embrace an ecological perspective and include
upstream approaches (NIH, 2015).
The use of the TTM allowed me to understand how parents perceive their
children’s oral health care needs. Prochaska and Velicer (1997) suggested that at-risk
populations are 40% in precontemplation or have no intention of taking their child to the
dentist, 40% in contemplation, and 20% in preparation. Identifying stages of behavior
allowed me to recognize necessary future planning toward moving parents into different
stages. Parental self-efficacy toward oral health care and parental decision making were
integral to the application of the TTM in this study. Specific procedures can be designed
to reduce resistance and facilitate progress toward parents escorting their children to
preventive oral health programs.
Additionally, SCT helped me to explain how parents observe, imitate, and learn
health care behaviors based upon social surroundings in the neighborhood. SCT helped to
explain how interaction with the environment and self affects parental behaviors.
Both the TTM and SCT helped me to consider the long-term changes in health
behavior that comprise diverse actions and adaptations over time (NIH, 2015). For
example, certain parents or children are not ready to focus on behavioral changes,
whereas others are in the process of changing their oral health behaviors. The TTM
indicates that people are at different stages of readiness to adopt healthful behaviors
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(NIH, 2015). The concept of readiness to change, including recognition of stages of
change, has been used in health behavior research for years. The TTM has been helpful in
explaining and predicting changes for a variety of behaviors, including tooth brushing
and other oral health care habits (NIH, 2015). Using interviews and observations based
upon the TTM and SCT, I attempted to highlight oral health behavior patterns of parents
and how they affect use of preventive oral health care for children.
Nature of the Study
This project was a qualitative study exploring perceptions and potential barriers in
relation to why parents or caregivers do not escort their children to free preventive oral
health programs. I used a case study design because this qualitative approach involved
investigating a real-life bounded system (Creswell, 2013). A case study is an in-depth
look at a single person or group of people and its relationship to a phenomenon
(Creswell, 2013). This study included 20 interviews with parents regarding perceptions of
free preventive dental care programs and perceived parental barriers. It was designed
around examining apprehension and possible obstacles pertaining to why parents do not
guide their children to dental disease prevention programs. Case study designs focus on a
single individual, organization, event, or program (Rudestam & Newton, 2015). It was a
case that has a specific time and place. The study progressed over time with in-depth,
open-ended, detailed data collection involving observations and interviews. The
interviews were audio recorded, and all documents and reports were analyzed (Creswell,
2013). The purpose of the research was to illuminate and apprehend this unique problem
of low preventive dental care program attendance and address concerns of perceived
parental barriers (Creswell, 2013).
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The data collection method involved individual interviews and observations, of
parents regarding perceptions of dental care and perceived barriers to free preventive
dental care programs (Laureate, 2015). Interviews consisted of semi structured,
openended questions situated around the primary research question. The interviews were
audio recorded, and observation and journaling were conducted during interviews; all
information gathered was transcribed verbatim later (Rudestam & Newton, 2015). After
initial observation, interviews were conducted face to face.
I began observations by collecting field notes, first by observing as an outsider,
and then by moving into the school setting and observing as an insider (Creswell, 2013).
Observation is an integral part of qualitative research (Creswell, 2013). Observation
started with parents or caregivers of children who had specific demographic and ethnic
backgrounds. Observation notes highlighted the setting, neighborhood, actions, attitudes,
and behaviors of parents toward preventive oral health programs. Per the University of
California (2015), if researchers want to find out what people do, they should observe
them. The strength of observation is the richness of description (University of California,
2015). Observation was fundamental in discerning the natural setting and was sensitive to
the participants’ perspective (Saldana, 2016). Observation makes it possible to cultivate
an in-depth and rich understanding of people, settings, phenomena, and the behavior of
people in a setting (Saldana, 2016).
Documents reviewed for this study included journals I kept during the study,
documents related to the interview setting and neighborhood, and messages sent during
text or email correspondence with the participants. Finally, I developed audiovisual
materials by recording conversations and all interviews.
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Secondary Data Types and Sources of Information
My plan was to gather extensive data that would provide rich informational
resources (Creswell, 2013). I used notes jotted down during interviews and observations,
as well as social media, texts, emails, and audiovisual materials (Rudestam & Newton,
2015). Additional documents consisted of journals kept during the study and information
on the program setting and neighborhood.
Definitions
For the purpose of this study, the following definitions were used:
Dental health professionals: A team of professionals who provide oral health care.
The team is composed of a dentist, a dental therapist, a dental hygienist, and a dental
assistant who work together to meet the many and varied dental and orally related needs
of the dental patient (Nunn, 2015).
Dental sealants: Thin plastic resin coatings applied to the tiny grooves on the
chewing surfaces of the back teeth (molars) to prevent tooth decay by forming a
protective physical barrier (CDC, 2016).
Healthy People 2020: The nation's framework for improved health for everyone.
The goals of Healthy People 2020 are to increase quality and years of healthy life and
eliminate health disparities (CDC, 2016)
Oral health disparities: Exist for many racial and ethnic groups, as well as groups
defined by socioeconomic status, gender, age, and geographic location. Economic factors
in poor oral health include access to care and an individual's ability to maintain dental
insurance (CDC, 2016).
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Oral heath literacy: The degree to which individuals have the capacity to obtain,
process, and understand basic oral health information and services needed to make
appropriate health decisions (Healthy People, 2010).
School-based dental sealant programs: Provide sealants to children from
lowincome neighborhoods and certain racial and ethnic groups at the highest risk for
tooth decay, who may not receive routine dental care (CDC, 2016).
Socioeconomic status: Generally seen as the social standing or class of an
individual or group. It is considered as a fusion of education, income, and occupation
(APA, 2016).
Untreated dental caries: Tooth decay (dental cavities) that has not received
necessary treatment (CDC, 2016).
Assumptions
The following assumptions were made concerning the implementation of this
study:
6. The parents had the opportunity to participate in a free preventive oral health
care program for their children.
7. The parent participants for the study were cooperative, honest, and able to
follow instructions.
8. The use of purposive selection produced a sample of parents with variations in
dental literacy and levels of knowledge regarding oral health diseases in their
children. This purposive sample of parent participants was indicative of
meeting inclusion criteria such as low socioeconomic status and specific
ethnic backgrounds.
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9. The data collected were a true representation of parent participants’ feelings
and attitudes toward free preventive dental programs for their children.
10. The sample of parent participants produced data saturation when I discerned
that it was no longer possible to obtain new information.
Scope and Delimitations
The study conducted for this dissertation was delimited to 15-30 purposively
selected parents of children who had been denied access to free preventive oral health
programs. Below is a list of requirements that was necessary to meet the objectives of this
project
5. The data were collected from underperforming Title I New York City
elementary schools at a public area such as a health fair, that had a private
place or section, chosen by parent participants based on convenience.
6. Study participants had a child or children aged 5-15 years attending the
underperforming Title I New York City elementary school that served as the
source for recruiting parents. The age of the children was important because
first and second molars erupt at this time, allowing for protective, preventive
dental sealant placement (American Dental Association [ADA], 2006).
Additionally, children of this age have developed adequate motor skills for
proper tooth brushing education techniques (Das & Singhal, 2009).
7. The participants lived in the low-socioeconomic neighborhood of the school
district. The selected parents were of Black, Hispanic, or Mexican descent
because oral health disparities continue to affect these racial and ethnic
groups.
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8. The parent participants spoke and read English fluently.
Limitations
The results of this qualitative study were affected by the following factors beyond
my control as the researcher:
5. Inaccurate reporting of perceived barriers by parents on the open-ended
questionnaire.
6. Incorrect personal information on the sociodemographic questionnaire or
consent form.
7. The arousal of response bias among the parents in the sample, such as the
tendency to agree with positive statements, answer with limited responses, or
respond in ways that are thought to be socially desirable or culturally
appropriate.
8. The limitation of researcher bias was controlled by triangulation of data and
by one other researcher reviewing and analyzing the data.
Significance
The intent of this study was to explore awareness of emotions and attitudes
toward free preventive oral health care programs in parents of children between the ages
of 5 and 15 years. Information from this study could enable universities, colleges, and
professional organizations to adjust program planning to increase the number of children
benefiting from preventive dental services. The only successful way to increase informed
consent and child attendance is to understand parental concerns (Chi, 2013; Divaris et al.,
2013; Dodd et al., 2014). Evidence suggests that school-based dental sealant programs
have been successful in reducing oral health disparities, reducing dental caries, and
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increasing access to care (Devlin & Henshaw, 2011). Examination of the literature
indicates a definite need for designing and implementing more community-based sealant
programs (Chi, 2013; Devlin & Henshaw, 2011; Divaris et al., 2013; Dodd et al., 2014).
This study may help the nation achieve its goal of a 50% reduction in dental caries in
children by 2020. However, if perceived parental obstacles are indicated as a deterrent to
the use of dental programs, school-based initiatives, or professional organizations,
perhaps identifying and eliminating them could encourage policy change. For instance,
trust was a common social and behavioral issue that emerged as a theme; perhaps
tailoring strategies such as alternative preventive treatment, alternating time schedules to
accommodate parents that work, web-based educational programs, participatory
communication, and motivational interviewing could be pursued to improve a
community’s position on positive preventive oral health care (Chi, 2014). Additionally,
parental barriers were seen as complex; a multidisciplinary approach may be necessary
that includes elements such as expanded partnerships with pediatricians and nurses (Chi,
2014; Fontana & Wolf, 2011). This study could promote social change by indicating ways
to positively modify the oral health behaviors of children by teaching them how to take
care of their oral health, such as twice-daily brushing with fluoride toothpaste. This study
was an attempt to highlight the social impact of oral health problems, such as more than
51 million lost work and school hours (Devlin & Henshaw, 2011), to enable the
community to become stronger by increasing acceptance of quality preventive dental care
programs for children.
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Summary
Currently, 1 in 5 children aged 5 to 11 years has untreated dental caries (CDC,
2016). The percentage of untreated caries in children from low-income families is twice
as high as rates for children from high-income homes (CDC, 2016). Numerous studies
show that dental sealants reduce caries in permanent teeth by 81% for 2 years after they
are placed and can continue to be effective 4 years after placement (Ahovuo-Saloranta et
al., 2013). However, perceived parental barriers are preventing high-risk children from
receiving preventive dental care. This qualitative case study was important to explore and
understand the unique perspectives on parental barriers to free preventive dental care
programs for children. Understanding perceived parental barriers to these programs may
afford universities, colleges, and professional organizations the insight necessary to
reevaluate how to elicit more parental consent for at-risk children to use these programs.
A higher attendance rate would mean increases in preventive oral health education,
literacy, and dental sealant placement, ultimately enabling reduction in childhood caries
and oral health disparities.
In the following chapter, literature that influenced the current study is introduced.
The following chapter also presents an exhaustive discussion of literature that has made a
contribution to furthering the investigation of perceived parental barriers to free
preventive dental care programs for children. It provides a synthesis of current research
findings and justifies why this study was necessary.
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Chapter 2: Literature Review
Introduction
In this chapter, an overview of theories and concepts surrounding perceived
parental barriers to free preventive oral health programs is presented. I compare and
contrast elements such as low-socioeconomic status that affect children of various ethnic
descents whose caregivers appear not to provide parental consent for preventive dental
care for their children (Glenny et al., 2013; Spence et al., 2014). I explored past and
current literature on Prochaska and DiClemente’s (1983) trans theoretical model (TTM)
of behavior change and Bandura’s (1986) social cognitive theory (SCT), as well as the
current understanding of how perceived barriers to preventive dental care for low-income
parents relate to children’s oral health. Understanding parental barriers to children’s
preventive oral health programs may help to increase access through signed consent and
ultimately reduction of caries in high-risk low-socioeconomic-status children.
Additionally, dental universities, colleges, and dental organizations may implement
programs that support and acknowledge parental concerns to increase attendance and
child participation.
In this chapter, I present a detailed literature review on the lack of knowledge
surrounding perceived parental concerns regarding free preventive oral health programs.
The first section includes specific search terms applied to establish relevant articles. Next,
I describe the theoretical and conceptual frameworks I applied to understand how
multidimensional parental perceptions, attitudes, and beliefs relate to lack of child
attendance at oral health interventions. Finally, I present an analysis of literature that
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pertains to potential parental barriers to preventive oral health care for children and
establishes the need for this study.
Literature Search Strategy
To obtain credible and current evidence to support this research study, a review of
the literature from multiple sources was conducted. Search engines used included
Medline with full text (EBSCO), PsycINFO (Ovid), ERIC, PubMed, and Google Scholar.
The Walden University Library and New York University College of Dentistry Library
were used to find full-text articles. The main search terms, oral health disparities and
oral health, were used in combination with terms such as children, low socioeconomic
status, attitudes, dental anxiety, self-efficacy, self-care behaviors, barriers to care,
prevention, interventions, and school-based sealant programs. For example, iterative
conjugations of attitudes, dental anxiety, self-efficacy, and self-care behaviors were
searched in PsycINFO and ERIC, and children, low socioeconomic status, barriers to
care, intervention, and school based sealant programs were searched in Medline with full
text (EBSCO), PubMed, and Google Scholar. While reviewing each article, I scrutinized
the reference list for pertinent additions to the literature review. I also engaged the
Internet search engine Google Chrome to locate and access material on relevant topics,
organizations, and governmental statistics. The majority of published articles used in my
review ranged from 2013 to the present. However, one seminal article from 2005 was
used.
Theoretical Foundation
No single theory or conceptual model dictates health behavior research or practice
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(Vernon & Howard, 2015). In fact, health behavior theories tend to evolve over time
(Vernon & Howard, 2015). In dentistry, some of the most popular theories in oral health
revolve around variations of self-efficacy (Jones et al., 2014; Vernon & Howard, 2015;
Zhou et al., 2015). Self-efficacy is the belief that changes in behavior will result in a
positive outcome (Jones et al., 2014). Additionally, if the severity of the perceived threat
is high and the behavior change is manageable, people tend to adopt the modified
behavior (Jamieson et al., 2014).
This project incorporated Prochaska and DiClemente’s (1983) TTM of behavioral
change as well as Bandura’s (1986) SCT to enable understanding of a community’s
attitudes, feelings, and perceptions on accessing quality preventive dental care for
children.
Traditionally, oral health has been influenced by measures such as the presence
and severity of dental caries and periodontal disease (Vernon & Howard, 2015). However,
parents are often unaware of dental caries in their children’s teeth or how to prevent it
(Horowitz et al., 2013). TTM suggests that individuals can fluctuate through six stages of
behavior change before termination of a negative behavior (Jamieson et al., 2014).
Behavior and attitudes associated with each level become apparent as individuals weigh
the pros and cons of change (Jamieson et al., 2014). These stages of change are often
noticeable, allowing for health care workers to successfully move them on toward the
next level (Jamieson et al., 2014). In a study by Jamieson et al. (2014) on a vulnerable
population of pregnant non-Aboriginal women, pre contemplative and contemplative
stage of change constructs were both associated with poor self-rated oral health and oral
health impairment. This evidence suggests that poor self-rated oral health is related to
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both non ideal dental visiting patterns and higher levels of dental disease experience
(Jamieson, 2014). Incorporating TTM into psychosocial interventions might help to
improve oral health outcomes (Jamieson, 2015).
However, oral health behavior change does not happen as the result of one single
event or intervention (Horowitz et al., 2013; Wade et al., 2011), nor does education alone
provide enough information to alter parental perceptions of prevention programs
(Horowitz et al., 2013; Miltiades, 2013). Researchers have shown that ethnic/racial
differences persist in dental-service usage patterns and oral health status, even after
controlling for traditional socioeconomic determinants (Miltiades, 2013).
Much like TTM, SCT constructs include self-efficacy (Jones et al., 2014).
However, SCT also includes other constructs such as knowledge, fatalistic beliefs, and
observational learning (Jones et al., 2014). SCT is a comprehensive approach to
understanding human behavior, motivation, affect, and thought processes (Jones et al.,
2014). SCT suggests that self-efficacy can be attained by multiple methods (Jones et al.,
2014). These methods include experiencing success, vicarious learning, and verbal
persuasion (University of Twente, 2016). Evaluating behavior change depends on the
fluctuating factors of environment, people, and behavior (University of Twente, 2016).
TTM and SCT are two models of behavior change that enable a unique
understanding of a community’s attitudes, feelings, and perceptions on accessing quality
preventive dental care for children. These models offer this through qualitative
exploration of participant parents, as attitudes and oral health behaviors can be assessed
and modified. The research question of what perceived barriers would prevent parents
from having their children attend a free preventive dental care program was addressed
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with the TTM and SCT, including the concepts of self-efficacy and learning through
others (Bandura, 1986; Prochaska & DiClemente, 1983). In a similar study by Dodd et al.
(2014), adolescents’ perception of oral health needs was identified as low (no risk) based
upon their beliefs that brushing eliminated oral disease. The belief that brushing
eliminates disease can be attributed to a learned parental or cultural ideal, which would
best be explored by the TTM and SCT.
Conceptual Construct
Cultural beliefs can have a negative influence on prevention-seeking oral health
care (Miltiades, 2013). For instance, in Black, Hispanic, and Mexican cultures, many
people rely on social networks such as family, friends, church, and neighbors for health
information (CDC, 2015). In a study by Miltiades (2013), false beliefs concerning
preventive oral health care were highlighted, such as the belief that the use of baking soda
prevents dental caries. Miltiades (2013) suggested that future research should further
expand upon cultural beliefs and the impact of early childhood influences on later life
decisions regarding accessing dental care and oral health. In this study, participants did
not receive parental oral hygiene instruction; Miltiades suggested that it is reasonable to
posit that participants’ parents did not emphasize oral hygiene when raising their children.
The current research can benefit from this by exploring additional ethnicities
and cultural beliefs of care-seeking behavior through similar questioning. However,
differences were on how they perceive preventive programs for their children as opposed
to themselves. In a seminal study by Kelly et al. (2005), parents who did not take their
children for preventive oral care were not aware of the consequences of poor oral health.
Kelly et al. (2005), suggested that further investigation was necessary to explore cultural
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factors in order to enable effective community-based interventions. Askelson et al. (2015)
suggested that there is limited evidence-based knowledge regarding how parental
influence affects preventive dental-care-seeking behavior for children. The current study
was an attempt to explore this phenomenon.
Literature Review
Low Socioeconomic Status
Beginning this overview with an understanding of dental caries is important.
Dental caries is the most prevalent childhood disease (CDC, 2015). It affects more
children than asthma (CDC, 2015). In fact, according to a report from the Surgeon
General (2000), childhood caries is 5 times more common than asthma, 4 times more
common than early childhood obesity, and 20 times more common than diabetes
(American Academy of Pediatrics [AAP], n.d.; Ezer, Swoboda, & Farkouh, 2010;
National Children’s Oral Health Foundation [NCOHF]; 2016; NIDCR, 2000). In the
United States alone, 60% of children will have had caries at some point (AAP, 2013;
Ezer, Swoboda, & Farkouh, 2010). Dental caries is preventable. Dental caries
disproportionality affects children from low socioeconomic backgrounds (AAP, n.d.a.;
CDC, 2015; Ezer, Swoboda, & Farkouh, 2010; NIDCR, 2000; NCOHF; 2016). Children
who suffer from dental pain miss more than 51 million school hours due to oral diseases
(Devlin, 2011; Jackson et al., 2011). Numerous studies have indicated that populations
that reside in low socioeconomic neighborhoods are at increased risk of dental disease
(Beck et al., 2014; CDC, 2015; Guarnizo-Herreno & Wheby, 2012; Horowitz et al.,
2013). Further, studies have indicated that parents from low socioeconomic backgrounds
have less education, less access to oral health services, and lower dental health literacy
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than their middle-class counterparts (Dodd et al., 2014; Rahbari, 2015). Parental
education can be associated with the ability to identify oral health problems, as well as
access to care (Guarnizo-Herreno & Wehby, 2012). Parents in these communities also
have intermittent dental insurance due to employment history (Wallace & MacEntee,
2012). However, in a contrasting study, Chi et al. (2013) indicated that most low-income
children are covered by public insurance such as Medicaid or the Children’s Health
Insurance Program (CHIP) and that lack of dental insurance should not be considered a
barrier to preventive oral health care. Children from low socioeconomic neighborhoods
are 3 times more likely to have untreated dental caries than children living above the
federal poverty line (Devlin & Henshaw, 2011). Neighborhood characteristics that have
been suggested to influence oral health include safety, social networking, information
about dental services, and number of dental providers (Guarnizo-Herreno & Wehby,
2012; Valente, 2015).
Free Preventive Dental Care Programs
Understanding the services provided by free preventive dental care programs will
enable a better understanding of how these programs attempt to increase access to care
and decrease oral health disparities in low-income neighborhoods. A preventive dental
care program always provides a comprehensive oral examination (Ahovuo‐Saloranta.,
2013; Ahovuo‐Saloranta et al., 2016; Beck et al., 2015; CDC, 2015; Children’s Dental
Health Project [CDHP], 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al.,
2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). An oral
examination enables health care providers, specifically dentists, to visualize or clinically
see dental diseases. Dental disease may take various forms, such as a carious lesion in a
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tooth; a soft-tissue lesion on the lips, buccal mucosa (cheeks), tongue, throat, or gingiva
(gums); a missing tooth or filling; a misaligned bite; or recurrent caries.
If a child has caries or red, inflamed gingiva (gingivitis), the child can be referred
to a local dentist for treatment, such as a restoration (filling) or cleaning (child
prophylaxis). Some programs offer children a fluoride treatment in the form of a varnish
(Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC,
2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al., 2015;
Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Fluoride varnish is
medicine that protects the outer layer of the tooth (enamel) from the effects of bacterial
invasion (caries or decay; CDC, 2015). Fluoride varnish is an effective way to prevent
dental caries (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al.,
2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al.,
2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Fluoride
varnish gets painted on all teeth surfaces, leaving a protective sticky film on the teeth, and
it acts like a vitamin that makes tooth enamel stronger (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al.,
2014; Devlin & Henshaw, 2011; Dye et al., 2015; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010).
Programs that provide fluoride varnish also provide children with oral hygiene
education. Oral hygiene education teaches children how to take care of their teeth, such as
proper brushing techniques (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta,
2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Dye et al., 2015;
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Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty,
2010). Proper brushing twice daily reduces the incidence of dental diseases
(AhovuoSaloranta et al., 2016; Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015;
CDHP,
2014; Chi et al., 2014; Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al.,
2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Additionally, some programs perform cleanings (child prophylaxis) and apply
protective preventive dental sealants on permanent molars (Ahovuo‐Saloranta et al.,
2016; Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al.,
2014; Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010). Dental sealants are a protective plastic that covers the biting
surfaces of permanent molars and prevents bacteria from residing in the pits and fissures
(grooves) of the teeth, sealing out decay (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013;
Siegal & Detty, 2010). Dental sealants have been proven to be a cost-effective way to
reduce and prevent dental caries in children (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta, 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
Dye et al., 2015; Devlin & Henshaw, 2011; Northridge et al., 2015; Olmstead et al., 2013;
Siegal & Detty, 2010).
Often, the amount of preventive care depends on the facility. Mobile dental units,
universities, colleges, professional organizations, and schools provide all of the
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aforementioned preventive services for children. Churches and community programs may
only offer dental examinations, referrals to local dentists, fluoride treatments, and oral
hygiene instructions (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck
et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et
al., 2015; Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Regardless of their range of offerings, these services are an excellent way for
communities to increase dental disease awareness and improve oral health
(AhovuoSaloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC, 2015;
CDHP,
2014; Chi et al., 2014; Devlin & Henshaw, 2011; Dye et al., 2015; Northridge et al.,
2015; Olmstead et al., 2013; Siegal & Detty, 2010).
Decreasing Oral Health Disparities
Dental colleges, universities, and professional organizations implement free
preventive dental care programs in an attempt to increase access to dental care and
decrease oral health disparities (CDC, 2015). However, attendance rates are often low
(Divaris et al., 2012; Glenny et al., 2013; Spence et al., 2014). Parents of these high-risk
children do not allow their children access to these programs, thereby increasing
challenges to necessary preventive dental care (Divaris et al., 2012; Glenny et al., 2013;
Spence et al., 2014). Identified barriers to care include lack of transportation, money,
insurance, and access to dentists; loss of wages and time; and fear (Devlin & Henshaw,
2012). However, it has been indicated that even when these barriers have been removed
by reaching children at school, parents have not signed consent forms (Divaris et al.,
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2012; Glenny et al., 2013; Spence et al., 2014). Children are dependent on parents to
meet their oral health needs (Divaris et al., 2012; Glenny et al., 2013; Spence et al.,
2014).
Culture, Attitudes, and Behaviors
This study explored the perceived parental perceptions of free preventive oral
health programs. It unveiled attitudes and preventive behaviors of parents and cultural
preventive practices of specific ethnic backgrounds. Dodd et al. (2014), adds to the
knowledge base by suggesting that perceptions of dental disease is inadequate in low
socioeconomic neighborhoods. In fact, Dodd et al. (2014), indicated parents as one of the
barriers to adolescent dental absence. Parental responsibility to work, and low selfefficacy
are barriers for adolescent dental health (Dodd et al., 2014). Horowitz et al. (2013),
suggested most adults in Maryland, did not have enough knowledge regarding tooth
caries or how to prevent it. Dodd et al. (2014), determined most adolescents indicated
pain as the main reason for visiting a dentist. In fact, adolescent participants failed to
connect preventive care with lessening of pain or dental disease (Dodd et al.,
2014). A historical study by Kelly et al. (2005), indicated that dental visits were for pain
not treatable at home. Similarly, individuals from low socioeconomic backgrounds felt
dental care was less critical to their overall health, and that medical issues trumped dental
care (Kelly et al., 2005). This study added to knowledge because it specifically addressed
parents’ perceptions, and not that of adolescents. Emphasis was also placed upon how
individuals from low socioeconomic neighborhoods gathered oral health information
(Dodd et al., 2014). Guarnizo-Herreno & Wehby (2012), indicated higher unemployment
rates accounted for parental psychosocial status, and information gathering accounted for
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cultural preventive practices. According to Dodd et al. (2014), changing current
perceptions of preventive oral health care from a luxury to a necessity required multiple
educational interventions. This study explored current parental perceptions of care
seeking behaviors, to fulfill a gap in the literature of limited evidencebased knowledge,
regarding how parental influence effects the preventive dental care seeking behavior for
their children who supports effective community-based interventions.
Gaps in the Literature
This research project investigated an extensive amount of literature on the topic of
oral health disparities and children. In doing so, multiple gaps in literature were found. I
highlighted them in chronological order to enable understanding of how and why this
current project fulfills the research gap. Kelly (2005), executed a qualitative study on
diverse ethnic/racial backgrounds on caregivers that do not seek preventive care for their
Medicaid enrolled children. The limitations from this study include the lack of diversity
of participants, and future research suggested to explore cultural factors that may be
necessary to enhance community based interventions (Kelly, 2005). The lack of
exploration on cultural factors is considered a gap in the literature. Baldani et al. (2011),
revealed and confirmed that cultural beliefs and perceptions regarding oral health were
important individual barriers. Guarnizo-Herrano & Wehby (2012), quantified
contributions of socioeconomic status, demographic, and neighborhood characteristics to
oral health disparities. Their limitations include the lack of data on maternal attitudes and
behavior of preventive health seeking (Guarnizo-Herrano & Wehby, 2012).
Recommneded future research, and the gaps in literature made it necessary to explore
cultural and maternal attitudes and preventive behavior seeking oral health care. Chi
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(2014), examined the relationship between caregiver’s refusal of preventive
immunizations and preventive fluoride varnish. The limitations of the study suggested
parents with private insurance had higher response rates than those with publicly insured
or uninsured children. Again, indicative of gaps in literature, future research identified
social and behavioral factors related to parental/caregivers’ refusal of preventive care,
with the goal of developing multidisciplinary strategies to help guardians make optimal
preventive care decisions for their children (Chi, 2014). Rahbari and Gold (2015), in a
pilot study found that a mother’s oral hygiene habits and frequency towards dental visits
were related to the oral hygiene habits and frequency in dental visits of their toddlers.
Again, confirming the need for future research to understand the multiple factors of oral
health relating to women and their children. This study explored current parental
perceptions of preventive care seeking behaviors to fulfill the gaps in the literature
presented by Chi (2014), Guarnizo-Herrano and Wehby (2012), and Rahbari and Gold
(2015), of limited evidence-based knowledge regarding how parental influence affects the
preventive dental care seeking behavior for their children which will support effective
community-based interventions.
Summary and Conclusions
The current literature review includes current research in the area of preventive
dental care, potential barriers to care, attitudes and behaviors that may affect preventive
seeking dental care, effects of low socioeconomics on dental caries, and the increasing
disparities in children’s oral health. Dental sealants, when placed on permanent molars,
are a cost-effective way to reduce childhood caries (Ahovuo‐Saloranta et al., 2016;
Ahovuo‐Saloranta., 2013; Beck et al., 2015; CDC, 2015; CDHP, 2014; Chi et al., 2014;
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Devine, 2011; Devlin & Henshaw, 2011; Dye et al., 2015; Kierece et al., 2016;
Northridge et al., 2015; Olmstead et al., 2013; Siegal & Detty, 2010). Oral health care
interventions attempt to reduce oral health disparities in children by placing free dental
sealants on the biting surface of third-grade children from low-performing Title 1
elementary schools (Ahovuo‐Saloranta et al., 2016; Ahovuo‐Saloranta., 2013; Beck et al.,
2015; CDC, 2015; CDHP, 2014; Chi et al., 2014; Devine, 2011; Devlin & Henshaw,
2011; Dye et al., 2015; Kierece et al., 2016; Northridge et al., 2015; Olmstead et al.,
2013; Siegal & Detty, 2010). Some parents are increasing the risk and oral health
disparity gap by not allowing their children access to these programs (CHCS, 2015; Chi
et al., 2013; Chi, 2014; Glenny et al., 2013;). Horowitz et al. (2013), and Lee et al.
(2012), among numerous others, confirm barriers to preventive care such as access, low
dental literacy, and low socioeconomic neighborhoods (CDC, 2015; Guarnizo-Herreno &
Wehby, 2012). Attitudes and cultural oral care behaviors of low-income Mexican women
such as brushing with baking soda described as preventive oral care (Miltiades; 2013).
What’s known is that various racial groups such as Black, Hispanic, and Mexican
children from low socioeconomic status face multiple barriers to preventive oral health
care (Askelson, 2014; CDC, 2015; Chi et al., 2013; Chi, 2014; Guarnizo-Herreno &
Wehby, 2012; Miltiades, 2013; Rahbari & Gold, 2015). Multiple gaps in the literature
indicated the need to explore oral health perceptions and dental care seeking behaviors of
parents for their children (Askelson, 2014; CDC, 2015; Chi et al., 2013; Chi, 2014;
Guarnizo-Herreno & Wehby, 2012; Miltiades, 2013; Rahbari & Gold, 2015). This current
study extended knowledge around barriers to children’s care by exploring parental
perceptions of free preventive oral care programs for their children. Understanding the
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parental barriers and perceptions of free preventive care programs increased the
knowledge base to develop appropriate clinical and policy solutions aimed at optimizing
the oral health of children. In the following chapter, the methodology that was used,
participants, sample size, question design, clarification of coding and analysis procedures,
and interpretation of results towards central themes exploring perceived parental barriers
of free prevention programs for children is discussed in detail.
Chapter 3: Research Method
Introduction
In this research project, a qualitative case study design was used to explore oral
health awareness, emotions, and attitudes in relation to the dental care behaviors of
parents and caregivers of children aged 5-15 years in underperforming Title I New York
City elementary schools. Caries affects children’s permanent teeth the most between the
ages of 5 and 15 years (CDC, 2015). A qualitative design has distinguished potential
barriers to free preventive dental care programs for children. Comprehending the
numerous viewpoints of parents concerning the oral health of their children may allow for
free preventive oral health care programs to be successful in the community. By
assimilating into the neighborhood and engaging parents through open-ended questions
and multiple conversations, I sought to understand sensitivities surrounding preventive
oral-care-seeking behaviors. The goal was to find out whether these programs should
continue with an inferior success rate or attempt to recognize and reduce perceived
parental barriers to care. A greater understanding of perceived parental barriers may assist
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in efforts to increase rates of informed consent for children to participate in these
programs and consequently promote an increase in rates of high-risk children receiving
preventive dental care. Understanding parental refusal of preventive care may help in
identifying the social, economic, and policy implications of oral health decision making
(Chi, 2014).
In this chapter, a detailed description of the research study design is presented,
including the rationale, the research questions, my role as researcher, the methods for
selecting and recruiting parent participants, data collection procedures, and the strategy
for data analysis. An overview of ethical concerns related to the study and the issue of
trustworthiness is also presented.
Research Design and Rationale
The primary qualitative research question was the following: What perceived
barriers would prevent parents from having their children attend a free preventive dental
care program?
The subquestions were the following:
8. Is lack of trust an issue for parents?
9. Are cultural issues perceived as a barrier?
10. How can free preventive dental care programs more efficiently reach
children?
11. What are the real-life perceptions of these programs by parents?
12. What other life events prevent children from attending?
13. What are parents’ perceptions of preventive dental care?
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14. How was parents’ dental care addressed when they were children?
In a qualitative study, a researcher can adjust questions as themes emerge during the data
collection process.
A qualitative case study design was undertaken for this inquiry. In this study, I
examined the emotions and attitudes of parents toward preventive oral health programs,
as well as the potential reasons why parents do not escort their children to free preventive
dental care programs. This qualitative case approach was the best fit for this study
because it involved exploring a real-life bounded system in a place and a unit in time
(Creswell, 2013). I sought to investigate parental perceptions with in-depth, detailed data
collection involving observations, open-ended interviews, audiovisual recordings,
documents including emails and texts, and social networks (Creswell, 2013). The aim of
the research was to illuminate and understand this unique problem and concern (Creswell,
2013). The qualitative case study design facilitated exploration of perceived parental
barriers within a context of free preventive dental care programs using a variety of data
sources (Baxter & Jack, 2008). A case study ensured the use of multiple lenses to explore
various facets of the issue, which allowed the phenomenon to be revealed and understood
(Baxter & Jack, 2008; Creswell, 2013). The evidence was analyzed with written
transcription of conversations inside the software program NVivo11 Pro. The goal was to
uncover and identify repeated themes related to the phenomenon (Creswell, 2013).
Culture and low income are important contributors to high dental caries rates.
However, the use of ethnography would not have been appropriate for this study, in that
the group of interest would have been too large. Further, there was more than one ethnic
group in the group or case of interest (CDC, 2015). Rates of dental caries are highest in
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Black, non-Hispanic and Hispanic of Mexican descent communities, which makes it
challenging to narrow down a specific culture of interest (CDC, 2015). Another reason
that a case study was the best fit is that it provided me with an in-depth understanding of
parents’ perceptions of preventive oral health behaviors as a case rather than a large
disproportionate group. A quantitative study would also not have been appropriate
because it would have led to numerical data or information that could be turned into
numbers (Patton, 2014). A quantitative study would have involved making statistical
inferences from data. A qualitative study was more appropriate because it made it
possible to gain a deeper understanding of feelings, opinions, attitudes, and trends in
thought among parent participants.
Role of the Researcher
Case study research suggests the importance of presenting the researcher’s
position in the study (Creswell, 2013). I have experience in preparing and implementing
preventive oral health programs for children with oral health disparities. I am involved
with this issue both professionally and personally. My professional involvement comes in
the form of helping to initiate free preventive oral health programs with the New Jersey
Dental Hygienists Association (NJDHA). On a personal level, I volunteer my time with
Give Kids a Smile (GKAS) and Wings of a Dove Foundation to offer dental health
education and to implement preventive oral care to decrease oral health disparities in
children. I do not believe that my experience in this area placed me in any supervisory or
power relationship over my parent participants. I will use any knowledge gained from
this study to enhance future preventive programs.
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For this study, I first entered the community as an outsider researcher, and with
time I began to understand the settings and culture of the participants and assimilated as
an insider researcher. My role as the researcher was to engage myself in the community
for advancement of facial recognition, show my intentions, and encourage free and honest
conversations with the parent participants (Capella University, 2017; Robert Wood
Johnson [RWJ], 2008). Assimilation within the community allowed for credible,
trustworthy interviews, documentation, and audio data collection. Biklen (2010)
suggested that the quality of evidence relates to the credibility of the investigator’s
fieldwork. Per Patton (2014), the credibility of the inquirer depends on training and
presentation. I was personable and professionally prepared because these qualities have
been shown to provide more successful responses. Training and experience ensure
trustworthiness. I had one colleague who culturally matched the participant demographic
assist me with the interview process, but the colleague did not have access to the
interviews due to the need to protect participants’ privacy. Having one colleague with me
who culturally matched the demographic was necessary to gain parent participants’ trust
and assure them of the ability to speak freely.
There was no known researcher bias, and to decrease the potential for future bias,
I had one colleague who was experienced with qualitative data review and code the
information to cross reference for similarity in findings. I coded the data for themes, and
I had my colleague code and triangulate the data to decrease any researcher bias. I
decreased bias by positioning myself ultimately as the narrator of themes and stories
presented by the parent participants. A considerable limitation of qualitative research is
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that the results can easily be influenced by the researcher’s personal biases and
worldview.
The design was purposefully descriptive thorough understanding of participants’
feelings (Miles, Huberman, & Saldana, 2014). The descriptions developed through this
study are rich, meaningful, and thick (Miles et al., 2014). Ensuring trustworthiness and
alleviating doubt concerning investigator bias began with making sure that the accounts
of the participants made sense, sounded true, and reflected the voice of the participants,
displayed by readers living vicariously through them (Maxwell, 2013; Miles et al., 2014).
For consistency, I ensured that rival explanations were investigated and that the findings
could be reproduced in other studies (Maxwell, 2013; Miles et al., 2014; Patton, 2015).
The data are displayed in a matrix, which shows sequential steps that were used to
link the emerging themes and provide credibility (Maxwell, 2013; Miles at al., 2014).
Triangulation of data for the confirmation of findings was conducted to decrease potential
researcher bias (Maxwell, 2013; Miles et al., 2014). Triangulation enhanced
trustworthiness when I collaborated with another researcher during data analysis
(Maxwell, 2013; Miles et al., 2014).
Justification for Incentives
I interviewed the parents of children living in a low socioeconomic neighborhood.
Money, time, and lack of transportation to the interview were potential problems for the
participating parents (CHCS, 2016; Glenny et al., 2013). To remove these barriers, it was
necessary to offer food (i.e., a light breakfast or lunch), a MetroCard for transportation,
and a small incentive for loss of work wages. A MetroCard for 20 participants maximum
was purchased at $110. Each MetroCard was $5.50 each. A small breakfast or light lunch
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for 20 participants would cost $100. However, interviews were conducted eight at time
and breakfast/lunch was not necessary. Incentives were necessary to get parents to open
up about the perceived barriers to preventive oral health programs for their children. To
provide such incentives, I offered $15 gift cards for participation, which I estimated
would cost $300 for 20 participants. Incentives may have some implication for
participation bias (Hsieh & Kocielnik, 2016). Participant bias occurs when a study
becomes non representative due to a disproportionate number of participants who have
similar traits (Patton, 2015). However, researchers have argued that incentives provide a
broader participant base (Hseih & Kocielnik, 2016; Singer & Cooper, 2008). The total
cost to run this study was $510.00.
Methodology
Participant Selection
For this study, I reached and interviewed the parents/caregivers of children
between the ages of 5 and 15 years. Parents’ ages ranged from 18 to 60 years. These
parents had incomes below poverty level, which is less than $24,240 for a family of four,
and they resided in low socioeconomic neighborhoods (Office of the Assistant Secretary
for Planning and Evaluation, 2015). The parents came from diverse cultural and ethnic
backgrounds that represented the high-risk demographic for children with oral health
disparities. For instance, they were of Black, Hispanic, Chinese, and Mexican decent.
Although participants’ racial and ethnic backgrounds were significant to this study, the
study was open to anyone who fits the demographic criteria. Participants had one or more
child attending an underperforming Title I elementary public school that provided free
lunch programs. The elementary schools represented in my study offer programs that
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provide free lunch for children. These Title I elementary public schools are in
communities where residents are living below poverty level and are described as having
low socioeconomic status. Additionally, parent participants in this study never had a
child attend a free preventive oral health program. Parent participants spoke and read
English. Exclusion criteria applied to minors and anyone who was not a parent, guardian,
or caregiver of a child between the ages of 5 and 15 years.
Sampling
In qualitative inquiry, purposeful sampling focuses case selection in sequence with
the investigation’s purpose, questions, and data collected (Patton, 2015). Purposeful
sampling is about selecting participants with information-rich cases to study. Cases are
selected related to the phenomenon of interest (Patton, 2015). The participants were
selected due to the need to explore parents’ perceptions of free preventive oral health
programs and preventive oral-care-seeking behaviors of parents for their children. Parents
were purposefully sampled and asked to participate in the research project by
systematically selecting parents that had one or more children in an underperforming Title
I elementary school, and did not sign the consent form for an oral health program (Cohen
& Crabtree, 2006).
Sample Size
There are no true sample size rules in qualitative research (Marshall, Cardon,
Poddar, & Fontenot, 2013; Patton, 2013). Qualitative research requires continuous
reorganization. Miles (2014), suggested that a chosen sample size may not supply a
researcher with data-rich sources. Qualitative samples need to be purposive rather than
random (Miles, Huberman, & Saldana, 2014). Size defines the ambitiousness of the
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inquiry, what is affected, what will be beneficial, what will have virtue, and what is done
with the available time and resources (Patton, 2013). A small sample size can produce an
understanding that is rich in data, whereas a large sample size can be useful in exploring
phenomena and documenting diversity (Patton, 2015). Additionally, the size of a sample
can be fluctuated (Patton, 2015). Sample size becomes a matter of subjective judgment
based on making relevant associations, repetitive information, measuring explanations as
well as reaching saturation (Patton, 2015).
Justifying the size of a sample in qualitative research can be accomplished in one
of three ways (Marshall et al., 2013). First, a researcher can cite the recommendations of
qualitative methodologists (Marshall et al., 2013). Second, a researcher can cite
methodologies that have been used in previous studies with similar questions and designs
(Marshall et al., 2013). Finally, a researcher can demonstrate saturation within the data
(Marshall et al., 2013).
According to Miles, Huberman, and Saldana (2014), the minimum sample size for
a multiple case study is five. Creswell (2013) suggested six for a case study and no more
than 20-30 interviews for grounded theory. According to Marshall et al. (2013), for a
single case study, 15-30 interviews are needed, depending on culture and study design.
For this design, I recruited 20 parent participants. My rationale was that if 20 participants
showed up, it could be expected that 20 participants would explain why they did not
escort their children to a free preventive oral health program. This number had been used
in previous studies and modifications can be made for data saturation (Marshall et al.,
2013). Twenty participants were a starting point; this target was decreased when
saturation was reached sooner than anticipated (Creswell, 2013; Huberman, & Saldana,
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2014; Marshall et al., 2013; Miles,2014; Patton, 2013). With this research, I gained
information-rich data to help future initiatives determine the reasons that parents may
deny consent for their children to attend free preventive oral health programs or may be
“no shows” at these programs. Cultural differences were explored, along with cultural
access to preventive dental services (Marshall et al., 2013). Purposeful strategies leave
the question of sample size open, which is a direct paradigm of qualitative inquiry (Miles,
Huberman, & Saldana, 2014). The principle of saturation was used to determine sample
size. After 20 interviews, it was expected that no new themes would emerge from the data
and that the data would become repetitive (Creswell, 2013; Patton, 2015; Rudestam &
Newton, 2015; Saldana, 2016; Walker, 2012). Saturation ensured that adequate amounts
of quality data had been collected (Walker, 2012). Saturation was reached in this study
when all the data had been analyzed and it was deemed unlikely that new data would add
to the story, phenomenon, theory, or framework (Mason, 2010).
Participant Recruitment
For the purpose of this study, I attempted to contact parents who had not
consented to a dental examination for their children at underperforming Title I New York
City elementary schools. I had access to the location of parents through the New York
University College of Dentistry Pediatric Department, which was currently at the school
providing dental examinations and oral health services for high-risk in children in third
grade whose parents had provided consent. Parents of third grade children had been asked
to sign a form if they did not want their children to participate in a clinical examination
by a dentist during school hours.
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I posted a recruitment flyer for this study in public places near the
underperforming Title I New York City elementary school, such as grocery stores, cafes.
markets, and public playgrounds, indicating an opportunity and incentive for parents to
discuss their lack of consent if they were willing to do so. Additionally, Wings of a Dove
Foundation, a neighborhood community church program that implements oral health
preventive programs for low-income children, had agreed to post a recruitment flyer
around the vicinity of the church. Parents attending the church fit the same demographic
and inclusion parameters. After receiving all relevant ethics committees’ approvals, I
recruited parents using a flyer posted around the church asking if they would like to
participate in the study. If they were willing to participate and fit the inclusion criteria,
parent participants were asked to sign an informed consent form prior to an interview.
The consent form contained information on participant privacy, the voluntary nature of
participation, the rationale for the study, risks and benefits of being in the study,
incentives, and my contact information.
Instrumentation
The initial data collection instrument; an observation sheet, was inspired by a
template used by Aussie Childcare Network (2016). The observation sheet included two
narrative boxes. I titled the top box observation, and the bottom box interpretation (see
Appendix A). Observations strength is the plentitude of narration and imagery (University
of California, 2015). Observation is the quintessence of appreciating an understanding of
the participant’s natural settings, and their way of viewing the world around them (RWJF,
2008). Observations included body language, attitudes towards the interviewer,
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preventive programs, and their child’s oral health. The observation checklist allowed me
to visually describe the parent participants during, and after data analysis.
I also used an interview protocol sheet. Interviews were conducted face to face
after upon completion of the informed consent sheet (Maxwell, 2005). Interviews
consisted of semi-structured, open-ended questions, organized around the primary
research question. The goal of the research question was to obtain a comprehensive
understanding of the perceived parental barriers to free preventive dental care programs
for their children (Rudestam, 2011). The interview protocol sheet enabled me to stay
focused, and on track during questioning. The interviews were audio recorded, and I took
interview notes on site. Information gathered was transcribed at a later time (Nalzaro,
2014). I created the questions on the protocol sheet, they were inspired by a similar
seminal qualitative study by Kelly et al. (2005). Kelly et al. (2005), utilized a similar
interview instrument during seven focus group sessions containing an average of nine
participants in each. Kelly et al. (2005), compared White and African American caregiver
utilizers and non utilizers of preventive dental care services for their children. It was
appropriate for me to use this instrument for context, however, modifications were made
to include multicultural specificity which the Kelly et al (2005), study lacked (see
Appendix B for Revised Survey). The interview questions relied upon TTM to show self-
efficacy in parental dental care seeking habits, and self-efficacy of their children’s oral
health. This study ventured to describe what parents find important about oral health that
might make them visit a dentist or take their child to a preventive program. SCT was also
identified from interview questions when parents were asked to express where they
learned about dental care, and when should they take their child to the dentist. Social
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learning or imitating behaviors played a role in how often children or parents receive
dental care, and for what reasons. Content validity was established by the appropriateness
of the tools, processes, and data (Lueng, 2015). For instance, data collection and analysis
enhanced validity by using triangulation of researchers, resources, theories, and a
welldocumented audit-trail of materials and processes (Lueng, 2015). The current study
aimed to identify and explore any culturally specific issues during the interview, data
collection, and analysis process. The interviews were audio-taped to allow for precision
in data collection, verbatim transcription, and analysis. The observation checklist and
interview protocol questionnaire were two data collection instruments that enabled
collection of parent participant’s feelings and attitudes towards free preventive oral health
care programs.
Procedures for Data Collection
The first question, what perceived barriers would prevent a parent from having
their child attend a free preventive dental care program? Data were collected through
observation such as environment, attire, and ethnicity. To identify body language, tone,
and attitudes, both observation and responses during interviews toward preventive dental
care was be illuminated. Immediately following initial observation questions from the
interview protocol was asked. These questions such as; how acceptable do you find free
preventive oral health programs enabled data collection. Audio recording interviews
allowed for verbatim analysis and triangulation of the data to ensure that consistency in
interpretation of the data occurred. The second question; is lack of trust an issue for
parents? Was answered through interview question since you have never taken your child
to a preventive oral health program, is lack of trust an issue. The third question; are
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cultural issues perceived as a barrier? Was answered by interview questions Are there any
cultural or racial concerns/reasons why a parent or caregiver would not have their
child/children attend a preventive care program? Question four; how can free preventive
dental care programs more efficiently reach children? Was answered by the interview
question what are some reasons people might not take their children to the dentist. What
are the real-life perceptions of these programs by parents? Was answered by the interview
question; how acceptable do you find these programs. What other life events prevent
children from attending? Was answered by the interview question; what are something
things that might make it difficult to take a child to the dentist. What is the parent’s
perception of preventive dental care? Was answered with the interview question; what are
your experiences with dentists that accept Medicaid for your children. How was the
parents dental care addressed as a child? Was answered by the interview question; how
have you felt about the dental care you received. All interviews were audio recorded.
Data Collection
The data were collected by interviewing parents from underperforming Title I
elementary schools in New York City, in a place of choice by participants; such as a local
library, or facility of parent’s choice. I collected all data. The interviews were conducted
at increments of eight interviews in one day throughout a week. This entailed two to four
interviews a day for one week or longer. I scheduled interviews around convenient times
for the participant parents. The interviews were timed and last for maximum of 20
minutes. The data consisted of journaling during the study, at the program setting, and
around the neighborhood. Audio recording materials recorded conversations and
interviews. Other documentation collected was any other material including messages
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sent through texts or emails with the participants. If recruitment of participants was low, a
follow-up plan was to recruit parent participants at a Brooklyn Church named Emmanuel
Church of God, through Wings of a Dove Foundation that contains the same cultural
characteristics and demographics as the parents from underperforming Title I elementary
schools. A total of nine parents were recruited through Emmanuel Church of God. Same
interview and data analysis procedures were utilized. As parent participants exited the
interview they were thanked for their time, given incentives for participating, and advised
that their questions were helpful. They were also advised that a 1-2-page summary of
results would be available for their review after the results of the research were analyzed.
Parent participants were asked if interested they may be recruited for additional follow-up
interviews if necessary. However, additional follow-up has not been indicated.
Data Analysis Plan
Qualitative research generates large amounts of documentation. The interview,
researcher’s notes, and observations were transcribed into a matrix and placed into the
software program NVivo11 Pro. The matrix condenses data (Miles, Huberman, &
Saladana, 2015). Data compression at best, condensed, polished, balanced, and organized
data so that conclusions were drawn (Miles et al., 2015). Before the formation of the
matrix, the researcher bolded, highlighted, underlined, or used color rich text, of words
and passages that felt worthy of future consideration (Saldana, 2015). In other words, I
built a logical chain of evidence (Miles et al., 2015). Precoding scrutinized the data by
pointing to deeper issues that deserved attention (Miles et al., 2014). Coding and
categorizing data for themes were done before coding (Miles et al., 2015). Coding and
analysis required continually revisiting the data and scrutinizing the categories of data
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until I was sure that the themes and categories used to summate and describe the findings
were honest and an accurate reflection of the data, that was gathered (Hancock, 1998).
For this study, I recorded ideas, and journaled in the right column of transcripts that
abetted to make evolving codes more accountable. Any discrepant data was analyzed
further to avoid sticking with first impressions, or clinging to an initial hunch (Saldana,
2015).
Issues of Trustworthiness
To ensure credibility I identified as the role of a skeptic (Northern Illinois
University, 2013). By doing so, rival explanations of phenomena that arose were checked
with the data collected and required further data collection to prove or disprove
phenomenon. This skepticism allowed me to eliminate other confounding variables that
might be a possible causal relationship to perceived parental barriers to free preventive
oral health care programs (Northern Illinois University, 2013). Additionally, I used
method triangulation with observations and interviews. Method triangulation allowed for
double data collection and enhanced the strengths and weakness of each method
(Northern Illinois University, 2013). I also utilized data triangulation in the form of
conducting interviews at different times and in different places. To ensure transferability I
used rich content and contextual description to provide enough information about the
participants, participant selection, sample size, data collection and analysis methods, to
allow for the study to be replicated and conducted again with a different group of people
or in a different setting (Northern Illinois University, 2013; Patton, 2015). The
dependability of the study was maintained through investigator triangulation, and an audit
trail. Investigator triangulation occurred with the use of one additional colleague that
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reviewed the audio recordings, analyzed the participant behavior from observed data
collection form, and in interpreted the data for uniformity of codes and themes (Northern
Illinois University, 2013). An audit trail also maintained and added continuous
documentation which allowed a colleague to verify descriptions and aid me during
analysis and coding (Northern Illinois University, 2013; Patton, 2015; Saldana, 2015).
Confirmability was insured by journaling during the research process. Constant critical
self-reflection regarding potential bias from me was recorded (Northern Illinois
University, 2013; Patton, 2015; Saldana, 2015). Additionally, inter coder agreement was
done by having one of my colleagues test my codes by evaluating data and providing
their interpretation. Finally, inter coder reliability was ensured with thick rich description
and verbatim information to reflect the meaning of the parent participants (Northern
Illinois University, 2013; Patton, 2015; Saldana, 2015). Collegiate review of data
provided me with solid evidence for interpretation and conclusion of evidence (Northern
Illinois University, 2013; Patton, 2015; Saldana, 2015).
Ethical Procedures
For this study, Walden Institutional Review Board (IRB) reviewed and accepted
the interview questions and research methodology. IRB approval number is 04-21-
170456669 and expires on April 20th, 2018. IRB ensured that all human subject research
be conducted in agreement with all federal, institutional, and ethical guidelines. IRB
safeguards that questions relating to the participation of parents and caregivers in the
study were clear, and did not contain sensitive content. Ultimately IRB protected the
rights and welfare of participants in a study. The ethical concerns regarding parent
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participants in this study were privacy. I made every attempt to protect the private lives of
parent participants.
In qualitative research, the narrative can cause a divulgence of damaging
representation. This technique can cause uneasiness for participants as the narrative or
dissemination of results can include words or characterizations that intimately mirror the
target group. I was conscious of how this information would portray certain subgroups. I
was cognizant and mindful of conflicts of interest and sensitive issues surrounding
participant’s views, culture, and feelings. Ultimately, I am accountable for protecting the
privacy and interests of all participants.
Every parent participant signed a consent form. The consent form described the study and
explained the research topic. It was written in English, and on a grade level that the
parent participants understood. If at any time during the interview a parent felt
uncomfortable with the line of questioning, they could leave at free will, with no harm to
them. Furthermore, I removed any identifiable and personal information that might be
traced back to the participants. All data collected is kept in my locked desk drawer. After
five years, all data will be destroyed.
Summary
In this chapter, the research procedures for the study regarding perceived parental
barriers to free preventive oral care programs for their children were explained. I have
provided a detailed interpretation of the qualitative research design, and a rationale for a
case study approach appropriate for this study. I presented a sampling plan, study settings,
procedures for recruitment, data collection and analysis methods, based on a case study
approach to qualitative inquiry. I also discussed any potential bias and trustworthiness
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threats, and described a series of techniques, including the methods of triangulation, to
address these potential threats to the credibility of the research.
Furthermore, I included the observation checklist and an interview questionnaire in
Appendix A and Appendix B. Chapter 4 includes the results of this study, where I
describe the gathered data along with the method of analysis and a discussion of the
results.
Chapter 4: Results
Introduction
The purpose of this qualitative case study was to explore parental perceptions and
potential parental barriers to free oral health prevention programs for children. It was an
attempt to identify any repetitive themes that would prevent a parent from signing a
consent form or allowing a child to participate in oral health initiatives.
The primary qualitative question was the following: What perceived barriers
would prevent parents from having their children attend a free preventive dental care
program?
The sub questions were the following:
8. Is lack of trust an issue for parents?
9. Are cultural issues perceived as a barrier?
10. How can free preventive dental care programs more efficiently reach
children?
11. What are the real-life perceptions of these programs by parents?
12. What other life events prevent children from attending?
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13. What are parents’ perceptions of preventive dental care?
14. How was parents’ dental care addressed when they were children? This
chapter highlights the setting, demographics of the parent participants, data
collection techniques, data analysis, evidence of trustworthiness, and results.
Setting
Parent participant interviews were conducted at various locations to enable
cultural diversity in the findings. Interviews began in the beginning of May and ended at
the end of June 2017. The first set of interviews was at a Health Fair located in China
Town, NYC, outside Public School (PS) 130. The interviews captured a small, close-knit
Asian community as well as culturally diverse passersby who were interested in
discussing preventive-care-seeking behaviors. The second setting was in Flatbush,
Brooklyn, outside the church of Emmanuel of God. Once again, parent participants were
those who did not allow their children access to free oral health programs. Ethnic
backgrounds of residents in this area of Brooklyn included Haitian, Jamaican,
Dominican, and African American. The final group of parents were recruited outside
Public School 3, in Staten Island, NY, after their children had been escorted onto a school
bus on Staten during an early morning interaction between me and parental guardians.
Parent participants were Hispanic, and those who did not allow their children access to
free oral health programs.
Demographics
There were two men and 18 women parent participants. Parent participants’ ages
ranged from 22 to 49 years. Each parent had at least one child enrolled in an
underperforming NYC public elementary school. Children’s ages ranged from 18 months
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to 20 years. The average household in the study had two children, but participants had as
many as eight. Parent participants were from low socioeconomic backgrounds and were
living in low-income neighborhoods. In terms of ethnic and cultural background, there
were five Asian American participants, two Caucasian participants, four Hispanic
participants, and nine African American participants.
Data Collection
For this study, I interviewed 20 parent participants using a 22-question openended
questionnaire (see Appendix). Each parent participant read and signed the consent form
and matched the inclusion criteria. Once the parent participants agreed to participate,
they read and signed the consent form. They were asked to agree with being audio
recorded. After parents provided consent for audio recording, the interviews took place.
An initial conversation included a review of the purpose of the study and the particulars
in the consent form. Parent participants were reminded that participation was voluntary.
Participants were also advised that they could end the interview at any time. Their privacy
was emphasized, and they were assured that their identities would be protected and would
never be revealed. The audio recorded interviews lasted between 5 and 15 minutes,
depending on how much the parent participants wanted to elaborate on their answers. The
interview data were audio recorded using a digital recorder. Additionally, notes were
taken as parents spoke, and as parents exited the interview, I wrote down my thoughts
regarding the interaction on the questionnaire and observation form (see Appendix). I
thanked parents for their time and participation and gave each parent a $5.50 MetroCard
and a $15.00 American Express gift card. The audio recordings were immediately
downloaded into the sound organizer on my laptop. These audio recordings were then
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uploaded into NVivo 11 Pro, where they were transcribed verbatim by me. The
transcribed audio recordings were then highlighted for themes and coded.
Following the coding, a memo was created describing the interview and expanding on
ideas that emerged. The memos were linked to each of the transcribed interviews in
NVivo 11 Pro.
Characteristics of the parent participants are described in Table 1. Cultural
diversity by ethnic background is described in Table 2. Data were collected in the manner
described in Chapter 3 with no variations.
Table 1
Characteristics of Parent Participants
Characteristic
Number of
individuals
Male
2
Female
18
Average age
39
Age group
Under 30
31-41
Over 42
5
7
8
Average number of children
Number of children per parent
2.9
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5 children
6 children
7 children or more
11
5
4
Table 2
Cultural Diversity of Parent Participants
Ethnic background
Participants
Caucasian
3
Hispanic
4
African American
7
Asian
5
Indian
1
Total
20
Data Analysis
Following the case study methodology described by Saldana (2015), data analysis
consisted of gathering comprehensive and in-depth, detailed, rich information about each
parent participant by precoding, selective coding, creating analytic memos from
observations, and diagramming. Using case study methodology, data collection and data
analysis were done simultaneously, using a process of deduction, validation, and
inductive reasoning (Saldana, 2015). Data collection was stopped at 20 participants, at
which point saturation was achieved. Data analysis continued well after the data
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collection cycle. The purpose of data analysis was to establish an understanding of why
parents would not allow their child or children to attend a free oral health program.
Precoding
The precoding method consisted of highlighting and bolding notable quotes that
were worthy of attention during transcription (Saldana, 2015). Codes were created as new
concepts emerged. As the coding emerged, sub codes were added that highlighted similar
concepts. A total of 20 interviews were conducted, transcribed, and coded. A total of 23
nodes were created, resulting in nine categories. Table 3 includes the nine categories and
themes and the frequency of coded segments for the parent participants.
Table 3
Table of Codes and Categories and Themes
Categories and themes
Parent participants
Too busy, no time
5
Cost
7
Cultural
17
Immigrants
12
Lack of insurance
4
Lack of trust
21
Scared
9
Transportation
5
Importance of referrals
6
Analytic Memos
Following each interview, I created a memo or preliminary jotting (Saldana,
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2015) summarizing the interview and commenting on potential concepts and participant
observations. Analytic memos were set up to expand on new or emerging concepts.
Additionally, memos were used to store demographic information such as participants’
age, number of children, and date and time of interview. Memos were then updated to
summarize the interviews and analytic memos. This updated memo began the process of
moving concepts from codes to themes and categories.
Selective Coding
The concluding phase of data analysis was selective coding. This part of the
analysis allowed for inductive reasoning by connecting codes to repetitive themes, and
then final categories of expressed words, descriptions, and repetition of feelings
expressed by parent participants toward free oral health prevention programs. In this
process, direct quotes were taken from the transcribed interviews and original concepts
and narrowed into nodes by adding verbatim feelings of parent participants. The use of
diagrams was developed to describe the frequency of data.
Evidence of Trustworthiness
To ensure credibility, method triangulation was used with observations and
interviews. This double data collection technique enhanced the strengths and weaknesses
of each tool chosen (Northern Illinois University, 2013). Data triangulation in the form of
conducting interviews at different times and in different places was added as well.
Credibility was also assured by using the interview questions as a guide and keeping the
interview focused on the research questions.
To ensure transferability, rich content and contextual descriptions were provided
containing sufficient information about the participants, participant selection, sample size,
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and data collection and analysis methods. This abundance of description will allow for
the study to be replicated and conducted again with a different group of people or in a
different setting (Northern Illinois University, 2013; Patton, 2015).
The dependability of the study was maintained through investigator triangulation
and a detailed audit trail. Audio recorded interviews, along with transcriptions, were sent
to the committee chair for intercoder agreement. All codes, categories, and themes were
reviewed by the committee chair. Coding began immediately as I transcribed the
interviews. Transcripts were created by listening to each interview and typing each
response to a question word for word, reviewing and rewinding as needed. Transcribing
the recording verbatim allowed me to catch exact words and phrases from parent
participants. Confirmability was ensured by journaling during the research process and
constant self-reflection reduced bias.
Results
This eight research questions organize this results section. At the end of this
chapter, a unified explanation of the potential barriers to free preventive oral health
programs is presented.
Primary Research Question
The primary research question was as follows: What perceived barriers prevent
parents from having their children attend a free preventive dental care program?
The key themes and categories for the primary research question are presented in
Table 4. This question focused on what parents expressed as the reasons their child or
children were not attending free preventive oral health programs. The themes and
categories were supported by comments by parent participants. The themes were called
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too busy, no time and scared. The categories related to this theme were “not allowed as a
child, don’t care, laziness, time, and not important.” For instance, Mom14 expressed,
“they’re scared, or the parents themselves are scared, or they don’t have the time, it’s not
important, not the number one thing.” Mom14 suggested that parents “don’t gives
themselves enough time to bring their kids there.” Mom13 said, “I would say scheduling,
that it could be transportation and scheduling and staying organized if you have more
than one kid.” Mom16 suggested, “some people might not believe in doctors like
whatsoever, poor time management, no time to take them or they just don’t care.” Mom3
identified the following possibilities: “no insurance and that it’s a stigma that going to the
dentist is scary, and it might hurt.” Mom5 admitted, “sometimes I don’t have time
*laughs* to make an appointment to go there and get it done, that the hardest part.”
Mom6 thought that lack of attendance might occur “because they don’t care first of all or
they don’t understand the consequences or they’re not doing any prevention.” Mom8
offered, “maybe the child is scared, or maybe the parents feel like the work their child
may need might be a lot, say, the health insurance doesn’t cover the expenses for it.”
Mom9’s explanation was “way too busy.” Mom10 cited “convenience, laziness, getting
rest or relaxing.” Mom12 explained, “well, like I said, I think it’s, umm, a lack of
information.” Further, she said, “if kids are parenting young, they don’t have their family
push, left on there on devices it’s not a priority.” Mom12 went on to say that parents
“may not be exposed to it so they don’t think it’s a problem, I think that’s major.” Mom15
remarked, “I would say the way I was brought up, my father would not let us, so my
stance and some others I know, it’s the way we were brought up.”
Table 4
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Key Themes and Categories for Primary Research Question
Key themes
Categories
Selected extract
Busy, no time
Laziness
Scheduling
Transportation
Mom7: “too busy”
Dad1: “they don’t have the time,
it’s not important, not the
number one thing”
Mom10: “convenience, laziness,
I'm being absolutely honest,
ummmm, parents want
convenience, also a
combination of laziness and
just it’s, it’s for myself”
Mom14: “sometimes I don’t
have time *laughs* to make
an appointment to go there
and get it done, that the
hardest part”
Mom5: “I would say
scheduling, that it could be
transportation and scheduling
and staying organized if you
have more than one kid”
Scared
Might hurt
Concerned about cost
Worried about care
Mom14: “they’re scared, or the
parents themselves are scared”
Mom14: “maybe the child is
scared, or maybe the parents
feel like the work their child
may need might be a lot”
Mom8: “it’s a stigma that going
to the dentist is scary and it
might hurt”
Research Subquestion 1
The first subquestion was as follows: Is lack of trust an issue for parents?
The key themes and categories for Subquestion 1 are presented in Table 5. The
focus of this subquestion was the exploration of trust as a potential barrier to preventive
oral health program attendance. This subquestion was answered by participants from their
perspective as parents. The themes and categories developed are supported by comments
150
from the parent participants. The theme of this research question was; trust is an issue in
the lack of attendance from children at the free preventive oral health program.
Categories included the following: trust is not an issue, communication or language
barrier, lack of education, unsure of the program’s motive, and cultural issues relating to
child participation. However, as Table 6 indicates, the results were mixed, as 10 out of 20
parent respondents suggested that lack of trust was not an issue while the other half
suggested that it was.
Trust is not an issue. Half of the parent participants reported that trust was not an
issue when deciding whether their child or children were attend a free oral health
prevention program. For instance, Dad2 said, “no, trust would not be an issue.” Mom8
remarked, “no, it’s a benefit to the child, and parent, not to run around, and find
someone.” Dad1 expressed, “I would trust, I guess I would trust them, why wouldn’t a
parent.” Mom5 stated, “no, no, I don’t think so.”
Communication or language barrier. Parent participants expressed concern
when describing their feelings towards free preventive oral health programs for their
children. For instance, Mom 3 said, she would be more open to “someone who speaks
their language.” Mom12 remarked, “communication is a barrier, no one speaks the
language in the community, how will you bring awareness to a family if there’s a
communication and language barrier.”
Lack of education. A couple of parents suggested that education or lack of
proper education was a reason they did not allow their child or children to attend an oral
health program. Mom 15 said, “it was trust, and not getting myself educated, because I
thought that it was interns, again going off stuff that I had heard, it was interns, and they
151
didn’t know what they were doing.” Mom9 reported, “parents are not educated on it.”
Unsure of motive. A few parents reported they were unsure of the motive. This
uncertainty led them to the decision to decline their child admission to the free oral health
program. Mom9 said, “they think there’s a catch behind it.” Mom10 remarked, “right,
and what’s the motive, what are they getting out of it, they don’t want to genuinely help
us, when that’s the not the case all the time.” Mom6 reported, “I would have to meet them
first just to know that person first before they start doing health questions.” Mom13
expressed, “I think it’s the trust of confidentiality, we live in a society where it has been
broken a lot, so it’s more so anytime you hear you need to give social or private
information, like, for instance, if that’s done, how do you show client or customer that,
you know there’s a waiver that you signed off, to show its confidential info, or prove to
them your information is secure.” Mom16 remarked, “if they never met the doctor before,
they could be a little iffy about it.”
Cultural. A few parents reported reasons why they did not sign consent forms to
oral health programs for their child or children, were cultural. For instance, Mom10 said,
“someone I know, may not send her children, because she finds that people of color, treat
people of color, I don’t want to say better, for a lack of words, I guess a little bit more
attentive, that’s her experience, something that important to her go to someone.” Dad2
remarked, “culturally, no matter what race you are, pride is always an issue, I have to
share my personal information, there stereotyping the fact that there is something for free,
depending on what neighborhood you’re in, you know, and it’s kind of a shame, that most
African Americans, some people, may not go to that, like, if you put into a mixed
neighborhood, it stupid, its really about pride, because it’s like, we have this, and we have
152
that, and that with all races honestly.” Mom12 expressed, “like this is available, but like I
said, if you have this, umm, that they can’t get culture or group represented, to speak to
the group, it would be an easier connection, we can do this, and have access to it. Like
when a Caucasian comes into an all African American community people pull back, but if
I see someone of my own, or Muslim relating to me, like if I don’t understand the
dynamics of certain cultures, how they’re raised, and their own personal society, but
when they see one of their own, they will be more open to receive.” Mom15 voiced, “the
stories that my father gave us, when he was doing his stuff, and I don’t know if it’s true or
not, it was just my father’s way, that they used to run test on us immigrants, and they
didn’t care about immigrants, and it was just a way of them to doing things, tests on us,
before they gave them to the public, he really put that into our mind, like my brother still
don’t go to the doctor, and he’s a grown man so.”
Table 5
Table of Codes and Categories
Categories
Parent participants
Trust not an issue
10
Communication barrier/language
2
Lack of education
2
153
Unsure of motive
4
Cultural
4
154
Table 6
Is Trust an Issue for Not Participating in a Free Oral Health Program?
Parent participant
Yes
No
Mom 1
X
Mom 2
X
Mom 3
X
Mom 4
X
Mom 5
X
Mom 6
X
Mom 7
Dad 1
X
X
Mom 8
X
Mom 9
X
Mom 10
X
Mom 11
Mom 12
Mom 13
Mom 14
Mom 15
Mom 16
Dad 2
X
X
X
X
X
X
X
Total
10
10
155
Table 7
Key Themes and Categories for Research subquestion 1
Key
themes
Trust not
an issue
Categories
Selected extract
Did it as a child
Recommended
Benefit
Mom7 & Dad1: “grew up in Japan and every year we would see
a different dentist I think every year for me it’s so natural”
Mom6: “I mean if it’s like a dentist I don’t know or not
recommended maybe I would be a little bit more cautious”
Mom19: “Yes at least that’s a reminder to because they check it
and let me know to follow up with a dentist”
Mom8: “it’s a benefit to child and parent not to run around and
find someone”
Trust is
an
issue
Communication/language
barrier
Lack of education
Unsure of motive
Cultural
Mom 3: “would be more open to someone who speaks their
language”
Mom12: “communication is a barrier, no one speaks the
language in the community, how will you bring awareness to
family if there’s a communication and language barrier”
Mom 15: “it was trust and not getting myself educated because I
thought that it was interns again going off stuff that I had
heard it was interns and they didn’t know what they were
doing”
Mom9: “parents are not educated on it”
Mom9: “they think there’s a catch behind it” Mom10: “what’s
the motive, what are they getting out of it, they don’t want to
genuinely help us when that’s the not the case all the time”
Mom6: “I would have to meet them first just to know that person
first before they start doing health questions”
Mom13: “I think it’s the trust of confidentiality, we live in a
society where it has been broken a lot, so it’s more so anytime
you hear you need to give social or private information”
Mom16: “if they never met the doctor before they could be a
little iffy about it”
Mom10: “someone I know may not send her children because
she finds that people of color treat people of color I don’t want
to say better for a lack of words I guess a little bit more
attentive that’s her experience, something that important to her
go to someone”
Dad2: “culturally no matter what race you are pride is always an
issue I have to share my personal information there
stereotyping the fact that there is something for free
depending on what neighborhood you’re in you know and it’s
kind of a shame that most African Americans some people
may not go to that like if you put into a mixed neighborhood
it stupid its really about pride because it’s like we have this
and we have that and that with all races honestly”
Mom12: “like this is available but like I said if you have this
umm that they can’t get culture or group represented to speak
to the group it would be an easier connection we can do this
and have access to it”
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Research Subquestion 2
The second subquestion was the following: Are cultural issues perceived as a
barrier?
The key codes and categories for Subquestion 2 are presented in Table 8. This
question focused on ethnicity in relation to feelings that parents expressed about being a
patient, experiences with their children, or previous experiences with family members.
The subquestion was asked of all parent participants. Comments from parent participants
supported the themes and categories. Again, a few remarks were mixed; Asian parents felt
that it was natural to see whichever dental professional was available regardless of
culture, whereas parents of other cultures did not feel as comfortable with this. Table 9
presents key themes and categories for Subquestion 2.
Comfortable with their own culture. Parent participants reported feeling more
comfortable escorting their children to free preventive programs when they identified
with oral health professionals from their own culture. For instance, Mom3 said, “I guess
in Chinatown they probably want to stick with someone who speaks their language.”
Mom11 reported, that when she “seen someone up there from their ethnic background
and she felt more comfortable.” Mom12 expressed, “when these free oral health
programs can get culture or ethnic groups represented to speak to the group it would be
an easier connection for the community.”
Cultures’ health-seeking behavior. Parents reported that in certain cultures,
preventive oral health care is not important. In fact, Mom12 said, “minorities if it’s not
bad don’t worry, out of sight out of mind, if it’s not bad no worries, we respond to
emergency situation instead of prevention.” Mom13 remarked, “it’s kind of a shame, that
157
most African Americans, some people, may not go to that, like, if you put into a mixed
neighborhood, it stupid, it’s really about pride.”
Culture affected how they were raised.
Parent participants expressed how their family cultivated the way the used preventive oral
health programs. For instance, Mom12 reported, “if I don’t understand the dynamics of
certain cultures, how they’re raised, and their own personal society, I would not attend a
program, but when they see one of their own, they will be more open to receive.” Further,
Mom15 reported, that her experiences from her childhood effects how she and her
siblings attend preventive initiatives. Mom 15 went on to say, “what I went through with
my father, it’s sad to say, but most of the West Indians just feel like its a way for the
government to find out information so my father was very not wanting us to do it. I still
had that mindset, until I had my children, and until I got educated.”
Culture not seen as a barrier. Most of the Asian parent’s participants expressed how
they felt culture was not, or should not, be considered a barrier to free oral health
preventive services for children. In fact, for Mom7 and Dad1, reported “seeing a different
dentist yearly for a screening, was part of a free oral health program in Japan.” This was
considered a natural process. Other parent participants, such as Mom5 said, “they should
not have any restrictions. Mom8 was so surprised by the question, she reported, “can’t
think of any reason why they wouldn’t take their children to the school.” Mom10 said,
that for most of her life “my dentist is Jewish, I'm African American, Native American.’
Mom10 went on to say, that she now “sees someone from her own culture and is very
happy.”
158
Table 8
Table of Codes and Categories
Categories Parent participants Comfortable with own culture 4
Cultures’ health-seeking behavior 3
Affected how they were raised 3
Culture not seen not a barrier 6
159
Table 9
Key Themes and Categories for Research Subquestion 2
Key themes
Categories
Selected extract
Culture as a barrier
Culture not a
barrier
Comfortable with
own
How they were raised
Not an issue
Mom3: “I guess in Chinatown they probably
want to stick with someone who speaks their
language”
Mom11: “seen someone up there from their
ethnic background and felt more comfortable”
Mom12: “that they can’t get culture or group
represented to speak to the group it would be
an easier connection we can do this and have
access to it, like when a Caucasian comes into
an all African American community people
pull back”
Mom12: “minorities may feel like if it’s not
precedence I not their own family if it’s not
bad don’t worry, out of sight out of mind, if it’s
not bad, no worries we respond to emergency
situation instead of prevention”
Mom13: “the fact that there is something for free
depending on what neighborhood you’re in
you know and it’s kind of a shame that most
African Americans some people may not go to
that like if you put into a mixed neighborhood
it stupid it’s really about pride”
Mom12: “if I don’t understand the dynamics of
certain cultures how they’re raised and their
own personal society but when they see one of
their own they will be more open to receive”
Mom15: “I would say the way I was brought up
my father would not let us so my stance and
some others I know it’s the way we were
brought up”
Mom5: “They should not have any restrictions”
Mom8: “can’t think of any reason why they
wouldn’t take their children to the school”
Mom10: “my dentist is Jewish I'm African
American Native American”
Mom15: “for my case no”
160
Research Subquestion 3
The third subquestion was the following: How can free preventive dental care
programs more efficiently reach children?
The key codes and categories for research question 4 are presented in Table 10.
This question focuses on various ways parent participants expressed how to improve
child attendance at free preventive oral health programs. The research question was asked
to all parent participants. Comments from parent participants support the themes and
categories. Parents were very vocal in describing improvements towards child and parent
turnout. Table 11 presents key themes and categories for Subquestion 3.
Advertise more.
Parent participants reported that they did not receive enough flyers or handouts from the
program’s advertising when dental professionals would be visiting the children’s school.
For instance, Mom2 said, “wasn’t always aware of when they were coming, only when
they give us information.” Mom8 reported, “they don’t advertise it as much.” Mom15
responded, “I just wish the schools took more time to speak to the parents, I think that’s
what is it mostly.” Mom12 expressed, “a lack of information really parents might not be
aware of what’s available.”
Notices in my language.
Parent participants reported that when they first came to the country they could not read
the notices, or consent forms, their children took home. They expressed frustration, and
what they did with them. Mom15 said, “they would send a paper, and we used to throw it
away, we didn’t even look at it, we can’t read the paper, and some of us can’t read it.”
161
Mom10 responded, “I could not read the language, I did not let my son attend, I regret
that.”
Send reminders.
A portion of lack of child attendance, is related to the child not showing up. One of the
parent participants suggested how to send better reminders, in order to decrease failed
appointments. Mom13 reported, “you know what’s a good idea, sending reminders out,
the texting, that helps, even though I have a phone, tech savvy text messages help better
than the emails, and better than voicemail.” Mom 13 went on to say, “as a parent, when
do we have time to sit down and read all of our emails at the end of the day, and to read
all of them no.”
Table 10
Table of Codes and Categories
Categories Parent participants
Advertise more 4
Notices in my language 3
Send reminders 3
Table 11
Key Themes and Categories for Research Subquestion 3
Key themes
Categories
Selected extract
162
Unaware of
program
Advertise more
Notices or
consent forms in
my language
Send reminder
Mom2: “only when they give us
information”
Mom8: “they don’t advertise it as much”
Mom13: “sometimes when it is so public
people tend not to but when it’s a little
bit private they do attend sometimes
you catch those people that won’t
normally attend”
Mom10: “I could not read the language”
Mom9: “there’s a waiver that you signed
off to show its confidential info or
prove to them you information is
secure”
Mom15: “I just wish the schools took
more time to speak to the parents I
think that’s what is it mostly”
Mom12: “a lack of information really
parents might not be aware of what’s
available”
Mom15: “they would send a paper and
we used to throw it away we didn’t
even look at it we can’t read the paper
and some of us can’t read it”
Mom13: “you know what’s a good idea
sending reminders out the texting that
helps even though I have a phone tech
savvy text messages help better than
the emaid better than voicemail as a
parent when do we have time to sit
down and read our emails at the end
of the day and to read all of them no”
Research Subquestion 4
The fourth subquestion was the following: What are the real-life perceptions of
these programs by parents?
The key codes and categories for Subquestion 4 are presented in Table 12. This
question focuses on any perceived real-life barriers that might prevent a parent from
163
allowing their child or children to attend a free oral health program. The research question
was asked to all parent participants. Comments from parent participants support the
themes and categories. Parents were detailed in describing what they felt was a reallife
issue for non-attendance in these programs. Table 13 presents key themes and categories
for Subquestion 4.
All parent participants reported that these free preventive programs are great for
children. Their own experiences as a child have been mixed as one would assume. Most
parents indicated that they learned about improving their dental health through school.
Location, transportation, and cost, are consistent themes as barriers.
Table 12
Table of Codes and Categories
Categories
Parent participants
Location
4
Transportation
3
Cost
3
Table 13
Key Themes and Categories for Research Subquestion 4
Key themes Categories Selected extract
164
Location
Transportation
Cost
Distance to
event
How will I
get there?
Bus, train,
childcare
Mom12: “I think the location of where they’re
having it, you know, like, a free resource, we
having this program, but commute is great, or size
of family they may not have the resources to take
the whole group over there, and then child care
might be a factor, need someone to watch kid, lots
of other variables, its secondary but a factor of
locale”
Mom10: “have to pay for self and children”
Mom6: “the cost”
Mom9: “they don’t have no funds”
Table 14
Average Experiences for Parent Participant Responses
_______________________________________________________________________
Negative Positive
Their experiences as a child 10 10 Learned about
oral health in school 15 05 Learned about oral health
from family 05 15
Their children’s experience is better 20 0
Experiences with Medicaid 14 06
Believe dental problems are as serious 19 01
as other health problems
Research Subquestion 5
The fifth subquestion was the following: What other life events prevent children
from attending?
The key codes and categories for Subquestion 5 are presented in Table 15. This
question focuses on any other life events that may prevent a parent from allowing their
child or children to attend a free oral health program. The research question was asked to
all parent participants. The themes and categories are supported by comments from parent
participants. Parents were detailed in describing what they felt was a real -life event that
165
might present for non-attendance in these programs. Table 16 presents key themes and
categories for Subquestion 5.
Some parent participants reported that scheduling was a potential issue for not
signing parental consent forms. Scheduling and getting to the event, were described as
being hard. Some parents reported that they feared pain. Parents also indicated that either
they or their child was afraid of pain. One Mom said, it was a stigma, that going to the
dentist is scary, and it might hurt. Once again, cost was an issue. Mom6 said, “the cost,
and also sometime, if they got some work done on the teeth that was difficult or painful,
they don’t want to go back.”
Table 15
Table of Codes and Categories
Categories
Parent participants
Hard to schedule
4
Scared
3
Cost
3
Table 16
Key Themes and Categories for Research Subquestion 5
Key themes
Categories
Selected extract
166
Schedule
Scared
Cost
Difficulties making
appointment
Painful, fear of unknown
Worried about money
Mom16: “no time to take them”
Mom13: “I would say
scheduling and staying
organized if you have more
than one kid to make an
appointment to go there and
get it done that the hardest
part”
Mom5: “to make an
appointment to go there and
get it done that the hardest
part”
Mom2: “hard to schedule”
Mom3: “it’s a stigma that going
to the dentist is scary and it
might hurt”
Mom8: “maybe the child is
scared”
Mom14: “they’re scared or the
parents themselves are
scared”
Mom2: “I don’t have insurance
I don’t care I wouldn’t go as
much it’s just costly”
Mom 8: “health insurance
doesn’t cover the expenses for
it”
Mom12: “if they don’t have the
finances and have to pay out
of pocket might be a
hindrance, if finances are
kind of tight”
Mom6: “the cost, and also
sometime if they got some
work done on the teeth that
was difficult or painful they
don’t want to go back”
Research Subquestion 6
The sixth subquestion was the following: What is the parents’ perception of
preventive dental care?
167
The key codes and categories for Subquestion 6 are presented in Table 17. This
question focused on the parent’s perception of preventive dental care. The questions were
asked specifically to understand parents’ experiences as children as well as their
perception of preventive dental services for their children. The research question was
asked of all parent participants. Comments from parent participants supported the themes
and categories. Parents spoke freely and were detailed in describing their personal dental
experience and that of their children. Table 18 presents key themes and categories for
Subquestion 6. All 20 parent participants reported, “dental problems are as serious as
other health problems.”
Table 17
Table of Codes and Categories
Categories
Parent participants
Negative experiences as a child
4
Parents aware of consequences
9
Children are unaware of consequences
10
Table 18
Key Themes and Categories for Research Subquestion 6
Key themes
Categories
Selected extract
168
Negative experiences as a child
Parents aware of consequences
Children are unaware of
consequences
Traumatizing
Make appointments, take them
to the dentist regularly
No idea, don’t realize
importance
Mom3: “I don’t have the best
care when I was a kid they
don’t say what’s going to
happen before it happens they
do things and so it’s a little bit
traumatizing”
Mom15: “for me it was
difficult but for my kids it was
easy”
Dad2: “never went to dentist as
a child”
Mom6: “taking them and
making appointments on a
regular basis”
Mom3: “bring them to a
dentist every 6 months”
Mom2: “prevent them from
eating more too much candy
sweets are not too good once in
a while its ok”
Mom13: “some are and some
aren’t I think the younger
generation is becoming more
aware I think it’s more so like
rather they are aware of it but
do they practice it” Mom3: “I
don’t think they realize that
to get rid of how important it
is to have clean teeth before
they go to sleep” Mom6: “no
I don’t think they know that’s
why it important to take
them”
Research Subquestion 7
The seventh subquestion was the following: How was the parent’s dental care
addressed as a child?
The key codes and categories for Subquestion 7 are presented in Table 19. This
question focuses on how the parent’s dental care was addressed as a child. The
169
research question was asked to all parent participants. Comments from parent
participants supported the themes and categories. Parents were detailed in describing
their dental experiences as a child. Table 20 presents key themes and categories for
Subquestion 7. Some parent participants reported never visiting a dentist as a
child. Others reported traumatizing experiences. Mom3 said, “when I was a kid they
don’t say what’s going to happen before it happens, they do things, so it’s a little bit
traumatizing.” Most parents expressed that not having dental insurance would
be a barrier to care. For instance, Mom2 indicated, “I don’t have insurance I don’t care
I wouldn’t go.” Parents reported that the way they learned to take care of their teeth
was at school. In fact, Mom15 responded, “when I was growing up it was from school
not from my parents.”
Table 19
Table of Codes and Categories
Categories
Parent participants
Never taught at home
5
Would not go without insurance
9
Table 20
Key Themes and Categories for Research Subquestion 7
Key themes
Categories
Selected extract
170
Never taught at home
Would not go without
insurance
Oral health
education
Infrequent dental
visits
Mom1: “my dentist first of all
then school”
Mom15: “when I was growing up
it was from school not from my
parents”
Dad2: “health class in school”
Mom11: “I don’t that often
because I might have been I
might be not having insurance I
would be embarrassed that
somebody is not going take me
without it”
Mom12: “it’s just that the
information is not really out
there where people would be
more accessible or more
exposed to it”
Mom2: “I don’t have insurance I
don’t care I wouldn’t go”
Summary
In Chapter 4, the results of this study were presented. The results presented are
associated with the research question and subquestions. To answer the primary research
question, parent participants were asked what perceived barriers would prevent a parent
from having their child attend a free preventive dental care program. The themes
associated with this research question were a lack of time and scared. To answer the first
subquestion, parent participants were asked; is the lack of trust an issue for parents. The
theme associated with this research question was divided, as half of the parents reported
that trust was an issue; while the other half reported a non-issue. To answer the second
subquestion, parent participants were asked if cultural issues were perceived as a barrier.
The themes associated with this research question was either culture was an issue or it
171
was not. Asian parent participants felt comfortable seeing whoever was available,
regardless of the ethnic background, while other cultures do not feel as satisfied. To
answer the third subquestion, parent participants were asked how can free preventive
dental care programs more efficiently reach children. The theme associated with this
research question were unaware of the program, and advertise more effectively. To
answer the fourth subquestion, parent participants were asked what are the real-life
perceptions of these programs by parents. The themes associated with this research
question were location, transportation, and cost. To answer the fifth subquestion, parent
participants were asked what other life events prevent children from attending. The
themes associated with this research question were challenges in scheduling
appointments, scared, and cost. To answer the sixth subquestion, parent participants were
asked what is the parent’s perception of preventive dental care. The themes associated
with this research question were negative parental experiences as a child, parent’s
awareness of dental periodicity, and children unaware of the consequences of poor oral
hygiene. To answer the seventh subquestion, parent participants were asked how was the
parent’s dental care was addressed as a child. The themes associated with this research
question were, never taught how to take care of their teeth at home, and they would not
frequent, or journey to the dentist without dental insurance.
The discussion of the results described in this chapter, recommendations, and
conclusions will be presented in Chapter 5.
172
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
A qualitative case study design was used to explore the oral health perceptions
and dental care behaviors of parents with children aged 5-15 years in underperforming
Title I, New York City, elementary schools. The purpose of the research was to illuminate
and apprehend the unique problem of low preventive dental care program attendance and
to understand perceived parental barriers to the use of such programs. Recognizing the
numerous oral health perspectives of parents regarding their children enabled awareness
of parental refusal of preventive care, which may, in turn, help in identifying the social,
economic, and policy implications of oral health decision making.
Key Findings of the Study
Nine themes emerged from the data relating to perceived parental barriers to free
oral health programs. Of those initial nine, repetition was found in six of the themes: too
busy/scheduling, scared, cultural differences/immigrants, trust, cost, and lack of
insurance.
The first theme, “too busy,” captured the way that some parents described
potential reasons for not escorting their children to preventive oral health programs.
Parents said they just “didn’t have time.” Parents also described either “scheduling an
appointment or keeping a scheduled appointment” as a challenge in attending oral health
services.
The second theme, “scared,” captured a way that parents described either their
feelings about going to the dentist or how they thought the children would feel about
receiving dental care or attending an oral health program.
173
The third theme, “cultural differences,” related to cultural influences on
preventive health care decision making, how cultural dissimilarities weighed decisions on
how parents chose oral health providers, and why parents decide not to seek preventive
services. Lack of trust emerged as parents expressed concerns over dental professionals
not speaking their language, or not looking the way, they did. Parents were hesitant to
attend a program where their “ethnic background was not represented.”
The fourth theme, “unaware of the program,” involved how parents reported lack
of knowledge about a free preventive program for their children. The fifth and sixth
themes were related to cost and money. “Costly” was how parents described how money
was a concern in relation to dental care. Cost and money influenced decisions regarding
transportation and childcare, as well as the way parents felt about dental care.
The seventh theme, “negative experiences or traumatizing as a child, “related to
how some parents described receiving dental care as children.
The eighth theme, “lack of dental insurance,” was expressed as a barrier to dental
care visits. Most parents expressed that they “would not go to the dentist without dental
insurance.”
Themes and categories from each of the eight research questions can be narrowed
down to the following: time, money, scared, cultural differences/lack of trust, and lack of
insurance as potential parental barriers to preventive oral health programs. Time,
money/cost, scared/fear, and lack of insurance are themes that have been reported in
numerous previous studies. Themes of culture and trust are contemporary concepts.
174
Culture and Trust
One of the original themes to emerge from this study is cultural issues and trust.
For instance, parents reported that they “probably wanted to stick with someone who
spoke their language” (Mom3). If they saw someone who “resembled themselves or had a
more familiar face and communication, and values, an individual with high esteem, or
seen as a leader, parents were more willing to attend” (Mom11). One parent participant
questioned the motives of others who were not of the same culture, wondering, “what’s
the motive, what are they getting out of it, they don’t want to genuinely help us when
that’s the not the case all the time” (Mom10). This statement indicates trust issues;
moreover, the parent participant stated that she might not send her children because she
had found that “people of color treat people of color—I don’t want to say better, for a
lack of words, I guess a little bit more attentive, that’s her experience, something that
important to her to go to someone” (Mom10). Parents openly responded that trust and
cultural history were issues for them. Mom15 explained, “it was trust and not getting
myself educated because I thought that it was interns again going off stuff that I had
heard, it was interns and they didn’t know what they were doing.” She reflected, The
stories that my father gave us when he was doing his stuff, and I don’t know if it’s true or
not, it was just my father’s way that they used to run test on us immigrants and they
didn’t care about immigrants, and it was just a way of them to doing things, tests on us
before they gave them to the public. (Mom15)
Parents described “lack of trust and of confidentiality,” remarking that “we live in a
society where it has been broken a lot” (Mom13). Parents also suggested that no matter
what race you are, pride is always an issue; I have to to share my personal information
175
their stereotyping the fact that there is something for free depending on what
neighborhood you’re in, you know, and it’s kind of a shame that most African
Americans, some people may not go to that, like if you put into a mixed neighborhood,
it stupid, it’s really about pride because it’s like we have this, and we have that, and that
with all races honestly. (Mom13)
Unaware of the Program
Another interesting concept arose during the interview regarding ways that oral
health programs can effectively reach parents. This question may have never been asked
before. Parents were more than willing to share insights into ways that these programs
can attract parents and convince them to keep scheduled appointments. For instance,
parents made the following comments: “we are not notified, only when they give us
information” (Mom2); “they don’t advertise it as much” (Mom8); “I just wish the schools
took more time to speak to the parents; I think that’s what is it, mostly” (Mom12); “a lack
of information, really; parents might not be aware of what’s available” (Mom15). Some
parents discussed language barriers: “I could not read the language” (Mom10); “they
would send a paper, and we used to throw it away; we didn’t even look at it, we can’t read
the paper, and some of us can’t read it” (Mom15). Mom19 mentioned a “waiver that you
signed off to show its confidential info or prove to them your information is secure.”
Other participants suggested ways to send reminders:
what’s a good idea, sending reminders out, the texting, that helps, even though I
have a phone, tech-savvy text messages help better than the emails and better than
voicemail. As a parent, when do we have time to sit down and read our emails at
the end of the day, and to read all of them, no. (Mom13)
176
Interpretation of the Findings
This study confirms themes of time, cost, lack of insurance, and fear that were
found in previous studies (Baldani, 2011; Chi, 2014; Kelly, 2005; Rahbari & Gold, 2015;
Wallace & MacEntee, 2011). Additionally, it highlights new themes, such as lack of trust
and cultural differences (Baldani, 2011; Rahbari & Gold, 2015). It also confirms that
cultural sensitivity and trust in dental professionals are still lacking (Divaris et al., 2014;
Kierce et al., 2016). It also confirms that encouraging, supporting, and educating
caregivers on oral health care are integral to improving children’s oral health (Divaris et
al., 2014; Kierce et al., 2016). Further, it confirms that cultural compatibility and
sensitivity are needed in public health areas (Wallace & MacEntee, 2012).
In a similar study by Kelly et al. (2005), parents who did not take their children
for preventive oral care were not aware of the consequences of poor oral health. This
study disconfirms Kelly et al. (2005), in that all parent participants responded that they
were aware of the consequences of poor oral health. In fact, all 20 parent participants
indicated an understanding that dental problems are just as serious as other health
concerns. A limitation of the Kelly et al. (2005), study was the lack of diversity in
participants. The current study represents a more diverse group of parent participants.
Guarnizo-Herrano and Wehby (2012), and Askelson et al. (2015), suggested that there
was limited evidence-based knowledge regarding how parental influence affects
preventive dental-care-seeking behavior for children. This study adds to the knowledge
base by highlighting that “minorities may feel like if it’s not precedence, it’s not their
own family, if it’s not bad, dont worry, out of sight, out of mind, if it’s not bad, no
worries; we respond to emergency situation instead of prevention” (Mom12).
177
Baldani et al. (2011), suggested that cultural beliefs and perceptions regarding oral
health are important individual barriers. This study confirms Baldani et al., in that
parental belief systems can positively and negatively influence ways that parents seek
free preventive care. Rahbari and Gold (2015), in a pilot study found that mothers’ oral
hygiene habits and frequency of dental visits related to the oral hygiene habits and
frequency of dental visits of their toddlers. This study disconfirms Rahbari and Gold
(2015), because parents in this study often did not have dental care as children yet
reported they wanted to take their children to the dentist. Additionally, parents often
reported that they had learned about dental care through school or from their dentist, not
from their parents.
Theories
This study incorporated behavioral change theories such as that of Prochaska and
DiClemente (1983) and the TTM of behavioral change, as well as Bandura’s (1986) SCT,
which indicates that self-efficacy is the belief that changes in behavior will result in
positive outcomes (Jones et al., 2014). If the threat of dental caries is high and the
severity of pain or dental disease higher, people tend to adopt behavioral change
(Jamieson, 2014). This study confirms that the perceived threat of dental disease was not
high in parents; therefore, behavior change such as signing a consent form for a free
prevention program for their child or children was not likely during the time of the study.
Both stages of change constructs were associated with poor self-rated oral health and oral
health impairment. This study confirms that poor self-rated oral health is related to both
non ideal dental visiting patterns and higher levels of dental disease experience (Jamieson,
2014). SCT explains how parents observe, imitate, and learn health care behaviors based
178
upon social surroundings in the neighborhood. It can be confirmed with responses in this
study indicating that parents seek preventive care from a “referral, someone a friend
recommends, word of mouth.” Asking people such as friends, family, and neighbors for
referrals is critically important, and “referrals says a lot.” Using SCT helped to explain how
the interaction between the environment and self affects parental behaviors. Parents tend
to imitate and follow those they look up to and resemble.
Limitations of the Study
One of the biggest limitations of this study was the discussion of personal
information, such as the oral and dental care habits of parents and their children. There
was the possibility of inaccurate reporting of perceived barriers by parents on the
openended questionnaire. During the interviews, parents decided what they wanted to
share. Most parents said that they would allow their children to attend a preventive oral
health program; however, there was no proof that this was true. In fact, the nurse/health
manager at the school suggested that out of 300 parents, only 30 signed the consent form.
This tied into the arousal of response bias among the parents in the sample, such as the
tendency to agree with positive statements, supply limited responses, or respond in ways
that were thought to be socially desirable or culturally appropriate. Another limitation of
the study may have been the divulgence of incorrect personal information on the
sociodemographic questionnaire or consent form. However, most parents in this study
were honest about their age and ethnicity. The final potential limitation was researcher
bias; however, this was minimized through triangulation of data whereby one other
researcher reviewed and analyzed the data.
179
Recommendations
A major finding in this study was how culture and ethnicity contributed to
whether or not parents allowed their children to attend an oral health program. In future
research, culture and ethnicity should be further investigated. Additionally, in future
studies, cultural elements such as familial history, language, immigration status, and the
changing demographics of neighborhoods should be assessed before initiating a
preventive oral health program. There continues to be a need to explore qualitative data
on maternal attitudes and behavior in relation to maternal or caregiver preventive health
seeking (Guarnizo-Herrano & Wehby, 2012). Because this study addressed multiple
ethnicities, it is interesting to note that the majority of Black parents expressed a lack of
trust in free preventive oral health services when compared to their Asian counterparts,
who were exposed to these services as children. Perhaps future research can attempt to
replicate findings to see if early exposure as children and increased attendance can be
generalized or explored further. If Black parents are “skeptical of who’s” running oral
health initiatives, perhaps there is a need to incorporate more leaders and dental
professionals from the neighborhood to increase child attendance.
Social phenomena such as facial recognition of leaders as well as referrals and
recommendations of providers and health services play a part in how members of certain
cultures seek preventive oral health care. Parents identified “referrals, recommendations,
and recognition of community leaders” as ways to encourage parental consent. More
research is needed to better understand how interactions in social networks relate to how
parents seek preventive oral health services (Chi, 2014; Valenti, Palinkas, Czaja, Chu, &
Brown, 2016). Future research is needed for developing multidisciplinary designs to
180
understand the social and behavioral phenomena related to parents or caregivers’ denial
of preventive care to help caregivers make optimal preventive care decisions for their
children (Chi, 2014). Parents expressed a lack of preventive education and an “out of
sight, out of mind mindset.”
Parents also mentioned that they “were not educated enough” to understand the
importance of oral health interventions. Dodd et al. (2014) suggested that changing
current perceptions of preventive oral health care so that it is seen as a necessity rather
than a luxury will require multiple educational interventions. Future research should
include the addition of educational intervention for parents to ascertain whether
perceptions change.
Implications
In promoting increased rates of children attending free preventive oral health
programs, this study may help the nation achieve its goal of 50% reduction in dental
caries in children by 2020 (Office of Disease Prevention and Health Promotion, 2017). A
reduction in caries can first be attained by educating children on prevention and proper
oral hygiene, such as brushing twice daily with fluoride toothpaste and having fluoride
varnish applied to teeth to protect them from dental caries. Children can take this learned
information home and help to educate and change the oral health habits of their parents.
For instance, children often read the handouts that are sent into their households from
dental professionals; as one participant remarked, “my daughter reads everything to me”
(Mom15).
Some common social and behavioral issues arose, such as “skepticism of these
programs” and a “lack of trust from those that are not educated” or “immigrants from
181
another country.” This knowledge could enable universities, colleges, and professional
organizations to tailor strategies such as using dental professionals who “match
ethnically” with clients or are “leaders in the community” to talk with parents in order to
raise the number of children benefiting from preventive dental services (Mom11). Trying
alternative measures such as “taking more time to speak with parents” (Mom15), learning
about the culture, and languages spoken in the community beforehand can be beneficial
to increasing program sustainability. Additionally, by showing “passion and love for the
community” (Mom11), and demonstrating that they “genuinely want to help” (Mom10)
may increase parental acceptance.
On the community level, and nationally, poor oral health issues contribute to more
than 51 million lost work and school hours (Devlin & Henshaw, 2011; Jackson et al.,
2011; New York State Department of Health, 2017; NIH, 2014). Parents expressed
unawareness of free preventive programs. Parents also made suggestions such as
“sending out more flyers or more media.” Parents suggested that programs “send out
more posters … send more home to parents, a way to send out more information …,
spread the word more” (Mom14). Making more people aware of the program might
enable the community to become stronger in its struggle to increase acceptance of quality
preventive dental care programs for children.
Conclusion
Oral health has a significant impact on the overall health and well-being of
individuals and the nation (Devlin, 2011; NIH, 2014). Poor oral health leads to illnesses
that affect and restrict one’s ability to work, learn in school, function at home, and
diminishes the quality of life (Healthy People, 2010; Jackson, 2011; NIH, 2014; Kierce et
182
al., 2016). Dental caries is a preventable disease. However, 42% of children aged 2
through 11 years old have had dental caries in their primary (baby) teeth. Additionally, 21
% of children have distressing untreated caries in their permanent (adult) teeth (NIDCR,
2014). A disproportionate number of dental caries can be found in certain low
socioeconomic communities such as Black, Hispanic, and Mexican (CDC, 2015;
Koppelman & Cohen, 2016). Reducing oral health disparities in children has been on the
agenda of the US Department of Health and Human Services (HHS), dental universities,
colleges, and professional dental associations through initiatives such as Healthy People
2010, 2020, 2030, and free preventive oral health programs (Adesanya, Bailey, Belcher,
Beltran, Branch, Brand, Craft, Donohue, Dye, Thorton-Evans, Garcia, Hyman, Joskow,
Lester, Makrides, Manksi, Mehegan, Mouden, Nelson, Norris, O'Hara, Cherry-Peppers,
Ricks, & Rollins, 2016).
Parents or caregivers should understand the consequences for not taking their
children to the dentist or a free preventive oral health program. This research shows they
still do not. Parents are not receiving the information they need to educate themselves on
the necessity for dental care for their children. In this study, parental concepts such as the
lack of trust and cultural dissimilarities emerged as themes, as did themes of; money, fear,
lack of insurance, unaware of program, transportation, time, and location/access to care.
These findings illustrate the need for dental professionals to be from the
community. Dental professionals need to physically resemble the individuals found in the
neighborhood, or at least have a passion for enabling change. These oral health providers
can be recognized leaders, or come from referrals, which will enhance and encourage
trust, and program sustainability. Dental universities, colleges, and professional
183
organizations, need to find more creative ways to educate parents on the importance of
children’s oral health.
Untreated dental caries is painful. Children often do not have a voice or choice in
seeking preventive care. Identifying parental refusal of preventive care can help socially,
economically, and with policy implications towards positive oral health decision-making
for children.
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