URC

Use of a Focus Group of Chariton County Citizens to Investigate Opinions, Attitudes, and Recommendations for the Chariton County Oral Health Program

Whitney Trusty
Courtney Perrachione
Truman State University


Abstract

The purpose of this study was to conduct two focus groups to investigate the opinions, attitudes, and recommendations for improvement of the Oral Health Program in Chariton County, Missouri. A focus group interview guide included questions about each participant’s perceptions of the Chariton County Oral Health Program Initiative and how the program might be improved over time.

“Affordability” and “access” were repeatedly reported as important factors in whether or not a Chariton County citizen would seek oral healthcare. Chariton County faces challenges similar to those of other communities when attempting to incorporate a dental health program into the area.

Introduction

Among the concerns with America’s children, tooth decay is the most prevalent and also the most treatable. Tooth decay affects people of all ages and directly affects the overall health of individuals. Over 108 million Americans lack dental insurance coverage, compared to 47 million Americans who lack health insurance (Fisher-Owens et al., 2008). Moreover, many of those with coverage do not receive dental care for reasons such as inability to pay out of pocket, lack of access to dental care, fear, and lack of understanding that oral health affects overall health. In order to decrease the prevalence of tooth decay, it is vital to provide appropriate access to dental care and to educate the public about its importance of dental care.

Incorporating a dental health program or a dental private practice into a community can be challenging. In a low income, rural area, it is especially important that the local dentist accept Medicaid because “low-income children have twice as much dental caries as their more affluent peers” (Lalumandier & Molkentin, 2004). According to Griffith (2003) many people are unable to receive appropriate care due to a shortage of dentists who accept Medicaid. In the state of Missouri, dental offices accept MC+, which helps many low-income children to receive adequate dental care. The use of a mobile dental care unit is another good option for serving a large area with a shortage of available dentists. This service combats the barrier of physical proximity by allowing all citizens of an area to receive adequate care. One major disadvantage to a mobile dental care units is that they are to be used primarily for preventive, diagnostic, and referral services. A permanent dental clinic is preferable when performing more extensive dental procedures (Griffith, 2003).

An article entitled “Establishing a Dental Practice in a Rural, Low-Income County Health Department” explained how a health department in rural North Carolina established a dental practice in Pender County. The authors “found it very difficult to recruit and retain professional staff.” Because of this possibility, it is important to offer a competitive salary, if possible, or to supplement a lower salary with other employee benefits. The Pender County dental practice offered “more flexible clinic hours and family leave time” (Griffith, 2003).

Although providing access to dental care is vital to receiving care, many more barriers exist. A study performed by Kelly, Binkley, Neace, and Gale (2005) found that caretakers who perceived oral health to be associated with overall health were more likely to take their child to the dentist. “Nonutilizing” parents (parents who do not take their children to the dentist despite enrollment in Medicaid) were also more likely to state “aesthetic motivations (appearance and self-esteem) as being more important reasons than health concerns for accessing care.” Clearly when budgets are tight, aesthetic needs are likely to go unmet. Furthermore, “Nonutilizing White caregivers reported that dental care was less important than other medical care and they would engage in preventive health behaviors before preventive dental care.” The belief that dental care is separate from overall health is only compounded by the lack of funding provided for dental care. Clearly, education about the importance of dental care can help encourage individuals, parents, and children to engage in proper oral health behaviors, but policy change regarding the funding of dental care is required before these preconceived beliefs can be fully changed.

Because tooth decay is preventable and changeable, it is imperative that a system of dental care be available in all communities. Improving access to dental care will allow many of those with dental insurance coverage to receive the care they need. It is also important to treat those who lack dental coverage when funding is available. Furthermore, education about proper oral health behaviors and the importance of receiving regular dental care is a fundamental step in improving oral health in the community. Thus, the purpose of this study was to use a focus group to investigate the perceptions of Chariton County, Missouri, citizens about the availability of a system of dental care for their community.

Methods

Sample

After institutional IRB approval, as well as participant consent, a focus group consisting of 20 members of the local School Health Coalition and four members of the Board of Trustees of the Chariton County Health Center was convened January 12, 2009 at the Chariton County Health Center. A second focus group consisting of 11 citizens, mostly parents or those involved with youth-serving organizations, was convened at the Chariton County Health Center April 9, 2009.

Instrument

A written questionnaire consisting of ­14 questions was used as an interview guide by the investigators to facilitate the focus groups (Appendix A). The questionnaire was reviewed and critiqued by Chariton County Health Center experts and subsequently revised. Each question was open-ended to encourage as much participation as possible. The questions concerned each participant’s perceptions of the Chariton County Oral Health Program Initiative and how the program might be improved over time. The questions moved from introductory/opening queries about the importance of good oral hygiene to key Questions about access to oral health care and utilization of the Chariton County Oral Health Program Initiative (Chariton Smiles) program. Ending questions asked about specific strategies recommended for establishing and incorporating a new dentist into the community and how others in Chariton County might be encouraged to visit the dentist regularly and take part in the dental screenings and sealants program.

Procedure

Before conducting the two focus groups, the facilitators were trained in group facilitation skills and group dynamics by an experienced certified health education specialist. The facilitators conducted the focus groups during regularly scheduled Board meeting times. The focus group was used as an exploratory process to generate ideas and uncover opinions and attitudes of a group of generally homogeneous participants in a familiar, comfortable setting.

A focus group script was created to ensure a reliable structure for more accurate results for the two separate focus groups. The script included a time for introduction to allow the investigators to inform the participants of the use of the tape recorder. The participants were advised that they may leave at any time and the tape recorder would be turned-off if that was the participants’ preference. Following the introduction, the questions were presented, followed by a closing, giving the participants an additional opportunity to express opinions and ask any additional questions.

The conference room in the Chariton County Health Center was chosen for the focus groups. Tables were set up in a round-table fashion with all participants facing each other. The investigators maintained a casual, open-minded atmosphere to encourage full group participation. The focus group script was followed by the investigators conducting both groups to maintain reliability and to ensure the discussion remained on task. All responses were recorded by the notes of two research assistants and by audiotape.

Analysis

The focus group sessions were recorded and transcribed, key words, trends, and themes were tracked and analyzed.

Results

Focus Group #1

“When I was a kid, dentists were always on the second floor of the building and by the time you got halfway up the stairs all you wanted to do was run right back down them. I don’t want that for my grandkids.” (Focus group #1 participant)

This focus group allowed members of the School Health Coalition to discuss recommendations on how improve the dental health system in the Chariton County community. Participants were able to speak freely about opinions or strategies they had concerning past programs as well as future planning.

In the introductory/opening questioning about the definition of good oral health, group participants seemed to agree that “having a good smile” symbolized good oral health along with having “straight teeth” and “being pain free.” The importance of oral health was generally rated as high, but not as high as physical health, especially when finances could not cover both types of healthcare. Even though all participants agreed that “oral healthcare and overall healthcare were integrally tied to each other,” it was also noted that other citizens would be less likely to see a dentist than a doctor, unless they were in serious pain.

During the key questions discussion, it became clear that the Chariton Smiles program was making great strides in the community’s awareness of and belief in the importance of good oral healthcare. Because there are not very many dentists in or around Chariton County, the program, specifically dental screenings for their children during school-time, has been viewed as “very helpful” to parents. Interestingly, when asked by Health Officials, some students are now able to name a dentist faster than they can name a doctor!

“You can’t have bad things going on in your mouth and feel good.” (Focus group #1 participant)

Participants noted that there were still a few barriers to accessing the Chariton Smiles program for some families. For example, some participants noted a feeling that parents were afraid to have their children participate in the oral health screenings because of the possibility of further expensive dental work. Other concerns were that if extensive work was needed for a child, other than by the area dentist, there were no specialists within a reasonable driving distance. To access an oral surgeon or orthodontist, the families would have to travel a long distance. Other barriers to treatment included work schedules, insurance difficulties or non-acceptance, cost, and lack of awareness.

Based on these deterrents, participants were asked for other suggestions for the Oral Health Program. Responses included: flat rates for some procedures with sliding scale costs for others, payment plans to be made available and advertised, dental varnishes to be available in schools, and money set aside to continue yearly dental screenings at schools.

During ending questions, participants were asked how to encourage others to go to the dentist. Most noted that having a dentist in Chariton County would make dental visits much more accessible for families. Similarly, having a dentist with very flexible and evening hours would also make visits more convenient. Promoting dental care as important for adults and the elderly and not just for children was encouraged. Above all else, affordability was repeatedly reported as a huge factor in whether or not a Chariton County citizen would seek oral healthcare.

“I think a lot of people around here have ties to farming, and they all have huge deficits they’re willing to pay, they just can’t pay it up front.” (A focus group #1 participant talking about payment plans for dental care)

Participants remarked that one dentist attempted to establish a local practice Chariton County. He could not keep his business afloat and had to move elsewhere. In order to make sure that the new dentist is able to stay, practice, and survive in the County, the focus group was asked to recommend ways to help establish and incorporate the dentist into the community and the culture. Even before arrival, it was recommended that the Health Center promote the new dentist by newspapers and fliers. “The more people hear his name, the more they will remember him and consider [making appointments]”. It was recommended that the new dentist be assigned as primary dentist to children who have no listed dentist in school records. While promoting the new dentist, “it should be made abundantly clear what his office hours are, what kinds of insurance he takes, what his payment options are, and how far he is in comparison to other dentists who are farther away”. This will help break loyalties to dentists outside of the community who are too far away to be truly helpful or about to retire anyway. Parents will also need to be educated about “planning ahead for dental work.” Other considerations include emergency and preventive care.

Many participants recommended familiarizing the dentist with families and the community and promoting a sense of community by hosting an Open House at the dental office. School field trips to the dentist office would familiarize students. Others offered the following suggestions: “WIC could also pass out information to new parents who will need a dentist and get them thinking about dental care . . . .” “If the dentist could be included in the Health Fair in the spring, that would also help establish his name and connection to the community,” “Any chance for the dentist to present himself as friendly and welcoming would help break the parent’s preconceived notion that going to the dentist will always result in pain and will make it more likely for them to seek expensive, follow-up care.”

In order to finance these promotional ideas as well as continued care for children in the community, some focus group participants made several suggestions regarding money and future funding. It was recommended that “people leave money to the cause in their estates, or if there were elderly community members who had some extra to spare, they could donate it to a fund for children who need care and cannot afford it.” Also, it was mentioned that the “Catholic Church may have money set aside already for dental care of the community that could be beneficial.” It was also brought up that “the success of the program to-date should be brought to the attention of legislators in Jefferson City in order to receive further funding from the government.”

Finally, when participants were asked to brainstorm strategies and ideas to address children with Medicaid or those without any insurance, participants often mentioned using a sliding scale and payment plans for services and treatments. The participants vigorously expressed the need to educate community members about obtaining pre-approval from Medicaid in order to take advantage of the dental benefits of the program.

“I would hate to think that after the grant was over we would drop the ball. [Now that]we have a dentist in the county . . . we need to continue the screenings, we need to continue the oral health curriculum, and we need it to be part of our health system. We’ve tried band-aid approaches to different things in the past twenty years here, and we know they don’t work. You get a few folks in and a few problems fixed but ten more pop up. We have to . . . work with parents and convince the general public how important it is.” (Focus group #1 participant)

Focus Group #2

“I find that people who don’t have good oral health do not smile as much. So I think it’s very important that you feel good about how your teeth look and feel.” (Focus Group #2 participant)

This focus group was conducted to allow the people of Chariton County to express their opinions regarding the Chariton County Oral Health Program, Chariton Smiles, and offer suggestions of how the program may be improved to better serve the needs of Chariton County. After a brief introduction, the participants were asked to describe what good oral health meant to them. The consensus was that appearance (e.g., white, straight teeth) and absence of cavities were the two most important components of good oral health. When asked how important oral health was to each participant, the entire group agreed that oral health was very important, giving it a nine (9) on a scale of ten (10). Participants stated that the main goal was to avoid the consequences of having poor oral health: “[Bad oral health] also comes with a lot of pain, discomfort, and cost of going to see the doctor for antibiotics or the dentist.” The group was then asked whether oral or physical health is more important. All agreed that both physical and oral health were interchangeable and related. Furthermore, when asked whether oral health affects physical health, one participant stated: “If your teeth hurt, you physically don’t feel good.”

Next, the participants were asked about the barriers to oral healthcare present in Chariton County. Accessibility was the largest personal barrier according to the participants. As there was currently no dentist in the county, all participants must drive outside of the area in order to receive oral healthcare. Disregarding the one participant who stated he had not been to the dentist in over two (2) years, the average distance each participant had to drive to the dentist was 32 miles. Furthermore, many people would be forced to travel to either Columbia or Kansas City for certain procedures, 70 and 115 miles respectively. When asked about the barriers to care for other people in Chariton County, two common responses were (a) inability to find a provider who accepts Medicaid or MC+ and (b) lack of insurance or other financial reasons, stating: “You hear more and more about people say that if they let something go, [dental care and insurance] is what they let go—[either] for their children or themselves.” However, the most common response was lack of time. One participant stated: “A lot of people are really busy . . . they don’t have time to go all the way to Columbia.” Others claimed that it was difficult to find time to take off work to get to the dentist.

Participants were then asked to comment on the current Chariton County Oral Health Program, Chariton Smiles. After the researcher described what Chariton Smiles had done in the past, participants were asked if any of their children had participated in the oral health screenings and sealants offered through the local schools. Two (2) of eleven (11) participants had school-aged children who had participated in the oral screenings. Unfortunately, both participants stated that their children had been misdiagnosed. One participant stated: “…They identified two spots [that needed treatment], and then we took her to the dentist and there wasn’t anything wrong with her teeth…but it was fine…that was better news for me.” The other participant stated that a filling had been mistakenly identified as an area of concern for her child. Despite the negative experiences with the oral screenings, one participant hoped that the screenings would help to motivate parents to take their children to the dentist regularly. When asked how to improve the current Chariton Smiles program, the most common suggestions were: (a) send home permission forms for screenings and sealants more than one time, (b) hand out permission forms directly to parents at parent-teacher conferences, back-to-school night, or registration, and (c) increase awareness for the program through advertising. Suggestions for advertising included a catchy ad in the local newspapers, a blurb in the bulleted list of upcoming events in the local newspapers, radio public service announcements, and video public service announcements to be played in the waiting room of doctor’s offices. Many participants stressed that the local high-school art and drama students could be used to make the newspaper ads and video public service announcements, respectively.

The cost is a big thing [that hinders people from visiting the dentist]. (Focus Group #2 participant)

The participants were asked if they visited the dentist regularly (i.e., one to two times each year). All but one participant claimed to visit the dentist regularly. When asked what would encourage others in Chariton County to visit the dentist regularly, it was agreed that a local dentist who accepts Medicaid and MC+ would be the best encouragement to non-utilizing people. One participant stated, “Having [a dentist] . . . locally, rather than [having to go to] another part of town [would encourage others to visit the dentist]. I think a lot of people do whatever’s handy. . . . Right here, right now. Some people aren’t going to go either way, but for the people that want to [go to the dentist], it’d be a lot of help [having a local dentist].” When discussing the need for Medicaid-accepting provider, one participant stated, “. . . A lot of dentists won’t accept Medicaid, or they’ll accept [new Medicaid patients] on the second Thursday of every third month.”

All participants were very supportive of the new dental practice being established in Chariton County, especially when informed that the new provider would be accepting as many patients as possible for the time being. Then, participants were asked what strategies they would recommend to incorporate the new dentist into the Chariton County community. All participants agreed that because the need for a dentist in Chariton County was so great, all that would be required is advertising to spread the word.

Finally, the participants were asked how the oral health program should address those who have Medicaid or those who are unable to pay for healthcare services. One participant suggested a monthly payment plan for those who cannot afford to pay for all services up front. Others stated that a sliding scale would work well to decrease the cost for those who were unable to pay.

Discussion

Chariton County faces challenges similar to those of other communities when attempting to incorporate a dental health program into their area. As the literature suggests, it is important that a dentist practicing in a low-income, rural area and accept Medicaid (Lalumandier & Molkentin, 2004), and the focus group participants echoed this recommendation. Access to dental care was also noted by the participants as a major barrier, although they did not recommend mobile dental units to combat the dentist shortage like some other communities have used (Griffith, 2005). Possibly, because the Chariton Smiles program can provide much of the diagnostic and referral services; especially to the children in the community, this was not perceived as a viable option.

Although focus group participants generally believed that dental care was just as important as medical care, they recognized that not all County residents would view it that way. Low-income, non-dental care utilizing citizens view medical care as more important than dental care. Participants perceived that County citizens, like those described in the literature, would be less likely to visit a dentist than to visit a physician (Kelly, Binkley, Neace, & Gale, 2005), especially when finances were a barrier; and that citizens needed to be educated about the importance of proper dental health. The literature also noted that funding can be a major barrier to policy and culture change; focus group participants also commented on that fact and brainstormed ideas to generate more funding.

All in all, the opinions, perceptions, and recommendations of the focus groups should be observed together with all other data when developing the program plan. Because the process focused more on brainstorming than on seeking consensus, the findings should not stand alone. It was important that focus groups consisting of those from various backgrounds or subgroups were conducted until no new ideas were generated from the two groups. It is also recommended that additional quantitative, secondary data, and relevant community needs assessment data be gathered and analyzed in conjunction with these findings before making any final planning decisions.

Recommendations

Based on the responses given by the participants in the two focus groups, it is clear that in order to improve oral healthcare in Chariton County, barriers to care must be overcome. The most commonly stated barriers were accessibility, ability to pay, and lack of Medicaid-accepting providers. The Chariton County Health Center has already taken great strides in order to overcome these barriers. The new dental clinic will be established in Chariton County, Missouri, saving citizens of Chariton County from driving an average of thirty-two (32) miles to visit the dentist. Furthermore, the dental clinic will accept Medicaid and MC+ and provide a sliding-scale fee schedule in order to lower the cost for lower-income patients. Interestingly, one participant also suggested the use of a monthly payment plan, if necessary, for those patients who are unable to pay for all services up-front. Most participants stated that lack of time was a large barrier to seeking oral healthcare. By allowing citizens to visit a local dentist and by providing some evening clinic hours, the new dental clinic will help to overcome this barrier.

Participants in both groups demonstrated adequate knowledge regarding oral health and positive opinions of its importance in their daily lives. Furthermore, all participants maintained positive opinions of the Chariton Smiles program, despite two negative experiences with the dental screening process. Participants in the second focus group stated that the necessary adjustments to the program only involved advertisements and reminding parents to sign the permission forms for their children to take part in the dental screenings and sealants. There were many suggestions for increasing awareness of Chariton Smiles, especially from participants in the second focus group. They were also very passionate about how high-school art and drama students might be used in the production of program advertisement materials. Allowing the community members themselves to become involved in the process encourages a strong sense of ownership in the program. It is very important that the community becomes involved in the program to advance the cause and allow as many children as possible to take part in the dental screenings and receive dental sealants.

Oral health is often overlooked when time and money are seemingly scarce. When taken to the extreme, this is a grave error. Physical health and oral health are interchangeable; one will affect the other. Chariton County has taken great strides in improving the overall oral health of its citizens. By providing education and assistance in overcoming barriers to care, the Chariton County Health Center will positively impact the health of its citizens for years to come.

References

Fisher-Owens, S. A., Barker, J. C., Adams, S., Chung, L. H., Gansky, S. A., Hyde, S. & Weintraub, J. A. (2008). Giving policy some teeth: Routes to reducing disparities in oral health. Health Affairs, 27(2), 404-412.

Griffith, J. (2003). Establishing a dental practice in a rural, low-income county health department. Journal of Public Health Management Practice, 9(6), 538-541.

Kelly, S. E., Binkley, C. J., Neace, W. P., & Gale, B. S. (2005). Barriers to care-seeking for children’s oral health among low-income caregivers. American Journal of Public Health, 95(8), 1345-1351.

Lalumandier, J. A., & Molkentin, K. F. (2004). Establishing, funding, and sustaining a university outreach program in oral health. Health Affairs, 23(6), 250-254.


Appendix A

Opening/Introductory Questions:

  • How do you know if a person has good oral health? *Oral Health describes how healthy your mouth is, including the teeth and gums.*
  • How important is good oral health to you?
  • Which is more important to you, oral health (teeth and gums) or physical health (body, heart, lungs)? Why?
  • Do you believe that oral health affects physical health? If yes, how?

Key Questions

  • How accessible is oral healthcare to you? *By accessible, we mean how easy can you get it? How far away? Do you have a way to get there?*
  • What, if anything, prevents others in Chariton County from getting oral healthcare? *Describe “Chariton Smiles”* “Chariton Smiles” is the current oral health program in Chariton County that is working to help the people in Chariton County have good oral health. Activities presented by “Chariton Smiles” include oral health presentations and curriculum in schools, comprehensive screenings in pre-schools, Head Starts and K-12 schools, sealant clinics for applying sealants for students in grades 2-7, an oral health media campaign, distribution of dental care resource guides to every parent, and more.
  • Have your children or any children that you know of participated in the oral health screenings and sealants program in school?
  • What are your opinions of the oral health screenings and sealants program in school?
  • What would you like to see in an oral health care program for our Chariton County community?

Ending Questions

  • Do you visit the dentist regularly (i.e. 1-2 visits each year)? *Split Focus Group into Non-utilizing and Utilizing*
  • What would encourage others in Chariton County to visit the dentist regularly? *Combine groups*
  • What are your opinions of establishing a new dentist or dental practice into the Chariton County community?
  • What strategies would you recommend to help a dentist become a part of the Chariton County community culture? *Culture includes popular activities, beliefs and values*
  • How should the oral health program address those who have Medicaid or those who are unable to pay for health care services?


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