How People on Social Assistance Perceive,Experience,and Improve Oral Health

Abstract

Oral diseases are highly prevalent among people on social assistance. Despite benefiting from public dental coverage in North America, these people rarely consult the dentist. One possible reason is rooted in their perception of oral health and the means to improve it. To respond to this question, largely unexplored, we conducted qualitative research through 8 focus groups and 15 individual interviews in Montreal (Canada). Thematic analysis revealed that people on social assistance: (a) define oral health in a social manner, placing tremendous value on dental appearance; (b) complain about the decline of their dental appearance and its devastating impact on self-esteem, social interaction, and employability; and (c) feel powerless to improve their oral health and therefore contemplate extractions and complete dentures. Our research demonstrates that perception of oral health strongly influences treatment preference and explains low and selective use of dental services in this disadvantaged population.

INTRODUCTION

Oral diseases (dental and gingival) are highly prevalent among the poor in industrialized countries and represent a tremendous burden for both the people (Bedos et al., 2003) and society (Satcher, 2000). Despite their great need for treatment, underprivileged people rarely consult a dentist, even though some of them benefit from public dental insurance, such as Medicaid recipients in the USA (US General Accounting Office, 2000) and people on social assistance in Canada (RAMQ, 2005).

To explain poor people’s limited use of dental services, most researchers have focused on barriers to access. Very few, however, have studied their motivations for seeking dental care. One study (Bedos et al., 2005) paid attention to their interpretation of symptoms and their definition of dental illness, but no one has explored their perception of oral health and how this affects their decision to seek professional care.

In this study, we focused on a particular group of underprivileged people: those on social assistance in Montreal, Canada. We selected this group, one of the poorest in our society, because it shows a high prevalence of oral disease and low use of dental services despite public dental insurance. Two research questions guided our inquiry: (a) How do people on social assistance perceive and experience oral health? and (b) What kinds of strategies do they develop to improve oral health?

METHODS

Research design

Because their exploratory, open nature is well-suited to understanding the experiences and perceptions of consumers and health professionals, qualitative methods were used to assess the oral health perspectives of people on social assistance (Pope and Mays, 1995). We first conducted a series of focus groups, because this approach, based on the interaction of several participants, allows new perspectives to emerge (Morgan, 1998). We estimated that focus groups were particularly relevant, since the concept of oral health, unexplored in this population, would be well-addressed through the synergy of participants building on each other’s comments.

We subsequently organized individual interviews with a new sample of participants, to deepen our understanding of topics that focus group participants considered as major issues. Individual interviews, indeed, allow for the collection of in-depth information that focus groups do not always permit, because each focus-group participant has only a moderate amount of time to talk (Bower and Scambler, 2007).

Sample Recruitment

All participants had to be: (1) on social assistance, (2) French-speaking, and (3) aged between 20 and 55 yrs. For the focus groups, we relied on key informants from a disadvantaged neighborhood in Montreal who were living in the area and volunteering in local community centers; they were able to provide a list of eligible persons from which we determined the sample.

For the individual interviews, we placed recruitment posters in community centers and on billboards in the same neighborhood. In addition to the three criteria mentioned above, recruitment for individual interviews was guided by the needs of the analysis. In qualitative research, data collection and analysis are quasi-simultaneous, which allowed us, after having analyzed initial data, to “purposefully select” participants who were “information-rich” (Patton, 2002) on themes of interest related to their experience of oral health.

Fifty-seven individuals took part in 8 focus groups (5–10 participants per group) organized in 2002, and 15 participated in one-on-one interviews from 2005 to 2007 (Table 1).

Focus Group and Individual Interview Procedure

The focus groups were conducted in a local community center, while individual interviews took place either in the home of the participant or in a community center. Before starting, each participant signed a consent form approved by an academic IRB that had also agreed on the study protocol. The discussion was then conducted in French and lasted about two hours for the focus groups, and between one and two hours for the individual interviews, with a follow-up interview when necessary to elaborate upon certain issues.

With respect to the focus groups, a professional moderator addressed a list of themes related to participants’ perception of dental health and illness. To stimulate the discussion, he used three hypothetical scenarios developed by the research team, using data from a previous study (Bedos et al., 2003). These scenarios portrayed three individuals’ dental status and oral-health-care-related behaviors. The moderator read these scenarios and then asked participants to comment: for example, “What do you think of this individual’s dental status?” “What should one do in such a situation?”

The semi-structured individual interviews were conducted by an experienced researcher using an interview guide built upon salient themes that emerged from the focus group data: perception of oral health, teeth, and appearance; experience and strategies to improve oral health.

Data Analysis

We conducted a thematic analysis, which is a “method for identifying, analysing and reporting patterns (themes) within data” (Braun and Clarke, 2006). The analysis consisted of interview debriefing, transcript coding, and data display and interpretation. The debriefings, which took the form of written comments made by the interviewer immediately following the interview, served to evaluate the data collection, summarize main findings, identify new hypotheses, and prepare subsequent interviews as well as the coding.

The focus groups and individual interviews were all audio-recorded and transcribed verbatim to be coded. We developed an initial list of codes inspired by the research questions, but refined this list throughout the coding. The process, in which we used NVivo software (QSR International, Cambridge, MA, USA), involved cutting the transcripts into meaningful segments and assigning codes to the segments. We then examined the codes and their corresponding passages through an iterative process, regrouping them into broad themes. Once the themes were identified, we described them in a text and illustrated them with data extracts. This process was conducted by two members of the research team, who checked and validated their interpretations.

RESULTS

Perception of Oral Health

When asked about the meaning of oral health and the value of teeth, male as well as female participants insisted on the tremendous importance of appearance and, comparatively, put little emphasis on dental disease. This does not mean that they considered diseases and their symptoms as minor issues—they acknowledged suffering from them—but that appearance was paramount. They consequently defined oral health in a social as opposed to a biomedical perspective, the “visible” taking over the “invisible” (Table 2).

Straight, white teeth hence epitomized oral health and were considered the most important element of appearance: Well, healthy teeth show; they’re nice, they’re straight, and they’re clean. [O] Teeth furthermore symbolized various personal qualities: “Teeth reflect a person’s personality” [FG 7]; “Even though I look the person in the eye, I always come back to: ‘oh, their teeth aren’t nice’ ( . . . ). Deep down, I’m judging the person”. [D] White teeth were perceived as a reflection of good hygiene and, more generally, as an indicator of self-care and overall health; conversely, discolored teeth signaled self-neglect (Table 2 ).

Participants also linked aesthetics to positive social outcomes: “We live in a society based on appearance.” Successful people necessarily conform to this standard: “Just watch television; they all have white teeth. Look at actors and actresses.” [FG 1] The participants described different situations, such as socializing or dating members of the opposite sex, in which the smile and the teeth can lead to attraction or revulsion.

Dental appearance was also seen as essential with respect to employability: “An interview for a job is all about appearance.” Participants thus believed that bad teeth were a serious handicap affecting how they would be judged: “an employer, with several candidates, and one comes along whose teeth are all black ( . . . ), he won’t be tempted to hire him” [FG 7]. It was also argued that even if an employer overlooked bad teeth in favor of a pleasant overall appearance, no one with bad teeth would be entrusted with an important job.

Experience of bad Oral Health

Whereas participants insisted on the importance of having beautiful teeth, many complained about their appearance and, in particular, about missing, discolored, or crooked teeth. They recognized that the decline of their dental appearance had started as early as childhood or adolescence. Most of them considered that their dental status had reached a critical stage, in that their smile was already or would soon be compromised. For instance, sharing a photo of herself as a teenager, one participant waxed nostalgic about her former smile: “You see; perfect, white teeth. Everyone used to ask me if I had dentures.” [A]

Participants added that their unattractive teeth had devastating repercussions on self-image and sociability. Many were ashamed and had developed ways of hiding their teeth, such as avoiding smiling or altering their smile. Other concealment strategies included covering the mouth with a hand, turning the head, or placing the tongue in front of the hole left by a missing tooth (Table 3 ).

Insensitive remarks by others also troubled participants: “Sometimes, people comment: ‘yellow teeth’ ” [K]. They also acknowledged that their unattractive teeth had a negative impact on their self-esteem and self-confidence: “You know, you have yellow teeth, you smile at people, and you feel uncomfortable” [N]. Bad dental appearance and low self-esteem constituted barriers to interaction, causing some to avoid social gatherings, especially if the people they were to meet had nice teeth (Table 3 ).

Some considered their teeth such a handicap as to render them unemployable. This lack of confidence kept some of them from even applying for a position: “I go out and all, but to go and get a job, I’m afraid they won’t take me”. [A] This feeling of shame could even lead them to not consider a job that would require working in front of the public (Table 3 ).

Strategies to Improve Oral Health or Appearance

Participants described several strategies for preserving or improving dental appearance, including hygiene, professional treatment, extraction, and dentures. While emphasizing the need for individual measures of oral hygiene, they acknowledged having neglected their teeth for years and assumed a large part of the responsibility for their current dental condition. Yet despite describing efforts to gain control, many felt discouraged and powerless, especially those with irreversible dental conditions like missing front teeth (Table 4 ).

Participants also recognized dentists’ contributing role to their oral health and appearance. Manifesting a keen interest in bleaching techniques, many acknowledged having already consulted on that matter. However, they were disappointed that the treatment was expensive and not covered by their public dental plan. “White fillings” were also often discussed as a desirable method of oral enhancement (Table 4 ).

Finally, participants also described a radical ultimate possibility: extracting all remaining teeth and replacing them with dentures. Even though some identified drawbacks to dentures—in particular the fact that they are not natural—they nonetheless emphasized several advantages: Participants compared them with plastic surgery and argued that dentures guarantee a perfect smile and put an end to suffering and dental visits. Consideration of this drastic procedure indicates the sense of fatality participants felt when confronted with their own powerlessness in preserving their teeth and dental appearance (Table 4 ).

DISCUSSION

Our study revealed three main points that have scarcely been documented in the literature: (a) People on social assistance put tremendous value on dental appearance, as Kelly et al.(2005) recently remarked, and define oral health in a social rather than in a biomedical manner; however, (b) they complain about the progressive decline of their dental appearance during the life course and describe its devastating impact on self-esteem, social interaction, and employability; and (c) even though they favor treatment aimed at improving appearance, some feel powerless, envisioning multiple extractions and complete dentures as a reasonable solution, even deliverance.

The inductive nature of our methodological approach provided data whose depth and complexity could hardly have been obtained through traditional quantitative research. But our study was limited in that it reflected a particular group of poor people: French-speaking adults receiving public assistance in Montreal. As a consequence, our findings might not be generalizable to recipients from other ethnic or geographic backgrounds. For instance, the perception of dentures might be different among Medicaid recipients in the USA, not only because edentulism has not been as prevalent there as in the province of Quebec (Brodeur et al., 1996; World Health Organization, 2008), but also because complete dentures are covered in Quebec and generally not in the USA (NCSL Health Care Program, 2003).

Overall, our study demonstrates that, among people on social assistance, perception of oral health influences preference for certain treatments and explains selective use of dental services. Less expected was the tremendous impact of poor dental appearance on social and professional aspects of their lives as well as on their mental health. Our research thus carries multiple implications on political, public health, and professional levels.

From a political standpoint, oral health should be considered an important issue. Indeed, participants’ unsatisfying dental appearance weakened their self-esteem, which in turn limited their ability to be socially and professionally active. In brief, poverty influences poor oral health, as research demonstrates (Poulton et al., 2002), which in turn reinforces poverty, as we reveal. Thus, in addition to what a recent study suggests (Hyde et al., 2006), analysis of our data provides a strong impetus to policy-makers toward improving the oral health of people on social assistance so as to facilitate their social and professional integration and therefore, ultimately, to combat poverty.

From a public health perspective, poor oral health should be considered a serious problem that goes beyond the frontiers of the dental field, because it impedes the self-esteem and mental health of a vulnerable population (Hudson, 2005). Improving this population’s dental appearance could become part of a strategy aimed at improving their mental health. With respect to dental public health, our research suggests, as does that of Poulton et al.(2002), that oral health promotion programs should target children first, to prevent pathological processes that are cumulative and may be irreversible by adulthood.

Our findings also have serious implications for dental professionals. Contrary to common belief, people on social assistance care about their oral health and appearance. The profession should be responsive to these concerns, adopting a patient-centered approach to find common ground when planning a treatment. At a population level, we urge the dental profession to increase efforts toward improving access to dental services for people on social assistance.

Table 1.

Description of the Sample

	Number of Participants
Variables	Focus Groups	Individual Interviews
*For the Family Status variable, the focus group total is less than 57 because of one non-response.
Age
20–35 yrs	23	2
36–55 yrs	34	13
Sex
Female	30	8
Male	27	7
Family status*
One of a couple	15	3
Single	41	12
Dental status
Dentate (fully or partially)	47	15
Edentulous	10	0
Total	57	15

Table 2.

Participants’ Quotations Illustrating Their Perception of Oral Health

Themes	Quotations
Emphasis on aesthetics	Participant 1: Well, dental health, it seems to me that it’s like your body’s health. It’s the appearance of your teeth, if you have a nice set of teeth . . .
	Participant 2: The smile . . . the smile . . . [FG 3]
	White teeth are healthy teeth. [K]
	Participant 1: “It is true that when you look at someone and he smiles and he has bad teeth . . . ”
	Participant 2: “We’re less inclined to approach him” [FG 6].
Aesthetics as an indicator of self-care	Participant: Well, I look above all at appearance-health ( . . . )
	Interviewer: And what exactly does that mean?
	Participant: ( . . . ) When you care for yourself in general in terms of hygiene and aesthetics, well, it shows. [C]

Table 3.

Participants’ Quotations Illustrating Their Experience of Bad Oral Health

Themes	Quotations
Strategies to hide teeth	Before, [I had] a big smile; I had all my teeth back then, didn’t I? They called me Smiley because I had a nice smile. [ . . . ] since I lost my teeth, I’m embarrassed to laugh. I laugh . . . like this. A strained smile, you might say. Yet I never smiled like that in my life before. [FG 3]
Repercussions of bad teeth on sociability	Well, I‘d say I go out less. I go less to see my friends. It’s true! They’re Italian [in origin], and they all have nice teeth. [O]
Repercussions of bad teeth on employability	I could have gone to work at Tim Horton’s, but at one point I turned it down because it was with clients a lot, and you have to give a big smile. I turned it down. [J]

Table 4.

Participants’ Quotations Illustrating Their Strategies to Improve Oral Health or Appearance

Themes	Quotations
Oral hygiene	I brush my teeth every day: it doesn’t make a difference” [FG 8].
	Well, imagine doing skincare and getting absolutely no results. Like, even if I brush my teeth, my tooth [extracted canine] won’t come back. The hole will still show. People will see the hole. They won’t see the white teeth. [A]
Selective professional treatment	Participant: The back [teeth] can always wait.
	Moderator: You take care of the ones that show?
	Participant: Yes, just enough to keep myself from ending up with black teeth and having everyone stare at me. [FG 8]
	I said: “I’d like them to be white”. So then she [the dentist] said : “we can bleach your teeth, with this stuff meant especially for whitening, but it’s 200 dollars”. So I said: “ . . . I’ll try to get 200 bucks together, then I’ll come see you”. [L]
	Even while on social assistance, ( . . . ) I had fillings done with . . . instead of the horrible black fillings ( . . . ), I had fillings done that don’t show.” [E]
Removal of remaining teeth in favor of full dentures	Dentures are theoretically perfect, in that . . . they’re all straight, your teeth are all lined up one next to the other, they’re all the right size, they’re all the right width . . . it’s like false breasts . . . [FG 8]
	There are those with crooked teeth, or they’re missing a tooth. You look at them and they’re missing two or three front teeth. They’d be better off getting them all removed and having dentures, and having nice teeth afterwards. [Y]
	I’m self-conscious. Because I’d like to have white teeth. And I can’t. Until I have them removed, and have dentures, and then they’ll be white. [FG 1]

Footnotes

Notes

Acknowledgements

This study was supported by the FRSQ Network for Oral and Bone Health Research and the Canadian Institutes of Health Research. We thank Robert Hétu, Laurence Boucheron, Mike Benigeri, Marie Olivier, Paul Allison, and Christine Loignon, who were involved at different stages of this research. Finally, we express our gratitude to the people who participated in this study.

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