Introduction

Dental caries and periodontal disease are among the most prevalent chronic diseases among adults in the United States (US). The 2000 Surgeon General’s report labeled poor oral health a “silent epidemic” and called attention to the persistent disparities in oral health status, access to care, and unmet needs [1]. Nationwide, between 2001 and 2010, adult dental care utilization declined from 41 to 37 % [2]. Individuals with less income, less education, and racial/ethnic minorities experience greater barriers to dental care compared with the general public [1]. Regular dental care access is critical to prevent and treat caries and periodontal disease, yet remains a challenge among some populations, including Latinos.

Latinos comprise the nation’s largest and fastest growing racial/ethnic minority group, making up 17 % of the US population (53 million in 2012) [3]; one-fourth live in poverty [4]. In 2008, 31 % of Latino adults reported fair or poor oral health [5]. The American Dental Association (ADA) found that non-English speaking Latinas from low-income families without health insurance were more susceptible to having plaque, cavities, and periodontal disease than their counterparts [6]. Similarly, economically-disadvantaged women on the US-Mexico border in California were at higher risk for poor oral health due to additional vulnerability during pregnancy, low literacy levels, inadequate transportation, and language barriers [7]. Latino health data show that migrant populations, in particular, are disproportionately affected by poor oral health due to a lack of access to care, income, and language barriers [8]. According to the 2009 California Health Interview Survey (CHIS), 10 % of Latinas could not afford needed dental services, and 11 % did not have any dental coverage [9]. Non-English speaking migrant women were the least likely to receive dental services [7], suggesting a need to focus on this subpopulation.

Migrant status is an additional vulnerability experienced by Latino immigrants [10]. The Public Health Service Act and the Migrant and Seasonal Agricultural Worker Protection Act defines different types of agricultural workers, including those that migrate to follow crops. However, this study employed a broader definition of “migrant worker,” to include gardeners, nannies, and other types of day laborers, and not just migratory agricultural workers [11]. Failing to define “migrant workers” prevents accuracy in identifying specific health data [12, 13]. With respect to dental services, 44 % of Hispanic adult agricultural workers in California reported a usual source of dental care and 34 % reported a recent dental visit [14]. The Affordable Care Act (ACA) did not mandate adult dental coverage as an essential benefit and it is optional in states’ Medicaid programs [15]. Between 2009 and 2014, Denti-Cal, California’s dental component in Medicaid, was eliminated creating access disparities for the state’s vulnerable populations [16].

Within this context, this study sought to identify facilitators and barriers that low-income Mexican migrant women in North San Diego County, California encounter when trying to access dental care for themselves and their families.

Theoretical Framework

The behavioral model for vulnerable populations (BMVP) provided the theoretical orientation for understanding this population’s needs [17] and identifying relevant factors for dental utilization [18]. Vulnerable populations include rural and racial/ethnic minorities and undocumented immigrants [17]. The original Behavioral Model of Health Services Utilization focused on the individual’s use of health services as determined by their predisposition to seek care, enabling resources, and their need for treatment [19]. The BMVP vulnerability component is useful for studying Mexican migrant health because it removes the “blame the victim” personal deficiency orientation of many individually-based theoretical models [20]. In the BMVP, predisposing factors include several social structural characteristics, such as immigration status, mobility, discrimination and literacy [17]. Enabling factors include personal, family and community resources that help or hinder vulnerable populations to acquire needed health services. Need factors include perceived and evaluated health status. Few studies have systematically explored dental utilization in this dually-vulnerable population (Latina women, migrant status) [21, 22]. Consistent with the guiding theoretical framework, it was hypothesized that women would experience barriers in accessing dental services due to their low-income, racial/ethnic minority status, and language barriers.

Methods

Study Design

Six focus groups were conducted with Mexican migrant women in North San Diego County (North County); three with community residents averaging 10 participants per focus group and three with community health workers/leaders (Lideres) averaging 7 participants per focus group. Focus groups were conducted as part of the community-based participatory research (CBPR) study known as Boca Sana, Cuerpo Sano (BSCS; Healthy Mouth, Healthy Body). BSCS was a 1-year formative research CBPR study funded by the DentaQuest Foundation, available through the Centers for Disease Control and Prevention-funded Prevention Research Centers and the National Community Committee. The formative research study sought to inform an intervention to increase oral health literacy and reduce dental care access barriers among North County’s migrant families [23, 24]. It was led by a federally qualified health center (FQHC) that is also a migrant health center (Vista Community Clinic; VCC), an academic institution (San Diego State University; SDSU) and its affiliated health disparities research institute (Institute for Behavioral and Community Health; IBACH) [25], and two other organizations. Throughout the one-year planning period, the four funded partners collaborated with over twenty community partners in the North San Diego County region and sought in-depth input from Lideres and community members during all stages of planning and developing an oral health intervention. This study was approved by the SDSU Institutional Review Board.

Participant Recruitment

Focus group participants were either part of an existing Lideres network or a community resident in one of the three targeted communities in North County. Bilingual (English/Spanish) Site Coordinators recruited a convenience sample of male and female community residents and Lideres to participate using flyers and verbal announcements; only females participated. Participant inclusion criteria included: self-identification as Mexican migrants or part of a Mexican migrant family; 18 years or older; speak and understand Spanish; and reside in North County. One community resident focus group and one Lideres focus group were held in Vista, Fallbrook and Pala/Rainbow, which differ in geography (urban/rural), population, needs and services. Vista and Fallbrook migrant communities primarily engage in urban labor, while Pala/Rainbow area migrants engage in farmwork. The VCC Program Director obtained written informed consent in Spanish. Childcare, refreshments and a $25 gift card were provided to minimize barriers to participation.

Focus Group Procedures

The VCC Program Director, a native Spanish-speaker with a demonstrated history of established rapport and work experience within Mexican migrant communities, moderated all focus groups in Spanish during February 2013. She served as a liaison between the migrant community and VCC health services, and led the Farmworker CARE coalition, which brings together community-based organizations to improve the living and working conditions of agricultural workers and their families in North County [26]. A VCC Health Educator assisted with note-taking and audio recording. The three community resident focus groups were conducted at the Pala Fire Station, and two different residences in Fallbrook and Vista. The three Lideres groups were held at the Pala Fire Station, the VCC Women’s Center and a Fallbrook residence.

The community resident and Lideres focus group guides included 13 questions assessing their experiences with accessing dental care and strategies for promoting oral health. The questions for both guides were developed by the study team in part to better understand the community’s experiences with dental providers and barriers to accessing services and how to best design an oral health educational intervention program. This paper’s analyses focused on responses to these first five questions (same for both groups), which are listed in Table 1. The full guide included another set of questions for both groups to aid in planning the future oral health educational intervention, such as preferred popular education methods, preferred educational session length, meeting place, frequency, and incentives. The Lideres answered additional planning questions informing the design of the intervention and support they would need to conduct such a program, based on their experiences leading other popular educational programs in the community (feedback not described or analyzed here).

Table 1 Focus group guiding questions
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According to the BMVP, domains such as knowledge, structural barriers and experiences are relevant to understanding the health and health-seeking behavior of vulnerable populations [17]. Participants completed a short demographic survey after the focus groups.

Data Analyses

A bilingual research team member transcribed verbatim all focus groups in their original language of Spanish, then translated all transcripts from Spanish to English, for data coding and analyses. Portions of the transcriptions were checked for accuracy.

Focus group data were reviewed and BMVP concepts were coded for community residents and Lideres separately to identify dental care access facilitators and barriers for themselves and their families. One community resident focus group was not audio-recorded due to technology malfunction, therefore handwritten notes and a summary were used for the analyses. Notes were written on hard copies of the transcripts prior to coding. A grounded theory approach was used to allow the researchers to identify themes beyond those specified by BMVP. Figure 1 displays an adapted version of the BVMP for dental care used in this analysis. Separate codebooks were used for community resident and Lideres focus groups in order to maintain data accuracy. The first author created the codebooks, which were reviewed by another more experienced co-author, and then analyzed in NVIVO 10.2.0, a qualitative data analysis software. NVIVO analysis and query features were used to facilitate the review of codes and interpretation process. Text segments that represented BMVP concepts were identified and presented in Tables 2 and 3.

Fig. 1
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The behavioral model for vulnerable populations, adapted for dental care use among migrant women

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Table 2 Summary of predisposing factors and representative quotes by respondent type
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Table 3 Summary of barriers and corresponding quotes by respondent type
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Results

Twenty-two (22) Lideres participated in one of three focus groups (Group 1: six; Group 2: six; Group 3: ten). Thirty community residents participated in one of three focus groups (Group 1: fifteen; Group 2: six; Group 3: nine). All participants were female Mexican migrant workers or part of a Mexican migrant family. Women’s average age was 36 years old (range 18–81). With the exception of two participants, all women had been living in the US for over 9 years. Not all participants had children, but most had two children over the age of 15. Participants provided input on predisposing factors (Table 2) and barriers (Table 3). Most comments reflected barriers to accessing dental care, rather than enabling factors.

Predisposing: Immigration Status (Table 2, Theme A)

According to Lideres, immigration status was viewed as the main barrier to accessing dental care. They feared immigration status exposure if they voiced complaints to their dentist (see A1). Immigration status was also a barrier given their inability to travel to Mexico for dental care (see A2). Community residents indicated that immigration status contributed to their inability to leave the country for health care, obtain dental insurance, and find insurance providers who covered undocumented immigrants (see A3, A4). Participants preferred receiving care in their home country, and more generally, desired binational access to care. The most prevalent theme described by both Lideres and community residents was immigration status as a barrier to obtaining government-funded insurance.

Predisposing: US Dental Care Experiences (Table 2, Theme B)

Participant’s US dental care experiences shaped their impression of care. Participants felt that there was a lack of respect from staff towards patients. Disrespect was not only evident from providers, but also from supporting dental office staff. Lideres shared experiences of feeling unwanted in dental offices due to the staff’s unwelcoming attitude towards patients (see B1, B2). Community residents expressed a lack of trust between patients and dental providers and staff (see B4, B5), as well as a desire for better customer service. However, in contrast to these negative experiences, some community residents expressed positive experiences noting that when dentists expressed care for their patients, it encouraged them to keep appointments.

Predisposing: Language Barriers (Table 2, Theme C)

For both sets of participants, language barriers and lack of access to Spanish-speaking staff affected their ability to obtain dental care. Lideres noted that they avoided making appointments if they knew the provider only spoke English. Not having a translator at the dentist office, or not having someone that the patient trusted, was a barrier to seeking dental care, in part because of concerns of what would be lost in translation (see C1–C3). A recurring concern within language barriers was the difficulty of communicating with providers and staff, and the distance it created between patients and providers. Community members overwhelmingly described receiving poor patient service due to language barriers. Further, participants felt that providers did not treat patients with respect because they would take advantage of the language barrier and conduct services that clients had not approved (see C4).

Predisposing: Transportation (Table 2, Theme D)

Only Lideres described transportation as a barrier to accessing dental care services. Lideres stressed that using a city bus was time consuming and that most routes were not convenient because they required extra walking time from bus stops to their home or dental office.

Predisposing: Spirituality (Table 2, Theme E)

An unanticipated predisposing factor discussed by community residents was their ability to use spirituality and religion to overcome barriers in accessing dental care. Their faith allowed them to have a positive attitude towards their health. They also stressed the need to eliminate negativity towards providers and staff and instead have faith and trust that a higher being would provide them with a solution to their dental care needs.

Barriers: Insurance (Table 3, Theme F)

Lideres and community residents alike voiced that independent providers and lack of government-funded dental insurance were the most pressing barriers they faced when attempting to access dental care (see F1, F2, F4, F5). For those with health insurance, they still encountered barriers due to coverage plan restrictions (see F3, F6). Women on Medicaid (a government-funded insurance program for those of low-income) encountered frustration with the limited coverage provided.

Barriers: Cost (Table 3, Theme G)

The cost of visiting a dentist was a barrier that they felt was impossible to overcome (see G1). With public or private dental insurance, the out-of-pocket cost was still too high. Participants compared costs in Tijuana and San Diego; cost in San Diego was impossible to pay with their incomes. Referring to the predisposing factor of spirituality, a participant noted that even a higher being could not help her make the payments (see G2).

Barriers: Discrimination (Table 3, Theme H)

Lideres described the challenge of being treated differently than others during dental visits which made participants feel unwanted due to their race, language and class status (see H1). Others felt discriminated against based on their type of insurance coverage (see H2).

Barriers: Negligence/Dissatisfaction (Table 3, Theme I)

Provider negligence and dissatisfaction are not part of the original BMVP, yet they were barriers identified by participants. A recurring concern among Lideres was providers’ lack of responsibility and medical negligence. One participant shared how a provider removed the wrong tooth and showed no interest when she sought to speak with a supervisor (see I1). Participants considered bad customer service from staff as negligence (see I2). In contrast, one participant shared that personal negligence of not prioritizing her health played a role in not accessing care in a timely manner (see I3).

Barriers: Wait Time (Table 3, Theme J)

Wait time is another construct that is not in the original BMVP but is a relevant factor. For both Lideres and community residents, the amount of time spent waiting to be seen by a provider was overwhelming, leading them to cancelled appointments (see J1), and contributing to delays in care. Participants also shared their beliefs that wait time differed depending on insurance coverage (see J2).

Discussion

Summary of Findings

This study identified facilitators and barriers that Mexican migrant women from three communities in North San Diego County encounter when trying to access dental care for themselves and their families. Lideres and community residents identified immigration status, negative US dental care experiences and language access and literacy as predisposing factors and barriers to accessing dental services. The former is consistent with the BMVP model [19]; previous research suggests that Mexican immigrants in the US cross the border into Mexico to obtain health services [27, 28], and immigration status may limit their ability to cross. Respeto, or respect, was lacking in health care interactions with providers and staff (see Table 2, Theme B). Respeto is an important component of effective provider-patient communication [29]. Consistent with these findings, previous research found that Latino immigrants experience negative health outcomes because of their difficulty communicating with providers [30]. Transportation was identified as an important predisposing factor among Lideres. As Syed and colleagues found, bus users were twice as likely to miss their appointments compared to car users [31]. Community residents identified spirituality as a predisposing reinforcer for seeking dental care. Research suggests that religion helps Latino immigrants gain control and bolster their real or perceived health status [32].

In terms of barriers, Lideres and community residents reported insurance coverage, cost, dissatisfaction and wait time as factors associated with dental care access. Lideres reported discrimination as a barrier to accessing quality dental services. These findings fit with Blendon et al. [33] showing that when racial/ethnic minorities were discriminated against in a healthcare setting, they felt they did not receive quality health care. Lideres and community residents also reported feeling neglected by their dental providers. Ruiz-Beltran and Kamau [29] found that providers’ lack of interest created a cultural barrier between Latino patients and providers. Participants reported that disrespect from staff was one of the most overt dissatisfactions with dental services, a finding consistent with that of Gelberg et al. [17]. Finally, both groups stressed frustrations with the amount of time they needed to wait to be seen by a dentist, resulting in cancelled appointments. A study found that an effective appointment system and reduced patient wait time are critical to improving patient satisfaction [34]. Reducing wait time of initial appointments may favorably affect the rate of kept appointments [35].

Limitations

Study limitations include possible selection bias; by recruiting community-involved migrant Mexican women, results may not generalize to the migrant population in San Diego County. Participant reports of their experiences at the dentist offices and interactions may be skewed by recall or social desirability biases. The size of the focus groups was appropriate, yet six focus groups may not provide representative data. Finally, focus groups with men as well as FQHC administrators, dental providers and staff would have provided additional information.

Implications

Future research should focus on the implications of immigration status and eligibility for dental coverage. As a 2009 CHIS report found, over 51 % of undocumented Latino adults in California were uninsured [9]. In California, Medicaid coverage for undocumented immigrants is available with restrictions, yet excludes preventive dental services [36]. This study found that patients are willing to return to dental offices with a language barrier, as long as they felt welcomed and respected. Community-based mobile outreach clinics can be effective in uncovering illnesses and directing patients to a healthcare provider [37]. Bringing services to the community also reduces transportation barriers.

The ACA improved healthcare access for millions of California residents, yet initially excluded undocumented immigrants [38]. The ACA created a national Medicaid minimum eligibility of 133 % of the poverty level, and states had the option to expand Medicaid and allow private insurance companies to provide improved comprehensive insurance coverage [39]. States may also set additional eligibility criteria, yet California excludes migrants from coverage. This provides an opportunity for insurance coverage expansion and a healthier state overall. Covered California is the state’s insurance marketplace, where individuals or businesses can purchase plans [39]. Yet, not until 2015 were adults eligible to enroll in Denti-Cal at an additional cost [40]. Providers who accept Denti-Cal remain limited and migrants still rely on the services of FQHCs for needed dental care [6]. California recently passed The Health for All Act (SB 1005) which allows individuals who are currently excluded from Medi-Cal or an exchange program to purchase insurance [41]. Barriers would likely still remain for vulnerable populations, yet it is a step in the right direction.

This study has implications for multi-level and systems approaches to improving dental care and oral health status more generally. From a policy perspective, the evidence that participants desired binational health care suggests that innovative models are needed for border residents. Findings related to feeling discriminated suggests that cultural-competency training for dental care providers and their staff, including improving language access, is a critical component for ensuring quality care.

Conclusions

This study identified predisposing factors and barriers that Mexican migrant women encounter when trying to access dental care services for themselves and their families. Qualitative data provided a rich foundation for future intervention planning. It informed the development of an oral health community education program [23] and insights into needed policy changes. Socially-constructed barriers should not be the reason why vulnerable populations continue to face health disparities. Oral health disparities are a significant public health problem, and there are opportunities for researchers, dental providers and policymakers to take action towards a more equitable and healthy future.