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Download an App with a Professional Dental Knowl- Posed Was “Constant Reminders.” Participating Women Edge Plugin at Every Diferent Stage Wang et al. BMC Oral Health (2020) 20:333 https://doi.org/10.1186/s12903-020-01327-9 RESEARCH ARTICLE Open Access Interprofessional collaboration and smartphone use as promising strategies to improve prenatal oral health care utilization among US underserved women: results from a qualitative study Lin Wang1,2, Johana Ren3, Kevin A. Fiscella4, Sherita Bullock5, Mechelle R. Sanders4, Elizabeth L. Loomis4, Eli Eliav1, Michael Mendoza4,6, Rita Cacciato1, Marie Thomas3, Dorota T. Kopycka‑Kedzierawski1, Ronald J. Billings1 and Jin Xiao1* Abstract Background: Data on barriers and facilitators to prenatal oral health care among low‑income US women are lacking. The objective of this study was to understand barriers/facilitators and patient‑centered mitigation strategies related to the use of prenatal oral health care among underserved US women. Methods: We used community‑based participatory research to conduct two focus groups with eight pregnant/ parenting women; ten individual in‑depth interviews with medical providers, dental providers and community/social workers; and one community engagement studio with fve representative community stakeholders in 2018–2019. Using an interpretive description research design, we conducted semi‑structured interviews and focus groups which were audio‑recorded, transcribed, and analyzed for thematic content. Results: We identifed individual and systemic barriers/facilitators to the utilization of prenatal oral health care by underserved US women. Strategies reported to improve utilization included healthcare system‑wide changes to promote inter‑professional collaborations, innovative educational programs to improve dissemination and implemen‑ tation of prenatal oral health care guidelines, and specialized dental facilities providing prenatal oral health care to underserved women. Moreover, smartphones have the potential to be an innovative entry point to promote utiliza‑ tion of prenatal oral care at the individual level. Conclusions: Low‑income women face multiple, addressable barriers to obtaining oral health care during preg‑ nancy. Inter‑professional collaboration holds strong promise for improving prenatal oral health care utilization. Keywords: Prenatal oral health, Underserved pregnant women, Inter‑professional collaboration Background Despite the well-documented association between poor maternal oral health, preterm/low-birth-weight deliv- *Correspondence: [email protected] 1 Eastman Institute for Oral Health, University of Rochester Medical eries [1, 2] and increased tooth decay in children after Center, Rochester, NY, USA birth [3], many mothers-to-be do not receive timely oral Full list of author information is available at the end of the article health care [4]. Oral health is an important component © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wang et al. BMC Oral Health (2020) 20:333 Page 2 of 15 of general health and should be maintained during preg- appropriate referral pathways to Public Dental Services nancy [5]. Although recommendations for prenatal oral [21]. health care have been widely disseminated in the US at Data on barriers and facilitators to prenatal oral health both the state [6] and national level [7], utilization of care among low-income US women are lacking. Given prenatal oral health care remains low. A national sur- diferences in cultural beliefs, social environments, vey [8] recently released by a dental insurance company, and health care systems, it is challenging to apply fnd- Cigna, found that 43% of women did not have a dental ings from other populations to women receiving care in checkup during pregnancy while 76% admitted to sufer- underserved settings in the US. To address this gap, we ing from oral health problems (pain, gum bleeding and used community-based participatory research (CBPR) oral infection) during pregnancy. Oral health care utili- [22] to assess perceptions, barriers and facilitators, and zation during pregnancy is even lower among African patient-centered mitigation strategies related to use of American women [9], ethnic minorities [10], and women prenatal oral health care by underserved US women and with socioeconomic impediments [11]. Tus, prenatal by a cohort of medical/dental providers and community/ oral health represents an important, but often-neglected social workers. Qualitative analysis of data used an inter- health disparity [12, 13]. Understanding factors that ena- pretive description research design with triangulation ble or hinder the use of prenatal oral health care is crucial across multiple data sources. to identify efective strategies to promote and maintain good oral health in pregnant women. Methods At the patient level, demographic, socioeconomic, psy- Study design chological, and behavioral factors afect utilization of prenatal dental care. Among women living in California, We examined a clinical phenomenon (limited utilization a population-based study found that the primary rea- of prenatal oral health care) to identify themes and pat- son for not obtaining dental care was lack of perceived terns related to reported perceptions of oral health care need, followed by fnancial barriers [4]. A survey among among underserved women, medical/dental providers 625 women (a predominantly Caucasian population of and community/social workers. We used the interpretive relatively high socioeconomic status) living in Johnson description [23] research design which is best suited to County, Iowa, showed that increased prenatal dental investigate problems that are rooted in clinical practice. visits were associated with being married, having more Tis design was chosen to develop a coherent profes- frequent dental visits when not pregnant, having dental sional narrative that informs clinical practice and pro- insurance, and having knowledge of the possible con- motes a practice or policy change. Troughout the study, nection between oral health and pregnancy outcomes we applied the principle of respect, reactivity, and refex- [14]. Similar efects have been reported globally. Austral- ivity to build a trusting relationship between study par- ian [15, 16] and Iranian pregnant women [17] reported ticipants and study personnel, based on the strategies of that barriers to utilization of prenatal dental care Paterson [24]. Tis study was approved by the University included lack of knowledge, false beliefs, cost, fear, the of Rochester Medical Center Research Subjects Review limited number of dentists providing care to pregnant Board (RSRB 72596). We included all points in a checklist women, and inadequate recommendations from health of COREQ guidelines [25] for reporting focus groups and professionals. interviews. Te items for COREQ domain 1 are listed in At the clinician level, recommending prenatal oral "Appendix 1". health care utilization is not routinely practiced by maternity providers (general practitioners, obstetricians, Research settings and procedure and midwives) [18, 19]. A national survey [20] among 366 Study site US primary care physicians (PCPs) reported that 37% Tis study was conducted in 2018–2019 in Rochester, of PCPs rarely/never provided oral health counseling to NY. Rochester is the third most populous city in New their pregnant patients. Being a female PCP, receiving York State, with a population of 208,046 residents. Te continuing education on oral health-related topics, per- University of Rochester Medical Center and Rochester ceived preparedness to provide oral health counseling, Regional Health System are the two leading providers of and counseling adults with other health conditions con- comprehensive care for Rochester residents holding both tributed to increased prenatal oral health counseling private and state-supported medical insurance. Preg- [20]. Moreover, midwives in Australia reported a reluc- nant women whose income is equal to or lower than tance to discuss oral health with pregnant women and an 138% of the Federal Poverty Treshold are eligible for unawareness of the possible impact of poor oral health NY State-supported dental insurance (Medicaid) which on maternal and child health, as well as not knowing provides coverage for adult dental procedures including Wang et al. BMC Oral Health (2020) 20:333 Page 3 of 15 comprehensive oral examinations, extractions, and A research assistant took notes and audio recorded each restorative/endodontic/periodontal procedures [26]. focus group session. We collaborated with two local organizations (Uni- versity of Rochester and
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