Using Focus Groups to Design Systems Science Models that Promote Oral Health Equity
While the US population overall has experienced improvements in oral health over the past 60 years, oral diseases remain among the most common chronic conditions across the life course. Further, lack of access to oral healthcare contributes to profound and enduring oral health inequities worldwide. Vulnerable and underserved populations who commonly lack access to oral healthcare include racial/ethnic minority older adults living in urban environments. The aim of this study was to use a systematic approach to explicate cause and effect relationships in creating a causal map, a type of concept map in which the links between nodes represent causality or influence.
To improve our mental models of the real world and devise strategies to promote oral health equity, methods including system dynamics, agent-based modeling, geographic information science, and social network simulation have been leveraged by the research team. The practice of systems science modeling is situated amidst an ongoing modeling process of observing the real world, formulating mental models of how it works, setting decision rules to guide behavior, and from these heuristics, making decisions that in turn affect the state of the real world. Qualitative data were obtained from focus groups conducted with community-dwelling older adults who self-identify as African American, Dominican, or Puerto Rican to elicit their lived experiences in accessing oral healthcare in their northern Manhattan neighborhoods.
The findings of this study support the multi-dimensional and multi-level perspective of access to oral healthcare and affirm a theorized discrepancy in fit between available dental providers and patients. The lack of information about oral health at the community level may be compromising the use and quality of oral healthcare among racial/ethnic minority older adults.
Well-informed community members may fill critical roles in oral health promotion, as they are viewed as highly credible sources of information and recommendations for dental providers. The next phase of this research will involve incorporating the knowledge gained from this study into simulation models that will be used to explore alternative paths toward improving oral health and healthcare for racial/ethnic minority older adults.
Overview of article
- This study used qualitative methods and systems modeling to create a causal map, a type of concept map in which the links between nodes represent causality or influence, and evaluate social accessibility of oral health services for minority groups
- Soft systems modeling techniques are likely to be the most useful addition to public health because they allow for more complexity, flexibility, and political sensitivity in health systems. However, there still needs to be more accountability in hard systems modeling, especially in defining how they developed such models
Methods of article
- This study conducted focus groups with a sample of 194 racial/ethnic minority men and women aged 50 years and older living in northern Manhattan who participated in one of 24 focus group sessions about improving oral health for older adults
- Qualitative data were obtained from focus groups conducted with community-dwelling older adults who self-identify as African American, Dominican, or Puerto Rican to elicit their lived experiences in accessing oral healthcare in their northern Manhattan neighborhoods
- Causal maps were derived from focus group data. For example, the authors derive a composite causal map of decisions on where to go for oral healthcare based on information extracted from focus groups with African American, Dominican, and Puerto Rican older adults
- Through the creation of the causal map, 2 key issues emerged in social accessibility for minority populations: 1) Knowledge about dental providers and where they work; and 2) Going to and returning to dental visits, specifically circumstances at dental practices that motivate such visits
- Responses for how patients found their dental providers include: resources from insurance plans; phone calls to third-party services; Internet searches; referrals from healthcare providers, and recommendations from relatives and friends. Recommendations from friends and family proved to be very important. Word of mouth was the primary route of spread of information
- Several participants were frightened about going to the dentist either because of fear and the associated pain of dental procedures or the fear of contracting diseases at the dental office. Recommendations from trusted family members and friends may minimize such fears because dental providers and oral healthcare settings have already been vetted
- Social relationships play a large role in oral health behaviors and practices, which may increase or decrease social disparities
- A computer model may be used to communicate and learn about life events that may impact social relationships and thus health decisions
- Insights from the focus groups revealed several important considerations such as, inability to pay for oral health services, family members’ recommendations’ importance in findings a dental provider, and desire for more information about oral health. Of these, inability to pay and desire for more information were most important and justify 2 key types of interventions: 1) Social and behavioral (e.g. community based outreach) ; and 2) Policy (e.g., health insurance coverage)
- Limitations to this study include inability to control for exposure times, selection bias, and underrepresentation or racial/ethnic minorities