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How health professionals perceive and experience treating people on social assistance: a qualitative study among dentists in Montreal, Canada
© Bedos et al.; licensee BioMed Central Ltd. 2013
Received: 9 April 2013
Accepted: 18 October 2013
Published: 5 November 2013
In Canada, the prevalence of oral diseases is very high among people on social assistance. Despite great need for dental treatment, many are reluctant to consult dental professionals, arguing that dentists do not welcome or value poor patients. The objective of this research was thus to better understand how dentists perceived and experienced treating people on social assistance.
This descriptive qualitative research was based on in-depth semi-structured interviews with 33 dentists practicing in Montreal, Canada. Generally organized in dentists’ offices, the interviews lasted 60 to 120 minutes; they were digitally recorded and later transcribed verbatim. The interview transcripts were coded with NVivo software, and data was displayed in analytic matrices. Three members of the research team interpreted the data displayed and wrote the results of this study.
Dentists express high levels of frustration with people on social assistance as a consequence of negative experiences that fall into 3 categories: 1) Organizational issues (people on social assistance ostensibly make the organization of appointments and scheduling difficult); 2) Biomedical issues (dentists feel unable to provide them with adequate treatment and fail to improve their oral health); 3) Financial issues (they are not lucrative patients). To explain their stance, dentists blame people on social assistance for neglecting themselves, and the health care system for not providing adequate coverage and fees. Despite dentists’ willingness to treat all members of society, an accumulation of frustration leads to feelings of powerlessness and discouragement.
The current situation is unacceptable; we urge public health planners and governmental health agencies to ally themselves with the dental profession in order to implement concrete solutions.
The burden of oral diseases is high among underprivileged people in North America and constitutes a serious public health issue [1, 2]. Yet, despite a high prevalence of oral diseases and a great need for dental treatment, most people living in poverty rarely consult a dentist [3–5]. This applies particularly to people on social assistance, who could benefit from public dental insurance programs. In the United States, for instance, use of dental care services is very low among Medicaid recipients, whether adults or children [6, 7]. A similar phenomenon occurs in Canada: in the province of Quebec, people on social assistance often adopt a wait-and-see approach and try to adapt to symptoms rather than consult an oral health professional [8–10]. In brief, public dental insurance programs for people living in poverty are insufficient to ensure timely use of dental services and eliminate disparities in access.
Several factors could explain this disturbing situation: the dental care pathway for people on social assistance depends on how they define oral health , oral illness and need for treatment ; it is also impeded by indirect costs related to transportation  and services not covered by public insurance . In addition, the relationship with oral health professionals seems to be a crucial element. Indeed, many people on social assistance report negative experiences with the dental care system: in the United States, for instance, Medicaid enrolees have described disrespectful and discriminatory attitudes by oral health professionals toward them because of their status . In Canada as well, people on social assistance have reported complicated relationships with dentists and deplored a lack of sensitivity to their situation .
For their part, many dentists in North America seem reluctant to treat people on social assistance. Indeed, in the United States, dentists’ participation rate in the Medicaid program remains low  for various reasons: cancelled appointments, low reimbursement rates, poor compliance, and complicated paperwork [15–17]. Despite these findings, we actually know very little about how dentists experience treating people on social assistance. One of the reasons is that previous studies relied on structured questionnaires; based on deductive approaches, they did not favor the emergence of new perspectives and tended to provide de-contextualized data. We therefore decided to conduct qualitative research whose objective was to better understand how dentists perceived and experienced treating people on social assistance. In particular, we were interested in deepening our understanding of the difficulties that they may encounter with this group of people.
We used a descriptive qualitative research design based on open-ended, semi-structured interviews. Qualitative methodologies are indeed indicated for exploring complex phenomena about which little is known . The flexibility of the design, consisting of simultaneous data collection and analysis, also allowed us to sample on the basis of emerging concepts and gather information on topics that derived from the first analyses.
We conducted this study in Montreal, Canada, a multicultural city with 1.6 million inhabitants  and almost 1400 general dental practitioners . We adopted a maximum variation sampling strategy  to recruit general dentists with potentially diverse experiences with people living in poverty. In particular, we wanted to meet clinicians with various years of experience, working in several types of settings (multi practice, solo practice) and with different professional status (owners, employed). This is why, for instance, we contacted dentists practicing in diverse types of neighbourhoods, including underprivileged areas and affluent districts.
We recruited the dentists by sending a written invitation (by mail, email, or fax) and a subsequent telephone call to plan an interview. In the written invitation as well as during the phone call, we informed them that they had no obligation to participate and could take the time they needed to decide on whether to participate or not. We stopped recruiting when we obtained data saturation, “the point at which additional data does not improve understanding of the phenomenon under study”  and simply reiterates what has been previously collected.
Experienced interviewers collected data between 2004 and 2007 through in-depth, semi-structured interviews. Generally organized in participating dentists’ offices, the interviews lasted 60 to 120 minutes; they were digitally recorded and later transcribed. Before each interview, the participants were invited to read a consent form approved by the academic ethics committee of McGill University’s Faculty of Medicine. We encouraged them to ask questions about the research and their rights as participants prior to signing the consent form.
Researchers used an interview guide that focused on dentists’ experiences with people on social assistance. This guide was designed to help interviewers identify the problems and difficulties faced by dentists. In order to obtain more in-depth information on the topics discussed, researchers used “probing” techniques : when necessary during the course of the discussions, they formulated follow-up questions that also allowed them to explore unanticipated but relevant emerging topics.
We performed a thematic analysis, a “method for identifying, analysing and reporting patterns (themes) within data” . The analysis comprised several parts: interview debriefing, transcript coding, data display and interpretation.
The debriefings were conducted between the interviewer and the main researcher after each interview. They served to summarize the main findings, identify emerging hypotheses, and prepare subsequent interviews. Coding of the interview transcripts was carried out using NVivo software. We used an initial list of codes inspired by the research questions, but refined this list throughout the coding. The process 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, grouping them into broad themes and displaying them in analytic matrices, as recommended by Miles . We finally described the themes in a text and illustrated them with excerpts of the data.
To improve the rigor and credibility of our results, three members of the research team conducted this process, checking and validating their analysis. In particular, they coded initial transcripts separately and then compared their findings; for each instance of coding disagreement they discussed their interpretations, refined the codes, and undertook coding again until agreement was reached. Furthermore, the researchers carefully pondered the analytic matrices while comparing their interpretation of the results. Again, when confronted with divergence, they discussed the data until jointly able to agree upon an interpretation.
Description of the sample
Sample description (N = 33)
61 or more
Western background (Canadian)
Non-western background (Non-Canadian)
Years of experience as a dentist
31 or more
Type of clinical setting
Owner (or co-owner)
Employed (paid by percentage)
Issues identified by participating dentists
Types of issue
Problems reported by dentists
Explanations provided by dentists
Main sources of the issues according to dentists
Dentists find the organization of appointments and scheduling difficult for people on social assistance
● People on social assistance tend to consult in an emergency
● People on social assistance
● They often miss appointments and have no valid reasons for that
● People on social assistance
● They have little availability during off-peak hours
● People on social assistance
Dentists feel unable to provide them with adequate treatments and improve their oral health
● Public dental insurance does not cover several treatments
● Public health care system
● People on social assistance lack motivation to care for their health
● People on social assistance
Dentists perceive patients on social assistance as non lucrative and a threat to the financial sustainability of their clinic
● The reimbursement rates of the government are too low
● Public health care system
● The treatments performed are often basic
● People on social assistance
● Missed appointments cause lost wages
● People on social assistance
Organizational Issues – Dentists find the organization of appointments difficult for people on social assistance
People on social assistance tend to consult in an emergency and often miss appointments
That, I’ll be honest, is one of the things that bugs me the most even now. They don’t show up. They don’t show up, they don’t call, they don’t let us know, and that’s just how it is. [CL3]
People on social assistance do not have valid reasons for missing appointments
“I went to bed at 4 in the morning. I didn’t feel like coming.” They’ll tell you. They went to a bar, they went out to a strip show. They were watching t.v. They went out on the town with their buddies. And then, well, of course, when you go to bed at 4 and you have an appointment at 10 in the morning, well, sometimes… [CL12]
People on social assistance are not flexible and have little availability during off-peak hours
It’s simple; you don’t give a morning appointment to someone on social assistance because that’s when he sleeps! […] They tell us: “not in the morning, not too early in the morning. Not 9 a.m. Not 10 a.m. We get up late.” Fine. “So we’ll give you one in the afternoon.” “Well, no; I work.” […] So these patients want to come in the evening when I don’t work, so they’ll come on a Saturday and take the spots of my good patients’, who make an honest and steady living. [CL13]
Biomedical issues - Dentists feel unable to provide people on social assistance with adequate treatments
Public dental insurance does not cover several treatments; people on social assistance cannot afford to pay for treatments not covered
It is unsatisfying to be very limited in the treatments I can offer people on assistance. The treatments we can offer people on assistance are treatments that date back to the thirties, to the fifties. […] So for someone who likes technology a lot, who likes to perform a lot of state-of-the-art treatments, it’s disappointing. I have to say that, usually, I get no pleasure from treating people on social assistance; it’s not because they’re on social assistance, it’s because of the limits placed on me in terms of treatment options. [AL10]
People on social assistance lack motivation to care for their health and neglect themselves
I have experienced the same thing my colleagues have; we all have. Patients on welfare are not always reliable. [CB2]
Dentists feels powerless and discouraged
We try telling them, « floss and brush your teeth ». There is often a generalized level of neglect. The [dental] hygienist, for example, often gets really discouraged. [AL5]
Financial issues – Dentists perceive patients on social assistance as non lucrative and a threat to financial sustainability
The government fee schedule is too low
Even though we’re paid, when it comes down to it, it’s almost pro bono work. Because to, say, remove a tooth, I think it’s something like 13 dollars. It costs me more in electricity, material, my assistant, my secretary, and all that, than what I make. [AL3]
The low reimbursement rates are unfair and frustrating
It annoys me to be paid less by [public] health insurance. It really annoys me because I don’t take less good care of that particular patient. I can’t sterilize the instruments less. I can’t use poorer quality materials. I only have one kind of amalgam, so I use it for everyone. Of course, maybe, for another [person not on public assistance], I might give them a crown, but you can’t work less well just because someone is on social assistance. So I don’t know why we shouldn’t be paid the same price. But instead of giving to the United Way [charity], I give to the public insurance scheme. [CL8]
People on social assistance's missed appointments create a “wage gap”
Given that, first of all, just seeing them pays less than the same procedure I would give to you or someone who has [private] insurance, I don’t get the same fees. And if I’ve scheduled an hour for restorations and he doesn’t show up, plus, you know, in addition to losing the fees I would have had with a normal patient, I lose the hour as well. [CL2]
People on social assistance are a threat to financial sustainability
Currently, I have very few. I don’t mind at all. It’s not like I have a big clientele of only them… [CB2]
Dentist: I like my work. Except for the fact that my colleagues make more money than I do, and they’re always rubbing my face in it, and I have to live with it. […] The only thing… society judges success according to how much money we make, so psychologically it has an effect [on me], to see that I am below average, I guess, compared to other dentists. [AL4]
Organizational issues – Dentists find the organization of appointments and scheduling difficult for people on social assistance
The child supposedly is in pain because he has a big cavity. We’ll say: “Ok, fine, we’ll schedule him as soon as possible”. And then, [it’s] a missed appointment. You know, it’s frustrating because the kid was in pain, it’s free, he has an appointment, we want to treat him, we make room and then, missed appointment. So in the long run, you develop a kind of [attitude]: “Oh, no; not a welfare patient!” [CL2].
It’s because they don’t wake up in time, it’s not nice out, it’s too nice out, they have the flu. Excuses. Except that at a certain point, when you schedule five appointments and he misses four of them, with different excuses… my tolerance decreases after the third one. [AL5].
Even though they didn’t work, they weren’t available as we would have wanted, like in the morning. They could demand an evening appointment. The secretary was a bit bothered by that. […] She of course complained: “So, they don’t work; why don’t they come in the morning?” Because morning appointments are always much harder to book. [CB1].
Biomedical issues – Dentists often feel unable to provide people on social assistance with adequate treatment or to improve their oral health
Even if I offer to let them pay bit by bit, it doesn’t work at all. [The patients say] “No, I don’t have any money”. The government reimburses extractions, [so] it doesn’t cost them anything. [CB1].
Each time a patient needs a root canal and it’s not paid for by social assistance, well, obviously, they never have it done. So then, we have to extract teeth, often even those of children, of adolescents. To remove permanent teeth. That, I would have to say, has been my worst experience. [CL11].
Most of the time, I find they’re not motivated enough. Their [oral] hygiene is very poor. Even though dental services are free, not everyone takes advantage of them. [CL4].
When someone comes to you and says,“This tooth hurts, it’s swollen”, you look at the rest of the mouth and, yikes, you wonder where to start; that’s not pleasant. That’s what we see with people on social assistance. [CL21].
It’s as if I’m wasting my time talking to a wall. [CL7].
So we can’t apply everything we’ve just learnt in school, and therefore we’re forced to practice two kinds of dentistry: dentistry for our regular clientele and dentistry for our welfare clientele. It’s frustrating for the dentist. [CL9].
Financial issues - Dentists perceive patients on social assistance as non lucrative and a threat to the financial sustainability of their clinic
I like doing good quality work but, unfortunately, with the fees that social assistance gives us, I mean, we’re talking 12 dollars for an extraction and 5 dollars for the second one, that barely pays for the anesthesia and your muscle power. And that is if it’s an easy extraction. So even for restorations, exams, cleanings, everything is really a lot less. So, if we want to do a good cleaning, then what the government pays is not much. [CL7].
That’s what’s frustrating for a dentist. I’ll perform an extraction that, to my mind, is worth the price I would charge you, say, but when I perform the same extraction for a person on social assistance I’ll get paid maybe a fourth of what it’s worth. So it’s frustrating. Of course it’s the person on assistance who suffers the consequences in the sense that we’re maybe frustrated… [CL2].
You know that [insurance for those on social assistance] pays about a third of the standard rate of the Dental Association. […] I don’t mind. But when they miss their appointments, then I pay for it three times over. I am already only getting a third as it is and then… I lose a regular patient that could have had that spot, stuff like that. [AL6].
But I can’t of course complain because I don’t have many of them. So if I have one once in a while I don’t mind treating them, but if I had ten a day I’d be stressed out. It would annoy me. [CL2].
With respect to limitations, it is important to note that our study reports the experiences and perspectives of a relatively small number of dentists, even though the size of the sample is adequate considering our methodology . Let us also mention that the sample may not be representative of Canadian dentists. In particular, it did not comprise dentists that systematically refuse to treat people on social assistance, a practice that has not been documented in Canada but has been observed in the United States [6, 17] and France .
Our team of experienced researchers and highly skilled interviewers employed a series of procedures that enhance credibility [18, 25], such as prolonged engagement of the researchers in the community of private dentists, peer-debriefing after the interviews, rigorous data coding, and triangulation of interpretations. Finally, the inductive nature of our approach provided data whose depth could not have been sounded through traditional quantitative research.
Even though studies have already shown that missed appointments, poor compliance, and low reimbursement rates may lead North American dentists to exclude people on social assistance, our research provides results that are original. First, it describes the complexity of dentists’ perceptions in a way that has not been shown. For each of the three dimensions, dentists experience failures that tend to accumulate. These failures also generate emotional reactions among oral health professionals, such as anger and discouragement, which may impact on their relationship with patients on social assistance.
Second, our study highlights the importance of a biomedical dimension: dentists explain how challenging it is to improve the oral health of patients on social assistance. Furthermore, some feel constrained, performing a “dentistry for the poor” that does not reach the standards of “regular dentistry”. Most dentists express their aversion to the former, which is limited to rudimentary and low quality treatments. In particular, because the Quebec public dental insurance program is not comprehensive, dentists must often extract teeth that could be restored if the patients were able to pay. This type of situation creates major ethical dilemmas for professionals trained to achieve high standards of care; it also generates feelings of devaluation.
Third, most dentists perceive themselves as victims with little power to resolve the issues they describe. Instead, they criticize an inadequate health care system; reimbursement rates for people on social assistance are too low and not all dental procedures are covered. They also blame people on social assistance: missed appointments, emergency visits and lack of availability during off-peak hours are considered signs of self-neglect and disrespect for others. For instance, some participants mentioned laziness as a reason for missing appointments, which reflects common stereotypes about poverty . It also echoes the painful sentiment of people on social assistance: they feel misunderstood by oral health professionals [10, 13, 14, 27] and, in a more general way, by society at large [28, 29]. In fact, many people on social assistance actually work several hours per week in work reintegration programs, and therefore have limited availability for appointments during the day. This “blaming the victim attitude”, which has already been shown among physicians , reflects professionals’ misunderstanding of poverty and exclusion.
In order to increase dentists’ willingness to treat people on social assistance and improve their access to dental care, solutions addressing all three main issues are needed. We must consider and respond to dentists’ complaints, in particular the fact they blame both people on social assistance and the public dental care system for the organizational, biomedical, and financial issues described in this article.
To address the tensions and conflicts between dentists and people on social assistance, we suggest: a) helping current  and future professionals – through dental education programs  – to better understand people living in poverty and avoid victim blaming [32, 33]; b) inviting dentists and people on social assistance to confront their perspectives and together develop solutions that will facilitate their clinical relationships; joint problem identification and solutions might be found by bringing all stakeholders together in what is referred to as participatory action research.
In addition, we suggest addressing current limitations of the health care system by improving coverage and fees. It is worth noting that, in the United States, augmented Medicaid payment rates are associated with dentists’ increased participation in the program as well as increased utilization of dental services by Medicaid recipients [17, 34].
Several successful programs in the United States, such as Access to Baby and Child Dentistry (ABCD)  and Head Start , constitute strong bases leading to better oral health outcomes; modified versions of these programs could be expanded to serve adults as well.
In conclusion, we would emphasize the common goals uniting our research with the principles upheld by the American Dental Education Association , who stated in 2010 that “access to basic oral health care is a human right”; “the oral health care delivery system must serve the common good”; and that “the oral health needs of vulnerable populations have a unique priority”. According to these principles, the current situation is unacceptable, and we urge public health planners, governmental bodies, and community groups to join forces with the dental profession in order to implement concrete solutions. We also invite researchers to contribute to this effort and perhaps even lead such processes. In particular, we suggest the development of participatory action research projects that will allow people on social assistance, clinicians, and policy makers to confront their perspectives and together find solutions.
This study was supported by grants from the Canadian Institutes of Health Research (CIHR) and the Quebec Research Fund (FRQ-S and RSBO). The main author also received fellowships from CIHR and the FRQ-S. We thank Dr. Alissa Levine and Dr. Jean-Noel Vergnes for their critical and useful review of the manuscript. As well, we would like to express our gratitude to the dentists who participated in this study. This paper is in loving memory of Pr. Jean-Marc Brodeur: Jean-Marc was a brilliant co-researcher, a humanist, and a dear friend.
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