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Self-reported oral health and dental service utilization of vulnerable pregnant women registering for… Jessani, Abbas Ali 2014

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   SELF-REPORTED ORAL HEALTH AND DENTAL SERVICE UTILIZATION OF VULNERABLE PREGNANT WOMEN REGISTERING FOR THE PRENATAL PUBLIC HEALTH PROGRAM IN FRASER HEALTH, BC, CANADA.   by Abbas Ali Jessani  D.D.S., University of Karachi, 2010  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (CRANIOFACIAL SCIENCE)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) February 2014  ? ABBAS ALI JESSANI, 2014  ii Abstract  Objective: To determine the baseline self-reported oral health and dental service utilization of pregnant women from diverse ethno cultural backgrounds within the geographical are of the Fraser Health Authority in British Columbia, Canada.  Method:  A prospective 34-item cross-sectional survey was administered to all the women enrolling for a prenatal registration program between October 2012 and January 2013. For data analysis, a two-sample t-test was used, and categorical variables were tested using a chi-square test. Multivariable logistic regressions were used to estimate the odds ratio.   Results: A total of 740 pregnant women filled out the questionnaire. The majority (84%) of the respondents rated their oral health as good or excellent. Fifty two percent of the women had visited dental professional during last year. Almost 1/3 of those reporting symptoms of depression rated their oral health as fair or poor. Forty-one percent reported having bleeding gums, 22% experienced tooth sensitivity, and 13% had persistent dry mouth since the beginning of their pregnancy. When asked about the beliefs associated with pregnancy, 37% of the respondents expected bleeding gums, and 34% expected tooth sensitivity. Women born in India had visited a dental professional 2.8 times more often than women who had been born elsewhere. Those with dental insurance were 6.6 times more likely to visit a dentist than those without insurance.  iii       Conclusion: The majority of pregnant women considered dental care during pregnancy to be very important and had previously visited a dental professional within the last year. However, more than 1/3 had experienced one or more oral problems while more than half held false beliefs about the effects of pregnancy upon oral health. These reported oral beliefs and problems could be addressed with patient education during routine pre-natal care and subsequent referral to a dentist if needed.              iv   Preface This study was approved by the University of British Columbia, Office of Behavioral Research Ethics Board (Certificate Number: H12-01049) and Fraser Health Research Ethics Board.                     v Table of Content Abstract ........................................................................................................................................... ii Preface............................................................................................................................................ iv Table of contents..............................................................................................................................v List of Tables ................................................................................................................................. ix List of Figures ................................................................................................................................. x List of Abbreviations ..................................................................................................................... xi Acknowledgements ....................................................................................................................... xii Dedication .................................................................................................................................... xiii Chapter 1: Introduction ................................................................................................................... 1 1.1 Oral Health and the Canadian Health Measure Survey ....................................................... 1 1.2   Oral Health and Pregnancy ................................................................................................ 2 1.2.1 Hormonal Changes During Pregnancy .......................................................................... 4 1.2.2 Dental Decay (caries) ..................................................................................................... 4 1.2.3 Early Childhood Caries .................................................................................................. 4 1.2.4 Gingivitis........................................................................................................................ 5 1.2.5 Periodontitis and Associated Complications ................................................................. 6 1.2.5.1 Preterm Birth and Low Birth Weight Babies ....................................................... 6 1.2.5.2 Periodontitis Related Preeclampsia ...................................................................... 7 1.2.6 Gestational Diabetes Mellitus ........................................................................................ 7 1.2.7 Systemic Complications for the Expectant Mother and Fetus ....................................... 8 1.2.8 Oral Tumours ................................................................................................................. 9 1.2.9 Socioeconomic, Cultural and Need Factors ................................................................... 9 1.3 Dental Public Health in Canada Health Authorities in British Columbia .......................... 13  vi 1.3.1 Fraser Health Authority ............................................................................................... 14 1.3.1.1 Best Beginnings Prenatal Program ..................................................................... 14 1.3.2 Canadian Health Measure Survey and Prenatal Dental Questionnaires ...................... 17 1.4 Research Question .............................................................................................................. 19 1.5 Objectives ........................................................................................................................... 19 Chapter 2: Material and Methods .................................................................................................. 20 2.1 Proposed Framework for this Study ................................................................................... 20 2.2 Proposed Survey Questions ................................................................................................ 23 2.3 Study Design and Protocol ................................................................................................. 26 2.4 Phase 1 ? Pilot .................................................................................................................... 27 2.5 Phase 2 ? Main Study ......................................................................................................... 28 2.6 Data Variables .................................................................................................................... 29 2.6.1 Selection and Construction of Outcome Variables ...................................................... 29 2.6.2 Selection and Construction of Independent Variables ................................................. 30 2.6.2.1 Predisposing Variables ....................................................................................... 30 2.6.2.2 Enabling Variables .............................................................................................. 30 2.6.2.3 Needs Variables (Self-assessed Oral Health) ..................................................... 31 2.7 Data Analysis ..................................................................................................................... 34 Chapter 3: Results .......................................................................................................................... 35 3.1 Descriptive Analysis .......................................................................................................... 35 3.1.1 General Characteristics of the Study Population ......................................................... 35 3.1.2 Descriptive Oral Health Characteristics of the Study Population ................................ 35 3.2. Bivariate Analysis ............................................................................................................. 45  vii 3.2.1 Self-reported Oral Health with Psychosocial (pre-disposing and enabling) Variables................................................................................................................................................ 45 3.2.2 Dental Service Utilization with Psychosocial (pre disposing and enabling) Variables................................................................................................................................................ 49 3.2.3 Self-reported Oral Health Status with Self-Assessed Dental Conditions and Beliefs . 52 3.2.4 Dental Service Utilization with Self-Assessed Dental Conditions and Beliefs ........... 54 3.3 Multivariate Analysis ......................................................................................................... 59 3.3.1 Self-Reported Oral Health Status and Dental service utilization................................. 59 3.3.2 Self-Assessed Dental Conditions and Beliefs .............................................................. 61 Chapter 4: Discussion ................................................................................................................... 63 4.1 Key Findings ...................................................................................................................... 65 4.1.2 Self-Assessed Oral Health (Need Variables) with Dental Service Utilization and Self-Reported Oral Health ............................................................................................................ 69 4.1.3 Aboriginal Community ................................................................................................ 72 4.2 Summary ............................................................................................................................ 73 Chapter 5: Conclusions, Recommendations and Limitations ....................................................... 74 5.1 Conclusion ...................................................................................................................... 74 5.2 Recommendations  Dental Public Health Organization and Professionals .................... 74 5.2.1 Future Directions ...................................................................................................... 76 5.3 Limitations ...................................................................................................................... 76 References ..................................................................................................................................... 78 Appendices .................................................................................................................................... 83   viii Appendix A - Citations from the Systematic Literature Search on Oral Health and                             Pregnancy ...................................................................................................... 83 Appendix B - Core Competencies for Oral Health Promotion Outlined by The Canadian                           Association for Public Health Dentistry. ...................................................... 91 Appendix C - Concepts of Validity ...................................................................................... 93 Appendix F - Best Beginning Prenatal Registration Form ................................................... 97 Appendix G - Dental Questionnaire ..................................................................................... 98                  ix List of Tables Table 1 General Characteristics of the Study Population ?????????????.....?36 Table 2 Predisposing (demographic) Characteristics of the Study Population with Self-                    Reported Oral Health..................................................................................................47 Table 3 Enabling Characteristics of the Study Population with Self-Reported Oral Health...48  Table 4 Predisposing (demographic) Characteristics of the Study Population with Self-                          Reported Dental Service Utilization.????????.....?????????.50  Table 5   Enabling Characteristics of the Study Population with Self-Reported Dental Service                 Utilization??...?????????????????????????? 51  Table 6   Self-Reported Oral Health with Self Perceived Oral Conditions and Beliefs.............53 Table 7   Self -Assessed Oral Health of the Study Population with Dental Service                 Utilization....................................................................................................................56   Table 8    Self -Assessed Oral Health of the Study Population with the Country of Birth?....58 Table 9  Multivariate Analysis of Self-Reported Oral Health and Dental Service                 Utilization................................................................................................................?60  Table 10  Multivariate Analysis of Self-perceived Condition and Beliefs?................???62  x List of Figures  Figure 1 Key Words and Database Used for the Systematic Literature Search???????.....3 Figure 2 Different Aspects of Needs .................................................................???????..12 Figure 3 Andersen's Emerging Model (taken from Andersen1995)??????....????....22 Figure 4 Functional Model ? Modification of Andersen's Emerging Model (adapted from                    Andersen's 1995)?????????????????????????......?.33 Figure 5 Self-Reported Oral Health of the Study Population????????????..........38 Figure 6 Self-Reported Oral health Status Reported (fair or poor) of the Study Population According to their Region of Birth..................................................................................................39 Figure 7 Self-Reported Dental Service Utilization of the Study Population ??...???...?....40 Figure 8(a) Self-Reported Dental Conditions of the Study Population???????....??...42 Figure 8(b) Self-Reported Pregnancy Related Oral Health Beliefs of the Study Population.?.....43 Figure 9 Dental Service Utilization with Self-Reported Oral Health of the Study Population.?..44          xi List of Abbreviations  BB  Best Beginning (Prenatal registration form in Fraser health authority) BC  British Columbia  CHMS  Canadian Health Measure Survey CHW  Community Health Worker DND  Department of National Defense ECC  Early Childhood Caries FHA  Fraser Health Authority FoD  Faculty of Dentistry GDM  Gestational Diabetes Mellitus Ig                    Immunoglobin IL                    Interleukin LBW  Low Birth Weight OCDO  Office of Chief Dental Officer PGs                 Prostaglandins  PHN  Public Health Nursing PTB  Pre-Term Birth TNF                 Tissue Necrotic Factor UBC  University of British Columbia VCH  Vancouver Coastal Health WHO  World Health Organization    xii Acknowledgements I would like to express my heartfelt gratitude to my supervisor Dr. Mario Brondani for his consistent guidance and support throughout this endeavour. He is not only an excellent academic and researcher, but his work ethic and wisdom are truly a great source of inspiration. I would like to extend my sincere thanks to my advisory committee members, Drs. Kavita Mathu Muju, Denise Laronde and Victoria Lee for their expertise and constructive feedback that helped me to think outside the box. I would also like to extent my sincerest appreciation to Dr. Heather Bush and Hsin- Fang Li (Grace) for their great help and support for the statistical analysis of my project. I would like to thank my faculty members, Dr. Jolanta Aleksej?nien? and Dr. Rosamund Harrison for their kind and constructive feedback on my research proposal.  I would like to thank the Fraser Health Authority for their tremendous support and collaboration, and I would especially like to thank Carolyn King, Marilyn Blondahl and Jennifer Riley for all their academic and logistical assistance. To the staff of Surrey Memorial Hospital, thank you for all your cooperation during the four months of data collection.  To my parents, Naseem and Abdullah, and my sisters, Shireen and Nadia, thanks for your constant love and prayers. Sincere gratitude and thanks to my aunts, Niyamet and Munira, and my uncles, Shaffin and Barkat, for their enormous support and affection since I moved to Canada in September, 2011. I would further like to acknowledge how grateful I am to be a part of one of the best learning institutes in the world. I have enjoyed and learned during every bit of my academic experience at the Faculty of Dentistry in UBC.     xiii Dedication I would like to dedicate this work to my beloved parents, Naseem and Abdullah. I can?t thank you enough for all the hardships you have endured to provide me with the best education and for making me a good human being. Thank you for being the best parents in the world! To my aunt, Niyamet Hamirani, who is as close to me as my parents. I cannot thank you enough for all your encouragement and motivation in the past two years. You made me feel at home and loved me more than your son. It is because of you that I was as able to do well in my academics. Thank you for being there through thick and thin.  Last but not least, this work is also dedicated to my two beloved and adorable sisters, Shireen and Nadia, for always being my strength and support.   1                                          Chapter 1: Introduction  1.1 Oral Health and the Canadian Health Measure Survey  Oral health is an integral part of the general well-being of an individual. The condition of our mouth affects the way we eat, speak, smile and develop social relations.(1) Unfortunately, the publically funded Canadian health care system does not cover any substantial provision of dental health care. Communities, such as aboriginal and refugee, seniors living in long-term care facilities and children with special needs, receive some basic coverage for dental care but for the most part, dental services are provided by the private sector on the basis of ?fee for service?. According to Timmreck et al, 2003, there is no or little information available at the population level regarding the oral health needs of the Canadian population. Needs assessment is therefore of primary importance when designing a public health intervention catering to the widespread needs of Canadians.(2) Released in 2011, the Oral Health component of the Canadian Health Measure Survey (CHMS) provided valuable information about the baseline of oral health of Canadians. According to the CHMS, although three out of four Canadians visit a dental professional every year, one forth still does not have any kind of insurance and have to pay for dental expenses out-of-pocket. In fact, the high cost of dental treatment is the most common barrier preventing full access to dental care.(3) As a result, almost 20% of Canadians are unable to get proper oral and dental care. Twice as many lower income Canadians, including pregnant women, experience oral diseases such as dental decay compared to Canadians from the higher socioeconomic strata.(3) Therefore, it is important for us to identify the oral needs of low-income pregnant women who might be at elevated risk for oral disease. This will enable us to set our priorities for the effective delivery of resources to meet the specific dental needs of this   2 particular stratum of the population. There is no population-wide data available from the CHMS or any other public health organization regarding the oral health status of women during pregnancy in Canada. 1.2   Oral Health and Pregnancy  Oral health care and oral disease prevention before, during and after pregnancy is one of the most important aspects of general health for mother and newborn.(3) More often than not, however, pregnant women and their health professionals are unaware of the potential risks of oral diseases during this natural life event.(3) Poor maternal oral health has consequences to the pregnancy itself as it can be related to, or the cause of, miscarriages, preterm birth (PTB) or low birth weight (LTW). (4) Moreover, poor maternal oral health is believed to be associated with early childhood caries and long-term systemic disorders after birth for the newborn. However, the current literature does not offer indisputable evidence or a full understanding of the mechanisms of how poor oral health affects pregnant women and their infants. In order to better understand the associations of the above pregnancy-related conditions with poor oral health, a detailed yet non-systematic literature review was conducted as depicted in Figure 1. Appendix 1 shows the list of the 130 publications gathered from this review that I used to develop my research (proposal) which included peer reviewed papers, reports, letters to the editor, thesis and books. Other publications were also used throughout the thesis to support or refute my findings.        3 Figure 1 - Key words and database used for the systematic literature search.   Total number of papers reviewed: 130 Search Engine: Ovid Medline Key  Words: (pregnan* or prenatal and (oral health and  dent* care) and (Poverty or poor or socio economic status ): 68 abstracts  Exclusion criteria: clinical information, genetics, etc. Excluded: 3 Papers included:  65 Search Engine:  Ovid Medline Key words: (cultur* or ethni* and Value and belie*) and (oral health or dent* care):  299 abstracts   Exclusion criteria: language other than English, growth hormone, in vitro pregnacy, abortion, etc. Excluded: 39         Papers included:  10 Search Engine: Google Scholar  Key words: oral care during pregnancy, oral care, pregnancy and low socioeconomic status, health authorities in Canada, health authorities in BC, etc. Non-refered papers, reports, press release  and other subject-specific publications:  55   4 1.2.1 Hormonal Changes During Pregnancy  Complex physiological and hormonal changes are normally expected during pregnancy. Some of these changes can, however, adversely affect the oral cavity.(5) For example, hormonal fluctuations, particularly of progesterone and estrogen, can alter collagen production at the gingival level and affect the immune system by altering an acute neutrophilic response.(6) Such alteration can potentially lead to lower levels of antioxidants and may induce xerostomia in up to 50% of pregnant women.(3, 4) As a result from the altered immune response and disturbance in saliva production, the oral cavity may became more susceptible to various diseases including dental caries, gingivitis, periodontitis and oral tumours (7) discussed ahead. 1.2.2 Dental Decay (caries) Dental decay is the most common oral infection worldwide contributing to tooth loss, and can also affect pregnancy. The major risk factors associated with the high prevalence of dental caries in pregnancy are lack of readily available fluoride, a diet high in sugar and frequent snacking (especially in pregnancy), changes in oral hygiene habits (including frequency and efficacy), and lower socioeconomic status.(3, 8) These risk factors can further increase the susceptibility to, and prevalence of, dental caries during pregnancy, especially when associated with frequent erosion of the dental enamel due to gastric reflux (e.g., increased acid in the mouth) and infrequent or nonexistent dental checkups.(8) In turn, the cariogenic bacteria associated with tooth decay can be transmitted to the newborn, which can be a risk factor for early childhood caries (ECC).(3, 9)  1.2.3 Early Childhood Caries        Mothers with a high prevalence of dental caries have a greater tendency to vertically transmit cariogenic bacteria to their infants through saliva, for example while kissing or sharing food using the same spoon.(9, 10) The most common and active transmissible organisms   5 involved in early childhood caries are Streptococcus mutans and Streptococcus sobrinus, and lactobacillus species, with mutans being associated with the early colonizing bacteria of ECC. (10, 11) Other risk factors associated with ECC include improper child brushing habits, substitution of sugary beverages for breast milk and allowing the infant to fall asleep while being breast or bottle-fed.(12-14) ECC seems to be a risk factor for problems with growth and development, eating and phonetic alterations, low self-esteem and poor school attendance.(6) The associated costs of treating ECC are extremely high. According to the Association of Dental Surgeons of British Columbia (1999), more than 5,000 children under the age of four are treated annually under general anesthesia for ECC with an annual estimated cost of 10 million dollars.(6) Dental diseases and their treatment, including ECC, are the greatest contributors to hours lost from school or work in total: 40.36 million hours lost per year in Canada, and 2.26 million hours lost per year in British Columbia, respectively.(6)  1.2.4 Gingivitis  Gingivitis is a reversible inflammation of the gingival tissue that affects 60% to 75% of pregnant women. (15, 16) Although gingival inflammation is most commonly caused by the accumulation of plaque around the tooth, the decreased immune response and alterations in the hormonal milieu during pregnancy can also contribute to its development. In fact, half of pregnant women are likely to experience a significant exacerbation of gingivitis, albeit mostly transient.(15) If followed up with proper oral hygiene measures, it is most likely to subside after childbirth.(5) If left untreated, however, this inflammation may lead to periodontitis and destruction of the periodontal tissues around teeth.(5)     6 1.2.5 Periodontitis and Associated Complications The bacterial infiltration caused by gingivitis can further spread below the gum line and stimulate a chronic inflammatory reaction. This can result in subsequent bone loss and breakdown of the surrounding periodontal tissue. The American Academy of Periodontology suggest that, like tooth decay, this condition can culminate in tooth loss if left untreated.(5) According to the New York State Department of Health in 2006, almost half of women of reproductive age suffer from periodontitis and of those who are pregnant, 30% develop periodontal disease.(17) This chronic inflammation has been linked with preterm birth and low birth weight, with preeclampsia and gestational diabetes. 1.2.5.1 Preterm Birth and Low Birth Weight Babies A baby born at less than 37 weeks of gestation and weighing less than 2500 grams is considered as a preterm birth (PTB) and to be of low birth weight (LBW), respectively. (17) According to some research, periodontal disease could be considered an independent risk factor for PTB and LBW.(17) This can be due to the increased levels of inflammatory mediators that are produced in response the periodontal inflammation and toxins. This inflammation can lead to the increased production of circulating cytokines (e.g., tumour necrosis factor, interleukin 8, interleukin). Furthermore, it can increase the uterine stimulating factors such prostaglandins, which can have an effect on the placental function that can induce early labour. (18) The key factors involved in PTB and LBW include: IgG anitibodies, periodontal pathogens (mainly Tanneralla forsythia, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Treponeam denticola, Fusobacterium nucleatum and Campylobacter rectus) and increased levels of cytokines. (18) The presence of higher levels of fetus IgM in the fetal blood cord samples of the pregnant women with the chronic periodontal disease suggests an   7 association of periodontal disease with the PTB and LBW.(19, 20) The other known risk factors for PTB and LBW include substance abuse, very low or very high maternal age, alcohol consumption, multiple births, low socioeconomic status, previous history of PTB, and urinary tract infections.(21, 22) However, studies have also correlated PTB and LBW with periodontitis although not without controversy.(19, 23) In fact, some researchers have refuted this association by highlighting potential biases in such findings in terms of differences in study design, sample size, population involved (e.g., socioeconomic status, race), outcome measures (e.g., definition of preterm or low birth weight or fetal loss), exclusion and inclusion criteria and the clinical indices used to measure the level of disease.(23) Nonetheless, research also suggests that taking proper care of the mother's periodontal health during pregnancy can contribute towards a healthy pregnancy and a healthy newborn.(24, 25) 1.2.5.2 Periodontitis Related Preeclampsia Periodontitis has been also associated with preeclampsia, pregnancy-induced hypertension, which usually presents after 20 weeks of gestation and affects approximately 5% of pregnant women.(26) However, the exact pathophysiology of the mechanism is not known. Another theory suggest that the inflammatory mediators of periodontal infection can damage the endothelial lining of placental vasculature by increasing the placenta's vascular permeability. Thereby, active periodontitis-related bacteria and their metabolites are subsequently able to enter the placenta, which can culminate in sepsis and abortion.(5, 26, 27) 1.2.6 Gestational Diabetes Mellitus  According to the American College of Obstetricians and Gynecologists, Gestational Diabetes Mellitus (GDM) is presented as carbohydrate intolerance with onset during pregnancy.(28) Periodontal disease can cause or complicate GDM. Some evidence suggests that periodontal   8 inflammation can elicit a transient bacteremia caused by the pathogens in subgingival plaque. This bacteremia can further cause a sustainable systemic inflammatory response involving periodontal inflammatory mediators and cytokines such as TNF-a IL-1B, IL-6, IL-8 and C-reactive protein by entering the blood circulation. This systemic inflammation (caused by chronic periodontitis) can increase the insulin resistance, causing the destruction of pancreatic B-cells. This may increase the glucose tolerance level hence manifesting the symptoms of GDM.(29, 30) Studies suggest that GDM can significantly increase the risks of maternal and infant morbidity.(31) Although early detection and management of periodontal disease can improve insulin resistance and glycemic levels, untreated periodontal disease can further lead to long-term health complications for both mother and infant.(31)  1.2.7 Systemic Complications for the Expectant Mother and Fetus Research suggests that the by-product of periodontal inflammation in the form of a C-reactive protein can contribute to cardiovascular disease, stroke and diabetes mellitus.(18) Some studies also suggest that the risk of cardiovascular diseases may increase in pregnant women with poor periodontal health.(18) These complications can also be extended to infants born preterm or with low birth weight. As adults, these infants might be at additional risk for developing diabetes and cardiovascular disorders.(32, 33) The exact pathophysiology of this mechanism is still unknown but it has been hypothesized that it is the formation of atheromas in the form of plaques in the inner lining of arteries that lead to atherosclerosis and other CVS disorders.(33)  Furthermore, the presence of bacteria in the placenta can also be associated with poor neurologic outcomes during fetal development such as cerebral palsy, a group of chronic conditions affecting body movements and muscle coordination; periventricular leucomalacia, a major form of brain white matter injury associated with the subsequent development of cerebral palsy,   9 intellectual impairment and visual disturbances; and Alzheimer?s Dementia, a neurodegenerative disorder that leads to selective memory impairment.(34, 35) Although the exact pathophysiology of the above conditions has not yet been fully understood, it has been theorized that the inflammatory mediators from periodontitis during pregnancy can alter the internal cellular environment and affect the genomic machinery of the fetus.(35)  1.2.8 Oral Tumours  Although not common, another variety of oral pathology that can affect pregnant women is a benign neoplasm. It is estimated that up to 5% of pregnant women may experience these benign growths that clinically and histopathologically resemble a pyogenic granuloma (a benign tumour-like condition of the skin and mucus membrane) that grows on the gingival surface particularly after the first trimester.(36)  This condition is most likely to occur due to the increased levels of progesterone, in association with bacteria from plaque and calculus, subsequently contributing to the development of this condition. (36) Unlike gingival inflammation, this condition is not believed to be associated with adverse pregnancy outcomes and usually subsides after pregnancy. However, this transient pathology can affect the normal masticatory function and can limit the nutritional intake of both the mother and consequently, the fetus during pregnancy.(37) 1.2.9 Socioeconomic, Cultural and Need Factors Oral health during pregnancy can be further affected by a number of social, economic and cultural factors that prevent pregnant women from attaining basic and essential oral health care either because of financial constraints or beliefs. Studies worldwide have indicated that oral care might not be a priority for pregnant women and their health care professionals due to a variety of factors mostly related to ethno-cultural health values and beliefs.(38)    10 There seems to exist a direct correlation between poverty, lower socioeconomic and educational status and acquiring oral health care during pregnancy, which places pregnant women at greater risk for the health complications discussed above.(38) In fact, some ethno-cultural groups believe that oral problems can be quite expected during pregnancy. For example, there is a Chinese belief that the fetus can ?utilize? the mother?s calcium and as a result, the pregnant woman could expect quite normally to lose teeth, to have tooth decay or to have existing fillings falling out.(39, 40)  A mother?s health education also plays a key role in shaping the oral health of her children. A mother with bad dietary and oral hygiene habits can encourage the same eating and hygiene behaviours in her children. As a result, children may demonstrate lack of, or improper care, for their oral health during their childhood and adult life.(40) Financial affordability, lack of dental insurance and high rates of dental needs also play a great role in shaping care-seeking behaviour.(41, 42) Therefore, the population in general including pregnant women can be deprived of getting basic dental care when needed. According to the American Pregnancy Risk Assessment Monitoring System, not more than 50% of pregnant women receive oral care.(41)  Predisposing factors for this insufficient dental service utilization include low socioeconomic status, immigrant or refugee status, lack of cultural adaptation, lack of physical access to a dental office, misconceived values and beliefs about oral health, alcohol consumption, tobacco abuse or simply lack of awareness about oral health care during pregnancy.(43, 44) It has also been shown that women who do not receive relevant oral health care information or who do not have prior dental knowledge are unable to engage in preventive health care behaviour. (42)   11 Although publicly funded educational and preventive oral health initiatives exist, they might not be enough to address the extensive dental needs of Canadians.(45) Moreover, there is no comprehensive data on the oral health needs of pregnant women in Canada. Due to financial unaffordability and lack of resources for meeting the unknown dental care needs of the population, Wright et al used the following illustration to distinguish the differences between health care needs, supply and demand in a general population.(46)                      12 Figure 2: Different aspects of needs (Adopted from Wright et al. 1998 and Ramraj et al. 2012)                 According to Wright et al, need is defined as a ?capacity to benefit?. He further elaborates that resources should be available for the population, once the needs have been identified. Demand is ?what patients ask for? and supply is the final outcome or resource, which is provided by the health care system, private or public.(46) It is an undeniable fact that the rising cost of dental services restricts people from obtaining even the most very basic dental care. As a result, more efforts are needed at the population level to address the oral health needs of Canadians in general, and pregnant women in particular.(46) One way of doing this would be by focusing more on the prevention and early clinical intervention which could lead to a substantial cost       Demands  (Expressed needs)         Needs  (Normative needs)     Met     Unmet    Supply   13 benefit for both the population and the health care system. This could be accomplished by strengthening the dental public health programs and initiatives on local and provincial levels.(46) 1.3 Dental Public Health in Canada Health Authorities in British Columbia The field of dental public health is dynamic and has been evolving over time in Canada. It mainly involves dental health needs assessments, surveillance, disease and injury prevention, health promotion and protection and aids for improving the dental health of populations.(30, 47) The Canadian Association of Public Health Dentistry (CAPHD) has defined specific tasks for the improvement of the oral health of the population.  The CAPHD has been leading the development of the core tasks for dental public health professionals with the ongoing support from Public Health Agency of Canada as part of the larger Pan-Canadian Public Health Core Competencies initiative (See Appendix 2).  In summary, it is essential to strengthen and standardize the practices within organizations as well as complex public health strategies. As the public health systems and services vary between and within provinces and territories across Canada, so does the usage of discipline competencies. As a result, the adoption of dental public health task requires acceptance and commitment from a variety of groups including federal and provincial/territorial governments and regional health care authorities. Within this context, there are seven major health care authorities in British Columbia that have preventive dental public health programs catering to the needs of their regional populations.  In B.C., the seven major health authorities are: Vancouver Coastal Health (VCH), Fraser Health (FH), Northern Health, Vancouver Island Health Authority, Interior Health, Provincial Health Service Authority and First Nation Health Authority. Like in other Canadian provinces, most of the prenatal dental programs in B.C focus on educating pregnant women in maintaining their oral   14 health during pregnancy. (45) Fraser Health is the largest health authority in BC, and it is described ahead.   1.3.1 Fraser Health Authority Fraser Health (FH) works to improve the health and quality of life of the people associated with it.(48) It is divided into three major zones: North, South and East. Each zone has its own infrastructure of local public health units, which are designed to meet the health care needs of their target populations. FH serves more than 1.6 million people, which include a large Asian population consisting of Indo-Canadians, Korean and Filipino descent. It has an annual operating budget of 2.6 billion dollars, and includes 12 acute care hospitals and 7760 residential care beds, and houses 1,547 residents in public mental health homes and community centers.(48) FH current oral health promotion initiatives include fluoride varnish application for children up to the age of 4-yrs old, oral health education in elementary schools, preschool dental resource kit for children at age three that includes oral health education material and oral health care program for the adults with developmental disabilities. Fraser Health also has been involved with research in Public Health Dentistry, one of which in collaboration with Simon Fraser University that highlighted the appalling oral care treatment needs of the government-assisted refugees.(49) FH also runs a prenatal program called ?Best Beginnings?, which is similar to programs offered by other provincial health authorities reaching pregnant women and their new born(s).  1.3.1.1 Best Beginnings Prenatal Program     The Best Beginnings (BB) ?is a direct public health resource to promote the health and wellness of the pregnant women, new mothers, babies two years of age and families using a population health approach that seek to raise the health status of those most in need?.(50) The   15 program has been designed to provide universal health services to all pregnant women, as well as enhanced services for those who are vulnerable, their children and families. It aims to use the best available public health evidence to minimize adverse outcomes while enhancing protective factors during pregnancy. It collaborates with maternity care providers to facilitate seamless care across prenatal services. (50) All pregnant women under the umbrella of FH are encouraged to register in the BB program within 18 to 20 weeks of pregnancy (Appendix 7 shows the BB form). This permits access to all prenatal health services to promote a healthy prenatal experience for mothers and their future babies. According to the FH, the BB registration form serves as a pre-screening tool on the existing social, economic and health care problems associated with the pregnant women. It supports woman?s health rights from the time that she conceives, throughout the prenatal period and after delivery. The primary goal of BB registration is to provide health and community resource information about all pregnant women while identifying vulnerability factors during pregnancy and providing evidence based public health interventions to the pregnant women.  In terms of vulnerability, the BB form identifies pregnant women which may be at health risks if they report tobacco use, symptoms of depression, financial difficulties, earlier or advanced age, food insecurity, aboriginal status, lower educational level, among other concerning factors. Once the pregnant woman is identified as having possible risk factor(s), she is placed into a vulnerability category as per the pathways below:  Pathway A        Selected population Pathway B        Symptoms of depression Pathway C        Vulnerability   16 Pathway D        Tobacco use Pathway E         Mail Environmental Tobacco Smoke (ETS) pamphlet Pathway F         No Follow-up  Pathway A: FH recognizes the importance of improving the health status of the indigenous residents due to their historical health disparities and social economic inequalities. Approximately 40,000 First Nations people from 32 different bands are provided with essential health care through FH. All the aboriginal women are eligible for Public Health Nursing (PHN) assessment, care and education. Pathways B and D:  Pathways B and D include women who present with any positive responses to depression or tobacco smoking, respectively. Women identified within these pathways are also eligible for PHN. Pathway C: This pathway overlaps with pathway A, and includes those aboriginal women who also have at least one of the following risk factors: young/old maternal age at pregnancy, insufficient income, symptoms of depression, tobacco smoking and a lower level of education.  Women identified with this pathway remain eligible for PHN assessment.  Pathway E: This pathway includes women who answer yes to the second-hand smoke question on the registration form and who do not meet the criteria for A, B, C or D pathways. Women identified in this pathway receive information that is mailed out only.   Pathway F: This pathway represents those pregnant women who do not meet the criteria for the pathways A, B, C, D or E. They will not receive prenatal PHN follow up.  Other risk factors including the experience of violence from an intimate partner are also identified and addressed accordingly. Based on the initial prenatal registration and the pathway identification, contact with the pregnant woman is established within the next seven calendar   17 days for further vulnerability assessment. For pathways B, C or D these assessments are completed over the telephone. For pathway A, the vulnerability assessment is completed over the phone or in person. If the contact number is not available, three visit attempts over a period of three weeks are made. The pathways identify women with health risks who are offered various services and referrals ranging from nutritional counselling, alcohol and smoking cessation programs, sexual health, to immunization. Likewise, the same pregnant woman can be assigned to more than one pathway and receive the follow up based on their self-reported vulnerable factor(s). (50)   Although comprehensive, the BB form does not have any question regarding oral health, access to dental care or attitudes or the values and beliefs of pregnant women towards their oral care. These were important issues that I have identified and discussed earlier. FH than took an initiative to include dental question(s) in the registration form that lead to the partnership for my research. Also, no designated pathway exists to identify pregnant women vulnerable to the consequence of oral diseases.  Different oral health questionnaires exist in the dental literature to assess respondents? knowledge, attitudes and behaviours on topics ranging from their own health, satisfaction with services, treatment needs, health values and beliefs and so on. These questions are mostly self-completing and vary in length (e.g., number of questions) and answering format (e.g., frequency of events, level of agreement or satisfaction, etc.). Below I present and discuss some of these existing questions, including the Canadian Health Measure Survey and others. 1.3.2 Canadian Health Measure Survey and Prenatal Dental Questionnaires  Before 2007, when the Office of Chief Dental Officer (OCDO) and the Department of National Defense (DND) started the data collection for the oral component of CHMS, there was   18 no nationwide data available on the clinical status of Canadians.  Dentists from the DND traveled across Canada to examine almost 6,000 participants in 15 communities randomly selected from all over Canada from March 2007 to February 2009. This sample size is a representation of the 97% of the Canadians aged 6 to 79 years old. Although CHMS includes data on self-reported general and oral health followed by the clinical examination, it does not seem to have been developed under a particular framework or supporting theory to base its questions. The validation process used to evaluate the questions is also unknown (See Appendix 2 as I elaborate on my understanding of validity and its relevance to questionnaire development). Moreover, the results of the CHMS do not specify any particular findings regarding oral care and pregnancy, but the questions posed could be used for surveying pregnant women.     My literature review (Figure 1) also directed me to existing prenatal dental questionnaires. Most of them focus on parental knowledge, beliefs and behaviours for oral health of toddlers,(51) parental influence on adolescents oral health behaviour,(52) knowledge, attitude and behaviour of partners or care takers regarding transmissibility of caries,(53) parental risk attitudes and caries-related behaviours,(54) and the parental beliefs and attitudes towards child caries prevention.(55) Some examples of the questions include ?has your child ever had dental caries? ?(Yes, No, Don?t know), ?can dental caries be transmitted from person to person?? (Yes, No, Don?t know), ?if our child uses fluoride toothpaste, it will prevent tooth decay?? (1=strongly disagree, 5=strongly agree), ?it is not worth to battle with our child to brush his/her teeth twice daily? (1=strongly disagree, 5=strongly agree). These questions do not necessarily target the oral health attitudes, knowledge and beliefs of pregnant women.  A recent study from the UBC Faculty of Dentistry entitled ?Can prenatal dental public health program can make a difference?? presents a questionnaire designed to explore the   19 knowledge, attitude and behaviour about oral health care practices of pregnant women and to identify the most common oral problems experienced by them.(45) Given the current evidence on the links between the lack of oral health and the risks to pregnancy, Fraser Health partnered with the UBC Faculty of Dentistry to design oral health-related question(s) to the BB form. The literature review I have conducted enabled me to develop new, and modify existing, oral health questions in the light of my research questions and objectives:    1.4 Research Question What is the baseline self-reported oral health status and dental service utilization of pregnant women from diverse ethno-cultural backgrounds in Fraser Health Authority in BC 1.5 Objectives: 1) To design and test question(s) to identify the baseline of self-reported oral health status and dental service utilization during pregnancy. 2) To identify the baseline self-reported oral health and dental service utilizations of pregnant women in Fraser Health Authority.  3) To examine how independent variables (e.g., educational levels, dental insurance availability, perceived oral health status) correlate with self-reported oral health status and dental service utilization.      20                           Chapter 2: Material and Methods  2.1 Proposed Framework for this Study Given the nature of my research and in the context of the BB form and development of a dental questionnaire (discussed below), Andersen and Newman model of Health Services (1995) (Figure 3) appears to fit quite well with my research question and objectives.(56) This model was first developed in 1960 to examine the use of health services and to foster the even-handed promotion and access of health services. After a series of modifications, the latest form presented in 1995 determines the role of different societal and individual factors that may influence one?s utilization of health care services. As shown in Figure 3, the model comprises three major factors: predisposing (demographics), enabling (ability to pay or difficult living conditions) and needs factors (health status or perceived needs). The model has been used in various researches to predict the most important factors that could influence health service utilization. According to Babitsch, Figure 3 has been widely used in various studies as a theoretical framework and adapted to different areas of health care research.(57, 58) The main predisposing variables examined in most of the studies using this model are age, gender/sex, education and ethnicity. The main enabling factors are income and financial affordability, financial condition, health insurance and having a usual source of care or a family doctor.(58, 59)   22 Health care system    External Environment   Predisposing                Enabling  Characteristics    ?   Resources  ?  Need    Personal Health            Practices          Use of Health              Services  Perceived Health Status     Evaluated Health Status   Consumer Satisfaction  ENVIRONMENT POPULATION CHARACTERSTICS HEALTH BEHAVIOUR OUTCOME Figure 3: Andersen's Emerging Model (taken from Andersen1995) Figure 4: Functional model ? Modification of Andersen's Emerging Model  23  2.2 Proposed Survey Questions Based on the above literature review and framework to address my research question and objectives, I suggested the following seven self-reported questions. These questions enabled me to determine the overall oral health status (including self-perceived oral health conditions) and dental service utilization of pregnant women.  Question 1 1.A Please rate the health of your mouth: (choose one) (  ) Excellent (  ) Good (  ) Fair (  ) Poor    Rationale:  This question has been widely utilized (41, 59, 60), and was also part of the CHMS. It is very likely that those who answer ?excellent? or ?poor? are telling us that their mouths are in fact clinically good or bad, respectively, as found by Pitiphat and colleagues and others.(60, 61) It can then serve as surrogate measure for the oral health status while providing an economical alternative to clinical examination.(62) 1.B How important do you think the health of your mouth is during pregnancy? (  ) Very important  (  ) Moderate important  (  ) Somewhat important  (  ) Not important  (  ) I don?t know       Rationale: Adapted from the CHMS, this question helped me to gauge the level of importance of oral care as perceived by the respondents during pregnancy.   24 Question 2  2.A Do you have an insurance or government program that covers all or part of your dental expenses? (  ) Yes  (  ) No  (  ) Don?t know  (  ) I was refused coverage  2.B If yes, then is it: (  ) An employer sponsored plan? (  ) A private plan? (  ) A government program for social service? (  ) A government program for First Nations and Inuit?  Question 3 In the past 12 months, have you avoided having some or all the dental treatment that was recommended because of the cost? (  ) Yes  (  ) No  Rationale:  The above questions # 2 and 3 were used to identify the status and type of dental coverage of my study population, as employed by others (41). It also helped me to determine if financial affordability can be an influencing factor to seek the recommended dental treatment.  Question 4 When was the last time you saw a dental professional (dentist, dental hygienist, denturist) (choose one)? (  ) Less than 1 year ago (  ) 1 year to less than 2 years ago (  ) 2 years to less than 3 years ago (  ) 3 years to less than 4 years ago (  ) 4 years to less than 5 years ago (  ) 5 or more years ago  25  Question 5 Do you usually see a dental professional (dentist, dental hygienist, denturist) (choose one)? (  ) ? more than once a year for checkups or treatment (  ) ? about once a year for checkup or treatment (  ) ? led than once a year for checkup and treatment  (  ) ? only for emergency care (  ) ? never  Rationale: Questions 4 and 5 focus on the pattern of dental care attendance, which I used to identify the respondents? seeking oral care behaviour during or before pregnancy. In fact, the given choices of answers may or may not be correlated with the independent variables such as low income, smoking, refugee status, and so on.(59) Question 6 Since the beginning of your pregnancy to today, have you had any one or more of the following conditions:  Toothache                                                                                                   (  )Yes  (  )No Pain in your teeth when consuming hot or cold foods or drinks                (  )Yes  (  )No   Severe tooth or mouth pain at night                                                           (  )Yes  (  )No    Pain around your jaw joints                                                                        (  )Yes  (  )No                                                             Bleeding gums while brushing your teeth                                                  (  )Yes  (  )No                                                     Persistent dry mouth                                                                                   (  )Yes  (  )No                                                                           Persistent bad breath                                                                                   (  )Yes  (  )No                                                                          Rationale: Also modified from the CHMS, this question about self-perceived knowledge of one?s own oral health enabled me to identify the most prevalent self-reported oral problems experienced by pregnant women. There have been studies indicating that this type of question can be used as a surrogate measure for the actual oral health status where clinical examination cannot be conducted.(63)  26 Question 7: During your pregnancy, what do you think is most likely to happen in your mouth? (You may choose more than one answer) ( ) I may lose a tooth or teeth ( ) My teeth may become loose ( ) My teeth and gums may become sensitive ( ) I may lose calcium from my mouth/body because of my baby ( ) I may have a cavity or cavities in my teeth ( ) I may have one or more dental fillings falling out/lose a filling(s) ( ) I may avoid brushing and/or flossing ( ) My gums may bleed ( ) I may develop an oral tumour(s)/cancer ( ) I should avoid seeing a dentist/dental professional because__________________  ( ) None of the above ( ) Other ____________________________  Rationale: This question was developed based on my literature review. It asks for the held beliefs regarding oral care during pregnancy, which may or may not be influenced by the respondents? ethnic backgrounds or education levels. I was also interested in finding any potential correlation between the most prevalent self-reported oral conditions and self-reported oral health related beliefs. Moreover, the answers given to this question could be very helpful for health authorities and policy makers for designing the educational material that could target the false beliefs and misconceptions identified by this study.  2.3 Study Design and Protocol  As mentioned above, one of my objectives was to identify the baseline of self- reported oral health and dental service utilization as reported by pregnant women affiliated with the FHA. In order to accomplish this objective, I attached the above seven questions to the BB registration form for easy reading, together with the consent to participate in the study (Appendix E).  27 This study was carried out in two phases over four months. In phase 1, I conducted a brief pilot study for about a week to test the proposed questions. Phase 2 comprised of the main study in which data was collected via the BB form and the attached dental survey distributed to all the women attending prenatal registration at the Surrey Memorial Hospital, the largest hospital in FH enrolling more than 4000 pregnant women/year, all of which are encouraged to register into the BB program.  2.4 Phase 1 ? Pilot After obtaining ethics approval from FHA (Appendix 5) and UBC Ethical Research Board (UBC BREB # H12-01049), the proposed dental questions were piloted within a sample of seventeen individuals including pregnant women and their husbands, and hospital staff at the Surrey Memorial Hospital family planning and birthing unit who came from various ethno-cultural background. This diversity and size of the target population offered me the opportunity to carry out my data collection at the Surrey Memorial Hospital. The pilot entailed a brief face-to-face interview to get general ideas about the questions as volunteer participants answered them. I was interested in respondents? ideas about questions? comprehension, clarity and syntax coherence. Although the questions were based on existing questions of the CHMS, the general feedback helped me to make necessary changes. In order to proper elicit information about the questionnaire, I asked participants the following:  a) Are there any difficult words to understand? b) Is there clarity in the words? c) Is there any redundancy with the questions or their options? d) If you were told to rewrite this question, how would you do that? e) Are the given options enough? Or would you like to include any other option? Why?  28 f) Would you like to exclude any option? Why? g) Is there any redundancy with the options? Which ones? Thirteen out of seventeen respondents did not raise any concerns with the questions. Others gave the following comments/suggestions about question # 7: Respondent 1 reported that she did not find this question important because her doctor mentioned that her gums would bleed during pregnancy anyways. She further said that she has been advised by her family doctor not to visit a dentist during pregnancy.  Respondent 2 and 9 suggested adding the option ?None of the above? in case respondents did not believe that any of the listed conditions would happen while Respondent 9 further suggested to replace the word ?mobile? with ?loose? to make it more reader friendly.  Respondent 3 suggested including other questions(s) about smoking and/or other tobacco consumption to compare with the other dental questions. She was probably unaware that the BB form already asks the questions regarding smoking and tobacco consumption.  All the necessary changes were made after discussing them with my thesis supervisor and committee members. 2.5 Phase 2 ? Main Study:  Upon agreement with FH, I chose a full birth cycle from October /12 to February/13 to collect my data. Just like the pilot, this phase was carried out in the family planning and birth unit at Surrey Memorial Hospital on the volunteer basis.  If agreeing to participate in my study, participants were advised to detach the consent form for their records while filling out the BB form and the dental survey. The BB forms were kept in the reception area where a public health nurse collected them twice a week (mostly on Tuesdays and Fridays). In order to collect as much BB forms and survey as possible, I went to Surry Memorial  29 Hospital twice every week, on Mondays and Thursdays, before the public health nurse. I separated all the dental survey and made copies of the BB registration form while leaving the original to the nurse. I gave each respondent an ID code (to match the respective survey with the BB form) while de-identifying the forms by blacking out all the personal information such as name, address, postal code, care card number, date of birth, telephone number and other contact information. As requested by FH, all the data was numerically coded and entered into Microsoft Excel spreadsheet for statistical analysis (see ahead). However, if participants wanted to fill out only one of the documents (either the BB form or the survey), they could well do so even though I could not use this data form analysis purposes.  This second phase of my study reached 835 registrants in the 4-month birth cycle. From these, 740 (87%) responded fully to the survey and the BB form registration. This number held enough statistical power to tease out the potential relationships and correlations between the different variables presented above. Given that the Prenatal Registration Program is also voluntary, the actual number of pregnant women that were seen at Surrey Memorial Hospital during that time was probably larger. 2.6 Data Variables: Given the content of the survey questions and BB form, I have identified the following variables to focus my data analysis based on Anderson and Newman?s model. 2.6.1 Selection and Construction of Outcome Variables The dependent/outcome variables in my study are the self-reported oral health (from Question # 1) and dental service utilization during pregnancy (from Question # 4), which helped me to determine the overall behaviour of the participants to pursue dental services during pregnancy. The first outcome variable was derived by asking pregnant women to rate the health of their  30 mouth (?excellent,? ?good,? ?fair? and ?poor?). The answers were dichotomized, and the first of these two options indicated that the respondents were satisfied with the health of their mouth while the last two options indicated those that were not satisfied with the health of their mouth. The second outcome variable, which was dental service utilization, was derived from a question asking about their last dental visit (?less than one year?, ?more than one year?, ?more than five years?, ?never?). 2.6.2 Selection and Construction of Independent Variables The independent variables were grouped as per Anderson and Newman?s model constructs, including predisposing, enabling, and needs.  2.6.2.1 Predisposing Variables Predisposing variables were understood as those factors associating with unmet dental needs. They included demographic factors such as sex (in this study it was just focused on females), age, education (having minimum of high school education in this study), immigration status (born in Canada or outside Canada and number of years living in Canada) and smoking status (smoker or non smoker). 2.6.2.2 Enabling Variables Enabling variables were understood as those factors associating with the acquisition of dental care. The main variables in this category were income adequacy and dental insurance. The respondents who had dental insurance were further asked about the type of insurance they had (e.g., private, employer sponsored, government, etc). Although there was no question regarding the total household income and professions of the respondents, the BB form asked if these  31 women were having trouble living within their total household income (?yes? or ?no?). This question acted as a surrogate to determine the income adequacy in this population. 2.6.2.3 Needs Variables (Self-assessed Oral Health) Health needs were self-assessed as per question # 1.B on the importance of oral health during pregnancy (?very important,?  ?moderate important,? ?somewhat important,? and  ?not at all important?), self-reported oral conditions # 7 (oral pain, dry mouth, bleeding gums, etc.) and oral beliefs during pregnancy (bleeding gums, dry mouth, etc.). These questions on self-assessed oral health (status and beliefs) helped me to determine the self-perceived oral care needs of this group of population.  The above outcome and independent variables lead to the modification on the Newman and Anderson model (Figure 3). Under enabling, predisposing and needs factors (now as self-assessed oral health), I was able to outline the important characteristics of my study population that were influential to the outcome variables of self-reported oral health and of dental service utilization which let me to produce Figure 4.   33    Health care system (Health Authority)   External Environment   Predisposing                Enabling                Self-assessed Oral     Characteristics    ?   Resources      ?  Health                                                                        ? Smoking                  Dental insurance    Self-perceived oral ? Immigrant status      Living difficulty    conditions. ? Aboriginal status     Assistance with      Self-reported oral  ? Education                transportation         health                                                                 Self-reported oral                                                                       health beliefs                                                                 Self-reported                                                                    importance of oral                                                                               health   Use of Dental             Services  ? Avoided dentist due to cost ? Dental visit frequency Self -reported oral health     Dental service utilization  ENVIRONMENT POPULATION CHARACTERSTICS HEALTH BEHAVIOUR OUTCOME Figure 4: Functional model ? Modification of Andersen's Emerging Model (adapted from Andersen's 1995)   34  2.7 Data Analysis All the important variables were transferred to the Statistical Package for the Social Sciences (SPSS Institute Inc. version 9.3) using Microsoft Excel for MAC (Version 14.2) spreadsheet. Continuous variables were summarized using descriptive statistics (n, mean ? SD). Categorical variables were summarized using frequencies and percentages to examine the sample characteristics and to identify the overall needs and patterns of dental visits in the population. Continuous variables were compared by using two sample t-tests, and categorical variables were tested using the chi-square test of association. Multivariable logistic regressions were used to estimate the odds ratio and 95% confidence interval for self-reported oral health, symptoms, and dental beliefs. Significance was considered at p-values < 0.05.  Given that my two outcome variables were self reported oral health and dental service utilization, both seemed to be influenced by the same predisposing, enabling and self-assessed oral health factors. Moreover, due to the nature of my study and to tease out the strongest correlations of different psychosocial factors, both outcome variables also served as independent variables. For this reason, I have chosen to discuss both of my outcome variables together with the most significant predisposing and enabling factors and self-assessed oral health factors in the light of existing literature, ahead (page 57).    35                                                   Chapter 3: Results  3.1 Descriptive Analysis 3.1.1 General Characteristics of the Study Population  The demographic characteristics of the study population are presented in table 1. The mean age of the women was 30.2 (SD ? 4.8) years. The majority (79%) had a prenatal consultation with their obstetrician or midwife during the first trimester, as expected. Eighty five percent had completed high school. Five percent reported that they are currently smoking while 13% reported to be subjected to second hand smoking on daily or weekly basis (Table 1). Five percent had aboriginal status, and 5% had refugee status. Thirteen percent reported the symptoms of depression, while 14% had difficulty living within their total household income (Table 1). The women were from twenty different countries, but most were either born in Canada (36%) or India (34%). Eighty-nine percent reported speaking English and 16% reported the need for an interpreter in order to complete the survey (data not shown). Eighty-eight percent of the respondents reported that they plan to breast feed their baby (data not shown). 3.1.2 Descriptive Oral Health Characteristics of the Study Population:   Seventy one percent of the women valued their oral health as important during pregnancy (Data not shown). Most of the respondents regarded their oral health as excellent (55%) or good (29%), while 14% rated their oral health as fair and 2% as poor (Figure 5). Amongst the women who rated their oral health as fair or poor, 19% were from Asian countries other than India, 18% were from India, and 17% were from Canada (Figure 6). More than half (56%) of all the respondents visited a dental professional in the last year for regular care, while 23% saw a dental professional for emergency only. Nine percent of the respondents had never visited a dental professional (Figure 7).   36 Table 1 - General characteristics of the study population Population Characteristics Total Participants N (%) First Pregnancy  Yes 293 (41.3%) No 415 (58.5%) Refugee Status  Yes 40 (5.5%) No 681 (94.5%) Years living in Canada  Born in Canada 252 (34.6%) Less than 5 yrs 197 (27.0%) 5-10 years 149 (20.4%) More than 10 yrs 131 (18.0%) Aboriginal Status  Yes 37 (5.5%) No 632 (94.5%) Completed high school   Yes 617 (85.2%)  No 107 (14.8%) Someone to talk   Yes 667 (91.9%)  No 59 (8.1%) Assistance with transportation*  Yes 650 (89.8%) No 74 (10.2%) Difficult to live on income?  Yes 101 (14.2%) No 611 (85.8%) Depressed during the past month   Yes 67 (9.3%)  No 653 (90.7%) Little interest during the past month   Yes 91 (12.7%)             No 627 (87.2%)                                                  * Women reported needing assistance with childcare, housing and transportation.  ? Women reported having difficulty living within their household income.  37 Population Characteristics Total Participants N (%)  Tobacco         Never smoked 567 (81.0%) Currently smoking 39 (5.6%) Quit smoking less than 1 yrs ago 37 (5.3%) Quit smoking more than 1 yr ago 56 (8.0%) People smoke around you  Daily 59 (8.6%) Weekly 31 (4.5%) Monthly 13 (1.9%) Less than monthly 53 (7.7%) Never 530 (77.3%)  Note: The sample size for each question varies with respect to the number of participants who provided responses. The percentages shown in this table represent row percentages.                38  Figure 5: Self-reported oral health of the study population Women from the surveyed population reporting the health of their mouth as excellent, good, fair or poor. (N=717)           Excellent 29% Good 55% Fair 14% Poor 2%  39 Figure 6: Self-reported oral health status (fair or poor) according to their region of birth Women from Asia, Canada and India were more likely to rate the health of their mouth as fair/poor than other parts     of the world.  (N=707)             0.0 18.8 16.7 12.5 10.0 17.7 0.0 15.9 0.05.010.015.020.025.0Percent fair/poor oral health (%)  40 Figure 7:  Self-reported dental service utilization of the study population Women from the surveyed population reporting their last dental visit (within the last year, more than one year, for emergency care or never). (N=702)                        More than once a year 28% About once a year 28% Less than once a year 12% Only for emergency care 23% Never 9%  41            According to figure 8(a), the most common self-reported oral problems during pregnancy were bleeding gums (42%), tooth sensitivity (22%) and dry mouth (13%). Almost 37% self-reported they had none of the listed problems.  The most common self-reported dental beliefs regarding pregnancy acquired oral conditions were bleeding gums (38%), tooth sensitivity (36%) and depletion of calcium from the teeth (28%) (Figure 8b). According to figure 9, women who visited a dental professional within the last year were likely to rate their oral health as excellent/good than the women who hadn?t consulted a dental professional in more than two years. Different beliefs were more prevalent depending upon the woman's ethnicity. Pregnant women from India (22%), Africa (11%), Canada (36%) and Middle East (9%) all shared the beliefs that tooth sensitivity, bleeding gums, and calcium loss were to be expected during pregnancy (data not shown). Women from Asian countries other than India expected to have bleeding gums during pregnancy (data not shown).             42  Figure 8(a): Self-reported dental conditions of the study population Women reported having one or more dental conditions during pregnancy. Tooth sensitivity, bleeding gums and   tooth ache were the most common self-reported dental conditions by this surveyed population. (N=740)                                                    9.2 21.9 8.5 9.9 41.8 13.4 7.6 36.6 0.010.020.030.040.050.0Percent with Condition (%)  43 Figure 8(b): Self reported pregnancy related oral health beliefs of the study population Women reported having one or more oral health related beliefs due to pregnancy. Tooth sensitivity, bleeding gums  and losing calcium were the most commonly held dental beliefs by this surveyed population. (N=740)             6.1 6.2 36.5 27.8 18 8.8 9.1 37.8 3 1.6 01020304050loseteethbecomeloosebecomesensitivelosecalciumhavecavityfillingsfallingavoidbrushinggum maybleeddeveloptumoravoiddentistPercent with belief (%)  44 Figure 9: Dental service utilization vs. self-reported oral health of the study population Bivariate comparison of self-reported oral health with dental service utilization. Women reporting the health of their  mouth as excellent or good were more likely to visit a dental professional within the last year than the women who  rated the health of their mouth as fair or poor. (N=703)             051015202530354045Excellent Good Fair PoorDental service utilization (%)  Self-reported oral health More than once a yearAbout once a yearLess than once a yearOnly for emergency careNever 45 3.2. Bivariate Analysis 3.2.1 Self-reported Oral Health with Psychosocial (pre-disposing and enabling) Variables:  The enabling characteristics are of the study population with self-reported oral health are presented in table 2.  There were no significant differences between how women rated their oral health and mean age, country of birth, aboriginal or refugee status, years living in Canada, and a high school education. Almost 81% of women reported no history of smoking.  A greater proportion of never smokers and women who had quit smoking more than one year prior to completing the survey rated their oral health as excellent or good.  Similarly women who were subjected to daily second hand smoke were less likely to report their oral health as excellent than women who were exposed to second hand smoke less frequently.   Women with dental insurance (53%) were more likely to report the health of their mouth as excellent (35%) as compared to those without dental insurance (47%) (excellent 22%) while women without dental insurance (47%) had a higher proportion of women who rated their oral health as  fair (20%) or poor (4%) (P<0.001) (Table 3).  Of the women with insurance, those with employer sponsored insurance rated their oral health higher than women using government or First Nations sponsored dental insurance (P<0.001). Although not significant more women reporting symptoms of depression rated their oral health as fair or poor than women reporting no symptoms of depression. There was no significant difference in the self-reported oral health found for women who had difficulty living within their total household income compared to women who did not have difficulty living within their income.  There was a trend for women who already had children to report their oral health as  46 worse than those without children (P=0.057). Hence, no statistical significance was found in self-reported oral health with depression and living difficulties (Table 3). Women who reported visiting a dental professional in last 2 years (46%) were more likely to rate the health of their mouth higher (excellent 37%) than the women who hadn?t visited a dental professional in more than 5 years (13%) (excellent 20%)  (P<0.001) (Table 3).            47 Table 2: Predisposing (demographic) characteristics of the study population with self-reported oral health  Total Participants  N (%) Excellent  N (%) Good  N (%) Fair  N (%) Poor  N (%) P-value  Age       Mean (? SD) 30.2 (4.8) 30.4 (4.7) 30.5 (4.7) 28.7 (5.7) 31.7 (4.7) 0.130 Median (min, max) 30 (16, 48) 30 (19, 43) 30 (17, 48) 29 (16, 45) 33 (23, 42)  Country of Birth      0.695 Canada 258 (36.0%) 83 (32.2%) 132 (51.2%) 38 (14.7%) 5 (1.9%)  Indian 237 (33.1%) 63 (26.6%) 132 (55.7%) 36 (15.2%) 6 (2.5%)  Others? 222 (31.0%) 60 (27.0%) 127 (57.2%) 28 (12.6%) 7 (3.2%)  Aboriginal      0.454 Yes 36 (5.5%) 8 (22.2%) 21 (58.3%) 7 (19.4%) 0 (0.0%)  No 617 (94.5%) 187 (30.3%) 334 (54.1%) 82 (13.3%) 14 (2.3%)  Refugee      0.679 Yes 37 (5.3%) 10 (27.0%) 23 (62.2%) 3 (8.1%) 1 (2.7%)  No 663 (94.7%) 191 (28.8%) 358 (54.0%) 97 (14.6%) 17 (2.6%)  Years of living in Canada              (Mean, ? SD) 1.2 (1.1) 1.0 (1.1) 1.3 (1.1) 1.4 (1.2) 1.3 (1.0)  High school education      0.150 Yes 601 (85.2%) 182 (30.3%) 321 (53.4%) 82 (13.6%) 16 (2.7%)  No 104 (14.8%) 23 (22.1%) 60 (57.7%) 20 (19.2%) 1 (1.0%)  Smoking status           0.027 Never smoked 552 (80.9%) 159 (28.8%) 304 (55.1%) 76 (13.8%) 13 (2.4%)  Currently smoking 38 (5.6%) 7 (18.4%) 22 (57.9%) 5 (13.2%) 4 (10.5%)  Quit > 1 yr ago 37 (5.4%) 8 (21.6%) 20 (54.1%) 9 (24.3%) 0 (0.0%)  Quit < 1 yr ago 55 (8.1%) 22 (40.0%) 24 (43.6%) 8 (14.5%) 1 (1.8%)  Passive smoking      0.001 Daily 59 (8.8%) 10 (16.9%) 31 (52.5%) 16 (27.1%) 2 (3.4%)  Weekly 31 (4.6%) 9 (29.0%) 11 (35.5%) 7 (22.6%) 4 (12.9%)  Monthly 13 (1.9%) 5 (38.5%) 6 (46.2%) 2 (15.4%) 0 (0.0%)  Less than monthly 53 (7.9%) 19 (35.8%) 27 (50.9%) 6 (11.3%) 1 (1.9%)  Never 513 (76.7%) 150 (29.2%) 290 (56.5%) 64 (12.5%) 9 (1.8%)   Note: The sample size for each question varies with respect to the number of participants who provided responses. The percentages shown in this table represent row percentages.                                                  ? Other countries were grouped as African, Central and South American, European and Middle Eastern countries.  48 Table 3: Enabling characteristics of the study population with self-reported oral health   Total     Participants N (%) Excellent N (%) Good N (%) Fair N (%) Poor N (%)   P-value  Living difficulty?       0.095 Yes 101 (14.5%) 24 (23.8%) 52 (51.5%) 21 (20.8%) 4 (4.0%)  No 594 (85.5%) 178 (30.0%) 327 (55.1%) 75 (12.6%) 14 (2.4%)  Dental insurance       <0.001 Yes 351 (52.7%) 124 (35.3%) 193 (55.0%) 29 (8.3%) 5 (1.4%)  No 315 (47.3%) 68 (21.6%) 171 (54.3%) 63 (20.0%) 13 (4.1%)  Type of insurance*  (N=349)     <0.001 Employer sponsored  326 (93.4%) 117 (35.9%) 181 (55.5%) 25 (7.7%) 3 (0.9%)  Government program for social services 16 (4.6%) 2 (12.5%) 9 (56.3%) 3 (18.8%) 2 (12.5%)  First nations/Inuit 7 (2.0%) 0 (0.0%) 4 (57.1%) 3 (42.9%) 0 (0.0%)  Have children      0.057 Yes 400 (56.5%) 104 (26.0%) 234 (58.5%) 51 (12.8%) 11 (2.8%)  No 308 (43.5%) 100 (32.5%) 150 (48.7%) 51 (16.6%) 7 (2.3%)  Assistance with transportation**      0.956 Yes 634 (90.1%) 183 (28.9%) 346 (54.6%) 90 (14.2%) 15 (2.4%)  No 70 (9.9%) 22 (31.4%) 36 (51.4%) 10 (14.3%) 2 (2.9%)  Depressed/hopeless      0.385 Yes 64 (9.1%) 15 (23.4%) 34 (53.1%) 12 (18.8%) 3 (4.7%)  No 638 (90.9%) 187 (29.3%) 349 (54.7%) 87 (13.6%) 15 (2.4%)  Dental utilization      <0.001 last 2 years ago 325 (46.2%) 120 (36.9%) 172 (52.9%) 29 (8.9%) 4 (1.2%)  2 to 5 years ago 285 (40.5%) 60 (21.1%) 164 (57.5%) 55 (19.3%) 6 (2.1%)  < 5 years ago 93 (13.2%) 19 (20.4%) 49 (52.7%) 18 (19.4%) 7 (7.5%)  Note: The sample size for each question varies with respect to the number of participants who provided responses. The percentages shown in this table represent row percentages. *Participants were asked to identify an insurance type if they answer, ?Yes? to the question ?Do you have an insurance or government program that covers all or part of your dental expenses.                                                    ? Women reported having difficulty living within their household income. ** Women reported needing assistance with childcare, housing and transportation.  49 3.2.2 Dental Service Utilization with Psychosocial (pre disposing and enabling) Variables: Women who were older at the time of the survey were more apt to have visited a dental professional within the last year than younger pregnant women (P=0.015) (Table 4). Women who were born in Canada were more likely to have visited a dental professional within the past year (56%) than the women born in India (29%) and other countries (53%) (P<0.001) (Table 4).  Former smokers who had quit less than one year prior to the survey were more likely to have visited a dental professional within the last year than never smokers and those who had quit more than one year age (P=0.039).  Time of last visit with a dental professional was not associated with aboriginal or refugee status, years living in Canada, high school education or exposure to second hand smoke.  Table 5 displays the enabling characteristics of the study population with self-reported dental service utilization.  Women with dental insurance were more likely to have visited a dental professional within the past year (69%) than women who did not have dental insurance (23%) (P<0.001).   Women who had a more recent dental professional visit were more likely to rate their oral health higher than those women who had not visited a dental professional in more than 5 years (P<0.001). Amongst those who visited a dental professional within the past year, 60% rated the health of their mouth as excellent and 45% good compared to those who visited a dental professional in more than five years (10% and 13%, respectively) (P<0.001) .  Women who reported symptoms of depression (9%) were less likely to visit a dental professional (32%) in less than a year than the ones who were not depressed (48%) . Already having children and type of insurance was not associated with date of last dental professional visit.   50   Table 4: Predisposing (demographic) characteristics of the study population with self-reported dental service utilization  Total Participants  N (%) Less than 1 year ago  N (%) 1 to 5 years ago  N (%) ?5 years ago  N (%) P-value Age      Mean (? SD) 30.2 (4.8) 30.7 (4.9) 30.1 (4.9) 28.8 (4.3) 0.015 Median (min, max) 30 (16, 48) 31 (17, 48) 30 (16, 45) 29 (17, 38)  Country of Birth     <0.001 Canada 253 (35.4%) 141 (55.7%) 87 (34.4%) 25 (9.9%)  Indian 238 (33.3%) 68 (28.6%) 120 (50.4%) 50 (21.0%)  Others 223 (31.2%) 119 (53.4%) 84 (37.7%) 20 (9.0%)  Aboriginal     0.844 Yes 36 (5.6%) 18 (50.0%) 13 (36.1%) 5 (13.9%)  No 612 (94.4%) 296 (48.4%) 246 (40.2%) 70 (11.4%)  Refugee     0.721 Yes 39 (5.6%) 17 (43.6%) 18 (46.2%) 4 (10.3%)  No 658 (94.4%) 307 (46.7%) 264 (40.1%) 87 (13.2%)  Years of living in Canada        (Mean, ? SD) 1.2 (1.1) 1.2 (1.2) 1.3 (1.1) 1.3 (0.9)  High school education     0.201 Yes 597 (85.3%) 285 (47.7%) 239 (40.0%) 73 (12.2%)  No 103 (14.7%) 41 (39.8%) 44 (42.7%) 18 (17.5%)  Smoking status     0.039 Never smoked 548 (81.2%) 247 (45.1%) 226 (41.2%) 75 (13.7%)  Currently smoking 37 (5.5%) 19 (51.4%) 12 (32.4%) 6 (16.2%)  Quit > 1 yrs ago 37 (5.5%) 15 (40.5%) 18 (48.6%) 4 (10.8%)  Quit < 1 yr ago 53 (7.9%) 36 (67.9%) 15 (28.3%) 2 (3.8%)  Passive smoking     0.246 Daily 57 (8.6%) 21 (36.8%) 27 (47.4%) 9 (15.8%)  Weekly 31 (4.7%) 14 (45.2%) 12 (38.7%) 5 (16.1%)  Monthly 13 (2.0%) 7 (53.8%) 2 (15.4%) 4 (30.8%)  Less than monthly 52 (7.8%) 29 (55.8%) 19 (36.5%) 4 (7.7%)  Never 511 (77.0%) 241 (47.2%) 207 (40.5%) 63 (12.3%)  Note: The sample size for each question varies with respect to the number of participants who provided responses. The percentages shown in this table represent row percentages.   51  Table 5: Enabling characteristics of the study population with self-reported dental service utilization  Total Participants N (%)  Less than 1 year  N (%) 1 to 5 years ago  N (%) ?5 years ago  N (%) P-value Living difficulty??     0.069 Yes 101 (14.6%) 41 (40.6%) 40 (39.6%) 20 (19.8%)  No 589 (85.4%) 281 (47.7%) 239 (40.6%) 69 (11.7%)  Dental insurance      <.001 Yes 349 (52.2%) 241 (69.1%) 96 (27.5%) 12 (3.4%)  No 319 (47.8%) 74 (23.2%) 175 (54.9%) 70 (21.9%)  Type of insurance*      0.290 Employer sponsored  325 (93.4%) 223 (68.6%) 92 (28.3%) 10 (3.1%)  Government program  16 (4.6%) 9 (56.3%) 7 (43.8%) 0 (0.0%)  First nations and Inuit 7 (2.0%) 4 (57.1%) 2 (28.6%) 1 (14.3%)  Have children     0.899 Yes 398 (56.4%) 185 (46.5%) 162 (40.7%) 51 (12.8%)  No 308 (43.6%) 140 (45.5%) 125 (40.6%) 43 (14.0%)  Assistance with transportation??     0.038 Yes 630 (89.9%) 299 (47.5%) 252 (40.0%) 79 (12.5%)  No 71 (10.1%) 24 (33.8%) 32 (45.1%) 15 (21.1%)  Down and depressed     0.018 Yes 66 (9.5%) 21 (31.8%) 37 (56.1%) 8 (12.1%)  No 632 (90.5%) 304 (48.1%) 244 (38.6%) 84 (13.3%)  Self-reported oral health     <.001 Excellent 199 (28.3%) 120 (60.3%) 60 (30.2%) 19 (9.5%)  Good 385 (54.8%) 172 (44.7%) 164 (42.6%) 49 (12.7%)  Fair 102 (14.5%) 29 (28.4%) 55 (53.9%) 18 (17.6%)  Poor 17 (2.4%) 4 (23.5%) 6 (35.3%) 7 (41.2%)    Note: The sample size for each question varies with respect to the number of participants who provided responses. The percentages shown in this table represent row percentages. *Participants were asked to identify an insurance type if they answer, ?Yes? to the question ?Do you have an insurance or government program that covers all or part of your dental expenses??                                                     ?? Women reported having difficulty living within their household income ?? Women reported needing assistance with the childcare, housing and transportation.  52  3.2.3 Self-reported Oral Health Status with Self-Assessed Dental Conditions and Beliefs  Table 6 shows the self-reported oral health in regards to self-perceived oral conditions and beliefs. Amongst the women who reported having toothache during pregnancy, 7% rated their oral health as excellent and 40% as good while 43% rated the health of their mouth as fair and 9% as poor (P<0.001) (Table 6). Amongst the women who reported having a dry mouth during pregnancy, 19% rated their oral health as excellent and 55% as good while 24% rated their oral health as fair and 24% as poor respectively (P<0.001) (Table 6). Amongst the women who believed they would lose calcium during pregnancy, 11% of them rated their oral health as excellent and 53% as good while 19% rated their oral health as fair and 4% as poor (P=0.008). Amongst the women who believed that their teeth might become sensitive during pregnancy, 27% of them rated their oral health as excellent and 53% as good while 15% rated their oral health as fair and 3% as poor (Table 6). Amongst the women who believed in avoiding tooth brushing during pregnancy, 12% of them rated their oral health as excellent and 47% as good while 30% rated their oral health as fair and 19% as poor (P<0.001) (Table 6).        53 Table 6: Self-reported oral health with self-perceived oral conditions and beliefs  Total Participants  N (%) Excellent  N (%) Good  N (%) Fair  N (%) Poor  N (%) P-value Importance of oral health during pregnancy      <0.001 Very/Moderate/Somewhat Important 643 (91.7%) 195 (96.5%) 353 (92.7%) 81 (80.2%) 14 (82.4%)  Not Important/Don't know 58 (8.3%)         7 (3.5%)  28 (7.3%)  20 (19.8%)  3 (17.6%)    Self-perceived oral conditions?? Toothache  67 (9.3%) 5 (7.4%) 27 (40.2%) 29 (43.3%) 6 (9.0%) <0.001 Sensitivity  160 (22.3%) 31 (15.0%) 76 (19.4%) 43 (42.2%) 10 (55.6%) <0.001 Other pain  62 (8.6%) 5 (2.4%) 25 (6.4%) 27 (26.5%) 5 (27.8%) <0.001 Jaw pain  71 (9.9%) 9 (4.4%) 32 (8.2%) 22 (21.6%) 8 (44.4%) <0.001 Bleeding gums  306 (42.7%) 59 (28.6%) 178 (45.5%) 59 (57.8%) 10 (55.6%) <0.001 Dry mouth  99 (13.8%) 16 (19.1%) 55 (55.0%) 24 (24.2%) 4 (4.04) 0.014 Bad breath  56 (7.8%) 8 (3.9%) 27 (6.9%) 17 (16.7%) 4 (22.2%) <0.001 Others  262 (36.5%)  103 (50.0%) 141 (36.1%) 16 (15.7%) 2 (11.1%) <0.001  Self-reported oral health beliefs ?? Lose teeth  45 (6.3%) 6 (2.9%) 17 (4.3%) 18 (17.6%) 4 (22.2%) <0.001 Tooth become loose  46 (6.4%) 9 (4.4%) 21 (5.4%) 15 (14.7%) 1 (5.6%) 0.003 Tooth become sensitive  269 (37.5%) 74 (27.5%) 145 (53.1%) 41 (15.2%) 9 (3.5%) 0.622 Lose calcium  204 (28.5%) 48 (11.2%) 108 (52.9%) 39 (19.1%) 9 (4.4%) 0.008 Have cavity  132 (18.4%) 26 (12.6%) 60 (15.3%) 35 (34.3%) 11 (61.1%) <0.001 Fillings fall out  63 (8.8%) 5 (2.4%) 35 (9.0%) 20 (19.6%) 3 (16.7%) <0.001 Avoid brushing  66 (9.2%) 8 (12.1%) 31 (46.9%) 20 (30.3%) 7 (10.6%) <0.001 Gum may bleed  276 (38.5%) 77 (37.4%) 145 (37.1%) 45 (44.1%) 9 (50.0%) 0.422 Develop tumour  22 (3.1%) 3 (1.5%) 8 (2.0%) 11 (10.8%) 0 (0.0%) <0.001 Avoid dentist   12 (1.7%)  2 (1.0%) 3 (0.8%) 6 (5.9%) 1 (5.6%) 0.001   ?? Respondents were able to choose more than one answer.       54 3.2.4 Dental Service Utilization with Self-Assessed Dental Conditions and Beliefs The women who took part in this study overwhelming reported that oral health was important to some degree.  Almost 92% of the women felt their oral health was very/moderate or somewhat important. Women who considered that the health of their mouth as very/moderate to somewhat important were more likely to see a dental professional (48%) in the past year than the women who considered the health of their mouth was not important/don?t know (25%) (P=0.004). Women who had not seen a dental professional in more than 5 years were more likely to  experience jaw pain than women who had more recent visits (P=0.013).  There were no significant differences amongst date of last dental visit and women who experienced toothache, sensitivity, bleeding gums, dry mouth or bad breath.  Although not significant it is interesting to report that women who had visited a dental professional within the last year reported more tooth sensitivity (47%) than women who hadn?t been to a dental office in more than 5 years (15%).  Similarly, women who had been to a dental professional within the last year reported experiencing bleeding gums (47%) more frequently than women who hadn?t seen a dental professional in more than 5 years (15%). Interestingly, there was no difference in the women who experience no oral conditions during their pregnancy and year of last visit (P=0.206).  Examining the women?s self-reported oral health beliefs and last dental visit was also shown in table 7.  Women who had a dental visit within the last year were more likely to believe that their teeth would become sensitive (P<0.001), they would lose calcium while they were pregnant (P=0.016), and their gums would bleed (P=0.012).  Women who hadn?t had a visit within the last 5 years were more likely to believe they would lose teeth (P=0.045), develop a cavity (P=0.016), have a filling fall out (P=0.045), and develop a tumour (P=0.015).  there was a  55 trend for women who hadn?t been to a dental professional in more than 5 years to avoid brushing as compared to women who visited the dental professional more recently (P=0.06).  Those who visited a dental professional within the past year were more likely to believe that their gums and teeth might become sensitive during pregnancy (44%) than those who did not visit a dental professional in the last year (49%) (P<.0001) (Data not shown).  Of interest, women who had visited a dental professional within the last year were more likely to report their oral health as excellent versus women who hadn?t been to a dental professional in more than 1 year, while rated their oral health as poor (P<0.001).         56 Table 7: Self -assessed oral health of the study population with dental service utilization                                                  ?? Respondents were able to choose more than one answer.    Total Participants N (%) Less than 1 year ago  N (%) 1 to 5 years ago  N (%) ?5 years ago  N (%) p-value Importance of oral health during pregnancy     0.004 Very/Moderate/Somewhat Important 638 (91.8%) 306 (48%) 256 (40%) 76 (12%)  Not Important/Don't know 57 (8.2%) 14 (25%) 28 (49%) 15 (26%)  Self-perceived oral conditions ?? Toothache  68 (9.5%) 31 (9.5%) 31 (10.7%) 6 (6.3%) 0.238 Sensitivity  162 (22.7%) 76 (46.9%) 61 (37.6%) 25 (15.4%) 0.810 Other pain  63 (8.8%) 23 (7.0%) 26 (8.9%) 14 (14.7%) 0.261 Jaw pain  73 (10.2%) 22 (6.7%) 33 (11.3%) 18 (18.9%) 0.013 Bleeding gums  308 (43.1%) 141 (46.7%) 120 (38.9%) 47 (15.2%) 0.184 Dry mouth  99 (13.9%) 41 (12.5%) 43 (14.8%) 15 (15.8%) 0.605 Bad breath  56 (7.8%) 23 (7.0%) 26 (8.9%) 7 (7.4%) 0.746 None of the above  262 (36.7%) 120 (36.6%) 114 (39.2%) 28 (29.5%) 0.206 Self-reported oral health beliefs *** Lose teeth  45 (6.3%) 13 (4.0%) 22 (7.6%) 10 (10.5%) 0.045 Tooth become loose  46 (6.4%) 15 (4.6%) 22 (7.6%) 9 (9.5%) 0.162 Tooth become sensitive  270 (37.8%) 146 (44.5%) 108 (37.1%) 16 (16.8%) <0.001 Lose calcium  204 (28.6%) 96 (47.0%) 96 (33.0%) 12 (12.6%) 0.016 Have cavity  132 (18.5%) 53 (16.2%) 60 (20.6%) 19 (20.0%) 0.016 Fillings falling  64 (9.0%) 20 (6.1%) 30 (10.3%) 14 (14.7%) 0.045 Avoid brushing  67 (9.4%) 22 (6.7%) 28 (9.6%) 17 (17.9%) 0.062 Gum may bleed  277 (38.8%) 143 (43.6%) 109 (37.5%) 25 (26.3%) 0.012 Develop tumour  22 (3.1%) 4 (1.2%) 11 (3.8%) 7 (7.4%) 0.015 Avoid dentist  12 (1.7%) 8 (2.4%) 3 (1.0%) 1 (1.1%) 0.313 Self reported oral health      <0.001 Excellent 199 (28.3%) 120 (36.9%) 60 (21.1%) 19 (20.4%)  Good 385 (54.8%) 172 (52.9%) 164 (57.5%) 49 (52.7%)  Fair 102 (14.5%) 29 (8.9%) 55 (19.3%) 18 (19.4%)  Poor 17 (2.4%) 4 (1.2%) 6 (2.1%) 7 (7.5%)   57 3.2.5 Country of Birth with Self-Assessed Dental Conditions and Beliefs Next we compared self-perceived oral conditions and oral health beliefs amongst women by country of birth (Table 8).  Almost all women, regardless of where they were born, reported that oral health while they were pregnant was important to some degree.  A greater proportion of non-aboriginal Canadian women reported having bleeding gums (39%) more often than Indian women (26%), aboriginal women (16%) and women born elsewhere (4%) (P=0.001).  Similarly, more non-aboriginal Canadian women experienced sensitivity than women born in countries other than India and Canada (33%), Indian women (19%) and aboriginal Canadian women (1%) (P=0.015).    More aboriginal Canadian women experienced a toothache (24%) than the other women but the result was not significant.  Upon comparison of country of origin and oral health beliefs (Table 8), non-Aboriginal Canadians (38%) and ?other? women (38%) were more likely to believe they would lose calcium during pregnancy than Indian women (22%) and Aboriginal women (3%) (P=0.003). More Canadian women believed their teeth would become sensitive than women from ?other? (39%), India (20%), and aboriginal Canadians (18%) (P<0.001).  Similar results were found for the belief that their gums would bleed with 52% of Canadian born women, compared to 37% of women from other countries, 25% of women from India and 18% of aboriginal women (P<0.001). Women from Asian countries other than India expected to have bleeding gums during pregnancy (data not shown)     58                                                   ??? Other countries were grouped as African, Central and South American, European and Middle Eastern countries ??? Respondents were able to choose more than one answer.   Total Participants N (%) Aboriginal Canadian N (%) Non-aboriginal Canadian N (%) Indian N (%) Others??? N (%) P-value Importance of oral health during pregnancy      0.061 Very/Moderate/Somewhat Important 648 (91.7%) 17 (100.0%) 220 (92.4%) 206 (88.0%) 205 (94.0%)  Not Important/Don't know 59 (8.3%) 0 (0.0%) 18 (7.6%) 28 (12.0%) 13 (6.0%)  Self-perceived oral conditions??? Toothache  68 (9.2%) 4 (23.5%) 25 (10.2%) 20 (8.0%) 19 (8.4%) 0.166 Sensitivity  162 (21.9%) 6 (1.0%) 66 (47.7%) 40 (18.5%) 50 (32.5%) 0.015 Other pain  63 (8.5%) 1 (5.9%) 23 (9.3%) 21 (8.4%) 18 (7.9%) 0.924 Jaw pain 73 (9.9%) 1 (5.9%) 23 (9.3%) 24 (9.6%) 25 (11.0%) 0.865 Bleeding gums  309 (41.8%) 7 (16%) 121 (39%) 81 (26%) 100 (4.2%) 0.001 Dry mouth  99 (13.4%) 2 (11.8%) 36 (14.6%) 33 (13.2%) 28 (12.3%) 0.898 Bad breath  56 (7.6%) 2 (11.8%) 21 (8.5%) 17 (6.8%) 16 (7.0%) 0.787 Others  271 (36.6%) 7 (41.2%) 81 (32.9%) 106 (42.4%) 77 (33.9%) 0.116 Self-reported oral health beliefs Lose teeth  45 (6.1%) 1 (5.9%) 15 (6.1%) 14 (5.6%) 15 (6.6%) 0.975 Tooth become loose  46 (6.2%) 1 (5.9%) 16 (6.5%) 16 (6.4%) 13 (5.7%) 0.985 Tooth become sensitive  270 (36.5%) 3 (17.6%) 129 (52.4%) 50 (20.0%) 88 (38.8%) <0.001 Lose calcium  206 (27.8%) 6 (3%) 76 (38%) 45 (22%) 79 (38.3%) 0.003 Have cavity  133 (18.0%) 2 (11.8%) 50 (20.3%) 36 (14.4%) 45 (19.8%) 0.255 Fillings falling  65 (8.8%) 1 (5.9%) 19 (7.7%) 20 (8.0%) 25 (11.0%) 0.547 Avoid brushing  67 (9.1%) 1 (5.9%) 25 (10.2%) 21 (8.4%) 20 (8.8%) 0.868 Gum may bleed  280 (37.8%) 3 (17.6%) 129 (52.4%) 63 (25.2%) 85 (37.4%) <0.001 Develop tumour  22 (3.0%) 1 (5.9%) 10 (4.1%) 6 (2.4%) 5 (2.2%) 0.518 Avoid dentist  12 (1.6%) 0 (0.0%) 6 (2.4%) 2 (0.8%) 4 (1.8%) 0.494 Self-reported oral health      0.373 Excellent 206 (28.7%) 2 (11.8%) 81 (33.6%) 63 (26.6%) 60 (27.0%)  Good 391 (54.5%) 10 (58.8%) 122 (50.6%) 132 (55.7%) 127 (57.2%)  Fair 102 (14.2%) 5 (29.4%) 33 (13.7%) 36 (15.2%) 28 (12.6%)  Poor 18 (2.5%) 0 (0.0%) 5 (2.1%) 6 (2.5%) 7 (3.2%)  Table 8: Self -assessed oral health of the study population with the country of birth  59 3.3 Multivariate Analysis 3.3.1 Self-Reported Oral Health Status and Dental service utilization  Upon multivariate analysis, the following variables remained significant: birth place, dental insurance, and depression (Table 9).  The only psychosocial variable to remain significant in multivariate analysis is the place of birth.  Women born in India were less likely to self-report any oral conditions than women born in other countries (OR=0.34).  As shown in Table 9, the odds of visiting a dental professional in the past year were 2.86 times greater for the women born in India than women born elsewhere, while other variables in the model were held constant. Women with dental insurance were 6.61 times more likely to have visited a dental professional within the past year than women without dental insurance. The odds of visiting a dental professional in the past year were 0.59 times lower for those who are not depressed than for those who are depressed, while other variables in the model were held constant.          60 Table 9: Multivariate analysis of self-reported oral health and dental service utilization   Odds ratio (OR) 95% Confidence Interval (CI)                                 Psychosocial variables with self-reported oral health ? Birth Place (Indian vs Others) 0.339 0.120 0.954 Birth Place (Canada vs Others) 0.727 0.215 2.457 Depressed  (No vs Yes) 0.750 0.284 1.981 Living Difficulty (Nom vs Yes) 1.900 0.763 4.733 Smoking (No vs Yes) 1.171 0.425 3.226 High School (No vs Yes) 0.915 0.219 1.229 Insurance   (No vs Yes) 0.519 0.219 1.229                              Psychosocial variables??? with Dental service utilization ? Insurance (No vs Yes) 6.614 4.620 9.468 Birth Place (Indian vs Others) 2.861 1.881 4.351 Depressed  (No vs Yes) 0.592 0.386 0.906 Living Difficulty (No vs Yes) 1.086 0.697 1.694 Smoking (No vs Yes) 0.928 0.610 1.413 High School (No vs Yes) 1.166 0.715 1.900 Birth Place (Canada vs Others) 1.456 0.944 2.247                                                       ? The reference for the independent variables is the category level after "vs". ??? Predisposing and enabling variables by Newman and Andersen that included: birthplace, dental insurance, education, smoking status and difficulty living within the total household income.    61 3.3.2 Self-Assessed Dental Conditions and Beliefs The results of multivariate analysis of psychosocial variables and the belief that the women?s teeth would become sensitive are in table 10.  The only variable to remain significant is country of birth.  The odds of believing that the teeth may become sensitive during pregnancy were 0.40 times lower for Indians than for women born in other countries keeping all the other variables in the model held constant. Similarly, women born in Canada were 1.88 times more likely to believe they would have bleeding gums during their pregnancy than women born in other countries.  Hence it is not surprising that women born in India were less likely to believe they would have bleeding gums.   Women without dental insurance were less likely to believe they would suffer from bleeding gums (OR=0.71). The odds of having any self-reported oral health conditions were 0.34 times lower for Indians than for all the other races, while other variables in the model are held constant.  62 Table 10: Multivariate analysis of self-perceived oral conditions and beliefs    Odds ratio (OR) 95% Confidence Interval (CI) Psychosocial variables**** with Self-reported oral conditions? Birth Place (Indian vs Others) 0.339 0.120 0.954 Birth Place (Canada vs Others 0.727 0.215 2.457 Depressed  (No vs Yes) 0.750 0.284 1.981 Living Difficulty (No vs Yes) 1.900 0.763 4.733 Smoking (No vs Yes) 1.172 0.425 3.226 High School (No vs Yes) 0.915 0.320 2.620 Insurance (No vs Yes) 0.519 0.219 1.229                   Psychosocial variables with belief of teeth becoming sensitive Birth Place (Indian vs Others) 0.397 0.256 0.615 Birth Place (Canada vs Others) 1.370 0.917 2.046 Depressed  (No vs Yes) 0.892 0.574 1.388 Living Difficulty (No vs Yes) 1.172 0.737 1.864 Smoking (No vs Yes) 0.847 0.563 1.272 High School (No vs Yes) 0.688 0.407 1.161 Insurance (No vs Yes) 0.711 0.502 1.006                    Psychosocial variables with belief of getting bleeding gum? Birth Place (Canada vs Others) 1.878 1.250 2.822 Birth Place (Indian vs Others) 0.614 0.402 0.939 Insurance (No vs Yes) 0.710 0.504 1.000 Depressed  (No vs Yes) 0.802 0.521 1.235 Living Difficulty (No vs Yes) 1.009 0.642 1.585 Smoking (No vs Yes) 1.370 0.907 2.071 High School (No vs Yes) 0.747 0.449 1.244                                                  **** Predisposing and enabling variables by Newman and Andersen that included: birthplace, dental insurance, education, smoking status and difficulty living within the total household income. ? The reference for the independent variables is the category level after "vs".   63                                              Chapter 4: Discussion  To the best of my knowledge, this was the first study done at the sub-population level in British Columbia and perhaps in Canada to identify the baseline of self-reported oral health and dental service utilization amongst a diverse population of pregnant women. Although the CHMS represents the baseline of oral health for the Canadian population, it did not include high-risk groups such as pregnant women. Given that oral conditions such as periodontitis and gingivitis may be related to adverse pregnancy outcomes, and that such conditions can be highly prevalent during this life event, pregnant women might be considered a high risk group for the adverse effects of oral conditions.(15)         The majority of my results confirmed the findings from the CHMS 2011. The proportion of pregnant women in this study who rated their oral health as excellent/good was almost identical to the results of the CHMS (83% vs. 84%, respectively). Fewer of the pregnant women had dental insurance than those who took part in CHMS (53% vs. 62%) and only slightly more pregnant women reported avoiding dental treatment due to cost (19% vs. 16, respectively). This disparity may be due to the fact that my surveyed population had more financial barriers than other Canadians. This could be because of various psychosocial factors such as being at the lower socio economic strata of the population as per the composition of the area reached by Fraser Health.(48) It is for this reason that the results of this study can be useful for health care agencies, including the Fraser Health Authority and policy makers to develop evidence-based educational and clinical programs catering to the oral care needs of this previously untouched population. The main objectives met in this study were: 1) To design and test question(s) to identify the baseline of self-reported oral health status and dental service utilization during pregnancy.  64 A combination of questions adapted from the CHMS along with new questions were tested and attached to the BB prenatal registration form. This enabled the development of a standardized tool to compare the results of my research with the existing data on the oral health of Canadians. 2) To identify the baseline self-reported oral health and dental service utilization of pregnant women in Fraser Health Authority.   The two-outcome variables of this study, self-reported oral health and dental service utilization were explored in this population. In regards to self-reported oral health, a high proportion of women (84%) rated the health of their mouth as excellent/good while 16% reported their oral health as fair/poor (Figure 5). In terms of dental service utilization, more than half (56%) had visited a dental professional within the last year for regular care, while 23% had seen a dental professional for emergency care only. Nine percent of the respondents had never visited a dental professional including during their current pregnancy (Figure 6).  3) To examine how independent variables (e.g., educational levels, dental insurance availability, perceived oral health status) in Andersen and Newman?s predisposing, enabling factors and perceived oral health assessment (need) factors are correlated to influence the overall self- reported oral health status and dental service utilization. According to my bivariate analysis, the main predisposing and enabling factors that influenced the overall self-reported oral health were: 1) a minimum of high school education; 2) having dental insurance; and 3) visiting a dental professional within the past two years. For dental service utilization, the main predisposing and enabling factors included: 1) dental insurance; 2) self-reported oral health status; and 3) country of origin. The most significant self-perceived need factors (self-reported oral conditions and oral health related beliefs) that influenced the two outcome variables were: bleeding gums, tooth sensitivity, toothache, and dry mouth. Regarding  65 oral health related beliefs during pregnancy, more than two-thirds of women expected to lose calcium and to have bleeding gums and/or expected to have tooth sensitivity due to their pregnancy.   4.1 Key Findings:  4.1.1 Pre-Disposing and Enabling Factors with Dental Service Utilization and Self-Reported Oral Health  As recommended in the guidelines of both the American Dental Association and the American Association of Periodontology, all pregnant women should receive a comprehensive dental and periodontal checkup during pregnancy.(64) However, according to the findings, psychosocial barriers, financial barriers and belonging to certain ethnic groups seem to be major risk factors for women not receiving basic dental care. These factors have been also identified under Andersen and Newman?s model (Figure 3) as having influence on overall oral health status and dental service utilization.(56)  According to this study, almost half of the surveyed population, which included both Aboriginal and non Aboriginal Canadians, reported consulting a dental professional within the last year. Studies by Gaffield et al. and Lyndon-Rochelle et al. also suggested similar patterns of dental service utilization during pregnancy in the state of Arkansas, Illinois, Louisiana and North Dakota ranging from 43 to 49 percent.(3, 41) According to the findings reported by Roger et al. 30 to 50% of the women they surveyed sought dental care during pregnancy and consulted a dental professional more frequently during pregnancy than at other times.(65) This is a positive care seeking behaviour that should be promoted by allied health care providers to avoid the common misunderstanding that dental care cannot occur during pregnancy.(66) Such positive behaviour may be also due to the fact that the majority of my participants considered having  66 good oral health as very important during pregnancy.(66) However, those who felt that oral health during pregnancy was important tend to have higher levels of education, also discussed by Gaffield et al.(41) Perhaps the time of pregnancy could be used to educate this population regarding efficient oral health practices and to introduce oral heath related behavioural modifications.(66)  In this study population, the most important enabling factors that seemed to influence the overall dental service utilization was having dental insurance and the financial means to afford dental care, as a well-known finding across similar and different populations.(3, 67) However, it remains almost a privilege to have dental coverage in North America, where the provision of dental care is not publicly funded. Having dental insurance also implies that the individual or the sponsor has a job with fringe benefits and probably has minimal difficulty living within the total household income. On the contrary, 12% of my participants reported difficulty living within their total household income and almost half of them reported not having any form of dental insurance. Not surprisingly, more than one third of those reporting income difficulties had never consulted a dental professional or have done so for emergency purposes only. Dinas et al. had also identified similar pattern of dental visits in Greece, where having free dental treatment was a predictive factor of dental service utilization.(67) This may imply that like other marginalized groups, pregnant women from the lower socio economic strata face difficulties in accessing the care they need.(45) The other financial limitation for accessing dental care despite having dental insurance could be having only limited dental coverage that may not cover all the aspects of dental treatment. This could be of serious concern as oral health problems may lead to adverse pregnancy outcomes.(17) For this reason, there should be publicly funded programs offering coverage for basic dental treatment for pregnant women including dental and periodontal  67 assessments. This would have a beneficial effect by preventing any dental related adverse outcomes that may harm both the mother and the fetus.  Attempts have been made to examine the association of various psychosocial factors with dental service utilization.(68) Their findings suggest that a woman?s level of education and awareness of good oral heath can influence the overall oral health status and dental service utilization during pregnancy.(37, 41) One of the most influential predisposing factors that seem to influence the overall dental service utilization in my study population was having a minimum of a high school education and being Canadian born.(3) This may be due to the fact that women born in Canada have more awareness regarding their oral care as a result of the different oral health programs and available information as compared to women who were born in other regions of the world with lower levels of education. Additionally, with participants from this study being born in more than 20 different countries, there is a high possibility that these women held certain oral health related beliefs and practices that could have explained some of the findings, including the belief that calcium is lost from the teeth to the fetus and that tooth decay is common(69). Such beliefs and others that I found may have been influenced by various social, cultural and religious norms with a negative impact upon dental service utilization.(69) Conversely, the odds of consulting a dental professional were almost three times higher for the women born in India than for those born in other parts of the world according to my findings. This demonstrates that an individual?s ethnic background can be a strong independent factor affecting the overall dental service utilization in this population. However, due to the lack of research there are no conclusive results on this subject.(70)   Another factor that seems to affect the dental care utilization in the general population, including pregnant women, are their health care providers.(42) During the pilot of the survey at  68 Surrey Memorial Hospital, one of the respondents raised a concern that her physician advised her not to seek dental care during pregnancy. I am not certain why she was advised to do so and although this was not the part of my questionnaire, research does suggest that there is widespread misconception about the use of dental services during pregnancy held by health care professionals including dentists.(42) This is a setback in the light of the current evidence that dental appointments during pregnancy are not only safe, but highly recommended.(71) It is also important to bear in mind that the vast majority of my participants consulted with their midwives and family doctors during the first trimester of their pregnancy, although I am not certain whether these women had received any information on the importance of oral health by their health care providers during their first antenatal visit. According to Gunay et al. and Honkala et al. up to 71% of the women did not receive any oral care instruction from their family doctors or health care providers during their pregnancy.(72, 73) Although some studies suggest that obstetricians have acknowledged the importance of dental care during pregnancy, only a small portion of obstetricians actually encourage pregnant women to seek dental care. Both pregnant women and their healthcare professionals seem to have doubts in regards to the safety of dental treatment during pregnancy, although dental treatment including periodontal treatment is safe throughout the course of pregnancy.(42, 74)   Nonetheless, dental professionals should consider their pregnant patients? current health status such as existing medical conditions (e.g. gestational diabetes mellitus, preeclampsia), gestational age of the fetus and the general health of the woman before providing any dental treatment. In fact, some considerations for a dental visit during pregnancy include: shorter appointments, avoiding morning scheduling when the patient is experiencing morning sickness, limit the procedures to those judged routine and essential while avoiding extensive and multiple  69 surgical treatments and use of antibiotics and local anesthesia should be administered with caution.(69)  The predisposing and enabling factors mentioned above (e.g., having dental insurance) seemed to also influence the overall self-reported oral health of this surveyed population positively given that almost two thirds of the respondents who rated their oral health as fair/poor did not have dental insurance. As they have financial barriers and no dental insurance, participants may have felt reluctant to pursue necessary dental treatment, which could impact their overall self-esteem and quality of life. In fact, the multivariate analysis confirmed that the odds of reporting the oral health status as fair/poor were two times higher in the population who had difficulty living within their total household income when all the other psychosocial variables in the model were held constant. This implies that having dental coverage and financial means to afford dental care not only affected the overall oral health status but was also one of the most important driving forces for the dental service utilization.(42)  Another important factor that seemed to affect the oral health of this population was their pattern of dental visit. According to the results, women who had visited a dental professional within the last year for regular checkup were more likely to rate the health of their mouth as excellent/good as compared to their counter parts. This could be due to the fact that the women who visited dental professional within the last year for regular checkup were more concerned about their oral health hence, took care of their oral health and rated their oral health as excellent/good.(75)  4.1.2 Self-Assessed Oral Health (Need Variables) with Dental Service Utilization and Self-Reported Oral Health  A significant proportion of women reported to have one or more dental conditions and they believed were due to their pregnancy. Unfortunately, their self-reported oral conditions were not  70 confirmed by any clinical examination, which is one of the limitations of this study. However, it has been reported in various studies that fluctuations in the sex hormones during pregnancy can increase a woman?s susceptibility to oral conditions such as gingivitis and periodontitis.(17) According to my study, almost two thirds of the respondents reported having bleeding gums which confirmed the findings by Gaffield et al., Christensen et al., and Lyndon-Rochelle et al.(3, 41, 75) However, it remains unknown as to whether or not these women considered these oral health related conditions to be a problem or a normal occurrence. According to Gilbert and Nuttall, self-reported gingival health can underestimate its clinical status.(71) This is of a concern given that pregnancy-induced gingivitis and periodontitis may lead to adverse pregnancy outcomes such as PTB or LBW.(17) Given the frequent self-reported gingival inflammation, participants might have considered it normal during pregnancy and not necessarily as a problem per se. This can be further supported by some previous studies that suggest that many people do not perceive gingival bleeding as a sign of gingival inflammation.(75) Although pregnancy gingivitis is a transient condition that may subside after childbirth, it can be associated with potential adverse pregnancy outcomes if left untreated.(4) The other most prevalent self-reported oral conditions were tooth sensitivity, dry mouth and toothache, which were also found by Shashidhar in 2009.(76) Just like bleeding gums, more than one-third of my participants expected to get tooth sensitivity during pregnancy and may not have considered it as a problem.  Due to the anonymity of participation and the time frame of my study, I was not able to conduct a qualitative research to tease out the roots of the self-reported oral health beliefs and oral health-related practices, or the reasons why they believed that certain oral conditions would be expected to occur during pregnancy.  Nonetheless, beliefs of getting certain oral conditions during pregnancy were widespread in  71 my surveyed population. More than half of the respondents expected one or more dental conditions during pregnancy (Tables 6, 7 and 8). The most common held beliefs during pregnancy were: bleeding gums, loss of a tooth and losening of a tooth due to pregnancy. However, I do not know if such beliefs were held before the onset of pregnancy. For instance, although almost one third of the respondents reported avoiding tooth brushing during pregnancy, it remains unknown if this avoidance was also prior to the pregnancy. Another belief held by my participants was ?losing calcium? or a tooth during pregnancy. Such an expectation has been often reported Chinese belief that the fetus can ?utilize? the mother?s calcium and as a result, the pregnant woman should expect to lose teeth, to have tooth decay or to lose dental fillings.(39, 77) In fact, a 2005 survey in the United States also found that the old wives tale ?one tooth for a baby? was very much alive.(69) In this study, most of the beliefs related to oral health during pregnancy were prevalent regardless of the country of origin, which asks the question: Where did these beliefs originate? According to Glover, ?beliefs have to be considered holistically and that no belief exists in isolation in the mind of the believer?.(78) In the context of my study, this may imply that the oral health beliefs identified by this population could be due to the co-existing oral health related changes due to normal hormonal fluctuations, which would make them believe that certain oral conditions would be indeed ?attributed? to pregnancy. In fact, this could lead to a ?normalization? of a belief, which could explain why participants who expected tooth sensitivity and calcium depletion were also more likely to rate their oral health as excellent/good. Unfortunately, there is a lack of evidence in the literature that attempts to unfold the roots and origins of oral health related beliefs in this important phase of a women?s life. In total, more than half of the participants consulted a dental professional within the last year.  72 However, almost 50% of the women reporting one or more dental beliefs and oral conditions did not consult a dental professional within the last year, while those who did visit a dental office did so for emergency care. This is of concern given that the literature suggests that health professionals, including dental professionals, are unsure about providing dental treatment during pregnancy.(42)(17)     4.1.3 Aboriginal Community:    According to my surveyed population, two-thirds of the Aboriginal pregnant women rated their oral health as excellent/good, which was an equal percentage compared to the non-Aboriginal population.  More than half reported not visiting a dental professional within the last year. Despite the fact that aboriginal communities have extended dental coverage as the Non-Insured Health Benefits from Health Canada.(79) However, due to a long history of discrimination and neglect, this ethnic group seems to have more psychosocial deprivations as compared to other Canadians.(31, 79, 80) According to CHMS 2011, the aboriginal community in Canada has a greater need for medical and dental care in comparison to other Canadians. This may imply that aboriginal pregnant women are also at risk for not receiving proper dental care. It is for this reason that Fraser Health, as well as other health authorities, pay special attention to the care provided to aboriginal pregnant women and has designated a vulnerability pathway solely for aboriginal pregnant women. The inclusion of dental education, oral health related counselling and basic dental care in this pathway might be beneficial in providing a more holistic approach to healthcare amongst these women. In fact, BC was just introduced to the First Nations Health Authority via the BC Tripartite Framework Agreement on First Nation Health Governance to set out its operational start-up plans, goals, priorities, program plans and services, evaluation process and use of funding provided by Canada and BC.(79)   73 4.2 Summary:  In summary, there is a need to provide evidence-based education and awareness to this population of pregnant women. It is suggested that more focus be placed on the education, prevention and early clinical intervention regarding dental care so that health and financial complications can be addressed beforehand. Also, more research is needed to explore the roots of the beliefs on restricting dental care during pregnancy.(81)                74 Chapter 5: Conclusions, Recommendations and Limitations  5.1 Conclusion  Given the findings from this study, pregnant women not only need education but also proper care for their higher levels of unmet needs. The key findings suggested that dental service utilization is related to ability to pay (e.g., having dental insurance), the woman's country of origin, and self-reported oral conditions including bleeding gums, tooth sensitivity, tooth ache and dry mouth. The most common oral-health related beliefs held by pregnant women were the expectation of bleeding gums, tooth sensitivity and losing calcium due to pregnancy. These beliefs associated with the related oral conditions may put women at risk for the adverse effects to herself and the fetus.  Overall, this study provided a baseline of self-reported oral health status, conditions, beliefs and dental service utilization by pregnant women from the largest BC health authority. With the help of the modified Andersen Newman model, it highlighted the predisposing and enabling psychosocial factors that may influence the overall oral health and dental service utilization by pregnant women.(56) This data can be used by the Health Authority to identify the existing need for oral care and education that could be provided to this population. However, more work is needed to explore the roots of the most commonly held dental beliefs during pregnancy.  5.2 Recommendations for Dental Public Health Organization and Professionals The aim of dental public health organizations and professionals is to improve the overall oral heath quality of life of communities and populations. During the past decade there has been some progress in preventing the most common dental diseases, however, more attention is needed for those groups with specific needs such as pregnant women. Based on the findings of my study,  75 policy makers, public health professionals and organizations could develop programs that could increase the awareness of oral health during pregnancy and involve the pregnant women and their health care providers with a positive impact on the overall dental services utilization. For example, services and educational programs could be developed which focus on educating pregnant woman, midwives, family doctors, obstetricians as well as dental professionals. Educational material on importance of oral care during pregnancy could also be developed and made available to the pregnant women in various prenatal clinics and could be given along with the other health related educational material routinely provided to them. Due to the lack of awareness and lack of public information, the New York Department of Health (2006) released a set of guidelines regarding oral health practices during pregnancy. According to this document, all pregnant women should consult their dental professionals during pregnancy. The document further emphasized that delay in dental care during pregnancy can raise some serious risks to mother and fetus.    Although financial affordability and availability of dental services are major drivers of dental service utilization, limited public health dollars and publically funded programs hinder the provision of dental care.(81) Alternatively, midwives who are closely involved with the pregnant women or the public health nurses, could be trained to conduct basic dental examinations and refer for proper care, or at least discuss issues that can be prevented while dispelling wrong beliefs about oral health and pregnancy.(81) The seven oral health questions that I have used could be permanently attached to the BB pre-natal registration form. Also, within the context of the BB program, there could be an assigned pathway that could highlight the vulnerability due to oral health. Like other designated pathways, the ?oral health? pathway would identify those women at risk for oral diseases who would be  76 properly followed up by the public health nurse and referred for education and/or dental treatment if needed.  5.2.1 Future Directions There should be some follow up studies to explore the roots of oral-health related beliefs during pregnancy. This research could be done in the form of focus groups or one-on-one individual interviews that could explore some of the roots of these oral health-related misconceptions during pregnancy. This should be done both on pregnant women and their health professionals so that awareness and educational programs could be designed accordingly. Clinical examinations and studies could be performed to identify the magnitude and severity of the self-reported oral conditions.   5.3 Limitations 1. All the questions in the dental survey were self-reported and I was unable to identify the severity of the reported conditions.  2. I do not know why some of the women had not visited a dental professional within the last year. I do not know if they avoided the dental visit due to anxiety or any cultural or ethnic beliefs, which may have influenced the dental service utilization.   3. Sixteen percent of the respondents highlighted the need for an interpreter. As a result, it remains unknown as to whether or not they fully understood the survey questions. I was also unsure if spouses, family members or accompanying persons had translated the survey for respondents.  Despite of the limitations, this study provided comprehensive self-reported data on the overall oral health of pregnant women at the sub-population level of a diverse ethnic community, which has not been done before in Canada. 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Fratiglioni L, Viitanen M, von Strauss E, Tontodonati V, Herlitz A, Winblad B. Very old women at highest risk of dementia and alzheimer's disease: Incidence data from the kungsholmen project, stockholm. Neurology 1997;48: 132-8. 36. Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA. Altered tissue metabolism of progesterone in pregnancy gingivitis and granuloma. Journal of clinical periodontology 1991;18: 262-6. 37. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. American family physician 2008;77: 1139-44. 38. George A, Johnson M, Duff M, Blinkhorn A, Ajwani S, Bhole S, et al. Maintaining oral health during pregnancy: Perceptions of midwives in southwest sydney. Collegian 2011;18: 71-9. 39. Kwan SY, Holmes MA. An exploration of oral health beliefs and attitudes of chinese in west yorkshire: A qualitative investigation. Health education research 1999;14: 453-60. 40. Poutanen R, Lahti S, Tolvanen M, Hausen H. Parental influence on children's oral health-related behavior. Acta odontologica Scandinavica 2006;64: 286-92. 41. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. Journal of the American Dental Association 2001;132: 1009-16. 42. Mangskau KA, Arrindell B. Pregnancy and oral health: Utilization of the oral health care system by pregnant women in north dakota. Northwest dentistry 1996;75: 23-8. 43. Edelstein BL. Disparities in oral health and access to care: Findings of national surveys. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association 2002;2: 141-7. 44. Kowash MB, Pinfield A, Smith J, Curzon ME. Effectiveness on oral health of a long-term health education programme for mothers with young children. British dental journal 2000;188: 201-5. 45. Lin DL, Harrison R, Aleksejuniene J. Can a prenatal dental public health program make a difference? Journal 2011;77: b32. 46. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. Bmj 1998;316: 1310-3. 47. World health organization. Ottawa charter for health promotion, 1986. Accessed on november 30, 2011. 48. Fraser health official website. Retrieved from http://www.Fraserhealth.Ca/. Accessed on november 27, 2011. 49. C K. Understanding the oral health needs of government assisted refugees MSc Dissertation 2012;Simon Fraser University. 50. Primary project folder of best beginnings provided by the fraser health authority. .  81 51. Gussy MG, Waters EB, Riggs EM, Lo SK, Kilpatrick NM. Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural victoria. Australian dental journal 2008;53: 52-60. 52. Mattila ML, Rautava P, Ojanlatva A, Paunio P, Hyssala L, Helenius H, et al. Will the role of family influence dental caries among seven-year-old children? Acta odontologica Scandinavica 2005;63: 73-84. 53. Sakai VT, Oliveira TM, Silva TC, Moretti AB, Geller-Palti D, Biella VA, et al. Knowledge and attitude of parents or caretakers regarding transmissibility of caries disease. Journal of applied oral science : revista FOB 2008;16: 150-4. 54. Skeie MS, Riordan PJ, Klock KS, Espelid I. Parental risk attitudes and caries-related behaviours among immigrant and western native children in oslo. Community dentistry and oral epidemiology 2006;34: 103-13. 55. Skaret E, Espelid I, Skeie MS, Haugejorden O. Parental beliefs and attitudes towards child caries prevention: Assessing consistency and validity in a longitudinal design. BMC oral health 2008;8: 1. 56. Andersen RM. Revisiting the behavioral model and access to medical care: Does it matter? Journal of health and social behavior 1995;36: 1-10. 57. Babitsch B, Gohl D, von Lengerke T. Re-revisiting andersen's behavioral model of health services use: A systematic review of studies from 1998-2011. Psycho-social medicine 2012;9: Doc11. 58. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health services research 2000;34: 1273-302. 59. Ramraj C, Quinonez CR. Self-reported cost-prohibitive dental care needs among canadians. International journal of dental hygiene 2013;11: 115-20. 60. Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ. Validation of self-reported oral health measures. Journal of public health dentistry 2002;62: 122-8. 61. Palmqvist S, Soderfeldt B, Arnbjerg D. Self-assessment of dental conditions: Validity of a questionnaire. Community dentistry and oral epidemiology 1991;19: 249-51. 62. Joshipura KJ, Pitiphat W, Douglass CW. Validation of self-reported periodontal measures among health professionals. Journal of public health dentistry 2002;62: 115-21. 63. Douglass CW, Berlin J, Tennstedt S. The validity of self-reported oral health status in the elderly. Journal of public health dentistry 1991;51: 220-2. 64. Manau C, Echeverria A, Agueda A, Guerrero A, Echeverria JJ. Periodontal disease definition may determine the association between periodontitis and pregnancy outcomes. Journal of clinical periodontology 2008;35: 385-97. 65. Rogers SN. Dental attendance in a sample of pregnant women in birmingham, uk. Community dental health 1991;8: 361-8. 66. Bates SB, Riedy CA. Changing knowledge and beliefs through an oral health pregnancy message. Journal of public health dentistry 2012;72: 104-11. 67. Dinas K, Achyropoulos V, Hatzipantelis E, Mavromatidis G, Zepiridis L, Theodoridis T, et al. Pregnancy and oral health: Utilisation of dental services during pregnancy in northern greece. Acta obstetricia et gynecologica Scandinavica 2007;86: 938-44. 68. Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV, et al. Factors related to utilization of dental services during pregnancy. Journal of clinical periodontology 2005;32: 815-21.  82 69. Russell SL, Mayberry LJ. Pregnancy and oral health: A review and recommendations to reduce gaps in practice and research. MCN The American journal of maternal child nursing 2008;33: 32-7. 70. Butani Y, Weintraub JA, Barker JC. Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature. BMC oral health 2008;8: 26. 71. Gilbert AD, Nuttall NM. Self-reporting of periodontal health status. British dental journal 1999;186: 241-4. 72. Gunay H, Goepel K, Stock KH, Schneller T. [position of health education knowledge concerning pregnancy]. Oral-prophylaxe / Herausgeber, Verein fur Zahnhygiene eV 1991;13: 4-7. 73. Honkala S, Al-Ansari J. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in kuwait. Journal of clinical periodontology 2005;32: 809-14. 74. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth 2012;39: 238-47. 75. Christensen LB, Jeppe-Jensen D, Petersen PE. Self-reported gingival conditions and self-care in the oral health of danish women during pregnancy. Journal of clinical periodontology 2003;30: 949-53. 76. Acharya S, Bhat PV, Acharya S. Factors affecting oral health-related quality of life among pregnant women. International journal of dental hygiene 2009;7: 102-7. 77. Fitzsimons D, Dwyer JT, Palmer C, Boyd LD. Nutrition and oral health guidelines for pregnant women, infants, and children. Journal of the American Dietetic Association 1998;98: 182-6, 89; quiz 87-8. 78. Glover J. Systems of belief. 79. Dental coverage for first nations by health canada. Retrieved from http://www.Hc-sc.Gc.Ca/fniah-spnia/nihb-ssna/benefit-prestation/dent/index-eng.Php. Accessed on june 3, 2013. 80. Young TK. Review of research on aboriginal populations in canada: Relevance to their health needs. Bmj 2003;327: 419-22. 81. Schwarz E. Access to oral health care - an australian perspective. Community dentistry and oral epidemiology 2006;34: 225-31.          83 Appendices  Appendix A - Citations from the Systematic Literature Search on Oral Health                             and Pregnancy.  1. Slade GD. Assessing change in quality of life using the oral health impact profile. Community dentistry and oral epidemiology 1998;26: 52-61. 2. Timmreck,t.C. (2003). Planning, program development, and evaluation (2nd ed.). Sudbury, ma: Jones and barlett publishers. . 3. Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. American journal of public health 2004;94: 765-71. 4. Laine MA. Effect of pregnancy on periodontal and dental health. Acta odontologica Scandinavica 2002;60: 257-64. 5. Matevosyan NR. Periodontal disease and perinatal outcomes. Archives of gynecology and obstetrics 2011;283: 675-86. 6. Association of dental surgeons of british columbia (november 23, 2001). Children?s dentistry task force report. Vancouver: Adsbc. 7. Guncu GN, Tozum TF, Caglayan F. Effects of endogenous sex hormones on the periodontium--review of literature. Australian dental journal 2005;50: 138-45. 8. Murphey C, Fowles E. Dental health, acidogenic meal, and snack patterns among low-income women during early pregnancy: A pilot study. Journal of midwifery & women's health 2010;55: 587-92. 9. Aaltonen AS. The frequency of mother-infant salivary close contacts and maternal caries activity affect caries occurrence in 4-year-old children. Proceedings of the Finnish Dental Society Suomen Hammaslaakariseuran toimituksia 1991;87: 373-82. 10. Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: Evidence for a discrete window of infectivity. Journal of dental research 1993;72: 37-45. 11. Loesche WJ. Role of streptococcus mutans in human dental decay. Microbiological reviews 1986;50: 353-80. 12. Gibson S, Williams S. Dental caries in pre-school children: Associations with social class, toothbrushing habit and consumption of sugars and sugar-containing foods. Further analysis of data from the national diet and nutrition survey of children aged 1.5-4.5 years. Caries research 1999;33: 101-13. 13. Al-Malik MI, Holt RD, Bedi R. The relationship between erosion, caries and rampant caries and dietary habits in preschool children in saudi arabia. International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children 2001;11: 430-9. 14. Li Y, Wang W, Caufield PW. The fidelity of mutans streptococci transmission and caries status correlate with breast-feeding experience among chinese families. Caries research 2000;34: 123-32.  84 15. Alwaeli HA, Al-Jundi SH. Periodontal disease awareness among pregnant women and its relationship with socio-demographic variables. International journal of dental hygiene 2005;3: 74-82. 16. George A, Johnson M, Blinkhorn A, Ellis S, Bhole S, Ajwani S. Promoting oral health during pregnancy: Current evidence and implications for australian midwives. Journal of clinical nursing 2010;19: 3324-33. 17. Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes. A systematic review. Annals of periodontology / the American Academy of Periodontology 2003;8: 70-8. 18. Bokhari SA, Khan AA. The relationship of periodontal disease to cardiovascular diseases--review of literature. JPMA The Journal of the Pakistan Medical Association 2006;56: 177-81. 19. Cruz SS, Costa Mda C, Gomes-Filho IS, Rezende EJ, Barreto ML, Dos Santos CA, et al. Contribution of periodontal disease in pregnant women as a risk factor for low birth weight. Community dentistry and oral epidemiology 2009;37: 527-33. 20. Jared H, Boggess KA, Moss K, Bose C, Auten R, Beck J, et al. Fetal exposure to oral pathogens and subsequent risk for neonatal intensive care admission. Journal of periodontology 2009;80: 878-83. 21. Heimonen A, Rintamaki H, Furuholm J, Janket SJ, Kaaja R, Meurman JH. Postpartum oral health parameters in women with preterm birth. Acta odontologica Scandinavica 2008;66: 334-41. 22. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371: 75-84. 23. Davenport ES, Williams CE, Sterne JA, Sivapathasundram V, Fearne JM, Curtis MA. The east london study of maternal chronic periodontal disease and preterm low birth weight infants: Study design and prevalence data. Annals of periodontology / the American Academy of Periodontology 1998;3: 213-21. 24.        Lopatin DE, Kornman KS, Loesche WJ. Modulation of immunoreactivity to periodontal disease-associated microorganisms during pregnancy. Infect Immun 1980;28:713?8.  25. American Dental Association. Women?s oral health issues. Chicago: American Dental Association; 1995. 26. Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, et al. Periodontal disease and preterm birth: Results of a pilot intervention study. Journal of periodontology 2003;74: 1214-8. 27. Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled trial. Journal of periodontology 2002;73: 911-24. 28. Paternoster DM, Fantinato S, Manganelli F, Nicolini U, Milani M, Girolami A. Recent progress in the therapeutic management of pre-eclampsia. Expert opinion on pharmacotherapy 2004;5: 2233-9. 29. Davison JM, Homuth V, Jeyabalan A, Conrad KP, Karumanchi SA, Quaggin S, et al. New aspects in the pathophysiology of preeclampsia. Journal of the American Society of Nephrology : JASN 2004;15: 2440-8.  85 30. Practice bulletin. Clinical management guidelines for obstetrician-gynecologists on gestational diabetes 2001. American College of Obstetricians and Gynaecologists Committee on Practice Bulletins ? Obstetrics (98) 525-8 31. Agwunobi AO, Reid C, Maycock P, Little RA, Carlson GL. Insulin resistance and substrate utilization in human endotoxemia. The Journal of clinical endocrinology and metabolism 2000;85: 3770-8. 32. Novak KF, Taylor GW, Dawson DR, Ferguson JE, 2nd, Novak MJ. Periodontitis and gestational diabetes mellitus: Exploring the link in nhanes iii. Journal of public health dentistry 2006;66: 163-8. 33. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: Prevalence, risk factors, maternal and infant outcomes. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2001;75: 221-8. 34. Genco RJ, Grossi SG, Ho A, Nishimura F, Murayama Y. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. Journal of periodontology 2005;76: 2075-84. 35. Grau AJ, Becher H, Ziegler CM, Lichy C, Buggle F, Kaiser C, et al. Periodontal disease as a risk factor for ischemic stroke. Stroke; a journal of cerebral circulation 2004;35: 496-501. 36. Volpe JNotN, 4th ed, . WB Saunders, Philadelphia 2001. 37. Fratiglioni L, Viitanen M, von Strauss E, Tontodonati V, Herlitz A, Winblad B. Very old women at highest risk of dementia and alzheimer's disease: Incidence data from the kungsholmen project, stockholm. Neurology 1997;48: 132-8. 38. Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA. Altered tissue metabolism of progesterone in pregnancy gingivitis and granuloma. Journal of clinical periodontology 1991;18: 262-6. 39. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. American family physician 2008;77: 1139-44. 40. George A, Johnson M, Duff M, Blinkhorn A, Ajwani S, Bhole S, et al. Maintaining oral health during pregnancy: Perceptions of midwives in southwest sydney. Collegian 2011;18: 71-9. 41. Kwan SY, Holmes MA. An exploration of oral health beliefs and attitudes of chinese in west yorkshire: A qualitative investigation. Health education research 1999;14: 453-60. 42. Poutanen R, Lahti S, Tolvanen M, Hausen H. Parental influence on children's oral health-related behavior. Acta odontologica Scandinavica 2006;64: 286-92. 43. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. Journal of the American Dental Association 2001;132: 1009-16. 44. Mangskau KA, Arrindell B. Pregnancy and oral health: Utilization of the oral health care system by pregnant women in north dakota. Northwest dentistry 1996;75: 23-8. 45. Edelstein BL. Disparities in oral health and access to care: Findings of national surveys. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association 2002;2: 141-7.  86 46. Kowash MB, Pinfield A, Smith J, Curzon ME. Effectiveness on oral health of a long-term health education programme for mothers with young children. British dental journal 2000;188: 201-5. 47. Lin DL, Harrison R, Aleksejuniene J. Can a prenatal dental public health program make a difference? Journal 2011;77: b32. 48. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. Bmj 1998;316: 1310-3. 49. World health organization. Ottawa charter for health promotion, 1986. Accessed on november 30, 2011. 50. Fraser health official website. Retrieved from http://www.Fraserhealth.Ca/. Accessed on november 27, 2011. 51. C K. Understanding the oral health needs of government assisted refugees MSc Dissertation 2012;Simon Fraser University. 52. Primary project folder of best beginnings provided by the fraser health authority. . 53. Authority BBsPFPbFH. 54. Gussy MG, Waters EB, Riggs EM, Lo SK, Kilpatrick NM. Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural victoria. Australian dental journal 2008;53: 52-60. 55. Mattila ML, Rautava P, Ojanlatva A, Paunio P, Hyssala L, Helenius H, et al. Will the role of family influence dental caries among seven-year-old children? Acta odontologica Scandinavica 2005;63: 73-84. 56. Sakai VT, Oliveira TM, Silva TC, Moretti AB, Geller-Palti D, Biella VA, et al. Knowledge and attitude of parents or caretakers regarding transmissibility of caries disease. Journal of applied oral science : revista FOB 2008;16: 150-4. 57. Skeie MS, Riordan PJ, Klock KS, Espelid I. Parental risk attitudes and caries-related behaviours among immigrant and western native children in oslo. Community dentistry and oral epidemiology 2006;34: 103-13. 58. Skaret E, Espelid I, Skeie MS, Haugejorden O. Parental beliefs and attitudes towards child caries prevention: Assessing consistency and validity in a longitudinal design. BMC oral health 2008;8: 1. 59. Andersen RM. Revisiting the behavioral model and access to medical care: Does it matter? Journal of health and social behavior 1995;36: 1-10. 60. Babitsch B, Gohl D, von Lengerke T. Re-revisiting andersen's behavioral model of health services use: A systematic review of studies from 1998-2011. Psycho-social medicine 2012;9: Doc11. 61. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health services research 2000;34: 1273-302. 62. Ramraj C, Quinonez CR. Self-reported cost-prohibitive dental care needs among canadians. International journal of dental hygiene 2013;11: 115-20. 63. Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ. Validation of self-reported oral health measures. Journal of public health dentistry 2002;62: 122-8. 64. Palmqvist S, Soderfeldt B, Arnbjerg D. Self-assessment of dental conditions: Validity of a questionnaire. Community dentistry and oral epidemiology 1991;19: 249-51.  87 65. Joshipura KJ, Pitiphat W, Douglass CW. Validation of self-reported periodontal measures among health professionals. Journal of public health dentistry 2002;62: 115-21. 66. Douglass CW, Berlin J, Tennstedt S. The validity of self-reported oral health status in the elderly. Journal of public health dentistry 1991;51: 220-2. 67. Manau C, Echeverria A, Agueda A, Guerrero A, Echeverria JJ. Periodontal disease definition may determine the association between periodontitis and pregnancy outcomes. Journal of clinical periodontology 2008;35: 385-97. 68. Rogers SN. Dental attendance in a sample of pregnant women in birmingham, uk. Community dental health 1991;8: 361-8. 69. Bates SB, Riedy CA. Changing knowledge and beliefs through an oral health pregnancy message. Journal of public health dentistry 2012;72: 104-11. 70.       Sabatka S, Bhattacharyya I, Cohen DM, Hunter J. Oral health for the pregnant patient: a review. Access 2000;14(4):41?4.  71.        Pertl C, Heinemann A, Pertl B, et al. Aspects particuliers du traitement dentaire chez la patiente enceinte (The pregnant patient in dental care: survey results and therapeutic guidelines). Schweiz Monatsschr Zahnmed 2000;110(1):42?6.  72. Dinas K, Achyropoulos V, Hatzipantelis E, Mavromatidis G, Zepiridis L, Theodoridis T, et al. Pregnancy and oral health: Utilisation of dental services during pregnancy in northern greece. Acta obstetricia et gynecologica Scandinavica 2007;86: 938-44. 73. Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV, et al. Factors related to utilization of dental services during pregnancy. Journal of clinical periodontology 2005;32: 815-21. 74. Russell SL, Mayberry LJ. Pregnancy and oral health: A review and recommendations to reduce gaps in practice and research. MCN The American journal of maternal child nursing 2008;33: 32-7. 75. Butani Y, Weintraub JA, Barker JC. Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature. BMC oral health 2008;8: 26. 76. Gilbert AD, Nuttall NM. Self-reporting of periodontal health status. British dental journal 1999;186: 241-4. 77. Gunay H, Goepel K, Stock KH, Schneller T. [position of health education knowledge concerning pregnancy]. Oral-prophylaxe / Herausgeber, Verein fur Zahnhygiene eV 1991;13: 4-7. 78. Honkala S, Al-Ansari J. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in kuwait. Journal of clinical periodontology 2005;32: 809-14. 79. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth 2012;39: 238-47. 80. Christensen LB, Jeppe-Jensen D, Petersen PE. Self-reported gingival conditions and self-care in the oral health of danish women during pregnancy. Journal of clinical periodontology 2003;30: 949-53. 81. Acharya S, Bhat PV, Acharya S. Factors affecting oral health-related quality of life among pregnant women. International journal of dental hygiene 2009;7: 102-7. 82.       Adams MM, Shulman HB, Bruce C, Hogue C, Brogan D, PRAMS Working Group.  88 The Pregnancy Risk Assessment Monitoring System: design, questionnaire, data collection and response rates. Paediatr Perinat Epidemiol 1991;5:333?46.  83. Gilbert B, Shulman HB, Fischer LA, Rogers MM. The Pregnancy Risk Assessment Monitoring System (PRAMS): methods and 1996 response rates from 11 states. Matern Child Health J 1999;3(4): 199?209.  84. Fitzsimons D, Dwyer JT, Palmer C, Boyd LD. Nutrition and oral health guidelines for pregnant women, infants, and children. Journal of the American Dietetic Association 1998;98: 182-6, 89; quiz 87-8. 85. Glover J. Systems of belief. 86. Dental coverage for first nations by health canada. Retrieved from http://www.Hc-sc.Gc.Ca/fniah-spnia/nihb-ssna/benefit-prestation/dent/index-eng.Php. Accessed on june 3, 2013. 87. Young TK. Review of research on aboriginal populations in canada: Relevance to their health needs. Bmj 2003;327: 419-22. 88. Schwarz E. Access to oral health care - an australian perspective. Community dentistry and oral epidemiology 2006;34: 225-31. 89. Canadian health measure survey, Oral Health component, 2007-2009 pages 2,3,6,11. Retrieved from http://www.hc-sc.gc.ca/hl-vs/pubs/oral-bucco/fact-fiche-oral-bucco-stat-eng.php (accessed on October 24, 2011). 90. Consideration for the dental treatment of a pregnant women by Connecticut State Dental Association. Retrieved from http://www.csda.com/ConsiderationsDentalTreatmentPregnantWoman_singlelayout.pdf 91. Dental care becomes more important during pregnancy by U-T SanDiego. Retrieved from http://www.utsandiego.com/news/2013/Apr/30/dental-pregnancy-health/ 92. Dental care during pregnancy by American Dental Association http://www.ada.org/sections/scienceAndResearch/pdfs/forthedentalpatient_may_2011.pdf 93. Dental Care During Pregnancy. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=909 94. Dental coverage for first nations by health Canada. Retrieved from http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/dent/index-eng.php. Accessed on June 3, 2013 95. Dental work in pregnancy by pregnancy association. Retrieved from http://americanpregnancy.org/pregnancyhealth/dentalwork.html 96. Federal/Provincial/Territorial Joint Task Group on Public Health Human Resources. Building the Public Health Workforce for the 21st Century. Ottawa, 2006. 97. Obstacles for pregnant women seeking dental care. 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Influence of hormonal variation on the periodontium in women. Periodontol 2000 1994;6:79?87.  103. Mealey BL. Periodontal implications: medically compromised patients. Ann Periodontol 1996;1(1):256?321.  104. Offenbacher S, Sieff S, Beck, JD. Periodontitis-associated pregnancy complications. Premat Neonat Med 1998;3:82?5.  105. Women reluctant to believe pregnancy and oral health link. Retrieved from http://www.frostmagazine.com/2013/06/women-reluctant-to-believe-pregnancy-and-oral-health-link/. 106. Ana Carrillo-de-Albornoz, Elena Figuero, David Herrera, Pedro Cuesta and Antonio Bascones-Mart?nez. (2011) Gingival changes during pregnancy: III. Impact of clinical, microbiological, immunological and socio-demographic factors on gingival inflammation. Journal of Clinical Periodontologyn/a-n/a 107. Dental Care During Pregnancy. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=909 108. Hujoel PP, Lydon-Rochelle M, Bollen AM, Woods JS, Geurtsen W, del Aguila MA. Mercury exposure from dental filling placement during pregnancy and low birth weight risk. Am J Epidemiol 2005;161(8):734?40. 109. Jared H, Boggess KA, Moss K et al (2009) Fetal exposure to oral pathogens and subsequent risk for neonatal intensive care admission. J Periodontol 80(6):878?883 110. Jeffcoat MK, Hauth JC, Geurs NC, et al. Periodontal disease and preterm birth: results of a pilot intervention study. J Periodontol 2003;74:1214-1218 111. Joshipura, K. J., Pitiphat, W. and Douglass, C. W. (2002), Validation of Self-reported Periodontal Measures Among Health Professionals. Journal of Public Health Dentistry, 62: 115?121.  112. Kevin L. Moss, James D. Beck and Steven Offenbacher. (2005) Clinical risk factors associated with incidence and progression of periodontal conditions in pregnant women. Journal of Clinical Periodontology 32:5, 492-498 113. Skaret E, Espelid I, Skeie MS, Haugejorden O. Parental beliefs and attitudes towards child caries prevention: Assessing consistency and validity in a longitudinal design. BMC Oral Health 2008;8:1 114. Skeie, M. S., Riordan, P. J., Klock, K. S. and Espelid, I. (2006), Parental risk attitudes and caries-related behaviours among immigrant and western native children in Oslo. Community Dentistry and Oral Epidemiology, 34: 103?113 115. Soukaina Ryalat, Faleh Sawair, Zaid Baqain, Nicola Barghout, Wala Amin,  90 Darwish Badran and Eman Badran. (2011) Effect of Oral Diseases on Mothers Giving Birth to Preterm Infants. Medical Principles and Practice 20:6, 556-561 116. U.S. Government Accounting Office. Oral health: Dental disease is a chronic problem among low income populations. Washington: U.S. Government Accounting Office; 2000. 117. Wasylko L, Matsui D, Dykxhoom SM, Rieder MJ, Weinberg S. A review of common dental treatments during pregnancy: implications for patients and dental personnel. J Can Dent Assoc 1998;64(6):434?9. 118. World Health Organization. Ottawa charter for health promotion, 1986 119. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: Prevalence, risk factors, maternal and infant outcomes. Int J Gynaecol Obstet 2001;75:221-228. 120. Offenbacher S, Katz V, Fertik G, et al. Periodontal infections as a possible risk factor for preterm low birth weight. J Periodontol 1996;67(suppl 10):1103?30.  121. Dasanayake A. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998;3(1):206?12. 122. Yolanda Mart?nez-Beneyto, Mar?a V. Vera-Delgado, Leonor P?rez and Antonio Maurandi. (2011) Self-reported oral health and hygiene habits, dental decay, and periodontal condition among pregnant European women. International Journal of Gynecology & Obstetrics 123. Caroline A Crowther, Natalie Thomas, Philippa Middleton, Mei-Chien Chua, Marco Esposito and Caroline A Crowther. Treating periodontal disease for preventing preterm birth in pregnant women. 124. Catia M. Gazolla, Adair Ribeiro, Marcos R. Moys?s, Luiz A.M. Oliveira, Luciano J. Pereira and Ant?nio W. Sallum. (2007) Evaluation of the Incidence of Preterm Low Birth Weight in Patients Undergoing Periodontal Therapy. Journal of Periodontology 78:5, 842-848 125. U.S. Department of Health and Human Services. Oral health in America: A report of the Surgeon General?Executive summary. Rockville, Md.: U.S. Department of Health and Human Services; 2000:1?13. 126. Caulfield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res 1993;72:37?45.  127. Lee A, McWilliams M, Janchar T. Care of the pregnant patient in the dental office. Dent Clin North Am 1999;43(3):485?94. 128. Zachariasen RD. The effect of elevated ovarian hormones on periodontal health: oral contraceptives and pregnancy. Women Health 1993;20:21?30.  129.  Wasylko L, Matsui D, Dykxhoom SM, Rieder MJ, Weinberg S. A review of common dental treatments during pregnancy: implications for patients and dental personnel. J Can Dent Assoc 1998;64(6):434?9.  130. Teeth and Pregnancy. Retrieved from ww.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Teeth_and_pregnancy  91 Appendix B - Core Competencies for Oral Health Promotion Outlined by The                            Canadian Association for Public Health Dentistry.  1. Oral Public Health Sciences  This involves appropriate knowledge as well as useful critical thinking skills and competency in the fields of behavioural and social sciences, biostatistics, epidemiology, environmental public health, demography, workplace health, and the prevention of chronic diseases, infectious diseases, psychosocial problems and injuries.  2. Oral Health Assessment and Analysis  This category describes competencies needed to collect, assess, analyze and apply information to make evidence-based decisions, prepare budgets, and make recommendations for policy and program development.  3. Oral Health Program Planning, Implementation and Evaluation  This category illustrates the competencies essential to effectively choose options, and to plan, implement and evaluate programs in dental public health. This also includes the management of stressful incidents such as outbreaks and emergencies.  4. Oral Health Policy Planning, Implementation and Evaluation  This is needed for effective planning, implementation and evaluation of policies in dental public health for the improvement and protection of oral and general health.  5. Partnerships, Collaboration and Advocacy  This involves judicious usage of partnerships and collaborative efforts for the common goal of improving the health and well-being of the public.     92 6. Diversity and Inclusiveness  This category identifies the socio-cultural competencies required to interact effectively with diverse individuals, groups and communities. It is the combination of attitudes and practices that result in inclusive behaviors, practices, programs and policies. 7. Communication  This refers to the internal and external exchange of ideas and information, whether written or verbal, the provision of appropriate and adequate information to different audiences, computer literacy, and the ability to work with the media and use social marketing techniques. 8. Leadership  Leadership plays a pivotal role in improving performance of the individuals comprising an organization and enhancing the quality of the working environment. This also enables organizations and communities to create, propagate and apply shared visions, missions and values.15 In summary, it is essential to strengthen and standardize practices within organizations as well as the complex public health strategies of a wider scale. As public health systems and services vary between and within provinces and territories across Canada, so do the usage of discipline competencies. As a result, the adoption of dental public health strategies requires acceptance and commitment from a variety of groups including the federal and provincial/territorial governments, as well as regional health care authorities. Within this context, there are six major health care authorities in British Columbia that have preventive dental public health programs catering to the needs of their regional populations     93 Appendix C - Concepts of Validity  In order to cater the relevant responses from a designed survey, researchers have always relied upon the process of validation in respect to the target population. The test of validity has been designed to address the issues of the forms and study conditions that might affect the interpretation of the results.* In order to determine the validity of the CHMS questions, I would like to discuss the types and attributes of the validity and correlate it with my proposed questions. I will base this discussion on a theoretical ground only given the unavailability of information about the validation process used by the CHMS. As a result, I offer my personal understanding and interpretation of the validity literature in relation to the CHMS.  Trinitarian Concept vs. Unitarian Concept of Validity:  In the Trinitarian concept of validity, the concept of construct, criterion and content validity goes as: 1. Content Validity: It is known as a fixed property of a questionnaire that is based on the expert judges? which determines the relevance of the content of the questions to what it intends to measure. Also known as logical validity, it refers to the clarity, comprehension, relevance and precession of the questions in a survey. 2. Criterion Validity: It refers as a correlation of a questionnaire?s score with some other measure, usually a ?gold standard? that has been used and accepted in the field. This type of validity does not provide any theoretical basis of the test score with what it was intend to measure. Hence, there is an uncertainty if what has been measured, was the true aim of the designed construct. It is divided in to two types:   94 Concurrent Validity:  it refers to the association of the questionnaire?s results with the defined criteria. Predictive Validity: It can be viewed as the extent to which the questionnaire?s results predict a given criteria in the future 3. Construct Validity: refers to underline theory or construct, which forms the basis of the questionnaire in order to capture a particular observation or behaviour in a population. Many of the underlying constructs are based on the larger theories or clinical observations. In most of the psychological instruments, the measurements or scores are derived with the help of a hypothetical construct. In the case of the third proposed question from CHMS above, one could hypothetically signify that a women who reports to have bleeding gums would need to be provided with the provisions for an immediate dental care. Construct validity can be further divided in to two types Convergent Validity:  ?It refers to the similar response to like-questions, either within the same instruments or between instruments with the same theoretical framework?. Discriminant Validity: It refers to the ability of an instrument to discriminate between respondents who experience the same phenomenon in different ways or between similar questions in an instrument with different theoretical frameworks. The Unitarian concept of validity relies upon the criterion related evidence, combined with the professional judgment (content validity) in order to accurately reflect the construct, integrated in the theoretical framework in a questionnaire.    95 Appendix D - Ethics Approval Certificate from Fraser Health Authority  96 Appendix E - Consent For Participation                                                                   Oral Health Care Needs and Behaviour of Pregnant Women  Master of Science Student: Dr. Abbas Jessani Supervisor:  Dr. Mario. Brondani  voluntaryanonymousconfidentialDr.3Mario3A3BrondaniDr.3Abbas3Jessani   97 Appendix F - Best Beginning Prenatal Registration Form     98 Appendix G - Dental Questionnaire              1. Please rate the health of your mouth: (choose one)                                                                                                  (  )Excellent     (  ) Good     (  ) Fair        (  ) Poor  1.2 How important do you think is the health of your mouth during pregnancy?  (  ) Very important    (  ) Important    (  ) Somewhat important    (  ) Not important    (  ) I don?t know      2. Do you have an insurance or government program that covers all or part of your dental expenses? (  ) Yes      (  ) No   (  ) Don?t know                                        (  ) I was refused coverage  2.1. If yes, then is it:  (  ) An employer sponsored plan? (  ) A private plan? (  ) A government program for social service? (  ) A government program for First Nations and             Inuit?   3. In the past 12 months, have you avoided having some or all the dental treatment that was recommended because of the cost? (  ) Yes        (  ) No  4. When was the last time you saw a dental professional (dentist, dental hygienist, and denturist)? (choose one)                                                                                                   (  ) Less than 1 year ago (  ) 1 year to less than 2 years ago (  ) 2 years to less than 3 years ago (  ) 3 years to less than 4 years ago (  ) 4 years to less than 5 years ago (  ) 5 or more years ago (  ) never  5. How often do you see a Dental professional (dentist, dental hygienist, and denturist)? (choose one)                                                                                                   (  ) More than once a year for checkups or                     treatment (  ) About once a year for checkup or treatment (  ) Less than once a year for checkup or treatment  (  ) Only for emergency care (  ) Never     6. Since the beginning of your pregnancy to today, have you had any one or more of the following conditions: a) Toothache                                                (  ) Yes     (  ) No    b) Sensitivity in your teeth when consuming  hot or cold foods or drinks                  (  ) Yes     (  ) No                                                                                          c) Other pain in your mouth                     (  ) Yes     (  ) No       d) Pain around your jaw joints                 (  ) Yes     (  ) No                                                                                                                                                                                                             e) Bleeding gums while brushing        your teeth                                              (  ) Yes     (  ) No                                                                                                f) Persistent dry mouth                              (  ) Yes     (  ) No   g) Persistent bad breath                             (  ) Yes     (  ) No h) Others __________________________________                                                                                                                                                                                                              7. During your pregnancy, what do you think is most likely to happen in your mouth?  (You may choose more than one answer)  (  ) I may lose a tooth or teeth (  ) My teeth may become lose  (  ) My teeth and gums may become sensitive (  ) I may lose calcium from my mouth/body         because of my baby (  ) I may have cavity or cavities in my teeth (  ) I may have one or more dental fillings falling        out/lose a filling(s) (  ) I may avoid brushing and/or flossing         (  ) My gums may bleed (  ) I may develop oral tumor/cancer  (  ) I should avoid seeing a dentist/dental        professional because______________________           _______________________________________ (  ) I don?t know (  ) None of the above (  ) Other __________________________________ 

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