Table 3.

Themes and Sample Quotes.

Theme 1: Barriers to preventive dental services for preschool children in Chelsea, MA
Construct	Sample Quotes
Structural Appropriateness Type of dental services Perceived quality of care Health system organization Provider characteristics Financial Insurance Reimbursement Out-of-pocket costs Personal/Family Socio-demographics Acculturation Oral health attitudes/literacy English proficiency Dental fear Immigration status Competing priorities Community Caries epidemic Cultural norms and practices Dental tourism	Parent: “When they had a little bit of decay, they used to just do bonding, just fill it in. Now, they have to cap the whole teeth; I wasn’t satisfied with that….maybe they get more out of insurance.” Early childhood program provider: “People don’t really get a lot of information… so I just think that the preventive side (of dentistry) is not very strong and that’s why you see so many kids (with cavities). Pediatric Provider: “These are baby teeth; they’re going to fall out. I won’t worry about it until their new teeth come in. So we’re up against some of those faulty notions about dental care.” Dental provider: “I think that among the Hispanic community, the prevalence of decay is so high that it’s looked at as just a normal part of growing up, and not as something that can be prevented.” Pediatric Provider: “I do feel like there’s not enough (dentists) comfortable with the younger age groups, who see our patients with Mass Health.” Parent: “Like in our culture, they cry, we give a lolly. And the truth I learned hear about doesn’t give too many candies to kids, and I thought well, I didn’t care about that. Now I know and I learned. When my kids are eating something, if its candy, I say go brush your teeth after. But I think we need more education about…” Parent: “Insurance (is a problem). Yeah, because sometimes we don’t know where to go to apply or…some people help us to find the right information…And sometimes we try and somebody say no…Well what can we do if nobody helps me?” Interviewer: “At what age do you think a child should have their first dental visit?” Parent: “2 years because they are, they have their first teeth. And they need to take care of them. I haven’t taken my daughter yet, but I see her teeth…I mean asking them to brush their teeth every time before they go to bed at night. And I think her teeth are alright. They are clean. They are no black spots on them.” Pediatric Provider: “It’s hard, a lot of my patients are cared for by other family members, who may be even more recent arrivals to the country, and so they may not have a lot of information or familiarity with dental prevention for little kids. So I don’t know how to reach all of those parents that don’t interact with any of the services. I think WIC would be good, because WIC sees everyone. And I don’t know if they’re going to do something like that, I’m not sure if they do or they don’t.” Early childhood program provider: “…first of all that parents don’t have any coverage for themselves. And the adults don’t get any dental…they don’t have financial access to dental services. And without that being kind of integrated into the family for all members, then I think it’s a little harder to get it integrated for the children.ldvn16 Parent: “Well, my situation when I was staying with my father. My father didn’t understand English well. So, all he was saying was yes, yes, yes, just for him to like-- because he knows I was in pain. So, they pulled out my two front teeth without his-- well, nobody was there to explain it to him. So, when he noticed that they were pulling out my teeth he was really frustrated, really angry at them.” Interviewer: “At what age do you think a child should have their first dental visit?” Parent: “Age two. Early on at one if they’re not speaking they might act out. Then you might have to hold them down and then they might resent that you’re holding them at one-year-old to look in their mouth, because they’re very agile. But you can explain to them that they are going to the dentist. And then at that age most of the teeth are coming in already. That’s why I pick age two.”
Theme 2: Facilitators of preventive dental services for preschool children in Chelsea, MA
Construct	Sample Quotes
Personal/Family Prior dental experience Family dentist Health System Availability Accessibility Continuity of care Child-centric services Efficacy of treatment Pediatrician referrals Medical/Dental Integration Policy/Community Environment Outreach and engagement Early childhood programs Oral health education Oral health policies Schools	Parent: “I am almost 40 years, and when I go to the dentist now, I cry when they have to take away my teeth. I really feel bad! I do not want my child to go through the same thing I did.” Parent: “…there are so many dentists in Chelsea. Chelsea is not very big…. I like that we have choices. There are many choices. If you don’t like one, then there are other dentists available and you don’t have to go too far.” Dental provider: “We have a variety of services; when we talk to our counterparts throughout the state we always talk about how fortunate we are in Chelsea to have really good access to dental care.” Parent: “…her pediatrician gave me a list of dentists around Chelsea and close to me; …there were some (dentist) representatives down on the first floor (of the pediatric office) and they were giving out papers and actually making appointments the same day for them to check on kids.” Pediatrician: “I have fostered a relationship with the dentists in the area, so I know them, and I can call their office and beg for my patients to be seen sooner.” Parent: “I think that (the dentists) do a pretty good job of letting it be known that they take any kind of insurance, so people come.” Parent: I wanted him to get into the routine because I’ve seen a lot of other kids that they are so afraid of the dentist, and I wanted him to see that there is nothing to be afraid of. The younger he saw them the better it is. Parent: “Well, I’m a person it’s important for me to go to the dentist. If the baby has enough teeth and they’re eating different types of food with sugar, which is candy, just as soon as possible just for them to prevent having cavities in the early stage.” Interviewer: “At what age do you think a child should have their first dental visit?” Parent: “I year old. Before, I did not have any idea – for my first child I lived in NewYork and they sent us a card. But I could not read the paper, and so I did not know. Here in Chelsea, when MassHealth sent the card (to tell me to take my child to the dentist), I went to the doctor, I asked when should my child go to the dentist, - she said when they are 6 months they should go to the dentist, just to see how the teeth are growing. So I think it is better when the child is 6monhts or 1 year.”