How primary health care teams perceive the integration of oral health care into their practice: A qualitative study

Recently, new models for the integration of oral health into primary care have been proposed. However, these models may be adopted by a variety of health care systems, and will reach successful outcomes only if they can be adapted to suit the local context. To this end, the objective of this study was to explore the perceptions of Quebec primary health care teams on the integration of oral health into primary care. A qualitative approach and interpretive description methodology were used to conduct the study within a case-study design. Purposeful sampling with maximum variation and snowball technique were used for recruitment of study participants. Seventy-four in-depth, semi-structured interviews and five focus groups were conducted with primary health care teams including health care providers and managers working in a rural and an urban health care center. The interview guide and study conceptual framework were based on the Rainbow model. Data collection and data analyses were conducted concurrently and continued until saturation was achieved. To analyze the data, four phases of qualitative analysis were followed. The thematic analysis included interview debriefing, transcript coding, data display, and interpretation. Data analysis was conducted both manually and with the use of Atlas-ti software. A total of four themes emerged from the interviews and focus group discussions. These themes covered all domains of the study theoretical model and included: 1) drivers of integration; 2) importance of integration; 3) professionals’ role in integrated care; and 4) barriers and enablers of integration. In general, most of the barriers expressed by study participants were related to the organizational and system domains of integration. Primary health care teams who provide care in rural and urban areas in Quebec expressed their concerns on the absence of integrated oral health services. Implementation of governance policies, the prioritization of educational and management measures as well as inter-professional collaboration toward innovative care models could facilitate this integration.

Introduction Various health organizations have proposed the integration of oral health into primary care as an effective approach to improve access to oral health care [1][2][3][4].
Primary oral health care has been defined by Isman [5] as "the integration of services that promote and preserve oral health, prevent oral disease, injury and dysfunction and provide a regular source of care for acute and chronic oral diseases and disabilities." Although various demonstrations and pilot programs have shown promising results for the integration of oral health into primary care, the rate of implementation of this approach remains low [6][7][8]. Our comprehensive scoping review on this topic showed that one of the main barriers for primary oral health care is the lack of collaborative work and related suboptimal competencies of health care providers [9,10]. Accordingly, in many countries strategic health care plans have been implemented to promote interprofessional collaboration, increase knowledge, improve skills, and shape positive attitudes towards primary oral health care. As an example, the US Health Resources and Services Administration has encouraged primary health care providers to develop competencies in the areas of primary oral health care including: risk assessment, oral health evaluation, preventive intervention, counseling and education and interprofessionnal collaborative practices [11]. As defined by D'Amour and Oandasan [12], interprofessional work: "The process by which professionals reflect on and develop ways of practicing that provide an integrated and cohesive answer to the needs of the client, family, and populations." In fact, interprofessional collaboration has been introduced as the main facilitator for the integration of oral health into primary care. However, several recent studies conducted in Europe and North America have shown that many general practitioners and other non-dental health primary care workforce still have limited knowledge on interprofessional practice extended to the field of dentistry, and often have negative attitudes toward the adoption of primary oral health care in their regular practice [13,14]. Characterized by teamwork and effective communication between various professionals, the collaborative practice could vary based on working environment, health care policies, and stakeholders' perspectives, beliefs, and values in the real world of health care [15]. Understanding these values and identifying patterns among individuals' perspectives are essential for planning and implementation of collaborative practices oriented toward primary oral health care as well as holistic global health care.
Therefore, the objective of this study was to answer the following research question: How do Quebec primary health care providers and managers perceive the integration of oral health into primary care and its associated barriers and facilitators?

Methods
This study used qualitative research methodology within a case study design in a defined time and setting. Interpretive description, introduced by Thorne, was incorporated as a theoretical scaffolding [16]. This qualitative methodology has been selected as it generates useful findings in the context of clinical applied health care disciplines and it allows understanding the characteristics, patterns, and structure of a clinical phenomenon. In the interpretive description, the researchers' foreknowledge of the studied phenomenon and in particular, their clinical expertise is considered to be the starting point for orienting the research design [16]. The inquiry can then be refined as the research progresses and finally, in the context of integrated oral health care, the research results will inform health care organizations to design and build an infrastructure that will facilitate this integration [16].

Conceptual framework
The Rainbow model of Integrated Care introduced by Valentijn et al. [17] has been used as the study's conceptual framework. This framework has been revised after reaching a consensus through an international Delphi process. According to this revised framework the integrated care can be extended from person-focus care to a well-defined population with specific needs [18] and on four levels: clinical, professional, organizational and system integration. The normative and functional integration has been identified as enablers of integration process.

Study context and setting
In Canada dental care is mostly private thus costs are out-of-pocket or covered by employerbased insurance or via restricted specific programs for priority population. Such programs vary amongst province. In Quebec, publicly-funded dental care covers some priority population such as children under 10 years old, individuals covered by social insurance or those with special needs who receive hospital-based dental care. In 2015, in order to optimize quality, continuity, and accessibility of health care services, the Quebec Ministry of Health and Social Services changed the health care organizational structure by merging 182 health care organizations in different health regions into the creation of 34 integrated health and social services centers (HSSIC).
This research study was conducted in two public health care centers in the province of Quebec, Canada, from November 2016 to October 2017. The selection of study mega-centers (cases) was based mainly on their territories and population served. The first health care center serves an exclusively urban territory and offers services to a diverse population including a high number of seniors and new immigrants. The second health care center covers a larger territory including rural, semi-rural, and urban regions. In the latter center, the vast majority of the population consists of residents of the most disadvantaged rural region in Quebec. In both centers, oral health care services within the primary care sector were dispensed via the public health department under the supervision of a local public health dentist, offering free preventive oral health care services exclusively to children via center-affiliated dental hygienists.

Participants' selection
Purposive sampling, a maximum variation strategy, and snowball technique were used to identify and recruit study participants [19,20]. Their eligibility criteria included being from the primary health care sector and having a least one year of work experience in this sector. The study participant recruitment continued until data saturation was reached. All identified individuals agreed to participate in the study.

Data collection
Semi-structured interviews and focus group discussion were used as data collection methods. The focus groups included main teams of primary health care (public health, home care, children and youth health services) and were organized to stimulate the discussion between the study participants. Focus groups are particularly useful to explore shared visions and the degree of consensus on a specific topic [21]. The combination of two methods allowed gaining detailed, in-depth understanding of various professionals' perspectives in addition to generating new insights from group reflection and a dynamic, real-world peer-to-peer interaction [22].
A preliminary interview guide (data in S1 File) with open-ended questions was developed by the research team (HH, YC, LL, EE), based on the Rainbow model and the existing literature on primary health care integration. The interview guide contained general questions on the role of health care providers in primary care, and specific questions related to oral health: population oral health needs, oral health evaluation processes, as well as clinical, organizational, professional, functional, normative, and systemic factors influencing oral health integration into primary care (data in S2-S5 Files). The interview guide was pilot-tested to ensure the clarity of questions, and necessary adjustments were made accordingly.
The research team has considerable experience in qualitative research and the doctoral candidate (HH) was trained in advance in qualitative research interviewing methods to collect the data. At the beginning of each interview and focus group, the interviewer (HH) introduced herself, provided information on the study, and explained the procedure. Then informed written consent was obtained from each study participant.
The audio-recorded face-to face (n = 68), telephonic interviews (n = 6) and focus group discussions (n = 5) lasted around 60-90 minutes and took place in the primary care sector of each health care center. The telephonic interviews were conducted to address some participants' inability to participate in focus groups or face-to-face interviews because of time constraints.
Data collection and analysis were performed concurrently. This approach allowed us to expand the content of interviews and focus groups based on field-notes and ensured the reflexivity of researchers as well as validity of the saturation level [23,24].
Ethical approval was obtained from the institutional review board of the Université de Montréal and health care centers.

Data analysis
Following a thematic content analysis, four phases of qualitative analysis were identified as detailed by Bengtsson [23]: 1) decontextualization; 2) recontextualization; 3) categorization; and 4) compilation. Each of these stages was revised by other research team members who had deep knowledge on the integration concept in different disciplines. The involvement of an interdisciplinary research team prevented errors in data analysis, personal and interpretation bias, and ensured that no relevant data were excluded, thereby maintaining the confirmability and the credibility of the analysis [25].
In the phase of decontextualization, transcription of data was performed with repeated examination of recorded data by the first author (HH). Debriefing and reflexive field notes made it possible to better understand the context and the participants' discourse. Then, an "inductive open coding process" followed [26]. The content areas were identified and accordingly, the text was divided into meaning units, which were subsequently condensed and transformed into codes. The use of a code explanation document facilitated the tracking of coding decisions, and maximized the dependability of the data analysis.
In the recontextualization phase, codes were reviewed against the original interview transcriptions. The research team regularly and thoroughly discussed uncertainties in coding and interpretation, and obtained agreement to ensure the study's credibility.
In the phase of categorization, codes with similar conceptual content (meaning units) were grouped to identify the themes (Table 1).
Finally, the last stage (compilation) comprised analysis and interpretation. Although descriptive, the manifest analysis was followed by a latent analysis to understand hidden meanings of the original texts.
In the data interpretation, similarities and differences in rural and urban settings as well as the literature findings were considered, to maximize the transferability and authenticity of the research. Trustworthiness of the study was maximized by using principal guidelines in qualitative research [26]. A respondent validation was performed with 5 individuals.
Data analysis was conducted manually and was assisted by the use of Atlas-ti software (ATLAS-ti Scientific Software Development GmbH, Berlin, Germany).
Consolidated criteria for reporting qualitative research (COREQ) were followed.
A total of four themes emerged from the interviews and focus group discussions and included: drivers of integration; importance of integration; professionals' role in integrated

Drivers of integration
This theme comprises two sub-themes as detailed below.
Oral health care service missing in publicly funded health services. The majority of study participants stated that, at the organizational and clinical level, integrated oral health services were either completely absent or largely insufficient in their primary health care organization: Oral health needs as a driver of integration. Regarding the scope of an integrated care approach, both person-centered and population-centered needs were reported by study participants. For example, at the clinical level, for newborns and children, needs included parent's lack of awareness and education on oral health, teeth/oral mucosa trauma and pain, oralhealth-related problems in rare/genetic diseases, and lack of general anesthesia services for special needs children (intellectual or physical impairments). we're dealing with . . . they get it at home, they get it very young, before they're even in school, so maybe it has to start with the nurses . . . We have really good perinatal and early childhood nurses who see them for the vaccination, and they are the ones who work really close especially with these very underprivileged mothers." (P18) "We have certain children who need general anesthesia to remove caries, because they have intellectual impairments, they have autism or other disorders."(P23) Regarding elders, especially those staying in long-term health care facilities, the majority of health care providers highlighted an increase in the demand for integration of oral health into primary care because of an increase in the number of patients with multi-morbidities, impaired physical and mental health, as well as evolution in their oral health needs: "At the beginning of my practice in 2002, most of the residents had dental prostheses; it was easy to clean, but now more people keep their teeth and the dental health is often bad, the teeth are missing, decayed, and in bad condition."(P18) "For sure, we need a dentist, we need a dentist because the people . . . the elderly . . . like today a day at minus 30 [degrees], if someone has a problem I am obliged to put them in an ambulance, or in an adapted transport, to send them here to the village."(P9)

Importance of integration
The non-dental health care providers, especially those being sensitive to health care challenges of vulnerable populations or tasked with patients' oral health evaluation (e.g., nutritionists, occupational therapists, and nurses), were in agreement that the integration of oral health into primary care fits into the concept of holistic primary care and they considered it instrumental for the prevention of diseases and improving access to oral health care for specific populations: In the context of functional integration, they also highlighted the challenges of non-integrated care and its negative impact on general health: "Well, generally I would not do that [evaluation and care of mouth], but I can realize the consequences of not doing so-either that the person is going to choke because she's going to bed with food in her mouth, deterioration of the teeth will happen, and we may have an infection because there are cavities that settle in . . . after that there is an even more serious physical problem that will settle in."(P18) "There are some dentists. . . they refuse to take care of patients, especially those on welfare, for financial reasons, that's why for me it's a big problem . . . It's a problem we would not have if they were integrated into the health care network." (P32) Although the dentists participating in the study were not familiar with the concept of integration, they agreed that integration processes are necessary to improve the access to oral health care for vulnerable populations: ". . .to be included in the RAMQ; personally, I had people who could not afford to pay for an extraction, then I think that in our society this should be a minimum. Minimum However, a few general practitioners emphasized that the problem of access to "needed care" will not be resolved by integration: "I do not see the advantage of integrating these things. If you really want to have an advantage for the population, they should have access to dental and oral care, free of charge. In

Professionals' role in integrated care
In regard to professional integration, general health care providers positively perceived this integration and the majority considered oral health integrated care necessary to better accomplish their professional role. This role was described as participation in linkage and/or coordination processes.
" . . . there are vulnerable families, but sometimes you have to push, make the calls for them, because they do not have the instinct to call, make an appointment right now [. . .] so we will try to push for them to be seen by a dentist." (P16) In the rural center, where the primary health care team included a dental hygienist, integration was reported as a coordination process including oral health screening to identify patients with special needs, sharing knowledge and clinical information as well as facilitating the transfer between settings:

"We have X [the hygienist] who interacts with us a lot, if there are things we do not know, we ask questions, we talk, we make visits with her, we refer." (P16)
However, the majority of the health care providers believed that they didn't have the necessary competencies to play an important role in oral health care and they highlighted the need of adding dental workforce to their team.
"I think I would have less work because at the moment any problem of the patient is referred to me, even though I am not the most competent person to evaluate it; any health problem so oral health problems too, even if my therapeutic arsenal is an antibiotic and a painkiller, it makes me think sincerely that, if there were a second, third line integrated, oral health problems would be referred directly to professionals more qualified than me, then I wouldn't have to take care of this area, which is really not my specialty. I Table 2 presents a summary of the barriers and facilitators and their representative quotations.

Barriers and enablers of integration
In general, most of the barriers expressed by study participants were related to the organizational and system domains of integration. These included the lack of health policies and governance mechanisms to facilitate the delivery of oral health services in the continuum of care. These gaps and other factors such as lack of competencies, shortage of qualified and trained primary care providers, and high costs of integrated services were most reported as barriers to primary oral health care. The most frequently reported facilitators were situated at the meso level and in fact represented the primary health care providers' wishes for their health care organizations since the integration has not been realized in these organizations. These included the optimization of coordination mechanisms and interprofessional collaboration in the professional domain as well as supportive policies in the system integration domains, at the macro level. Other facilitators included budget allocation, fundraising strategies, and innovative care models.

Discussion
This study explored the perceptions of primary health care teams on the integration of oral health into primary care. To our knowledge this is the first study conducted in Canada on this concept. Our results showed that in general, and regardless of geographical location of health care organizations, oral health care services were perceived as absent in the primary public health care sector and integration was seen as a vehicle to respond to the clientele's oral health needs. The importance of oral health integration into primary care seemed to be rooted in the perceived oral health needs of priority population groups including children, adolescents, and elders, and was linked to the providers' incapacity to address these needs in the current health care system in Canada. Furthermore, primary health care teams both in rural and urban health care centers reported an association between the oral health needs of the priority population and their professional roles. These results are in line with the findings of previous studies [27] that demonstrated the positive impact of perceived professional responsibility on integration processes and collaborative practices. In our study, these collaborative practices were mostly expressed in terms of linkages and coordination processes. Furthermore, although the lack of primary oral health care services and the importance of oral health care integration were highlighted by the study participants, they did not have concrete ideas on the mechanism of integration into their current practice. Thus, for some general practitioners, specially those working in rural areas, the concept of integration was not considered as an element of public health as long as services are not free of charge. These issues can be explained by the fact that primary care providers understand the clinical operational processes of integrated care better than theoretical models, taxonomies, and parameters of integrated care. Furthermore, dental and oral health care is considered mostly as a secondary line of care provided solely by dentists. Several previous studies [28,29] concluded that oral health promotion and prevention of oral

Care coordination mechanisms and interprofessional collaboration
Subtheme: Case management "Yes, it's always an interdisciplinary team and we all know each other. Then everyone has his/her own agenda and then let's say. . . aaa. . . anything. . . after 7 weeks,. . . follows the 8th when the dental hygienist comes, and I inform the dental hygienist how it's going. . . The baby is 9 weeks old, you can go, all that, then each person has his schedule and once it's done we fill in the intervention plan on file."(P23) Subtheme: Interdisciplinary planning ". . . I think it's like a kind of intervention plan with all the different services, where, for example. . . the nurse, the school social worker and the dental hygienist will sit down then they will make an intervention plan in relation to the services, the needs of that client. I see it like that, integrating is where all the services are bound together in order to better help the child. "(P7) "We saw that it works well, then we integrated it into our action plan, so we schedule an appointment. . . we notify J [the hygienist]. . . We then have to go together to visit the resident. . . the follow-ups work better with vulnerable residents especially."(P23) "If the hygienist notices disorders unrelated to teeth, she will draw my attention to them. Likewise, If I see something wrong with teeth I would notify her, we always worked well together."(P22) Subtheme: Interdisciplinary education and training "I think that an aspect to be prioritized would be the training."(P24) "We need education. . . this is what we need." (P19) "We should have more staff, well trained staff. We agree that everything to do with nursing, everything evolves, like all other things, everything evolves, so we must be trained to keep up accordingly."(P38) Normative integration Subtheme: Shared vision "All employees do prevention here. So, everyone is in primary care, but also with a prevention component. . . Because we said it's an important part."(P23) Subtheme: Leadership "Is it allowed!?. . . We decided to implement it [hygienist as a team member] because we noticed. . . I'll tell you something, we implemented prenatal classes too. Because we decided this is an important part, the same thing with the nutritionist, then we looked at the development of the child, I am also a psycho educator, therefore, we looked at the development of the child then this is it, we decided it's important at a certain age, the appearance of the teeth, the baby bottle. . . anyway, plenty of such things, then we concluded that is the time when the hygienist should intervene."(P23) (Continued ) diseases must be "everybody's business." Our study adds to these findings that the progress of oral health integration into primary care necessitates tailored designs and role-specific approaches which take into account each profession's needs in practice, analyzing both context and group interrelations. Professionals' age did not appear to be a contributing factor in integration. In our study older and more experienced professionals expressed generally the same views as younger ones. On the other hand, rurality seemed to empower positive perception on the integration via interprofessional collaboration. This could be explained by the oral health needs that vulnerable populations encounter in rural and remote areas. There was largely a consensus across health care providers of various disciplines on the types of barriers and facilitators in terms of primary oral health care, but the importance accorded to these varied from one discipline to another. For example, at the micro level, in the clinical integration domain, in silo practices was a barrier reported mostly by general practitioners and dentists, leading to fragmented care and absence of structured coordination mechanisms. There is a global knowledge that oral health is part of general health and thus exclusion of dental care from primary care can lead to major harms to patients' health [30,31]. Despite various initiatives intended to close the gap between medical and dental care through integrated health care programs, lack of coverage of dental care by medical insurance and the limited number of dentists working in the public sector remain major problems to address in meeting the oral health needs of priority populations [32].
Our study results are in line with previous studies that recommend the development of core competencies for primary care providers as the strategy to address this barrier [9,11]. Increasing the education and training of primary care practitioners will lead to early detection of oral diseases and will empower preventive approaches [27]. Some participants raised aspects of ageism, age discrimination in providing care for elders, especially when prevention is of interest. This could be related to several issues such as limited empirical evidence for treatment of chronic diseases, health professionals' view of aging as a process of decline, and preferences for using their knowledge and skills to cure acute illnesses rather than managing chronic conditions. Some studies have shown that practice integration could be facilitated through interventions that don't require additional resources [33]. Structured protocols and the history of How primary health care teams perceive the integration of oral health care into their practice collaboration of primary care teams with dental hygienists through public health programs in Quebec seem to have contributed to oral health awareness among the primary care providers. Therefore, the integration of oral health care into primary care teams could be realized by the addition of allied dental workforce to the primary care teams without adding substantial cost to the health care system. In regard to the organizational integration, time constraints and roles ambiguity seem to be important barriers in the provision of oral health care by members of health care teams such as nurses and social workers. However in terms of functional integration, limited interoperability of information systems, lack of appropriate tools and guidelines, as well as various logistical aspects such as dentists' remuneration policies or dental equipment availability were reported by study participants as demotivating factors in adopting integration processes in interdisciplinary teams. At the macro level and in the systemic domain, lack of human resources, integrated services costs, and low political priority accorded to oral health were reported mostly by managers. These findings were similar to results of our recent scoping review [10] on the integration of oral health into primary care.
Several limitations should be noted for this study. First, our study didn't include the perspectives of patients in regard to the integration of oral health into primary care. Secondly, our results cannot be considered as exhaustive due to their sensitivity to the teams and context. For example, the composition of primary healthcare providers in the public health care system in Quebec is skewed towards females, which was heavily reflected in our sampling. Views and perceptions on oral health integration into primary care could be related to gender differences. Likewise, the transferability of the findings to other contexts or settings, which is equivalent to external validity in quantitative research, could be considered as a study limitation. However, we enhanced the transferability of findings by providing a detailed description of the specific context and assumptions that were central to the research. Finally, like any qualitative study, the researcher was the primary instrument for data collection and analysis. Despite this inevitable subjectivity of the study, considerable overlap of some thematic content across health care disciplines suggests that there is a shared understanding of integration aspects and that our findings might be transferable to other settings. Further studies are needed to explore the extent of providers' views and to address the various levels of integration in order to deliver oral health care in the primary care sector.

Conclusion
Primary health care teams who provide care in rural and urban areas of Quebec expressed their concerns on the absence of integrated oral health services. Our study results suggest that advancing oral health integration into primary care necessitates adjusted designs and role-specific approaches which take into account each profession's needs in practice, analyzing both context and group interrelations Implementation of governance policies, the prioritization of educational and management measures as well as inter-professional collaboration toward innovative care models could facilitate this integration.