I really like my dentist. She is like an angel. Her office is one of the few accepting patients with Medi-Cal in Koreatown. You don’t know how embarrassing it is to see a doctor with Medi-Cal, but she makes me feel comfortable. It is always a big concern to poor people like me if there is any extra cost for treatment. My dentist always checks the coverage before I ask. She makes sure that there is no unexpected cost at the end. God bless her! [female, 60]
This participant also shared her negative experience related to Medi-Cal in another clinic:
I am diabetic. It was diagnosed about two years ago. When I went to see a cardiac doctor, the nurse who saw my chart said that I should be tested for blood sugar. Then the other nurse said, ‘No, she is Medi-Cal.’ I was badly hurt when I heard that. I don’t deserve to have that simple strip test because I am Medi-Cal. I felt devalued and degraded. I hate going to clinics and showing my Medi-Cal card. [female, 60]
On a quantitative question, more than 36% of the participants reported having negative experiences in dental clinics (e.g., discrimination, unfriendliness, mistreatment, overtreatment), which seemed to contribute to their dissatisfaction with services. Participants particularly expressed a high level of dissatisfaction with cost and care quality. Some participants receiving medical benefits from social insurance programs seemed to have lowered their expectations:
I have no complaints. Everything is fine. I am very grateful for what they offer to me. How can I ask for more? [female, 93]
Areas for improvement. The main improvement that participants wanted to be related to affordability and accessibility:
I wish there are options for dental care that seniors can easily use without worrying about the cost. It would be wonderful if basic dental services is covered. [female, 74]
There are only a few Korean dentists who accept patients with Medi-Cal, and the option is becoming more limited every year. I don’t know what to do if my current doctor says she doesn’t receive Medi-Cal patients any longer. [female, 60]
Another area for improvement relates to patients’ informational and relational needs. Participants wanted to better understand their conditions and be able to make informed decisions:
I have never seen a dentist who is kind enough to explain the conditions and treatment options to patients. Doctors and nurses speak their medical jargon like special codes and ignore me. Even when I ask a question, they don’t respond well. They should respect their patients. [male, 82]
Also, participants noted the need for oral health education:
I realized the importance of oral health when I became old. I should have known it earlier. People should get educated when they are young so that they can build good lifelong habits. I have two grandkids. Every time I see them, I talk about the importance of brushing well. [male, 79]
Discussion
This qualitative study explored the oral health and dental care experiences among older Korean immigrants and identified contextual factors influencing their dental service use. Older Korean immigrants reported many oral health problems such as missing or broken teeth, gum problems, pain, poorly fitted dentures, and dry mouth. These problems negatively impacted various aspects of life, ranging from eating restrictions to low self-confidence. This finding is in line with previous research reporting poor oral health status among older immigrants.8-10 However, despite their poor oral health, there was a lack of perceived need for dental care. The fact that older ethnic minority adults tend to consider oral health care less important than other health care10 and tend to seek dental care only when urgently needed21 may explain this discrepancy. Given that the perceived need for dental care is one of the major driving forces of dental care service use,9,10 it is important to understand the potential mechanisms of the discrepancy and to identify ways to promote awareness of the importance of preventive dental care.
The study findings also identified four specific barriers to dental care services: (1) insurance and finance, (2) language, (3) social support, and (4) knowledge and beliefs. Many participants did not have dental insurance and had a high level of financial burden, and thus were not able to use dental care services despite their needs. These findings are consistent with previous research which identified lack of dental insurance and financial strain as significant barriers to the use and unmet needs of dental care services for older adults.7,9,10 Moreover, a considerable number of the study participants with Medi-Cal were not aware of its dental coverage. Such a lack of knowledge about insurance benefits serves as a barrier by discouraging individuals from using health services.22,23
Limited English proficiency was a barrier because it limited the available service options. Korean immigrants experienced difficulty in communicating with health professionals and thus preferred Korean dentists who shared language and culture. All study participants had, in fact, visited Korean-speaking dentists within the Korean community. Korean-speaking dentists are more available to older Korean immigrants in Los Angeles than in many communities; however, the options for dental care services and the sources for oral health information are still primarily limited to the Korean enclave and not readily available in the broader Los Angeles area.
Due to financial burdens and limited English proficiency, many older Korean immigrants depend on their adult children for support in seeking dental care. However, the older adults’ deep sense of burden and desire for independence served as barriers to care. For example, fear that they would cause concern and impose financial obligations on their adult children prevented many older Korean immigrants from using dental care services. This finding highlights the significant roles of social support and family network for older Korean immigrants relative to dental care. It also provides further insight into the impact of social support mechanisms on the use of dental services and calls for the need to enhance access to formal support (e.g., community organizations and agencies) to reduce the family burden and older individuals’ sense of dependency.
In addition to poor knowledge and beliefs about insurance benefits, participant responses reflected varying levels of knowledge and beliefs about appropriate preventive dental care measures and pessimistic views on dental care based on the belief that poor oral health is a natural process of aging. Consistent with previous research,10,21 they also placed a lower priority on dental care than on other health care and sought dental care services only for curative purposes, rather than preventive purposes. Although these findings warrant further exploration, knowledge and beliefs about oral health and dental care among older Korean immigrants seem culturally embedded and also closely interconnected with the language barrier. That is, older Korean immigrants obtain health information from informal and ethnically homogenous networks due to their limited English proficiency, and such information can be misleading, reinforce cultural norms and beliefs in specific health behaviors, and ultimately lead to inadequate health decisions.22,23
The structural and cultural barriers may also be associated with compromised care quality and patient safety. In fact, about 30% of study participants were dissatisfied with the dental service they had received, and over 36% reported that they had had negative experiences in dental clinics, such as mistreatment or overtreatment. The study identified several approaches for improving dental care use, including affordability, accessibility, and enhancement of oral health literacy through education. Multilateral efforts from diverse stakeholders—such as health policymakers, oral health service providers, and local ethnic community agencies—would be required to proactively address these areas for improvement.
One of the unique study findings was the interconnected nature of the three core categories: oral health needs, service barriers, and service outcomes. Challenges in each category exacerbated challenges in the other two, creating a vicious circle of poor dental care. For example, older Korean immigrants who experience multiple service barriers may experience poor service outcomes due to (1) limited service options, or (2) compromised care quality and aggravated oral health, or (3) a lower level of perceived need for dental care because they are discouraged about using dental care services. Poor service outcomes and a lower level of perceived need for dental care caused by multiple service barriers may then serve as subsequent barriers to service use. Service outcomes and oral health needs are also interconnected in that continued unsatisfactory service outcomes may discourage individuals and lower the level of their perceived needs for dental care, which may lead to aggravated oral health status. Thus, it is critical to understand the mechanisms through which the challenges of the three categories influence one another and to take a comprehensive approach to better address the varied challenges facing older Korean immigrants.
The study has several limitations. First, restricting the sample to older Korean immigrants who live in Los Angeles may limit the generalizability of the study findings. Older Korean immigrants who live in other, smaller Korean communities or who live outside of Korean enclaves may have different experiences than the study participants. Thus, future research should expand the scope of the target population to include diverse geographic locations. Second, the small purposive-based sample may not represent the larger population of older Korean immigrants. Third, despite our research team’s effort to ensure the trustworthiness of the study, each member’s biases and perceptions may have influenced the interpretation of data to some extent.
Despite the limitations, this study has several significant implications for policy and practice to promote optimal oral health and dental care. The discrepancy between the perceived and actual needs for dental care calls for action to raise older Korean immigrants’ awareness and understanding about the significance of preventive dental care. Also, a variety of services and programs that respond to the needs and barriers identified in the study need to be developed. For example, financial burden, lack of awareness of benefits covered by Medi-Cal, and language are major service barriers for some older Korean immigrants; therefore, developing a culturally and linguistically tailored education program about the dental care services covered by Medi-Cal would promote their use of dental care services. Taking a comprehensive and multilateral approach that includes policy-, community-, and individual-level efforts is also critical to better address the interconnected oral health and dental care challenges. By identifying oral health and dental care challenges in the areas of oral health needs, service barriers, and service outcomes, our study not only sheds light on the varied experiences of oral health and dental care among older Korean immigrants but also informs the development of services and programs responsive to the identified needs and barriers.