Study design

The original study design was an in-depth in-person qualitative examination about oral cancer and quantitative surveys. Due to limitations in engaging in participatory research internationally during the COVID-19 pandemic coinciding with this study (Spring 2020–Summer 2021), the original research methodology of a mixed methods convergent study was significantly modified to reach participants remotely through the Internet. We chose Facebook as it had the potential to target certain demographic characteristics through Facebook ads to facilitate research recruitment efforts [27]. Through our history of collaboration, social media is widely used and provided an ideal opportunity to recruit participants for a remote survey study.

The original key informant and focus group interview guides were modified and incorporated into an Internet-based open-ended written questionnaire and multiple-choice survey. The questions were formulated using Andersen’s behavioral model of health service use as a framework, which provides multilevel factors that facilitate or impede an individual’s access to healthcare services. A systematic review on dental services use based on the Andersen model found that predisposing characteristics (e.g., gender, age, marital status or ethnicity) and need factors were linked to dental utilization [28]. In this study, Andersen’s model will be used to explore and predict a sample of Palauans’ intentions and behaviors as they utilize healthcare services.

Recruitment

Facebook users aged 18 and older within Palau were invited to complete the survey online through a secure site. Facebook ad invitations (Figure 2a and 2b) were shareable, allowing social media users to re-post the invitation in the form of snowball sampling. The survey and consent forms were made available in both English and Palauan. All questions had the option of text-to-speech functionality to mitigate limitations of literacy. The survey was available through Facebook ads from May 23, 2021, through May 31, 2021, for a total of nine days. The survey period was limited solely by funding availability. There was no financial compensation provided to participants.

Data were collected through a secure data collection site hosted by the University of Rochester using the REDCap system (Research Electronic Data Capture, Vanderbilt University). Informed consent to participate in the survey was required and obtained electronically, and the study was considered minimal risk. This study was approved and determined to be exempt from review by the Palau Institutional Review Board and University of Rochester Research Subjects Review Board (approved May 20, 2021, STUDY6206).

Measures

The survey was comprised of closed- and open-ended questions that investigated current use of dental services (access, frequency, and purpose) and attitudes and beliefs about betel nut use and oral cancer. Closed-ended questions included Likert scales, sliding scales, and multiple-choice responses. Demographic information was also collected, including education level, age, gender, and island of residence within Palau.

Data analysis

The open-ended survey responses were analyzed and coded independently by two members of the research team (KR, AS) using open coding processes and inductive reasoning based in grounded theory to discover emerging and important themes. Open coding of the free-text responses involved (a) each of the two coders independently identifying themes of the responses, (b) discussing and agreeing on initial themes, (c) grouping similar thematic codes into summarizing categories, (d) identifying conceptual codes, and (e) final agreement on all levels of thematic codes by the coders. Both researchers coded the free-text responses independently. Then both coders reviewed their codes, and discrepancies were resolved through multiple discussions to reach consensus. A finalized codebook with code frequencies was created to identify and describe the final emergent themes on feasibility of dental services in Palau.

Statistical analyses were conducted using SPSS (IBM SPSS Statistics, version 9.8.0.0). The primary outcome was defined as ease of seeking dental care. Responses of “neutral,” “somewhat easy,” and “very easy” were considered positive. Demographic characteristics were evaluated as predictors. These included age, gender, level of education, and location of residence. Each predictor was evaluated in cross tabulation individually as well as through logistic regression.

Free response results

Theme 1: Lack of available appointments and number of dentists

The difficulty in making prompt appointments was a pervasive theme among respondents when asked about barriers to seeking dental care in Palau. The wait time to see a dentist, that is, the time between calling to make the appointment and when that appointment could be scheduled, was felt to be quite long. This perception seemed to apply to both preventive and treatment-oriented visit requests.

Six to 8 months waiting for your appointment, to see a doctor’s or dentist.

I have to make an appointment and I have to wait for a very long time for them to contact me so by the time they call I have to cancel because something comes up.

Dental visitation list is very long that it takes about 4 to 5 months for anyone to get their teeth cleaned. Sometimes you just forget about your appointment because you waited so long.

In addition to long wait times until an appointment could be made, many respondents noted the hours that dentistry clinics were open were a limiting factor. Obligations such as employment/work and childcare were identified as barriers to accessing dentists during these hours.

I do wish the dental would be open on weekends to serve or help those people with [a] tight working schedule like me.

Work schedule and that the dental is closed on weekends.

Many respondents reported that the difficulty in making prompt appointments was due to a lack of dentists available in Palau. This deficit was frequently identified as part of the difficulty in making appointments and a barrier to care.

If we could have more dentists.

More dentists, more supplies, more resources.

Availability of dentists (need more).

Scheduling, fees, lack of supplies and/or shortage of dentist.

Theme 2: Seeking dental care is limited by cost

The costs of obtaining dental care were another frequently cited barrier to access among the respondents. Unfortunately, the format of the survey did not encourage detailed commentary on responses. Therefore, many respondents simply wrote “cost” or “financial” for this question. The mention of cost was the third most frequent code from the category of barriers to care.

It’s always the cost and whether my medical savings account with the gov’t can cover it.

Dental service in Palau is very expensive.

Too expensive and always fully booked.

Theme 3: Resources at multiple levels exist to facilitate obtaining dental care

Respondents identified a number of resources that promote the ability to get dental care. These resources exist at multiple levels as described in the socioecological model. For example, at the government/policy level, there are insurance programs to help with the cost. At an individual level, having transportation was seen as a facilitator to care.

Local health insurance so it won’t come directly out of my pocket.

Sometimes have enough government medical savings to cover cost.

I have my own vehicle to drive to the dentist.

I have transportation that I can use to go to the dentist if I need to.

Theme 4: Dental clinics provide services that promote obtaining dental care

Dental clinics have systems in place to help facilitate dental care. Respondents identified system elements in the dental care infrastructure, such as reminder calls and availability for emergency appointments, as ways that dental clinics help promote receiving care.

It is just a phone away; all I need is to call to make an appointment.

I can call anytime for appointments or walk in for any emergencies.

You can easily make an appointment. They will call you to remind you for your appointment.

Dental registrar calls me as soon as there is a cancellation.

Limitations

Facebook was the only recruitment method utilized in this study, so responses came from a convenience sample. In addition, the duration of the survey was limited exclusively by availability of funding. Results cannot be generalized to all adult Palauans due to the small sample size and are limited to those who have access to the Internet and social media. Demographic groups that were overrepresented were females, higher education levels, and those 18 to 54 years old. Although Topolovec-Vranic and colleagues [32] did not find a difference between male and female recruitment in their scoping review of social media recruitment in medical research studies, our sample does support female selection bias in our sample characteristics. Predisposing characteristics to seeking dental care, as defined by the Andersen model, found in other studies of dental utilization in LMICs include adults who identify as female and have higher education levels [13, 14]. Although these characteristics were highly represented in our sample, our analysis did not find these to be significant predisposing characteristics to seeking dental care. Males and the elderly are underrepresented in this sample, which may reflect differences in interest in the topic as well as social media patterns of use. Respondents’ geographic distribution reflected the general population, where the majority of respondents (60.5%) were from the urban center of Koror (compared to 70% of Palau’s general population).

The online survey included open-ended questions, which may limit the trustworthiness of the qualitative research; free-text responses within structured surveys rarely produce data rich enough to achieve the characteristics of rigorous qualitative research [33]. Previous studies support the use of open-ended questions as an adjunct in survey research for reasons that also apply to our studies [34, 35]. The open-ended responses provide deeper insight into explaining and contextualizing the close-ended survey responses, as well as providing direction for future exploration. The information from the open-ended responses provides an initial perspective, from the standpoint of the community [36], in lieu of in-person engagement and query, of barriers and facilitators to dental care that should be further enriched with follow-up in-depth interviews and/or focus group interviews.

Future directions

With the relatively high incidence and prevalence of oral cancer in Palau, an oral screening program would be invaluable to reducing the morbidity and mortality from this disease. These findings provide many trajectories for future studies. Toward the goal of developing an oral cancer screening program using existing dental care infrastructure, a cost-benefit analysis for screening through regular dental health exams versus the cost of treatment for oral cancer would be a useful adjunct to this investigation. The availability and reach of existing insurance and MSA programs would also be important. This investigation would also benefit from deeper exploration through qualitative methods, i.e., interviews and/or focus groups, to further clarify the perceived difficulties in securing dental appointments from both patient and dental health provider perspectives. The survey component of this investigation would benefit from a broader and larger population sample in an effort to make the results more generalizable to the Palau population overall.

Recommendations about implementing oral cancer screenings will require exploring in greater depth the decisions to seek care among high-risk individuals, that is, those who chew betel nut and/or tobacco, especially with concomitant use of alcohol. The use of telehealth in oral cancer screening has also been investigated in low-resource communities and would be another approach to investigate for screening in Palau [37, 38, 39, 40, 41]. A multilevel approach to screening that implements elements of social networks, social organizations, community infrastructure, and government public policy should also be further investigated in regard to dental utilization in Palau.