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Theorizing oral healthcare management in the COVID-19 pandemic: a qualitative study in the municipalities of Minas Gerais, Brazil

Leiriane Alves de Souza - Souza L.A; Universidade Federal de Uberlândia, Pós-graduação em Odontologia; leiriane.souza@ufu.br; ORCID: https://orcid.org/0000-0002-0301-0189
Lorena Maria Evangelista Leonel – Leonel, L.M.E; Universidade Federal de Uberlândia, Faculdade de Odontologia, lorena_leonel1@hotmail.com; ORCID: https://orcid.org/0009-0004-0983-1086
Jaqueline Vilela Bulgareli – Bulgareli, J.V; Universidade Federal de Uberlândia, Faculdade de Odontologia, Departamento de Odontologia Preventiva e Social, jaquelinebulgareli@gmail.com; ORCID: https://orcid.org/0000-0001-7810-0595
Álex Moreira Herval – Herval, A.M; Universidade Federal de Uberlândia, Faculdade de Odontologia, Departamento de Odontologia Preventiva e Social; alexmherval@ufu.br; ORCID: https://orcid.org/0000-0001-6649-2616

Abstract
The study develops a theory for the management of oral health services in the COVID-19 pandemic, based on the meanings produced by oral healthcare managers. A qualitative study was carried out in municipalities in the state of Minas Gerais, Brazil, with primary care and specialized dental services. Data were collected through remote semi-structured interviews. The data were analyzed using grounded theory and theorized based on the National Humanization Policy, issued by the Brazilian Ministry of Health. The theorizing that emerged from the study made it possible to understand that the health crisis acted as a phenomenon that destabilized the traditional management process, promoting changes in the understanding of individuals in managerial roles. However, the lessons learned during this period were related to the acquisition of knowledge, not to changes in the verticalized management model. This result was evidenced by an absence of social participation, with only the lack of complaints ombudsmen being considered. In addition, it was found that managers were committed to the political and institutional recognition of dentistry but did not have the same commitment to recognizing the social importance of oral healthcare in public health services.
Keywords: Dental Health Services; Dental Care; Dental Specialties; Health Management; COVID-19.

Introduction
The COVID-19 health crisis has strongly affected dental services due to the transmissibility of the virus1. During the first two years of the pandemic, this resulted in the suspension of elective services, while urgent and emergency care continud2,3, leading to a decrease in dental appointments4. In primary healthcare, urgent consultations decreased by 42.5% and specialized consultations dropped by 44.1%4, with a focus on endodontic treatments5.
The World Health Organization recommended the adoption of strategies to combat the COVID-19 pandemic according to the particularities of each country6. South American countries developed guidelines focused on dental care and biosafety protocols7. In Brazil, the state and municipal health departments defined their regulations based on the norms and protocols issued by the Ministry of Health8,9.
In Brazil, this health crisis generated an accumulated demand for oral health services that added to the historical backlog of unmet needs already existing in the country and highlighted regional inequalities4, constituting a challenge for managers of the public health system (Sistema Único de Saúde, SUS). This resulted in heightened expectations for managers, including the augmentation of human, physical, and equipment resources8, the execution of extensive prevention and control measures in dental care2, the integration of innovative practices such as teledentistry10, and the adoption of minimally invasive procedures11.
This study is based on the unprecedented restriction/suspension of dental services that occurred during the COVID-19 pandemic and the consequent need to reorganize dental care work processes. In the state of Minas Gerais, the 14 health macroregions had to adapt their structures, educational activities, care provisions, and service organization12. Thus, the aim of this study was to develop a theory for the management of oral health services in the COVID-19 pandemic, based on the meanings produced by oral healthcare managers in municipalities offering primary and specialized dental services.

Methods
This qualitative research drew on the theoretical insights of symbolic interactionism to answer the question: “What meanings were produced by oral healthcare managers on the adequacy of the oral healthcare network during the COVID-19 pandemic?” The project was approved by the Research Ethics Committee of the Federal University of Uberlândia (CAAE 52461721.6.0000.5152; approval protocol: 5.064.667). Its results were presented according to the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ).
The study included professionals who had been in management and advisory positions in oral healthcare services for at least two years in municipalities that offered primary and specialized dental services, regardless of their professional category. The sample was intentional, with invitations being sent to the managers of the municipalities that were the headquarters of the health macroregions and/or hub cities of Minas Gerais. The participants were recruited via phone calls to the official numbers, and subsequently the invitations were sent to the official emails of the municipalities. In the phone calls, the potential participants were notified of the interviewer’s credentials (i.e., a dentist working in the public health system, specialized in health management, with a master’s in environmental health and occupational health, and a doctoral candidate in dentistry) and were informed that she was in dental care during the pandemic. After agreeing to participate in the study, they were asked to complete an online form with the following information: age, sex, education, time in current position, and professional affiliation(s).
Semi-structured interviews were conducted using a script developed by the authors based on the theoretical framework. This script addressed the following topics: (1) challenges for the adaptation of people management in the oral healthcare network; (2) strategies effectively implemented by the oral healthcare network to meet societal demands for dental care; (3) political and financial challenges faced by oral healthcare management teams during the COVID-19 pandemic; and (4) prospective directions for the post-pandemic period. Two pilot interviews were conducted with former oral healthcare coordinators, which were not included in the analysis.
The interviews were conducted from July to December 2022 by a single interviewer (L.A.S.) on a video conference platform. They were all recorded (both audio and video) and then transcribed. The interviewees were not consulted for validation of the interview transcripts or analyses. The number of interviews was limited by theoretical saturation13.
The data were analyzed using grounded theory. For the processing of the empirical data, L.A.S. conducted open and axial coding, and, with the help of field notes, memos were constructed. This stage was reviewed by A.M.H., who held three consecutive rounds of discussions with L.A.S. Selective coding was carried out by L.A.S. and A.M.H. and reviewed by J.V.B. Finally, the diagrams were created for the analysis of the relationships between the categories and the construction of the main category of the study14.
For the theorization, we adopted the National Humanization Policy (PHN) as a reference, which envisages horizontal communication among SUS workers, managers, and users, and the collective production of health based on caring and humanized relationships. Regarding this, the theorization of the data was based on the principle of triple inclusion: 1) inclusion of different subjects (managers, professionals, and SUS users); 2) inclusion of the collective (organized social movements or sensitive singular experiences); and 3) inclusion of phenomena that destabilize traditional models of care and management, producing tensions in work processes15,16.

Results and Discussion
Nine managers participated in the study, all of whom were dental surgeons. The majority were women, aged 40–59 years, with a graduate diploma and/or master’s degree. The characteristics of each manager are presented in Table 1.
Table 1

Overall, the interviews lasted approximately 8 hours, averaging 53 minutes each. There was no need to contact any of the interviewees for repeat interviews. Two managers withdrew from the study during the interview scheduling period, as they no longer held the management position. After analyzing the empirical data, six categories emerged, whose codes are presented in Table 2, together with examples taken from the interviews.
Table 2

The theorization on the management of oral health services during the health crisis indicated that insecurity and questioning allowed for the horizontalization of relations between managers and oral healthcare professionals. This scenario was modified only with the publication of technical documents and the introduction of COVID-19 vaccinations. Although the managers recognized the ombudsman (or the absence of complaints) as a form of public participation, there was no effective inclusion of users in the decision-making process. The humanized approach between managers and professionals required for the resumption of activities, facilitated through negotiation spaces, does not seem to have taken root as a permanent practice. However, the need for constant improvement in the negotiation and management of supplies was perceived, in addition to the importance of seeking recognition for dentistry.
Figure 1

“You had to instill confidence in the professionals, even though you were feeling very scared”
The first category stems from the managers’ reflection on the “self” in the initial phase of the health crisis, as they (the managers) felt as if they were in the shoes of the other (oral healthcare) professionals by sharing their uncertainties in the face of the pandemic. Thus, with the onset of the health crisis, the managers showed understanding of the contamination risk that the professionals were exposed to, as they were also afraid. However, even with this insecurity, the managers had to manage the professionals, exposing their vulnerabilities and facing questions. This process promoted the destabilization of the traditional management model and the hegemonic relationship between managers and workers. The public health crisis, then, introduced some elements advocated by the PNH: it was a phenomenon that strained labor relations and thereby fostered the production of caring and humanized relationships17.
Unlike other countries, where dental care is predominantly private, in Brazil, oral healthcare is offered by the public health system18. Thus, with the suspension of elective dental care, the Brazilian strategy was to assign the oral healthcare teams to jobs that other primary healthcare teams would do19, like vaccination, fast tracking, notification, and monitoring of COVID-19 cases20.
The reorientation of workers to assist in COVID-19-related services was made possible through the development of collaborative practices and the acquisition of new skills21,22. This joint action, characteristic of the interprofessional model, transcended the multiprofessionalism usually present in health services, which is limited to sharing the same work environment23.
However, these additional responsibilities for the oral healthcare teams constituted a challenge for the managers, as they had to deal with the workers’ discontent. The resistance of healthcare professionals was also observed during the Ebola crisis (Senegal, 2014 to 2016), which required managers to provide support to confront fears and engage them in addressing the crisis24. Changes in work processes should result from the interaction of the different subjects involved in health production to build and propose the necessary adjustments25.

Factors intervening in the management process during the COVID-19 pandemic
The second category reflects on the emerging “self” of managers in response to technical regulations. The publication of official guidelines and the introduction of vaccinations brought reassurance and confidence for professionals to carry out their duties. These elements redefined the environment perceived by the managers and changed their social interaction with healthcare professionals. There can be perceived in this category a return to a similar “self” to what is usually observed under verticalized management.
Highly qualified managers and official technical documents were also identified as elements that reassured and engaged healthcare professionals during the Ebola epidemic in Senegal24. On the contrary, a lack of qualified management can compromise the capacity for guidance and governance when intervention is necessary26.
The acceptance of COVID-19 vaccines also represented an essential factor for managers to minimize fear and insecurity. Studies have found that the decision to get vaccinated was mainly related to the fear of exposure to SARS-CoV-227,28, trust in the efficacy of the vaccines29, and trust in immunization programs26. Conversely, distrust towards vaccines stemmed mainly from unsubstantiated information disseminated by media outlets and social networks30.

Participation of healthcare professionals in management
As it became possible to resume a similar level of dental care to what was available before the pandemic, the managers attributed meanings to the stances taken by the professionals, forming the third category. The profile the managers attributed to the professionals who readily made themselves available to resume dental care services was one of a commitment to the care of the population; to those who demonstrated reluctance to resume these services, they attributed a profile of complacency. Faced with these stances, the managers adopted a horizontal management approach, creating spaces for dialogue and agreements to gradually increase the volume of services, thereby perceiving themselves as being understanding managers. Since the use of dialogue and collective agreements brought positive results, a symbol of commitment to care was produced by both parties.
This dialogical moment is consistent with the PNH, in that tensions in the work process gave rise to more humanized relationships15,16. Health management encompasses the ability to mediate conflicts, organize the opinions and interests of workers, and build participatory environments for decision-making17. Verticalized management leads to a lack of commitment and demotivation among professionals31, which can compromise the effort and engagement necessary in the execution of health services32.
The PNH calls for the creation of spaces for permanent collective decision-making33, with the inclusion and participation of the subjects involved in health production at different levels34, aiming for real and lasting transformations, unlike the current management model33. Thus, it was understood that the health crisis facilitated the horizontalization of the relationship between managers and workers. However, no meanings were produced that would indicate the continuation of this model. This is borne out by another study in the state of Minas Gerais, which also indicated a return to the verticalization of oral healthcare management35.

“The population seems to have understood more than the professionals”
The fourth category was formed by the meanings attributed by the managers to the population’s attitudes. Despite the existence of patients who did not accept the cancellation of services, which was attributed to denialism, the predominant behavior of the population was to avoid seeking out healthcare services. When interpreting this behavior, the managers generated meanings of compliance and understanding. The managers interpreted people’s decision not to seek out dental care as their having understood the limitations of the moment—a result confirmed by the low number of complaints to the ombudsman. The analysis of the relationship between management and the population, which the PNH proposes to foster by strengthening forums for control and citizen participation36, revealed that the managers recognized the ombudsman as an element to be considered by management, but did not seek to include the population in the decision-making process.

“We had to transform, restructure, and reorganize ourselves”
In the fifth category, it was analyzed how the destabilization of the traditional management model required managers to optimize their skills and acquire new knowledge about management processes. This redefinition of the environment promoted self-reflection for managers, modifying the “self.” The main meaning attributed to this process was one of incompleteness and the need to step out of one’s comfort zone (to modify the pre-pandemic “self”).
Although managers are expected to be able to respond efficiently in unfavorable contexts37, COVID-19 required a high level of strategic reorganization of healthcare networks. It became necessary for managers to coordinate their services by defining new flows and protocols38, covering all bases and resolving issues. Thus, lessons were learne regarding the organization, integration, and strengthening of health systems and the political commitment to ensuring resources39.

“Dentistry has to move on like the others; it has to keep pace and not lag behind”
The sixth category brings the meaning that the managers attributed to dentistry, understanding it as little recognized and in need of greater appreciation—a meaning that emerged from the integration in the work of other professionals. Symbols were also assigned that referred to the incompleteness of dentistry (i.e., the need for network expansion and better resource allocation).
Oral health is still peripheral in inter-federal spaces and social discussions40. There is a desire for greater political representation in decision-making bodies in order to achieve a less fragmented, less incipient network41. It is also necessary to strengthen the political and institutional mechanisms for the effective integration of the oral healthcare network 40.
This study had some limitations. The interviews were conducted via video calls, which reduces the capture of non-verbal language; however, this decision was imposed by the pandemic scenario and the desire to include managers from different parts of the state. Moreover, the short time that the interviewees had held management and advisory positions may have limited the symbols and meanings they attributed to the adjustments made to address the health crisis. Nonetheless, this is consistent with the reality, insofar as healthcare managers are replaced with each political cycle. Future studies could focus on managers with more time in management and advisory positions and could seek to advance the understanding of the meanings attributed to the relationship between management and the population.

Conclusion
The analysis of the meanings produced by oral healthcare managers during a public health crisis enabled the development of a theory that phenomena that destabilize traditional models, as proposed for inclusion by the PNH and observed during the COVID-19 pandemic, have the potential to transform relationships, as they promote modifications to managers’ “self” that are translated into horizontalized management interactions. Some elements, such as technical documents and vaccinations, provided reassurance for the managers and partially enabled a return to a verticalized management “self.” Thus, the lessons learned during the critical years of the pandemic were not related to changes in the management model, but rather to the need to take action to acquire knowledge in planning, bidding, and public budgeting. Furthermore, the managers pointed out the need for greater visibility of dentistry. In their relationship with the population, the managers have ombudsman’s offices as spaces for popular participation, but community participation in the strict sense of the term was not considered. Finally, it was understood that managers seek the advancement of oral healthcare management through political and institutional recognition, but there is no effort for the social recognition of dentistry in public health services.

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